Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3727_Библиотеки_им_академика_М_И_Перельмана
.pdf
https://t.me/med1917
CHAPTER
40
https://t.me/med1917
Open surgical treatment for
superficial truncal incompetence
Michael C. Dalsing
40.1 INTRODUCTION
A patient with an incompetent saphenous vein may be
asymptomatic or present with advanced disease. The
incompetent vein may be an isolated nding or be associated with perforator and/or deep venous disease. It is
a common nding in the United States, with over a third
of the population having some clinical manifestation of
underlying venous pathology. In the past, the open removal
of the offending incompetent saphenous system constituted
the primary method to deal with supercial truncal insufciency, but less invasive options have usurped its role,
demoting it to a less prominent but still useful option in
specic circumstances.
40.2 PERTINENT ANATOMY
The variability of lower extremity venous anatomy adds
complexity to the operation and is discussed extensively in
a prior chapter with excellent illustrations. However, some
veins and associated nerve anatomy pertinent to the open
operation deserve emphasis.
The saphenofemoral junction (SFJ) is an important structure visualized during high ligation of the great
saphenous vein (GSV), and it must be properly recognized
when dissected to avoid injury to adjacent deep veins.
There are many tributaries that join the GSV near the
SFJ in the groin. The four most common are the anterior
accessory GSV, the external pudendal vein, the supercial
circumex iliac vein, and the supercial epigastric vein,
but one can also encounter the thigh posterior accessory
GSV (although it can join lower in the medial thigh) and
occasionally the posterior and anterior thigh circumex
veins. One or more of these tributaries can join the common femoral vein directly. One anatomic dissection study
found that there are at least four “common variations” as
these veins join the GSV, and knowledge of this variability
can provide clarity during open dissection.
cial external pudendal artery is a landmark that helps to
identify the termination of the GSV as it enters the common femoral vein but remember that it can lie anterior
or posterior to the GSV. Protection or denitive ligation
and division of this artery is required to prevent unwanted
bleeding during or after the procedure.
1
The super-
The GSV is doubled in the calf in 25% of the population
and in the thigh in about 8%, a fact to remember so that
denitive removal of the incompetent vein is accomplished.
The posterior accessory GSV is a common tributary that
begins posterior to the medial malleolus, ascending on the
posteromedial aspect of the calf, and joins the GSV distal
to the knee. It has direct connection to the deep calf veins
via at least three prominent calf posterior perforating veins,
and insufciency in this vein may be an important component of a patient’s symptoms. Recognize that the anterior
accessory GSV in the upper thigh can course deeply in the
subcutaneous tissue yet supercial to the muscular fascia,
much like the GSV but more anteriorly. This is important
since anterior accessory GSV insufciency may be the cause
of symptoms rather than GSV insufciency.
As a rule, the saphenous nerve lies adjacent to the GSV
below the knee but separate from it above the knee. In
about 12% of cases, the nerve is directly next to the vein at
the knee, so an injury risk still exists. Below the knee, the
nerve lies in direct proximity to the GSV with a few exceptions (2 of 60 dissections).
the knee is one reason not to treat into this area. The nerve
branching is forked toward the foot, so pulling the vein
from the leg in an upward direction is more likely to engage
the nerve and disrupt it, while distal removal of the vein
is less likely to do so. This fact provides some support for
distal vein extraction during open operation.
data did not demonstrate any signicant clinical impact of
saphenous nerve dysfunction after extensive saphenectomy
below the knee, but our patient population may have had
more advanced disease than others and the ndings are not
generalizable.
removal can result in numbness and/or paresthesia of the
inside arch of the foot, inside of the ankle, inner calf, and
lower knee.
The saphenopopliteal junction (SPJ) lies deep to the
fascia that encompasses the calf muscles. Although the SPJ
may be absent or rudimentary, when present it generally
joins the popliteal vein 4 cm at or above the knee crease
(somewhat higher in 25% of cases and lower in 1%).
a minority of cases, it can terminate in the upper calf by
joining the gastrocnemius veins or GSV, or it can proceed
in a more cephalad direction to join the femoral vein or
connect to the GSV by way of the intersaphenous vein.
Knowing that the SSV runs in the subcutaneous soft tissues
5
Damage to the saphenous nerve during GSV
3
This close association below
4
Our personal
6
In
2
DOI: 10.1201/9781003328971-45
405405
406 Chapter 40 Open surgical treatment for superficial truncal incompetence
https://t.me/med1917
in the lower two-thirds of the leg and then dives deep into
the fascia with impressive variability is critical to avoiding unnecessary and potentially harmful dissections deep
to the fascia. Eliminating the deep dissection in favor of
a more supercial ligation is advocated, since no data are
available suggesting that ush ligation on the popliteal vein
results in a better outcome.
7,8
This variability is one of the
reasons the Society for Vascular Surgery/American Venous
Forum (SVS/AVF) guidelines committee recommends intraoperative duplex imaging as the safest way to identify the
SSV during an operation.
The posterior tibial nerve most commonly lies lateral
to the SSV but may twist around the SSV near the SPJ.
7
9
Damage to the posterior tibial nerve can result in loss of
plantar exion, loss of exion of the toes, and weakened
inversion of the foot. The peroneal nerve lies lateral to
the SPJ but, like the posterior tibial nerve, can be at risk
during subfascial dissection.
9,10
Damage to the peroneal
nerve can result in the inability to move the foot, ex
the toes or ankle, feel the shin or top of the foot, and/or
experience pain in the lower leg and/or foot. The risks of
nerve injury associated with deep fascial dissection of the
SVV especially near the popliteal vein is one reason for
eliminating deep dissection in the popliteal space during
SSV removal. In the nal analysis, extensive subfascial
dissection to expose the popliteal vein and perform a high
ligation is unwarranted.
The ultrasonic relationship of the sural nerve to the
SSV has been extensively studied by Ricci and colleagues.
11
It lies close to the SSV in the distal leg, with a more distant relationship in the mid to upper calf, where it divides
into the medial and lateral sural cutaneous nerves. Where
the gastrocnemius muscles become prominent in the mid
to upper calf, the sural nerve has often, but not always,
divided and separated from the SSV making it less prone
to injury.
centimeters) appears the safest area in which to remove
the SSV to minimize sural nerve injury.
12
Overall, the proximal one-third of the leg (~10
9
It does not share
a perivenous fascia with the vein, as occurs in the case of
the GSV and saphenous nerve. Damage to the sural nerve
can result in numbness or paresthesia of the outer side of
the foot, outer heel, ankle, and back of the leg below the
knee.
40.3 DIAGNOSIS AND INDICATIONS
FOR INTERVENTION
The initial indication that an incompetent saphenous system exists is based on patient symptoms: pain, swelling,
heaviness, itching, skin discoloration, cramps, ulcers, and
even overt bleeding from supercial veins resulting from
minor trauma. The psychological ramications related
to the unsightly appearance of varicose veins or other
associated signs such as hyperpigmentation or ulceration
are important to the patient’s perception of disease severity and ultimately to interventional success. A detailed
history and physical examination are essential to establishing the diagnosis so that the CEAP clinical classication can be documented as recommended by SVS/AVF
7,13
guidelines.
One should make special note in female
patients to rule out vulvar varicosities, which are easily missed due to patient and/or physician reluctance to
complete a proper examination. Physical examination
can suggest SFJ or SPJ as well as perforator vein insufciency, but it requires venous duplex imaging to conrm
the clinical impression.
The critical need for venous duplex imaging prior to
any saphenous intervention has become evident. A systematic review found that duplex imaging changed management over that indicated by handheld Doppler study
in 10–25% of cases.
1) recommendation by the SVS/AFV guidelines for duplex
ultrasound scanning as the diagnostic test of choice to
evaluate venous reux.
14
These data support a strong (grade
13
The lower extremity venous
duplex facilitates procedure planning and appropriate
care. It allows completion of the CEAP classication in
terms of etiology, anatomic distribution, and pathophysiology. A detailed description of venous duplex imaging
is contained in a prior chapter of this text. The addition
of other diagnostic modalities is generally not required;
however, based on unique patient conditions, one might
consider magnetic resonance venography, computed
tomographic venography, standard venography, or intravenous ultrasonography.
The patient’s symptoms determine the need for intervention. Diagnostic testing, specically venous duplex
imaging, conrms venous pathology that may be the
underlying cause of the patient’s complaints. Using the
CEAP classication to dene the patient’s venous condition
in detail provides a basis for proper intervention selection.
To help quantify the patient’s current clinical state helps
the surgeon to standardize care and to measure the result
of an intervention; thus, the patient’s clinical severity score
is recorded. The SVS Venous Clinical Severity Score is a
physician-generated measurement tool that incorporates
patient-reported, physician-observational, and clinical
measurements in one scoring system and has been recommended as the best estimate of symptom relief by the SVS/
AVF guidelines.
7
A generic quality-of-life (QOL) measurement tool allows comparison with other disease states and
a general estimate of the ill effect of both the disease state
and, ultimately, the effect of treatment. Several disease-specic QOL scoring systems are available, with some more
heavily weighted to evaluating early-stage disease (varicose
veins), while others are more appropriate for characterizing patients with more advanced disease.
7
The general
health of the patient must also be evaluated to allow a
realistic estimate of the risk and potential benet of any
intervention. It is the surgeon’s duty to explain the time-related risks and benets of any intervention and potential
alternatives. Ultimately, however, the patient will have to
decide whether the symptoms he or she is experiencing are
sufciently severe to warrant the risk of open venous surgery. The current guidelines for the care of patients with
supercial truncal reux clearly states that “symptomatic”
patients with “axial reux” “who are candidates for intervention” are recommended for “supercial venous intervention.” Symptoms drive treatment, and delays to “try”
compression stockings are not warranted based on current
13
data.
40.7 Technical aspects of open superficial truncal surgery 407
https://t.me/med1917
40.4 ABSOLUTE\RELATIVE
CONTRAINDICATIONS
TO OPEN OPERATION
The lack of a patent vein into which the stripping device
can be advanced is a contraindication to that procedural
component. The complete lack of a deep system capable of
draining the lower leg of venous blood is a contraindication
to saphenous vein removal. Although thought to be indicative of many of those with prior deep venous occlusive
disease, the reality is that most patients with deep disease
have sufcient reserve to allow saphenous removal when
needed.
must be recognized, or healing may be an issue. If concerns
for healing based on clinical and hemodynamic parameters
exist, a detailed investigation and elimination of arterial
disease as a confounding variable is required. This is especially concerning in patients with venous ulceration and,
in fact, an arterial pulse examination and measurement of
ankle-brachial index is recommended in all such patients.
In addition, associated medical conditions which might
place the patient at higher risk of anesthetic complications
(cardiac, pulmonary, endocrine, renal disease), increased
bleeding or thrombotic events (uncorrectable coagulopathy, thrombophilias, cancer, immobility), or infection
(open wounds, systemic infection) must be appropriately
considered and controlled for optimal results. Multiple
prior groin explorations are a relative contraindication to
open surgery due to a higher risk of complications, which
include lymphatic leakage and major vascular injury.
retrospective study of 128 groin re-explorations for recurrent varicose veins, there was a 40% rate of wound complications.
scarring are important considerations.
15,16
Severe peripheral vascular occlusive disease
18
In a
19
Previous groin infection and radiation-induced
The decision to recommend minimally invasive endovenous ofce procedures over contemporary (High
Ligation and Stripping) HL&S in this guideline was
made based on differences in early outcomes, including periprocedural pain and discomfort, need for
analgesia medications, early minor adverse events,
early QoL measures and earlier return to regular
activities.
13
17
for endovenous treatment are vein tortuosity, aneurysmal
dilation, and adherence to the overlying skin, which can be
overcome with an open approach.
mandate an open operation.
There may be situations in which recurrence post ablation is due to saphenofemoral or saphenopopliteal reux
or neovascularization, which will require surgical exploration to treat.
may be needed if arteriovenous stulae develop post ablation that are symptomatic, while asymptomatic stula may
resolve spontaneously.
HL&S is recommended when endovenous ablation is
not available or the venous anatomy precludes endovenous treatment (1, B).
the incompetent anterior and posterior accessary GSV (2,
13
All other ablation options, including HL&S, are sug-
C).
gested over ultrasound-guided foam sclerotherapy (UGFS)
due to reduced closure rates and lower QOL parameters at
5 years, but the data are not robust (2, C).
21
Furthermore, open surgical intervention
22
13
A similar suggestion is made for
13
Patient preference may
13
40.6 GUIDELINE-DIRECTED
OPERATIVE TECHNIQUE
Lessons learned over many years have resulted in a less
extensive operative removal of truncal veins while having
little effect on the ultimate outcome. The entire GSV vein
removed from groin to ankle following an extensive groin
dissection is no longer advocated due to potential nerve
injury and an increased incidence of groin neovascularization. Likewise, an aggressive dissection and high ligation
of the SSV with full SSV removal from knee to ankle is
no longer advocated, again to minimize nerve injury while
having little effect on ultimate outcome. The most detailed
recommendations come from the 2011 SVS/AVF guidelines without signicant comment in the newest one.
essence, HL&S of the GSV to the knee is suggested, while
high ligation of the SSV at the knee crease but 3–5 centimeters distal to the SPJ and removal to mid-calf is suggested. The guidelines do prefer invagination stripping of
the vein. Intraoperative duplex imaging at critical junctions
or when questions arise during surgery is considered best
practice.
7,13
7
In
40
The same is true for the removal of the anterior accessory
or posterior accessory GSV.
40.5 OPEN OPERATION PREFERRED
There are certain conditions in which open surgery may
be the preferred method of removing the pathologic
saphenous vein. In some locations, the expense of ablation devices is prohibitive, and therefore, open surgery
provides a viable option.
intervention by third-party payers may be an issue in some
locales.
er-diameter, incompetent veins coursing within the saphenous canal. The anatomic variations that pose challenges
13
Catheter-based therapy is ideal for straight, small-
20
Payment for the endovascular
40.7 TECHNICAL ASPECTS OF
OPEN SUPERFICIAL TRUNCAL
SURGERY
40.7.1 Anesthesia
Some patients opt for general or regional anesthesia (spinal, epidural, femoral nerve block with supplemental local)
but more commonly for tumescent anesthesia.
interventionalists also use an antianxiety agent for patient
comfort. An RCT studying using one dose of perioperative
antibiotic prophylaxis demonstrated a signicant decrease
in the risk of wound-related complications.
perioperative deep venous thrombosis (DVT) prophylaxis
13,23
Some
24
The issue of
408 Chapter 40 Open surgical treatment for superficial truncal incompetence
https://t.me/med1917
is best managed by early and frequent postoperative ambulation in patients who are free of associated risk factors.
In those patients with additional thromboembolic risk
factors, such as thrombophilia, prior history of DVT or
thrombophlebitis, and/or obesity, the recommendation is
prophylaxis with low-molecular-weight heparin, low-dose
unfractionated heparin, or fondaparinux.
7
40.7.2 Operative procedure
40.7.2.1 Patient positioning
40.7.2.1.1 Great saphenous vein surgery
The patient is positioned in the supine position, and the
entire leg to umbilicus is prepped and draped in routine
sterile fashion to expose the entire leg and foot to the umbilicus. The initial dissection to expose the groin anatomy
may be performed with the patient at or slightly elevated.
However, for the stripping of the vein from the body, the
patient should be positioned in Trendelenburg position to
minimize vein distention and blood loss.
40.7.2.1.2 Small saphenous vein surgery
The patient is placed in the prone position for a bilateral
procedure. A prone position is also quite acceptable for a
unilateral procedure, but a semi-lateral position with the
leg to be operated on facing upward on the operative eld
would sufce. Duplex imaging has either dened the SSV’s
association with the deep and supercial veins preoperatively or should be accomplished intraoperatively. Flexion
of the knee relaxes the tight popliteal fascia for easier exposure. The initial dissection to expose the venous anatomy
may be performed with the patient at or slightly elevated.
However, for the stripping of the vein from the body, the
patient should be positioned in Trendelenburg position to
minimize vein distention and blood loss.
40.7.2.2 Eliminate proximal reflux: high ligation
and division
40.7.2.2.1 Saphenofemoral junction (SFV)
A transverse incision is made in the skin, 1–2 cm below
the inguinal skin crease or somewhat higher in the obese
patient. This approach facilitates easy closure at the completion of the operation via an incision that is somewhat
self-approximating (Figure 40.1A1, see arrow). The incision begins just medial to the femoral artery pulse and
extends 3–5 cm medial, which is centered over the proximal saphenous vein and common femoral vein junction.
Using cephalad and caudal retraction, the GSV and its
branches, as well as the anterior surface of the common
femoral vein, are visualized. The visualized major branches
of the GSV are ligated. In the past, ligations were past the
secondary branching, but such extensive dissection is no
longer standard and was never data driven.
taken to visualize the supercial external pudendal artery
and either protect it from harm or formally ligate and
divide it to prevent undesirable arterial bleeding preoperatively or postoperatively. This artery helps to mark the
termination of the GSV and can lie anterior or posterior
to it as it enters the common femoral vein (Figure 40.1A2,
7
Care must be
see arrow). If not accomplished during prior dissection, the
anterior surface of the common femoral vein is formally
visualized so as not to injure it during GSV ligation and to
ensure that the vein to be stripped is not the femoral vein.
At this stage, the GSV at the knee can be exposed via a
transverse incision centered over the vein (Figure 40.1B1).
Through this incision, the stripping device can be placed
from caudal to cephalad and will exit the GSV at the groin
incision. Except in obese patients, the rather rigid stripper
can be palpated along the length of the GSV within the
subcutaneous compartment.
ing can conrm the subcutaneous location of the stripping
device within the GSV. When satised that the anatomy
has been correctly dened and dissected, the GSV is ligated
ush on the common femoral vein with a double ligature
or oversewn with a 5-0 nonabsorbable running suture (Figure 40.1A2) after securing it to the stripping device with
a large silk tie to allow division of the GSV. Alternatively,
some surgeons ligate the GSV on the common femoral vein,
transect it, and pass the stripping device from cephalad to
caudal. Either way, the GSV is divided to disconnect it from
the deep system prior to stripping.
Alternatively, duplex imag-
40.7.2.2.2 Saphenopopliteal junction (SPJ)
In current practice, a 2- to 4-cm transverse incision is made
directly over the duplex marked SPJ. If duplex is not available, this incision is generally placed just below the knee
crease and transverse, with the goal of nding the SSV and
following it cephalad to the desired point of ligation. The
soft tissue is dissected in the transverse direction and then
the deep fascia is incised in the longitudinal direction if
ush ligation is the goal (Figure 40.2A1). Standard anatomy has the SSV in a subfascial rather than subcutaneous
location for this dissection. Historically, the SSV is dissected
to allow all tributaries to be ligated after clearly dening the popliteal vein (Figure 40.2A2). The tibial nerves
pass near the popliteal vein, and both structures must be
identied and protected from harm. Ligation of the SSV
ush on the popliteal vein can be accomplished before or
after placement of the vein-stripping device via the distal
vein. After stripper placement, the SSV is ligated to it and
the vein divided. If retrograde placement of the stripping
device is planned, then ush ligation on the popliteal vein
is performed and the distal saphenous vein can be opened
for stripper placement. Note that the subfascial component
of the dissection and direct division off the popliteal vein
is not a part of the current open operation of ligation and
division of the SSV. The dissection is limited to the subcutaneous or just subfascial SSV with division and ligation
in this location. In one article, this is described as the area
where the SSV makes about a 45-degree angle into the subfascial plane as seen by duplex imaging.
8
40.7.2.3 Removal of the incompetent vein: axial
stripping
40.7.2.3.1 Great saphenous vein
In most cases, GSV incompetence is present at the junction
and into the vein proper, requiring removal of the pathologic vein for long-term success. Removal of the vein to
the knee is acceptable with no preoperative reux noted
40.7 Technical aspects of open superficial truncal surgery
https://t.me/med1917
409
40
40.1 The supine patient’s general anatomy is demonstrated in the long leg drawing. The top inserts demonstrate (A1) the proximal
GSV with branches, with particular emphasis on the supercial external pudendal artery (arrow), which may be located above or
below the insertion of the GSV into the common femoral vein. Lack of attention to the artery can result in unwanted bleeding. (A2)
depicts ligation and division of all branches with ush ligation of the GSV on the common femoral vein and a Codman-type stripping device lying within the vein distally. (B1) depicts a small incision centered over the GSV just at the knee to expose and control
the vein. The saphenous nerve may lie close to the vein in this area and should be completely dissected away from the vein. (B2)
demonstrates the stripping passing upward to exit the GSV in the groin area (A2); in addition, a second stripper exits the distal vein
for removal of the calf GSV if deemed appropriate, but generally is not done in current practice. In this depiction, a small head is
attached to the distal stripper, but often the vein is simply tied to the small bullet on the end of the stripper. The vein is divided before
stripping is undertaken. If vein removal does not include the calf component, the distal vein would be ligated and divided. (C1) is the
artist’s depiction of a small incision centered over the ankle GSV to expose and control it. Note the proximity of saphenous nerve to
vein (arrow); the nerve is dissected and pushed away from the vein as much as possible. (C2) shows the distal vein ligated with the
proximal stripper in place and ligated to the vein. Before stripping, the vein is divided.
410 Chapter 40 Open surgical treatment for superficial truncal incompetence
https://t.me/med1917
40.2 This artist’s depiction shows the patient in prone position with the general location of the SSV beginning at the latter malleolus
and terminating near the knee crease (incision proximal). (A1) depicts the saphenopopliteal junction, which lies deep to the investing
fascia rather than in the subcutaneous tissue in which the SSV lies in the more distal leg. Take special care to protect the tibial nerves
(arrow). It should also be understood that the intersaphenous vein may be a major proximal extension of the SSV. (A2) shows the SSV
ligated ush with the popliteal vein and a PIN stripper has been placed downward in the open distal SSV. (A3) is a magnied view of
the PIN stripper ligated to the SSV via a “oating knot,” and the invagination process has begun. Please note that in current practice
the SSV is dissected about 3 cm below the popliteal insertion as it turns into the deep fascia to diminish the chance of nerve injury. B
demonstrates the general length of SSV removed in the upper to mid-upper calf (about 10 centimeters) as the pin stripper is pushed
to the skin level, cut down to expose allowing SSV stripping. (C1) demonstrates the proximally placed PIN stripper being forcefully
pushed through the vein wall and subcutaneous tissues to indent the skin at the ankle (older standard). An 11 blade or similar small
knife punctures the skin allowing the distal stripper to egress. (C2) shows the distal PIN stripper exposed; it will be grasped and
pulled downward, invaginating the vein from the body.
40.7 Technical aspects of open superficial truncal surgery
https://t.me/med1917
411
into the calf. But even with distal reux, current practice
prefers removal only to the knee to minimized saphenous
nerve injury.
7
If stripping to the knee is planned, a 1- to 2-cm-long
transverse incision is located at or just below the knee centered over the GSV to allow easy exposure (Figure 40.1B1).
The vein is dissected from surrounding tissue with sufcient length to allow silk ties to control bleeding from the
vein proximally and distally and to allow division. Vein
stripper devices consist of a rather stiff long wire with or
without the ability to attach a “head” of various sizes to aid
in vein removal. The various strippers have specic modications with names such as Codman, Myers, and Varady
and are available from a variety of manufacturers. What is
being used as a stripping device is entering the hybrid era
of management, and the use of an interventional sheath
with the vein tied to it has been reported.
25
The distal GSV
at the knee exposure is suture ligated to seal the distal vein
and the cephalad vein opened to allow placement of the
stripping device into the vein and advanced within the GSV
and eventually out of the vein at the groin incision. We like
to palpate the stripper within the subcutaneous saphenous
compartment to provide some tactile impression that it lies
in the correct subcutaneous position. We do this by grasping both ends of the stripping device and lifting upward to
tether or bowstring it, allowing improved palpation within
the subcutaneous tissue. Alternatively, duplex imaging can
conrm proper location within the subcutaneous tunnel.
The vein in the knee area is divided to allow the vein to ultimately be pulled from the body in a downward direction.
In the groin, the saphenous is ush ligated on the common
femoral vein, the distal vein is ligated to the stripper, and
the vein transected. When using one of the stripping devices
(e.g., the Codman-style device), variously sized heads may
be placed on the stripper to aid in complete vein removal,
but we generally choose the smallest available, or none, to
minimize the mass of tissue required to exit the distal incision. Others perform invagination stripping with excellent
results, a method which is described in more detail in the
section on SSV stripping. Some nuanced technical aspects
of the stripping operation have been recently presented by
Iafrati and O’Donnell.
26
If the below-knee GSV demonstrates signicant reux
on preoperative imaging and is deemed sufciently significant to warrant stripping at the same setting, the GSV at
the ankle is exposed via a 1-cm-long transverse incision
positioned 1 cm anteriorly and medially to the medial
malleolus (Figure 40.1C1). The subcutaneous tissue is
dissected from around the vein to separate the saphenous
vein from the nerve, if present, and to allow a cephalad
and caudal silk ligature to be placed around the vein. The
caudal end of the vein is ligated and, with gentle traction
on the cephalad suture, the anterior surface of the vein is
opened, through which a stripping device can be advanced
to the calf incision. The vein is ligated to the stripper at
the ankle and the vein transected. Rather than ligating the
saphenous vein at the calf incision as previously described,
the vein is left open, and the stripper is allowed to exit the
vein, which is then ligated to it with a silk tie. We generally
do not add a stripper head to the device in this location
since the small obturator located on the device is generally sufciently large to prevent the vein from pulling off it
during extraction. The saphenous vein in the calf is divided
to allow the vein to be removed from the body. Rather than
stripping the entire saphenous vein with its accumulated
bulk through the ankle incision, which might tend to drag
the saphenous nerve with it, we have employed this two-incision technique for complete vein excision.
With the saphenous vein secured to the stripping device
and transected proximally and distally to allow extraction,
the patient is placed in a steep Trendelenburg position.
The proximal vein is extracted rst. The distal end of the
stripper lying within the proximal vein is grasped rmly,
and with a constant and determined distal pull, the vein
is removed from the body. After proximal pressure has
secured acceptable hemostasis, the distal vein is removed in
a similar fashion, with external pressure held for improved
hemostasis. The use of tumescent anesthesia with a vasoconstricting agent helps to decrease bleeding in the tunnel
when used.
A technical modication that allows extraction of the
GSV from the body without a distal incision involves the
use of a reusable 3.5-mm-diameter cryoprobe, which can
be placed from proximal standard saphenous exposure
into the distal vein, stopping about 5 cm below the knee.
When in place, liquid nitrous oxide is injected into the distal probe to freeze the probe tip to the vein at −85°C. The
vein is then invaginated on itself by pulling the cryoprobe
from distal to proximal, with the vein now trailing and
being pulled from its compartmental bed. The proximal
vein was divided from its attachment, with the common
femoral vein allowing removal. Compression is applied and
the proximal wound closed.
27–29
Its use outside of Europe
appears to be minimal, but it might have some utility in situations where a reusable probe addresses a cost-efciency
29
need.
40.7.2.3.2 Small saphenous vein
Extraction of the SSV may follow the same process as
depicted for the GSV. The distal SSV may be exposed via
a transverse incision directed over the vein at the point of
reux termination as determined by preoperative duplex
imaging or in the mid-calf or ankle if reux involves the
entire vein (Figure 40.2B and 40.2C). The sural nerve is
not as closely adherent to the SSV as the saphenous nerve
is to the GSV, but it can lie close to the SSV in the distal
to mid-third of the leg. The nerve has small accompanying
arteries, and all must be protected from harm when dissecting the vein. After making the incision, the subcutaneous
tissue is dissected to isolate the vein and to allow proximal
and distal control with silk ties. The distal vein is ligated,
and the proximal vein opened to allow advancement of
the stripping device. The vein is ligated to the stripper and
transected. The stripper is advanced and exits the vein at
the knee crease incision. The vein is tied to the stripper
in this location and, following ligation from the popliteal
vein, the vein is transected. Following institution of the
Trendelenburg position, the vein is pulled downward and
from the body with external compression being applied for
2–5 minutes to control any bleeding. Many surgeons will
remove 10 cm or less of the proximal vein to prevent nerve
injury and with the thought that recurrence is unlikely in
this short vein.
40
412 Chapter 40 Open surgical treatment for superficial truncal incompetence
https://t.me/med1917
An alternative method of stripping the SSV is depicted
in Figure 40.2. Note that the same method could be used for
stripping the GSV, although a few more incisions would be
required to allow stripping of the entire vein. The method
depicted is the perforate–invaginate (PIN) technique of
Oesch. The SSV is ligated from the connection to the popliteal vein, and a stainless steel semi-rigid PIN stripper (30 or
47.5 cm long) is backloaded and passed retrograde down
the vein. Retrograde bleeding is controlled by a suture encircling the vein with the stripper lying within. The stripper is
passed down the vein and past any area of reux, at which
point it is forcefully pushed anteriorly to allow palpation.
An 11 blade incises the skin via a stab incision, exposing
the distal tip and vein about 10 centimeters into the SSV
(current technique) or at the ankle (old technique) (Figure
40.2B, 40.2C1, and 40.2C2). The vein can be exposed and
ligated distally or ligated after the stripper exits the incision during stripping. The stripper can be forcefully pushed
out of the distal SSV to allow stripping, accounting for the
“perforate” part of the PIN technique. The proximal vein
is ligated to the stripper via a “oating knot.” A silk suture
is tied to the stripper and pulled a short distance into the
vein; the suture then encircles and ligates the vein, with a
long trailing component of the suture left in place to allow
vein removal if the vein breaks during stripping (Figure
40.2A3). The patient is placed in the Trendelenburg position during stripping. Pulling the distal stripper invaginates
the vein, which eventually allows it to be pulled out from
the distal incision. If the vein happens to break midway
into its removal, the PIN stripper can be pulled into the
vein via the trailing suture and the vein exposed, ligated
to the stripper, and pulled into the proximal wound for
removal. External compression provides hemostasis.
40.7.3 Adjunctive and technical
considerations
At this point, branch varicosities can be removed by various techniques. The data available for estimating the overall results of open saphenous surgery to other techniques
have often, but not always, involved some type of removal
of branch varicosities. Incompetent perforator veins may
be, but are generally not, addressed at this time.
If clinically indicated, bilateral surgery does not appear
to increase the overall risk of complications.
of GSV stump closure has little impact on neovascularization and subsequent recurrence; therefore, simple ligature
or oversewing is acceptable.
7
High ligation alone as a treatment of a pathologically
incompetent saphenous vein proved to be unsuccessful
due to recurrent reux and clinically apparent varicosi-
31
The removal of the vein is an integral component
ties.
of the open operation. Whether less invasive procedures
such as the Cure Conservatrice et Hemodynamique de
l’Insufsance Veineuse en Ambulatoiere (CHIVA) or Ablation Selective des Varices sous Anesthesie Locale (ASVAL)
management of varicose veins will be more successful
than simple high ligation is currently debatable and not
championed in the United States. With or without formal
high ligation of the GSV, only branch varicose veins are
removed as directed by duplex imaging in these techniques.
30
The method
A recent comparison of ablation techniques would suggest
that CHIVA has a high recurrence rate both clinically and
by ultrasonic imaging.
32
When considering all the available data, routine preoperative prophylactic anticoagulation is not supported by
Critchley and associates or by the SVS/AVF guidelines committee members. The rate is low and generally not clinically
signicant when patients use compression and are allowed
to ambulate early.
7,18
Based on their study ndings, Critchley et al. started administering 40 mg of enoxaparin 1 day
prior to surgery and continued for 1 week postoperatively
for patients with a history of venous thromboembolism.
40.7.4 Wound closure/dressings/
postoperative care
The groin and posterior knee incisions used to allow high
ligation can be closed with deep subcutaneous layers of
interrupted 3-0 absorbable sutures and a running subcuticular 4-0 absorbable suture. The distal incisions used to
expose the vein and allow stripper inversion and removal
can be closed with one or two everting 4-0 absorbable
sutures. The incisions are covered with sterile ats and a
compression wrap is applied from the foot to as much of
the thigh circumferentially as possible, with slightly more
compression applied distally and tapering proximally. A
sterile at dressing covers the groin wound. The patient
is instructed to remove the dressing in 48 hours if desired
and replace it with similar daily compression until seen in
the clinic in about a week. The 2011 SVS/AVF guidelines
recommend postoperative compression for a period of 1
week to reduce hematoma formation, pain, and swelling
7,33
(1, B).
Same-day discharge after anesthesia recovery is standard, and patients are instructed to resume routine activities not involving heavy lifting or water sports. They should
walk as desired but refrain from long periods of standing
or sitting, and when reclining should have their legs elevated to improve venous drainage. Placing a wedge at the
foot of the bed to allow leg elevation when sleeping may
decrease swelling. A mild pain reliever is often provided,
but many patients only use an anti-inammatory with
good effect.
are involved in heavy labor.
34
The patient is off work for 1–2 weeks if they
35
Showering is permitted with
proper wound protection. The patient is generally seen in
5–7 days for wound inspection and examination. If healing
is progressing well, routine daily activities, including showering and light work duties, can be started.
40.8 COMPLICATIONS
With open surgery comes the risks involved with opening
the groin, knee crease, and smaller incisions to remove the
vein. Nerve injury and hematoma formation have also
been reported to constitute a higher risk than that associated with less invasive methods. However, with the limited
dissection and stripping guided by ultrasonic imaging conducted during modern open surgery, the risk is minimized.
An obvious deciency of comparing HL&S to other methods of treatment, even in RCTs, is the variability of the
40.9 Conclusion 413
https://t.me/med1917
denition of a particular complication. Some studies dene
the parameters for inclusion well, while others do not,
and even when there is denition clarity, it varies between
studies. Understanding all these caveats when considering
minor and major complications, one meta-analysis was
able to combine pertinent data to address complications of
HL&S as compared to other methods.
tions mentioned earlier, one meta-analysis did not attempt
such comparisons.
36
14
Due to the limita-
Statistically, HL&S is associated with an increased risk
of minor adverse events when compared to radiofrequency
ablation (RFA), no statistical difference when compared to
endovenous laser ablation (EVLA), and a lower risk when
compared to UGFS.
14
To capture all adverse events, many
studies report events as within 3 months of the procedure,
so the following statistics are based on this time interval. In
the RCTs analyzed in the Cochrane review, minor adverse
events were noted as hematoma (0%–62%, median 8.3%),
saphenous nerve injury (1%–23%, median 5%), wound
problems (2%), bruising/pigmentation (0%–90%, median
6%), and phlebitis (0%–4.5%, median 1%), highlighting
the great diversity of event denitions.
infection was reported at a rate of (1.8%–5.8%) in other
studies.
37–39
A recent report conrms the premise that the
36
Minor wound
more GVS stripped, the higher the incidence of saphenous
nerve dysfunction: 0% in the thigh, 4% at the knee, 17%
at the middle calf, and 22% to the ankle.
40
A compilation of meta-analysis and individual study
data found HL&S to be associated with more periprocedural pain, need for analgesia, early minor adverse events,
decreased QOL measures, and delayed return to regular activities as a reason for endovenous ablation being
selected as rst-line therapy when available.
13
These factors
become comparable shortly after the postoperative period
and so do not affect long-term results.
The typical list of serious complications included in a
comparative meta-analysis are death, pulmonary embolism, DVT, myocardial infarction, stroke, transient ischemic
attack, visual symptoms, generalized allergy, anaphylaxis,
hemorrhage requiring transfusion or surgery, severe pain,
severe neuralgia, endovenous heat-induced thrombosis III
or IV, readmission, and others.
14
Some of these potential
complications are not related to the open procedure and
will not be consider further. No recent study has reported
mortality associated with HL&S. The incidence of DVT is
very low (0%–1.4%), and PE is rarely mentioned, although
it does occur.
37,38,41,42
Wound problems requiring intervention (antibiotics and/or debridement) from the studies
included in the Cochrane review ranged from 0% to 6%
and was the most common adverse event noted.
36
The use
of prophylactic antibiotics reduces this risk, and an RCT
demonstrated two factors that increased groin wound
infection risk: obesity and current smoking.
24
The other
potential complications such as myocardial infarction,
severe neuralgia, readmissions, signicant hemorrhage, or
anaphylaxis have not been reported in the recent literature.
A meta-analysis has demonstrated no statistical differences
in major adverse events between HL&S and other endovascular ablation methods.
14
Although not reported in the
recent literature, the surgeon should not forget that injury
to the femoral vein and artery during HL&S has been
reported rarely (<1%) but can be devastating, especially
when the entire vascular structure is stripped.
43
40.8.1 Results
Technical success is a measure that the Cochrane group
felt had sufcient RCT data to allow comparison between
methods of saphenous ablation.
36
It is dened as complete
anatomical obliteration, or absence of reux, within the
GSV on duplex ultrasound at 6 weeks and 5 years. At
less than or equal to 6 weeks, the technical success rate
was reported as 95%–98%, at 1 year 85%–88%, and
at 5 years 84a5–97% for HL&S.
36
They found that the
technical success was better with EVLA but not RFA at
less than 5 years, but beyond 5 years no clear differences
could be determined when compared to HL&S. Compared
to UFGS, HL&S demonstrated a better technical success
up to and after 5 years of intervention. In a more recent
meta-analysis incorporating both RTC and a large series to
analyze anatomic closure rates, HL&S was associated with
higher anatomic closure rates at 30 days and 5 years when
compared with RFA and UGFS (with moderate certainty),
while no signicant difference was seen when compared
with EVLA at 5 years.
14
Recurrent varicose veins indicate a failure of initial
treatment or disease progression and likely reect a temporal component. Recurrence in the Cochrane study was
dened as varicose veins present as reported by the clinician or patient at least 1 year following intervention.
36
The recurrence rates of the included RCTs at 1 year was
9%–20% and at 2 years 11%–37% but did increase with
time to 69% at 8 years in one study.
recurrence rates in other studies have been reported at
58%–69%.
36,44
Based on a recent meta-analysis, RFA may
36
At 8–10 years,
have fewer recurrence long-term (>5 years) than HL&S,
while UGFS was associated with an increased risk of recur-
14,36
rence.
For more advanced disease in which venous ulcer
healing and prevention of recurrence are the markers of
success, supercial vein surgery is benecial especially in
preventing recurrence.
17,45
40.9 CONCLUSION
The rapid rise of less invasive means to ablate the truncal
saphenous systems and, therefore, eliminate reux has relegated open surgery to a niche procedure. However, there
are situations in which the cost of care, patient preference,
and/or anatomic considerations reafrms the open operation as a useful technique in the treatment against truncal
insufciency. Saphenous ablation, whatever form taken
to accomplish it, does provide patient relief that is better
than compression alone and is proven to aid in the care
of patients with advanced disease, especially those with
venous ulceration. Knowledge of the anatomic variability
of the lower leg supercial venous system is required for
optimal open surgical results. The results of open saphenous surgery are the same as less invasive procedures in
terms of long-term benet, but the procedure is less well
tolerated and has a higher morbidity in the short term.
40
Соседние файлы в папке Библиотека им академика М.И. Перельмана