CONTENTS  •  Volume 12  Number 3 1997

Editorial

Original Articles

86   Ambulatory Venous Pressure and Leg Volume Measurements Before and After Surgery for Primary Varicose Veins
M. Vayssairat, K. Chakkour, P. Gouny, A. Taccoen, C. Cheynel, N. Baudot and 0. Nussaume

91  ‘Inversion’ Stripping of the Long Saphenous Vein
S. Wilson, S. Pryke, A. Scott, M. Walsh and S. G. E. Barker

96   Measurement of Peripheral Venous Oxygen Saturation in the Leg Using Near-Infrared Spectroscopy
D:Wertheim, A. Salaman, J. Melhuish, R. Williams, I. Lane and K. Harding

100 Videophlebography with Foot Venous Pressure Measurements: Description of a Technique for Diagnosing Venous Dysfunction
O.Björgell, 0. Ekberg, H. Åkesson and R. O!sson

107  The Long Saphenous Vein Compartment
A. Caggiati and S. Ricci

Case Report

115  Magnetic Resonance Imaging of Deep Venous Thrombosis with Anomalous Inferior Vena Cava
A. J. Liddicoat, A. R. Moody and N. J. M. London

Letters

PD Coleridge Smith

Discussion continues about whether the saphenous vein should he removed in patients with lower limb varicose veins, and also about the best method for removing this vein. It used to he common practice to perform complete stripping of the long (great) saphenous vein from groin to ankle, until a number of papers highlighted the risk this poses to the saphenous nerve, which may be damaged in up to 10% of these procedures. Following this discovery, many surgeons adopted the practice of ligating the sapheno-femoral junction and leaving the saphenous vein in place. It was anticipated that ligating the vein at one end would prevent venous reflux into the vein and remove the likelihood that this would then fill varices in the leg. It was not until the widespread use of duplex ultrasonography that it was realised that although the saphenous vein often remains patent under these circumstances, it continues to fill through tributaries or perforating veins in the thigh and this venous reflux, in turn, tills recurrent varices in the calf. This is now widely recognised as a source of venous reflux, amongst those who regularly investigate patients with recurrent varicose veins using duplex ultrasonography. Although it would now seem logical to remove the saphenous vein in patients presenting with long saphenous vein incompetence, other pressures have built up. particularly from cardiac surgeons who use this vessel for coronary artery bypass grafting. It has become more desirable to preserve this vein, and a number of surgical procedures have been devised to restore valvular competence or divert flow from the saphenous vein back into the deep veins by appropriate division of the saphenous vein near a perforator (CHIVA treatment). Articles concerning these types of treatment have been published in previous issues of this journal and readers are left to form their own opinions concerning the efficacy of’ these types of treatment. I take the view that, in the short term, some of the valve restoring procedures may have helped to reduce the diameter of the dilated saphenous vein, but in the long term it is unclear whether such procedures achieve an effect which is superior to sapheno-femoral ligation. Perhaps it is possible to repair venous valves before the degenerative process advances too far and the integrity of the saphenous vein is lost, but as yet I doubt if the best procedure has been devised.

In the interim, the majority of surgeons believe that removing the long saphenous vein from the sapheno-femoral junction to the upper calf is the most appropriate procedure (often known in Europe as ‘short stripping’). But how is it best carried out? Babcock stripping using a large olive passed down the leg has been widely used fur many years. However, the procedure of saphenous vein stripping results in substantial bruising in the thigh and there have been attempts to reduce this by modifying the technique. Some time before Babcock devised this method, a California surgeon (Kellers) used an inverting technique to remove short lengths of saphenous vein. This was first reported in 1905. Subsequently van der Stricht, Ouvry and Oesch have devised their own modifications to this technique to allow greater lengths of vein, up to the entire saphenous vein, to be removed in one piece. A number of articles concerning these techniques have been published previously in the pages of Phlebology. It has been suggested that these methods reduce the bruising caused by saphenous vein stripping, although this has never been proved by objective measurement. In this issue. Barker et al. report their randomised comparison of an inverting technique compared to a Babcock-type method and come to the conclusion that the inverting method results in less postoperative pain. There are few direct comparisons in the literature on the treatment of venous disease in which objective measurement has been made to assess new techniques. More frequent are patient series which report the authors’ success with a particular method. I often suspect that the achievements reported in these articles owe more to the skill of the individual surgeon rather than the technique itself! In Barker’s article inverting stripping reduced peroperative blood loss and discomfort reported by the patients one week following surgery, compared to the Babcock method. This appears to be a significant advantage and is perhaps due to the smaller size of the stripper required to remove a vein by an inverting technique, compared to the large olive employed in the Babcock method. Less damage is probably caused to the superficial layers of fascia which envelope the saphenous vein, leading to reduced discomfort. The inverting stripping method is becoming more widely used and therefore it is reassuring that clinical advantages of’ its application can he demonstrated. I am certain that we will continue to use saphenous vein stripping for many years until saphenous vein preserving or restoring treatments or drugs are devised, and therefore it is pleasing to be able to report a small advance in this field.

Contents

D. A. Shields¹, S. K. Andaz¹, J. B. Porter², J. H. Scurr¹ and P. D. Coleridge Smith¹
Departments of ¹Surgery and ²Haematology, UCLMS, The Middlesex Hospital, London, UK

Objective: To measure soluble CD54 (ICAM-1) and CD62E (E-selectin) as markers of neutrophil adhesion in four groups of patients with varying severity of’ venous disease and compare the values obtained with those in age- and sex-matched control subjects.

Keywords: CD54; CD62E; Endothelial activation; Varicose veins; Venous disease; Venous hypertension; Venous ulceration - aetiology

Correspondence and offprint requests to: Mr D. A. Shields, Department of Surgery, The Norfolk and Norwich Hospital, Brunswick Road, Norwich NR1 3SR. UK.

Contents

M. Vayssairat, K. Chakkour, P. Gouny, A. Taccoen, C. Cheynel, N. Baudot and 0. Nussaume
Department of Vascular Surgery, Tenon Hospital, Paris, France

Objective: To compare clinical disability, ambulatory venous pressure (AVP) and leg volume before and after venous surgery, and to relate the changes to those observed after one night preoperative inhospital rest.

Results: Varicose vein surgery improved disability (p = 0.001) and two AVP parameters: recovery time (RT, p = 0.0049) and the calf muscle pump index (CMPI), which rose by 345% (95% confidence intervals: 29, 659). Preoperative supine rest for one night improved disability (p = 0.0016) and reduced leg volume (p = 0.0002). The improvements induced by surgery correlated with the changes induced by rest, for disability (p =0.016). RT (p = 0.006) and CMPI (p = 0.033).

Conclusion: Surgery improves venous function in patients with primary varicose veins. AVP remains a standard method of evaluating CVI. Combined with volumetry, it allows sensitive comparisons between different treatments. Because venous function varies greatly with daily activity, it is imperative to standardize the times at which venous function is evaluated.

Keywords: Ambulatory venous pressure; Chronic venous insufficiency; Haemodynamics; Leg volume; Varicose veins; Venous surgery

Correspondence and offprint requests to: Prof. Michel Vayssairat, Department of Vascular Surgery. Tenon Hospital, 4 rue de la Chine, 75020 Paris, France.

Contents

S. Wilson¹, S. Pryke¹, R. Scott¹, M. Walsh² and S. G. E. Barker^2
1Department of Surgery. Maidstone Hospital, Maidstone, Kent, and ²Department of Surgery, University College London Hospitals, London. UK

Objective: To assess a novel device designed for ‘inversion’ stripping of the long saphenous vein during varicose vein surgery.

Keywords: Long saphenous vein; Varicose veins; Vein stripping

Correspondence and offprint requests to: Mr S. G. E. Barker, Department of Surgery, University College London Medical School, Charles Bell house, 67-73 Riding House Street, London WIP 7LD, UK.

Contents

D. Wertheirn^1,2, R. Salaman¹. J. Meihuish¹, R. Williams². I. Lane¹ and K. Harding^1
1Wound Healing Research Unit, Department of Surgery, University of Wales College of Medicine, Cardiff: and ²Department of Electronics & IT, University of Glamorgan, Pontypridd, UK

Background: It has been suggested that poor healing of wounds may be associated with reduced tissue oxygenation. A non-invasive method of assessing peripheral venous oxygenation has been investigated.

Method: Changes in oxyhaemoglobin (O₂Hb), deoxyhaemoglobin (HHb), oxidized cytochrome aa₃ (cyt aa₃ and total haemoglobin (tHb) were monitored in the left lower leg of seven healthy volunteers. A short period of’ venous occlusion was achieved by rapidly inflating a sphygmomanometer cuff placed around the leg to 60 mmHg. The changes in O₂Hb and tHb, with respect to the baseline readings. were evaluated. PSvO₂ was calculated from (ΔO₂Hb/ ΔtHb) x 100%.

Results: From 17 sets of readings on the seven volunteers the median PSvO₂ calculated was 64% (range 50-86%).

Conclusion: This method appears to be a simple means of evaluating PSvO₂. A change in cyt aa₃ was often seen associated with the venous occlusion.

Keywords: Near-infrared spectroscopy; Peripheral venous oxygen saturation; Venous occlusion

Contents

0. Björgell¹, 0. Ekberg¹. H. Åkesson² and R. Olsson¹
Department of ¹Diagnostic Radiology and ²Vascular Surgery. Malmö University Hospital, Lund University, Malmö. Sweden

Objective: To introduce phlebography with simultaneous video recording of the fluoroscopy (VIP, videophlebography). to improve phlebography performed in patients with venous dysfunction. Ambulatory foot venous pressure (AVP) was measured in the same session.

Design: Descriptive study of an improved phlebographic technique.

Setting: University Hospital MAS, Malmö, Sweden.

Study group: Forty-one consecutive patients (50 legs) referred to phlebographic investigation. In the last 27 legs the AVP was also measured.

Intervention: Phlebography with video recording and measurement of AVP.

Results: In 49 out of 50 (98%) of the VIPs, information allowing a detailed description of venous function was obtained. Normal closing of venous valves, seen on the ascending VIP. combined with a normal venous pressure made it possible to exclude deep vein incompetence and avoid descending phlebography. In 16 out of 27 legs (59%) this combined approach showed that descending phlebography was unnecessary.

Conclusion: VIP provides an adequate image of the venous anatomy, important in preoperative evaluation. The combination of this technique with AVP may clarify the pathophysiological abnormalities resulting from the venous dysfunction.

Keywords: Ambulatory foot venous pressure; Chronic venous insufficiency; Deep vein incompetence; Deep vein obstruction; Perforating vein incompetence; Phlebography; Post-thrombotic sequelae; Superficial vein incompetence; Videophlebography

Contents

A. Caggiati¹ and S. Ricci^2
1Department of Anatomy, University of Rome ‘La Sapienza’, Rome. and ²‘Ricci’ Phlebological Office, Rome. Italy

Objective: To define the relationship between the long saphenous vein and the connective framework of the subcutaneous tissue (hypodermis) of the lower limb.

Keywords: Hypodermis; Long saphenous vein; Ultrasonography; Vein surgery

Contents

J. I. Martinez-Leon, J. C. Bohórquez-Sierra, A. R. Sánchez-Guzmán, F. N. Arribas-Aguilar, F. Ceijas-Lioreda, M. Rodriguez-Pinero and C. Bohórquez-Sierra 
Angiology and Vascular Surgery Unit, Hospital Umversitario Puerto del Mar, Cadiz, Spain

Objective: To report two cases of inferior vena cava (IVC) and iliac vein thrombosis secondary to expansive and ruptured abdominal aortic aneurysms.

Keywords: Abdominal aortic aneurysm; Inferior vena cava; Inflammatory aneurysm; Retroperitoneal fibrosis; Venous thrombosis

Contents

A. J. Liddicoat¹, A. R. Moody² and N. J. M. London³
Departments of Radiology. ¹Leicester Royal Infirmary; ²University of Nottingham: and ³Dcpartrnent of Surgery, University of Leicester. UK

Design: Case report.

Setting: Leicester Royal Infirmary.

Patients: A 17-year-old male patient presenting with postoperative deep venous thrombosis secondary to anomalous inferior vena cava.

Interventions: Imaging to establish the diagnosis, anticoagulation and follow-up.

Main outcome measures: Serial magnetic resonance imaging and the clinical condition of the patient were assessed.

Results: The patient made a good recovery and did not require a laparotomy.

Conclusions: Magnetic resonance imaging is very useful in the detection of central deep venous thrombosis and anomalous inferior vena cava and should be considered in young patients with postoperative deep venous thrombosis.

Keywords: Anomalous inferior vena cava; Deep venous thrombosis; Magnetic resonance imaging

Contents

Copyright © 2000 Philip Coleridge Smith