- Email: [email protected]
Stripping operation with preservation of the calf saphenous veins for primary varicose veins: hemodynamic evaluation
doi:10.1016/S0967-2109(03)00080-2
Cardiovascular Surgery, Vol. 11, No. 5, pp. 341–345, 2003 2003 The International Society for Cardiovascular Surgery Published by Elsevier Ltd. All rights reserved. 0967-2109/03 $30.00
www.elsevier.com/locate/cardiosur
Stripping operation with preservation of the calf saphenous veins for primary varicose veins: hemodynamic evaluation Toshiya Nishibe∗, Masayasu Nishibe†, Fabio Kudo∗, Jorge Flores∗, Keiko Miyazaki∗ and Keishu Yasuda∗ ∗Department of Cardiovascular Surgery, Hokkaido University School of Medicine, Sapporo, Japan and †Department of Surgery, Eniwa Midorino Clinic, Eniwa, Japan Purpose. To study early changes in venous hemodynamics in stripping operation with preservation of the calf saphenous veins. Patients and methods. From October 1999 to December 2000, 110 extremities of 73 patients were treated for primary varicose veins. Based on preoperative ascending venography, 40 extremities underwent the groin-to-knee stripping of the GSV, 20 underwent the proximal division of the LSV, and 50 received combinations of both surgeries. To evaluate venous hemodynamic changes, air plethysmography was performed before operation and 7–14 days after operation. Results. The venous volume, venous filling index and residual volume fraction were improved after surgery, but the ejection fraction did not change. The overall incidence of nerve injury was 4.5% (five limbs). Conclusions. In stripping operations, the preservation of the calf saphenous veins, which is shown to be advantageous in reducing saphenous or sural nerve injuries, does not adversely affect early venous hemodynamic improvement. 2003 The International Society for Cardiovascular Surgery. Published by Elsevier Ltd. All rights reserved. Keywords: Varicose vein, Saphenous vein, Hemodynamics, Venous insufficiency
Introduction The stripping operation, as advocated by Myers 40 years ago, is the accepted standard for treating primary varicose veins. However, there is a well-known complication, injury to the saphenous or sural nerves, which has been reported to have a high incidence of 23–50% [1–3]. Several authors proposed preservations of the calf saphenous veins, and they showed that this significantly reduced the incidence
of nerve injury to less than 5% [2–4]. They also reported a low recurrence rate of 12.5% up to 3.7 years [2,3]. However, it has not been well documented whether hemodynamic improvement may be affected by the preservation of the calf saphenous veins. We thus prospectively studied the early changes in venous hemodynamics in 110 extremities of 73 patients undergoing the groin-to-knee stripping of the greater saphenous vein (GSV), proximal division of the lesser saphenous vein (LSV), and combinations of both, in which the calf saphenous veins were routinely preserved.
Correspondence to: Toshiya Nishibe. Department of Surgery, Division of Thoracic and Cardiovascular Surgery, Fujita Health University, 1-98, Dengakugakubo, Kutsukake, Toyoake, Aichi 470-11, Japan. Tel.: +81-562-93-7370; e-mail: [email protected]
CARDIOVASCULAR SURGERY
OCTOBER 2003 VOL 11 NO 5
341
Stripping operation with preservation of the calf saphenous veins: hemodynamic evaluation: Toshiya Nishibe et al.
Patients and methods Patients In this prospective study, from October 1999 to December 2000, surgery was performed on 110 extremities of 73 patients (12 men, 61 women) with primary varicose veins. All extremities were assigned to C2S (varicose veins with symptoms including aching, pain, congestion, skin irritation, muscle cramps, and other complaints attributable to venous dysfunction) in accordance with the Reporting Standards for Venous Disease by the Ad Hoc Committee on Chronic Venous Disease [5]. Based on preoperative ascending venography, 40 extremities were found to have incompetence of the GSV, 20 to have incompetence of the LSV, and 50 to have incompetence of both the GSV and LSV. Procedures for preoperative ascending venography were performed as described elsewhere. To briefly summarize, the patient was placed in a 60° semi-upright position, and 40 ml of contrast material was injected through a 22-gauge plastic intravenous cannula that was placed into a dorsal vein of the foot. Tourniquets were applied on the thigh and ankle to drive contrast into the deep venous system. While the contrast material was being filled in the deep venous system, the patient was asked to perform a sustained Valsalva maneuver to enhance venous incompetence of the GSV and LSV. The study was monitored by live fluoroscopic examination. Venous incompetence of the GSV and LSV was defined as the leakage of the contrast material into the GSV or LSV, respectively (Figure 1a and b). Surgical procedures The same vascular surgeons (T.N., K.M. and M.N.) or staff under their direct supervision performed the operations. Prior to surgery, all incompetent GSV and LSV were mapped with duplex scans and were marked with an indelible ink. The choice of anesthesia, local, spinal or epidural, was up to the anestheologist and the patient. The greater saphenous system. The surgical procedures were performed as previously described by Rivlin [6] with minor modifications. The patient was placed in a supine position. A 1-cm groin incision was made transversely just below the saphenofemoral junction. The GSV and its tributaries were identified by blunt dissection. The tributaries were ligated and divided. The GSV was then tied flush at the saphenofemoral junction, and transfixation ligation was performed near the first ligature. The lower incision was made transversely at the below-knee level. The distal GSV was identified, and was then carefully dissected from the 342
contiguous saphenous nerve. The GSV was tied distally, and another tie was placed proximally. With traction placed on the distal tie, a transverse venotomy was made, and the stripper was inserted and passed through the GSV proximally. The tip of the stripper was drawn out through a small incision in the proximal GSV. The tip was replaced with the head. The proximal GSV was tied just below the head, and was divided. The distal GSV was then divided. The inguinal wound was closed in two layers with subcuticular absorbable sutures. The elastic bandage was applied from the toe to the groin. The GSV was then stripped downward from the groin to the knee. The below-knee incision was approximated with subcuticular absorbable sutures. The lesser saphenous system. The patient was placed in a prone position. A 1-cm incision was made transversely at the popliteal fossa, and the deep fascia was opened transversely in the line of its fibers. The LSV was identified, and was then carefully dissected from the contiguous sural nerve. The LSV was tied flush proximally, and another tie was placed distally. Transfixation ligations were performed near the first ligatures. The LSV was then divided. The incision was closed with subcuticular absorbable sutures. The elastic bandage was applied from the toe to the knee. Additional procedures were performed selectively. All perforator veins larger than 4 mm were diagnosed as incompetent [7], and were divided through small incisions. The residual varicose veins were treated with sclerotherapy after postoperative air plethymography (APG) assessment. APG Venous hemodynamics was assessed by APG both before operation and 7–14 days after operation (before sclerotherapy). The APG machine, APG1000 (ACI Medical, Sun Valley, CA, USA) consisted of a tubular, polyurethane air cuff surrounding the calf, a pressure transducer, a cuff inflator air pump, an amplifier, and a recorder. The testing procedure of measurement was carried out as described previously by Christopoulos et al. [8]. Briefly, the cuff was calibrated with a known quantity (100 ml) of air. The cuff was fitted with the patient in the supine position. The leg was elevated to 45°, emptying the leg. After a steady state was achieved, the patient quickly stood while holding on to a walker so that the body weight was supported by the contralateral leg. Venous filling of the leg was then recorded continuously until a plateau, which represented the functional venous volume (VV, ml), was reached. The time to 90% of the VV (90% VV) was defined as venous filling time 90% (90% VFT). The venous filling index (VFI, ml/s) was calculated from CARDIOVASCULAR SURGERY
OCTOBER 2003 VOL 11 NO 5
Stripping operation with preservation of the calf saphenous veins: hemodynamic evaluation: Toshiya Nishibe et al.
Figure 1 Preoperative ascending venography. Venous incompetence of the GSV (a) and LSV (b) is shown
90% VV/90% VFT, which was related to reflux. The patient then performed one tiptoe maneuver to activate the calf muscle pump. The decrease in calf volume associated with one calf muscle exercise represented the ejection volume (EV). The ejection fraction (EF, %) was calculated from EV / VV × 100, which represented the pumping capacity of the calf. When a steady volume was again achieved, the patient performed 10 rapid tiptoe maneuvers to thoroughly empty the calf venous reservoir. The volume was recorded at the end of the exercise and the residual volume (RV) was determined as the difference between that volume and the baseline volume. The residual volume fraction (RVF) was calculated as RV / VV × 100, which was shown to correlate with ambulatory venous pressure.
Table 1 Change in the venous volume (VV) before and after operation Groups
Preoperation
Postoperation
p value
G group L group GL group
104.0 ± 5.9 108.2 ± 5.2 110.1 ± 5.6
79.1 ± 4.1 92.0 ± 4.5 87.7 ± 4.2
p ⬍ 0.0001 p ⬍ 0.0001 p ⬍ 0.0001
Results Hemodynamic changes Tables 1–4 Forty extremities underwent groin-toknee stripping of the GSV (G group), 20 extremities Table 2 Change in the venous filling time (VFI) before and after operation
Statistics
Groups
Preoperation
Postoperation
p value
Statistical analysis of data was performed with use of the Student paired t-test. The data are shown as the mean ± SE.
G group L group GL group
4.01 ± 0.35 2.58 ± 0.26 4.56 ± 0.38
1.38 ± 0.15 1.82 ± 0.20 1.76 ± 0.30
p ⬍ 0.0001 p = 0.0136 p ⬍ 0.0001
CARDIOVASCULAR SURGERY
OCTOBER 2003 VOL 11 NO 5
343
Stripping operation with preservation of the calf saphenous veins: hemodynamic evaluation: Toshiya Nishibe et al. Table 3 Change in the residual volume fraction (RVF) before and after operation Groups
Preoperation
Postoperation
p value
G group L group GL group
45.1 ± 2.6 38.7 ± 3.5 46.7 ± 2.6
30.1 ± 3.7 26.3 ± 4.9 29.8 ± 3.1
p ⬍ 0.0001 p = 0.0026 p ⬍ 0.0001
Table 4 Change in the ejection fraction (EF) before and after operation Groups
Preoperation
Postoperation
p value
G group L group GL group
46.2 ± 2.8 43.0 ± 4.7 44.4 ± 2.6
46.3 ± 3.1 47.5 ± 4.4 43.3 ± 3.3
p = 0.9590 p = 0.3080 p = 0.6699
underwent proximal division of the LSV (L group), and 50 extremities were treated with both (GL group). The G, L, and GL groups had a similar hemodynamic change before and after operation for all the variables evaluated. Before operation, the median values of the VFI and RVF in the G, L, and GL groups were high as compared with their normal values (VFI ⬍ 2 ml / min; RVF ⬍ 30%). The median values of VV and EF were within a normal range ( VV ⬍ 150 ml, EF ⬎ 35%). After operation, patients in the G, L, and GL groups significantly improved their VV, VFI, and RVF, with the last two parameters going below their normal values. The EF did not change significantly in any of the three groups. Nerve injury The overall incidence of nerve injury was 4.5% (five limbs): the saphenous nerve was injured in three limbs of the GL group and in two limbs of the G group, and the sural nerve was not injured.
Discussion and conclusions Saphenous and/or sural nerves are often injured following total stripping of the GSV and LSV for primary varicose veins [1–3]. The GSV is in intimate contact with the saphenous nerve from the medial malleolus to just above knee level, and the LSV is accompanied in its distal two-thirds by the sural nerve. To avoid nerve injury, Munn et al. [4] thus recommended the technique of varicose vein surgery described by Rivlin [6], in which the GSV and LSV of the lower leg were routinely preserved. Negus [2] also proposed a limited stripping operation, in which the GSV of the lower leg was preserved. His results revealed a low incidence of nerve injury (4.2%) as well as a low recurrence rate (12.5%) in 96 limbs with a mean follow-up time of 3.7 years. The present study also confirmed a low incidence of saphenous 344
and sural nerve injuries. However, there is little documentation on whether hemodynamic improvement may be affected by preservation of the calf saphenous veins. The venous hemodynamic change was evaluated by APG, which measures several parameters of venous physiology, including the VV, VFI, EF, and RVF. The VFI measures the venous filling rate of the calf, while the EF assesses the function of the calf muscle pump. The RVF, which correlates with ambulatory venous pressure, permits evaluation of the overall function of the lower extremity venous function. APG provides reproducible hemodynamic measurements that can be evaluated noninvasively in serial examinations [8,9]. Recently, several authors have reported that APG offers a technique for a noninvasive, objective, and quantitative evaluation of the results of venous surgery [9–11]. The present study clearly demonstrated that the venous hemodynamic improvement is achieved by the groin-to-knee stripping of the GSV, proximal division of the LSV, and combinations of both, in cases in which the calf saphenous veins were routinely preserved. The VV, VFI and RVF values decreased significantly and returned to normal after surgery, although the EF value showed no change. These findings suggest that the improvement in the overall function of the lower extremity venous function is associated with the abolition of venous reflux rather than the improvement in calf muscle function. These results are comparable with ones obtained by Gillespie et al. [10] for standard groin-to-ankle stripping of the GSV. Their study showed a significant reduction in VV and VFI. However, they did not find the significant reduction in RVF that we found. The lack of reduction of RVF could be associated with different degrees of clinical severity; there were more patients with severe clinical disease in their series than in our series, which may have reflux in the deep venous system. Study limitations The results could not be compared with those of saphenofemoral ligation or groin-to-ankle stripping of the GSV; several randomized controlled trials demonstrated that the results of GSV insufficiency following stripping operations were superior to those obtained by saphenofemoral ligation combined with sclerotherapy or multiple avulsions [12–14]. Studies have shown, as described above, that there was an increased incidence of injury to the saphenous nerve when the GSV was stripped from groin to ankle. In conclusion, venous hemodynamic improvement was achieved by the groin-to-knee stripping of the GSV, the proximal division of the LSV, and combinations of both surgeries, in operations in which the calf saphenous veins were routinely preserved. Although a long-term follow-up is desirable, this CARDIOVASCULAR SURGERY
OCTOBER 2003 VOL 11 NO 5
Stripping operation with preservation of the calf saphenous veins: hemodynamic evaluation: Toshiya Nishibe et al.
study confirms that, in stripping operation, the preservation of the calf saphenous vein, which is advantageous in reducing saphenous or sural nerve injuries, does not adversely affect early venous hemodynamic improvement.
References
9. 10.
1. Wellwood, J. M., Cox, S. J., Martin, A. et al. Sensory changes following stripping of the long sphenous vein. J. Cardiovasc. Surg., 1975, 16, 123–124. 2. Negus, D. Should incompetent saphenous veins be stripped to right down the ankle? Phlebologie, 1987, 40, 753–757. 3. Koyano, K. and Sakaguchi, S. Selective stripping operation based on doppler ultrasonic findings for primary varicose veins of the lower extremities. Surgery, 1988, 103, 615–619. 4. Munn, S. R., Morton, J. B., Macbeth, W. A. A. G. et al. To strip or not to strip the long saphenous vein? A varicose vein trial. Br. J. Surg., 1981, 68, 426–428. 5. Beebe, H. G., Bergan, J. J., Bergqvist, D. et al. Classification and grading of chronic venous disease in the lower limb. A consensus statement. Int. Angiol., 1995, 14, 197–201. 6. Rivlin, S. The surgical cure of primary varicose veins. Br. J. Surg., 1975, 62, 913–917. 7. Labropoulos, N., Mansour, M. A., Kang, S. S. et al. New
CARDIOVASCULAR SURGERY
8.
OCTOBER 2003 VOL 11 NO 5
11.
12. 13. 14.
insights into perforator vein incompetence. Eur. J. Vasc. Endovasc., 1999, 18, 228–234. Christopoulos, D. G., Nicolaides, A. N., Szendro, G. et al. Airplethysmography and the effect of elastic compression on venous hemodynamics of the leg. J. Vasc. Surg., 1987, 5, 148–159. Christopoulos, D. G., Nicolaides, A. N., Galloway, J. M. D. et al. Objective noninvasive evaluation of venous surgical results. J. Vasc. Surg., 1988, 8, 683–687. Gillespie, D. L., Cordts, P. R., Hartono, C. et al. The role of air plethysmography in monitoring the result of venous surgery. J. Vasc. Surg., 1992, 16, 674–678. Padberg, F. T., Pappas, P. J., Araki, C. T. et al. Hemodynamic and clinical improvement after superficial ablation in primary combined venous insufficiency with ulceration. J. Vasc. Surg., 1996, 24, 711–718. Sarin, S., Scurr, J. H. and Coleridges Smith, P. D. Stripping operation of the long saphenous vein in the treatment of primary varicose veins. Br. J. Surg., 1994, 81, 1455–1458. Neglen, P., Einarsson, E. and Eklof, B. T. The functional longterm value of different types of treatment for saphenous vein incompetence. J. Cardiovasc. Surg., 1993, 34, 295–301. Rutgers, P. H. and Kitslaar, P. J. R. Randomized trial of stripping versus high ligation combined with sclerotherapy in the treatment of the incompetent greater saphenous vein. Am. J. Surg., 1994, 168, 311–315.
Paper accepted 30 April 2003
345
Cardiovascular Surgery, Vol. 11, No. 5, pp. 341–345, 2003 2003 The International Society for Cardiovascular Surgery Published by Elsevier Ltd. All rights reserved. 0967-2109/03 $30.00
www.elsevier.com/locate/cardiosur
Stripping operation with preservation of the calf saphenous veins for primary varicose veins: hemodynamic evaluation Toshiya Nishibe∗, Masayasu Nishibe†, Fabio Kudo∗, Jorge Flores∗, Keiko Miyazaki∗ and Keishu Yasuda∗ ∗Department of Cardiovascular Surgery, Hokkaido University School of Medicine, Sapporo, Japan and †Department of Surgery, Eniwa Midorino Clinic, Eniwa, Japan Purpose. To study early changes in venous hemodynamics in stripping operation with preservation of the calf saphenous veins. Patients and methods. From October 1999 to December 2000, 110 extremities of 73 patients were treated for primary varicose veins. Based on preoperative ascending venography, 40 extremities underwent the groin-to-knee stripping of the GSV, 20 underwent the proximal division of the LSV, and 50 received combinations of both surgeries. To evaluate venous hemodynamic changes, air plethysmography was performed before operation and 7–14 days after operation. Results. The venous volume, venous filling index and residual volume fraction were improved after surgery, but the ejection fraction did not change. The overall incidence of nerve injury was 4.5% (five limbs). Conclusions. In stripping operations, the preservation of the calf saphenous veins, which is shown to be advantageous in reducing saphenous or sural nerve injuries, does not adversely affect early venous hemodynamic improvement. 2003 The International Society for Cardiovascular Surgery. Published by Elsevier Ltd. All rights reserved. Keywords: Varicose vein, Saphenous vein, Hemodynamics, Venous insufficiency
Introduction The stripping operation, as advocated by Myers 40 years ago, is the accepted standard for treating primary varicose veins. However, there is a well-known complication, injury to the saphenous or sural nerves, which has been reported to have a high incidence of 23–50% [1–3]. Several authors proposed preservations of the calf saphenous veins, and they showed that this significantly reduced the incidence
of nerve injury to less than 5% [2–4]. They also reported a low recurrence rate of 12.5% up to 3.7 years [2,3]. However, it has not been well documented whether hemodynamic improvement may be affected by the preservation of the calf saphenous veins. We thus prospectively studied the early changes in venous hemodynamics in 110 extremities of 73 patients undergoing the groin-to-knee stripping of the greater saphenous vein (GSV), proximal division of the lesser saphenous vein (LSV), and combinations of both, in which the calf saphenous veins were routinely preserved.
Correspondence to: Toshiya Nishibe. Department of Surgery, Division of Thoracic and Cardiovascular Surgery, Fujita Health University, 1-98, Dengakugakubo, Kutsukake, Toyoake, Aichi 470-11, Japan. Tel.: +81-562-93-7370; e-mail: [email protected]
CARDIOVASCULAR SURGERY
OCTOBER 2003 VOL 11 NO 5
341
Stripping operation with preservation of the calf saphenous veins: hemodynamic evaluation: Toshiya Nishibe et al.
Patients and methods Patients In this prospective study, from October 1999 to December 2000, surgery was performed on 110 extremities of 73 patients (12 men, 61 women) with primary varicose veins. All extremities were assigned to C2S (varicose veins with symptoms including aching, pain, congestion, skin irritation, muscle cramps, and other complaints attributable to venous dysfunction) in accordance with the Reporting Standards for Venous Disease by the Ad Hoc Committee on Chronic Venous Disease [5]. Based on preoperative ascending venography, 40 extremities were found to have incompetence of the GSV, 20 to have incompetence of the LSV, and 50 to have incompetence of both the GSV and LSV. Procedures for preoperative ascending venography were performed as described elsewhere. To briefly summarize, the patient was placed in a 60° semi-upright position, and 40 ml of contrast material was injected through a 22-gauge plastic intravenous cannula that was placed into a dorsal vein of the foot. Tourniquets were applied on the thigh and ankle to drive contrast into the deep venous system. While the contrast material was being filled in the deep venous system, the patient was asked to perform a sustained Valsalva maneuver to enhance venous incompetence of the GSV and LSV. The study was monitored by live fluoroscopic examination. Venous incompetence of the GSV and LSV was defined as the leakage of the contrast material into the GSV or LSV, respectively (Figure 1a and b). Surgical procedures The same vascular surgeons (T.N., K.M. and M.N.) or staff under their direct supervision performed the operations. Prior to surgery, all incompetent GSV and LSV were mapped with duplex scans and were marked with an indelible ink. The choice of anesthesia, local, spinal or epidural, was up to the anestheologist and the patient. The greater saphenous system. The surgical procedures were performed as previously described by Rivlin [6] with minor modifications. The patient was placed in a supine position. A 1-cm groin incision was made transversely just below the saphenofemoral junction. The GSV and its tributaries were identified by blunt dissection. The tributaries were ligated and divided. The GSV was then tied flush at the saphenofemoral junction, and transfixation ligation was performed near the first ligature. The lower incision was made transversely at the below-knee level. The distal GSV was identified, and was then carefully dissected from the 342
contiguous saphenous nerve. The GSV was tied distally, and another tie was placed proximally. With traction placed on the distal tie, a transverse venotomy was made, and the stripper was inserted and passed through the GSV proximally. The tip of the stripper was drawn out through a small incision in the proximal GSV. The tip was replaced with the head. The proximal GSV was tied just below the head, and was divided. The distal GSV was then divided. The inguinal wound was closed in two layers with subcuticular absorbable sutures. The elastic bandage was applied from the toe to the groin. The GSV was then stripped downward from the groin to the knee. The below-knee incision was approximated with subcuticular absorbable sutures. The lesser saphenous system. The patient was placed in a prone position. A 1-cm incision was made transversely at the popliteal fossa, and the deep fascia was opened transversely in the line of its fibers. The LSV was identified, and was then carefully dissected from the contiguous sural nerve. The LSV was tied flush proximally, and another tie was placed distally. Transfixation ligations were performed near the first ligatures. The LSV was then divided. The incision was closed with subcuticular absorbable sutures. The elastic bandage was applied from the toe to the knee. Additional procedures were performed selectively. All perforator veins larger than 4 mm were diagnosed as incompetent [7], and were divided through small incisions. The residual varicose veins were treated with sclerotherapy after postoperative air plethymography (APG) assessment. APG Venous hemodynamics was assessed by APG both before operation and 7–14 days after operation (before sclerotherapy). The APG machine, APG1000 (ACI Medical, Sun Valley, CA, USA) consisted of a tubular, polyurethane air cuff surrounding the calf, a pressure transducer, a cuff inflator air pump, an amplifier, and a recorder. The testing procedure of measurement was carried out as described previously by Christopoulos et al. [8]. Briefly, the cuff was calibrated with a known quantity (100 ml) of air. The cuff was fitted with the patient in the supine position. The leg was elevated to 45°, emptying the leg. After a steady state was achieved, the patient quickly stood while holding on to a walker so that the body weight was supported by the contralateral leg. Venous filling of the leg was then recorded continuously until a plateau, which represented the functional venous volume (VV, ml), was reached. The time to 90% of the VV (90% VV) was defined as venous filling time 90% (90% VFT). The venous filling index (VFI, ml/s) was calculated from CARDIOVASCULAR SURGERY
OCTOBER 2003 VOL 11 NO 5
Stripping operation with preservation of the calf saphenous veins: hemodynamic evaluation: Toshiya Nishibe et al.
Figure 1 Preoperative ascending venography. Venous incompetence of the GSV (a) and LSV (b) is shown
90% VV/90% VFT, which was related to reflux. The patient then performed one tiptoe maneuver to activate the calf muscle pump. The decrease in calf volume associated with one calf muscle exercise represented the ejection volume (EV). The ejection fraction (EF, %) was calculated from EV / VV × 100, which represented the pumping capacity of the calf. When a steady volume was again achieved, the patient performed 10 rapid tiptoe maneuvers to thoroughly empty the calf venous reservoir. The volume was recorded at the end of the exercise and the residual volume (RV) was determined as the difference between that volume and the baseline volume. The residual volume fraction (RVF) was calculated as RV / VV × 100, which was shown to correlate with ambulatory venous pressure.
Table 1 Change in the venous volume (VV) before and after operation Groups
Preoperation
Postoperation
p value
G group L group GL group
104.0 ± 5.9 108.2 ± 5.2 110.1 ± 5.6
79.1 ± 4.1 92.0 ± 4.5 87.7 ± 4.2
p ⬍ 0.0001 p ⬍ 0.0001 p ⬍ 0.0001
Results Hemodynamic changes Tables 1–4 Forty extremities underwent groin-toknee stripping of the GSV (G group), 20 extremities Table 2 Change in the venous filling time (VFI) before and after operation
Statistics
Groups
Preoperation
Postoperation
p value
Statistical analysis of data was performed with use of the Student paired t-test. The data are shown as the mean ± SE.
G group L group GL group
4.01 ± 0.35 2.58 ± 0.26 4.56 ± 0.38
1.38 ± 0.15 1.82 ± 0.20 1.76 ± 0.30
p ⬍ 0.0001 p = 0.0136 p ⬍ 0.0001
CARDIOVASCULAR SURGERY
OCTOBER 2003 VOL 11 NO 5
343
Stripping operation with preservation of the calf saphenous veins: hemodynamic evaluation: Toshiya Nishibe et al. Table 3 Change in the residual volume fraction (RVF) before and after operation Groups
Preoperation
Postoperation
p value
G group L group GL group
45.1 ± 2.6 38.7 ± 3.5 46.7 ± 2.6
30.1 ± 3.7 26.3 ± 4.9 29.8 ± 3.1
p ⬍ 0.0001 p = 0.0026 p ⬍ 0.0001
Table 4 Change in the ejection fraction (EF) before and after operation Groups
Preoperation
Postoperation
p value
G group L group GL group
46.2 ± 2.8 43.0 ± 4.7 44.4 ± 2.6
46.3 ± 3.1 47.5 ± 4.4 43.3 ± 3.3
p = 0.9590 p = 0.3080 p = 0.6699
underwent proximal division of the LSV (L group), and 50 extremities were treated with both (GL group). The G, L, and GL groups had a similar hemodynamic change before and after operation for all the variables evaluated. Before operation, the median values of the VFI and RVF in the G, L, and GL groups were high as compared with their normal values (VFI ⬍ 2 ml / min; RVF ⬍ 30%). The median values of VV and EF were within a normal range ( VV ⬍ 150 ml, EF ⬎ 35%). After operation, patients in the G, L, and GL groups significantly improved their VV, VFI, and RVF, with the last two parameters going below their normal values. The EF did not change significantly in any of the three groups. Nerve injury The overall incidence of nerve injury was 4.5% (five limbs): the saphenous nerve was injured in three limbs of the GL group and in two limbs of the G group, and the sural nerve was not injured.
Discussion and conclusions Saphenous and/or sural nerves are often injured following total stripping of the GSV and LSV for primary varicose veins [1–3]. The GSV is in intimate contact with the saphenous nerve from the medial malleolus to just above knee level, and the LSV is accompanied in its distal two-thirds by the sural nerve. To avoid nerve injury, Munn et al. [4] thus recommended the technique of varicose vein surgery described by Rivlin [6], in which the GSV and LSV of the lower leg were routinely preserved. Negus [2] also proposed a limited stripping operation, in which the GSV of the lower leg was preserved. His results revealed a low incidence of nerve injury (4.2%) as well as a low recurrence rate (12.5%) in 96 limbs with a mean follow-up time of 3.7 years. The present study also confirmed a low incidence of saphenous 344
and sural nerve injuries. However, there is little documentation on whether hemodynamic improvement may be affected by preservation of the calf saphenous veins. The venous hemodynamic change was evaluated by APG, which measures several parameters of venous physiology, including the VV, VFI, EF, and RVF. The VFI measures the venous filling rate of the calf, while the EF assesses the function of the calf muscle pump. The RVF, which correlates with ambulatory venous pressure, permits evaluation of the overall function of the lower extremity venous function. APG provides reproducible hemodynamic measurements that can be evaluated noninvasively in serial examinations [8,9]. Recently, several authors have reported that APG offers a technique for a noninvasive, objective, and quantitative evaluation of the results of venous surgery [9–11]. The present study clearly demonstrated that the venous hemodynamic improvement is achieved by the groin-to-knee stripping of the GSV, proximal division of the LSV, and combinations of both, in cases in which the calf saphenous veins were routinely preserved. The VV, VFI and RVF values decreased significantly and returned to normal after surgery, although the EF value showed no change. These findings suggest that the improvement in the overall function of the lower extremity venous function is associated with the abolition of venous reflux rather than the improvement in calf muscle function. These results are comparable with ones obtained by Gillespie et al. [10] for standard groin-to-ankle stripping of the GSV. Their study showed a significant reduction in VV and VFI. However, they did not find the significant reduction in RVF that we found. The lack of reduction of RVF could be associated with different degrees of clinical severity; there were more patients with severe clinical disease in their series than in our series, which may have reflux in the deep venous system. Study limitations The results could not be compared with those of saphenofemoral ligation or groin-to-ankle stripping of the GSV; several randomized controlled trials demonstrated that the results of GSV insufficiency following stripping operations were superior to those obtained by saphenofemoral ligation combined with sclerotherapy or multiple avulsions [12–14]. Studies have shown, as described above, that there was an increased incidence of injury to the saphenous nerve when the GSV was stripped from groin to ankle. In conclusion, venous hemodynamic improvement was achieved by the groin-to-knee stripping of the GSV, the proximal division of the LSV, and combinations of both surgeries, in operations in which the calf saphenous veins were routinely preserved. Although a long-term follow-up is desirable, this CARDIOVASCULAR SURGERY
OCTOBER 2003 VOL 11 NO 5
Stripping operation with preservation of the calf saphenous veins: hemodynamic evaluation: Toshiya Nishibe et al.
study confirms that, in stripping operation, the preservation of the calf saphenous vein, which is advantageous in reducing saphenous or sural nerve injuries, does not adversely affect early venous hemodynamic improvement.
References
9. 10.
1. Wellwood, J. M., Cox, S. J., Martin, A. et al. Sensory changes following stripping of the long sphenous vein. J. Cardiovasc. Surg., 1975, 16, 123–124. 2. Negus, D. Should incompetent saphenous veins be stripped to right down the ankle? Phlebologie, 1987, 40, 753–757. 3. Koyano, K. and Sakaguchi, S. Selective stripping operation based on doppler ultrasonic findings for primary varicose veins of the lower extremities. Surgery, 1988, 103, 615–619. 4. Munn, S. R., Morton, J. B., Macbeth, W. A. A. G. et al. To strip or not to strip the long saphenous vein? A varicose vein trial. Br. J. Surg., 1981, 68, 426–428. 5. Beebe, H. G., Bergan, J. J., Bergqvist, D. et al. Classification and grading of chronic venous disease in the lower limb. A consensus statement. Int. Angiol., 1995, 14, 197–201. 6. Rivlin, S. The surgical cure of primary varicose veins. Br. J. Surg., 1975, 62, 913–917. 7. Labropoulos, N., Mansour, M. A., Kang, S. S. et al. New
CARDIOVASCULAR SURGERY
8.
OCTOBER 2003 VOL 11 NO 5
11.
12. 13. 14.
insights into perforator vein incompetence. Eur. J. Vasc. Endovasc., 1999, 18, 228–234. Christopoulos, D. G., Nicolaides, A. N., Szendro, G. et al. Airplethysmography and the effect of elastic compression on venous hemodynamics of the leg. J. Vasc. Surg., 1987, 5, 148–159. Christopoulos, D. G., Nicolaides, A. N., Galloway, J. M. D. et al. Objective noninvasive evaluation of venous surgical results. J. Vasc. Surg., 1988, 8, 683–687. Gillespie, D. L., Cordts, P. R., Hartono, C. et al. The role of air plethysmography in monitoring the result of venous surgery. J. Vasc. Surg., 1992, 16, 674–678. Padberg, F. T., Pappas, P. J., Araki, C. T. et al. Hemodynamic and clinical improvement after superficial ablation in primary combined venous insufficiency with ulceration. J. Vasc. Surg., 1996, 24, 711–718. Sarin, S., Scurr, J. H. and Coleridges Smith, P. D. Stripping operation of the long saphenous vein in the treatment of primary varicose veins. Br. J. Surg., 1994, 81, 1455–1458. Neglen, P., Einarsson, E. and Eklof, B. T. The functional longterm value of different types of treatment for saphenous vein incompetence. J. Cardiovasc. Surg., 1993, 34, 295–301. Rutgers, P. H. and Kitslaar, P. J. R. Randomized trial of stripping versus high ligation combined with sclerotherapy in the treatment of the incompetent greater saphenous vein. Am. J. Surg., 1994, 168, 311–315.
Paper accepted 30 April 2003
345