PREOPERATIVE EVALUATION IN PRIMARY VARICOSE VEINS
Pfyffer M.
Schweiz Med Wochenschr 1998; 128:1772-80
COMMENTARY BY:
PD Dr. med. Eberhard Rabe
President, German Society of Phlebology
Bonn, Germany
The author states that careful personal history and clinical examination is the first
step in the preoperative evaluation of primary varicose veins. All would agree.
The aim of such evaluation in all types of varicose veins is to determine their relationship
to the deep and surrounding superficial venous system. The continuous-wave Doppler
is often adequate to examine the trunk of the greater saphenous vein but color-coded duplex sonography is necessary for evaluation of the deep venous system. The
purpose of such study is the detection of obstruction, the determination of valve
incompetence, the localization of incompetent perforating veins, and the identification
of anatomical variations at the saphenopopliteal junction. Phlebography should be
reserved for those cases producing inconclusive duplex sonography results or if no
duplex is available.
The purpose of the preoperative evaluation is to map out in detail the hemodynamic
and anatomic abnormalities in the groin and popliteal fossa and then to detect the
relevant incompetent perforators. In a diagnostic algorithm, the author gives his
opinion that in cases of telangiectasias, reticular veins, and isolated insufficiency of
the greater saphenous vein, the continuous-wave Doppler examination is sufficient
in most cases. In contrast, duplex sonography should be done in suspected lesser
saphenous vein insufficiency, in search for incompetent perforating veins, in recurrent varicose
veins after prior surgery, and in cases where continuous-wave Doppler investigation
is inconclusive. In the author's hospital, functional investigations such as photoplethysmography are not used in the preoperative evaluation of varicose veins.
COMMENTARY
The question as to how exhaustive the preoperative evaluation of varicose veins should
be has been widely discussed in recent years. There is consensus, however, that
only adequate preoperative diagnosis leads to satisfactory immediate surgical results,
and thus, hopefully, fewer recurrent veins in the long term.
I agree with the author that currently phlebography is no longer mandatory and should
be done only when noninvasive tests are inconclusive or unsatisfactory. Further,
I agree that careful personal history and clinical examination are the first step
and that continuous-wave Doppler is adequate in most cases of telangiectasias and reticular
varicosities. However, the author states that preoperative continuous-wave Doppler
examination is also sufficient in most cases of isolated greater saphenous vein
varicosities. In these cases, I believe that duplex sonography should also be done.
Continuous-wave Doppler is able to detect reflux in the incompetent vein but it gives
no morphologic information as to which of several veins is refluxing. Even if anatomic
variations in the groin are less common than in the popliteal fossa, we also encounter aneurysms in the junction, duplication of the saphenous vein, and variations
in the junction itself. Furthermore, we need duplex information concerning the deep
venous system and its patency. This article is valuable in that it provides an opportunity for discussion of the opinions expressed.
The author also discusses the controversial literature concerning functional investigations
such as photoplethysmography. In my opinion, functional tests are mandatory in
patients with varicose veins and a concomitant history of deep venous thrombosis.
In these cases, functional investigation with photoplethysmography or venous pressure
measurements must prove the benefit of venous surgery to the venous function.
This article clearly shows that invasive investigations are optional and not mandatory
in most patients with primary varicose veins before surgery. ivdfrab3
REOPERATION FOR RECURRENT SAPHENOFEMORAL INCOMPETENCE: A PROSPECTIVE RANDOMIZED TRIAL
USING A REFLECTED FLAP OF PECTINEUS FASCIA
Gibbs PJ, Foy DMA, Darke SG
Eur J Vasc Endovasc Surg 1999; 18:494-98
ABSTRACT AND COMMENTARY BY:
Byung-Boong (B.B.) Lee, MD, PhD, FACS
Surgeon in Chief and Chairman
Department of Surgery
Samsung Medical Center
Seoul, Korea
The object of this study was to prevent re-recurrence of varicose veins at the saphenofemoral
junction level.
Forty limbs with symptomatic recurrent varicose veins were thoroughly evaluated with
duplex scan and phlebography to confirm reflux from the previously well-treated
saphenofemoral junction. They were randomized into those who were to have pectineus
fascial flap coverage of the femoral vein and those who were not. All patients had reexploration
of the groin for re-ligation of the saphenofemoral junction. Additionally, multiple
stab avulsions of superficial varicosities were done and, if the saphenous vein was still present in the thigh, it was removed. Followup assessment was made with
clinical examination and duplex scans. Minimum followup in this group of patients
was 18 months.
On followup, tortuous vessels seen to have bidirectional flow and reflux of > 1 second
duration away from the common femoral vein were considered to have neovascularization.
Seventeen limbs in each group completed the reevaluation. A total of 15 limbs in each group showed re-recurrence arising from the femoral vein confirmed in 11, in
the patch group of 15 limbs, and in the non-patch group of 13/15. There was no statistically
significant difference in clinical re-recurrence of varicosities nor of re-recurrence arising from the common femoral vein between the patch and non-patch group.
Clearly, both groups showed extremely high rates of re-recurrences due to neovascularization.
The authors concluded that the patch of pectineus fascia failed to provide any advantage in preventing re-recurrence.
The authors' observations support the theory of neovascularization in the groin and
suggest that a conservative reexploration be carried out on recurrent varices until
a new technique is proven to reduce the high rate of re-recurrence.
COMMENTARY
Flush ligation of the saphenous vein at the saphenofemoral junction and meticulous
removal of tributaries with or without stripping of the long saphenous vein has
a reported groin recurrence rate of 20 to 30%. The re-recurrence rate reported in
the present study following proper management of the saphenofemoral junction is alarmingly
high (30/34 limbs). This suggests that there is no advantage in reexploration of
recurrent varicose veins at the saphenofemoral junction. It may be that this is
the right time to look again at the traditional concept based on radical management of
the multiple tributaries at the saphenofemoral junction.
In the past, our mentors and ourselves have advocated radical removal of tributaries
to the saphenofemoral junction. It may be that in the future we may have to preserve
venous drainage of the lower abdominal wall instead of removing the tributaries
to the saphenofemoral junction. This is possible by using the new technique of VNUS
radiofrequency closure of the saphenous vein without groin exploration to remove
the tributaries. It will be interesting to learn the natural fate of such a procedure.
vdlee195
RECURRENT VARICES AFTER SURGERY (REVAS): A CONSENSUS DOCUMENT
Perrin MR, Guex JJ, Ruckley CV et al.
Cardiovasc Surg 2000; 8:233-45
ABSTRACT AND COMMENTARY BY:
Ralph G. DePalma, MD
National Director of Surgery
Department of Veteran's Affairs
Washington, DC
Varicose veins following surgery are common, complex, and costly, and frequency of
recurrence ranges between 20 to 80% depending on the definition of the recurrence.
Because of the complexity of recurrence patterns and the many different approaches
to varicose vein treatment, an international consensus meeting was convened to consider
this topic. The group met in Paris in July 1998, and was chaired by Michel Perrin
and J. Jerome Guex.
The consensus defined REVAS as recurrent varicose veins in a lower limb previously
operated upon for varices. Clinical definitions included true recurrences, residual
veins, and new onset of varicose veins as a result of disease progression. The report
is divided into five sections: 1) Epidemiology and socioeconomic consequences, 2)
pathology, 3) clinical diagnosis, 4) vascular laboratory and radiologic investigation,
and 5) methods of treatment. Each topic was considered in detail by a subcommittee.
Review of pertinent literature and input from the entire group provided a consensus
statement insofar as present knowledge and literature would permit.
COMMENTARY
This report is useful for all professionals treating venous disease. The consensus
is unique in that it includes sclerotherapists. Within the report, there are disagreements
about sequences of treatment as well as approaches to treatment. These differences are made clear and the disagreements clearly spelled out. The literature review
is buttressed by 94 critically selected references. These references are useful
and provide an important resource for all workers in this field. Guidelines for
prospective studies complete the consensus report.
Ideally, future studies would include uniform terminology and definitions, also clinical
trials and protocols with enough in common to facilitate data comparison and specific
recommendations. Suggestions include analysis of risk factors for varicose vein recurrences, relationship between recurrence and initial pattern of chronic venous
insufficiency, and methods of primary and secondary intervention, including sclerotherapy.
The consensus endorses the value of routine preoperative duplex scanning prior to
the first operation for varicose veins. By itself, this is an important recommendation.
Study of the relationship between hemodynamics and clinical recurrences are also
suggested. Surprisingly little is known about the prophylactic role of compression
therapy or medical treatment upon recurrence. In short, there is no evidence to
suggest that compression therapy prevents primary venous disease or its recurrence.
Likewise, there is no evidence that medical therapy is useful.
Operative strategies to prevent neovascularization are presented as well as the role
of followup sclerotherapy in the treatment of recurrences. Ultrasound-guided sclerotherapy
versus conventional sclerotherapy are compared. The consensus emphasizes that there are many seemingly simple aspects of venous disease that are unknown or poorly
understood. The document is encyclopedic, and guidelines for future investigations
highlight these problems.
Practical recommendations are included in the sections on examination and vascular
laboratory evaluation. The relative weakness of continuous-wave Doppler examination
is noted. Duplex scanning is emphasized as well as the need for venography to selected surgical targets. Importantly, this group endorses the CEAP classification and
recommends that clinical and disability scores be employed routinely in order to
yield comparative data for scientific purposes. An addition to the CEAP classification
is also recommended for REVAS and includes topographical sites of recurrence, sources
of recurrence, amount of reflux, and the nature of the sources of recurrence.
One of the unique aspects of this document is that the group was directed by an experienced
venous surgeon and a prominent sclerotherapist. While their approach was encyclopedic
and idealistic, the consensus will require further investigation, treatment, classification and research into recurrent veins after venous surgery. The controversies
which demand the attention of all who treat venous disease are outlined. vddep291
THE EFFECT OF PREGNANCY ON THE LOWER LIMB VENOUS SYSTEM OF WOMEN WITH VARICOSE VEINS
Sparey C, Haddad N, Sissons G, Rosser S, de Cossart L
Eur J Vasc Endovasc Surg 1999; 18:294-99
ABSTRACT AND COMMENTARY BY:
Anthony J. Comerota, MD, FACS
Professor of Surgery
Chief, Vascular Surgery
Temple University
Philadelphia, Pennsylvania
This study evaluated the effect of pregnancy on women with preexisting varicose veins.
Eleven women were sequentially evaluated with venous duplex imaging for valvular
incompetence and venous diameter of both the superficial and the deep venous systems.
Unfortunately, the authors used calf-squeeze and Valsalva maneuvers to evaluate reflux
rather than rapid cuff inflation/deflation techniques. Duration of reflux > 0.5
seconds was accepted as abnormal. Patients were studied at 12, 20, 26, 34, and 38
weeks' gestation and then again at 6 weeks' postpartum.
The authors observed a greater dilation in diseased long saphenous veins compared
with veins that were not diseased. Not surprisingly, the diseased veins failed to
return to their 12-week diameter following delivery.
The findings of reflux were inconsistent, and the authors admitted difficulty in quantifying
reflux. Since the numbers of veins demonstrating reflux was small, they combined
the results from the right and left long saphenous veins in order to improve discriminatory ability. No patient had reflux in any vein in the deep venous system.
There was an increase in the velocity of reflux with advancing gestation which peaked
at around 26 weeks and gradually declined toward term and the puerperium. Interestingly, the duration of reflux decreased during pregnancy and increased again following
delivery.
The authors conclude that pregnancy has a significant effect on venous dilation in
lower extremity veins but most significantly in varicose veins. Normal veins return
to normal size following delivery but this was not observed in varicose veins. This
explains progressive deterioration in many such patients. Preexisting reflux becomes
worse during pregnancy and generally returns to pre-pregnancy levels following delivery.
If valvular function was normal in the early stages of pregnancy, it did not appear to deteriorate during pregnancy. The authors suggest that their observations challenge
the belief that pregnancy causes valvular reflux leading to the development of varicose
veins.
COMMENTARY
The authors make interesting observations in a relatively small number of pregnant
patients with primary varicose veins. However, we do not know the degree of dysfunction
of the varicosities prior to pregnancy nor do we know the degree of clinical discomfort. We have all treated women who developed symptomatic superficial venous insufficiency
and varicosities during pregnancy which persist after pregnancy. However, it appears
that none of the patients in this small study group would fall into this category. Changes which occur in the deep venous system with pregnancy are anticipated
based on previous observations. The findings in the superficial system are not surprising
although conclusions cannot be drawn based on the small number of patients.
The authors report that this small subset of patients is part of a much larger study.
I look forward to their overall report on the effects of pregnancy on the physiology
and pathophysiology of the superficial and deep venous systems. vdcom291
A PILOT STUDY COMPARING THE USE OF BELOW-KNEE AND ABOVE-KNEE GRADUATED STOCKINGS IN
PATIENTS WITH SUPERFICIAL VENOUS INCOMPETENCE
Berridge DC, Mercer KG, Thornton C, Weston MJ, Scott DJA
Phlebology 1999; 14:12-16
ABSTRACT AND COMMENTARY BY:
Steven E. Zimmet, MD
Secretary, American College of Phlebology
Austin, Texas
This is a prospective study on the effect of compression stockings on deep venous
flow in 12 patients (20 limbs) with greater saphenous vein incompetence and in 6
controls (12 limbs) with normal duplex findings. Subjects with deep venous incompetence
were excluded.
Femoral and popliteal venous velocities (FVV, PVV) were obtained via Doppler insonation
with subjects supine, in the 10-degree foot-down tilt position, and standing. Subjects
were randomized to below-knee (BK) or above-knee (AK) antiembolism stockings of either 18 or 22 mmHg at the ankle. After a baseline exam, each subject was asked
to wear a below-knee stocking at all times except when in bed. Examination was repeated
immediately after the stocking was applied and again after one week. Stockings were
then replaced with an above-knee type. The exam was repeated immediately after the
stocking was applied, after one week of wear, and immediately after removal. A small
window was cut in the popliteal fossa area of the stocking to facilitate ultrasound
study.
Results in the control group (mean age 32 years) showed that in the standing position,
a statistically significant increase was noted in FVV immediately after fitting
with below-knee stockings. This was not maintained at the one-week measurement.
A significant increase was also seen with the above-knee stocking but this increase was
maintained at one week. A significant decrease in PVV was noted in the supine position
when the below-knee stocking was fitted and after the above-knee stocking was removed. No other statistically significant changes were observed. The level of compression
stocking used in this group, however, is unclear.
Mean age in the venous group was 48 years (18 mmHg) and 47 years (22 mmHg). The below-knee
stocking had no significant effect on FVV or PVV in subjects with venous disease
with regard to the compression level. There were no significant changes for subjects in the standing position regardless of compression level or type. Above-knee
stockings (18 mmHg) produced a significant increase in PVV in the supine position
after fitting and after one week of wear. Above-knee stockings (22 mmHg) yielded
a significant increase in PVV and FVV in the supine position and in the 10-degree foot-down
position immediately after fitting. The increase in FVV was maintained in the 10-degree
foot-down position at the one-week examination. PVV increases were maintained in the supine and ten-degree foot-down position. No other significant changes were
observed.
The authors suggest that their pilot study indicates that higher compression stockings
and above-knee stockings yield more significant increases to the deep venous circulation
than do lower compression and below-knee stockings. They note that the mechanism of antithrombosis by compression remains unclear but that enhanced deep venous velocities
may reduce deep vein caliber and/or increase redistribution of venous return from
the superficial to the deep venous system, thereby increasing deep venous velocities. They note that increased velocities were maintained and velocities reduced only
in certain positions. They note that below-knee stockings may be as efficacious
as above-knee stockings clinically. They were unclear, however, as to how important
deep venous velocity increases are with regard to the thromboprophylactic effects of compression
hose.
COMMENTARY
Compression therapy is a cornerstone in the treatment of venous disease, ranging
from post sclerotherapy to venous ulcers to venous thrombosis prophylaxis. Despite
the fact that compression has been used since the time of Hippocrates, there is still
much to learn.
While it is well accepted that compression stockings reduce the risk of postoperative
venous thrombosis, it is unclear how this is achieved. There is data suggesting
that postoperative DVT is associated with venodilatation and that such venodilatation
may result in intimal tears. There is also data showing that compression can inhibit
coagulation pathways. Thus it may be that compression effects one or more of Virchow
triad: 1) Venous stasis, 2) hypercoagulability, or 3) blood vessel wall injury.
In addition, there may be other relevant factors as yet unidentified.
This is an interesting pilot study aimed at elucidating the effects of above-knee
and below-knee compression stockings (two different compression levels) on the deep
venous velocities in normal controls and in patients with incompetent greater saphenous
veins. The results are a step toward increasing our understanding of the physiological
effect of compression stockings in normal and abnormal venous systems. This study
suggests that 22 mmHg and above-knee compression stockings yield more significant
increases in deep venous velocities than do 18 mmHg and below-knee stockings. However,
the findings are a bit confusing and the clinical significance of these findings
is yet to be determined. Further, the mechanism by which thrombosis is prevented
remains unclear.
The mysteries of the effects of compression will be unraveled only by carefully designed
studies with an adequate number of subjects. Further studies are needed to clarify
the physiological effect of compression and the optimal use of compression in different clinical situations. vdzim291
COLOR DUPLEX-GUIDED SCLEROTHERAPY FOR THE TREATMENT OF VENOUS MALFORMATIONS
Yamaki T, Nozaki M, Sasaki K
Dermatol Surg 2000; 26:323-28
ABSTRACT AND COMMENTARY BY:
David M. Duffy, MD
Torrance, California
Although surgical extirpation is the standard method for the treatment of vascular
malformations, this procedure often leads to loss of motor function, nerve damage,
and massive bleeding if the excision is extensive. Sclerotherapy is an alternative
method of treatment for vascular malformations.
This study assessed the effect of color duplex ultrasound-guided sclerotherapy on
venous malformations and the coagulability induced by sclerosing solutions. Percutaneous
sclerotherapy by direct puncture under duplex ultrasound guidance was performed on
28 patients with venous malformations. Intravenous catheters were inserted into
duplex ultrasound-confirmed venous spaces. Fine plastic tubing filled with normal
saline was attached to the needle. When the needle tip was observed to pierce the
vein wall, aspiration of blood confirmed its intraluminal position. A mean volume of 3.6
ml of 3% polidocanol was injected. Subfascial ligation of the lateral marginal
venous collector was performed in patients with Klippel-Trenaunay syndrome. Thrombin-antithrombin III and D-dimer were measured preoperatively and on postop days 1 and 5.
Color duplex-guided sclerotherapy was effective in 82% of patients. This procedure
prevented inadvertent intraarterial injection. Although patients with venous malformations
showed greater coagulability, no serious thrombotic sequelae were noted.
COMMENTARY
This study is important for several reasons. Venous malformations of various kinds,
because of their size and location, present almost insurmountable obstacles to precise
and effective treatment. Surgery, embolization, the administration of interferon,
and a variety of other approaches have been tried. None of these is absolutely safe
nor do any offer the simplicity of this adaptation of color duplex guidance. Once
again, sclerotherapy is proving to be an extremely durable and versatile treatment
modality which is highly amenable to technological innovations undreamed of a century
ago.
Some findings reported in this study are intriguing. Pain was a common complication;
a great rarity in sclerotherapy, particularly with polidocanol. Also unusual is
early recanalization which occurred in 28% of patients (sometimes as early as four
weeks). Both suggest a response highly specific for venous malformations and unusual for
varicose veins. Polidocanol at a volume of 3% would also raise eyebrows among those
who use this agent. Nausea and vomiting commonly accompany the use of more than
6 cc of 3% polidocanol in patients weighing less than 50 kg. Hemoglobulinuria also occurred.
One must wonder how often this might occur following treatment of large varicose
veins.
In conclusion, this is an important study synthesizing new and old technologies and
producing a promising therapeutic modality for a very difficult problem. vdduf291
INTRAVENOUS LEIOMYOMATOSIS WITH CARDIAC EXTENSION: TUMOR THROMBECTOMY THROUGH AN
ABDOMINAL APPROACH
Harris LM, Karakousis CP
J Vasc Surg 2000; 31:1046-51
ABSTRACT AND COMMENTARY BY:
Richard E. Blackwell, Ph.D., M.D.
Professor of Obstetrics, Gynecology, and Surgery
University of Alabama at Birmingham
Birmingham, Alabama
This case report discusses intravenous leiomyomatosis, a rare benign disease first
described in 1896. The first case report of leiomyomatosis extending from pelvic
veins to the heart was reported in 1907.
A 48-year-old female presented with a six-month history of exertional dyspnea, recurrent
palpitations, and dizziness. She underwent a hysterectomy for benign uterine leiomyoma
31/2 years prior to admission. An electrocardiogram and echocardiogram performed six
months prior to admission were normal. She was noted to have hypertension, and a
renal ultrasound revealed a mass in the inferior vena cava (IVC). CT scan and transesophageal echocardiogram showed that the mass extended from the renal veins to the right
atrium and ventricle. A large, serpiginous mass extended into the ventricle with
no discrete point of attachment. Venography revealed an intraluminal defect from
L2 to the atrium without occlusion of the IVC. The mass appeared to be attached at the level
of the renal veins.
Through an anterolateral thoracoabdominal incision, the patient underwent mobilization
of the ascending colon by excising the lateral peritoneal attachments and the duodenum
(Kocher maneuver). The right ovarian vein was dilated and filled with tumor that was in continuity with the IVC mass. The IVC was mobilized by ligation of lumbar
veins. Vascular control was obtained inferiorly below the level of the tumor and
superiorly below the renal veins with a vessel loop encircling the tumor-filled
vena cava. The IVC was mobilized and the right ovary and right vein excised and blocked.
An elliptical incision was made at the junction of the ovarian vein into the IVC at
which point the tumor was found to be adherent. The tumor was gently delivered through
the venotomy with transesophageal guidance easily. Blood loss was 100 cc due to
cephalad control with a vessel loop. A small additional segment of vena cava was debrided
and excised to normal-appearing tissue. The vena cava was then repaired primarily.
Gross pathology of the lesion showed it to be 31 cm in length with varying widths.
Microscopic pathology confirmed intravenous leiomyomatosis. Histopathology was
identical to a tumor excised 31/2 years earlier.
COMMENTARY
Intravenous leiomyomatosis is a rare, well-differentiated, benign tumor that usually
presents with venous obstruction or cardiac irritability. The lesions are confined
to vascular channels and are exclusively reported in women, many of whom have had
previous hysterectomy for uterine leiomyoma.
Uterine fibroids are extremely common in the United States in women harboring leiomyoma
(one in 4 to 5). They tend to appear in the reproductive years (fourth or fifth
decade) although lesions have been reported in adolescents. They can persist in
the postmenopausal years and occasionally undergo sarcomatous change.
Uterine leiomyoma is responsible for one-third of all gynecologic admissions. It
has been estimated that 60% of all laparotomies performed on women involve fibroids.
It is of interest that uterine fibroids occur 3 to 9 times more often in blacks
than in whites yet intravenous leiomyomatosis is most common in Caucasian women in their
fifth decade with previous pregnancies. The authors note that of the 33 case reports
in the literature, mean age was 48 years and 64% of the women had had hysterectomy
six months to 20 years prior to presentation of the intravenous portion of the tumor.
One point hidden in this review is ovarian function. If one considers that the mean
age of menopause in the United States is 51.4 years, then 11/33 case reports would
fit this criteria. However, 22 women appeared to be premenopausal or perimenopausal.
This may be significant in that estrogen has been shown to promote tumor growth, progesterone
is a known mitogenic agent, and growth hormone synergizes with estrogen in inducing
uterine weight gain in animal model systems.
Another issue not addressed in the review is body weight. There is a direct correlation
of the ability of androgen precursors to be metabolized to weak estrogens by aromatase.
Estrogen replacement therapy must also be considered. A well-known therapy for endometrosis
is the inhibition of gonadotropin and subsequent estradiol production with GnRH
analogs such as leuprolide acetate. This therapy will result in a 47% reduction in tumor size in women with fibroids. Such therapy is often used to distinguish
benign from malignant tumors although there are several anecdotal cases where malignancies
have appeared to decrease in size with GnRH analog therapy. An interesting speculation is whether intravenous leiomyomatosis would respond in a similar manner. In
addition, if a postmenopausal patient were taking estrogen replacement therapy, discontinuation
of the hormone might result in regression of the tumor. This could be followed by transesophageal echocardiography. This trial might further simplify tumor
removal and differential diagnosis.
At least in the case of uterine fibroids, maximum response seems to be reached within
two months of suppressive therapy with Lupron 3.75 mg. This is generally continued
up to six months and discontinued because of reversible osteopenia. Sometimes this
osteopenia can be countered with calcium 1000 mg, supplemental vitamin D, and/or Fosamax.
vdbla291