Varicosities of the lower extremity

VARICOSITIES DESCRIPTION

OF THE LOWER

OF AN IMPROVED METHOD COMMIJNICATING

LIEUT. Cot.

EXTREMITY

OF TESTING VEINS

GEORGE T. MC~UTCHEN,

FOR INCOMPETENT

M.C.

FORT MCCLELLAN, AL.4RAhlA

T

HE subject of varicose veins has been <*louded by a great deal of conflicting opinion as to proper treatment and by the introduction of tests which fall short of their accIaimed vaiue. One school of thought leans toward over-simplification of the problem while another will produce chaos by applying ex’ery test, whether it is applicable or not, to each case. This is a reflection on our proper understanding of basic anatomical and physiological considerations. For purposes of clarity it is con\.enient to eliminate the names lvhich hn1.e been applied to various tests and to in lx~sic terms the fundamental state anat;omic considerations and a basic method of discoverlnp m-hat disturbance of physiology is present in the case under study. The basic considerations may be stated siml)ly: I. Do the varicosities invoIve the greater or lesser saphenous system? If they involve the greater s;?-stem, testing wil1 be carried out from the groin to the ankIe. If they in\rtrl\-e the lesser system, testing wiII be carried out from the popIitea1 space to the ankle. If both systems are involved, the testing must be separated for each system. 2. Are the vaIves in the superficial veins incompetent? The value of discovering this abnormalits has been grossIy ox-crrated. It may be ;icx:epted as firm fact, based on eIcmentar\: phJ;sics, that if a vein is dilated, its valves ;lre mcompetent. This is so because an!. 1 alve system designed originally to take cart of back Aow in a normal-sized vein wil1 fall short of its job, either kvholl> or in part, when that vein increases its caliber. \\‘hether or not the incompetent?: of the \,alvw in an? system of veins can be demonstrated clinically, the incompetency

had best be considerecl as present \vhen the \.erns :lre \ nricose. 3. Is the deep circulation patent? After application of a tourniquet at the point 01’

FIG. I. Demonstrates full Ieg exposure and draping with forlt board in pIace on the table. ‘The latter \vill allow for tilting of the tab11 aml assumption of 8 near erect position. FIG. 2. Table rift-ed toward erect position which :~ll~ivs for c%c.cution of cIinica1 trsts for vf’nous pal holo~ic:d con&t ions.

entrance of the main saphenous trunks into the deep circulation iupper thigh for great saphenous and iust below the knee for Iesser saphenousi with the veins distended the patient is allovled to walk a fe\v steps. If the veins become Iess tense, the deep circulation is patent. The application of a tight .\cI:: bandage followed by walking some distance as ;I test for patency of the 63

64

American JournaI of Surgery

McCutchen-Varicosities

JULY. 1946

FIG. 3. Tourniquets and bandage are in pIace for determination of sights of perforators by conventiona methods. The patient can be pIaced in the Trendelenburg position before application of tourniquets or bandage.

FIG. 4.

F

FIG. 6.

F

FIG. 4. Demonstrates distention of veins when patient is put in the reverse TrendeIenburg position. At the point marked “X” a large perforation is atmost invariably found. FIG. 3. Improved technic for determination of exit of incompetent perforators. The tourniquet is advanced from below upward on the lower extremity. At the points where perforators are suspected, the vein is exposed and severed between clamps. The perforator, if it is found, is treated in the same manner. Preliminary testing may be carried out by the application of two tourniquets at short distances from each other while the TrendeIenburg position is assumed, foIIowed by assumption of the reverse TrendeIenburg position. However, it is believed that the Iigation as illustrated acts in a more effective manner than the Iower tourniquet in stopping confusing flow from the distaI points of the vein. The clamp is pointing to a spot of diIatation in the vein where a perforator is suspected. FIG. 6. Demonstrates the incompetent perforator found at the point determined in Figure 5 at the point of the clamp. The trunk of the internal saphenous system has been clamped. The perforator can be seen entering the fascia of the Ieg and the saphenous trunk. FIG. 7. Mustrates points at which the saphenous trunk has been exposed. At aII of these points the presence of perforators was suspected.

Var..

LSXI

I, i-Y< /

McCutchen-

deep circulation is based on subjective manifestations and is IiabIe to faIIacious interpretation. Venographic study is onI)occasionaIIv necessary in these cases. 1. Are the communicating veins or “perforators” incompetent and, if so, lvhere are they Iocated? RecentI?- great and proper emphasis has been pIaced on this feature of th e pathoIogy of xwicosities. Se\.eral tests have appeared in the Iiterature for determining the location of these abnormal communicating veins. Anyone who will subject these tests to careful analysis will realize that they are not altogether acxurate. We discovered early in the use of these tests (with ACE bandage removed from beIow uplvard and with serial application of’ two tourniquets) that \ve Fvere able to detect areas of bulging distal to the ACE bandage or between the t\vo tour nrquets, but that upon exposing the \ein b\ incision over these points the perforator M’:LSnot always there. \Ye had merely dix>overed the point of maximum dilatation of the vein, subject to fiIling from the perforator, in the area between the two tourniquets. It might be found at a point some distance, medial or IateraI, from the area of tilling determined preoperatively. !l-e belie\-eel that it was essential to develop some method by which perforators might be ctiscox.ered as the operation progressed in order to overcome the shortcomings of tests for perforators carried out preoperati\.eIy. The method of employing vein strippers for the locxtion of perforators leads to improper LwncIusions, particuIarl_ Fvhen used below the knee. LateraI branches as \velI as perforators will obstruct the passage of the stripper loop. ‘The method of performing the necessary calisthenics for testing is described in the Iegends to the illustrations. N’e believe that this method is a \,aluabIe aid to this important phase of the operative treatment of varicose veins.

It is to be emphasized that the extreme reverse TrendeIenburg position should be assumed ;Lnd mainta;ned for five to ten I

minutes after all litrations are comoleted. If dilatation of an>- of the veins bdcomes manifest, it mav be assumed that an incomDetent oerforaior has been overlooked and iurther’search is in order. Careful at.tention to details of interpretation will obviate the Iikelihood of overIooking perforators as the operation progresses. ci