CONTENTS  •  Volume 14  Number 2   1999

Editorial

Original Articles

48    Four Years’ Follow-up Results of Three Different Percutaneous Treatments for Male Varicocele
M. Pocek, M. R. Guazzaroni, G. Sodani, M. N. Guazzaroni, A. Cancellieri, A. M. A. Sakr and G. Simonetti

54    Echoanatomical Patterns of the Long Saphenous Vein in Patients with Primary Varices and in Healthy Subjects
S. Ricci and A. Caggiati

59    Does a Double Long Saphenous Vein Exist?
S. Ricci and A. Caggiati

65    Venous Repair with Vascular Clips and Conventional Suture: A Comparative Experimental Study
P. B. Dimakakos, A. Pafiti-Kondi, A. Doufas, Th. Kotsis, Dr. Mourikis and D. Rizos

71    Interface Pressure Under Elastic Stockings with Compression Pads During Posture Changes and Exercise
M. Hirai

77    Clinical Significance of Corona Phlebectatica Associated with Varicose Veins
M. Hirai

80    Saphenous Venous Reflux Time is an Objective Assessment Tool that Relates to the Severity of Varicose Vein Symptoms
M. A. Elsharawy, L. A, Donaldson and A. K. Samy

Abstracts

Philip D. Coleridge Smith

Varicose vein surgery remains the standard method of treating patients with venous disease in many countries. I accept that some authors claim that echo-sclerotherapy could replace surgical removal of veins but comparative clinical studies do not appear to have been published so the relative efficacy of this treatment is difficult to assess. Varicose vein surgery has been in existence for many years, but it is only in this century that it has achieved any degree of sophistication. Babcock introduced the most widely used technique of saphenous vein stripping in 1908. This necessitates passing a large olive along the track of the vein which I always thought to be a very primitive technique likely to damage structures adjacent to the vein. In the days when Babcock stripping from the ankle to the sapheno-femoral junction was the routine method of removing the saphenous vein, there was a 10—15% incidence of saphenous nerve injury. This produced a large area of anaesthesia in the leg which many patients found troublesome. A possible alternative to this method was the use of Mayo external ring strippers. However, these would not routinely be used to remove the saphenous vein in the calf. In more recent studies it has been shown that limiting the region of stripping to the thigh and upper calf prevents damage to the saphenous nerve in the majority of cases. This leaves the saphenous vein in the calf as a possible source of recurrent varices. Little has been written about this problem and my own experience is that it is an occasional source of further varices and not a frequent problem. The strategy of limited stripping of the saphenous vein appears to be successful in reducing the risk of nerve injury and whist still preventing recurrent varices attributable to a residual, incompetent saphenous vein which could be left after sapheno-femoral ligation alone.

An alternative strategy to Babcock stripping is inverting stripping. Curiously, this was described before Babcock published his method. In 1905 Keller, a californian surgeon described a method of removing short segments of saphenous vein using only a strong ligature. Perhaps the limited length of vein which could he retrieved by this method prevented its widespread popularisation. However, van der Stricht and Ouvry have both published their adaptations of this method which can be used to remove the entire long saphenous vein, without major risk to the saphenous nerve. In both these techniques the use of a large olive passed along the track of the vein is avoided. One end of the vein is attached to a stripper wire or strong ligature passed along the vein to be removed. Traction on the ligature inverts the vein and allows its removal, usually necessitating far less force that would be required to pull a Babcock-type stripper through the vein track. In 1993 Andreas Oesch described a method of removing the long or short saphenous vein with the help of a long metal stripper which he referred to a as a ‘Pin-stripper’. This technique has been widely adopted, particularly in German speaking countries but is also commonly used in the UK and some centres in the USA. The use of a rigid metal stripper facilitates the passage of the stripper, rather than hindering it as might be expected. The stripper can be rotated allowing a degree of steering though varices and into the vein which it is desired to strip, rather than allowing passage of the stripper into a superficial varicosity. The aim of limiting the region of stripping to the thigh and upper calf is facilitated, since this stripper is more easily retrieved from the calf than a flexible stripper. But does this technique make any substantial difference to the patient? This question is addressed by a paper by Kent et al. published in this issue. These authors have found that inverting stripping reduces the extent of bruising resulting from removing the long saphenous vein. Bruising is always a problem when the saphenous vein is removed and may give rise to significant postoperative discomfort for the patient. To me it is surprising that inverting stripping does not achieve such large reductions in post-operative symptoms as I would expect. Much less force is required to remove the vein than with a Babcock stripper, and yet the reduction in pain after the operation compared to Babcock stripping seems to be relatively modest. However, pain is always a difficult entity to measure and Kent et al.were probably correct in assessing an objective postoperative consequence of their surgery, namely skin bruising, in order to investigate the advantages of this technique. Inverting stripping will remain a useful tool in the surgical management of varicose veins for the foreseeable future.

1. Murray AW, Britton AR. Bulstrode CJ. Thromboprophlaxis and death after total hip replacement. J Bone Joint Surg 1996;78:863-70.

Contents

P. J. Kent¹, J. Maughan², M. Burniston², T. Nicholas¹, A. Parkin² and P. J. Robinson³
Departments of ‘Vascular and Endovascular Surgery, ²Medical  Physics and ³Radiology, St James's University Hospital, Leeds, UK

Objective: To compare the extent of’ thigh haematoma formation after perforation-invagination (PIN) stripping with that occurring after standard plication stripping of the long saphenous vein.

Design: Prospective, within-case, randomised study with analysis on an intention-to-treat basis.

Setting: The radioisotope department of a university teaching hospital.

Patients: Fourteen patients undergoing bilateral varicose vein surgery.

Interventions: Red blood cell labelling in vivo with ⁹⁹Tc^m. Preoperative imaging of the long saphenous vein using a gamma camera. Randomisation of one leg to PIN stripping and the other to standard stripping of the long saphenous vein to the knee. Patients were reimaged 6 h postoperatively.

Main outcome measures: The extent of thigh haematoma formation.

Results: There was no significant difference with respect to the severity of varicosities in the long saphenous vein in the thigh between the limbs assigned to each group (n = 11) on the preoperative images (T = 25, O.5>p>0.1, Wilcoxon signed rank test). Thigh haematoma in the limbs that had undergone PIN stripping of the long saphenous vein was significantly less than that in the limbs that had undergone standard stripping (T = 10, O.O5>p>0.01, Wilcoxon signed rank test).

Conclusion: PIN stripping of the long saphenous vein results in significantly decreased haematoma formation compared with standard stripping.

Keywords: Complications; Haernatoma; Stripping; Varicose veins

Correspondence and offprint requests to: Mr P. J. Kent, Department of Vascular and Endovascuhar Surgery, St James’s University Hospital, Beckeit Street, Leeds LS9 7TF, UK. 

Tel: 0113-2433144;  Fax: 0113-2460098; E-mail: McdPJK@lecds.ac.uk

Contents

A. Fronek^1,2, M. Goldman³ and K. Fronek²
Departments of ¹Surgery. ²Bioengineering and Dermatology, University of California San Diego, La Jolla, California, USA

Objective: To evaluate the efficacy of three different interventional radiological procedures for the treatment of venous reflux in symptomatic male varicocele.

Design: Prospective study with a 48-month colour duplex ultrasound (CD) follow-up.

Setting: Department of Radiology, Tor Vergata University of Rome.

Patients: From January 1991 to December 1993, 45 symptomatic patients with third- to fourth-degree varicocele, according to Sarteschi’s CD classification, were randomly divided into three equal groups (15 patients each).

Interventions: The first group received sclerotherapy (Athoxysclerol), the second underwent embolisation (Gianturco coils), while the third group received combined sclero-embolisation therapy (Athoxysclerol and Gianturco coils).

Main outcomes measures: The frequency of recurrence for each procedure.

Results: Two recurrences (13%) after 1 and 2 years occurred in patients who underwent sclerotherapy. In the embolisation group, two patients showed residual varices (13%). Neither recurrence nor residue was seen in the third group, who received combined therapy.

Conclusions: Sclerotherapy provides good immediate results but drug dilution may cause a relapse shortly after treatment. Embolisation has a lower immediate success but better long-term success. Combined treatment provides the highest long-term success rate.

Keywords: Embolisation; Interventional radiology; Sclerotherapy; Therapy; Varicocele

Correspondence and offprint requests to: Professor Marco Pocek.  Department of Radiology. 'Tor Vergata' University of Rome, S. Eugenio Hospital, P. le Umanesimo 10, 00144 Rome, Italy. 

Tel: 39-6-59044161: Fax: 39-6-5916524.

Contents

S. Ricci¹ and A. Caggiati^2
1Private Phlebology Office and ²Department of Anatomy, University of Rome ‘La Sapienza’, Rome, Italy

Objective: To evaluate the pathway of reflux in incompetent long saphenous veins (LSVs), paying particular attention to the role of longitudinal saphenous tributaries in the thigh (accessory. saphenous veins, ASVs).

Design: Prospective study in a group of patients with primary varices. Comparison with the anatomical patterns in a group of normal subjects.

Setting: Private phlebology practice.

Patients: Sixty-seven patients with primary varices (100 limbs) and 66 subjects without varices and with competent saphenous veins (120 limbs).

Methods: Duplex ultrasound evaluation of the saphenous system in the thigh of patients and healthy subjects. The ‘eye’ ultrasonographic sign was used as the marker to distinguish the LSV from the longitudinal tributary veins of the thigh. 

Results: In 57% of limbs in patients with varices, reflux followed the saphenous vein, while in 43% the reflux spilled outside the LSV into an ASV (h or S types). When reflux followed the saphenous vein, no large calibre ASVs could be observed. In 30% of limbs in control subjects a parallel tributary vein with a similar calibre was found joining the LSV. 

Conclusion: Clinically visible varices in the thigh rarely comprise the LSV itself, but are usually dilated ASVs, the reflux stream passing from the proximal LSV into a more superficial ASV. The distal LSV running parallel beneath is often competent. In subjects with healthy LSVs, a large competent tributary vein is already present in the thigh in 30% of cases. This suggests that superficial deviation of reflux flow into an ASV in patients with varices may not arise from haemodynamically acquired changes, but could have a congenital origin.  This could even be a predisposing factor in the development of varices.

Keywords:  Duplex exploration;   Saphenous compartment;  Saphenous 'eye' sigh;  Saphenous incompetence;  Thigh varices

Correspondence and offprint requests to: Dr Stefano Ricci, Ambulatorio Flebologico ‘Ricci’, Corso Trieste 123, 1-00198 Roma, Italy. 

Tel: +39 068 8551523: Fax: +39 068 55h406.

Contents

S. Ricci¹ and A. Caggiati^2
1Private Phlebology Office and ²Department of Anatomy, University of Rome ‘La Sapienza’, Rome, Italy

Objective: To use ultrasonography to re-evaluate the incidence of LSV reduplication in healthy subjects and patients with varicose veins on the basis of a new definition of this anatomical aspect.

Methods: The presence of two parallel superficial venous channels in the lower limb was sought in a series of 610 duplex ultrasound examinations. The LSV was identified, by the ‘eye’ sign, running deeply in the hypodermis, closely ensheathed by two hyperechogenic laminae (the saphenous compartment). Tributary veins were identified by their more superficial course, lying outside the compartment. True LSV reduplication was considered to be present when two venous channels were present within the saphenous compartment.

Results: True reduplication of the LSV is extremely rare (1%) and only affects a segment of vein. Large tributaries running parallel to the LSV do not comprise true reduplication. hut may act as a ‘functional double vein’. Better understanding of the anatomy of the LSV may improve operative treatment for varicose veins and improve the use of saphenous veins as arterial grafts.

Keywords: Anatomy; Long saphenous vein; Saphenous reduplication; Ultrasound saphenous identification

Correspondence and offprint requests to: Dr Stefano Ricci, Ambulatorio Flebologico ‘Ricci’, Corso Trieste 123, 1-00198 Roma, Italy. 

Tel: +39 068 551523: Fax: +39 068 551406.

Contents

P. B. Dimakakos^1, A. Pafiti-Kondi^2, A. Doufas³, Th. Kotsis¹,D r. Mourikis⁴ and D. Rizos⁵
Departments of ¹Vascular Surgery. B’ Surgical Clinic, ²Pathology, ³Anesthesiology, ⁴Radiology and ⁵Honnonological and Biostatistics Unit, University of Athens, ‘Aretaeion’ Hospital, Athens, Greece

Objectives: The non-penetrating Vascular Clip System (VCS) was tested experimentally and compared with the conventional suture method on th~ venous system.

Materials and Methods: In five pigs. 30 transverse venotomies were carried out in the jugular and renal veins, and vena cava. Fifteen venotomies were reconstructed using autosuture clips and 15 using the standard needle and suture method. Eight weeks later, following phlebography, the specimens were examined macro- and microscopically.

Results: For both methods, the veins remained patent; however, significant stenosis of 8.9% (95% CI: 0.6—17.11 for the renal vein and 8.5% (95% CI: 1.2—15.7) for the vena cava occurred when the suture technique was used. The intima to media height ratio remained the same. The anastomosis time with the clips was significantly shorter (p<O.05),while the endothelium remained intact without any hyperplasia or inflammatory changes, which are usual findings of the suture technique.

Conclusion: Early and mid-term results show that the VCS clipped anastomotic technique seems to be effective and acceptable for venous reconstructions.

Keywords: Vascular clips; Vein reconstruction

Tel: (01) 7232310; Fax:  (01) 7286316.  

Contents

M. Hirai
Department of Surgery, Aichi Prefectural College of Nursing, Nagoya. Japan

Objective: To quantify the influence of posture and exercise on the interface pressure obtained under elastic stockings with compression pads.

Design: Interface pressure measurement and plethysmographic evaluation of elastic stockings with and without compression pads.

Setting: Department of Surgery, Aichi Prefectural College of Nursing, Nagoya, Japan.

Main outcome measures: Pressure measurements in 24 volunteers were obtained beneath elastic stockings, elastic bandages and short-stretch bandages during supine resting, standing, tip-toe exercise and walking, and the effect of elastic stockings on the muscle pump of the leg was evaluated by strain-gauge plethysmography in 40 limbs with varicose veins.

Results: Without compression pads, only short-stretch bandages showed a significant increase in pressure during standing and exercise. When pads were used, however, elastic stockings and bandages also showed a significant increase. With pads, significant improvement in the expelled volume during exercise was observed by strain-gauge plethysmography.

Conclusions: Interface pressure under elastic materials during posture and exercise is similar to that under short-stretch bandages when compression pads are used, and pads effectively augment the muscle pump.

Keywords: Compression pads; Elastic bandages; Elastic stockings; interface pressure; Sclerotherapy: Short-stretch bandages

Tel: 052-736-1401; Fax: 052-736-14 15.

Contents

M. Hirai
Department of Surgery, Aichi Prefectural College of Nursing, Nagoya, Japan

Objective: To investigate the clinical significance of corona phlebectatica.

Design: Clinical and plethysmographic evaluation of corona phlebectatica associated with primary varicose veins.

Setting: Department of Surgery, Aichi Prefectural College of Nursing, Nagoya, Japan.

Main outcome measures: In 411 limbs with greater saphenous incompetence, including 101 with skin changes and 310 without skin changes, clinical analysis and plethysmographic evaluation using the photoplethysmographic technique were carried out.

Results: In 204 of 411 limbs, corona phlebectatica was observed, including 75 coloured red and 129 coloured blue. Blue coronas were observed significantly more often then red coronas in limbs with skin changes. The half refilling time in limbs with skin changes was significantly shorter than that in limbs without skin changes. In limbs without skin changes, limbs with blue coronas showed a significantly shortened half refilling time than those with red coronas.

Conclusions: Blue coronas are a strong indicator of the presence of prolonged venous hypertension in varicose veins.

Keywords: Ankle flare; Corona phlebectatica; Photoplethysmography; Telangiectasias; Varicose veins

Tel: 052-736-1401; Fax: 052-736-14 15.

Contents

M. A. Elsharawy’, L. A. Donaldson² and A. K. Samy^2
1Vascular Department, Charing Cross Hospital, London and ²Department of Surgery, Grimsby General Hospital, Grimsby, UK

Methods: We describe a test based on measuring the venous reflux time (VRT) using hand-held Doppler (HHD). To evaluate the efficiency of this test, a prospective study of 61 consecutive primary varicose vein patients with sapheno-femoral incompetence was carried out. Patients were scored preoperatively by a self-assessment questionnaire. The score was compared with the VRT of the same patients. Six months after surgery, a similar self-assessment questionnaire was sent to all patients.

Results: The VRT was found to have a highly significant relationship to the preoperative score (p = 0.73. p = <0.001). It was also found that most of the patients with a low score of  £ 3 had a VRT of £13 s whilst most with a high score of >3 had a VRT of >13 s (sensitivity 78%, specificity 100%, accuracy 84%, p=<O.000l). Only 41 patients responded to the postoperative questionnaire, giving symptom scores of 0 in 40 patients and a score of 1 in one patient.

Conclusion: VRT is a simple, objective, non-invasive method of assessment of varicose veins, which relates strongly to the magnitude of the patients’ symptoms.

Keywords: Clinical assessment; Doppler ultrasound; Surgical treatment; Varicose veins

Contents

Copyright © 2000 Philip Coleridge Smith