Reconstruction
of the deep venous system associated with subfascial endoscopic perforator
surgery (SEPS)
(Portuguese
PDF version)
Eduardo
Toledo de Aguiar1, Alex Lederman2,
Patrícia Matsunaga3
1.
Associate professor, Vascular Surgery, Department of Surgery, Faculty
of Medicine, Universidade de São Paulo, São Paulo, SP,
Brazil.
2.
Vascular surgeon, Hospital Universitário, Universidade de São
Paulo, São Paulo, SP, Brazil.
3.
Resident on Vascular Surgery, Department of Surgery, Faculty of Medicine,
Universidade de São Paulo, São Paulo, SP, Brazil.
Correspondence:
Eduardo Toledo Aguiar
Rua Padre João Manuel, 222/40
CEP 01411-000 - São Paulo, SP, Brazil
Phone/Fax: +55 (11) 3085.3894
E-mail: etaguiar@usp.br
ABSTRACT
The
authors present a case report and support that a complete diagnosis
and the association of various adequate therapeutic techniques are
crucial. The case involves a 37 year-old, male patient with stab-wound
in the left groin, which had been operated eight years before and
did not present edema or recurrent ulcers in the limb. Ascending
venography evidenced obstruction of the femoral vein below the saphenofemoral
junction. The saphenous vein was anastomosed to the popliteal vein
above the knee. The ulcer healed but recurred two years later. Doppler
ultrasonography evidenced four insufficient perforator veins and
patent saphenopopliteal anastomosis. After subfascial endoscopic
perforator surgery (SEPS), the ulcer healed. There was no recurrence
after a follow-up period of four years. We conclude that it is crucial
to perform a complete diagnosis and to associate several therapeutic
techniques.
Key
words: venous insufficiency, saphenous vein, varicose veins,
wounds and injuries.
Palavras-chave: insuficiência venosa, veia safena, varizes,
ferimentos e lesões.
J
Vasc Br 2004;3(1):47-51
Chronic
venous insufficiency continues to be a challenge to modern surgeons.
Although venous ulcer is known since ancient times, it is difficult
to heal in some cases because of multiple lesions on the venous system
of lower limbs of the patient.
The objective of our report is to present a case of chronic venous insufficiency
and demonstrate that a complete diagnosis along with adequate therapeutic
techniques lead to a satisfactory result.
CASE
REPORT
J.C.O.,
male, 37 years old was stabbed on his left groin eight years ago, causing
severe bleeding. According to the patient, he was operated on the same
day and hemorrhage ceased. After that, the patient started complaining
of edema in left lower limb (even during night rest) but no complete
regression occurred. Later, there was pigmentation and dermatosclerosis,
and ulcers difficult to treat developed. Such ulcers used to occur every
year and, in the last year, three ulcers developed on the lateral side
of left leg and dorsum of the left foot.
The examination of the limb evidenced those changes (Figures 1A and
1B). All pulses were palpable, and the ankle-brachial pressure index
was 1.0. Ascending venography showed superficial femoral vein obstruction
below saphenofemoral junction, perforator insufficiency and collateral
circulation from the greater saphenous vein into the left external iliac
vein (Figures 2A and 2B).
 Figures
1 - View of the left leg of the patient in the beginning of treatment.
A-Ulceration
in the left lateral side and dorsum of the foot
B
- Lateral side of the foot with dermatosclerosis and a scar.
Figures
2 - Ascending venography.
A - Occluded femoral vein below saphenofemoral junction.
B
- Saphenopopliteal anastomosis above the knee.
On August
18, 1997 the patient was operated, and the left great saphenous vein
was anastomosed to the popliteal vein above the knee. Three months after,
two ulcers had already healed and the third one, in the lateral side
of the foot, was in advanced process of healing (Figures 3A, 3B and
3C). Monitoring venography evidenced patent saphenopopliteal junction.
Figures
3 - View of the leg of the patient in the end of treatment.
Compressive
therapy with elastic stockings and curatives healed the remaining ulcer.
However, 18 months after, the patient presented eczema and a small ulcer
just above the left medial malleolus. Color Doppler ultrasound showed
four insufficient perforator veins and patent saphenopopliteal junction.
The patient was referred to subfascial endoscopic perforator surgery
(SEPS) and underwent surgery on October 3, 1999. The four perforator
veins were cross-sectioned. The patient was discharged on first post-operative
day and the ulcer healed after 15 postoperative days. After that, the
patient resumed his professional activity. There was no recurrence of
the ulcer during the 36-month follow-up period. The patient still uses
elastic stockings.
COMMENTS
The case
reported here reflects the challenge faced by modern surgeons in choosing
the therapeutic approach to treating chronic venous insufficiency. Therapeutic
techniques chosen were based on two premises: 1) femoral vein obstruction
was an important factor for the occurrence of symptoms; and 2) although
venous obstruction had been successfully treated, perforator veins were
considered to be responsible for ulcer recurrence. Both premises are
discussed.
The fact that the patient was stabbed eight years before and had his
"hemorrhage ceased" after surgery is suggestive of a femoral
vein anastomosis. Venography confirmed a segmental obstruction of superficial
femoral vein just below saphenofemoral junction.
Vein ligation was the treatment of choice for traumatic lesions during
World War II. However, the experience in the Korean War and mainly in
the Vietnam War changed this concept. It is known that anastomoses for
treatment of venous lesions may lead to severe chronic venous insufficiency.1
Our patient was admitted with a swollen limb, pigmentation and dermatofibrosis
all over the leg and ulcers on the lateral side of the leg and dorsum
of the foot. This suggested that it was venous obstruction, and not
insufficiency of perforator veins, the main cause for the development
of symptoms and signs, since the latter occurs most frequently on the
medial side of leg.2 It was not possible
to perform air-displacement plethysmography or invasive methods to evaluate
venous pressure, which would allow for a better diagnosis and a more
precise indication of surgical procedure.3
Surgical treatment of chronic venous insufficiency has not deserved
the same attention of vascular surgeons as had peripheral arterial disease.
There are few groups dedicated to the study of venous reconstruction,
and the number of case reports published is small. In 1970, Husni proposed
the technique of in situ saphenopopliteal bypass to treat femoral
and popliteal vein obstruction, and that was basically the technique
used in our case.4 During the last years,
some surgeons have discredited such an approach because the results
are not long lasting, particularly in cases which resulted from deep
venous thrombosis.5,6 Cases such as the
one we described in the current report are rarer. Nevertheless, reports
of venous reconstruction mention that cases of external or post-traumatic
compression present the best long-term results for popliteal and femoral
veins.1,7,8
Ferris & Kistner have performed 46 venous reconstructions and observed
that, after a mean follow-up of six years for valve repairs and three
years for segment transposition, there was no thrombosis; only four
repaired veins have lost their valve function.9
However, such results are not similar to other studies. Perrin (2000)
studied venographies performed in early postoperative period and found
segmental thrombosis in 20.3% of vein repairs and confirmed that the
overall results were better for primary venous insufficiency.10
The technique used in the present case is similar to the transposition
of the femoral vein to the saphenous vein. However, instead of transposing
the femoral vein to the saphenous vein, the saphenous vein was transposed
to the popliteal vein above the knee. Some surgeons recommend the association
of this technique with an arteriovenous fistula to increase blood flow
through the repaired segment.11
There is some concern about durability of deep venous system reconstructions.
Valve repairs and segment transpositions remain patent for a long time
in 60% to 92% of cases. An important point to emphasize is that these
surgeries have been exclusively indicated to treat ulcers due to venous
insufficiency which are not responsive to routine therapeutic measures.12-14
Reflux through perforator veins is a factor that prevents or makes it
difficult to achieve a satisfactory result with venous reconstruction.
According to Sottiurai, perforator ligation and saphenous vein stripping
associated with valvuloplasty of the deep venous system or deep vein
transposition provides better results than ligation plus saphenous vein
stripping alone in cases of deep venous valve incompetence secondary
to deep venous thrombosis.3 Ferris &
Kistner argue that treatment of chronic vein insufficiency with perforator
ligation and saphenous vein stripping results in high recurrence rate
for ulcers in cases of deep venous system insufficiency.9
Subfascial ligation of incompetent perforator veins was performed through
Linton's procedure (with modifications) until the beginning of the 1990's.
The long incisions in the leg were painful and healing complications
were frequent. In 1985, Hauer introduced the endoscopic technique (subfascial
endoscopic perforator surgery - SEPS), which made the postoperative
period easier and more comfortable to go through. It also allowed for
reducing patient stay in the hospital, and avoiding healing complications
of long incision in the leg.15 This procedure
has been preferably indicated for cases of primary chronic venous insufficiency
and for C5 and C6 patients, that is, patients
who already presented or still present ulcer. In cases of secondary
chronic venous insufficiency, results are not as satisfactory, and become
even worse if there is occlusion of the deep venous system. Ulcer recurrence
rate is 20% after five postoperative years.16,17
More recent studies refer better results in the treatment of ulcer of
chronic venous insufficiency with video-assisted subfascial perforator
ligation procedure, indicating a 5-year ulcer recurrence rate of 13%.18
Tawes et al. have published the results of a multicentric trial with
832 patients who underwent SEPS. Fifty-five percent of them underwent
saphenous vein ligation and stripping at he same operation; 92% had
the ulcer healed or significantly improved; and 8% has no benefit from
the operation. Recurrent ulceration occurred in 4% of the patients after
15 months (mean). However, this rate was reduced with successful repeat
SEPS alone or associated with deep valvuloplasty in a second moment.
There was no early postoperative death, and patients were followed for
a period of 1 to 9 years (mean of 3 ½ years). The study concluded
that SEPS is efficient, safe and long-lasting.19
Such results have been confirmed by other studies.20
These data leads the reader to conclude that it is important to associate
several techniques in order to achieve a better result, that is, to
keep the ulcer healed. This suggestion has also been made in other reports.21
In a previous report, we described our initial experience with SEPS
in our service; our results agreed with those described in literature.22
In the case presented here, SEPS promoted healing of the recurrent ulceration
after deep venous system reconstruction and also favored the control
of the chronic venous insufficiency of the patient, so that the patient
remained without ulcers for a long time. This case demonstrates that,
when treating chronic venous insufficiency, mainly C5 and
C6 cases, it is of utmost importance that the physician is
aware of several therapeutic maneuvers so that they can be associated
when necessary.
However, a doubt still remains: how would the physician know if it is
necessary to perform these operations in one or more steps? There are
opinions favoring both approaches in literature. In our case, the advantage
of performing it in two steps was to find out that both steps were important
to the patient.
We conclude that the diagnosis of chronic venous insufficiency must
be complete (in clinical, etiologic, anatomical and pathophysiologic
terms), and that knowledge of various techniques is fundamental in order
to achieve the best result.
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