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Letter to the Editor, RE: EJVES 2004;28:104–107
Correspondence
M. Bongiovanni1, M. Pisacreta2, M. Ortu1, F. Tordato , R. Codemo2, C. Gervasoni1, R. Gornati2, S. Trovati1, R. Piolini1, E. Chiesa1, T. Porretta2, T. Bini1 a Institute of Infectious Diseases and Tropical Medicine, University of Milan, and bUnit of Vascular Surgery, Luigi Sacco Hospital, Milan, Italy 1
References 1 Friis-Moller N, Webber R, Reiss P et al. Cardiovascular disease risk factors in HIV patients–association with antiretroviral therapy. Results from the DAD study. AIDS 2003;17(8):1179–1193. 2 Holmberg SD, Moorman AC, Williamson JM et al. Protease inhibitors and cardiovascular outcomes in patients with HIV-1. Lancet 2002;360:1747–1748. 3 Moore RD, Keruly JC, Lucas G. Increasing incidence of cardiovascular diseases in HIV-infected persons in care. 10th Conference on Retroviruses and Opportunistic Infections, Boston, February 10–14; 2003, abstract 132. 4 DAD Study Group. Combiantion antiretroviral therapy and the risk for myocardial infarction. NEJM 2003;349:1993–2003. 5 Bozzette SA, Ake CF, Tam HK et al. Cardiovascular and cerebrovascular events in patients treated for human immunodeficiency virus infection. NEJM 2003;348:702–710. 6 Lipshultz SE, Fisher SD, Lai WW et al. Cardiovascular risk factors, monitoring, and therapy for HIV-infected patients. AIDS 2003;17(Suppl 1):S96–S122.
453
who had a double lumen endotracheal tube to allow both sides to be operated on at the same operation, which lead to hypoxia of the brain. Our experience is to use a similar endotracheal anaesthesia and but to only to perform this operation on one side at a time. As well as reducing the possible anaesthetic risk also allows the patients to experience any side effects especially the compensatory sweating. If this is troublesome then the patient may have no wish to have the other side done. A. Tiwari, A.M.S. Abeysekara, J.B. Coker, S. Jacob Department of Vascular Surgery, King George Hospital, Goodmayes, UK
References 1 Nyamekye IK. Current treatment options for treating primary hyperhidrosis. Eur J Vasc Endovasc Surg 2004;27:571–576. 2 Ojimba TA, Cameron AEP. Drawbacks of endoscopic thoracic sympathectomy. Br J Surg 2004;91:264–269.
Accepted 21 July 2004
Accepted 21 July 2004 doi:10.1016/j.ejvs.2004.07.013, available online at http://www.sciencedirect.com on doi:10.1016/j.ejvs.2004.07.015, available online at
Letter to the Editor, RE: EJVES 2004;28:104–107
http://www.sciencedirect.com on
Current Treatment Options for Treating Primary Hyperhidrosis We read with interest the comprehensive review article by Nyamekye.1 Some of the complications of treating hyperhidrosis using endoscopic thoracic sympathectomy, however, have not been fully discussed. In a recent review article by Ojimba and Cameron,2 significant complications of this procedure highlighted include death, (though as highlighted by the author never actually reported in the literature), bleeding, neuralgia and rebound sweating. The other problem, which has been highlighted is compensatory sweating which the authors have reported is probably more prevalent than actually reported. The patients who died from anaesthetic complication were those * In order to avoid possible confusion between the terminology used by the Authors and that suggested in #7, in this letter, the veins of the lower limb are designated with the original Latin terms.
I read with great interest the article from Dr MacKenzie and coll. entitled ‘The effect of Long Saphenous Vein stripping on deep venous reflux’ (EJVES 2004; 28: 104–107) which confirms that radical surgery of varicose veins enhance deep veins hemodynamics. The authors evaluated deep venous hemodynamics at the thigh by insonating only the Vena Femoralis.* Their findings would be further enhanced by extending Duplex evaluation to the Vena Femoralis Communis, due to its closer hemodynamic interdependency with of the proximal Vena Saphena Magna.1 The authors reported a ‘surprisingly common failure to obtain complete stripping’ of the Vena Saphena Magna after its stripping to the knee. In 62% of limbs, the postoperative Duplex demonstrated remnants of various length ‘.of the Vena Saphena Magna removed in the thigh’. This intriguing and apparently paradoxical finding could be explained by the particular anatomy of thigh superficial veins. The classic studies of Glasser,2 Eur J Vasc Endovasc Surg Vol 28, October 2004
454
Correspondence
Sherman3 and Haeger,4 demonstrated that one or even two large superficial veins may ascend parallel to the Vena Saphena Magna. A ‘double or triple saphenous system’ was firstly demonstrated by Leonardo da Vinci5 and it occurs in about one half of limbs (45–62%) evaluated by venography5 and sonography.6 These parallel veins are called ‘Accessories of the Vena Saphena Magna’ and designated on the basis of their topography in Anterior, Posterior or Superficial.7 Duplex can easily discriminate these veins from the Vena Saphena Magna because they course out of the Saphenous Compartment, in a more superficial plane of the subcutaneous tissue.8,9 In varicose limbs, the reflux may descend along the Vena Saphena Magna, along an accessory vein or both.9 But, the stripper strips only the vein in which it courses and the other automatically becomes a ‘residual’. If varicose, the residual vein benefits from surgery only when this abolishes the reflux or induces its thrombosis. If the residual vein will recanalize, it will look like a ‘remnant’. If a new reflux will develop (from the saphenic stump, from pelvic veins or from a perforator), it will descend along the residual vein to possibly nourish leg varicosities. Thanks to the different planar anatomy and fascial relationships,7 Duplex can discriminate the leg Vena Saphena Magna from its accessories, which are more frequently afflicted with varicose changes.10 The ‘.high incidence of below-knee reflux after stripping of the Vena Saphena Magna to the knee.’ probably concerns saphenous accessories and tributaries, because at the leg, the Vena Saphena Magna is rich of valves and well protected by the Saphenous Fascia against varicose changes.8 Concluding, I strongly agree with the authors
Eur J Vasc Endovasc Surg Vol 28, October 2004
convincement that ‘this study reinforces routine preoperative duplex’. But this must take into account the clear anatomical and topographical differences between saphenous trunks and accessories. A. Caggiati Department of Anatomy, University ‘La Sapienza’, Rome, Italy
References 1 Cappelli M, Molino Lova R, Ermini S, Zamboni P. Hemodynamics of the sapheno–femoral junction. Patterns of reflux and their clinical implications. Int Angiol 2004;23:25–28. 2 Glasser ST. An anatomic study of venous variations at the fossa ovalis. Arch Surg 1943;46:289–295. 3 Sherman RS. Varicose veins. Anatomic findings and an operative procedure based upon them. Ann Surg 1944;120:772– 784. 4 Haeger K. The surgical anatomy of the sapheno-femoral and sapheno–popliteal junctions. J Cardiovasc Surg 1962;3:420–427. 5 Shah DM, Chang BB, Leopold PW, Corson JD, Leather RP, Karmody AM. The anatomy of the greater saphenous venous system. J Vasc Surg 1986;3:273–283. 6 Ruoff BA, Cranley JJ, Hannan LA, Aseffa N, Karkow WS, Stedje KG, Cranley RD. Real-time duplex ultrasound mapping of the greater saphenous vein before in situ infrainguinal revascularization. J Vasc Surg 1987;6:107–113. 7 International Interdisciplinary Consensus Committee on Venous Anatomical Terminology. Nomenclature of the veins of the lower limbs: an international interdisciplinary consensus statement. J Vasc Surg 2002;36:416–422. 8 Caggiati A. Fascial relationships of the long saphenous vein. Circulation 1999;100:2547–2549. 9 Ricci S, Caggiati A. Does a double long saphenous vein exist? Phlebology 1999;14:59–64. 10 Cotton LT. Varicose veins. Gross anatomy and development. Br J Surg 1961;48:589–598.
M. Bongiovanni1, M. Pisacreta2, M. Ortu1, F. Tordato , R. Codemo2, C. Gervasoni1, R. Gornati2, S. Trovati1, R. Piolini1, E. Chiesa1, T. Porretta2, T. Bini1 a Institute of Infectious Diseases and Tropical Medicine, University of Milan, and bUnit of Vascular Surgery, Luigi Sacco Hospital, Milan, Italy 1
References 1 Friis-Moller N, Webber R, Reiss P et al. Cardiovascular disease risk factors in HIV patients–association with antiretroviral therapy. Results from the DAD study. AIDS 2003;17(8):1179–1193. 2 Holmberg SD, Moorman AC, Williamson JM et al. Protease inhibitors and cardiovascular outcomes in patients with HIV-1. Lancet 2002;360:1747–1748. 3 Moore RD, Keruly JC, Lucas G. Increasing incidence of cardiovascular diseases in HIV-infected persons in care. 10th Conference on Retroviruses and Opportunistic Infections, Boston, February 10–14; 2003, abstract 132. 4 DAD Study Group. Combiantion antiretroviral therapy and the risk for myocardial infarction. NEJM 2003;349:1993–2003. 5 Bozzette SA, Ake CF, Tam HK et al. Cardiovascular and cerebrovascular events in patients treated for human immunodeficiency virus infection. NEJM 2003;348:702–710. 6 Lipshultz SE, Fisher SD, Lai WW et al. Cardiovascular risk factors, monitoring, and therapy for HIV-infected patients. AIDS 2003;17(Suppl 1):S96–S122.
453
who had a double lumen endotracheal tube to allow both sides to be operated on at the same operation, which lead to hypoxia of the brain. Our experience is to use a similar endotracheal anaesthesia and but to only to perform this operation on one side at a time. As well as reducing the possible anaesthetic risk also allows the patients to experience any side effects especially the compensatory sweating. If this is troublesome then the patient may have no wish to have the other side done. A. Tiwari, A.M.S. Abeysekara, J.B. Coker, S. Jacob Department of Vascular Surgery, King George Hospital, Goodmayes, UK
References 1 Nyamekye IK. Current treatment options for treating primary hyperhidrosis. Eur J Vasc Endovasc Surg 2004;27:571–576. 2 Ojimba TA, Cameron AEP. Drawbacks of endoscopic thoracic sympathectomy. Br J Surg 2004;91:264–269.
Accepted 21 July 2004
Accepted 21 July 2004 doi:10.1016/j.ejvs.2004.07.013, available online at http://www.sciencedirect.com on doi:10.1016/j.ejvs.2004.07.015, available online at
Letter to the Editor, RE: EJVES 2004;28:104–107
http://www.sciencedirect.com on
Current Treatment Options for Treating Primary Hyperhidrosis We read with interest the comprehensive review article by Nyamekye.1 Some of the complications of treating hyperhidrosis using endoscopic thoracic sympathectomy, however, have not been fully discussed. In a recent review article by Ojimba and Cameron,2 significant complications of this procedure highlighted include death, (though as highlighted by the author never actually reported in the literature), bleeding, neuralgia and rebound sweating. The other problem, which has been highlighted is compensatory sweating which the authors have reported is probably more prevalent than actually reported. The patients who died from anaesthetic complication were those * In order to avoid possible confusion between the terminology used by the Authors and that suggested in #7, in this letter, the veins of the lower limb are designated with the original Latin terms.
I read with great interest the article from Dr MacKenzie and coll. entitled ‘The effect of Long Saphenous Vein stripping on deep venous reflux’ (EJVES 2004; 28: 104–107) which confirms that radical surgery of varicose veins enhance deep veins hemodynamics. The authors evaluated deep venous hemodynamics at the thigh by insonating only the Vena Femoralis.* Their findings would be further enhanced by extending Duplex evaluation to the Vena Femoralis Communis, due to its closer hemodynamic interdependency with of the proximal Vena Saphena Magna.1 The authors reported a ‘surprisingly common failure to obtain complete stripping’ of the Vena Saphena Magna after its stripping to the knee. In 62% of limbs, the postoperative Duplex demonstrated remnants of various length ‘.of the Vena Saphena Magna removed in the thigh’. This intriguing and apparently paradoxical finding could be explained by the particular anatomy of thigh superficial veins. The classic studies of Glasser,2 Eur J Vasc Endovasc Surg Vol 28, October 2004
454
Correspondence
Sherman3 and Haeger,4 demonstrated that one or even two large superficial veins may ascend parallel to the Vena Saphena Magna. A ‘double or triple saphenous system’ was firstly demonstrated by Leonardo da Vinci5 and it occurs in about one half of limbs (45–62%) evaluated by venography5 and sonography.6 These parallel veins are called ‘Accessories of the Vena Saphena Magna’ and designated on the basis of their topography in Anterior, Posterior or Superficial.7 Duplex can easily discriminate these veins from the Vena Saphena Magna because they course out of the Saphenous Compartment, in a more superficial plane of the subcutaneous tissue.8,9 In varicose limbs, the reflux may descend along the Vena Saphena Magna, along an accessory vein or both.9 But, the stripper strips only the vein in which it courses and the other automatically becomes a ‘residual’. If varicose, the residual vein benefits from surgery only when this abolishes the reflux or induces its thrombosis. If the residual vein will recanalize, it will look like a ‘remnant’. If a new reflux will develop (from the saphenic stump, from pelvic veins or from a perforator), it will descend along the residual vein to possibly nourish leg varicosities. Thanks to the different planar anatomy and fascial relationships,7 Duplex can discriminate the leg Vena Saphena Magna from its accessories, which are more frequently afflicted with varicose changes.10 The ‘.high incidence of below-knee reflux after stripping of the Vena Saphena Magna to the knee.’ probably concerns saphenous accessories and tributaries, because at the leg, the Vena Saphena Magna is rich of valves and well protected by the Saphenous Fascia against varicose changes.8 Concluding, I strongly agree with the authors
Eur J Vasc Endovasc Surg Vol 28, October 2004
convincement that ‘this study reinforces routine preoperative duplex’. But this must take into account the clear anatomical and topographical differences between saphenous trunks and accessories. A. Caggiati Department of Anatomy, University ‘La Sapienza’, Rome, Italy
References 1 Cappelli M, Molino Lova R, Ermini S, Zamboni P. Hemodynamics of the sapheno–femoral junction. Patterns of reflux and their clinical implications. Int Angiol 2004;23:25–28. 2 Glasser ST. An anatomic study of venous variations at the fossa ovalis. Arch Surg 1943;46:289–295. 3 Sherman RS. Varicose veins. Anatomic findings and an operative procedure based upon them. Ann Surg 1944;120:772– 784. 4 Haeger K. The surgical anatomy of the sapheno-femoral and sapheno–popliteal junctions. J Cardiovasc Surg 1962;3:420–427. 5 Shah DM, Chang BB, Leopold PW, Corson JD, Leather RP, Karmody AM. The anatomy of the greater saphenous venous system. J Vasc Surg 1986;3:273–283. 6 Ruoff BA, Cranley JJ, Hannan LA, Aseffa N, Karkow WS, Stedje KG, Cranley RD. Real-time duplex ultrasound mapping of the greater saphenous vein before in situ infrainguinal revascularization. J Vasc Surg 1987;6:107–113. 7 International Interdisciplinary Consensus Committee on Venous Anatomical Terminology. Nomenclature of the veins of the lower limbs: an international interdisciplinary consensus statement. J Vasc Surg 2002;36:416–422. 8 Caggiati A. Fascial relationships of the long saphenous vein. Circulation 1999;100:2547–2549. 9 Ricci S, Caggiati A. Does a double long saphenous vein exist? Phlebology 1999;14:59–64. 10 Cotton LT. Varicose veins. Gross anatomy and development. Br J Surg 1961;48:589–598.