Chapter 62 Venous Surgical Pitfalls
INTRODUCTION
Surgery on the superficial venous system is typically performed to address two specific conditions of the lower extremities: (1) symptomatic varicose veins and (2) superficial venous insufficiency. Varicose veins of the lower extremity are dilated superficial veins that are classified according to their size: small telangiectatic veins (“spider veins”); larger (1–3 mm) intradermal veins, which are not usually tortuous, called reticular veins; and finally, true varicose veins, which are greater than 3 mm and tortuous.1,2 These veins can cause cosmetic problems as well as pain. The overlying skin can darken as hemosiderin from the static blood is deposited in the area.3 Also, with the surrounding nerves, a sensation of dull aching is often described by the patient. The vast majority of patients with symptomatic varicose veins also have superficial venous insufficiency. Superficial venous insufficiency is a condition in which the valves present in the superficial veins are incompetent, which results in reflux of blood within the vein. Reflux of blood within the superficial veins—namely, the greater and lesser saphenous veins—results in elevated venous pressure. Venous hypertension leads to lower extremity edema, pigmentation, stasis dermatitis, lipodermatosclerosis, and venous ulceration of the lower extremities.
The objective of surgical intervention in patients with both symptomatic varicose veins and superficial venous insufficiency is twofold: removal of the symptomatic varicose veins and treatment of the superficial venous insufficiency.4
OPERATIVE PROCEDURE
Stripping of the GSV
The procedure is performed with the patient under general or regional anesthesia. A transverse incision in the groin is performed one to two fingerbreadths from the pubic tubercle. The saphenofemoral junction (SFJ) is identified (Fig. 62-1), and all of the tributaries of the GSV are ligated. The GSV is then divided at the SFJ and the stump is suture-ligated. A stripping device (Fig. 62-2) is then introduced into the GSV via a small incision in the lower thigh. The device is passed proximal to the groin incision, and the divided GSV at the SFJ is secured to the stripper and removed via the thigh incision5 (Fig. 62-3). The vein is usually removed above the knee only to avoid injury to the saphenous nerve, which is within the proximity of the GSV below the knee.
Injury to the Saphenous Nerve
• Consequence
Ligation of the GSV
The procedure is performed with the patient under general or regional anesthesia. A transverse incision in the groin is performed one to two fingerbreadths from the pubic tubercle. The SFJ is identified, and all of the tributaries of the GSV are ligated. The GSV is then divided at the SFJ and suture-ligated.7
Misidentification of the SFJ
• Consequence
GSV Ablation
Local anesthetic is used to anesthetize the skin overlying the GSV at the knee/distal thigh. Under ultrasound guidance, the GSV is punctured with a micropuncture needle, followed by placement of a 0.014″ guidewire through the needle. A small 4-Fr catheter is placed into the GSV over the 0.014″ guidewire. The 0.014″ guidewire is removed, and a 0.035″ J or Bentson guidewire is placed into the GSV and advanced into the common femoral vein. The laser catheter or radiofrequency catheter is advanced into the GSV over the 0.035″ guidewire and positioned at the SFJ under ultrasound guidance (Fig. 62-4A). The guidewire is removed, and the laser or radiofrequency catheter is pulled 2 cm distal to the SFJ (see Fig. 62-4B). The laser fiber or radiofrequency probe is then inserted into the catheter. Tumescent anesthesia (200–400 ml) is infiltrated into the perivenous tissues under ultrasound guidance. The laser fiber or radiofrequency probe is then armed, and laser energy or radiofrequency energy is delivered to the GSV during pullback of the laser fiber or radiofrequency probe. Energy delivered to the GSV results in ablation of the vein.
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