PRESERVATION
OF THE GREATER SAPHENOUS VEIN IN PRIMARY TRONCULAR VARICOSE VEIN SURGERY
(Portuguese
PDF version)
Guilherme
Benjamin Brandão Pitta1, Aldemar Araujo Castro2,
Lucigl Regueira Teixeira3, João Francisco Júnior4,
Fausto Miranda Júnior5, Emil Burihan6
1.
Associate professor, Surgical Department, Universidade Estadual de
Ciências da Saúde/Escola de Ciências Médicas
de Alagoas, Maceió, State of Alagoas, Brazil.
2. Graduate student, Universidade Federal de São Paulo/Escola
Paulista de Medicina (UNIFESP/EPM), São Paulo.
3. Ultrasonographer, Clínica MedAngio, Maceió.
4. Associate professor, Surgical Department, UNIFESP/EPM, São
Paulo.
5. Associate professor, Surgical Department, UNIFESP/EPM, São
Paulo.
6. Professor, Surgical Department, UNIFESP/EPM, São
Paulo.
Correspondence:
Guilherme Benjamin Brandão Pitta
Rua Desportista Humberto Guimarães, 1081/702
CEP: 57035-030 - Maceió - AL
Fax: +55 82 231.1897
E-mail: guilhermepitta@lava.med.br
This
study was supported by Universidade Federal de São Paulo/Escola
Paulista de Medicina, São Paulo. It includes part of the thesis
defended by "Pitta GBB. Preservation of greater saphenous vein
in primary troncular varicose vein surgery [Doctoral thesis]. São
Paulo: Universidade Federal de São Paulo/Escola Paulista de Medicina;
1998.".
ABSTRACT
Objectives:
The preservation of the greater saphenous vein in primary truncal
varicose vein surgery has become very common in the last ten years,
since it allows saving the greater saphenous vein for later use
as a vascular substitute. By comparing it with radical varicose
vein surgery, this type of surgery offers similar clinical results.
The assessment of the whole path of the greater saphenous vein should
shed some light on the changes put through by the surgery. The objective
of this study was to assess the preservation of the greater saphenous
vein during the primary truncal varicose vein surgery. We tested
whether the vein would remain patent and whether its diameter would
decrease.
Methods:
Prospective study of cases treated at a private clinic and at a
tertiary hospital. The study included patients with primary truncal
varicose veins with insufficient saphenofemoral junction who were
submitted to ligation and proximal section of the greater saphenous
vein, with ligation and incision at the saphenous crosse, associated
or not with ligation and/or section of incompetent perforators,
and resection of superficial varicosities. The patency and diameter
of the greater saphenous vein were determined by Doppler ultrasonography
at seven points in the lower limb: upper, medial and lower third
of the thigh, point J, upper, medial and lower third of the leg.
The procedure was carried out in three different moments: M0 (before
the surgery); M1 (30 to 60 days) and M2 (six and 12 months).
Results:
Forty-eight surgeries were performed on 36 patients. The severity
of the disease was as follows: class I in 69% (33/48) of the patients,
class II in 27% (13/48) and class 3 in 4% (2/48). Color Doppler
ultrasonography presented type I reflux in 37% (18/48) of the limbs,
type II in 35% (17/48) and type III in 27% (13/54). The greater
saphenous vein was patent in the upper third of the thigh in15/48
(30%), in the medial third of the thigh in 44/48 (91%) and from
the lower third of the thigh to the lower third of the leg in 48/48
(100%). The average diameter decreased in comparison with the diameter
observed before the surgery.
Conclusions:
The greater saphenous vein continues patent, with exception of the
upper third of the thigh. Patency between six and 12 months is greater
than that found in the period of 30-60 days. The diameter of the
greater saphenous vein decreases.
Key
words: varices, surgery, saphenous vein, ultrasonography
Palavras-chave: varizes, cirurgia, veia safena, ultra-sonografia.
J
Vasc Br 2002; 1(1):32-38.
INTRODUCTION
The preservation
of the greater saphenous vein has been an alternative to the surgical
treatment of primary truncal varicose veins. The necessity for its stripping
is questioned and its use as a vascular substitute is enhanced.1-8
Primary
varicose veins in the lower limbs are frequent in the population of
our country. The general prevalence rate of this disease is approximately
37.9%, affecting 30% of men and 45% of women; however, if we do not
include 9.4% of the patients who seek health centers and report problems
with their lower limbs, the prevalence rate will be 35.5%: 75.3% consist
of bilateral varicose veins and 24.7% are unilateral.9
Since the
surgical treatment options for primary truncal varicose veins of the
lower limbs is controversial, including techniques such as total stripping
of the greater saphenous vein or its preservation with proximal ligation,
an in-depth investigation into the saphenous vein-saving technique10
can elucidate the changes caused by this type of treatment.
The present
study included patients who suffered from primary truncal varicose veins
with insufficient saphenofemoral junction, submitted to ligation, section
and stripping of tributary veins at the saphenous crosse, with ligation
and proximal section of the greater saphenous vein, associated or not
with ligation and/or section of incompetent perforators and resection
of varicose collaterals. Our intention was to test two hypotheses related
to the preservation of the greater saphenous vein in the postoperative
period:
a) Partial
or total patency of the greater saphenous vein will be high due to the
drainage of the venous flow to perforating, superficial, and tributary
veins. In cases of thrombosis of the greater saphenous vein, recanalization
will be intense in order to make the vein functional again;
b) The
diameters of the greater saphenous vein measured at the level of the
thigh and leg will be small in relation to the preoperative period due
to the interruption of venous reflux.
PATIENTS
AND METHODS
The study
was approved by the Ethics and Research Committee of the Universidade
Federal de São Paulo/Escola Paulista de Medicina and is in agreement
with 1975 Helsinki statement, which was revised in 1983. This article
is part of a thesis.10
A prospective
study of a case series was carried out. The patients were treated at
a private clinic and at a tertiary hospital (Hospital do Serviço
Social da Indústria do Estado de Alagoas, Maceió - AL).
Consecutive patients with primary truncal varicose veins and insufficient
saphenofemoral junction were included. The patients were assessed as
to the topographic distribution of varicose veins,11
their clinical severity,12 and the level
of venous reflux.13 The surgical treatment2,5
consisted of ligation, section and stripping of tributary veins at the
saphenous crosse, with ligation and proximal section of the greater
saphenous vein, associated or not with ligation and/or section of incompetent
perforators and resection of varicose collaterals. Exclusion criteria
were: patients with insufficient deep venous system, insufficient saphenopopliteal
junction and those with unhealed venous ulcers, as well as those with
arterial or lymphatic diseases, psychiatric disorders, and those who
could not be followed up.
Two variables
were analyzed in the color Doppler ultrasonography of the greater saphenous
vein: a) patency; b) diameter. For the ultrasound exam, we used Sonoline
Versa Pro Ultrasound Imaging System, from Siemens Medical Systems, adapted
with probes of 5; 7,5; 8 and 10 Mhz; and Gatway echograph with Doppler
spectral analysis, with a basic unit equipped with a linear transducer
of 7.5 and 10 Mhz (Diasonic). The ultrasound exam (Doppler ultrasonography)
was carried out by high-frequency linear probes (7.5 or 10 Mhz), and
the venous anatomy was analyzed by mode B (two-dimensional imaging).
The anatomical and hemodynamic assays of primary truncal varicose veins
were complementted with pulsed Doppler (venous flow) and color imaging.5,14
Each variable
was analyzed in three different moments: a) M0 (moment zero) which corresponds
to preoperative evaluation; b) M1 (first moment) which consists of a
30-60 day period; c) M2 (second moment) which represents the period
between six months and one year.
Seven topographic points were defined for measurement points of the
greater saphenous vein in the lower limb: a) thigh, from point J, 10
cm (lower third of the thigh), 20 cm (medial third of the thigh) and
30 cm (upper third of the thigh); b) point J; c) leg, from point J,
10 cm (upper third of the leg), 20 cm (medial third of the leg) and
30 cm (lower third of the leg).
The sample
was calculated by using the estimated value of the ratio (P) of patent
veins after the surgical procedure,15 P
= 0.68, considering alpha = 0.05 and beta = 0.2. The interval range
comprised the 0.2 range (80% confidence interval). The sample size16
totaled 45 limbs.
Patency
was analyzed as a dichotomic variable - patent and nonpatent - in which
the patent ones were equal to the sum of patent variables, suboccluded
and recanalized and the nonpatent ones, which were equal to the occluded
ones. Moments M0, M1 and M2 were analyzed by McNemar17
test in each segment. The diameter variable - continuous numerical variable
- was evaluated by the analysis of variance with Wilcoxon test, between
each moment for each segment. The two-tailed alpha value was defined
as 0.05.
RESULTS
During
18 months - from August 1996 to January 1998 - 1,850 patients with vascular
diseases were treated at the outpatient clinic of Hospital do Serviço
Social da Indústria do Estado de Alagoas e da Endoclínica,
Maceió, State of Alagoas; 60% (1,110/1,850) had venous diseases
and 70% of these patients (777/1,110) revealed varicose veins in the
lower limbs on clinical examination.
Of
these patients, 29.9% (233/777) were referred to Doppler ultrasonography
at Clínica Diagnose, Maceió. In the same period, 81 varicose
vein surgeries were performed by means of other techniques: resection
of tributaries and/or ligation of perforators.
Altogether,
41 individuals were operated on with preservation of the greater saphenous
vein at the Hospital do Serviço Social da Indústria do
Estado de Alagoas, of whom 36 were followed up and five were excluded
for not showing up for control Doppler ultrasonography. Of the 36 patients
who were followed up, 89% (32/36) were females and 11% (4/36) were males,
with age averaging 47 years (minimum 24; maximum 80 years). Forty-eight
limbs were surgically treated, 48% (23/48) accounted for the right lower
limb and 52% (25/48) for the left lower limb.
The
distribution of lower limbs11, according to the number of faces on the
leg and thigh with varicose veins was: one face was affected in 2% (1/48);
two faces in 12% (6/48); three faces in 21% (10/48); four faces in 25%
(12/48); five faces in 23% (11/48); six faces in 8 % (6/48); seven faces
in 6% (3/48); and eight faces in 2% (1/48).
In
the preoperative period, the lower limbs were classified, during clinical
examination, as to their grade of venous insufficiency12: class 1 in
69% (33/48) of lower limbs, class 2 in 27% (13/48) and class 3 in 4%
(2/48).
Still
in the preoperative period, the classification of reflux13 with the
Doppler effect on continuous-wave ultrasonography was: type I in 37%
(18/48) of lower limbs, type II in 35% (17/48) of the limbs and type
III in 27% (13/48).
The
result of patency and diameter variables of the greater saphenous vein
are shown in Tables 1 and 2, respectively.
 Table
1 - Patency of the greater saphenous vein
 |
| Site |
|
Moment |
P
value (McNemasr
test)
|
| |
M0
|
M1 |
M2
|
|
| Thigh
|
upper
third |
48
(100%) |
4
(8%) |
15
(30%) |
M0
vs. M1, P > 0.1 |
|
|
|
|
|
M0
vs. M2, P < 0.001 |
|
|
|
|
|
M1
vs. M2, P < 0.01 |
|
medial
third |
48
(100%) |
22
(45%) |
44
(91%) |
M0
vs. M1, P < 0.001 |
|
|
|
|
|
M0
vs. M2, P > 0.1 |
|
|
|
|
|
M1
vs. M2, P < 0.001 |
|
lower
third |
48
(100%) |
23
(47%) |
48
(100%) |
M0
vs. M1, P < 0.001 |
|
|
|
|
|
M0
vs. M2, P = 1 |
|
|
|
|
|
M1
vs. M2, P < 0.001 |
| Point
J |
|
48
(100%) |
28
(59%) |
48
(100%) |
M0
vs. M1; P < 0.001 |
|
|
|
|
|
M0
vs. M2; P = 1 |
|
|
|
|
|
M1
vs. M2; P < 0.001 |
| Leg |
upper
third |
48
(100%) |
34
(70%) |
48
(100%) |
M0
vs. M1; P < 0.001 |
|
|
|
|
|
M0
vs. M2; P = 1 |
|
|
|
|
|
M1
vs. M2; < 0.001 |
|
medial
third |
48
(100%) |
38
(79%) |
48
(100%) |
M0
vs. M1; P < 0.01 |
|
|
|
|
|
M0
vs. M2; P = 1 |
|
|
|
|
|
M1
vs. M2; P < 0.01 |
|
lower
third |
48
(100%) |
40
(83%) |
48
(100%) |
M0
vs. M1; P < 0.05 |
|
|
|
|
|
M0
vs. M2; P = 1 |
|
|
|
|
|
M1
vs. M2; P < 0.05 |
|
M0:
initial moment; M1: moment between 30 and 60 days; M2: moment between
6 and 12 months.
Table
2 - Diameter in ml of the greater saphenous vein (mean and confidence
intervals of 95%)
|
| Site |
|
Diameters
at moments |
Wilcoxon
test for dependent samples |
|
M0
|
M1 |
M2
|
|
| Thigh
|
upper
third |
7.26 |
5.05 |
4.74
|
M0
vs. M1; P < 0.0001 |
|
|
6.51
to 8.01 |
4.57
to 5.53 |
4.21
to 5.23 |
M0
vs. M2; P < 0.0001 |
|
|
|
|
|
M1
vs. M2; P = 0.56 |
|
medial
third |
6.33 |
4.84
|
4.48 |
M0
vs. M1; P < 0.0001 |
|
|
5.45
to 7.22 |
4.38
to 5.39 |
3.81 to 4.55 |
M0
vs. M2; P < 0.0001 |
|
|
|
|
|
M1
vs. M2; P = 0.003 |
|
lower
third |
6.34 |
4.84 |
4.48 |
M0
vs. M1; P = 0.0001 |
|
|
5.51
to 7.17 |
4.36
to 5.32 |
4.01
to 4.88 |
M0
vs. M2; P < 0.0001 |
|
|
|
|
|
M1
vs. M2; P = 0.0646 |
| Point
J |
|
5.36 |
4.53 |
4.09 |
M0
vs. M1; P= 0.0002 |
|
|
4.79
to 5.93 |
4.11
to 4.46 |
3.76
to 4.43 |
M0
vs. M2; P< 0.0001 |
|
|
|
|
|
M1
vs. M2; P= 0.0246 |
| Leg |
upper
third |
5.10 |
3.91
|
3.43 |
M0
vs. M1; P< 0.0001 |
|
|
4.45
to 5.75 |
3.44
to 4.37 |
3.10
to 3.78 |
M0
vs. M2; P< 0.0001 |
|
|
|
|
|
M1
vs. M2; P= 0.0063 |
|
medial
third |
3.41
|
3.02 |
2.84 |
M0
vs. M1; P= 0.0020 |
|
|
2.89
to 3.93 |
2.57
to 3.47 |
2.59
to 3.10 |
M0
vs. M2; P= 0.0020 |
|
|
|
|
|
M1
vs. M2; P= 0.2651 |
|
lower
third |
3.18 |
2.86 |
2.76 |
M0
vs. M1; P= 0.0062 |
|
|
2.87
to 3.48 |
2.57
to 3.15 |
2.59
to 2.93 |
M0
vs. M2; P= 0.0135 |
|
|
|
|
|
M1
vs. M2; P= 0.6951 |
|
M0:
initial moment; M1: moment between 30 and 60 days; M2: moment between
6 and 12 months.
DISCUSSION
The
prospective study used allowed us to minimize error risks in the research
results by standardizing the intervention and the evaluation methods.
We
did not include patients with deep venous system insufficiency and vena
saphena parva insufficiency, since there is an important association18,19
between deep venous system and superficial venous system insufficiency.
By including only patients with superficial venous system insufficiency,
we avoid the influence of the insufficient deep venous system over the
final results.
Doppler
ultrasonography was chosen as evaluation method of the preserved greater
saphenous vein and of primary truncal varicose veins of lower limbs
because its quality is superior to that of clinical examination20
and continuous-wave Doppler ultrasound.14 The advantage of Doppler ultrasonography
is that it can identify insufficiency of collateral veins adjacent to
the greater saphenous vein, by employing color Doppler mode B, which
would be mistaken for greater saphenous vein insufficiency on continuous-wave
Doppler ultrasound.
Doppler
ultrasonography has high sensitivity and specificity if compared to
venography21 and plethysmography22,22
which is in agreement with another author,23
who described the technique for locating the sites of venous incompetence,
by using mode B and Doppler ultrasound. Due to its importance for the
assessment of the deep, perforating and superficial venous systems,24,25
Doppler ultrasonography is indicated as standard tool for the diagnosis
of venous reflux and anatomical visualization in cases of venous disease
of the lower limbs.
In
the postoperative period, the greater saphenous vein was controlled
by color Doppler ultrasonography. The greater saphenous vein was investigated
in the intermediate period (30 to 60 days) in order to assess initial
thrombosis, if present, and to assess patency, direction of the flow,
and diameter of the greater saphenous vein; in the late period (sixth
to 12th month), we precisely assessed the recanalization.
Our surgical technique was similar to that used by Hammarsten et al.2
and FONSECA et al.,5 who performed ligation
and section of tributaries and of the greater saphenous vein, ligation
and section of insufficient perforating veins and resection of varicosities.
We introduced the strippping of tributary veins from the greater saphenous
crosse after they were tied off and sectioned. This procedure was used
to reduce recurrent varicose veins at the crosse of the greater saphenous
vein, based on neoangiogenesis mechanisms,26,27
recanalization28 and inappropriate surgical
technique.29
We
also performed the ligation of insufficient perforating veins to the
thigh and leg, for its importance regarding the recurrence of varicose
veins at the level of the saphenofemoral junction30
and the perforating femoral vein insufficiency regarding the recurrence
of varicose veins after high ligation of the greater saphenous vein,31,32
for maintaining the saphenous vein reflux33
and for reducing the recurrence of varicose veins on the leg.2,34
Our patients
had a high frequency of varicose veins and insufficient perforators,
as pointed out by Correia Neto.35
The predominant
clinical status12 consisted of class 1 in 69% of the studied limbs,
which is in conformity with the findings by Fonseca et al.7
In the
classification of the saphenous vein reflux, the incidence of type I
accounted for 37%, with reflux up to the ankle, which is lower than
the incidence rate observed by Koyano & Sakaguchi (66.3%).13
After the
detailed investigation of primary troncal varicose veins and of saphenous
vein reflux from the deep venous system to the superficial system, the
diagnosis must be accurate and the surgical treatment must be adequate.3,36
Patency
of the preserved greater saphenous vein
We found
a patency rate of approximately 30% in the upper third of the thigh
in the postoperative period, which is similar to that observed by Schanzer
& Sklandy37 (24.5%) but different from
that found by McMullin et al. (47%).33
A patency
rate of approximately 90% was observed at the medial and lower third
of the thigh and of 100% on the leg. These data, except for the upper
third of the thigh, are in agreement with some authors2,5,7,8,15,38,39
but contrast to those obtained by other authors.33,37
The low
patency rate at the upper third of the greater saphenous vein can be
explained by the ligation and section of the vein and stripping of the
crosse tributaries.
Recanalization
of the greater saphenous vein around 40% was obtained between six and
12 months after the surgery, especially at the medial and lower third
of the thigh. Therefore, the vein was patent, as also reported by Sarquis.14
Partial
or total patency of the greater saphenous vein was high due to the drainage
of the venous flow to the perforating, superficial and tributary veins,
in cases in which thrombosis of the greater saphenous vein was present,
especially at the upper third of the thigh. Recanalization was intense
at the medial and lower third of the thigh and will make this vein functional
again, from the medial third of the thigh up to the ankle, thus allowing
its use as a possible vascular substitute.
Diameter
of the preserved greater saphenous vein
The reduction
of the diameter of the greater saphenous vein in the postoperative period
confirms the findings of two authors.5,40
Between the sixth and twelfth months after the surgery, we found diameters
at the medial and lower third of the thigh smaller than those observed
before the surgery, findings that are similar to those found by Hammarsten
et al.2
The interruption
of the venous reflux was possibly the cause for the reduction in the
diameter of the greater saphenous vein, with possible improvement of
esthetic aspects.
Research
implications
Several
randomized clinical studies2,37,41-45
relate to our study. The importance of this kind of controlled clinical
investigation helps to establish clinical decisions, but may yield results
that are not complementary.
Despite
the controversial studies previously mentioned and the fact that we
found a high patency rate in our study, even though recanalization was
remarkable in the segments of the medial and lower third of the thigh
and knee, our results are in agreement with the studies conducted by
Hammarsten et al.2
By the
patency results observed here, transformation of descending venous flow
into ascending flow and reduction in the diameter of most segments of
the greater saphenous vein, we understand that this surgical procedure
of preserving the greater saphenous vein is perfeclty justifiable; however,
controlled randomized studies are required in order to clarify the controversial
clinical findings (recurrent varicose veins and clinical status described
by Porter et al.12
According
to Darke's proposal,46 with which we agree
and which we extended, a radomized clinical assay should be conducted
with patients who suffer from primary truncal varicose veins with saphenofemoral
insufficiency, evaluated pre- and postoperatively by means of ascending
venography and color Doppler ultrasonography, by placing them into four
groups:
Group
1 - ligation in the inguinal region with stripping of the greater
saphenous vein and multiple resections of varicose collaterals;
Group
2 - ligation in the inguinal region with stripping of the greater
saphenous vein, identification and ligation of insufficient perforators
and multiple resections of varicose collaterals;
Group
3 - ligation in the inguinal region with preservation of the greater
saphenous vein and multiple resections of the varicose collaterals;
Group
4 - ligation in the inguinal region with preservation of the greater
saphenous vein, identification and ligation of the insufficient perforators
and multiple resections of varicose collaterals.
We conclude
that the greater saphenous vein remains patent, except for the upper
third of the thigh; patency between six and 12 months is greater than
that in the 30-60 period, and the diameter of the greater saphenous
vein decreases between 30 and 60 days after the surgery in comparison
with the diameter observed before the surgery.
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