Saphenopopliteal Junction Research Articles

Peroperative Venography in Sapheno-Popliteal Ligation: Still a Useful Technique

Objective: To establish the efficacy of peroperative venography in identifying the use of the sapheno-popliteal junction during varicose vein surgery. Design: Single patient group. Setting: District General Hospital, Edgware, Middlesex, UK. Patients: Forty-one patients undergoing sapheno-popliteal ligation for varicose veins of the lower limb. Interventions: Surgical exploration and ligation of the sapheno-popliteal junction. Main outcome measures: Peroperative venographic demonstration of the short saphenous vein and sapheno-popliteal junction. Results: Thirty-four sapheno-popliteal junctions (85%) lay at a site approachable by a conventional incision. Five junctions lay higher than this and one lower. Conclusions: On-table venography is an efficient, quick and reliable way of demonstrating the anatomical site of the sapheno-popliteal junction.

Recurrent varicose veins. Part 1: Evaluation utilizing duplex venous imaging.

There is the need to develop a universally accepted standard investigation for recurrent varicose veins. Duplex venous imaging offers a precise, non-invasive technique to make anatomic and hemodynamic diagnoses. A routine protocol of duplex imaging of recurrent varicose veins is described based on the known recurrent sources of reflux from deep to superficial veins. Results from this protocol indicate that incompetent perforating veins are the most common site of reflux from deep to superficial veins in patients with recurrent postsurgical varicose veins. Other important sites of reflux detected by this method are recurrent communications with the common femoral vein, the saphenopopliteal junction, and incompetent pelvic veins. Duplex imaging is recommended as a safe, non-invasive method of evaluating recurrent varicose veins.

Duplex ultrasound mapping of sites of deep to superficial incompetence in primary varicose veins.

Most patients undergoing treatment for primary varicose veins have only a clinical assessment or examination with a continuous wave Doppler. In this study duplex ultrasound was used to determine the site of deep to superficial reflux in 137 limbs of 96 patients presenting with primary varicose veins. The incidence of saphenopopliteal (22%) and perforator (28%) incompetence was higher than that in previous studies based on clinical examination. Only five limbs had deep venous incompetence at the popliteal level and three of these limbs had lipodermatosclerosis or ulceration. The saphenopopliteal junction was either absent or more than 10 cm from the knee joint in 13% of limbs. The information obtained from duplex scanning of patients with primary varicose veins facilitates surgical management and may lead to a lower recurrence rate.

Preoperative localisation of the saphenopopliteal junction with duplex scanning

The anatomy of the saphenopopliteal junction shows considerable variation, and clinical localisation of this junction is inaccurate. Duplex scanning in preoperative mapping of the saphenous vein system in bypass surgery has been shown to be highly effective. In 62 patients with clinical evidence of insufficiency of the saphenopopliteal junction, preoperative localisation with duplex scanning was performed in 66 extremities. In 62 extremities duplex localisation matched the operative findings and in four extremities a difference of 2 cm or more was found. There was 1 false negative surgical exploration. In 93% of the cases exact localisation of the junction enabled us to perform flush ligation of a small saphenous vein through minimal exposure. Preoperative duplex scanning of the saphenopopliteal junction is highly accurate.

Duplex Scanning of Recurrent Varicose Veins

Successful treatment of recurrent varicose veins depends on accurate assessment of the cause. Clinical examination with knowledge of previous treatment and Doppler assessment should detect most causes. Previously venograms for vulval veins, short saphenous disease and unusually distributed veins have helped. Experience with B-mode ultrasound for several years, duplex scanning for 18 months, and the manufacture of standoffs, has enabled us to examine veins from the inferior vena cava to very superficial varicosities. Previous research on vulval varicose veins has been re-examined by duplex scanning, but the evaluation of pelvic veins is more difficult. While the round ligament and male varicocele can be reasonably assessed, the preoperative assessment of the sapheno–femoral and sapheno–popliteal junctions is so accurate that it has supplanted the use of venograms. The study of Doppler wave forms to assess valve function and the detection of reversed flow, should also help in further studies on chronic venous insufficiency and perforating vein disease.

Functional Meaning of Different Injection Levels in the Course of Sclerotherapy

The successive changes of vein function in the course of sclerotherapy were studied by non-invasive photoplethysmography. The effect of injection at different levels was analysed in 30 patients, 22 with long saphenous varicosis, four with short saphenous varicosis and four with long saphenous varicosis and leg ulcers. The first two groups were treated by injections descending from the *crosse (saphenofemoral or saphenopo-pliteal junction) according to the method of Tournay. The third group (with leg ulcers) were treated by ascending injections, beginning adjacent to the ulcer and ending with crosse injection. Three case-reports are given, of one in each group, to show the typical changes of vein function in the different sclerosing methods. Crosse obliteration proved to be the most important step in improving vein function. It was followed by sclerosing of perforators of the lower leg, which influenced vein function in varying ways. Sclerosing remaining varicose dilations only optimized the cosmetic results without any measurable effect on vein function. According to our observations, failure to correct sapheno-femoral respectively sapheno-popliteal incompetence is inadequate treatment.

Treatment of varicose veins: modern concepts and methods.

Varicose veins have been a somewhat neglected entity. Treatment usually consists of routine stripping of the main trunks and excision of all distal tributaries, resulting in many unsightly scars. Modern diagnostic methods trace the origin of the reflux causing the condition. If the saphenofemoral or saphenopopliteal junction is involved, limited surgery is done, followed by sclerotherapy of the varicose tributaries later. Many cases can be treated with sclerotherapy only. A description of the new concepts is given. A diagnostic classification is presented, together with the corresponding methods of treatment.

Short Saphenous Vein Surgery, Pre-Operative Doppler Ultrasound Marking Compared with on-Table Venography and Operative Findings

Unidirectional Doppler ultrasound is a simple and inexpensive adjunct to the clinical examination of varicose veins; its accuracy in determining the level of the saphenopopliteal junction has not previously been assessed. A total of 30 limbs with saphenopopliteal reflux were examined with a portable Doppler on the day of surgery and the upper limit of reflux marked. This was compared with the findings of on-table venography and surgery. Venography provided accurate anatomical information in only 84% of cases, in the failures the Doppler mark proved useful by eliminating the need for multiple incisions. Doppler estimation of the saphenopopliteal junction was correct in only 40% of cases but in nine cases out of 10 it was within 2 cm; a distance that will allow appropriate surgery through a single incision. In experienced hands the use of unidirectional doppler may eliminate the need for pre-operative venography in selected cases.

Doppler ultrasound detection of saphenofemoral and saphenopopliteal incompetence and operative venography to ensure precise saphenopopliteal ligation.

Recurrent varicose veins may result from inadequate assessment or inadequate surgery. In this study, 110 consecutive patients (165 limbs) were assessed pre-operatively for the presence or absence of reflux at the saphenofemoral (SF) and saphenopopliteal (SP) junctions by clinical assessment and by Doppler ultrasound. The pre-operative results where then compared with findings at the time of surgery. Doppler ultrasound as a means of predicting SF and SP incompetence was superior to clinical assessment. Doppler Doppler ultrasound detected 100% (two false positives) of incompetent SF junctions, and 100% (six false positives) of incompetent SP junctions, compared to the clinical detection of 72% (no false positives) and 64% (five false positives), respectively. Short saphenous venography was performed in 36 limbs in which SP reflux was suspected on clinical assessment and/or by Doppler ultrasound. It proved valuable in demonstrating the level and mode of termination of the short saphenous vein. This guided the placement of the skin incision.