VD608R

INADVERTENT ARTERIAL INJURY DURING SAPHENOUS VEIN STRIPPING
Ramsheyi A, Soury P, Saliou C, Gigou F, Laurian C.
Arch Surg. 1998;133:1120-23

ABSTRACT AND COMMENTARY BY:
John Blebea, M.D., FACS
Associate Professor of Surgery
Penn State College of Medicine
Hershey, Pennsylvania

Among the complications associated with saphenous vein stripping, the most serious is associated arterial injury. This complication is rare enough that few surgeons have occasion to evaluate such patients. Timely postoperative diagnosis is often delayed because the associated pain is mistakenly ascribed to the surgical procedure itself.

The authors describe three cases which had been referred to them with this complication. All were young women ranging in age from 30 to 44 years with no preexisting peripheral arterial occlusive disease. Greater saphenous vein stripping had been attempted by general surgeons in all cases but the injury was not immediately recognized in two of them. In the first case, after recovery from anesthesia, the patient complained of pain and numbness in the leg. Angiography was done which showed disruption of the common femoral artery but visualization of the profunda femoris artery. Surgical exploration was performed by a vascular surgeon. The superficial femoral artery was found to be absent, the popliteal artery was found to be injured but intact, and the varicose saphenous vein was unstripped and intact. In the second case, 18 hours after surgery, the patient complained of persistent leg pain. Surgical exploration was undertaken and it was found that the common femoral artery was ligated and there was a missing superficial femoral artery, popliteal artery and tibioperoneal trunk. The associated greater saphenous vein was intact. Another patient developed intermittent claudication a few days after presumed saphenous vein stripping. Seven years later she was evaluated for this problem and it was documented by angiography that the proximal third of the superficial femoral artery was occluded and there was a missing posterior tibial artery. No intervention was initiated because the claudication was well tolerated. In the first two patients, surgical revascularization was attempted initially with a prosthetic graft which failed and later replacement with distal autologous venous bypasses. In both cases, fasciotomies were performed and external fixators to the ankle joint were placed to prevent a footdrop. Both patients required later toe amputations but the legs were salvaged.

The authors subsequently reviewed the literature concerning arterial injury during saphenous vein stripping and commented upon the types of injuries, their diagnoses, and appropriate treatment. There are few such cases reported in the world literature. The largest series is that of Natali in 1993 who described 19 cases during a 30-year time period. Of these patients, seven involved complete arterial strippings and 12 had ligation of the major trunk at the femoral bifurcation. Nine of these patients required a major leg amputation. Direct arterial trauma constituted the most frequent cause and resulted from attempts at blind hemostasis for control of hemorrhage. On the other hand, complete stripping of the artery occurs when the superficial femoral artery is mistaken for the saphenous vein and an intraluminal stripper is inserted from the groin. Thrombosis of the artery can also result from an intimal injury due to blunt trauma without total ligation.

The consequences of arterial trauma depend on the extent of the iatrogenic arterial injury and its level. Ligation or stripping of the common femoral artery is most serious, followed by trauma to the superficial femoral artery. The diagnosis is suggested by an unusual degree of pain, pallor, coldness and numbness in the foot in conjunction with absent pulses. Although tight bandages can present with these same symptoms, pain is relieved upon relaxation of the bandage. Deep venous thrombosis is an unusual cause of leg pain but should also be considered. On the basis of their experience, the authors recommend an angiogram for diagnosis of the extent and location of the arterial injury. They also suggest routine fasciotomies because of reperfusion edema and placement of an external fixator at the ankle to facilitate nursing care and prevent a footdrop.

COMMENTARY

Significant inadvertent arterial injuries should always be considered at the time of saphenous vein stripping. Accurate identification of the vessel to be stripped is most important. Of note, in these authors' experience, all patients were young females with a presumed lack of atherosclerotic disease. In these circumstances, a small artery that undergoes spasm after nearby dissection can falsely give the appearance of a vein. In this reported experience, such misidentification of vessels also appears to be associated with lack of vascular experience by the surgeon. Inadvertent stripping is also much less likely if an intraluminal stripper is inserted distally rather than from proximally in the groin.

Once such injuries occur, early and accurate diagnosis is mandatory to prevent limb loss. Undue pain postoperatively should be a sufficient reason to reexamine the leg, release any tight bandages, and palpate for distal pulses for an examination of clinical signs and symptoms of acute arterial injury. Unlike the authors, however, early arterial duplex ultrasound is our recommended technique of choice. This provides one with accurate diagnosis of an occlusive arterial lesion as well as its location. Additionally, one can also exclude any associated deep venous thrombosis. In circumstances where the extent of arterial injury is still not well defined, preoperative angiogram or magnetic resonance angiography can be employed. When the superficial femoral or popliteal arteries have been inadvertently stripped, the saphenous vein is still available for a distal bypass. Extensive arterial stripping from the groin to the ankle leaves the anterior tibial artery available for a distal bypass. Finally, if the injury is identified early enough, compartment pressures may be measured and subcutaneous limited, rather than extensive open, fasciotomies may suffice. We would not recommend external fixators. In our experience, they are not needed for local wound care as motor and sensory function in the feet may return if operative intervention is initiated in a timely fashion. vdble194

Suggested Reading

Natali J. ConsÈquences mÈdico: LÈgales des complications de la chirurgie veineuse superficielle des membres inferieurs. PhlÈbologie 1993; 46:613-18.

Perogaro M, Baracco C, Ferrero F, et al. Successful vascular reconstruction after inadvertent femoral artery stripping. J Vasc Surg 1987; 28:440-44.

Frilleux C, Pillot-Bienayme P. Les accidents artÈriels du traitement des varices. PhlÈbologie 1981; 34:632-38.

Liddicoat JE, Bekassy SM, Daniell MB, et al. Inadvertent femoral artery stripping: surgical management. Surgery 1975; 77:318-20.

Eger M, Coleman L, Torok G, et al. Inadvertent arterial stripping in the lower limb problems of management. Surgery 1973; 73:23-27.

Nabatoff RA. Anomalies encountered during varicose vein surgery. PhlÈbologie 1981; 34:21-27.

TECHNICAL DETAILS ON EXCISION OF THE SHORT SAPHENOUS VEIN
Creton D.
PhlÈbologie 1999; 52(2): 169-74

ABSTRACT AND COMMENTARY BY:
Attilio Cavezzi, MD
San Benedetto del Tronto (AP), Italy

Short saphenous vein (SSV) incompetence is associated with a variety of hemodynamic patterns which are detectable in the popliteal region. Surgery of the SSV is more complex and more delicate than it is for the long saphenous vein (LSV). A higher incidence of recurrence is reported for SSV operations.

The author describes his technical approach, including fundamental preoperative duplex mapping, local/regional anesthesia, the 3 cm incision at the popliteal level, segmental invagination stripping (by a plastic disposable stripper or a pin stripper), and phlebectomy of the tributaries. Flush ligation of the SSV at the popliteal vein level and ligation of incompetent gastrocnemius trunk when it joins the SSV, and fascia closure are recommended by the author. The length of the stripped segment depends on the extent of reflux. The author avoids excising the most distal segment where adjacent nerves are very close to the SSV.

Preoperative investigation is considered mandatory to clarify the source of reflux. Sometimes it is possible to avoid a popliteal incision when an incompetent vein of Giacomini is responsible for SSV reflux without a saphenopopliteal connection. Duplex will reveal the location of the saphenopopliteal junction which, in 78% of cases, will be between the popliteal line and 5 cm above. Preoperative duplex will show the anatomic and hemodynamic relationship with the gastrocnemius trunk, the type of saphenopopliteal junction which, in one-third of cases is of tortuous nature, and the extent of the SSV reflux.

Due to a relatively high incidence of thromboembolic complications (higher than for intervention on the LSV), prescription of low-molecular-weight heparin is advocated by Creton. In the case records of the author, neurologic complications of SSV interventions were 0% for limited short stripping (upper part) and 8% for long stripping (popliteal to ankle). When the invagination technique was not used, 20.8% neurologic complications have been described by other authors. Most of this author's recurrences (75%) were due to incomplete proximal excision of the SSV. Most remaining complications were from a popliteal perforator.

COMMENTARY

The author's experience in short saphenous vein surgery is well known and is reflected by his strict and correct diagnostic and therapeutic approach. Duplex scanning, or colorflow duplex imaging may (must) guide precisely the steps of the surgeon doing venous surgery. Using this tool, some recurrences such as new incompetence of the popliteal perforator are predictable in the presence of systolic reflux (during calf contraction) from the popliteal vein to the short saphenous vein as a demonstration of obstruction of deep venous system drainage is uncovered.

Technical surgical details vary among most surgeons but a few remarks are possible. The uniform ligation of the gastrocnemius trunk when there is a single stem joining the SSV with incompetent gastrocnemius veins may be excessive. Most gastrocnemius trunk reflux may disappear after ligation of the junction between the SSV and the gastrocnemius trunk (without ligating the SSV at popliteal level), having abolished the hemodynamic steal. Moreover, the formidable pump action of calf and gastrocnemius vein is well known and obstructing these conduits could impair this function. Differing opinions are still being gathered on this topic and no randomized study has definitively answered the question.

I personally share the author's opinions about invagination segmental stripping. We use only the plastic stripper. We also believe there are reduced nerve injuries and lymphatic complications. Also, we keep in mind that the SSV is rarely incompetent from its junction to the ankle. Use of low-molecular-weight heparin as a standard requirement may be debatable if immediate ambulation is allowed, such as after use of pure local anesthesia. I found it remarkable to read that no procedure for calf perforating veins is advocated when phlebectomy is actually a therapy for perforators. We completely agree with this opinion since most perforating veins have a reentry role in the lower part leg but never a pathogenic role as in primary varicose veins. vdcav194

SQUAMOUS CELL CARCINOMA COMPLICATING CHRONIC VENOUS LEG ULCERATION: A STUDY OF THE HISTOPATHOLOGY, COURSE, AND SURVIVAL IN 25 PATIENTS
Baldursson BT, Hedblad M-A, Beitnar H, Lindelof B.
Br J Dermatol 1999; 140:1148-52

COMMENTARY BY:
Mitchel P. Goldman, MD
La Jolla, California

All physicians practicing phlebology should read this excellent review on the incidence of squamous cell carcinoma in chronic venous leg ulceration.

The authors extracted all patients with a diagnosis of squamous cell carcinoma and venous leg ulcers from a list of 10,913 cases of patients with leg ulcer in the Swedish inpatient registry. Mean age at ulcer diagnosis was 56.4 years. They had histological slides evaluated by a dermatopathologist who graded the squamous cell carcinoma by its differentiation. Eleven tumors were well differentiated, ten were moderately differentiated, and four were poorly differentiated. The median survival of patients was one year. Metastases were certain in eight cases. The disease was lethal in ten cases which included all of the poorly differentiated tumors.

Details on each of the 25 cases are provided in an excellent table. A review of these cases discloses that less well-differentiated tumors are especially aggressive in the setting of chronic ulceration. This may be due to the advanced stage of disease at the time the patients were diagnosed with nonhealing ulcerations. Although most tumors were excised, there was a high incidence of recurrence requiring reexcision. Therefore, in treating these malignancies, one should consider either obtaining large margins or using Mohs' micrographic surgical control for total excision of these poorly differentiated tumors.

The take-home message from this, and almost all other reviews of squamous cell carcinoma developing in chronic leg ulceration, is that physicians should biopsy any ulcerations which are not healing with appropriate phlebological care or if the ulcerations are undergoing unusual growth. vdgol194

CHRONIC LEG ULCERS: THE IMPACT OF VENOUS DISEASE
Bergqvist D, Lindholm C, NelzÈn O.
J Vasc Surg 1999; 29:752-55

ABSTRACT AND COMMENTARY BY:
Julie A. Freischlag, MD
Professor and Chief
UCLA Vascular Surgery
Director, Gonda (Goldschmied) Vascular Center
Los Angeles, California

This manuscript provides an update on the prevalence and nature of chronic leg ulceration in three areas of Sweden: Sharaborg County, Uppsala County, and Malm– City. Despite the data being obtained a bit differently from each location (physician versus nurse reporting), the results are similar in that patients over age 15 have a 2.4% prevalence of leg ulcers from all causes and patients over age 64 have a 5.6% prevalence. Venous disease is the most common etiology but many ulcers, especially of the foot, can have a multitude of causes.

Patients with ulcers caused by venous insufficiency are younger when the ulcer originates (59 years versus 73 years), have a longer duration of ulcer history (13.4 years versus 2.5 years), and a higher incidence of recurrence (72% versus 45%). It is not surprising that these patients require lots of care - in the hospital, in the clinic, and at home with nursing. Patients studied with ulcers were from a lower socioeconomic group, and many of these patients were immobile.

COMMENTARY

It is my opinion that patients with ulcers need to be evaluated initially in a multidisciplinary clinic where etiologies other than venous insufficiency can be identified and treated and where superficial venous insufficiency can also be treated. We find that compliance with a treatment regimen (there are literally thousands!) is better when patients feel that they "belong" to our family of health care. Our nurse practitioner facilitates that ambience in our clinic. A moist environment is applied locally to the ulcer and compression is utilized as tolerated by the patient. Compression can be supplied by Coban, Ace wraps, stockings, or Unna boots. Encouragement is given and ulcer healing is applauded by our "family" of health care professionals.

Leg ulcers will continue to pose a challenge to the health care industry because they are chronic and recurrent and occur in patients with a fairly long life expectancy. By including the patient in an enthusiastic approach to the healing process and educating him in the techniques to prevent recurrence, we feel that we can provide the most impact on this chronic problem. vdfre194

FROM THE EDITOR'S DESK

News Item

Alberto Caggiati, MD, Ph.D. is conducting an informative survey to determine the terminology of tributaries to the saphenous veins. He points out that the official Terminologia Anatomica does not give detailed information about the saphenous vein tributaries. Prof. Caggiati terms this terminological chaos and he has found, on reviewing recent papers and textbooks, that the same tributary to the saphenous vein has been named more than ten different ways and that a particular name for a tributary has been used to indicate four different tributaries.

At this time, Prof. Caggiati is asking for personal suggestions and would like interested individuals to contact him directly. He seeks to answer three questions:

1. Which are the tributaries to the saphenous veins which should be included in Terminologia Anatomica ?

2. What are their anatomical markers with regard to origin, path, and main connections?

3. What is the most appropriate name for each of the tributaries?

Interested individuals may contact Prof. Caggiati at the Department of Anatomy, Via A. Borelli 50, I-00161, Rome, Italy.

NONOPERATIVE MANAGEMENT OF VENOUS LEG ULCERS: EVOLVING ROLE OF SKIN SUBSTITUTES
Skin Substitute Consensus Panel
Moneta GL, Falanga V (Co-Chairmen)
Vasc Surg 1999; 33:2

ABSTRACT AND COMMENTARY BY:
Warner P. Bundens, M.D., M.S.
Department of Surgery
University of California, San Diego
San Diego, California

This paper is the report of a consensus panel that met in late 1997. The panel included a range of disciplines including vascular surgery, dermatology, podiatry, plastic surgery, vascular medicine, and industry.

The paper reviews the epidemiology as well as the physical, financial, and psychological morbidity of venous ulcers. Regarding compression therapies, the paper states the "best method of applying compression remains controversial." Pharmacologic therapies are reviewed and a recent trial of pentoxifylline showing positive results is presented in some depth, though the panel states that "further studies are needed to establish the role of this hemorheologic agent in the management of chronic venous ulcers."

The use of conventional topical therapeutic agents is presented. A more in-depth review of growth factors and cytokines follows. The panel felt that though no large clinical trials have shown efficacy of such agents in treating venous ulcers, some studies in which these materials showed positive results in the treatment of other chronic wounds, such as neuropathic ulcers, indicates that they may have "considerable potential."

Descriptions and indications for the use of seven different skin substitutes, either under development or currently marketed, are presented as well as short summations of the relevant clinical studies. It appears from the text and tables that only the bilayered living skin construct, Apligraf was, at the time of the panel meeting, specifically indicated and FDA approved for treatment of venous ulcers. One clinical trial is cited in which this material was shown to be efficacious, especially for treatment of large and long-standing venous ulcers. The panel also presents the speculation that in addition to being a biologic cover, the graft may improve healing by releasing growth factors.

The paper concludes with a summary of venous ulcer patient management considerations. Most of these follow generally accepted practices, though some may seem more aggressive than many clinicians' routines. Compression therapy is recommended for initial treatment of venous ulcers but alternate treatments, such as skin grafts, surgery, and skin substitutes should be "considered" after four weeks or even as initial treatment for large, long-standing ulcers.

COMMENTARY

This is a remarkably good review paper. Topics are covered in a concise but thorough manner, and are well referenced. The comprehensive review and tabulation of available growth factors and skin substitutes is unique. One regrets that it took 18 months to bring this group's report to publication. Also, because consensus panels often present opinions as well as scientific evidence, disclosures of who sponsored the conference as well as any affiliations of panel members with companies that make the products discussed would have been welcome. vd-bun125

ETIOLOGY AND DIAGNOSIS OF BILATERAL LEG EDEMA IN PRIMARY CARE
Blankfield RP, Finkelhor RS, Alexander J, et al.
Am J Med 1998; 105:192-97

COMMENTARY BY:
Peter Charlesworth, FRACS
Auckland, New Zealand

The stated purpose of this study was to identify the causes of bilateral leg edema in a primary care setting and to determine the ability of primary care providers to arrive at the correct diagnosis using the information available at the initial clinical encounter. For reasons that are not entirely clear but possibly influenced by the perceived prevalence of venous disease in the general population, the authors hypothesized that venous insufficiency would be the most common cause of bilateral leg edema.

A total of 58 patients with bilateral leg edema were enrolled over a three-year period. Thirteen failed to complete the protocol, reducing the final study group to 45. Patients with certain known causes of leg swelling such as drugs, intra-abdominal malignancy, hypothyroidism, and idiopathic cyclic edema were excluded.

Patients were assessed initially with a comprehensive medical history and physical examination, including urinalysis. Almost all had bilateral pitting edema ranging from less than six months to over six years in duration. Although not specifically mentioned in the article, it is of interest that hand-held Doppler findings did not seem to have been included as an indicator of possible venous disease. Based on the history and physical examination, the primary care provider recorded an impression of the cause of the edema. Patients then underwent laboratory evaluation with echocardiography and duplex sonography. Most were examined by a cardiologist. Some were treated with medications in the interim and had no edema when seen by the cardiologist. The specialist then provided a second diagnosis of the etiology of the edema.

The clinical diagnosis profile of the primary care physician included venous insufficiency 71%, cardiac and/or pulmonary disease 22%, renal disease 13%, and lymphedema 2%. After laboratory and cardiology evaluation, the diagnosis profile included venous insufficiency 22%, cardiac and/or pulmonary disease 62%, renal disease 19%, lymphedema 2%, and idiopathic 27%. The meaning of venous insufficiency was simply defined as "retrograde flow across the venous valves in the legs, either at the level of the femoral, popliteal, or saphenous veins," presumably as shown on the duplex examination. No description of the actual clinical signs of venous disease was provided.

Several variables were statistically associated with a final diagnosis of venous insufficiency in the study. These included a history of venous stasis ulcers, brawny induration, previous treatment with Unna boots, and older age. There was no significant association between venous insufficiency and varicose veins, use of compression stockings, prolonged daily walking or standing, history of deep venous thrombosis, or gender. The incidence of cardiac and pulmonary disease was much higher than expected by the authors. In fact, in many patients the diagnosis was made only by echocardiography.

COMMENTARY

The results of this study reinforce the current wisdom that bilateral leg swelling is most commonly due to a systemic condition such as cardiac or renal disease. In my experience, many other cases without a specific, defined explanation will be considered idiopathic.

While patients with varicose veins may complain of intermittent leg swelling, few are demonstrated to have significant edema. In the context of venous pathology in general, severe edema probably implies major outflow obstruction and/or disturbed calf muscle pump function. Frequently, these problems will be unilateral and associated with a characteristic clinical history and/or obvious physical signs apart from the edema.

It appears that the authors' stated assumptions and results give a hint that the nuances of venous disease are not well understood at a primary care level. This is easy to say from the perspective of a specialist and maybe is not surprising given the myriad of conditions faced by the primary care physician today. However, the value of assessment with a continuous-wave hand-held Doppler in the examination of venous disease cannot be overestimated. vdcha194

THE PREVALENCE OF FACTOR V LEIDEN MUTATION IN PATIENTS WITH LEG ULCERS AND VENOUS INSUFFICIENCY
Maessen-Visch MB, Hamulyak K, Tazelaar DJ, et al.
Arch Dermatol 1999; 135:41-44

ABSTRACT AND COMMENTARY BY:
Mitchel P. Goldman, MD
La Jolla, California

The authors evaluated 92 patients with venous leg ulcers and 53 control patients for the prevalence of factor V Leiden mutations. They found that factor V Leiden mutation was significantly more frequent in patients with chronic venous insufficiency and venous leg ulcers than in the control group (23% versus 7.5%, p = 0.03). They also found that patients with factor V Leiden mutation were more likely to have a history of venous thromboembolism (91% versus 48%, p = 0.002). Finally, recurrent deep venous thrombosis and recurrent leg ulcerations occurred more frequently in patients with factor V Leiden mutation (43% versus 19%, p = 0.01).

COMMENTARY

Studies have shown that in 50% of patients with venous leg ulcers, a history of deep venous thrombosis can be made on the basis of clinical signs and symptoms. Other studies have shown that heterozygous factor V Leiden mutation increases the risk of venous thrombosis five- to seven-fold. Therefore, the authors speculate that there could be a correlation between the development of venous leg ulcers and chronic venous insufficiency and factor V Leiden mutation. This was confirmed in the Netherlands where it was found that 23% of patients with venous leg ulcers and factor V Leiden mutation compared favorably with previous studies showing an APC resistance rate of 26% in patients with venous leg ulcers. Therefore, one should consider prolonged anticoagulant and/or compression therapy in these patients with the aim of decreasing the risk of deep venous thrombosis and its sequelae of chronic venous insufficiency. vdgol195

PREVALENCE AND DISTRIBUTION OF INCOMPETENT PERFORATING VEINS IN CHRONIC VENOUS INSUFFICIENCY
Delis KT, Ibegbuna V, Nicolaides AN, Hafez H
J Vasc Surg 1998; 28:815-25

ABSTRACT AND COMMENTARY BY:
Prof. Lars Norgren
Department of Surgery
Lund University
Lund, Sweden

The role of incompetent perforators has been debated since they were first found. One of the main problems has been that reliable methods to study incompetence of the perforators have not been available. Venography has been used extensively but has been nonspecific. Many perforators have been found "guilty" but were improperly investigated. New technology has enabled a more careful analysis of perforators. Color-coded duplex scanning, although examiner dependent, is a reliable method and there should be a fair chance of finding all perforators and proving whether they are incompetent or not.

The present study analyzed 468 limbs in detail. These were classified according to the CEAP. The superficial and the deep venous systems were investigated and all perforators were researched medially, posteriorly, and anterolaterally. Perforators were also classified with regard to their level on the calf or thigh. Pathological reflux flow was defined as a duration > 5 seconds on three consecutive measurements.

Confirming previous knowledge, the incompetent perforators were mainly found medially. Also, the greatest frequency of perforators was seen in the middle third of the calf. The lower third of the calf contained the second largest proportion of perforators while lateral perforators were uncommon. Both incompetent perforating veins and deep vein incompetence increased the clinical severity of the chronic venous incompetence. The highest prevalence of incompetent perforating veins was seen in classes 5 and 6. The main localization was in the medial aspect of the mid-calf. The authors found that prevalence of incompetent perforating veins and their calf-to-thigh ratio increased linearly with the clinical severity of chronic venous incompetence. The prevalence of deep vein incompetence and the ratio of superficial and deep to superficial incompetence also increased linearly with the CEAP classification.

COMMENTARY

This is an extremely carefully conducted duplex study requiring highly experienced examiners to search for all possible perforators. This study confirms the fact that most perforators are seen in the medial aspect of the calf but it also points out that perforators are more often localized in the middle portion of the calf and not in the distal ankle.

The older view that perforators should be found at very specific heights from the sole of the foot is no longer accepted. There may still be a belief that most perforators are to be found in the distal part of the calf, but the findings of this study suggest otherwise.

It should be evident that the more severe the clinical stage, the more advanced the morphology regarding the number of incompetent venous segments. This has been proven by this study. It is also clear that more incompetent perforators are seen with more advanced venous incompetence. These findings are of great interest as we wish to learn more about the correlation between clinical stages and venous pathomorphology. On the other hand, the controversy still exists as to the extent these incompetent perforators contribute to severe symptoms compared to what is contributed by the incompetent superficial and/or deep venous systems. Therefore, conclusions cannot be drawn to what extent incompetent perforating veins should be ligated in the various clinical situations. ivdfnor