- Email: [email protected]
Surgical implications of saphenous venography
Surgical Implications of Saphenous Venography Thomas V. Thomas, MD, Kansas City, Missouri with the technical
assistance
of Patrick O’Brien
Contrast material studies to assess the competence and patency of the deep venous system have been utilized frequently; and the radiographic technics and clinical application are well recognized. Emphasis on opacification of the superficial venous system, however, has not been described previously. Venography of the greater saphenous system with surgical implications in the reconstruction of small vessels, such as the femoropopliteal, coronary, and brachial arteries, has been found to be a valuable adjunct in the management of selected patients in my experience. Until the widespread adoption of the greater saphenous vein as the most suitable small vessel substitute, the main clinical significance attached to it was the frequent development of varicosities in the superficial venous system. Maximal utilization of the greater saphenous vein from the groin to the ankle is likely to become a necessity in some patients in whom portions of the vein have been removed already. Saphenous veins have also been used in the management of chronic venous insufficiency of the lower extremities [I]. The technic described here was indicated only in some selected patients in whom there was doubt concerning the availability of a suitable segment of saphenous vein, and in whom prosthetic bypass grafts could not be used with satisfactory results.
Indications for Saphenous Venography
A significant number of patients admitted to the Surgical Service of the Veterans Administration Hospital in Kansas City, Missouri, have had one and two, or occasionally three and four previous operative interventions at revascularization of the leg at other non-Veterans Administration hospitals, and these patients sought medical help at our institution From the Surgical Service, Veterans Administration Hospital, Kansas City, Missouri. Reprint requests should be addressed to Dr Thomas, 155 South 18th Street, Kansas City, Kansas 66102.
Volume 123, May 1972
primarily for financial reasons. Therefore, occasionally we were forced to search for remaining segments of saphenous vein in a patient at areas frequently not considered, such as below the knee or in the area previously operated on itself. Preoperative knowledge of the availability of segments of saphenous vein has been time-saving and gratifying in some selected patients. Although operative records from other institutions are usually available, our operative findings of the size, length, and patency frequently have been different. Surprisingly, in some patients we have found sufficiently long segments of the saphenous vein available in the scarred operative sites above or below the knee. Those patients who have had multiple operations in the past may have a sclerotic or occluded cephalic venous trunk from repeated use, thus eliminating that vein as an alternative source of autogenous material. Patients in whom saphenous venography is indicated prior to the arterial bypass procedure and the benefits accruing therefrom are as follows: 1. Patients with poor distal vessel patency in whom the chances of success with a saphenous bypass graft are questionable without a good segment of vein. In these patients, if the available saphenous vein is small, sclerotic, or unsuitable for other reasons, exploratory incisions and direct arterial reconstruction may be avoided. (Figures 1A and 1B.) 2. Patients with a history of recurrent thrombophlebitis in whom the saphenous vein on palpation is beaded. This group also includes patients who have had prolonged parenteral fluid administration through the greater saphenous vein in the recent past. 3. Patients in whom arterial occlusions and varicosities of the greater saphenous system coexist. (Figure 2.) An occasional patient may give a history of ligation of the greater saphenous vein in the groin for thrombophlebitis or varicosities in the distant past. Such patients surprisingly enough may have a patent vein that is suitable for use. On the other
515
Thomas
Figure 1A and 16. Operative arteriograms on two patients with poor distal vessel patency. Although the bypass grafting procedures were performed only one week apart, tong-term patency and salvage of the timb have been determined by the difference in the rtuatity of the saphenous vein. Tire patient whose artery is shown in Figure IA has continued to have good results at the end of fourteen months whereas the one whose artery is shown in Figure 16 developed thrombosis three months later and subsequently has undergone amputation.
hand, there may be patients with a damaged or interrupted vein because of past trauma to the thigh. 4. Patients with previous reconstructive procedures, such as endarterectomy, bypass grafts, or mere explorations. Some patients may have their saphenous vein damaged, which the surgeon does not recognize, or they may have double greater saphenous veins of equal size with one still available. (Figure 3.) Occasionally a surgeon might have believed that the vein was unsuitable for use whereas a later examiner may find it eminently suitable. Preoperative knowledge of the availability of a suitable segment of the saphenous vein is critical in extremities ischemic with multiple operations and severe changes. (Figure 4.) Unnecessary exploration can be avoided if patency of the vein is not demonstrable. (Figure 5.) 5. Patients in whom a segment of greater saphenous vein has been used earlier, but who return later for additional bypass procedures elsewhere or on that leg. This problem probably arises more frequently because of the increasing use of segments of the saphenous vein for coronary disease [2] and the generalized nature of arteriosclerotic disease. (Figure 6.) 6. If the vein is preoperatively demonstrated, unnecessary dissection with damage to skin flaps, particularly in patients previously operated on, can be avoided. Occasionally a surgeon may be misled by a large tributary. Preoperative knowledge also helps the surgeon to plan the operative steps and prepare
516
the patient for use of the vein from the other arm or leg, when necessary. Technic To develop a simpie technic for discovering the superficial veins, five patients were studied initially. A Cournand needle was placed in the common femoral artery of patients with the diagnosis of femoropopliteal occlusion. Fifteen cc of Hypaque’ sodium (sodium diatrizoate 50 per cent) were injected, and the arterial phase obtained. Immediately after this, the thigh was fluoroscoped (fifteen to thirty seconds after the arterial injection) to visualize the greater saphenous system. Opacification was unreliable and too faint for obtaining any detail. Therefore, this technic was abandoned. In fifteen patients with the previously listed clinical situations and indications, the arterial phase was obtained first. After reviewing the arteriogram and if indicated, we placed a tourniquet in the midcalf and a second Cournand needle in the greater saphenous vein near the medial malleolus. Once the needle was in the lumen of the vein, the tourniquet was released. The patient’s position was horizontal and not tilted, and the leg was not elevated. Approximately 8 to 12 cc of Hypaque sodium 50 per cent was injected over a three- to five-second period. An x-ray film of the thigh or leg as necessary is obtained in twentyfive to thirty-five seconds in most cases A total
The American Journal of Surgery
Saphenous
Figure 2. Simultaneous opacification of the arterial and venous systems in a patient with occlusion of the femoral artery in midthigh and severe varicosities of the saphenous system. Although there are few areas of aneurysma/ dilatation, particularly around the knee joint, there was sufficient Iength of good quality saphenous vein for use.
Figure 3. Two greater saphenous veins of similar length and size are occasionally encountered. Recognition of this anomaly is of importance in grafting of vascular occlusions in two different vessels simultaneousiy or on different occasions.
Figure 4. Saphenous venography in a patient who had an aortofemoral graft earlier. This saphenous vein appears to be of good size with no major tributaries or areas of stenosis. At the time of exploration for femoropopliteal bypass graft it was approximately 7 to 8 mm in diameter.
Volume123,May1972
Venography
Thomas
delay of forty-five to sixty seconds was utilized in patients with varicosities or clinical evidence of slower venous return. These single exposures consistently gave good results. The diameter of the veins was proportional to the observation on the venogram although the actual size was slightly larger than the measurement on the roentgenogram. Because many of the relatively small veins could be inflated with meticulous preparation after stripping the adventitia [3], an attempt to eliminate any element of spasm was made in five patients. After the venogram was obtained as described, 2 cc of 1 per cent lidocaine was injected five seconds preceding the next injection of contrast medium. No enlargement of the veins was noted in any of the patients. I have not tried other antispasmodic or vasodilating drugs which may be able to reproduce the inflatable size of the veins. The information obtained regarding the size, anatomic location, variations, and levels of occlusion
Surgeons’ and investigators’ searches for autogenous saphenous veins for bypass grafting or patch grafting began with the contributions of Carrel and Guthrie [4] at the turn of this century. Clinical application and detailed surgical technics were reported approximately twenty years ago [5]. Widespread use, however, for femoropopliteal occlusive disease has occurred only during the past decade.
Figure 5. Saphenous venography in a patient with a history of femoropopliteal endarterectomy and wound infection. Despite the fact that the saphenous vein was not used during the previous operation, operative injuries had damaged and interrupted the continuity at the time of exploration. There is no opacification of the saphenous system above the fevel of the knee.
Figure 6. Saphenous venography on a patient who underwent aorto-anterior descending coronary bypass using a segment of proximal saphenous vein 4 inches in length. The venography opacifies the remaining saphenous vein. The remaining segment of saphenous vein can be used in the event that other small vessel occlusive lesions develop in this patient.
518
was confirmed at the time of exploration. Although there was an earlier belief that while the patient was resting in the horizontal position, no dye went into the deep system, in all studies we found that there was opacification of the deep system. Thrombus was not suspected on the venogram in any patient although one patient had clinical findings suggestive of it. Competent valves were demonstrable in most patients.
Comments
The American Journal of Surgery
Saphenous
The last three years have seen unprecedented progress in the treatment of arteriosclerotic disease of the coronary arteries. A patient who underwent surgical therapy may be a candidate for revision of the surgical therapy or for bypass of small vessel lesions elsewhere in the future. For technical ease and longterm success, it is essential that the segment of vein utilized be of satisfactory quality. In some patients a clinical or subclinical stage of thrombophlebitis develops with thrombosis of the remaining segment of vein on the operated side. Recanalization usually occurs in many of the thrombosed veins, but the functional value is questionable. Some of these are turned into a fibrotic and thick-walled vessel with a narrow lumen and rough intima. Preoperative recognition of such changes on physical examination or on utilization of venography may be beneficial in an occasional patient. Technics frequently used to opacify the deep venous system have been: (1) ascending phlebography, (2) descending phlebography, and (3) intraosseous phlebography [6]. Ascending phlebography is probably the most frequently used method. Contrast material is injected into one of the superficial veins of the dorsum of the foot. A tourniquet placed above the ankle directs all the contrast material into the deep system. The greater saphenous system and other superficial veins are sometimes opacified by the retrograde flow from the deep system through incompetent perforators. By eliminating the tourniquet, most of the dye will flow into the superficial system. The deep system is simultaneously opacified by the communicating branches at the level of the knee. Descending phlebography is carried out by injecting contrast material into the deep femoral vein at the level of the inguinal ligament; this technic is used exclusively for demonstrating the incompetent deep venous system of the thigh. Intraosseous phlebography is used frequently to opacify the azygos and intercostal veins and occasionally the deep veins of the leg by injecting contrast material into the needles placed in the marrow of a bone. This technic is less well tolerated by the patients and requires premedication and local anesthetics. The communicating veins remain closed or nonfunctional in the horizontal position while the patient is at rest; therefore, the superficial and deep systems are separate except at the saphenopopliteal and saphenofemoral junctions. Barber and Orley [A have demonstrated that with exercise the communicating channels open and the superficial veins empty their blood into the deep femoral veins. Stein and Evans [8] recently studied the venous system of the legs in twenty-seven patients who died with no ve-
Volume123,May1972
Venography
nous disease whatsoever. Phlebographic studies obtained immediately after death were correlated with the findings of dissection and review of microscopic sections of the venous system. There was 90 per cent accuracy of the phlebographic findings in relation to the anatomic and histologic studies. Therefore, venography is a reliable means for detecting thrombus in the venous system before and after death. The opacification of the deep venous system seen in our patients during superficial venography also has demonstrated the competency of the deep venous system as well as lack of thrombus and recanalization. Obvious varicosities of the greater saphenous system make them unsuitable for use as bypass grafts; fortunately, they are predominantly below the knee, thus making the segment of the vein above the knee still suitable for use. Congenital anatomic variations of the greater saphenous system are frequent, which adds another factor to the unpredictability of their use in some instances. Pregnancy and childbirth, operative intervention, fracture with immobilization, application of casts, and occupations demanding prolonged standing are some of the acquired factors which may affect the size, patency, and length of the greater saphenous system. Initial steps in our experience to opacify the veins without directly injecting the venous system were unsuccessful. We also learned that an element of spasm may exist in the greater saphenous vein with the passage of contrast material which was not reversible with lidocaine. A single exposure of the thigh after venous and arterial injections approximately fifteen to twenty seconds apart was attempted. This resulted in excessive overlap of the deep veins and arteries resulting in the loss of details in the important arterial distribution. Sympathectomy is not a satisfactory substitute for revascularization of the legs, particularly in patients with disabling claudication or rest pain. Dacron grafts for bypass have functioned satisfactorily in patients with good distal vascular tree and when the distal anastomosis is made above the knee joint. Therefore, the search for suitable segments of vein arises in patients with poor distal vessels and where the distal anastomosis is at the level of the knee joint or below. Long thromboendarterectomy of the femoropopliteal system has been a frustrating undertaking in my experience and therefore is resorted to only after sources of autogenous vein such as the opposite leg, below the knee, and the arm have been exhausted. Those patients with vessels unsuitable for reconstruction or absence of autogenous bypass material are encouraged to stop smoking and exercise by a
519
Thomas
graduated scale, particularly if there is no threat to the viability of the extremity. When claudication is the only complaint with no signs of ischemia, surgical intervention should be undertaken with caution. There is a possibility of making the conditions worse of some such patients when the vessels are not suitable for bypass grafting or when suitable graft is not available. Presence of varicosities need not be contraindication for consideration of that vein during bypass procedures. Obvious aneurysm in a varicose vein can be resected and end to end anastomosis carried out. Conclusion
Preoperative saphenous venography in selected patients is a valuable adjunct to the planning and execution of small vessel arterial bypass. Phlebographic findings correlated exceptionally well with the operative findings regarding the size, length, and patency
520
of the saphenous vein. Among those patients with previous operations and scar tissue, the venogram may be of help in dissection and avoiding injury to the saphenous vein. References 1. Dale WA: Crossover vein grafts for relief of ileofemoral block. Surgery 57: 606, 1965. 2. Thomas TV:-Aortocoronary bypass. Sorg Gynec Obstet 131: 753,197o. 3. Thomas TV: Role of thromboendarterectomy and bypass grafts in occlusive vascular disorders. Surgery 66: 965, 1969. 4. Carrel A, Guthrie CC: Uniterminal and biterminal venous transplantation. Sufg Gynec Obstet 2: 226. 1906. 5. Linton RF?: Some practical considerations ;n the surgery of blood vessel grafts. Surgery 38: al7, 1955. 6. Halliday P: Phlebography of the lower limb. Brit J Surg 55: 220,1968. 7. Barber THT, Orley A: Some x-ray observations in varicose diseases of the leg. Lancet 2: 175, 1932. a. Stein PD, Evans H: An autopsy study of leg vein thrombosis. Circulation 35: 671( 1967.
The American Journal of Surgery
assistance
of Patrick O’Brien
Contrast material studies to assess the competence and patency of the deep venous system have been utilized frequently; and the radiographic technics and clinical application are well recognized. Emphasis on opacification of the superficial venous system, however, has not been described previously. Venography of the greater saphenous system with surgical implications in the reconstruction of small vessels, such as the femoropopliteal, coronary, and brachial arteries, has been found to be a valuable adjunct in the management of selected patients in my experience. Until the widespread adoption of the greater saphenous vein as the most suitable small vessel substitute, the main clinical significance attached to it was the frequent development of varicosities in the superficial venous system. Maximal utilization of the greater saphenous vein from the groin to the ankle is likely to become a necessity in some patients in whom portions of the vein have been removed already. Saphenous veins have also been used in the management of chronic venous insufficiency of the lower extremities [I]. The technic described here was indicated only in some selected patients in whom there was doubt concerning the availability of a suitable segment of saphenous vein, and in whom prosthetic bypass grafts could not be used with satisfactory results.
Indications for Saphenous Venography
A significant number of patients admitted to the Surgical Service of the Veterans Administration Hospital in Kansas City, Missouri, have had one and two, or occasionally three and four previous operative interventions at revascularization of the leg at other non-Veterans Administration hospitals, and these patients sought medical help at our institution From the Surgical Service, Veterans Administration Hospital, Kansas City, Missouri. Reprint requests should be addressed to Dr Thomas, 155 South 18th Street, Kansas City, Kansas 66102.
Volume 123, May 1972
primarily for financial reasons. Therefore, occasionally we were forced to search for remaining segments of saphenous vein in a patient at areas frequently not considered, such as below the knee or in the area previously operated on itself. Preoperative knowledge of the availability of segments of saphenous vein has been time-saving and gratifying in some selected patients. Although operative records from other institutions are usually available, our operative findings of the size, length, and patency frequently have been different. Surprisingly, in some patients we have found sufficiently long segments of the saphenous vein available in the scarred operative sites above or below the knee. Those patients who have had multiple operations in the past may have a sclerotic or occluded cephalic venous trunk from repeated use, thus eliminating that vein as an alternative source of autogenous material. Patients in whom saphenous venography is indicated prior to the arterial bypass procedure and the benefits accruing therefrom are as follows: 1. Patients with poor distal vessel patency in whom the chances of success with a saphenous bypass graft are questionable without a good segment of vein. In these patients, if the available saphenous vein is small, sclerotic, or unsuitable for other reasons, exploratory incisions and direct arterial reconstruction may be avoided. (Figures 1A and 1B.) 2. Patients with a history of recurrent thrombophlebitis in whom the saphenous vein on palpation is beaded. This group also includes patients who have had prolonged parenteral fluid administration through the greater saphenous vein in the recent past. 3. Patients in whom arterial occlusions and varicosities of the greater saphenous system coexist. (Figure 2.) An occasional patient may give a history of ligation of the greater saphenous vein in the groin for thrombophlebitis or varicosities in the distant past. Such patients surprisingly enough may have a patent vein that is suitable for use. On the other
515
Thomas
Figure 1A and 16. Operative arteriograms on two patients with poor distal vessel patency. Although the bypass grafting procedures were performed only one week apart, tong-term patency and salvage of the timb have been determined by the difference in the rtuatity of the saphenous vein. Tire patient whose artery is shown in Figure IA has continued to have good results at the end of fourteen months whereas the one whose artery is shown in Figure 16 developed thrombosis three months later and subsequently has undergone amputation.
hand, there may be patients with a damaged or interrupted vein because of past trauma to the thigh. 4. Patients with previous reconstructive procedures, such as endarterectomy, bypass grafts, or mere explorations. Some patients may have their saphenous vein damaged, which the surgeon does not recognize, or they may have double greater saphenous veins of equal size with one still available. (Figure 3.) Occasionally a surgeon might have believed that the vein was unsuitable for use whereas a later examiner may find it eminently suitable. Preoperative knowledge of the availability of a suitable segment of the saphenous vein is critical in extremities ischemic with multiple operations and severe changes. (Figure 4.) Unnecessary exploration can be avoided if patency of the vein is not demonstrable. (Figure 5.) 5. Patients in whom a segment of greater saphenous vein has been used earlier, but who return later for additional bypass procedures elsewhere or on that leg. This problem probably arises more frequently because of the increasing use of segments of the saphenous vein for coronary disease [2] and the generalized nature of arteriosclerotic disease. (Figure 6.) 6. If the vein is preoperatively demonstrated, unnecessary dissection with damage to skin flaps, particularly in patients previously operated on, can be avoided. Occasionally a surgeon may be misled by a large tributary. Preoperative knowledge also helps the surgeon to plan the operative steps and prepare
516
the patient for use of the vein from the other arm or leg, when necessary. Technic To develop a simpie technic for discovering the superficial veins, five patients were studied initially. A Cournand needle was placed in the common femoral artery of patients with the diagnosis of femoropopliteal occlusion. Fifteen cc of Hypaque’ sodium (sodium diatrizoate 50 per cent) were injected, and the arterial phase obtained. Immediately after this, the thigh was fluoroscoped (fifteen to thirty seconds after the arterial injection) to visualize the greater saphenous system. Opacification was unreliable and too faint for obtaining any detail. Therefore, this technic was abandoned. In fifteen patients with the previously listed clinical situations and indications, the arterial phase was obtained first. After reviewing the arteriogram and if indicated, we placed a tourniquet in the midcalf and a second Cournand needle in the greater saphenous vein near the medial malleolus. Once the needle was in the lumen of the vein, the tourniquet was released. The patient’s position was horizontal and not tilted, and the leg was not elevated. Approximately 8 to 12 cc of Hypaque sodium 50 per cent was injected over a three- to five-second period. An x-ray film of the thigh or leg as necessary is obtained in twentyfive to thirty-five seconds in most cases A total
The American Journal of Surgery
Saphenous
Figure 2. Simultaneous opacification of the arterial and venous systems in a patient with occlusion of the femoral artery in midthigh and severe varicosities of the saphenous system. Although there are few areas of aneurysma/ dilatation, particularly around the knee joint, there was sufficient Iength of good quality saphenous vein for use.
Figure 3. Two greater saphenous veins of similar length and size are occasionally encountered. Recognition of this anomaly is of importance in grafting of vascular occlusions in two different vessels simultaneousiy or on different occasions.
Figure 4. Saphenous venography in a patient who had an aortofemoral graft earlier. This saphenous vein appears to be of good size with no major tributaries or areas of stenosis. At the time of exploration for femoropopliteal bypass graft it was approximately 7 to 8 mm in diameter.
Volume123,May1972
Venography
Thomas
delay of forty-five to sixty seconds was utilized in patients with varicosities or clinical evidence of slower venous return. These single exposures consistently gave good results. The diameter of the veins was proportional to the observation on the venogram although the actual size was slightly larger than the measurement on the roentgenogram. Because many of the relatively small veins could be inflated with meticulous preparation after stripping the adventitia [3], an attempt to eliminate any element of spasm was made in five patients. After the venogram was obtained as described, 2 cc of 1 per cent lidocaine was injected five seconds preceding the next injection of contrast medium. No enlargement of the veins was noted in any of the patients. I have not tried other antispasmodic or vasodilating drugs which may be able to reproduce the inflatable size of the veins. The information obtained regarding the size, anatomic location, variations, and levels of occlusion
Surgeons’ and investigators’ searches for autogenous saphenous veins for bypass grafting or patch grafting began with the contributions of Carrel and Guthrie [4] at the turn of this century. Clinical application and detailed surgical technics were reported approximately twenty years ago [5]. Widespread use, however, for femoropopliteal occlusive disease has occurred only during the past decade.
Figure 5. Saphenous venography in a patient with a history of femoropopliteal endarterectomy and wound infection. Despite the fact that the saphenous vein was not used during the previous operation, operative injuries had damaged and interrupted the continuity at the time of exploration. There is no opacification of the saphenous system above the fevel of the knee.
Figure 6. Saphenous venography on a patient who underwent aorto-anterior descending coronary bypass using a segment of proximal saphenous vein 4 inches in length. The venography opacifies the remaining saphenous vein. The remaining segment of saphenous vein can be used in the event that other small vessel occlusive lesions develop in this patient.
518
was confirmed at the time of exploration. Although there was an earlier belief that while the patient was resting in the horizontal position, no dye went into the deep system, in all studies we found that there was opacification of the deep system. Thrombus was not suspected on the venogram in any patient although one patient had clinical findings suggestive of it. Competent valves were demonstrable in most patients.
Comments
The American Journal of Surgery
Saphenous
The last three years have seen unprecedented progress in the treatment of arteriosclerotic disease of the coronary arteries. A patient who underwent surgical therapy may be a candidate for revision of the surgical therapy or for bypass of small vessel lesions elsewhere in the future. For technical ease and longterm success, it is essential that the segment of vein utilized be of satisfactory quality. In some patients a clinical or subclinical stage of thrombophlebitis develops with thrombosis of the remaining segment of vein on the operated side. Recanalization usually occurs in many of the thrombosed veins, but the functional value is questionable. Some of these are turned into a fibrotic and thick-walled vessel with a narrow lumen and rough intima. Preoperative recognition of such changes on physical examination or on utilization of venography may be beneficial in an occasional patient. Technics frequently used to opacify the deep venous system have been: (1) ascending phlebography, (2) descending phlebography, and (3) intraosseous phlebography [6]. Ascending phlebography is probably the most frequently used method. Contrast material is injected into one of the superficial veins of the dorsum of the foot. A tourniquet placed above the ankle directs all the contrast material into the deep system. The greater saphenous system and other superficial veins are sometimes opacified by the retrograde flow from the deep system through incompetent perforators. By eliminating the tourniquet, most of the dye will flow into the superficial system. The deep system is simultaneously opacified by the communicating branches at the level of the knee. Descending phlebography is carried out by injecting contrast material into the deep femoral vein at the level of the inguinal ligament; this technic is used exclusively for demonstrating the incompetent deep venous system of the thigh. Intraosseous phlebography is used frequently to opacify the azygos and intercostal veins and occasionally the deep veins of the leg by injecting contrast material into the needles placed in the marrow of a bone. This technic is less well tolerated by the patients and requires premedication and local anesthetics. The communicating veins remain closed or nonfunctional in the horizontal position while the patient is at rest; therefore, the superficial and deep systems are separate except at the saphenopopliteal and saphenofemoral junctions. Barber and Orley [A have demonstrated that with exercise the communicating channels open and the superficial veins empty their blood into the deep femoral veins. Stein and Evans [8] recently studied the venous system of the legs in twenty-seven patients who died with no ve-
Volume123,May1972
Venography
nous disease whatsoever. Phlebographic studies obtained immediately after death were correlated with the findings of dissection and review of microscopic sections of the venous system. There was 90 per cent accuracy of the phlebographic findings in relation to the anatomic and histologic studies. Therefore, venography is a reliable means for detecting thrombus in the venous system before and after death. The opacification of the deep venous system seen in our patients during superficial venography also has demonstrated the competency of the deep venous system as well as lack of thrombus and recanalization. Obvious varicosities of the greater saphenous system make them unsuitable for use as bypass grafts; fortunately, they are predominantly below the knee, thus making the segment of the vein above the knee still suitable for use. Congenital anatomic variations of the greater saphenous system are frequent, which adds another factor to the unpredictability of their use in some instances. Pregnancy and childbirth, operative intervention, fracture with immobilization, application of casts, and occupations demanding prolonged standing are some of the acquired factors which may affect the size, patency, and length of the greater saphenous system. Initial steps in our experience to opacify the veins without directly injecting the venous system were unsuccessful. We also learned that an element of spasm may exist in the greater saphenous vein with the passage of contrast material which was not reversible with lidocaine. A single exposure of the thigh after venous and arterial injections approximately fifteen to twenty seconds apart was attempted. This resulted in excessive overlap of the deep veins and arteries resulting in the loss of details in the important arterial distribution. Sympathectomy is not a satisfactory substitute for revascularization of the legs, particularly in patients with disabling claudication or rest pain. Dacron grafts for bypass have functioned satisfactorily in patients with good distal vascular tree and when the distal anastomosis is made above the knee joint. Therefore, the search for suitable segments of vein arises in patients with poor distal vessels and where the distal anastomosis is at the level of the knee joint or below. Long thromboendarterectomy of the femoropopliteal system has been a frustrating undertaking in my experience and therefore is resorted to only after sources of autogenous vein such as the opposite leg, below the knee, and the arm have been exhausted. Those patients with vessels unsuitable for reconstruction or absence of autogenous bypass material are encouraged to stop smoking and exercise by a
519
Thomas
graduated scale, particularly if there is no threat to the viability of the extremity. When claudication is the only complaint with no signs of ischemia, surgical intervention should be undertaken with caution. There is a possibility of making the conditions worse of some such patients when the vessels are not suitable for bypass grafting or when suitable graft is not available. Presence of varicosities need not be contraindication for consideration of that vein during bypass procedures. Obvious aneurysm in a varicose vein can be resected and end to end anastomosis carried out. Conclusion
Preoperative saphenous venography in selected patients is a valuable adjunct to the planning and execution of small vessel arterial bypass. Phlebographic findings correlated exceptionally well with the operative findings regarding the size, length, and patency
520
of the saphenous vein. Among those patients with previous operations and scar tissue, the venogram may be of help in dissection and avoiding injury to the saphenous vein. References 1. Dale WA: Crossover vein grafts for relief of ileofemoral block. Surgery 57: 606, 1965. 2. Thomas TV:-Aortocoronary bypass. Sorg Gynec Obstet 131: 753,197o. 3. Thomas TV: Role of thromboendarterectomy and bypass grafts in occlusive vascular disorders. Surgery 66: 965, 1969. 4. Carrel A, Guthrie CC: Uniterminal and biterminal venous transplantation. Sufg Gynec Obstet 2: 226. 1906. 5. Linton RF?: Some practical considerations ;n the surgery of blood vessel grafts. Surgery 38: al7, 1955. 6. Halliday P: Phlebography of the lower limb. Brit J Surg 55: 220,1968. 7. Barber THT, Orley A: Some x-ray observations in varicose diseases of the leg. Lancet 2: 175, 1932. a. Stein PD, Evans H: An autopsy study of leg vein thrombosis. Circulation 35: 671( 1967.
The American Journal of Surgery