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Download Download Veins and Lymphatics 2014; volume 3:1919 Multiple ligation of the Introduction Correspondence: Roberto Delfrate, Figlie di San proximal greater saphenous Camillo Hospital, via Fabio Filzi 56, 26100 vein in the CHIVA treatment The sapheno-femoral junction (SFJ) is a key Cremona, Italy. point for the venous drainage of the lower limb Tel.: +39.0372.421111 – Mobile: +39.334.9089110. of primary varicose veins E-mail: [email protected] from the foot up to the hip and gluteus, the Roberto Delfrate,1 Massimo Bricchi,1 lower abdominal wall and lower genital tract. Key words: saphenous-femoral disconnection, Claude Franceschi,2 Matteo Goldoni3 Moreover, the disconnection of the incompe- saphenous-femoral junction, neovascularization tent SFJ is a fundamental procedure to most recurrences, primary varicose vein surgery. 1 Surgery Unit, Figlie di San Camillo open superficial venous surgery.1-5 2 Hospital, Cremona, Italy; Angiology Unfortunately, most varicose recurrences are Received for publication: 11 September 2013. Consultant, Saint Joseph Hospital, Paris, due to SFJ neovascularization (recurrences) Revision received: 11 February 2014. France; 3Department of Consulting of observed in 25% to 94% of recurrent varicose Accepted for publication: 6 March 2014. Clinical Medicine, Nephrology and Health 6 veins. Conservative saphenous-femoral dis- This work is licensed under a Creative Commons Sciences, University of Parma, Italy connection is a very common surgical practice Attribution 3.0 License (by-nc 3.0). according to the conservative hemodynamic correction of venous insufficiency (CHIVA) ©Copyright R. Delfrate et al., 2014 method.7-12 For more than a decade we have Licensee PAGEPress, Italy Abstract tested a technique that requires a division of Veins and Lymphatics 2014; 3:1919 the SFJ and others that require only peculiar doi:10.4081/vl.2014.1919 Saphenous femoral disconnection is the key ligatures without division of the incompetent point of most surgical techniques in the treat- saphenous femoral tract. The simplicity of the ment of primary varicose vein surgery. The aim procedure, the safety of the maneuver, and the muscular groups that activates venous circula- of this study is to compare and analyze differ- effectiveness of the treatment have been our tion by emptying the deep venous system. All ent techniques for conservative saphenous- goals. theonly SFJs were studied in order to rule out both femoral ligation or disconnection. These tech- a Valsalva of pelvic origin and one deriving niques can be to perform mini invasive open from a lateral crural perforator. surgery and are suitable for implementation of the conservative hemodynamic correction of Materials and Methods use Surgical procedure venous insufficiency (CHIVA) method. The The saphenous-femoral disconnection-liga- aim was to present the follow-up by retrospec- SFJ disconnections and ligations were per- tion was performed between the SFJ and the tive analysis of three different ligation-discon- formed using three different techniques in first arch tributary, preserving both the arch nection techniques of the proximal great patients affected by SFJ reflux through the ter- tributaries and the great saphenous vein saphenous vein (GSV) according to the CHIVA minal and also subterminal valves responsible (GSV) trunk (Figure 1), while the refluxing method at the GSV end, i.e. between the very for clinical disorders. All the varicose patients tributaries were divided at their trunk connec- end of the GSV and the first arch tributary, were assessed by Duplex ultra sound (US), tion. A titanium clip (10 mm long and 1 mm according to the CHIVA method. The first thec- where the SFJ reflux was checked with the thick) was placed flush with the femoral vein nique consisted of a surgical division (crosso- Valsalva, squeezing and Paranà maneuvers in all cases of the the three groups in order to tomy). The other two consisted of triple super- with doppler sample on the femoral side of the prevent the presence of a residual saphenous posed ligation with No. 2 non-absorbable terminal valve, and SFJ were skin marked stump. The GSV ligation was performed with a braided coated suture without division labeled using the Duplex US Scan probe (12 MHz No. 2 non-absorbable braided coated suture in TSFL (triple saphenous flush ligation) and No. probe). The techniques were performed in out- the triple saphenous flush ligation (TSFL) 0 polypropylenene ligation TPL (triple patients, under local anesthesia and by the group, and with No. 0 polypropylenene ligation polypropylene ligation). The difference same surgeon. The surgeon and other co- in triple polypropylene ligation (TPL) group. between TSFL and TPL was in the thickness authors did the follow-up checkup using the The SFJ is exposed thanks to a previous sus- and type of material of the thread, though both same color doppler ultrasound equipment: in pension on silicone loops of the superficial epi- were non-absorbable. The followNon-commercial up of 56 TPL particular, neorevascularization was detected gastric vein, the pudendal vein and the great procedures, 61 crossotomy procedures, and 82 at the disconnection-ligation site using the saphenous vein. The first GSV ligation is per- TSFL procedures was analysed. The follow-up color fuction during the Valsalva maneuver. consisted of checking the sapheno-femoral The Valsalva maneuver was performed by hav- formed in a layer close to tributary outflow into junction occlusion with Duplex color ultra ing the patients to blow into a straw that was the SFJ, the second one as close as possible to sound. The incidence rates of neovasculariza- closed at one end: Cremona maneuver.13 In all the femoral vein, and the third one in an inter- tion (new vessels in the ligation or surgical the cases the Valsalva maneuver was per- mediate position. The disconnection is called disconnection site with saphenous-femoral formed after properly emptying of the deep crossotomy when it consists of a division. It is reflux during the Valsalva maneuver) were: venous system through the performance of a called selective ligature when no interrution is 4.9% for the crossotomy group, 6.1% for the Parana maneuver with the aim to prevent false performed. In case of crossotomy the fossa TSFL group and 37.5% for the TPL group. The negatives caused by the presence of a full deep ovalis was closed with a polypropylene suture. data analysed show satisfactory results with venous system. Parana is a gravitational test both crossotomy and TSFL. Crossotomy has performed on a patient standing in front of the Subjects and interventions proven to be an effective technique for per- examiner who pushes the patient’s back off The number of interventions and patients forming saphenous-femoral disconnection, but balance, either backward (posterior Paranà during follow-up visits are reported in Table 1. TSFL could also be a reliable, safe and low-cost maneuver) or forward (anterior Paranà The follow-up period was longer for crosso- varicose mini-invasive surgery in outpatients. maneuver). In order to maintain balance there tomy than the other two groups; in particular, TPL appeared to be less reliable. is an isometric reactive contraction of the in the TPL group the follow-up was always ≤12 [Veins and Lymphatics 2014; 3:1919] [page 19] Article months. Crossotomy is the technique that was patient who had had a unilateral procedure incidence 3/61=4.9%. No varicose veins recur- adopted and has been commonly used since with saphenous-femoral reflux recurrence rence was visible and all the patients were 2003, while the TSFL experience began in detected at 14 months after surgery didn’t asymptomatic. 2007. Since 2007 the number of crossotomy accept any further follow-up because he was Fifty-five patients (37 female, 18 male), had procedures has therefore been reduced and satisfied with the clinical result. Whereas the triple prolene ligature procedures (2004-2005). this is the reason why crossotomy procedures two other patients were satisfied with the Forty-nine of them had a follow-up check one usually require a longer follow-up. operation despite both showing a bilateral year after the operation; 21 showed recanaliza- saphenous-femoral reflux at the thigh: in one tion with saphenous-femoral reflux; 14 were Statistical analysis case at the preterminal valve, and in three asymptomatic with moderate Valsalva reflux at Normally distributed variables were report- cases at the middle of the thigh. Total recur- the upper third of the thigh and seven were ed as mean; otherwise, as median (interquar- rences amounted to 5/82=6.1% of all cases symptomatic with Valsalva reflux down to the tile range). Differences among groups for con- treated. The four cases of reflux below the pre- lower leg. All recurrences occurred between tinuous variables were assessed by means of terminal valve represented 4.8% out of the 82 the 3rd and 6th month after surgery. Re-opera- ANOVA followed by Tukey’s post-hoc test or the TSFL procedures. The rate of TSFL recanaliza- tion (crossotomy) under local anaesthesia and Kruskal-Wallis test followed by the Bonferroni tions was 4.8% below the pre-terminal valve. with a minimal surgical trauma, was per- post-hoc test. Differences in categorical vari- The Valsalva reflux flew clearly below the formed in three cases. The surgical dissection ables were assessed by means of the chi- preterminal valve only in three cases. showed new vessels around the polypropylene square test using the Bonferroni correction. Therefore the percentage of cases in which the thread. The cumulative incidence of recanal- Survival was considered as follows: i) the event reflux reached the proximal third and mid- ization was 21/56=37.5% at one year. Looking was neovascularization for the crossotomy thigh went down to 3.6%. All the patients were at the differences among groups (Table 1), age group, considered the control group; ii) the pleased with the clinical results and didn’t was not significant for neither the unilateral event was asymptomatic or symptomatic show any visible recurrence of varicose veins.
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