A lateral approach to the below-knee popliteal artery without resection of the fibula

LETTERS TO T H E E D I T O R S The Editors invite readers to submit letters commenting on the contents of articles that appear in the Journal. Also welcome are brief communications in letter form reporting investigative or clinical observations without extensive documentation and with brief bibliography (five titles or less), not requiring peer review but open to critique by readers. Letters to the Editors should be no more than 500 words in length and they may have to be edited for publication.

A lateral approach to the below-knee popliteal artery w i t h o u t resection o f the fibula

orly, and the deep fascia over the soleus muscle is then incised to expose the contents of the popliteal fossa (Fig. 2). The tibial nerve crosses the popliteal artery from the lateral to the medial direction, separated from it by the popliteal vein. Self-retaining retractors are used to maintain exposure, but care must be taken not to compress the common peroneal nerve between the blade and the fibula. Techniques of exposing this part of the popliteal artery have been regularly described, 1 3 but all rely on resection of the proximal fibula. The lateral approach has several advantages. First, it allows the surgeon to avoid a previously made medial incision and any concomitant scarring, wound contamination, infection, radiation damage, or grafted areas. Infection is more common when arterial reconstruction is performed through reopened wounds, and this is especially significant for prosthetic reconstructions. 4 Second, it may be desirable to avoid the medial side of the knee because of injury or burns in the case of urgent reconstruction for trauma. Third, compared with the posterior approach there is easy access to the long saphenous vein. Last, in the case of limited autogenous conduit the lateral approach provides a more direct route to the anterior tibial and dorsalis pedis arteries. Indeed, for patients who require popliteal-to-dorsalis pedis artery bypass graft-

To the Editors: We would like to describe a technique that achieves exposure of the below-knee popliteal artery without the need for resection of any part of the fibula. With the patients' knee flexed to approximately 90 degrees and held in partial medial rotation and adduction by an assistant, an incision is made along a line running posterior to the upper quarter of the fibula (Fig. l). As the incision is deepened into the fascial plane between the peroneus longus and the soleus, care should be taken to avoid the common peroneal nerve, which will be palpable in the upper angle of the incision, crossing the neck of the fibula, close to the posterior edge of the biceps femoris. It is important to recall that the common peroneal nerve gives off two cutaneous branches and several genicular branches. Both cutaneous nerves arise above the head of the fibula and pierce the deep fascia over the lateral head of the gastrocnemius. Neither the peroneal communicating branch or the lateral cutaneous nerve of the calf should be encountered if the incision is commenced below and posterior to the neck of the fibula. The lateral head of gastrocnemius is retracted posteri-

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Fig. 1. Position of leg for incision. 168

JOURNAL OF VASCULAR SURGERY/July 1997

J O U R N A L OF VASCULAR SURGERY

Volume 26, Number 1

Letters to the Editors

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ing procedures, the lateral approach to the popliteal artery has become our preferred approach. This technique was developed by dissection of limbs amputated at the above-knee level before discard. We would recommend that the technique be learned by others in this way. This simplified approach has the advantage in that there is no "blind" dissection deep to the fibula. Not resecting the fibula results in less tissue trauma with less chance of common peroneal nerve damage and less postoperative pain. Overall, the technique is simpler, safer, and quicker. Valery Usatoff, MBBS(Hons) Michael Grigg, FRA CS Vascular Surgery Unit Department of Surgery Monash University Medical School Alfred Hospital, Prahran, Victoria Australia

REFERENCES 1. Elkin CDC, Kelly RP. Arteriovenous aneurysm: exposure of the tibial and peroneal vessels by resection of the fibula. Ann Surg 1945;122:529-45. 2. Danese CA, Singer A. Lateral approach to the popliteal trifurcation. Surgery 1968;63:588-90. 3. Veith FJ, Ascer E, Gupta SK, Wengerter KR. Lateral approach to the popliteal artery. J Vase Surg 1987;6:119-23. 4. Ascer E, Collier P, Gupta SK, Veith FJ. Reoperation for polytetrafluoroethylene bypass failure: the importance of distal outflow site and operative technique in determining outcome. I Vase Surg 1987;5:298-310.

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Regarding "Hemodynamic and dinical i m p r o v e m e n t after superficial vein ablation in primary c o m b i n e d venous insufficiency with ulceration" To the Editors: A recent article by Padberg et al. (J Vase Surg 1996;24: 711-8) reported the beneficial effects of combined saphenous and perforating vein ligation in patients with venous ulceration caused by primary incompetence of the saphenous and deep systems. However, we believe a number of points need further discussion. First, although it is a noninvasive technique, air plethysmography (APG) gives no direct measurement of venous function. We would advocate the use of ambulatory venous pressure (AVI') measurement, which is considered to be the "gold standard" test of venous function, giving direct measurement of venous filling times (a measure of venous reflux) and the drop in venous pressure achieved on exercise (a measure of calf pump efficiency). Venous hypertension is, after all, the root cause of venous ulceration, and as such this parameter of venous function ought to be measured directly. AVP measurements are simple to perform and would have been easily incorporated into the methods because each patient underwent phlebography as part of the protocol. Second, the definitive test of saphenous surgery is not necessarily its influence on venous hemodynamics but on its clinical impact for the patient. With regard to ulcer healing, this cannot be assessed in this paper because the ulcers were healed before surgery by compression therapy and the follow-up period of 2 years is too short to meaningfully assess ulcer recurrence rates) ,2