References

Can precocious varicose surgery preserve the saphenous function?

Category: Chirurgie
Régifax le journal faxé de pathologie vasculaire. Kieffer E. eds, 1996.
D. CRETON
E C Ambroise Paré, rue Ambroise Paré, 54100 F-NANCY

During 1994, from 607 consecutive preoperative Doppler scans, which are systematically performed for all our varicose exeresis operations (except recurrence ), we defined several anatomical types of varix which corresponded to various hemodynamic types of dysfunction.

The varices involve only the long saphena, and were divided as follows (471) :

The varices in other areas were divided as follows (136) :

Although the age of the patients at the date of the operation does not correspond to the dates the varices appeared, we nevertheless felt that it would be useful to compare the ages of the patients at the date of the operation for each type of varix, in order to study the age at which the different categories of varix appear.

COMMENTS

The frequency of varices in each category corresponds approximately to the frequency found in a previous study [1]. Echo mapping is directly related to the concept of saphenous preservation. In 26% of cases the great saphenous vein is normal at the moment of the operation, and in 25% of cases it only partly flows back. This means that a preservation-orientated operation is possible in almost 50% of cases.

With regard to the great saphenous vein, in order to be able to understand the appearance of varices, we compared cumulative percentage curves for each type of varix in terms of the age of the patient at the time of the operation (Table I). The results clearly show that the varices which are operated on at an early date are those which do not directly concern the trunk of the great saphenous vein (isolated varicose branch, incontinent collateral of the trunk, incontinent 1st juxta-ostial saphenous tributary ). The reflux in the collateral saphenous tributaries seem to appear, on average, ten years before reflux of the saphenous trunk. In the same way, on the long saphenous trunk, the reflux initially appears to be partial (over the last 20 centimetres, or respecting the last 20 centimetres, or in tiers, respecting the last 20 centimetres and the leg saphenous vein ), and then the reflux would appear to be located between the groin and the Boyd perforator; finally the reflux is complete, from the ostium to the malleolar region.

Table I
50% of isolated vein refluxes are operated on at the age of : 33
50% of saphenous tributary refluxes are operated on at the age of : 36
50% of partial reflux of the sapheno-femoral junction are operated on at the age : 40.5
50% of partial reflux of the great saphenous vein are operated on at the age : 42
50% of short reflux of the great saphenous vein are operated on at the age of : 42.5
50% of complete saphenous refluxes are operated on at the age of : 44

The idea that the precocious ablation of these incontinent saphenous collaterals may protect normal saphenous function for a longer time, is based on several hemodynamic observations with regard to reflux competition at the level of the bifurcations. Indeed, the elimination of the incontinent saphenous collateral often renders the diameter of the lower portion normal, and makes the reflux that is often linked to this saphenous trunk disappear [2]. The idea that a reflux in a tributary can deteriorate the continence of the corresponding main trunk has been demonstrated at the popliteal saphenous junction [3], and at the femoral saphenous junction [4]. In these two studies, the ablation of the saphenous vein has allowed the reflux of the associated trunk to be eliminated.

CONCLUSION

This study allows us to believe that varicose illness affects saphenous collaterals before affecting the saphenous trunk. Furthermore, other studies show that the elimination of an incontinent collateral improves the continence of the corresponding main trunk. Consequently, more precocious selective exeresis of varices should allow normal continence of the saphenous vein to be preserved for longer.

REFERENCES

  1. CRETON D. Influence des examens ultrasonores préopératoires pour une chirurgie d'exérése variqueuse plus conservatrice .( évolution des techniques opératoires sur 7 ans).
    Phlébologie 1994 ; 47 : 227-234.
  2. VIDAL - MICHEL JP., BOURREL Y., ENSALLEM J. , BONERANDI JI. Aspect chirurgical des crosses saphès internes modérément incontinentes par " effet siphon" chez le patient variqueux.
    Phlébologie 1993 ; 46 : 143-147
  3. SOMJEN GM., ROYLE JP., FELLE G. , ROBERTS AK., HOARE MC., TONG Y. Venous reflux patterns in the popliteal fossa .
    J Cardiovasc Surg 1992 ; 33 : 85-91
  4. WALSH JC., BERGAN JJ., BEEMAN S. , COMER TP., JOLLA L. L'éveinage de la veine saphè interne supprime le reflux veineux fémoral.