Is a palpable short saphenous vein a useful clinical sign in varicose vein assessment?

The short saphenous vein (SSV) may be palpable in the popliteal fossa in patients with varicose veins. A prospective study has been carried out to determine the significance of this sign in the presence of primary varicose veins. The SSV was assessed by palpation of the popliteal fossa with the knee slightly flexed. Hand-held Doppler insonation (HHD) was also used in the out-patient clinic. All patients had SSV assessment by duplex scanning. One hundred and sixty legs were examined. In 68 the SSV was palpable; 39 (57%) of these had SSV reflux on duplex examination. When the SSV was not palpable (92 legs), only 1% (1 leg) refluxed on duplex scanning. SSV palpability had a 98% sensitivity, 75% specificity, 57% positive predictive value (PPV), and 99% negative predictive value (NPV). In comparison, HHD had 80% sensitivity, 87% specificity, 67% PPV and 93% NPV. The combined tests had 78% sensitivity, 73% specificity, 76% PPV and 100% NPV. Palpation of the SSV is a valuable part of clinical examination. If the SSV is not palpable, it is unlikely to reflux.     

The long saphenous vein: to strip or not to strip?

As 80% of varicose veins stem from incompetence of the great saphenous system, surgeons must choose between simple high ligation of the saphenofemoral junction with avulsion of varicosities or the same procedure done with additional stripping of the long saphenous vein. Many surgeons strip the long saphenous vein by using variations of Keller's 1905 report of inversion stripping. Others may use other techniques. When surgical procedures for varicose veins are compared, they are often measured by the recurrence rate. This, of course, is difficult to define. Comparisons of saphenous vein stripping versus ligation favor the results achieved by stripping but patient satisfaction appears to be equal and while stripping appears to give better satisfaction with regard to quality of life scores, in fact, the risk of nerve damage and subsequent litigation is quite real when the operation of stripping is done.     

Is there carotid artery aneurysm formation following saphenous vein patch endarterectomy?

The use of saphenous vein patching following carotid endarterectomy is reported to produce aneurysmal dilatation with the risk of thrombosis and possible rupture. The authors have studied patients who have had saphenous vein patch angioplasty following carotid endarterectomy to assess whether there is any progressive arterial dilatation. Thirty-five patients who had undergone saphenous vein patch carotid endarterectomy were age- and sex-matched with 31 subjects that had direct closure endarterectomy. All participants underwent carotid duplex scanning. The external diameters of the mid common carotid artery, the bulb and the proximal internal carotid artery were measured bilaterally. The diameters of the endarterectomized carotid were compared with the contralateral side using a paired t-test. Using an unpaired t-test, the saphenous vein angioplasty group was compared with the directly closed group. A graph was plotted of the ratio of internal carotid artery diameter of the saphenous vein angioplasty group (endarterectomized artery to the contralateral artery) against the length of follow-up, and the Pearson correlation coefficient was calculated. When the saphenous vein angioplasty group was compared with the directly closed group there was a significant difference between the carotid bulb (11.6 versus 9.7mm, P < 0.001) and internal carotid artery diameters (9.0 versus 7.0mm, P < 0.001). Longitudinal analysis of the saphenous vein angioplasty group showed that the increased diameter of the endarterectomized internal carotid artery progressed with time after surgery (r = 0.51, P < 0.005, and r = 0.56, P < 0.001). Vein patching increases the diameter of the internal carotid artery, and this may further increase with time possibly predisposing to aneurysm formation. Further longitudinal studies of paired data are required.     

Is saphenofemoral junction reconstruction necessary during stripping of the saphenous vein?

BACKGROUND: Patients who had undergone complete ankle-to-groin stripping of the greater saphenous vein were evaluated retrospectively to assess the necessity of saphenofemoral junction reconstruction during the stripping procedure. Since 1996, in addition to the conventional complete stripping operation, we routinely perform a saphenofemoral junction reconstruction in patients presenting with greater saphenous vein reflux associated with low-grade (grades I-II) saphenofemoral junctional reflux. In this method, the size of the common femoral vein was adjusted to the desired diameter by a running linear suture technique after division of the greater saphenous vein. METHODS: Retrospective evaluation revealed that 73 limbs in 56 patients treated with this technique (group I). This group of patients was matched to another group of 65 patients (78 limbs) with similar characteristics and symptoms (group II) in whom the conventional complete ankle-to-groin stripping of greater saphenous vein was the treatment. The 2 groups were compared with respect to the incidence of complications, including recurrence of varicosities, ecchymosis, lymphocele, lymphorrhagia, wound infection, and paresthesia in the operated extremity. All patients also were evaluated by Doppler ultrasonography at 6 months, 12 months, and annually thereafter to determine the saphenofemoral junction reflux time (valve reflux time). The mean duration +/- SD of follow-up was 6.7 +/- 1.6 years (range, 2.1-10.8 years). RESULTS: Recurrence of varicosity was noted in 14 patients, 3 in group I and 11 in group II (P = .02). There were no statistically significant differences between the 2 groups in terms of ecchymosis, hematoma, lymphocele, lymphorrhagia, wound infection, and paresthesia. At 6 months, a rapid decrease in valve reflux time was noted in group I (P = .0001). In addition, there was a significant improvement in valve reflux time at each subsequent Doppler examination in group I. Group II showed a decrease in valve reflux time, compared with the preoperative value (P = .068). During subsequent Doppler examinations, a decrease in valve reflux time also was noted in group II; this difference reached statistical significance only at 24 months (P = .04). CONCLUSIONS: We believe that saphenofemoral junction reconstruction is a simple technique to perform and that addition of this method to the conventional stripping provides more durable results with a lesser incidence of recurrence. This method should be considered as a treatment modality in patients with greater saphenous vein reflux associated with low-grade (grades I-II) saphenofemoral junctional reflux.     

How often is deep venous reflux eliminated after saphenous vein ablation?

BACKGROUND AND PURPOSE: Deep venous reflux resolution after great saphenous vein surgery has been reported, but the studies evaluated mainly patients with deep segmental reflux. We prospectively analyzed the effects of greater saphenous vein ablation on coexisting primary deep axial venous reflux compared with segmental venous reflux.Patients and methods Between February 1997 and June 2001, patients with primary deep venous reflux scheduled for greater saphenous vein surgery were included in the study. Limbs of patients with a history of deep venous thrombosis, thrombophlebitis, trauma, and orthopedic or venous surgery were excluded. After surgery, duplex scanning was repeated and patients were examined for persistent deep venous reflux. RESULTS: Thirty-three patients (38 limbs) were followed up with duplex scanning. Follow-up ranged from 2 weeks to 38 months. Preoperative axial deep reflux was present in 17 extremities, and segmental reflux was present in 21. The total number of incompetent segments was 59. Overall reflux abolishment rate was similar in extremities with axial and segmental reflux (30% vs 36%; P >.05). When segments were analyzed individually, abolishment of superficial femoral vein reflux was observed more often in extremities with segmental reflux than those with axial reflux (odds ratio, 4). In the extremities where deep reflux was not abolished with greater saphenous vein ablation, degree of reflux did not change significantly (P >.1). Duplex scanning was performed more than once during follow-up in 9 patients. In 3 of these patients reflux resolved by the second follow-up evaluation, and in 2 reflux was decreased at the second and third follow-up evaluations. CONCLUSION: In patients with concomitant deep and superficial venous reflux, saphenous vein ablation results in resolution of deep reflux in about a third of patients. Superficial femoral vein reflux is seldom corrected in limbs with axial reflux compared with those limbs with segmental reflux. To appreciate the effects of greater saphenous vein ablation, longer follow-up may be needed.     

Does the radial artery provide better long-term patency than the saphenous vein?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the radial artery provides better long-term patency than the saphenous vein. Altogether 379 papers were found using the reported search, of which 12 presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We concluded that there is evidence that radial artery grafts have a higher rate of patency than saphenous vein grafts. Surgeons can confidently use the radial artery as a second arterial bypass graft, particularly in patients with severe native-vessel stenosis.     

Preventing saphenous vein graft failure: does gene therapy have a role?

Gene therapy potentially allows local delivery and expression of cytokines, growth factors, and other mediators. In spite of increasing knowledge of the human genome, applications in clinical practice are only just beginning. The main limitations of effective clinical gene therapy are safety and low transfection efficiency. Saphenous vein grafts permit the transfection of the conduit ex vivo. This allows a variety of transfection techniques to be used, enhancing the transfection efficiency while limiting the risk of systemic complications. This review examines the potential mechanisms of gene delivery and genetic targets that may be applied to saphenous vein graft failure.     

Do residual arteriovenous fistulae after in situ saphenous vein bypass grafting influence patency?

PURPOSE: The purpose of this study was to evaluate the influence on patency of residual arteriovenous fistulae (AVF) after in situ saphenous vein bypass grafting. METHODS: Between January 1, 1994, and December 31, 1996, 98 in situ saphenous vein bypass grafting procedures were performed in 94 patients. Patency was evaluated with duplex scanning after operation and at 1, 3, 6, 9, and 12 months. RESULTS: The indications for operation were intermittent claudication in two patients and critical leg ischemia in 92 patients. Two above-knee and 48 below-knee femoropopliteal and 48 femorocrural in situ saphenous vein bypass grafting procedures were performed. The median follow-up period was 9 months (range, 1.5 to 12.5 months). There were no residual AVF in 45 veins (44%; group 1), but 110 residual AVF were found in 53 veins (56%; group 2). In group 2, 36 AVF in 18 veins were surgically or radiologically occluded mainly as a result of a flow velocity decrease distal to the AVF, but the remaining 74 AVF were treated conservatively. The 1-year cumulative primary patency rates were 68% in group 1 and 74% in group 2 (log-rank test, 0.47; degree of freedom = 1; P =.52). The 1-year cumulative assisted primary patency rates were 68% in group 1 and 81% in group 2 (log-rank test, 2.19; degree of freedom = 1; P =. 14). CONCLUSION: Residual AVF after in situ bypass grafting without influence on bypass graft hemodynamics do not compromise patency and thrombose spontaneously.     

Does saphenous vein arterialisation prevent major amputation in critical leg ischaemia? A comparative study

BACKGROUND: Arterialisation of the great saphenous vein has been suggested to improve distal circulation in patients with critical leg ischaemia not accessible for reconstructive surgery. As the technique has been a matter of controversy the aim was to assess the outcome of a series of own patients treated with arterialisation and compare them with conservatively treated patients. METHODS: Experimental design: a retrospective cohort study. Setting: an academic referral centre (Department of Surgery, Helsinki University Central Hospital) together with a district hospital (Peijas-Rekola Hospital). Patients and interventions: 14 consecutive patients with critical leg ischaemia treated with arterialisation of the great saphenous vein in the district hospital were compared with 14 age, sex, diabetes and symptom severity-matched controls with critical leg ischaemia treated conservatively in the academic referral centre. Measures: major amputations and patient survival. RESULTS: The leg salvage rate was 57% at one year in the arterialisation group and 54% in the conservative group (NS) but the survival rate at one year was 92% in the operative group and 64% in the control group (NS). CONCLUSIONS: Arterialisation did not have any effect on leg salvage. The results of this study do not support the use of arterialisation as a treatment for critical leg ischaemia     

What is the patency of the short saphenous vein when used for coronary artery bypass grafting?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was what the patency of the short saphenous vein is, when used for coronary artery bypass grafting. Altogether 347 papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that small reports give a two-year patency of 77% and a six-year patency of 65% and duplex studies show that the short saphenous vein may be from 2.8 mm to 4.2 mm in diameter. However, caution should be applied when considering these patency rates as they are derived from individual studies of <40 patients. The lesser saphenous vein may be considered as an alternative to brachial or cephalic vein in patients with unsuitable long saphenous vein, and unsuitable mammary, radial or gastroepiploic arteries.     

Detection of “functional” valves in reversed saphenous vein bypass grafts: Identification with duplex ultrasonography

Purpose: Although venous valve lesions have been cited as a mechanism of graft failure, the fate of venous valves in reversed saphenous vein (RSV) bypass grafts is unclear. The basis for this uncertainty is the difficulty in postoperative identification and follow-up of valve sites and the infrequent pathologic submission of vein graft lesions. This report describes the features of “functional” valves (FV) visualized in RSV grafts by ultrasonic duplex scanning.Methods: Sixty-six RSV infrainguinal vein grafts were prospectively studied with duplex ultrasonography from January 1992 to December 1995. Grafts were studied at 1, 2, 3, 4, 6, 9, 12, 18, and 24 months, then annually. FV identification was based on a characteristic ultrasound Doppler waveform and color flow pattern and visualization of the leaflets by B-mode imaging. The waveform consists of end-systolic valve closure followed by variable degrees of reflux. Immediate postoperative reactive hyperemia precludes detection, because flow reversal in the graft is needed for identification.Results: Since August 1994, 14 FV have been identified in 11 (17%) of 66 RSV grafts. The mean time to FV recognition after implantation was 10 months (range, 1 to 52 months), and the average follow-up was 15 months. One valve was completely competent. Seven (50%) of the FV were associated with the development of a <50% diameter reducing stenosis by Doppler velocity criteria. None of the FV has required intervention.Conclusions: “Functional” vein valves in RSV grafts are common and can be identified by ultrasonic duplex imaging. Awareness of the characteristics of FV during routine duplex graft surveillance will undoubtedly increase detection. The variable time course to identification of FV and duration of “function” warrants continued follow-up to determine the relationship of these valves to the development of stenotic lesions and graft failure. (J Vasc Surg 1997;25:522-7.)     

Endovenous laser treatment of saphenous vein reflux: how much energy do we need to prevent recanalizations?

The aim of this study was to report the results of high-energy endovenous laser treatment to measure the relationship between the fluence and the outcome in terms of recanalization. In 97 patients, 129 great saphenous veins were treated with endovenous laser treatment, using a 980-nm diode laser. Follow-up visits were done at 3 days, 1 month, and 6 months. The best results were noted 1 month postoperative, but at 6 months, control late recanalizations occurred decreasing occlusion rate to 90.6%. Patients were divided into 2 groups according to the outcome (occlusion or recanalization) at 6 months, and statistical analysis was done. The authors found 52 J/cm(2) mean fluence in the occlusion group and 43.7 J/cm(2) in the nonocclusion group. This was a statistical significant difference (P < .01). The occlusion rate on long term is fluence dependent. But recanalizations might occur even in these higher fluence treatment groups. A fluence of 52 J/cm(2) is advised.     

Does the right internal thoracic artery or saphenous vein graft offer superior revascularization of the right coronary artery?

A best evidence topic was written according to a structured protocol. The question addressed was whether the right internal thoracic artery (RITA) provides a superior outcome for revascularization of the right coronary artery (RCA) compared with the saphenous vein graft (SVG). Using a designated search strategy, 226 articles were found, of which five represented the best available evidence. The authors, journal, date, country of publication, study type, patient group studied, relevant outcomes and results were tabulated. Of these five studies, one offered level I evidence (data from a randomized trial) and four were level II studies (reports of observational data). The outcome measures varied considerably, but most included graft patency at varying levels of the follow-up. The randomized data showed strong evidence favouring the SVG, mainly in terms of mid-term patency. With the exception of a large cohort study that demonstrated the superior patency of the RITA compared with the SVG in the right coronary territory, the observational studies showed better results for SVG in graft patency, reintervention and cardiovascular complication rate. Overall, and in view of the methodological limitations and the different weight of evidence among studies, it appears that the SVG may offer a superior outcome for revascularization of the RCA when compared with the RITA.