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Venous system assessment after superficial femoral vein harvesting
(Portuguese PDF version)

Marco Aurélio Cardozo¹, Cláudia Bianco¹, Telmo Pedro Bonamigo²

1. MSc and specialist in Angiology and Vascular Surgery. Vascular surgeon, Irmandande Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil.
2. Associate professor, Vascular Surgery, Fundação Faculdade Federal de Ciências Médicas de Porto Alegre (FFFCMPA). Chairman of the Service of Vascular Surgery, Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil.

*This work was performed at the Service of Vascular Surgery of Irmandade Santa Casa de Misericórdia de Porto Alegre, Angiology and Vascular Surgery course, Fundação Faculdade Federal de Ciências Médicas de Porto Alegre, Porto Alegre, RS, Brazil.

Correspondence:
Marco Aurélio Cardozo
Rua Marquês do Pombal, 1199/401
CEP 90540-001 - Porto Alegre, RS
Brazil
Phone/Fax: +55 (51) 3337.2306
E-mail: macardozo@terra.com.br

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ABSTRACT

Objective: The purpose of this work was to assess venous morbidity of lower limbs after superficial femoral vein harvesting.

Methods: From December 1995 to May 2000, eight patients were submitted to nine femoral vein surgical harvesting to treat aortoiliofemoral synthetic vascular prosthetic infection. All of them were submitted clinical examination based on CEAP classification for chronic venous insufficiency of the lower limbs (clinical symptomatology, etiologies, anatomical sites and pathophysiological nature) and venous duplex scanning before and after the surgical procedure.

Results: No patient presented with clinically significant edema or signs of chronic venous insufficiency in the lower limbs used as donors of venous autografts. Follow up period ranged from 18 to 77 months.

Conclusion: The use of superficial femoral vein is a good surgical alternative for the treatment of vascular prosthetic infections, with minimal venous morbidity of the lower limbs after superficial femoral vein harvesting.

Key-words: femoral vein, venous insufficiency, lower limbs.
Palavras-chave: veia femoral, insuficiência venosa, membros inferiores.

J Vasc Br 2004;3(2):102-6

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The superficial femoral vein is an excellent alternative for lower limb revascularization.^1-4 It has also been successfully employed in arterial reconstructions of the aortoiliofemoral segment for treatment of vascular prosthetic infection, mycotic aneurysms, and patients with contamination of the surgical field by skin infection, ostomy, and entero-cutaneous fistulas.^5-13

Unfortunately, this technique is rarely employed in our environment. We believe that this is closely related to the fact that many surgeons feel apprehensive about the venous morbidity of the lower limb after superficial femoral vein harvesting. However, several cases have showed minimal venous morbidity during patient follow-up.^2-4,7,15,16

In this study, we evaluated the venous system of the lower limbs in patients who underwent superficial femoral vein harvesting for the treatment of vascular prosthetic infection.

PATIENTS AND METHODS

Between December 1995 and May 2001, 13 patients underwent 14 surgical procedures for reconstruction of the aortoiliofemoral segment with femoral vein. In all cases, the surgical indication was the treatment of vascular prosthetic infection. Five patients were excluded from the study. In two cases color Doppler ultrasound evaluation of the venous system was not performed in the preoperative period. Two patients died and one patient needed thigh amputation after surgery. In this study, eight patients underwent nine superficial femoral vein harvesting. One patient (case 3) underwent bilateral harvesting. Seven patients (87.5%) were male and one (12.5%) was female. Age ranged from 38 to 77 years (mean age of 62.1 years).

Indication for use of uni or bilateral lower limb deep veins depended on the size of the procedure. All patients were examined in an adequate room, under natural light, in dorsal decubitus position and orthostatic position for clinical verification of signs that could suggest or not the presence of venous insufficiency. The CEAP classification system was adopted to evaluate the lower limbs. This system provides a classification of venous diseases on the basis of clinical symptomatology, etiology, anatomy of disease distribution and pathophysiology.¹⁷ A preoperative and postoperative complementary study was performed through noninvasive evaluation of deep and superficial venous system with color Doppler ultrasound.

The surgical technique employed to dissect the superficial femoral veins is based on the study of Clagett et al.⁶ Nine superficial femoral veins were dissected. Suction drains were used on the bed of the dissected veins on all lower limbs. In the early postoperative period, all patients received prophylactic anticoagulation with subcutaneous conventional heparin. Compressive elastic bandage was applied for 72 hours and the patients were kept in Trendelemburg position until walking. In the late postoperative period, normal walking was recommended. Routine use of elastic compression stocking was not prescribed. Outpatient follow-up was scheduled at 30 days after surgery and, subsequently, at every six months.

RESULTS

The preoperative evaluation performed according to CEAP classification showed one patient (case 3) with primary and asymptomatic superficial varicose veins in the lower limbs (Table 1). Noninvasive investigation with color Doppler ultrasound revealed the presence of normal greater saphenous vein in six limbs (66.6%) and its absence in three limbs (33.3%). The study of deep venous system showed patent and compressible common, deep and superficial femoral , popliteal and leg veins, with phasic flow with breathing. And no evidence of reflux, thrombus or parietal changes was found in any patients.

Table 1 - Preoperative clinical examination (CEAP classification)

Case	Internal saphenous vein	Clinic	Etiologic	Anatomic	Pathophysiologic
1 RLL	yes	0A	-	-	-
2 LLL	no	0A	-	-	-
3 LLL RLL	yes yes	2A 2A	P P	SV 5 SV 5	R R
4 RLL	yes	0A	-	-	-
5 LLL	no	0A	-	-	-
6 LLL	yes	0A	-	-	-
7 RLL	yes	0A	-	-	-
8 LLL	no	0A	-	-	-

RLL: right lower limb; LLL: left lower limb; 0A: absence of varicose disease and asymptomatic; 2A: varicose veins and asymptomatic; P: primary; SV 5: nonsaphenous superficial veins; R: reflux.

Superficial femoral vein dissection was performed in nine lower limbs. These veins had an average length of 24 cm. The diameter ranged from 10 to 15 mm. Hypoplastic vein, thrombus formation, or fibrosed veins were not observed. All dissected veins had three valves. The surgical time from the completed dissection of the vein to the skin closure on the thigh was around 90 minutes.

During postoperative period, there was no surgical wound infection on the lower limbs used as donors of venous graft. There was no complaint about neurological injury of the operated lower limbs. Clinically significant edema on lower limb was not observed in any case after dissection of the superficial femoral vein. There was no significant change comparing to the preoperative clinical evaluation in seven patients (87.5%). One patient (case 3) referred strong pain and increased volume of the superficial veins on the lower limbs from where the superficial femoral veins were dissected (Table 2).

Table 2 - Postoperative evaluation of case 3 (CEAP classification)

Case	External saphenous vein	Clinical	Etiologic	Anatomic	Pathophysiologic
3 LLL RLL	Yes Yes	2S 2S	P P	SV 5 SV 5	R R

2S: symptomatic varicose veins; P: primary; SV 5: nonsaphenous superficial veins; R: reflux.

Color Doppler ultrasound revealed patent deep venous systems without reflux in eight patients. In one patient, who was asymptomatic, recanalized thrombosis of the popliteal vein and absence of reflux were found (Table 3).

Table 3 - Postoperative venous color Doppler

Case	Common femoral vein	Deep femoral vein	Popliteal Vein	Posterior tibial vein	Internal saphenous vein
	P R	P R	P R	P R	P R Ø
1	yes no	yes no	yes 2.4 s	yes no	yes no
2	yes no	yes no	yes no	yes no	absent
3 LLL RLL	yes no yes no	yes no yes no	RT no yes no	yes no yes no	yes yes 4.2 mm yes no 5.1 mm
4	yes no	yes no	yes no	yes no	yes no 2.9 mm
5	yes no	yes no	yes no	yes no	absent
6	yes no	yes no	yes 1.43 s	yes no	yes yes 3.3 mm
7	yes no	yes no	yes no	yes no	yes no
8	yes no	yes no	yes no	yes no	absent

P: present; R: reflux; Ø: diameter; LLL: left lower limb; RLL: right lower limb; RT: recanalized thrombosis.

DISCUSSION

Superficial femoral vein dissections of nine lower limbs were performed. The average size was 24 cm and diameter ranged from 10 to 15 mm. The number of valves (three valves) found in the veins was similar to the observation of Clagett et al.¹⁵ with 63 dissected veins. Nevelsteen et al.,⁷ in 26 dissected veins, noted a diameter that varied from 7 to 15 mm.

A patient who underwent bilateral superficial vein harvesting (case 3) presented with pain complaint and increased volume of the superficial veins, previously asymptomatic. No clinically significant edema was found in any of nine lower limbs used as donors of venous autografts. None patient developed clinical signs of chronic venous stasis. This finding has also been reported by authors who use deep veins from lower limbs as peripheral arterial substitutes, particularly femoro-popliteal shunts. These authors emphasize the preservation of the common femoral, deep femoral and ipsilateral great saphenous veins in order to avoid postoperative lower limb edema, even though its prevalence is rare.^2,18-19 Coburn et al.³ found severe venous stasis when the popliteal vein was sectioned below the knee line. Sladen et al.⁴ studied 25 limbs submitted to revascularization with femoral vein and absence of ipsilateral great saphenous vein. The authors demonstrated that, in this case, the postoperative edema is rare.

Fokin et al.⁵ were the first authors to use deep veins from lower limbs to treat vascular prosthetic infection of the aortoiliofemoral segment. Only one out of 12 patients presented with significant signs of venous insufficiency. Nevelsteen et al.,⁷ in 26 lower limbs used as donors of venous autografts for treatment of infected arterial prosthesis, demonstrated venous flow obstruction assessed by plethysmography in 80% of cases. No patient presented with functional incapacity, and one patient required prolonged use of elastic stocking due to edema of the lower limb and signs of chronic venous hypertension, manifested two years after surgery.

Recently, Wells et al.¹⁶ studied 86 lower limbs of 61 patients submitted to femoral vein harvesting for use as aortoiliofemoral shunt after removal of infected prosthesis, femoro-popliteal shunt, or major venous reconstruction. Follow-up period ranged from three to 37 months. Less than a third of the lower limbs presented discrete edema without changes in the skin (C3 of the CEAP classification). No patient developed signs of severe chronic venous insufficiency with skin changes , ulcerations (C4 - C6 of the CEAP classification) or claudication of venous origin. The results obtained were not influenced by presence or absence of the ipsilateral great saphenous vein. In 93% of the lower limbs studied, plethysmography examination revealed venous flow obstruction . The authors conclude that the major protective mechanisms in order to occur minimal venous morbidity are low incidence of reflux, presence of venous collateral circulation and physiologic rehabilitation of the lower limb.

Santilli et al.²⁰ developed an anatomic study with dissection of 44 superficial femoral and popliteal veins from 39 corpses, with emphasis on the length and location of valves and branches of these veins. They conclude that the safer length to perform dissection of the superficial femoral vein is around 28 cm in men and 22 cm in women, and for the popliteal vein 15 and 12 cm, respectively. The authors called attention to the importance of preserving one valve from the popliteal vein to avoid reflux. They also emphasized the preservation of a branch longer than 2 cm to avoid thrombosis of the vein.

CONCLUSIONS

The use of superficial femoral vein is a safe surgical option that can be offered to patients candidates to vascular restoration. The venous morbidity of the lower limbs used as donors of the venous autografts is minimal. No clinically significant edema, as well as chronic venous insufficiency, were observed during postoperative follow-up.

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