52 Across Specialties S KIN & ALLERGY N EWS • February 2008 Tourniquet Use Improves Varicose Stripping

BY PATRICE WENDLING early failure rate for endovenous proce- Chicago Bureau dures, Dr. Finkelmeier said. Patients with significant sapheno- C HICAGO — The minimally invasive ve- femoral junction reflux are optimal can- nous ablation procedure may breathe new didates for MIVA, but its advantage may lie life into surgical ligation and stripping for in the treatment of large duplicated saphe- patients with varicose . nous systems, which occur in 30%-40% of The MIVA procedure—as it’s been patients. These systems often contain dubbed by vascular surgeons at VeinSolu- large, tortuous branches that are difficult tions, a nationwide practice that special- to cannulate with an endovenous catheter INKELMEIER izes in cosmetic and therapeutic vein and treat with laser ablation. The branch- F care—borrows several characteristics from es are often injected after the primary a conventional surgical stripping proce- laser procedure with , but ILLIAM . W R dure, but the recovery time, return-to- this typically results in substandard results D work time, and cosmetic results are far su- including pain, tenderness, chemical perior, Dr. William Finkelmeier said at a phlebitis, and hemosiderin staining, Dr. OURTESY symposium on vascular sponsored Finkelmeier said. C by Northwestern University. “The beauty of the MIVA procedure is HOTOS

The use of a tourniquet during the out- that all branch varicosities are removed P patient procedure allows the surgeon to during the primary procedure,” he said. Photo shows extent of patient’s varicose Significant improvement can be seen strip the vein and perform the phlebec- Branch varicosities are outlined or circled veins before undergoing MIVA procedure. 5 weeks after the ablation surgery. tomies in a bloodless field, which greatly preoperatively with permanent marker as reduces the postoperative bleeding, bruis- the patient is in the standing position, with used to deliver the stripper through the in- ties, and a No. 1 phlebectomy hook to cap- ing, and pain that typically develop fol- an area for the phlebectomy puncture left cision to the groin, where a gauze pad ture the veins, Dr. Finkelmeier said. lowing conventional surgical stripping. unmarked. (Puncturing the skin over the soaked in bupivacaine (Marcaine) and ep- Because all branch varicosities have been The majority of MIVA patients return to ink can tattoo the skin.) inephrine is tied to the proximal head of decompressed, very large veins can be re- work in 2-7 days. Once the patient is under general anes- the stripper. The leg is exsanguinated with moved through the 18-gauge needle holes. “If you mention ligation and stripping thesia, a 1.5- to 2-cm incision is made at the an Esmarch bandage and a sterile tourni- And because there are no incisions in the to your patients, they think it’s their grand- groin in the inguinal skin crease or pubic quet is placed on the proximal thigh. leg, “in 3 months you can’t tell we were mother or mother’s operation,” he said. mons. The saphenous vein is encircled with The stripper wire is then pulled down there,” he said. “This is not your mother’s operation.” a 2-0 silk tie, and followed up to the saphe- into the saphenous tract and the entire The needle holes are covered with a Dr. Finkelmeier reported that excellent nofemoral junction. After the common vein is teased out intact over the stripper, very snug compressive dressing up to the cosmetic and therapeutic results have been femoral vein is carefully identified travers- which is pulled out through the groin to level of the tourniquet before it is re- achieved with minimal morbidity in 1,234 ing both proximally and distally, the saphe- avoid stretching the distal incision. Distal leased. The groin is anesthetized with MIVA procedures performed at the prac- nofemoral junction is ligated and the and phlebectomy wounds should not be Marcaine and epinephrine and the groin tice’s Indianapolis office, where he is a vas- branches divided. spread with a hemostat, Dr. Finkelmeier incision closed in two layers. cular surgeon and the director. No deaths A common Codman’s stripper is then said. The patient is able to walk out of the have been reported. The patients were passed retrograde down the vein to the The phlebectomies are then performed surgery center and shower that night, with aged 20-80 years. There have been no ear- knee, where a 2-mm incision is made over using an 18-gauge needle to puncture the only 4 of 10 patients requiring oral nar- ly failures, as compared with an 8%-15% the stripper. A No. 3 phlebectomy hook is skin over the previously marked varicosi- cotics for pain, Dr. Finkelmeier said. ■ DVT Prophylaxis Found to Be Underused in Surgery Patients

BY JEFF EVANS stroke and orthopedic surgery patients. Even though (LDUH) or low-molecular weight heparin (LMWH) for Senior Writer most patients did not have symptomatic thrombosis in moderate-risk patients. High-risk patients generally those studies, each patient underwent or a should receive LDUH every 8 hours, or a LMWH such B ALTIMORE — Methods for determining how and fibrinogen uptake procedure. Most series of major pro- as enoxaparin (Lovenox). when to use pharmacologic and mechanical interventions cedures in plastic surgery have found a risk of 1%-2% for Patients at highest risk for DVT need a full dose of a to prevent venous thromboembolism in surgical patients DVT and/or , generally without LMWH such as enoxaparin or the factor Xa inhibitor may remain open to debate, but the need for prophylax- prophylaxis, he said. fondaparinux (Arixtra) in combination with intermittent is should not, Dr. Morey A. Blinder said at the annual Deficiencies in any of the body’s natural anticoagulants, pneumatic compression (IPC) or graduated compression meeting of the American Society of Plastic Surgeons. such as antithrombin, protein C, and protein S, lead to a stockings, said Dr. Blinder, who is on the speakers bu- Prophylaxis is underused because substantial risk of thrombosis. reau for GlaxoSmithKline Inc., which manufactures many physicians believe that the in- Most series of major plastic About 5% of people with European fondaparinux. cidence of deep venous thrombosis heritage carry a mutation in the Other guidelines that have been issued by the Ameri- (DVT) in hospitalized patients is surgery procedures have blood-clotting factor V Leiden, can Society of Plastic Surgeons largely follow these rec- “too low” to warrant its considera- found a risk of 1%-2% which increases the risk of throm- ommendations but instead divide surgical patients into tion, said Dr. Blinder of the division bosis. In fact, 20%-30% of people low-, moderate-, and high-risk groups (Plast. Reconstr. of hematology and the department for DVT and/or pulmonary who have DVT without an identified Surg. 2002;110:1337-42). of pathology and immunology at embolism, generally cause turn out to be positive for the Dr. Blinder suggested that IPC devices may see rising Washington University, St. Louis. factor V Leiden mutation. use because newer, fanny pack–size devices are much Other physicians voice concerns without prophylaxis. “We’ve seen many, many patients smaller than previous ones that had to sit at the side of about bleeding complications—par- who have [a factor V Leiden muta- a bed. Graduated compression stockings are thought to ticularly in surgical patients—and about heparin-induced tion] as an inherited risk factor, and then you add on a increase blood circulation by restricting the venous di- thrombocytopenia, which occurs in 1%-2% of patients on second risk factor like surgery or like an estrogen-con- ameter. IPC devices also restrict venous diameter and are heparin. taining hormone, and that is enough to trigger a blood known to more than double the velocity of blood and in- “Many clinicians have the sense that venous thrombo- clot,” Dr. Blinder said. crease fibrinolytic activity. sis is not a particular problem in their practice,” because The American College of Chest Physicians’ evidence- A meta-analysis of 15 randomized, controlled trials us- they have not seen a DVT in one of their patients for sev- based guidelines for preventing venous thromboem- ing IPC to prevent DVT in surgical patients found that eral years or may have not known that a patient had a bolism stratify patients undergoing general surgery as low, the devices could drop the risk of DVT by 60%, compared DVT diagnosed a week after surgery by an internist or moderate, high, or highest risk, according to their age, the with no prophylaxis (Thromb. Haemost. 2005;94:1181-5). at the emergency department, Dr. Blinder said. type of operation, and underlying risk factors (Chest Investigators have not resolved the appropriate time to In the absence of prophylaxis, studies have found a 2004;126:338S-400S). start or stop prophylaxis, but some type of pharmacologic DVT prevalence of 10%-20% in medical patients, 15%- The guidelines advise early and frequent mobilization prophylaxis should be included along with mechanical 40% in general surgery patients, and about 20%-50% of for low-risk patients and low-dose unfractionated heparin methods, he advised. ■