Pitfalls in recurrent varicose vein surgery

Abstract

A 62-year-old lady previously had a left sapheno-femoral ligation with stripping of the long saphenous vein and multiple avulsions 10 years ago. The pre-operative duplex scan, performed by an experienced vascular technologist, showed a patent and competent deep venous system with no evidence of previous deep vein thrombosis. The sapheno-femoral junction (SFJ) was shown to have been surgically ligated but a small tortuous recurrence was noted to fill the groin varices. It was evident that the proximal long saphenous vein had been stripped. The residual mid-thigh long saphenous vein was significantly incompetent and filled by the sapheno-femoral junction recurrence and by a large atypical incompetent branch that coursed medially and proximally to the sapheno-femoral junction. The duplex report was reviewed by the surgeons and operative religation of the SFJ with avulsion of the new varicose veins was considered the best management. The patient had no clinical episode of deep venous thrombosis before surgery, but the large medial thigh varicose vein appeared to be unusual. Chase Farm Hospital have a policy of performing on-table varicogram for all atypical veins because a significant proportion could be a result of ovarian vein incompetence (Giannoukas et al, 2000) and the source may not be detected by duplex imaging (Urigo et al, 1993). Peri-operatively, a tributary of the atypical large medial thigh varicose vein was cannulated and an on-table varicogram was performed (Figures 1–3). It showed the absence of the ipsilateral left femoral vein with the contrast draining across the pubis into the contralateral femoral vein. The left groin was explored surgically to verify the varicogram findings and the surgeons were expecting to find an SFJ recurrence. The left femoral vein was found to be a thin solid cord structure with no doppler signal audible. This was presumed to have become fibrotic either from previous sapheno-femoral ligation or from previously unknown deep venous thrombosis prior to surgery. It was therefore decided that the SFJ recurrence should be left alone as the only venous outflow for the left leg was via these upper medial thigh recurrent varicose veins and the superficial collaterals that had developed across the pubis. The latter was recognized as being exactly the superficial venous reconstruction described by Palma (1976) for iliac venous obstruction. This phenomenon occurred naturally in our patient as a consequence of an unrecognized deep venous thrombosis in the left common femoral and external iliac veins (auto-Palma phenomenon) (Figure 4 (iv)).