Die Wertigkeit der endoskopischen subfaszialen Perforansdissektion (ESDP)

Surgery performed on incompetent perforator veins with “historical techniques”, such as the Linton operation, was associated with a relatively high complication rate. Hauer introduced a new method of endoscopic subfascial perforator vein interruption (SEPS) in 1985 and also developed it further; the indications for this endoscopic procedure were subsequently widened to range from primary varicose veins to advanced stages of chronic venous insufficiency. Few follow-up data from prospective randomized trials are available, and most clinical data refer to widely differing patient populations, so that the results are not comparable. In the case of uncomplicated superficial venous disease there are method-specific complications that should not be overlooked. As a result, the value of subfascial endoscopic perforator vein surgery relative to other methods is regarded with increasing criticism. Venous outflow obstruction from deep vein thrombosis was expected to be an ideal indication; however, data from the NASEPS Registry have demonstrated no benefit of the endoscopic procedure during follow-up. Eradication of main stem saphenous reflux will result in insignificant perforator vein reflux in approximately 80%. The haemodynamic consequences of incompetent perforator vein interruption have not yet been adequately documented. At this time, the main area of application of SEPS is in the treatment of multiple insufficient perforator veins of the medial calf and additional focal symptoms of chronic venous insufficiency, especially combined with paratibial fasciotomy and additional epifascial varicose vein surgery.     

A survey of the current management of varicose veins by members of the Vascular Surgical Society

The assessment and treatment of varicose veins by members of the Vascular Surgical Society of Great Britain and Ireland has been assessed by postal questionnaire. The response rate was 65%, of which 77% were general surgeons with a vascular interest, 21% were vascular surgeons only and 2% were non-vascular. Approximately four new patients with varicose veins are seen per surgeon per week in clinics with a median waiting time to be seen of 12 weeks. A median of three varicose vein operations per surgeon per week are undertaken with 10-15% of surgery being performed for recurrent disease. The commonest indications for surgery are symptomatic (97%) and complicated (98%) varicose veins, although 55% of surgeons also perform surgery for cosmesis. 65% surgeons routinely use hand-held Doppler in the assessment of varicose veins; of the other methods available, Duplex scanning was used as the first line investigation by 83%. Although over 60% of surgeons use sclerotherapy surgery is the preferred option for primary treatment for varicose veins associated with long or short saphenous reflux. 62% surgeons use deep venous thrombosis prophylaxis in patients undergoing varicose veins surgery selectively, and 27% use it routinely.     

Gross anatomy of primary varicose veins observed in endoscopic surgery

The gross anatomy of varicose veins is one of the most important factors in the study of varicosity. Because of wide variations in the extent of involvement and degree of severity of varicose veins, it is difficult to obtain live and intact specimens of varicose veins. With good illumination and magnified monitor viewing, the varicositic main channel, its tributaries, and the incompetent perforating veins can be dissected and visualized clearly during endoscopic surgery. Thus, the whole range of varicosities can be observed directly in situ. Characteristic features of the varicosities of 350 limbs have been recorded by video and photographs for study and classification. These features include: 1) poor contractility of varicose veins; 2) dilated and tortuous changes of varicose veins; 3) saccular or lateral bulging deformities of vein walls, or both; 4) uniformly dilated and tortuous deformities of a long vein; 5) varicositic changes of the accessory vein; 6) anatomic abnormalities of varicose veins, such as supernumerary tributaries, varicositic clusters, and a crowded relationship among the long saphenous vein, perforating vein and tributaries; 7) various conditions of the perforating veins; and 8) the close relationship among the long saphenous vein, perforating veins, and the saphenous nerve. These data provide valuable information for the study and management of primary varicose veins.     

内镜下深筋膜下交通支离断术治疗老年下肢慢性静脉性溃疡

目的 :探讨电视内镜下深筋膜下交通支静脉离断术治疗老年下肢慢性静脉性溃疡的可行性。方法 :大隐静脉曲张 6例 (10条肢体 ) ,同时存在浅静脉倒流、交通支静脉功能不全和静脉性溃疡 ,4条肢体深静脉功能不全。手术方法为高位结扎大隐静脉 ,分段抽剥 ,内镜下行深筋膜下交通支离断术 ,1例行股静脉戴戒术。结果 :术后肢体症状和浅静脉曲张消失 ,肢体溃疡或皮炎 3周内愈合。结论 :内镜下深筋膜下交通支结扎术具有微创、有效的特点 ,是治疗下肢静脉功能不全性溃疡的有效方法     

Superficial vein surgery and SEPS for chronic venous insufficiency

Venous insufficiency in its severe forms leads to skin changes which, in turn may be treated by surgical therapy. Interventions are directed towards correction of the underlying abnormal venous physiology. This involves removal of varicose veins and ablation of incompetent axial veins and relevant perforating veins. In performing ablation of saphenous vein reflux, techniques include high ligation with stripping, radiofrequency ablation, endovenous laser therapy, and foam sclerotherapy. Incompetent perforator interruption can be accomplished surgically by subfascial endoscopic perforator surgery (SEPS) or controlled sclerotherapy using ultrasound. A variety of techniques have emerged to manage the varicose veins themselves. Surgical treatment of chronic venous insufficiency with high ligation in the groin and inversion stripping of the great saphenous vein to the knee combined with stab avulsion of varicose veins continues to be the standard in treatment of varicose veins. There are few comparisons of sclerotherapy of perforating veins with SEPS, but SEPS has become the most popular of surgical options.     

Endoscopic sclerosing as an alternative method of treatment of the portal hypertension syndrome in children]

Endoscopic sclerosing of the varicose esophageal veins under the general anesthesy was conducted in 151 children aged from 4 mo to 14 years, 70 of them operated on before; while the hemorrhage continues--in 11, after the hemorrhage ending. Procedure was redone in 1 week. While the control esophagoscopy in 1 year after endoscopic sclerosing the vein obliteration was revealed in 17 children.     

Selective loss of extracellular matrix proteins is linked to biophysical properties of varicose veins assessed by ultrasonography

BACKGROUND: Dilatation and enhanced distensibility are specific biophysical properties of varicose veins. Both can be assessed by ultrasonography. The aim of this study was to analyse correlations between the vein wall protein content and these two biophysical properties of varicose veins. METHODS: Twenty-seven patients having surgery for varicose veins and six control patients with normal veins undergoing arterial bypass surgery were examined clinically and with ultrasonography the day before surgery. Fifty-two varicose and six control vein rings were harvested and analysed histopathologically and morphometrically; vascular tissue microarrays incorporated 116 vein wall sectors. RESULTS: Elastin loss in the adventitia (P = 0.010) and reduction of type III collagen in the intima and media (P = 0.004) were observed in varicose veins. Elastin loss correlated negatively with vein diameter at rest (P = 0.005), whereas loss of type III collagen in the intima correlated negatively with the increase in vein diameter at the Valsalva manoeuvre (P < 0.001). CONCLUSION: Loss of elastin and type III collagen occurs in varicose veins and can be assessed with ultrasonography in vivo by measuring vein diameter and distensibility.     

Viscoelastic properties and collagen content of the long saphenous vein in normal and varicose veins

Veins taken from patients undergoing surgery for varicose veins were compared with those obtained from patients undergoing other surgical procedures ('normals'). Varicose veins had a lower breaking strength and breaking energy than normal veins. Elastic stiffness was less in normals (tan theta = 41 (24] than in varicose veins (tan theta = 55 (18); P less than 0.01). There was no difference in viscoelastic behaviour between samples taken above, at, or below the valve leaflet insertion. In normals, perivalvular vein wall exhibited a 50 per cent lower breaking strength and elastic stiffness than vein from other sites. Collagen content was significantly higher in normal vein specimens in all sites examined (mean collagen content = 70 (21) micrograms/mg, versus 51 (20) micrograms/mg for varicose veins; P less than 0.001). We conclude that significant structural changes are seen in varicose veins. In normal veins, the perivalvular vein wall has distinct viscoelastic features when compared with vein wall from other sites. This difference was not found in veins which became varicose.     

Recurrent Varicose Veins Following Surgical Treatment: Our Experience with Five Years Follow-up

OBJECTIVE: To report the 5 year outcome of varicose veins surgery and to establish the factors determining recurrence. STUDY DESIGN: Prospective observational study. MATERIALS AND METHODS: This study reports the outcome in 1326 patients treated in a day surgery centre of an institutional referral centre. Patients were investigated clinically and by colour flow duplex scanning before operation. Treatments used included flush ligation of the sapheno-femoral junction (SFJ) and the sapheno-popliteal junction (SPJ). Incompetence of the great saphenous vein (GSV) and small saphenous vein (SSV) were managed by stripping of these veins. Perforating vein ligation and hook phlebectomy were also used. Patients were evaluated 3 weeks and 5 years following treatment by clinical examination and duplex ultrasonography. RESULTS: 412 patients were excluded from the study because they failed to attend for follow-up or did not wear elastic stockings post-operatively. No residual saphenous truncal reflux was found at the initial assessment 3 weeks following surgery. After 5 years, recurrence of varicose veins occurred in 332 patients out of 1326 (25 %). Recurrences arose at the sapheno-femoral junction in 109 out of 862 patients (13%), at the sapheno-popliteal junction in 39 out of 132 patients (30%), in both saphenous regions 38 out of 107 patients (36%) and in 146 out of 225 subjects (65 %) with secondary varicose veins. CONCLUSION: Varicose veins recurred despite technically correct surgery confirmed on post-operative duplex ultrasonography. The likelihood of recurrence increased in the presence of SSV reflux, perforating vein incompetence and post-thrombotic deep vein incompetence.     

内镜筋膜下交通静脉结扎治疗慢性下肢静脉性溃疡的临床体会

目的:探讨内镜筋膜下交通静脉结扎术(subfascial endoscopic perforator surgery,SEPS)治疗慢性下肢静脉性溃疡的临床效果。方法:回顾分析78例,86条下肢慢性静脉性溃疡患者行内镜深筋膜下交通静脉离断+大隐静脉高位结扎并抽剥术的临床资料。结果:患者术后均恢复良好,浅静脉曲张消失,溃疡愈合,未发生明显并发症,随访1~3年,无皮肤溃疡及浅静脉曲张复发。结论:大隐静脉高位结扎剥脱术+SEPS治疗下肢静脉性溃疡有效,患者创伤小、康复快,效果好。     

Arterio-venous fistula following a lumbar disc surgery

Vascular complications during posterior lumbar disc surgery are rare and its presentation with varicose veins is even rarer. A 23 year-old male patient presented with large varicose veins in right lower limb. He underwent a posterior lumbar spine discectomy surgery. He noticed mild swelling of the distal third right lower limb 3 months after index surgery and reported 6 months later when he developed varicose veins. Duplex Doppler confirmed varicose veins of the long saphenous vein and its tributaries with a patent deep venous system. A digital subtraction angiogram demonstrated a large right common iliac artery (CIA) false aneurysm with an arteriovenous fistula between right common iliac vessels. He had a right CIA covered stent insertion with good results. Varicose veins were later managed with sapheno-femoral junction ligation and a below knee long saphenous vein stripping. At six month follow-up the lower limb swelling had completely recovered and duplex ultrasound did not show any recurrence of varicose veins.     

Endoscope-assisted correction of primary varicose veins

The purpose of this study is to evaluate the possibilities and results of application of endoscopic surgery in the operation of primary varicose veins. With good illumination and magnified viewing, the varicosities, incompetent perforating veins, and healthy veins were clearly visualized. The incompetent perforating veins were clipped and divided securely. The varicose veins and tributaries were dissected and removed completely after being clipped and divided. The healthy veins were preserved if possible. Primary varicose veins in 43 limbs of 37 patients were operated. The operation was conducted through one access incision in 31 limbs (72%), two incisions in 11 limbs (25%), and three incisions in 1 limb. The mean number of incisions was 1.3 in each limb. Hematoma formation occurred in 1 patient due to the slipping of one clip on the third postoperative day. The other patients had uneventful postoperative courses. All 37 patients were reviewed 4 to 30 months postoperatively. Only one limb had recurrent varices at a new site. Ninety-seven percent of limbs (42 of 43) had no recurrence of varicose veins. Seventy-eight percent of patients (29 of 37) were extremely pleased with this operation. Although the other 22% of patients (8 of 37) appreciated this operation, they were not completely satisfied because some preoperative complaints persisted. In this series, the recurrent rate of varicose veins was low (1 in 43 limbs) and postoperative scarring was minimized, in addition to the advantages of endoscopic surgery. These results demonstrate that endoscopic surgery is a worthy alternative procedure for correcting primary varicose veins.     

Postoperative limb compression in reduction of haemorrhage after varicose vein surgery.

In varicose vein surgery, significant postoperative morbidity results from subcutaneous haematoma formation and limb swelling after saphenous vein stripping. We investigated the effectiveness of a high-compression short-stretch adhesive bandage compared with non-adhesive crêpe in reducing haemorrhage after stripping of varicose veins. Using 99mTc-labelled red blood cells, the degree of postoperative bleeding was assessed in 10 patients with bilateral varicose veins allocated for stripping and ligation. High-compression adhesive bandaging was applied to the experimental limb and a non-adhesive bandage to the contralateral control limb. Results show that adequate compression bandaging can decrease subcutaneous haematoma formation after stripping of varicose veins.     

Role of Subfascial Endoscopic Perforator Surgery (SEPS) in Management of Perforator Incompetence in Varicose Veins : A Prospective Randomised Study

The study was carried out to compare the efficacy of subfascial endoscopic perforator surgery (SEPS) and open subfascial ligation of perforators in varicose veins. This study was conducted on 100 patients of varicose veins from January 2006 to December 2010. Clinical scoring and color Doppler were performed in all the patients before surgery. Patients were divided into two groups: Group A and Group B alternately. Management of the perforators was done by subfascial endoscopic perforator surgery (SEPS) in Group A and by open subfascial ligation of perforators in Group B. Fifty patients were treated in each group. All the patients underwent ligation of incompetent saphenofemoral junction with stripping of long saphenous veins wherever the junction was incompetent with multiple ligation of superficial prominent veins. SEPS was done by two-port method without any tourniquet or balloon dissector. Total numbers of perforators ligated were 178 in Group A and 136 in Group B. Patients in both the groups got symptomatic relief of symptoms, but ulcer healing in 33 % patients in Group A was faster as compared to Group B. However, at 3 months of follow-up the ulcers healed in all the patients in both groups. Incidence of wound infection was higher in group B (16 %) as compared to group A (0 %). There were residual perforators in 8 % of patients on color Doppler at 3 months of follow-up in Group B while there was no residual incompetent perforator in Group A. Subfascial endoscopic perforator vein surgery is a safe and effective method for treating incompetent perforating veins. The number of perforators ligated in SEPS was more as compared to the open subfascial ligation group. Possibly some perforators may be missed on Doppler localization and missed ligation, which may be a cause of future recurrence in varicose veins. Early relief of symptoms in terms of ulcer healing was better in the SEPS group with less wound complication rate; however, all the ulcers healed in both the groups at 3 months of follow-up. Cosmetic results were equal in both the groups. Major advantage of SEPS was less incidence of wound complications and less incidence of residual incompetent perforators. Hence, SEPS should be added for the management of perforators along with conventional surgery in varicose veins.     

Accuracy of duplex evaluation one year after varicose vein surgery to predict recurrence at the sapheno-femoral junction after five years.

OBJECTIVE: To investigate whether the results of duplex examination 1 year after sapheno-femoral junction (SFJ) ligation might be helpful in predicting long-term results after 5 years. PATIENTS AND METHODS: Follow-up data concerning patients operated on for primary or recurrent varicose veins of the great saphenous vein were studied 1 year and 5 years after surgery, focusing on the thigh and groin region. Clinical examination was undertaken to detect recurrent thigh varicose veins. The site of SFJ ligation was carefully screened for any signs of neovascularisation by duplex ultrasound. Sensitivity, specificity, positive and negative predictive value of the 1-year duplex scan were calculated, based upon the outcome of a further duplex scan 5 years following surgery. RESULTS: A total of 100 limbs were studied: 50 limbs operated on for primary varicose veins and 50 limbs for recurrent varicose veins. The 1-year duplex ultrasound of the SFJ ligation site had a sensitivity of 80%, a specificity of 91%, a positive predictive value of 70% and a negative predictive value of 95% in assessing the 5 year recurrence rate. CONCLUSION: A postoperative duplex scan of the SFJ 1 year after varicose vein surgery to the great saphenous vein predicts which patients are most likely to have a good outcome 5 years after surgery. The 1-year duplex scan is a reliable diagnostic tool for future studies evaluating the effect of new methods of treating sapheno-femoral incompetence.     

Duplex-derived Evidence of Reflux After Varicose Vein Surgery: Neoreflux or Neovascularisation?

BACKGROUND: Recurrent varicose veins remain a problem in surgical practice despite improvements to the preoperative investigation of, and surgery for varicose veins. Neovascularisation accounts for some cases of recurrence within a few years of surgery, but other factors relating to disease progression must also play a part. We investigated whether new venous reflux (neoreflux) could occur in the early postoperative period (within 6 weeks) following successful varicose vein surgery. METHODS: Eighteen-month prospective observational study in the dedicated vascular surgery unit of a university teaching hospital. Forty-six patients, with primary saphenofemoral junction reflux, awaiting varicose vein surgery were chosen consecutively from the waiting list. All saphenofemoral surgery was performed in a standardised fashion. Assessments were performed prior to, at 6 weeks and at 1 year after surgery. Duplex ultrasound was used to identify and locate sites of reflux. RESULTS: Neoreflux was present at the 6-week postoperative scan in nine limbs after varicose vein surgery (19.6%), and resolved in 55.6% of patients within 1 year. Neovascularisation was noted in two limbs at the 1-year scan. CONCLUSION: New sites of reflux, which may resolve spontaneously, occur in the early postoperative period despite adequate varicose vein surgery. It is our hypothesis that this is a manifestation of the effect of altered venous haemodynamics in a system of susceptible veins.     

下肢静脉造影在下肢静脉曲张患者中的应用及阻塞性下肢静脉曲张发生的预测因素

目的 探讨下肢静脉造影检查在下肢静脉曲张中应用的临床意义,并分析阻塞性下肢静脉曲张可能相关的预测因素.方法 选取2019年1月至2021年12月因下肢静脉曲张于海军军医大学第二附属医院诊治的74例患者(111条患肢)为研究对象,对所有患肢行下肢静脉造影检查,采用病例报告表形式记录患者相关信息,根据有无深静脉阻塞表现分为...     

“一站式”治疗Cockett综合征合并下肢静脉曲张临床疗效

目的评估"一站式"方法(同期行髂静脉支架植入术和下肢静脉曲张术)治疗Cockett综合征合并下肢静脉曲张的安全性、有效性。方法对58例Cockett综合征合并下肢静脉曲张患者行"一站式"治疗,观察并记录术后并发症情况、有无静脉曲张复发,比较术前和术后门诊随访1、3、6、12个月时静脉临床严重程度评分(VCSS)、阿伯丁静脉曲张问卷(AVVQ)评分及髂静脉支架通畅率。结果对58例患者均成功施行"一站式"治疗,技术成功率100%。3例活动性溃疡患者术后1个月内溃疡完全愈合。术后无下肢深静脉血栓、肺栓塞等严重并发症发生。术后1、3、6、12个月VCSS和AVVQ评分较术前均明显降低(P均0.001);随访至12个月,髂静脉支架通畅率为100%,无下肢静脉曲张复发。结论 "一站式"方法治疗Cockett综合征合并下肢静脉曲张的安全性和有效性良好,短期髂静脉支架内通畅率满意,具有一定推广价值。     

射频消融治疗下肢静脉曲张的并发症探讨及预防策略分析

目的 总结下肢静脉曲张射频消融治疗后的并发症发生情况,并分析其预防策略。方法 收集2019年1月至2020年12月于西安交通大学第一附属医院进行射频消融治疗的617例下肢静脉曲张患者临床资料。于术后1周、1个月、3个月、6个月进行随访,观察所有患者术后患肢并发症的发生情况,包括皮下瘀血、血栓性静脉炎、色素沉着、皮肤烧伤、压力性水泡、隐神经损伤、深静脉血栓形成、肺栓塞。结果 术后,所有下肢静脉曲张患者的并发症均以皮下瘀血、色素沉着和血栓性浅静脉炎为主。术后1周,出现深静脉血栓4例,包括腘静脉血栓1例,肌间静脉血栓3例。无严重肺栓塞、隐神经损伤发生。皮下瘀血、血栓性浅静脉炎均于术后6个月时完全吸收;色素沉着吸收缓慢,术后6个月时,仍有5例患者存在色素沉着。结论 下肢静脉曲张患者经射频消融治疗后无严重并发症发生,常见并发症为皮下瘀血、色素沉着、血栓性浅静脉炎。选择合适的病例,采取适宜的规避技巧,以及进行规范化的培训可以减少下肢静脉曲张患者术后并发症的发生。     

Randomised trial of pre-operative colour duplex marking in primary varicose vein surgery: outcome is not improved.

OBJECTIVE: the ability of colour duplex to accurately locate incompetent venous sites has been widely published; its value in pre-operative marking in simple primary varicose vein surgery is evaluated in this study. DESIGN OF STUDY: prospective randomised controlled trial. SETTING: regional vascular service, hospital patients. SUBJECTS: consecutive patients (149) undergoing primary varicose vein surgery where the only difference was one group of patients received duplex marking prior to surgery. Six weeks and 12 months post-operatively all patients had a colour duplex scan to determine the accuracy of surgery and the presence of residual/recurrent varicose veins and completed the Aberdeen, SF-36, and EuroQol quality of life questionnaires. INTERVENTIONS: varicose vein surgery. MAIN OUTCOME MEASURES: Duplex evidence of venous incompetence, quality of life measures using the SF-36 and Aberdeen Varicose Veins Questionnaire. RESULTS: pre-operative marking of primary varicose veins by skilled duplex ultrasonography does not improve the accuracy or recurrence rate following surgery. Quality of life improved significantly following surgery in both groups, however there was no difference in this improvement between the groups. CONCLUSION: the trial has not demonstrated any additional benefit of pre-operative colour duplex marking over that of clinical and hand held Doppler marking in terms of satisfactory varicose vein surgery performance at 6 weeks or 12 months in patients with primary varicose veins of the long saphenous system. It role in the short saphenous system is less clear.