ROLE OF SUPERFICIAL VENOUS SURGERY IN THE TREATMENT OF VENOUS ULCERATIONS
 Bello M, Scriven M, Hartshorne T, Bell PRF, Naylor AR, London NJM.
Br J Surg 1999; 86:755-59

COMMENTARY BY:
Prof. Claude Juhan
Service de Chirurgie Vasculaire
HÙpital Nord - Chemin des Bourellys
13915 Marseille Cedex 20, FRANCE

Advent of ultrasound scanning has revealed that isolated superficial venous incompetence is not rare in legs with venous ulceration. In the authors' experience with 325 limbs with venous leg ulcer, isolated superficial venous incompetence was found in 55%. These patients were offered saphenofemoral or saphenopopliteal surgery without perforator surgery, skin grafting, or postoperative compression. It should be emphasized that the absence of postoperative compression was a feature of this treatment and is not advocated either by the authors or by this reviewer for routine use.

The aim of the study was to determine the ability of superficial venous surgery to heal venous ulcers without additional subfascial endoscopic perforating vein surgery. A total of 122 legs with normal deep venous competence had superficial venous surgery, most under local anesthesia (74%). Seven limbs (6%) had associated incompetent calf perforating veins. Treatment was by saphenofemoral ligation only in 57% of the limbs, saphenofemoral ligation and stripping to the knee in 20% of the limbs, 11% saphenopopliteal ligation, and 10% saphenofemoral and saphenopopliteal ligation. Only 3% of the limbs had both saphenofemoral ligation, saphenopopliteal ligation, and saphenous vein stripping. No lesser saphenous vein stripping was done, nor was calf perforator surgery performed.

The median time to healing of the leg ulcers was 19 weeks and the cumulative healing rate at 6, 12, and 18 months was 57%, 74%, and 87%. There were 18 limbs with ulcers that failed to heal. Two had recurrent saphenofemoral reflux. Most of the other cases had limited mobility caused by ankle or hip joint arthritis. Among the seven limbs with perforator reflux, five ulcers healed and, in all limbs, perforator incompetence disappeared after saphenous vein surgery. Large ulcers were not more resistant to healing than small ulcers, but simply took longer to heal.

COMMENTARY

This study emphasizes the importance of superficial vein incompetence as a cause of venous leg ulcers. It documents the fact that perforator incompetence can disappear after superficial vein surgery when the deep veins are normal. This experience presents a good argument against the use of routine subfascial perforator vein surgery at the time of superficial venous ablation. It seems to this reviewer that it is best to do standard saphenous surgery and reserve perforator ligation for a second procedure in case of persistent perforator incompetence and nonhealing or recurrent ulcerations.

This paper supports the idea that subfascial endoscopic perforator surgery should not be performed at the same setting with superficial vein surgery when the deep veins are normal. In this present experience, the healing rate probably would have been better if the authors had performed more long or short saphenous stripping instead of only high ligation.

It should be emphasized that avoiding postoperative compression was part of this study and was intended to demonstrate the efficacy of isolated superficial venous surgery. This attitude towards postoperative compression should not be considered a therapeutic rule. ivdfjuh1




MEASURING THE QUALITY OF LIFE IN PATIENTS WITH VENOUS ULCERS
 Smith JJ, Guest MG, Greenhalgh MA, Davies AH
J Vasc Surg 2000; 31:642-49

ABSTRACT AND COMMENTARY BY:
Joseph A. Caprini, MD
Louis W. Biegler Professor of Surgery
Northwestern University Medical School
Evanston, Illinois

This important study addresses the issue of quality-of-life outcomes in patients with venous ulcers. A total of 98 patients answered a short-form 36-item (SF-36) health survey and a venous ulcer questionnaire designed by the investigators. This questionnaire was developed by conducting interviews of patients with active venous ulceration and by reviewing the literature and expert opinions.

The methodology for developing the final questionnaire included an evaluation of each question for its face validity by two vascular surgeons. Questions were asked so that the patient first had to say whether they had a particular problem and then to grade the severity of this problem on a scale of 1 to 5. Three vascular surgeons independently weighed the questions for their perceived contributions for establishing severity. The questionnaires were scored as a summation of all positive responses and the scores were averaged. The questionnaire as a whole was rescaled to give a score ranging from 0 (no problem) to 100 (active ulceration).

The current study showed that a set of clinically derived questions subjected to rigorous analysis and development can produce a health outcome questionnaire with a good level of reliability and validity. The SF-36 showed reliability in ascertaining the adverse effects of venous ulceration and in showing internal consistency in the test/retest analysis.

COMMENTARY

In my opinion, this study of the Charing Cross Venous Ulcer Questionnaire is a landmark. It provides one of the best outcome measures for venous ulceration treatment. Now it is important to measure consequences of treatment in order to grade results. A validated questionnaire can be used to evaluate patients with venous ulcer and, in the future, can be used to evaluate those with chronic venous insufficiency. Some feel that appropriate outcome measures are important not only to evaluate the effects of treatment but also to evaluate the long-term effects of venous thrombosis prophylaxis.

I applaud the authors for their excellent work and encourage them to develop further measures that can be used in the broad range of patients suffering from chronic venous disorders. vdcap264




SAPHENECTOMY IN THE PRESENCE OF CHRONIC VENOUS OBSTRUCTION
 Raju S, Easterwood L, Fountain T, Fredericks RK, Neglen PN, Devidas M
Surgery 1998; 123;637-44

COMMENTARY BY:
Prof. Claude Juhan
Service de Chirurgie Vasculaire
HÙpital Nord - Chemin des Bourellys
13915 Marseille Cedex 20, FRANCE

Excision of varicose veins in the saphenous system associated with deep venous obstruction has long been considered to be contraindicated for fear of compromising collateral venous flow. Nevertheless, there have been occasional suggestions in the literature that excision of secondary varices may in fact be safe.

The objective of these authors was to test this concept using venous functional evaluation techniques in the modern era. They compared the results of saphenectomy in patients with morphologic and functional obstruction with the same operations in patients without obstruction. A total of 115 saphenectomy procedures performed on 111 patients were analyzed.

Saphenectomy alone was done in 19% and was associated with valve reconstruction for deep reflux in 81% of the limbs. The entire long saphenous vein was stripped in 75% of the limbs and the proximal saphenous vein from groin to knee in 25%. Morphologic and functional assessment of deep venous obstruction was carried out by means of ambulatory venous pressure measurement, air plethysmography, color duplex scanning, and venography. Fifty-one limbs without demonstrable obstruction were considered to be controls.

Postoperative venous testing was done 3 to 12 months after operation. All patients were seen for clinical followup 3 to 6 months after surgery. The severity of venous obstruction was graded according to the authors' arm/foot venous differential pressure technique.1 Grades 1 and 2 corresponded to completely compensated or partially compensated obstruction and grades 3 and 4 to partially or completely decompensated obstruction.

Among 64 limbs with grade 1 through 4 functional obstruction, 44% had stenosis and 56% had axial venous thrombosis with or without trabecular recanalization. After saphenectomy, the mean obstruction grade increased slightly in both control and obstruction groups without significant difference between them. Venous outflow fraction measurement did not show any significant progression of obstruction after saphenectomy in either the control or obstruction groups. Saphenectomy was well tolerated clinically by both groups.

Among 7 limbs with the most severe preoperative venous obstruction (grades 3 and 4), 70% (n = 5) had significantly improved obstructive grading, presumably as a result of elimination of reflux flow. Long-term venous testing, one to three years after operation, was available in 25 patients with obstruction and showed that the functional obstructive grade remained stable in 92% and worsened in 8% of the patients.

COMMENTARY

This study supports the idea that reluctance to remove the incompetent saphenous vein in limbs with postthrombotic obstruction is exaggerated. It is apparent that the relative contribution of the saphenous vein to collateral compensation is minor.

In this particular study, we should emphasize that we do not know how many limbs had complete occlusions without recanalization of the actual veins. Neither do we know the location of the obstructions, whether in the calf, popliteal, or femoral veins. We can suppose that complete occlusion of the popliteal vein would not be likely to tolerate complete resection of the long and short saphenous veins. Favorable results encountered in this series and mainly in the most severe cases could be partially explained by the fact that there were few complete deep occlusions and because only the long saphenous vein was resected. The authors never performed extensive superficial incompetent venous resections, particularly of the short saphenous vein. We believe that this can participate in the collateral venous network in cases of venous occlusion. ivdfjuh2

REFERENCE

1. Raju S, Fredericks R. Venous obstruction: An analysis of 137 cases with hemodynamic, venographic, and clinical correlations. J Vasc Surg 1991; 14:305-13.




RECONSTRUCTIVE SURGERY FOR DEEP VENOUS REFLUX: A REPORT ON 144 CASES
 Perrin M.
Cardiovasc Surg 2000; 8(4):246-55

ABSTRACT AND COMMENTARY BY:
Harold Welch, MD
Department of Vascular Surgery
Lahey Hitchcock Medical Center
Burlington, Massachusetts

Dr. Perrin presents a retrospective analysis of his extensive experience in deep venous reconstructive surgery for venous reflux.

A total of 144 limbs (133 patients) were operated on during a 14 1/2-year period from March 1983 to December 1997. All limbs were evaluated with preoperative phlebography, and the etiology of the disease (primary valvular insufficiency, postthrombotic syndrome, or Klippel-Trenaunay syndrome) was determined. All limbs were symptomatic (51% CEAP class 5 or 6). Noninvasive testing, which differed in the study period, included continuous-wave Doppler, duplex ultrasound, plethysmography, and air plethysmography. Surgical procedures included vein valve transplants (32), venous transposition (18), valvuloplasty (85), and Psathakis procedure (9).

As would be expected in a large series over 14 years, there were procedural variations within each operative group. In addition, 101 saphenous vein strippings and 22 perforator ligations (some in the same limb) were done at an unspecified time prior to the deep venous reconstruction. All patients underwent postoperative phlebography. Followup ranged from 12 to 168 months.

The results are difficult to summarize due to the subdivisions of procedures, hemodynamic results, and clinical results. Highlights include a postoperative thrombosis rate of 8.8% in patients with primary venous insufficiency versus 29.7% in patients with postthrombotic syndrome. For those who underwent vein valve transplant and venous transposition, there was no correlation between hemodynamic results and ulcer recurrence. However, there was a strong correlation in those who underwent valvuloplasty. In addition, valvuloplasty provided better protection against reflux than the other procedures.

Dr. Perrin presents his experience with deep venous reconstruction over a 14 1/2-year period. He modified the procedures or approach as guided by experience (i.e., abandoning the Psathakis procedure due to poor results). He acknowledges difficulty in comparing results between studies due to lack of information on etiology and hemodynamic changes.

COMMENTARY

It is challenging to assess results during a 14-year dynamic study but a few major points can be made. Dr. Perrin's results are consistent with others in showing that results of deep venous reconstruction are better in patients with primary venous insufficiency than in those with postthrombotic syndrome. In addition, those whose deep venous reflux was eliminated by the reconstruction did substantially better (31/36 without ulcer recurrence) than those with persistent or recurrent major reflux (10/24 without ulcer recurrence). Dr. Perrin claims that his postoperative deep venous thrombosis (DVT) rate is high because the event was identified by routine postoperative phlebography within 48 hours. This is clearly reasonable since the incidence of DVT in orthopedic joint arthroplasties is as high as 40 to 60%.

This nicely written report is a significant addition to the literature on venous reconstruction. vdwel264




BACTERIAL POPULATION OF CHRONIC CRURAL ULCERS: IS THERE A DIFFERENCE BETWEEN THE DIABETIC, THE VENOUS, AND THE ARTERIAL ULCER?
 Schmidt K, Debus ES, St. Je_berger U, Ziegler U, Thiede A
VASA 2000; 29:62-70

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

Almost all chronic wounds are contaminated with various bacteria. These wounds heal at different rates of speed. This caused the authors to evaluate chronic wounds in three distinct populations: Venous stasis ulcers, arterial ulcers, and diabetic ulcers. The objective was to answer the question of the relationship of differing populations of bacteria to the primary cause of the wound.

As expected, positive cultures were seen in 95% of arterial and venous ulcers and in 71% of diabetic foot ulcers. Diabetic foot ulcers with coexisting ischemia had an 86% rate of bacterial growth. Differences in bacterial populations between these wounds were not statistically significant. Staphylococcus aureus was the most frequently isolated pathogen. An attempt was made to correlate the rate of positive wound smears with clinical diagnosis of infection. The infection status was defined as degree of erythema, swelling, pain and fever.

A number of interesting observations were made. The most significant of these was that 22% of venous ulcers with a positive smear developed clinical infection. In contrast, a 70% incidence of clinical infection was seen in arterial and diabetic ulcers with a positive smear. Also of interest was the fact that venous ulcers tended to heal despite the presence of bacterial infection. This was in contrast to wounds of arterial origin in which 80% did not heal satisfactorily in the presence of infection. Undoubtedly, this difference is related to the pathophysiology of these wounds. Also, this fact might be related to the fact that once venous hypertension is treated and relieved, the primary etiologic factor causing the ulcer is controlled and the ulcer heals. With arterial ulcerations, the devitalized nature of the tissue with coexistent bacterial infection is recalcitrant until revascularization is achieved.

The authors admit that they were unable to culture all types of bacteria. Two infected diabetic lesions demonstrated no bacterial growth. The authors suspected that infection was being caused by anaerobic bacteria.

COMMENTARY

A limitation of the strength of this paper is that only aerobic populations were studied in chronic leg ulcers. We can take from this paper that the general policy of taking wound smears in venous ulcers does not appear to be useful. Bacterial colonization usually does not have a lasting influence on the healing process. The corollary to this is that arterial and diabetic ulcers would profit by study with smear and culture and would most likely benefit from appropriate antibiotic treatment of any bacterial infection which is present. ivdfgol2




CLOSURE OF THE GREATER SAPHENOUS VEIN WITH ENDOLUMINAL RADIOFREQUENCY THERMAL HEATING OF THE VEIN WALL IN COMBINATION WITH AMBULATORY PHLEBECTOMY: PRELIMINARY 6-MONTH FOLLOWUP
Goldman MP.
Dermatol Surg 2000; 26:452-56

ABSTRACT AND COMMENTARY BY:
John J. Bergan, MD, FACS
Professor of Surgery, University of California, San Diego
Clinical Professor of Surgery, USUHS, Bethesda, Maryland

This study utilized radiofrequency energy to close the incompetent and refluxing saphenous vein from the saphenofemoral junction distally. Delivery was through the Closure system to heat the vein wall and induce physical contraction of that structure. This report describes early experience with 12 legs in 10 patients treated in the United States. The followup was at six months with duplex ultrasound.

The patients were between 22 and 60 years of age (8 women, 2 men) and 12 legs were treated (6 right, 6 left). All had been studied with Doppler ultrasound to confirm saphenous reflux and to mark the location of the greater saphenous vein from the knee to the saphenofemoral junction. All operations were on an outpatient basis utilizing tumescent anesthesia with 0.1% lidocaine and epinephrine solution infiltrated along and around the entire length of the greater saphenous vein and distal tributaries. Care was taken to place the tumescent anesthesia between the greater saphenous vein and the epidermis. An average of 700 ml of anesthetic solution was required.

Either 8F or 5F VNUS endoluminal catheters were inserted. Manual pressure was exerted on the groin to prevent reflux into the greater saphenous vein and the radiofrequency catheter was activated. Pullback was monitored by intravenous temperature and an attempt was made to maintain this at 85 C. Pullback was accomplished at a rate of approximately 3.5 cm/min. Distal varicose tributaries were treated with ambulatory phlebectomy, and a bulky gauze dressing was applied. This was changed at 24 hours, and 30 to 40 mmHg graduated compression stockings were placed and worn for one week.

Two of 12 patients complained of heat at the saphenofemoral junction. Failure of heparinized saline flow occurred in one catheter and this caused localized thrombosis of the catheter tip. Purpura was seen in 8 of the 12 treated legs and 2 developed mild erythema over the greater saphenous vein closure site. All patients resumed preoperative activity within 24 hours and clinical evaluation at 3 and 6 months showed no evidence of recurrent or persistent varicose veins. Duplex evaluation by an independent laboratory verified complete closure with absence of retrograde flow at 3 and 6 months in all patients.




TRANSCATHETER DUPLEX ULTRASOUND-GUIDED SCLEROTHERAPY OF GREATER SAPHENOUS VEIN REFLUX: PRELIMINARY REPORT
 Min RJ, Navarro L.
Dermatol Surg 2000; 26:410-14

In this study, 51 greater saphenous veins in 50 patients were treated with transcatheter sclerotherapy. Confirmation of pretreatment reflux in the greater saphenous vein was obtained with continuous-wave Doppler and duplex ultrasound. Local anesthesia was utilized to gain access to the greater saphenous vein 15 to 45 cm (mean 35 cm) below the saphenofemoral junction. A 5F infusion catheter was placed over a 0.035-inch-diameter guide wire and the catheter positioned under ultrasound guidance at 3 cm below the saphenofemoral junction. Vein emptying was facilitated by a Trendelenburg position. The proximal portion of the greater saphenous vein was manually compressed to prevent reflux. A total of 2 ml of 3% sodium tetradecyl sulfate was administered through the catheter 2 to 3 cm below the saphenofemoral junction and additional amounts of 3% sodium tetradecyl sulfate were given along the course of the greater saphenous vein in approximately 0.3 ml increments at 3 to 5 cm intervals. Saphenofemoral junction compression was maintained for two minutes following removal of the catheter. Then 30 to 40 mmHg graduated compression stockings were placed and worn for seven days following treatment. Patients were instructed to walk immediately after the procedure and to continue their normal activities. Examination with continuous-wave Doppler was achieved at 24 hours, one week, and monthly following initial treatment.

At the early imaging intervals, all treated greater saphenous veins were closed with no flow detectable by continuous-wave or color Doppler. All veins were closed at 3- to 6-month followup (mean 8 months). No adverse reactions were seen.

COMMENTARY

Neil Sadick commented on the first presentation by Dr. Goldman and pointed out that the gold standard for treatment of saphenofemoral incompetence has been proximal ligation with distal removal of the saphenous vein. He pointed out that duplex-guided sclerotherapy of the saphenous vein has gained increased popularity and early reports have been encouraging but that inadvertent intraarterial injection had caused untoward sequelae and followup studies were showing recanalization of the greater saphenous vein during late followup.

Commentary on the transcatheter duplex ultrasound-guided sclerotherapy pointed out that intraoperative transcatheter sclerotherapy was done in the decade of the 1960s. Long-term results of that therapy proved to be unsatisfactory. It was pointed out that the author's table illustrating followup showed that only 10 of 51 limbs had been followed for as long as 12 months and that 22 were in the nine-month interval, 11 at six months and 8 had been followed only three months. The short followup described for the VNUS Closure technique was similarly too short.

These two minimally invasive techniques of saphenous vein ablation indicate that prospects for effective minimal invasion and total ablation of the saphenous vein are within reach. Although both techniques document intraluminal placement of the activating agent, a recent publication has suggested that for sclerotherapy this is not protection against massive tissue necrosis when high-concentration sclerosants are used. A theory has been proposed that chronic venous hypertension has allowed breakdown of the capillary barrier and that intravenous instillation of sclerosants reach the arterial arborization and there cause the massive tissue necrosis which has been observed.1

Finally, neither publication addresses the fundamental surgical dictum which states that the individual tributaries to the saphenofemoral junction must be isolated, ligated, and divided. Methods of ablation of the saphenous vein without surgical exposure of the saphenofemoral junction do allow definition of the natural history of such a procedure and this reviewer anxiously awaits the long-term results of performing saphenous ablation without control of the proximal tributaries.

REFERENCE

1. Bergan JJ, Weiss RA, Goldman MP. Extensive tissue necrosis following high-concentration sclerotherapy for varicose veins. Dermatol Surg 2000; in press.




125 REDO OPERATIONS FOR RECURRENT POPLITEAL VARICES AFTER SHORT SAPHENOUS VEIN EXCISION: ANATOMICAL AND PHYSIOLOGICAL HYPOTHESES OF THE MECHANISM OF RECURRENCE
 Creton D.
J des Malaides Vasculaires 1999; 24(1):30-36

COMMENTARY BY:
Prof. Claude Juhan
Service de Chirurgie Vasculaire
HÙpital Nord - Chemin des Bourellys
13915 Marseille Cedex 20, FRANCE

The questions posed in this study are how to explain recurrence of varices in the popliteal fossa after short saphenous vein surgery and how to prevent them. The author attempted to answer both using experience with 125 redo procedures in the popliteal fossa. The first operation had been performed for short saphenous vein incompetence. In almost all cases, preoperative duplex investigation had not been done; however, duplex examination was always performed prior to the reoperation. Recurrences were classified into five types:

Type I: Intact short saphenous vein (13.5%). Result of an inadequate incision with absence of adequate venous resection. Possibly some were a recanalized ligation.

Type II: Persistence of a short saphenous vein stump (42.5%). High ligation had not been performed flush with the popliteal vein. The stump was connected to superficial varices through incompetent tributaries or neovascular networks.

Type III: Persistence of a short saphenous vein trunk (19%). This was linked to a long stump by neovascularization.

Type IV: Presence of an incompetent popliteal perforating vein (23%). Overlooked during the first procedure or newly developed.

Type V: Popliteal varices fed by a venous network linked to a vasa nervorum of the sciatic nerve (2%).

In 75% of the redo operations, recurrence was due to an insufficient resection of the short saphenous vein upward (saphenopopliteal junction) or downward (saphenous trunk). Because no duplex assessment was done prior to the first surgical treatment, it was impossible to determine if incompetence of the popliteal perforating veins was present and overlooked or whether it appeared afterwards. The author noticed that recurrences in the popliteal fossa appeared earlier than those in the groin following long saphenous vein surgery. A total of 50% of patients had redo surgery less than five years after the initial treatment and 70% less than nine years after the initial treatment.

COMMENTARY

The author's observations reinforce rules of surgical treatment of varicose veins. These are to resect the short saphenous vein flush with the popliteal vein and to resect extensively all tributaries in the popliteal fossa.

Persistence of the short saphenous trunk can be responsible for recurrence due to neovascularization or perforator incompetence more distally. This observation negates the attitude of most surgeons who do not perform short saphenous trunk resection or stripping because of fear of superficial nerve damage. Invagination stripping downward reduces to nearly zero the risk of nerve injury. The frequent anatomic variability of popliteal fossa veins makes preoperative duplex investigation and mapping mandatory in order to prevent recurrences. ivdfjuh3