Bypass in the absence of ipsilateral greater saphenous vein: safety and superiority of the contralateral greater saphenous vein

PURPOSE: The purposes of this study were to evaluate the long-term results of different autogenous conduits used for infrainguinal bypass when ipsilateral greater saphenous vein (IGSV) is absent or inadequate and to determine the impact on the contralateral lower extremity. METHODS: The study was performed as a retrospective evaluation of a prospective vascular registry together with review of patient records and telephone follow-up. RESULTS: From January 1990 to June 2000, 226 autogenous infrainguinal reconstructions were performed in 203 patients without adequate IGSV. The patients consisted of 128 men and 98 women, with a mean age of 69 years. Prevalent risk factors included diabetes (51%) and prior coronary bypass (46%). Limb salvage was the predominant indication (93%), and 59% of the procedures were secondary reconstructions. All bypasses were completed with autogenous vein, which included contralateral greater saphenous vein (CGSV; 31%), single-segment lesser saphenous vein (5%), single-segment arm vein (19%), and autogenous composite vein (45%). Bypasses were performed to the tibial and pedal arteries in 84% of the cases. The 30-day mortality and graft occlusion rates were 1% and 9%, respectively. The overall postoperative morbidity rate was 24%, with a 7% rate of major complications. Follow-up was complete in 95% of patients over a mean period of 24 months (range, 0.1 to 106 months). The 5-year primary patency rates were significantly better for CGSV compared with autogenous composite vein grafts (61% +/- 7% versus 39% +/- 6%; P <.009). The 5-year secondary patency (60% to 73%) and limb salvage (78% to 81%) rates did not differ significantly between the three groups. Follow-up of the contralateral lower limb revealed that nine of 226 limbs (4%) were amputated at a mean of 36 months after the ipsilateral bypass. The overall 5-year contralateral limb preservation rate was 90% +/- 3%. Contralateral vein harvest and the presence of diabetes did not affect the need for bypass or amputation of the contralateral limb. CONCLUSION: For most patients with inadequate IGSV, the CGSV is the alternative conduit of choice because of its length, superior performance, ease of harvest, and minimal risk to the donor limb.     

Femoral venous reflux abolished by greater saphenous vein stripping

Preoperative venous duplex scanning has revealed unexpected deep venous incompetence in patients with apparently only varicose veins. Acting on the hypothesis that the deep vein reflux was secondary to deep vein dilation caused by reflux volume, the following was done. Between July 1990 and April 1993, 29 limbs in 21 patients (16 females) were examined by color-flow duplex imaging to determine valve closure by the method of van Bemmelen. Instrumentation included high-resolution ATL-9 venous interrogation using a pneumatic cuff deflation stimulus of reflux in the standing, nonweight-bearing limb. All limbs showed greater saphenous vein reflux. Twenty-nine showed superficial femoral vein reflux and of these three showed popliteal vein reflux. Duplex testing was performed by a certified vascular technologist whose interpretation was blinded as to the results of clinical examination and grading of the severity of venous insufficiency. Surgery was performed on an outpatient basis under general anesthesia using groin-to-knee removal of the greater saphenous vein by the vein inversion technique of Van Der Strict. Stab avulsion of varicose tributary veins was accomplished during the same period of anesthesia. In 27 of 29 limbs with preoperative femoral reflux, that reflux was abolished by greater saphenous stripping. In patients with popliteal reflux both femoral and popliteal reflux was abolished. Improvement of deep venous hemodynamics by ablation of superficial reflux supports the reflux circuit theory of venous overload. Furthermore, preoperative evaluation of venous hemodynamics by duplex scanning appears to provide useful pre- and postoperative information regarding venous insufficiency in individual patients.Presented at the Twelfth Annual Meeting of the Southern California Vascular Surgical Society, Coronado, Calif, September 17–19, 1993.     

Pressure-diameter relationship in the human greater saphenous vein

BACKGROUND: Compliance of artificial and autologous vascular grafts is related to future patency. We investigated whether differences in compliance exist between saphenous vein grafts derived from the upper or lower leg, which might indicate upper or lower leg saphenous vein preference in coronary artery bypass surgery. Furthermore, the effect of perivenous application of fibrin glue on mechanical vein wall properties was studied to evaluate its possible use as perivenous graft support. METHODS: Vein segments (N = 10) from upper or lower leg saphenous vein grafts were collected for histopathologic examination and smooth muscle cell/extracellular matrix (SMC/ECM) ratio was calculated. This ratio is suggested to be related with vascular elastic compliance. In a second group vein graft segments (N = 6) from upper and lower leg were placed in an in vitro model generating stepwise increasing static pressure up to 150 cm H(2)O. Outer diameter was measured continuously with a video micrometer system. Distensibility was calculated from the pressure-diameter curves. A third group of vein graft segments (N = 7) was pressurized after fibrin glue application to prevent overdistension, and studied in the same setup. RESULTS: Vein segments from the lower leg demonstrated a consistent higher relative response compared with the upper leg saphenous vein graft (0.9176 +/- 0.03993 vs 0.5245 +/- 0.02512). Both reach a plateau in the high-pressure range (> 100 cm H(2)O). A significant difference in in vitro distensibility between upper and lower leg saphenous vein was only found at a pressure of 50 cm H(2)O (p < 0.05). With fibrin glue, support overdistension is prevented as revealed by the maximum relative response between fibrin glue supported upper and lower leg saphenous vein segments (0.4080 +/- 0.02464 vs 0.582 +/- 0.051), and no plateau is reached in the pressure range up to 150 cm H(2)O. CONCLUSIONS: No upper or lower leg saphenous vein preference could be deduced from the differences in pressure-diameter response due to loss of distensibility (and thus of compliance) in the high-pressure range. Fibrin glue effectively prevents overdistension and preserves some distensibility in the high-pressure range in both the upper and lower leg saphenous vein. This might provide a basis for clinical application of perivenous support.     

Harvesting the greater saphenous vein with a subcutaneous vein remover

A subcutaneous vein remover has been developed to facilitate harvesting of the greater saphenous vein. The technique described is applicable only to the segment of saphenous vein above the knee. This technique was used in 19 selected patients without complication; however, intraoperative and postoperative precautions are necessary to prevent bleeding and injury to the vein.     

保留大隐静脉膝上主干行静脉曲张手术可行性分析

目的探讨在大隐静脉曲张手术中保留膝上主干的可行性。 方法选取2013年8月至2014年10月于本院进行治疗的60例大隐静脉曲张患者,随机分为试验组和对照组,各30例。对试验组临床不同分期的大隐静脉曲张患者行保留膝上主干的剥脱术,对照组行传统大隐静脉高位结扎+剥脱术方式。随访观察两组试验对象的预后情况。 结果试验组在疼痛评分、手术时间、出血量、住院时间、血肿例数等指标上显著优于对照组（t=3.268、4.325、5.670、5.931、χ²=3.547,P<0.01）,而深静脉血栓、静脉炎、复发率、血管内皮细胞生长因子（VEGF）、白细胞介素1（IL-1）水平两组对比差异无统计学意义。保留后的大隐静脉主干除腔内血流速度较术前减慢外（t=10.87,P<0.01）,其管径、通畅度、隐股瓣膜功能、并发血栓等对比差异无统计学意义。 结论相对于传统手术方式,保留大隐静脉膝上主干手术并未增加术后并发症发生率,由于其保留了大隐静脉主干,为大隐静脉曲张手术方式的多样性提供理论依据,为保留自身血管材料防治血管疾病,行血管库储备可行性提供了数据支持。     

Infrainguinal arterial reconstruction with nonreversed greater saphenous vein

Purpose: This study was undertaken to examine the effectiveness and the possible advantages of infrainguinal arterial reconstruction with nonreversed greater saphenous vein (NRGSV) grafts. We reviewed the results achieved with 189 consecutive NRGSV bypass procedures from July 1, 1985, to August 31, 1995, and compared them with 568 consecutive in situ greater saphenous vein (INGSV) bypass procedures completed over the same interval.Methods: NRGSV bypass procedures were performed by selecting the optimum inflow and outflow vessels and then excising the best available appropriate-length segment of greater saphenous vein. The valves were lysed with a Mills valvulotome using gentle antegrade distention with an isotonic electrolyte solution containing heparin (1000 U/500 ml) and papaverine (60 mg/500 ml). The graft was then translocated to the inflow site, where the proximal and distal anastomoses were sequentially completed, followed by a completion arteriography.Results: Demographic and risk factor characteristics did not differ between patients who underwent NRGSV and those who underwent INGSV bypass. Compared with INGSV bypasses, NRGSV bypasses were more commonly secondary procedures (26% vs 8%; p < 0.001) and were more often performed for limb salvage indications (89% vs 68%; p < 0.001). NRGSV bypasses also had more distal inflow vessels (23% superficial femoral artery [SFA] and 28% popliteal artery [POP] vs 10% SFA and 1% POP; p < 0.001) and more distal outflow vessels (52% tibial and 22% pedal artery vs 47% tibial and 3% pedal artery; p < 0.001) than did INGSV bypasses. Despite the higher incidence of secondary bypass procedures and more distal outflow vessels in the NRGSV group, the overall results achieved at 5 years did not differ between the two groups. The 5-year primary patency rates were 65% ± 5% for NRGSV and 72% ± 3% for INGSV ( p < 0.12), and the 5-year secondary patency rates were 74% ± 5% and 82% ± 2% ( p < 0.08), respectively. Similarly, the 5-year limb salvage rate among bypass procedures performed for limb salvage indications did not differ for NRGSV (82% ± 5%) and INGSV (90% ± 2%; p < 0.06).Conclusions: The application of the NRGSV bypass graft preserves the INGSV's main advantage of optimal size match between artery and vein at each anastomosis, but facilitates the tailoring of the procedure to the patients anatomy and the completion of the bypass with the shortest, best-quality conduit available. Our application of the NRGSV in a more challenging series of bypass procedures produced equivalent results to those achieved in a concurrent series of INGSV bypass procedures. (J Vasc Surg 1996;24;957-62.)     

Recurrent varicosity of the lesser saphenous vein. A 5-year follow-up

Between January 1st, 1992 and December 31st, 1996 we performed 1189 variectomies, 127 (11%) of these patients with recurrent varicosis. Only 5 (4%) of them exhibited an isolated perforator vein varicosis and 15 (1%) an isolated varicosis of lateral branches of the lesser saphenous vein. In 66 cases (52%) we noticed, as it was expected, a recurrent varicosis of the saphenous vein. The 41 patients (32%) with recurrent varicosis of the lesser saphenous vein were analysed exactly in detail. We used the classification described by Fischer. According to this we divided them up as follows. Type I: insufficiency of the lesser saphenous vein stump or from lateral branches of the lesser saphenous stump. Type II: recurrence by the femoro-popliteal vein. Type III: recurrence from the lateral branches vein. We obtained from type I: 27 patients (65%), from type II 6 patients and 8 patients (20%) from type III. The recurrences from the stump of the lesser saphenous vein dominated in male patients with 25 of 33; in female patients the recurrences from branches of the lesser saphenous vein with 4 of 8. The lesser saphenous vein was removed in 33 cases completely, and partly in 8 cases at the first operation. The ligation of the termination of the lesser saphenous vein in patients with a type I recurrence was done 16 times in fascial level and 8 times above the fascial level at the first operation. All the 27 type I patients were undergoing a subfascial ligation of the termination of the lesser saphenous vein at the second operation. We noticed the following complications: 2 haematomas, 2 lymphatic fistulas, 1 paraesthesia and 1 ilio-femoral venous thrombosis. After the recurrent operation we noticed no type I and no type II recurrence during follow-up, 17 out of the 26 patients examined again were satisfied. The value of the different investigations, indications, technical details, modifications and the results are discussed. CONCLUSIONS: The results demonstrate that most of the saphenous parvous vein stump recurrence would have been avoided by a sufficient ligation of the saphenous parvous stump at the first operation. It is obvious that an exact indication, a sophisticated operation technique and an experienced surgeon are necessary for successful therapy.     

Popliteal vein thrombosis after radiofrequency ablation of greater saphenous vein for varicose vein

Percutaneous endovenous techniques, such as radiofrequency ablation (RFA), have become the preferred method for treatment for varicose veins associated with great saphenous vein (GSV) insufficiency. Reports have shown safety and efficacy of these techniques with relatively few complications. Deep venous thrombosis after RFA is rare and usually involves extension of thrombus from great saphenous vein to common femoral vein, hence the requirement for postoperative ultrasound. We report a case of symptomatic popliteal vein thrombosis after RFA of GSV requiring anti-coagulation.     

大隐静脉高位结扎剥脱术后深静脉血栓形成12例分析

目的 探讨大隐静脉高位结扎剥脱术后深静脉血栓形成(deep venous thrombosis,DVT)的临床特点、病因及预防措施.方法 回顾性分析收治的12例行大隐静脉高位结扎剥脱术后合并DVT患者的临床特点及诊疗方法,并讨论病因及预防措施.结果 12例DVT患者中7例为中央型,2例为周围型,3例为混合型.DVT合并肺栓塞2例.10例中央型和混合型DVT的肢体增粗症状严重,肢围差距均＞5 cm.9例行下腔静脉滤器(inferior vena cava filter,(IV)CF)保护下的腘静脉置管溶栓术( catheter-directed thrombolysis,CDT)治疗,其中l例介入造影过程中发现左股静脉突然中断,中转手术行股静脉探查修复术、CDT及髂静脉支架植入术;8例发现左髂静脉压迫综合征的影像学表现,其中6例在CDT治疗后行髂静脉支架植入术.1例结合术前彩超及造影所见考虑为右大隐静脉残端血栓蔓延至股静脉,行股静脉切开取栓治疗.2例周围型DVT行抗凝为主的综合性药物治疗.本组12例DVT患者均取得较好的近期疗效.结论 手术损伤股静脉、大隐静脉残端过长、左髂静脉压迫综合征是大隐静脉高位结扎剥脱术后DVT的临床常见原因.术前明确下肢慢性静脉功能不全的病变类型、术中仔细操作、术后早期下床活动至关重要.     

Real time B-mode mapping of the greater saphenous vein

Real time ultrasound mapping of the greater saphenous vein (GSV) was performed in 30 consecutive patients admitted for in situ femoro-crural revascularisation. The overall accuracy in predicting the adequacy of the GSV for in situ bypass was 90%. The predictive value of finding the vein usable was 96%, whereas the predictive value of judging the vein inadequate was 50%. The scanning procedure provided morphologic information about the GSVs, including size, tributaries, varicosities, and double segments, which may prevent unnecessary dissection and may further shorten the duration of surgery. In our opinion the technique is sufficiently accurate to replace phlebography for the routine preoperative assessment of GSV in patients considered for in situ bypass. Veins judged inadequate at scanning, however, should be further evaluated.     

Combined ringing constriction and valvuloplasty in the treatment of varicosity of the great saphenous vein]

Eleven cases (17 limbs) of varicosity of the great saphenous vein were treated by combined ringing constriction and valvuloplasty of the femoral veins and the first valvula of the great saphenous veins using autogenous vein strips. Valvular incompetency of the femoral veins and the great saphenous veins wore corrected, and the physiological function of the great saphenous vein was restored.     

Infrainguinal reconstruction with arm vein,lesser saphenous vein,and remnants of greater saphenous vein: A report of 257 cases

Purpose: The purpose of this study was to evaluate the results of infrainguinal reconstructions with arm vein, lesser saphenous vein, and remnants of greater saphenous vein (ectopic vein grafts). Methods: The records of 222 patients who underwent 257 bypasses were retrospectively reviewed. Most of the grafts were placed for rest pain or tissue loss (88%) and were secondary reconstructions (70%) to the infrapopliteal level (90%). Single-length vein grafts were constructed in 66% of cases, whereas 34% were composite vein grafts. Results: Secondary graft patency was 70%, 52%, and 43% at 1, 3, and 5 years. Single-length grafts had significantly better patency rates at all intervals: 78% versus 56% at 1 year (p = 0.001), 60% versus 39% at 3 years (p = 0.004), and 52% versus 29% at 5 years (p = 0.002). The limb salvage rate was 69% at 5 years. Conclusions: Ectopic vein grafts with primarily arm vein are an acceptable alternative for infrainguinal reconstruction in the absence of suitable ipsilateral greater saphenous vein. (J VASC SURG 1994;20:451-7.)     

Methods of treatment of acute thrombophlebitis of greater saphenous vein

One-stage combination of thrombectomy on the thigh with compressive sclerotherapy is proposed. This method was used in 66 patients with acute thrombophlebitis of greater saphenous vein (GSV) trunk. It permitted to improve treatment quality, to reduce the scope of subsequent radical operation and to improve its cosmetic result. There were no intraoperative complications. All the patients were discharged in satisfactory state, repeated radical operation for varicose veins of the leg was recommended.     

Real-time color duplex scanning after sclerotherapy of the greater saphenous vein

A color real-time duplex scanner was used to scan the greater saphenous vein in 89 limbs of 55 patients to study the efficacy of prior greater saphenous vein sclerotherapy. The greater saphenous vein was insonated from the saphenofemoral junction to the knee to evaluate both reflux to a standardized 30 mm Hg Valsalva maneuver and evidence of greater saphenous vein obliteration by sclerotherapy. These data were correlated with the number of sclerosing injections used (mean, 1.8; range, 1 to 6), time from the last injection (mean, 27.5 mo.; range, 3 to 55 mo), and concentration of injectant used (0.5% to 3% sodium tetradecyl sulfate). Fifty-one of 89 injected limbs (57%) demonstrated reflux through the saphenofemoral junction, and reflux down the more distal greater saphenous vein was found in 67 of 89 injected limbs (75%). Greater saphenous vein obliteration was noted in only 18 of 89 injected limbs (20%); two were totally obliterated, and 16 were partially obliterated. The greater saphenous vein was obliterated in 6% below a refluxing saphenofemoral junction and in 40% below a nonrefluxing junction. A greater saphenous vein obliteration rate of 9% was found with a refluxing greater saphenous vein, and 50% in a nonrefluxing greater saphenous vein. Femoral vein reflux was identified in 11 of the 110 limbs (10%) and in every case was associated with both saphenofemoral junction and greater saphenous vein reflux. We noted a trend toward more successful results with more concentrated injectate (3% sodium tetradecyl sulfate). Fifty percent of patients reported improvement in symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)     

Thrombosis of the greater saphenous vein in a collegiate football place kicker

The greater saphenous vein is vulnerable in its superficial course overlying the distal tibia in the zone of impact of a kicker's foot. Minor repetitive trauma or a single traumatic event to this area may subject the vein to intimal trauma or other irregularities that may lead to vein thrombosis.     

Lengthening the greater saphenous vein with the use of the lateral femoral cutaneous vein

Besides quality, the length of the greater saphenous vein dictates the feasibility of vein bypass grafts in femorodistal popliteal or tibial revascularization. A simple and effective technique of lengthening the greater saphenous vein is described that allows the use of the laterofemoral cutaneous vein in continuity. This technique can be applied when the distal segment of the greater saphenous vein is inadequate or unavailable.     

Minimally invasive cardiac surgery for removal of the greater saphenous vein

Objective

To determine if saphenous vein required for coronary bypass could be quickly, easily and safely removed with a minimally invasive technique.

Design

A consecutive series.

Setting

A university centre.

Material and Methods

In cadavers, a standard mediastinoscope was used to remove segments of the greater saphenous vein. Thigh segments, superior leg segments and ankle segments were removed. Fifteen minutes were allowed for removal of a segment.

Results

Segments of vein 15 to 17 cm long could be removed. One segment could not be removed within 15 minutes. Thigh segments were easy to remove, calf segments were the most difficult. There were no avulsed side branches. All incisions were less than 5 cm long.

Conclusions

Saphenous vein can be harvested quickly and safely by a minimally invasive method. Lower extremity complications may be reduced and long-term patency improved with this in-situ technique of vein removal.     

Objective assessment of nerve injury after greater saphenous vein stripping.

AIM: The complication of nerve injury after greater saphenous vein stripping for varicosity is subjective, and a method for objective evaluation has never been established. The aim of this study was to evaluate postoperative sensory changes by quantitative assessment of current perception threshold (CPT), and to clarify the relation between CPT and symptoms. PATIENTS AND METHODS: Between January 2003 and August 2005, 27 limbs in 18 patients were enrolled. Quantitative sensory function was determined through CPT using a Neurometer (Neurotron, Inc., USA), with which saphenous nerve neural fiber selective minimum sensing values against three electrical stimuli (2000, 250, 5 Hz) were measured. CPT measurements were scheduled on the day before the operation, and 2-7 days, 1, 3, and 6 months after the operation. RESULTS: An increase in CPT value of more than 20% or decrease to below 50% compared to the preoperative value with at least two stimuli was defined as CPT abnormality. Subjective symptoms were observed in 13 limbs in the early postoperative period, and 10 limbs showed CPT abnormality. In 6 limbs with a CPT increase over 20% with all three stimuli, neurological symptoms continued for 6 months. CONCLUSIONS: CPT evaluation provides an objective indication of neurological symptoms in the lower limb following varicose vein surgery.     

Infrequent early recanalization of greater saphenous vein after endovenous laser treatment

OBJECTIVE: The frequency of recanalization of the greater saphenous vein (GSV) after endovenous laser treatment (ELT) is unclear. This study was undertaken to establish the incidence of early recanalization after ELT and to study the histopathologic features of reperfused and excised GSV. METHODS: One hundred nine GSV in 85 consecutive patients with clinical stage C(2-6) E(P,S) A(S,P,D) P(R) disease were treated with ELT. Twelve months of follow-up with duplex scanning at regular intervals was possible in 104 treated veins (95.4%) in 82 patients (96.5%). Recanalized vessels were removed surgically and examined at histopathology. RESULTS: ELT-induced occlusion proved permanent at duplex scanning over 12 months of follow-up in 94 of 104 GSV (90.4%) in 73 patients. In 4 patients, 5 GSV (4.8%) were recanalized completely after 1 week, after 3 months (n = 3), or after 12 months. Another 5 GSV (4.8%) in 5 patients exhibited incomplete proximal recanalization over the 12 months of follow-up. Finally, 9 recanalized vessels (8.6%) required further treatment with high ligation and stripping. Histopathologic analysis of recanalized GSV revealed a multiluminal pattern, as commonly noted in reperfusion after spontaneous thromboplebotic occlusion of the GSV. During follow-up, secondary incompetency of untreated lateral accessory saphenous veins was observed in two legs (1.9%). CONCLUSION: Early recanalization requiring retreatment is observed in less than 10% of GSV after ELT. The histopathologic pattern mimics recanalization after thrombophlebotic occlusion.