Ligation Of Incompetent Perforating Veins Research Articles

Early changes in the post-phlebitic limb: their clinical significance.

Abstract The long-term results of treatment of the established post-phlebitic syndrome by compression sclerotherapy or by ligation of incompetent perforating veins were unsatisfactory in approximately 40 per cent of patients. Changes in superficial venous pressure during exercise occurred when the deep veins were recanalized and the perforating veins became incompetent. These pressure changes could be used to select patients likely to develop the full syndrome. It is suggested that development of an intractable syndrome might be prevented if ligation of incompetent perforating and deep veins is performed before tissue changes become established.

The place of subfascial ligation of perforating veins in the treatment of the post-phlebitic syndrome.

Abstract Subfascial ligation of incompetent perforating veins was employed in the treatment of 103 patients. The patients were selected on clinical grounds and the existence of perforating veins was established by phlebography. The description of the technique employed stresses details contributing to safe and rapid healing when a radical exploration is performed through skin and subcutaneous tissues of poor vitality. The role of subfascial ligation in the treatment of the post-phlebitic syndrome is to control the disordered venous return consequent on obstruction of the calf-muscle pump. As such, the procedure is one part of the treatment of the limb as a whole.

Closed Subfascial Ligation of Incompetent Perforating Veins of the Lower Extremities

The purpose of this study was to determine the effectiveness of minimally invasive surgical procedures for interrupting incompetent perforating veins of the lower limb. A closed subfascial ligation was performed in 20 patients who had incompetent perforating veins in 28 limbs as diagnosed by a clinical examination and duplex scanning. Two small transverse incisions measuring 5-10 mm in length were made on both sides of the incompetent perforating vein. Using an aneurysmal needle, a suture (polypropylene No. 1) was placed in the subfascial plane to encircle the incompetent perforating vein from all directions. Next, this suture was tied through two incisions to ligate this perforator. The mean follow-up period was 26 months. The ligation of the incompetent perforators was successful in 27 of 28 limbs and no wound complications were observed. A closed subfascial ligation of incompetent perforating veins of the lower limbs is thus considered to be easy to perform, not overly invasive, safe, and to also have very encouraging results.

Treatment of primary varicose veins: An assessment of the combination of high saphenous ligation and sclerotherapy

This study was conducted to determine the optimal treatment for minimizing the recurrence of varicose veins, and to assess the value of the combined treatment of high saphenous ligation and sclerotherapy. A combined total of 967 limbs in 660 patients with primary varicose veins were treated. The treatments comprised: sclerotherapy alone in 81 limbs, high saphenous ligation alone in 3 limbs, a combination of sclerotherapy and high saphenous ligation in 843 limbs, and a combination of sclerotherapy and ligation of incompetent perforating veins in 10 limbs. Recurrent varicose veins appeared from 3 months after the initial treatment in 61 (6.3%) limbs. Saphenous-type recurrence, being the presence of saphenofemoral incompetence (SFI) and/or saphenopopliteal incompetence (SPI), was found in 20 limbs, and further treatment was given. Segmental-type recurrence, being superficial varices without SFI or SPI, was found in 41 limbs, all of which were treated with further sclerotherapy alone. To minimize the recurrence rate of varicose veins, the presence or absence of SFI, SPI, and incompetent perforating veins must be confirmed prior to the initial treatment. It was concluded that the combination of high saphenous ligation and sclerotherapy is effective for patients with SFI and/or SPI, whereas sclerotherapy alone is better for patients without SFI or SPI.

Classic versus Endoscopic Perforating Vein Surgery : a Retrospective Study

Purpose and Methods. In this retrospective non-randomized study the results of the Felder technique (n=29) were compared to two endoscopic techniques for ligation of incompetent perforating veins: using a mediastinoscope (n=19) and laparoscopic instruments (n=57). The indication was a venous ulcer in nine, five and thirteen patients respectively, lipodermatosclerosis in thirteen, five and twenty-four, and simple varicose veins in the remaining patients (NS).Results. The mean number of interrupted perforating veins was 4.2, 2.4 and 3.8 (p < 0.05). I he mean hospital stay was 3.5, 1.9 and 1.6 days (p < 0.0001). The mean period of convalescence was 8.7, 4.1 and 3.7 weeks (NS). The number of complications was 9 (suralis lesion 4, pain/swelling 4, wound problem 1), 6 (saphenous lesion 3, pain/swelling 3) and 15 (pain/swelling 14, deep venous thrombosis 1) (NS).Ten patients were lost to follow-up (five, two and three). Respectively 19, 12 and 45 patients were satisfied with the end-result. The condition had worsened in one, two and three patients (NS). During the short follow-up period all ulcers healed and there was no recurrence.Conclusion. The endoscopic techniques produce results comparable to the FELDER procedure, with smaller scars and a tendency towards a faster recovery.

Efficacy of subfascial endoscopy in eradicating perforating veins of the lower leg and its relation with venous ulcer healing.

The purpose of this study was to investigate the efficacy of subfascial endoscopy by use of a mediastinoscope in the identification and ligation of incompetent perforating veins in patients with venous ulceration of the lower leg. All patients who underwent subfascial endoscopy for venous ulceration between Jan. 1, 1994, and Mar. 1, 1995, at the Sint Franciscus Gasthuis in Rotterdam underwent duplex ultrasound scans of the lower leg before and 6 weeks after operation. The number and localization of the perforating veins on the mediodorsal side were compared with the findings during subfascial endoscopy. In 20 patients, preoperative duplex examination showed 46 incompetent and six competent perforating veins. During operation the site of 43 incompetent and all competent perforating veins was confirmed. Five additional perforating veins were found at operation (false-negatives). Postoperative duplex ultrasound scans showed six incompetent perforating veins (four persisting and two recurring perforating veins) in four patients, of which the ulcers did not heal in three. The ulcers of the other 17 patients healed. Subfascial endoscopy is an efficient technique in identifying incompetent perforating veins in patients with chronic ulceration of the lower leg. The persistence of incompetent perforating veins is related to failure of ulcer healing.

Miniincisional ligation of incompetent perforating veins of the legs.

The purpose of this study was to determine the effectiveness of a new surgical procedure for interrupting incompetent perforating calf veins in patients with recalcitrant venous ulcers. Eighteen patients with venous ulcerations in 26 limbs had incompetent perforators diagnosed by duplex scanning. All were taken to the operating room, where the fascial defects through which the perforators coursed were obliterated by a "pursestring" permanent suture placed on the leg fascia. Follow-up duplex scanning was carried out within 2 weeks of the procedure and every 6 months thereafter. The mean follow-up in this series was 22 months. Initial success in obliterating the perforators was noted in 24 (92.3%) of 26 legs. Three subsequent failures occurred within 6 months for a midterm success rate of 80.7%. No wound complications or infections occurred. All ulcers healed within 6 weeks of the procedure (mean, 23 days) in the successfully treated patients. Miniincisional ligation of incompetent perforating veins is easy to perform and has very encouraging early results.

The clinical relevance of measuring urinary vanillylmandelic acid (VMA) questioned: M. van Agteren 1, H.S.L.M. Tjen 1, J.W. Janssen 2. Departments of Internal Medicine 1 and Clinical Chemistry 2, Sint Franciscus Gasthuis, Rotterdam, Netherlands

Purpose: The purpose of this study was to investigate the efficacy of subfascial endoscopy by use of a mediastinoscope in the identification and ligation of incompetent perforating veins in patients with venous ulceration of the lower leg.Methods: All patients who underwent subfascial endoscopy for venous ulceration between Jan. 1, 1994, and Mar. 1, 1995, at the Sint Franciscus Gasthuis in Rotterdam underwent duplex ultrasound scans of the lower leg before and 6 weeks after operation. The number and localization of the perforating veins on the mediodorsal side were compared with the findings during subfascial endoscopy.Results: In 20 patients, preoperative duplex examination showed 46 incompetent and six competent perforating veins. During operation the site of 43 incompetent and all competent perforating veins was confirmed. Five additional perforating veins were found at operation (false-negatives). Postoperative duplex ultrasound scans showed six incompetent perforating veins (four persisting and two recurring perforating veins) in four patients, of which the ulcers did not heal in three. The ulcers of the other 17 patients healed.Conclusions: Subfascial endoscopy is an efficient technique in identifying incompetent perforating veins in patients with chronic ulceration of the lower leg. The persistence of incompetent perforating veins is related to failure of ulcer healing. (J Vasc Surg 1997 26:255-9.)

Surgical technique and preliminary results of endoscopic subfascial division of perforating veins

Direct surgical ligation of incompetent perforating veins has been reported to effectively treat severe chronic venous insufficiency. It is associated, however, with significant wound complications. We evaluate our early experience with endoscopic subfascial division of the perforating veins. From August 5, 1993, to December 31, 1994, 11 legs in nine patients (five male and for female) were treated with endoscopic subfascial division of perforating veins. Nine of the 11 legs had active or recently healed venous ulcers. Mean duration of the ulcerations was 5.6% years. Standard laparoscopic equipment with 10-mm ports was used to perform clipping and division of medial perforating veins through two small incisions made just below the knee, avoiding the area of ulcer and lipodermatosclerosis. Carbon dioxide was insufflated at a pressure of 30 mm Hg into the subfascial space to facilitate dissection, and a pneumatic thigh tourniquet was used to obtain a bloodless operating field. Concomitant removal of superficial veins was performed in eight limbs. Mean follow-up was 9.7 months (range, 2 to 13 months). A mean of 4.4 perforating veins (range, 2 to 7) were divided; tourniquet time averaged 58 minutes (range, 30 to 72). Wound infection of a groin incision and superficial thrombophlebitis were early complications; each occurred in one patient. In seven legs the ulcer healed or did not recur and symptoms resolved. In three legs, the ulceration improved, and in one it was unchanged. Endoscopic subfascial division of perforating veins seems to be a safe technique, with favorable early results obtained in a small number of patients. This preliminary experience supports further clinical trials to evaluate this technique.

Subfascial endoscopic ligation in the treatment of incompetent perforating veins

To assess the technique of subfascial endoscopic ligation of incompetent perforatory veins by use of a mediastinoscope. Prospective open clinic study. Two Departments of Surgery. Thirty-eight consecutive patients (40 legs) with recurrent or protracted venous ulceration of the lower leg were treated. Through a short, transverse incision of the skin and fascia in the proximal 1/3 of the lower leg a mediastinoscope (length 18 cm, diameter 12 mm) is inserted after which the perforating veins are ligated by haemoclips under direct vision. All legs showed signs of incompetent perforating veins by clinical examination, confirmed with continuous wave ultrasonography and in 31 legs there was associated deep vein incompetence. Sixteen patients had active ulceration at the moment of operation and 22 had a history of recent or recurrent ulceration. One patient developed an inflammatory reaction at the wound and in two legs a subfascial infection occurred, necessitating surgical drainage. No postoperative mortality was seen. All 16 ulcers healed within 2 months (mean: 34 days; range: 21-55 days). During a mean follow-up of 3.9 (range: 2-5) years only one out of 38 patients (2.5%) developed a recurrent ulcer. Subfascial endoscopic ligation of incompetent perforating veins by use of a mediastinoscope is a relatively simple technique with a low postoperative complication rate and a low recurrent ulcer rate which makes it a valuable method for treating incompetent perforating veins.

Sclerotherapy or Surgery as Treatment for Varicose Veins: A Prospective Randomized Study

Objective: To compare the long-term results following radical surgery or compression sclerotherapy (CST) of primary varicose veins. Design: Prospective, randomized study of 164 patients. The patients were assessed with clinical tests and foot volumetry, before the 6 months, 1, 3 and 5 years after treatment. Setting: Department of Surgery, University of Lund, Sweden. Patients: 164 patients referred to the clinic for treatment of symptomatic primary varicose veins. Eighty patients were randomized to surgery and 84 to CST. Interventions: Sclerotherapy was applied using the ‘empty vein’ technique followed by compression bandage for 6 weeks. The extent of surgery was determined by each patient's disease and included flush ligation of the long or short saphenous veins and subsequent stripping, ligation of incompetent perforating veins and resection of local varicosities. Main outcome measures: The recurrence rate of varicose veins and incompetence of perforators and saphenous veins. Results: Good results were achieved in both treatment groups immediately after the procedure, but the failures appeared earlier in the CST group and the number was higher compared with the surgery group. After 5 years only 10% of the operated patients were considered as treatment failures compared with 74% of the patients treated with CST. The clinical results were supported by the foot volumetry measurements. Conclusions: This study clearly indicates that patients with primary varicose veins and incompetent saphenous veins should be treated with surgery, and CST should be confined to local varicosities, isolated insufficient perforators or recurrences after adequate surgery.

Venous Stasis Ulceration

Forty-seven extremities with recurrent venous ulceration were treated by subfascial ligation of incompetent perforating veins. The limbs were observed for an average of 8.5 years (range, 0.5 to 13 years). The risk for recurrence was 22%, 41%, and 51% at 1, 3, and 5 years, respectively. Patients with bilateral ulceration or prior venous ligation were at the highest risk for recurrence, while those with prior excision of prominent varicose veins had a reduced risk. There has been no loss of limbs or life secondary to this venous problem during the 398 cumulative years of observation.