The management of recurrent varicose veins

Transcription

1 Annals of the Royal College of Surgeons of England (I98I) vol. 63 ASPECTS OF TREATMENT* The management of recurrent varicose veins F S A Doran FRCS S Barkat MB BS Bromsgrove and Mid-Worcestershire Hospital Group Key words: VARICOSE VEINS, RECURRENT; AETIOLOGY; RAD)IOLOGICAL IMAGE ENHANCEMENT; TREATMENT PLAN Summary Recurrent varicose veins are due to unidentified connections between the deep and superficial venous systems. Conventional clinical and radiological methods of identification are inefficient. In a series of 662 operations the rate of recurrence was over 40%0. By changing to a different radiological technique, using an image intensifier, it was found that the gastrocnemius veins in the popliteal fossa were a common cause of recurrence. This radiological technique also differentiated between those recurrences that required a second operation and those which ought to be treated by Fegan's method. Introduction The textbook description of recurrent and residual varicose veins divides the causes into two groups: those due to a defective operative technique and those due to a defective diagnostic technique. A defective diagnostic technique results in some connections between the superficial and deep systems of veins being missed at the primary operation, which leads to failure (I). Standard teaching asserts that the number of failures due to diagnostic error can be reduced by the resolute application of the multiple tourniquet test in the light of a sound knowledce of the venous anatomy of the limb, especially of the sites at which the superficial and deep systems connect, perforating the deep fascia as they do so. To this clinical method can be added venography, thermography, ultrasound, and pressure studies when necessary (2,3). Recently preoperative on-table phlebography to define the le'tel of the saphenopopliteal junction has been advocated (4). Material Before I 975 we conducted a clinical trial desianed to discover whether the primary treatment of varicose veins should be by operation or by injection by Fegan's method (5i). The total number of limbs was 502, the selection was random, and 222 were operated on. Each operation was planned according to the result of the multiple tourniquet test. A few venograms were made if the result of this test was ambiguous. Out of the 222 limbs operated on I96 (88.3%o) were followed up and examined at the end of one year. Of that number 88 (44.9%) needed additional treatment. When the operation was confined to the groin and stripping of the long saphenous vein 49.6%o were failures. From an earlier trial (6) concerned with shortstay surgery in which 440 limbs had been operated on for varicose veins we had learnt that many of the failures lay in the diagnostic group. There seemed to be Ino doubt that the multiple tourniquet test was apt to miss incompetent veins entering the popliteal fossa. On suspicion 75 popliteal fossae were explored. The findings fully supported Dodd's (7) assertion that over half of the incompetent short saphenous veins are accompanied by other varicosities. He illustrated I5 different types, paying particular attention to varicosity of the gastrocnemius veins. In a later article he reported 208 examples of varicosity in these veins, usually in those emerging from the medial head (8). The veins from the two heads of the gastrocnemius tend to join, forming a common trunk before entering the popliteal vein. In one of our patients this common trunk was equal in size to the popliteal vein; it was some time before we understood what we were looking at. The image intensifier Although many recurrences can be blamed on the popliteal fossa, it is not the only cause of failure. Moreover, a thorough exploration of the popliteal fossa is not a simple or a short operation and unless the incision is carefully made an ugly keloid scar will develop, made more unsightly if it is associated with a fatty hernia protruding through the popliteal fascia. It is not to be undertaken lightly. The Editor would welcome any comments on this paper by rea(ders *Fellows and Members interested in submitting papers for consideration with a view to publication in this series should first write to the Editor

2 The management of recurrent varicose veins 433 FIG. I To illustrate the confusing picture resulting from the standard reflux method of phlebography. In an attempt to limit the number of mistaken explorations of the popliteal fossa in cases in which the fossa was not in fact to blame it was decided to turn to venography for help. However, it was realised that the X-rays would have to be made in a different way. Since their introduction in I923 two ways have been used in filling the varicosities with the contrast medium. Either it could be injected directly into the affected veins or it could be injected into the deep system via the veins on the foot or at the groin and encouraged to fill the varicosities by reflux through the incompetent veins connecting the two systems. From the surgeon's point of view X-rays made in either of these ways have frequently turned out to be useless. The reason is simple: the superficial system of veins is swamped with contrast medium and as a result of this flooding the X-ray film shows an incomprehensible tangle of matted veins. As a guide to the surgeon it is of no use at all. Take, for example, the case illustrated in Figure i. This X-ray was made by injecting the medium into a vein on the foot, with a tourniquet above the ankle to steer it primarily into the deep system, with the danger of thrombosis in the soleus sinuses (9). Venograms of practical value to the surgeon can be made regularly if an image intensifier is used. The process is as follows. The table is given a I5 anti-trendelenberg tilt and the patient lies either supine or prone, whichever position facilitates the insertion of a butterfly needle into the clump of recurrent varicosities it is wanted to study (Fig. 2). A tourniquet is not placed above the ankle. Occasionally if the contrast medium is being lost too quickly into the iliofemoral vein a tourniquet is added at the groin. The surgeon watches the viewing panel and a radiographer injects the medium, very slowly, into the selected varicosities; the surgeon follows the flow of the contrast in the superficial veins and as soon as he sees it drop through into the deep system he asks his colleague to take the films. Also the surgeon writes down on the patient's notes what he has just seen, paying particular attention to the site of the connection between the two systems and whether there are more than one. Perhaps the main virtue of the method be- Fi.'_ L FIG. 2 Inject directly into recurrent vein (left). Note point at which contrast medium enters the deep systemr with the monitor (right).

3 434 F S A Doran and S Barkat This method of making venograms has another advantage over the conventional reflux methods. It differentiates those recurrences that will require a second operation from those suitable for Fegan's injection method. From experience it has been learnt that recurrences fed by several long narrow veins are difficult to find at operation with the patient lying flat. The last X-ray (Fig. 5) illustrates this point, the recurtent varicosity on the thigh being filled _, -- t;ithrough several slender connections with the femoral vein in Hunter's canal. With the canal laid open connections of this size and number are difficult to recognise with confidence. Leaks of these dimensions do well with Fegan's method. Over the years this radiological method has saved us from numerous frustrating and futile FIG. 3 Recurrence due to incompetent indirect medial gastrocnemius perforating veins (A-note typical obliquity). Long and short saphenous veins already stripped. B=popliteal vein... ing described is its ability to reveal incompetence of the gastrocnemius veins. This ability is illustrated by Figure 3. It has been chosen because A... it was made on a patient who developed recurrent varicosities, the primary operation having been the stripping of the long and short saphenous veins and the division of the medial ankle perforating veins. The film shows the leash of large veins crossing the medial condyle of the tibia obliquely before entering the popliteal vein, which is characteristic of incompetent medial gastrocnemius veins. This venogram both explained the failure of the extensive primary operation and indicated to the surgeon exactly what he had to do. Note again that there is no reflux into the soleus sinuses. The point made by Figure 4 is similar. As B- in the previous patient recurrence had followed the removal of both the long and short saphenous veins. In this case, however, the failure was due to incompetence of the lateral gastrocnemius surgical searches. For example, for long slender connections from the lower leg to the popliteal; from the upper leg to the profunda femoris; from the thigh to the iliofemoral segment; in addition to the common connection with the femoral in Hunter's canal. Also the patient is saved an unnecessary and unsuccessful operation. veins. Again their oblique course to the popliteal vein is characteristic, crossing the head of the fibula and the lateral tibial condyle. It will be noted that the veins are smaller than those shown in Figure 3. Dodd has stated that incompetent FIG. 4 Lateral recurrence (A) due to incomlateral gastrocnemius veins are less frequent and petent indirect lateral gastrocnemius perforating smaller than those from the medial head (7,8). veins (B). Long and short saphenous veins al- Our experience confirms this statement. ready stripped.

4 ... *, _. 'o''i-.,'t; * 8..:, t,-.,.,x, '..-:. K;.,..,''... \\<.,''.,.w..... ',,... The management of recurrent varicose veins 435 to crumble. The popliteal fascia was then incised vertically in the midline of the limb throughout the length of the skin incision. In a thin limb this exposed the tibial nerve and the short saphenous vein at once; in a fat one it made these two structures very easy to find. The tibial nerve was cleaned from one end of the incision to the other and a tape passed round it by which it was gently retracted to the lateral side of the wound. In most instances it was not necessary to expose the lateral peroneal nerve. The short saphenous vein has a thick wall, but the additional varicosities entering the popliteal fossa, particularly the medial gastrocnemius veins, are as fragile as they are large. The greatest care and gentleness are needed to avoid tearing them and the incision must provide good access with a minimum of retraction. We found that the incision described above provided this access. It also gave good access to the adductor A- canal at the opposite end of the fossa. Lastly, the vertical midline division of the popliteal fascia sews up strongly, No I chromic :; D :i S1 j '. -,., ',, Upper fic.p FIG. 5 Recurrence on thigh (A) due to multiple small connections with femoral vein in Hunter's canal (B). Long saphenous vein already stripped. Comments on exploring the popliteal fossa We have nothing to add to Dodd's (7,8) description of the additional varicosities which frequently accompany an incompetent short saphenous vein. Earlier we confirmed his findings F-- (see above). However, we abandoned the incisions.,.,. * he recommended because they did not give wide.,,... Ixtsrol : enough access to the upper and lower angles of...,,.e. the fossa and, in our hands, the vertical part of the incision lying in the medial groove behind -,.-,,.,,., -. >X g..-. A. the knee tended to form keloid. Finally we settled on the Z-shaped incision ):.',' :-'.:,.,; K.', a-.\:,: :.:: : (Fig. 6). The horizontal part was made first, across the full width of the knee and a finger's breadth above the transverse skin creases. From _',",' ss,;, '' a" s,' '., the outer end of this incision an oblique cut _"'-"t,...." '.F '- \,, was made aimed at the central point of the calf. To this was added another oblique cut, parallel to the first but starting from the inner end of the horizontal incision and reaching 4-5 in (io- >-St\uw X,.;'( k 12.5 cm) up the back of the thigh and ending in *' e'"''',.' t.'-,"",_ '..- " t.{ '. B^y' :. 't the midline. The overall vertical length of this incision was about 7 in (I7.75 cm). Each skin i} ','i, '; ''.' flap was then raised from its point to the midline of the limb. If the reflection was taken FIG. 6 Diagram of Z-shaped skin incision with across the midline the apices of the flaps tended flaps reflected. ; t, \ - -;.... : -.'... i..'.,.. \ : '..,. '

5 436 F S A Doran and S Barkat catgut being used as a continual stitch. It does not tear half-way along and therefore eliminates postoperative fatty herniae at the back of the knee. Furthermore, given that the incision has been made correctly, closing the popliteal fascia takes all the tension off the two triangular skin flaps, which fall into place and are best kept in position by interrupted fine nylon sutures. Continuous subcuticular sutures were a failure in our hands. References i Dodd H, Cockett FB. The pathology and surgery of the veins of the lower limb. Edinburgh: E and S Livingstone, I956: Ibid: Miller SS, Grossman JA, Foote AV. The ultrasonic detection of incompetent perforating veins. Br J Surg I97I;58: Hobbs JT. Peroperative venography to ensure accurate saphenopopliteal ligation. Br Med J 1980; 280: Doran FSA, White M. A clinical trial designed to discover if the primary treatment of varicose veins should be by Fegan's method or by an operation. Br J Surg I975;62: Doran FSA, White M, Drury M. The scope and safety of short-stay surgery in the treatment of groin herniae and varicose veins. Br J Surg 1972; 59: Dodd H. Varicosity of the external and pseudovaricosity of the short saphenous vein. Br J Surg I959;46: Dodd H. The varicose tributaries of the popliteal vein. Br J Surg I965;52: Walters HL, Clemenson J, Browse NL, Lea Thomas M. Iodine-I 25 fibrinogen uptake following phlebography of the leg: comparison of ionic and non-ionic contrast media. Radiology I980;135 :6I9-2I.