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Fibular Nerve Injury After Small Saphenous Vein Surgery
... При этом оставленный сегмент БПВ на голени, как показано в крупном долгосрочном продольном исследовании, в 4% случаев является причиной рецидива варикозного расширения вен [231]. Частота повреждения общего малоберцового нерва при кроссэктомии и стриппинге МПВ достигает 5-7%, а сурального нерва -2-4% [245,246]. Риск повреждения бедренной вены или артерии крайне мал (0,0017-0,3%), однако это осложнение крайне опасно ввиду того, что не всегда распознается своевременно [243]. Систематический обзор 87 исследований выявил 87 случаев повреждения крупных сосудов. ...
... -ЭВЛО и РЧО рекомендуются для устранения рефлюкса по интрафасциальным фрагментам поверхностных вен при рецидиве варикозной болезни [245,251,252,254,255]. УДД 4, УУР C -Операции по поводу ХЗВ, в том числе с использованием технологий термической облитерации вен, рекомендуется выполнять в амбулаторных и/или стационарных учреждениях сердечно-сосудистыми хирургами и хирургами [256]. ...
Varicose veins of the lower extremities are one of the most common peripheral vascular diseases. In Russia, this disease is diag- nosed in approximately 30% of adults, while chronic venous insufficiency (CVI) develops in 7% of the population. High incidence of varicose veins in employable people and progressive course of disease followed by CVI decompensation lead to QoL impair- ment and disability of patients. High prevalence of varicose veins of the lower extremities in our country emphasizes the importance of accurate and timely diag- nosis of this disease. Moreover, treatment technologies that can be used as widely as possible not only by cardiovascular surgeons and phlebologists, but also general surgeons and even other specialists are required. The expert group of the National Association of Phlebologists in collaboration with other professional communities prepared these clinical guidelines. The document was developed in accordance with the requirements of the Ministry of Health of the Russian Federation. The expert recommendations on the main issues of clinical and instrumental diagnosis of varicose veins are presented. Treatment approaches for varicose veins are described in detail. The authors discuss the use of compression, drug therapy, sclerotherapy, traditional surgical interventions and endovasal procedures. In addition, the issues of medical and social rehabilitation of patients with varicose veins are considered separately.
... When possible, compression (by elastic stockings or wraps) should be applied after surgical or thermal procedures [19], their role in complications prevention being acknowledged [20]. Superficial nerve injuries are very common during venous insufficiency classic surgery [21]. Even if this complication rate decreases greatly when minimally invasive procedures are used, nerve injury remains a risk with thermal ablation or cryostripping, too. ...
Objective:
The presentation of cryostripping as an alternative procedure useful in venous insufficiency treatment.
Methods:
This retrospective study presents the results of 1087 operated patients, including follow-ups. Cryostripping was practised in all mentioned cases. Patient follow-up was performed at one week, one month, and six months postoperatively by clinical examination, Doppler ultrasonography, CIVIQ-20 and r-VCSS questionnaires. Outcomes, complications, surgery and hospitalisation period, and benefits of the method were analysed.
Results:
Generally, good functional and aesthetic outcomes defined by clinical symptom remission, absence of insufficient veins on Doppler ultrasonography, QoL and r-VCSS improvement (p < 0.001) were obtained. Complications included bruising ⌀ < 2 cm (32.38%), haematoma (8.92%), saphenous nerve injury (3.49%), deep vein thrombosis (0.18%). Recurrence was noted in 2.94% cases. Mean duration of procedure was 42 ± 12.5 min, mean duration of hospitalisation was 1.05 ± 0.36 days. Compared to high ligation and conventional stripping, the postoperative complications were reduced; compared to other minimally invasive procedures, the costs were reduced.
Conclusions:
Cryostripping seems to combine the radicality and efficacy of the stripping technique with the cosmetic advantage of the endothermal procedures, being an effective therapeutic method perfectly adapted to the economic conditions of middle-income countries health system. It is also suitable as day-case surgery.
... The sural nerve is a common candidate for autologous nerve grafting as it represents a non-critical sensory nerve leaving a relatively small area of sensory deficit after harvest (Riedl et al., 2008;de Alvarenga Yoshida et al., 2012;Kerver et al., 2012;Riedl and Frey, 2013). Cadaveric studies have demonstrated that the maximum obtainable average sural nerve length is approximately 43 cm per leg with a range of 35-47 cm (Riedl et al., 2008). ...
Peripheral nerve injury (PNI) is found in a relatively large portion of trauma patients. If the injury is severe, such as with the presence of a long segmental gap, PNI can present a challenge for treatment. The current clinical standard of nerve harvest for the repair of long segmental gap PNI can lead to many potential complications. While other methods have been utilized, recent evidence indicates the relevance of cell therapies, particularly through the use of Schwann cells, for the treatment of PNI. Schwann cells (SCs) are integral in the regeneration and restoration of function following PNI. SCs are able to dedifferentiate and proliferate, remove myelin and axonal debris, and are supportive in axonal regeneration. Our laboratory has demonstrated that SCs are effective in the treatment of severe PNI when axon guidance channels are utilized. However, in order for this treatment to be effective, optimal techniques for cellular placement must be used. Thus, here we provide relevant background information, preclinical, and clinical evidence for our method in the treatment of severe PNI through the use of SCs and axon guidance channels.
... The drawback of this access is the limited scope for access to the popliteal vessels and the possibility of injuring the fibular nerve. 20 A saphenous vein with good caliber is the ideal graft material in these cases, since it is autologous, more malleable, more resistant to folding and to thrombosis, and less prone to infections. In the present case, surgical access to the aneurysms in both limbs was accomplished via a posterior route, which is usually considered preferable in cases with short aneurysms limited to the popliteal fossa. ...
Popliteal artery aneurysms are the most frequent type of peripheral aneurysm, accounting for 85% of the all of these aneurysms. Usually asymptomatic, they are generally diagnosed during clinical examination. Incidence is higher among males and seniors. They are bilateral in 50% of the cases and 60% are associated with abdominal aortic aneurysms. This paper describes a 72-year-old male patient who presented with two bilateral pulsatile masses, one in each popliteal region, was otherwise asymptomatic, and had a history of hypertension and dyslipidemia. Clinical examination and ultrasound imaging confirmed a diagnosis of bilateral aneurysms of the popliteal arteries. Popliteal artery aneurysms can be treated with open bypass surgery, with or without aneurysm resection, or with endovascular surgery. This Therapeutic Challenge discusses these possibilities.
... Similarly, another 2 cases of CFN injury after small saphenous vein stripping were described and stressed the importance of careful preoperative ultrasonographic investigation of the anatomy of the vein. Further, determining the location of the saphenopopliteal joint, and careful dissection far from fibular nerve and restricted to the popliteal fossa should be implemented during vein stripping (15). ...
Entrapment neuropathies of the fibular nerve and its branches are often underdiagnosed due to the lack of reliable diagnosis using clinical examination and electrophysiologic evaluation. Most fibular nerve compressions may be classified into 2 broad categories: (a) mechanical causes, which occur at fibrous or fibro-osseous tunnels, and (b) dynamic causes related to nerve injury during specific limb positioning. Foot drop resulting from weakness of the dorsiflexor muscles of the foot is a relatively uncommon presentation and closely related to L5 neuropathy caused by a disc herniation. However, we herein describe a rare case of usually painless foot drop triggered by a cyst at the proximal tibiofibular joint compressing the deep fibular nerve. The presence of multilevel disc diseases made the diagnosis more difficult. Foot drop is highly troubling, and health care providers need to broaden their search for the imperative and overlapping causes especially in patients with painless drop foot, and the treatment is variable and should be directed at the specific cause. The magnetic resonance imaging (MRI), including high-resolution and 3D MR neurography, allows detailed assessment of the course and anatomy of peripheral nerves, as well as accurate delineation of surrounding soft-tissue and osseous structures that may contribute to nerve entrapment. Knowledge of normal MRI anatomy of the nerves in the knee and leg is essential for the precise assessment of the presence of peripheral entrapment conditions that may produce painless or painful drop foot. In conclusion, we stress the importance of preoperative anatomic mapping of entrapment neuropathies to minimize neurological complications. © 2016, American Society of Interventional Pain Physicians. All rights reserved.
... A very rare form of complication described in the literature are lesions of the sensory and the motor tibial nerve, which is located in the back of the knee in close proximity to the saphenopopliteal junction. If this is damaged by heat or through the insertion of a needle, sensory disturbance, as well as talipes calcaneus, can be expected [17][18][19]. ...
Treating varicose veins using endovenous thermal techniques - especially laser and radio frequency ablation - has emerged as an effective alternative to open surgery with stripping and high ligation. Even though these methods are very gentle and patient-friendly, they are nevertheless accompanied by risks and side effects. Compared to open surgical therapy, the risk of damage to peripheral and motor nerves is reduced; however, it still exists as a result of heat exposure and tumescent anaesthesia. Non-thermal methods that can be applied without tumescent anaesthesia have been introduced to the market. They pose a considerably lower risk of nerve lesions while proving to be much more effective. This paper investigates data on postoperative nerve damage and paraesthesia using internet research (PubMed). It analyses the current state of knowledge regarding non-thermal treatment methods and takes into account the latest developments in the use of cyanoacrylate to close insufficient saphenous veins.
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... Varicose veins surgery is one of the most frequent operations carried out in Europe as well as one of the most frequent causes of civil-law proceedings against general and vascular surgeons, especially in West European countries, which results mainly from incidental nerve injury. 1,2 The increase in medical claims forces a search for the method of varicose veins treatment that can guarantee the fewest complications possible. ...
Objectives:
Saphenous nerve injury is the most common complication after surgical treatment of varicose veins. The aim of this study was to establish its frequency at great saphenous vein long stripping when four methods of surgery were applied.
Methods:
Eighty patients were divided into four groups depending on different stripping methods. Sensory transmission in saphenous nerve and sensory perception of shank were examined before surgery and two weeks, three and six months afterwards with clinical neurophysiology methods.
Results:
In 36% of patients, surgeries caused the injury of saphenous nerve mainly by proximal stripping without invagination (65%, group I). Transmission disturbances ceased completely after three months in patients undergoing distal stripping with invagination (group IV), while in group I they persisted for six months in 35%. Group IV patients were the least injured and group I the most.
Conclusion:
Neurophysiological findings may suggest that distal stripping with vein invagination gives the best saphenous nerve sparing.
Hoje em dia a praticidade na transmissão da informação é algo fundamental, pois todos estão cada vez menos dispostos a fazer grandes leituras, com muito pouco conteúdo de aplicabilidade pratica, O livro Manual de Complicações em Cirurgia Vascular é resultado da união de um grupo de colegas, com o objetivo de fornecer uma literatura atualizada e objetiva, sobre as adversidades passíveis de ocorrerem na prática da nossa especialidade, inicialmente, a partir de uma ideia do Dr. Heriberto Brito de Oliveira, que frente às demandas como perito médico e assistente técnico, frequentemente se deparava com essas situações.
Tais adversidades, podem sim ocorrer, independente da técnica ou do cuidado do cirurgião, portanto essa obra tem a finalidade de tornar acessível a todos, o conhecimento dos eventos adversos mais frequentes, nas diversas áreas da cirurgia vascular tais como, nas cirurgias arteriais e venosas, procedimentos endovasculares, trauma vascular, escleroterapia, dentre outras, tendo também um capitulo dedicado a legislação sobre a “fleboestetica”, contemplando desta forma, as áreas de maior abrangência do nosso dia a dia, podendo então ser vista como uma forma de ensino, alerta e ate mesmo como respaldo técnico, para as demandas jurídicas.
Atentando-se para um formato mais pratico, podendo ser acessado on line, este manual é portanto somente no formato digital e está disponível aos profissionais de forma gratuita, com o propósito de disseminar o conhecimento, à todos os cirurgiões, em especial aos mais jovens, de forma ágil, moderna e sem custo.
Esta obra só foi possível graças à disponibilidade dos colegas de todos os cantos do Brasil, em dividirem seu precioso tempo, na confecção de seus capítulos, ficando aqui nosso agradecimento à todos.
Os autores.
Chronic venous disease, CEAP, Reticular veins, Telangiectasias, primary varicose veins, pelvic varicose veins, post-thrombotic syndrome, Venous malformations, phlebopathy, Compression treatment, Compression stockings, medical treatment, venoactive drugs, endovenous laser ablation, radiofrequency ablation, Non-thermal ablation, phlebectomy, venous stenting, Superficial thrombophlebitis, venous ulcers, sclerotherapy, diagnostics, treatment, guidelines
Popliteal artery aneurysm (PAA) is a rare condition with an incidence ranging from 0.8 to 2.8%; however, it constitutes approximately 70–85% of all peripheral artery aneurysms. It is asymptomatic in the majority of cases but can cause pain and edema due to venous and neuronal compression. The most severe complication is limb lost due to thromboembolic event. Although surgical treatment left its place to endovascular treatment in the 1990s, surgical treatment still maintains its importance in preventing complications. Here, we aim to report our experience and results of the surgical management of popliteal aneurysms in this study. In this retrospective study, a total of 21 patients who were operated on due to popliteal artery aneurysm between October 2017 and January 2020 were analyzed. Patients with pseudoaneurysm and those who are infected and complicated were excluded from our study. The mean age was 63.3 ± 9.6; females were 17 (81%). Mean follow-up was 19 ± 8 months. More than two risk factors were found in 14 (66.7%) patients. Aneurysmectomy was performed successfully in all patients. Autologous saphenous vein graft was used in 11 (52.4%), whereas 6-mm polytetrafluoroethylene (PTFE) graft was preferred in 10 (47.6%) patients. During the follow-up period, limb loss rates were 16.7% and 83.3%, respectively. The difference was statistically significant (p < 0.05). No relation was found between the aneurysm diameter and postoperative graft occlusion. Limb loss rate was high in popliteal aneurysm repair using PTFE graft due to graft occlusion; saphenous vein graft is more superior in terms of mid-term graft patency.
Introduction:
Iatrogenic nerve injury during surgery is a major source of concern for both patients and surgeons. This study aimed to identify the nerves most commonly injured during surgery, along with the commonly associated operative procedures.
Materials and methods:
A literature search was conducted using the PubMed database to identify nerves commonly injured during surgery, along with the surgical procedure associated with the injury.
Results:
The following eleven nerves, ranked in order with their associated surgical procedures, were found to be the most commonly injured: (1) intercostobrachial nerve in axillary lymph node dissections and transaxillary breast augmentations, (2) vestibulocochlear nerve in cerebellopontine tumor resections and vestibular schwannoma removals, (3) facial nerve in surgeries of the inner ear and cheek region, (4) long thoracic nerve in axillary lymph node dissections, (5) spinal accessory nerve in surgeries of the posterior triangle of the neck and cervical lymph node biopsies, (6) recurrent laryngeal nerve in thyroid surgeries, (7) genitofemoral nerve in inguinal hernia and varicocele surgeries, (8) sciatic nerve in acetabular fracture repairs and osteotomies, (9) median nerve in carpal tunnel release surgeries, (10) common fibular nerve in varicose vein and short saphenous vein surgeries, and (11) ulnar nerve in supracondylar fracture surgeries.
Conclusion:
Although the root cause of iatrogenic nerve injury differs for each nerve, there are four unifying factors that could potentially decrease this risk for all peripheral nerves. These four influencing factors include: knowledge of potential anatomical variations, visual identification of at-risk nerves during the procedure, intraoperative nerve monitoring, and expertise of the surgeon.
Objectives:
Comparison of a flush sapheno-popliteal junction ligation versus a mini-invasive foam sclerotherapy-assisted ligation.
Methods:
Forty-eight chronic venous disease patients underwent sapheno-popliteal junction flush ligation (group A). Forty-one patients underwent small saphenous vein ligation by means of mini-invasive incision with foam sclerotherapy of the popliteal stump (group B).
Results:
At 4.1 ± 3.3 years mean follow-up, sapheno-popliteal junction recurrence was detected in four patients of group A (4/48; 8.3%) and in two cases of group B (3/41; 7.3%) ( P= ns). Mean procedural time was 36 ± 11 minutes versus 21 ± 6 minutes ( p<0.0001). A mild post-operative paresthesia lasting more than 24 h was reported in 6.3% (3/48) of group A versus 2.4% (1/41) ( p<0.009) of group B. At one-year check-up, Aberdeen Varicose Vein Questionnaire significantly improved in both groups with no significant difference between group A and B.
Conclusions:
Foam-assisted mini-invasive sapheno-popliteal ligation represents a time and clinical-effective option, associated with a decrease in post-operative paresthesia risk.
Background:
Chronic venous disease (CVD) is extremely common worldwide. The prevalence is increasing with age and is associated with a reduced quality of life, particularly in relation to pain, physical function and mobility. Symptomatic chronic venous insufficiency (CVI) with venous ulcer at its' endpoint, indicates interventional surgery to cure venous reflux therewith promoting wound healing and preventing recurrence. To our knowledge up to now no coherent study has been undertaken in patients with CVI who underwent an open venous surgery concerning complications, venous hemodynamics and perioperative symptomology in one study population. This was undertaken in our retrospective, single-centre, consecutive case-control study in a single patient population of a university clinic in northern Germany. Part I covers postoperative complications in relation with co-morbidities, co-medication and clinical presentation. Part II will focus on pre- and postoperative hemodynamics and evolution of symptoms.
Methods:
Records of n = 429 (467 extremities) patients from 2009-2013 treated with open surgery were analysed. Number and type of complication were evaluated with regards to demographic parameters, co-existing medical conditions and procedure related aspects. Complications were grouped as no events (NE), neglectable adverse events (NAE), non-neglectable adverse events (NNAE) and severe (life-threatening) adverse events (SAE).
Results:
In 467 extremities of 429 patients with CVI 130 (27,84%) postoperative complications were observed after open surgery, thereof 64(13,7%) NAE, 66(14,14%) NNAE and 0 SAE. 29 (6,76%) patients developed a postoperative surgical site infection, thereof 4 (0,9%) with consecutive septicaemia. Except one case with nerval lesion and paraesthesia and hypoesthesia not resolving after 12 month all complications resolved within surveillance time span of 12 month. Patients developing NAE had a higher BMI (p = 0.003), were more likely to have diabetes mellitus (p < 0.001), and co-morbidities leading to the intake of anti-platelet or anticoagulation drugs (p < 0.001). Metabolic syndrome (p < 0.001) and anti-platelet or anticoagulation (p < 0.001) could be defined as independent risk factors for the development of complications. Patients receiving open surgery of small saphenous veins had 8 times higher risk of calf muscle venous thrombosis (p = 0.001).
Conclusion:
Patients with a metabolic syndrome or receiving anti-platelet therapy or anticoagulation medication should undergo open venous surgery under hospital conditions with routine postinterventional surveillance visits. Patients undergoing an open surgery of SSV are definite candidates for postoperative subcutaneous heparin thromboprophylaxis. In general Stripping below knee increases the risk of postoperative sensory deficit. This resolves in almost all patients within one year.
Unlabelled:
OBJECT.: The object of this study was to highlight the challenge of insufficient donor graft material in peripheral nerve surgery, with a specific focus on sciatic nerve transection requiring autologous sural nerve graft.
Methods:
The authors performed an anatomical analysis of cadaveric sciatic and sural nerve tissue. To complement this they also present 3 illustrative clinical cases of sciatic nerve injuries with segmental defects. In the anatomical study, the cross-sectional area (CSA), circumference, diameter, percentage of neural tissue, fat content of the sural nerves, as well as the number of fascicles, were measured from cadaveric samples. The percentage of neural tissue was defined as the CSA of fascicles lined by perineurium relative to the CSA of the sural nerve surrounded by epineurium.
Results:
Sural nerve samples were obtained from 8 cadaveric specimens. Mean values and standard deviations from sural nerve measurements were as follows: CSA 2.84 ± 0.91 mm(2), circumference 6.67 ± 1.60 mm, diameter 2.36 ± 0.43 mm, fat content 0.83 ± 0.91 mm(2), and number of fascicles 9.88 ± 3.68. The percentage of neural tissue seen on sural nerve cross-section was 33.17% ± 4.96%. One sciatic nerve was also evaluated. It had a CSA of 37.50 mm(2), with 56% of the CSA representing nerve material. The estimated length of sciatic nerve that could be repaired with a bilateral sural nerve harvest (85 cm) varied from as little as 2.5 cm to as much as 8 cm.
Conclusions:
Multiple methods have been used in the past to repair sciatic nerve injury but most commonly, when a considerable gap is present, autologous nerve grafting is required, with sural nerve being the foremost source. As evidenced by the anatomical data reported in this study, a considerable degree of variability exists in the diameter of sural nerve harvests. Conversely, the percentage of neural tissue is relatively consistent across specimens. The authors recommend that the peripheral nerve surgeon take these points into consideration during nerve grafting as insufficient graft material may preclude successful recovery.
Objective: To study the different modes of terminations of the small saphenous vein, using color Doppler ultrasound, based on the Kosinski classification. Patients and method: A total of 1,000 lower limbs were studied in 500 patients (400 women and 100 men), with mean age of 49.3 + 16.6 years. The anatomic variations of the small saphenous vein termination were registered in a protocol specifically developed for the study. The terminations were divided into three types, according to the Kosinski classification: Type I, when the termination was in the popliteal vein. This type had two subtypes: (a) termination exclusively in the popliteal vein and (b) in both the popliteal vein and the greater saphenous vein. Type II, with termination in thigh veins, with three subtypes: (a) deep veins of the thigh; (b) in both the deep veins of the thigh and the greater saphenous vein, and (c): in the greater saphenous vein. Type III, with termination in leg veins, with two subtypes: (a): in the greater saphenous vein below the knee and (b) in deep leg veins (gastrocnemius veins). The distances of the termination from the popliteal skin crease were also registered. Results: Type I termination was found in 528 limbs (52.8%), with subtype I(a) found in 431 limbs (43.1%) and subtype I(b) in 97 limbs (9.7%). Type II termination was found in 444 limbs (44.4%), with subtype II(a) found in 286 limbs (28.6%), subtype II(b) in 102 limbs (10.2%) and subtype II(c) in 56 limbs (5.6%). Type III was found in 28 limbs (2.8%), with subtype III(a) found in 20 limbs (2%) and subtype III(b) in eight limbs (0.8%). Conclusion: The small saphenous vein presents anatomical variations in its termination. It often terminates in thigh veins (97.2%), communicating with the popliteal vein in half of the cases (52.8%). It seldom terminates in leg veins (2.8%).
The aim of the presented work was to assess the causes of injury to great nerves during varicose vein surgery and comment on the consequences.
This was a retrospective study of 2344 patients operated on for primary varicose veins between the years 1980 and 2005.
In three patients out of 2344 the peroneal nerve was injured. The three patients underwent neurosurgery. In the first patient transplantation of the sacral nerve was performed. In the second patient the nerve was released from ligatures, and in the third patient the nerve was first released from the cicatrice and the transposition of the tendon of the posterior tibial muscle followed. All three patients went through intensive rehabilitation. The first patient still wears peroneal splint, the limb is atrophic. In the second patient the function has been well restored and he is not disabled anymore. However, the restitution of the lower limb function is not sufficient for him to work as a teacher of physical education. The third patient still suffers from serious paresis of the peroneal nerve.
Even a frequent and relatively simple intervention such as varicose vein surgery may be accompanied by serious complications affecting patients for the rest of their lives. Serious motor nerve injuries are encountered only in operations in the popliteal fossa and the fibula head. Complications are more frequent when operations are performed by young general surgeons than when they are performed by an experienced surgeon or an expert in vascular surgery. The affected patients should be referred for neurosurgery; however, results are unpredictable. In spite of an intensive rehabilitation and possible plastic surgery the patients are permanently affected.
Common peroneal nerve (CPN) injury produces considerable and serious disability. The nerve is most frequently damaged as a result of trauma (sharp or blunt, traction, fracture, laceration, and avulsion). Less often iatrogenic injury is the cause of damage (application of tight plaster, retraction injury, division during operation). Even rarer is the complete or partial division of CPN during varicose vein operations. In the UK, on average 34 patients every year begin legal action against their medical attendants in connection with the treatment of varicose veins, on a background of an estimated 100,000 procedures performed. Nerve damage is the most frequent of all major complications that result in legal action; it is cited in 15% of cases. The commonest nerve injury, accounting for about half the cases, is to the common peroneal nerve just before or, as it crosses the neck of the fibula. We present three examples in two cases, which outline the risk of CPN injury, the spectrum of clinical presentation and the problems produced by a failure to recognise the deficit immediately. Regional anatomy, consequences of nerve damage and management options is discussed.
The complication rate in varicose vein surgery has not been viewed separately for the sapheno-femoral and the saphenopopliteal junction. From 1.10.1988 to 31.12.99 we prospectively registered the major vascular and neural complication rate. A total of 31,838 ligations of the saphenofemoral junction and 6,152 ligations of the saphenopopliteal junction were performed. There were seven major vascular injuries (0.017 %) and three major neural injuries (0.0074 %). The specific risk at the saphenofemoral junction amounts to: major venous injury n = 4 (0.013 %) without development of a post-thrombotic syndrome (PTS); no arterial injury and no major neural injury. At the saphenopopliteal junction we found three major venous injuries (0.049 %) with development of PTS in all cases. There were three major neural injuries (0.049 %) with complete regeneration in two cases and one permanent paresis of digit V. Since operations on the saphenopopliteal junction show a higher risk of major vascular und major neural injury, flush ligation of the saphenopopliteal junction should not be forced in every case.
Varicose veins are a frequent burden, also in the small saphenous system. Yet its basic anatomy is not described consistently. We therefore investigated the fascial and neural relationships of the small saphenous vein (SSV) as well as the frequency and position of valves and the different junctional patterns, also considering the thigh extension.
We dissected the legs of 51 cadavers during the regular dissection course held in winter 2007 at Innsbruck Medical University, with a total of 86 SSVs investigable proximally and 94 SSVs distally.
A distinct saphenous fascia is present in 93 of 94 cases. It starts with a mean distance of 5.1 cm (SD 1.2 cm) proximal to the calcaneal tuber, where the tributaries to the SSV join to form a common trunk. The neural topography at the level of the gastrocnemius muscle's origins shows the medial sural cutaneous nerve in 88% medially and in 12% laterally to the SSV, the tibial nerve in 64% medially and in 36% laterally, and the common fibular nerve in 98% medially and in 2% laterally to the vein. The saphenopopliteal junction (SPJ) resembled in about 37% type A (UIP-classification), 15% type B, and 24% type C. A total of 17% of specimens showed a venous web or star at the popliteal fossa and 6% had a doubled junction. A thigh extension could be demonstrated in about 84%. A most proximal valve was present in only 94% at a mean distance of 1.2 cm (SD 1.4 cm) to the SSVs orifice. A consecutive distal valve was only present in 65% with a mean distance of 5.1 cm (SD 2.3 cm).
Two fascial points or regions can be described in the SSVs' course and its own saphenous fascia is demonstrated macroscopically in almost all cases. The neural topography is highly individual. The SPJ is highly individual where we found hitherto unclassified patterns in a remarkable number of veins. Venous valves are not as frequent as we supposed them to be. Furthermore, not all most proximal valves seem to be terminal valves.
The variable anatomy of the short saphenous vein (SSV) and the potential failure to identify the saphenopopliteal junction (SPJ) contribute to an increased risk of damage to the common peroneal nerve (CPN) during surgical exploration. The aim of the present study was to determine the variation of the SPJ, its relationship to the CPN, and the relationship of both SPJ and CPN to defined anatomical landmarks.
Measurements of the distance between the SPJ and CPN, and the defined anatomical landmarks (fibula head, lateral joint space, lateral femoral epicondyle), were undertaken on 30 cadaveric limbs following careful dissection of the popliteal fossa.
The level of SPJ termination was classified as low (below), normal (within 100 mm above) and high (more than 100 mm above), the lateral femoral epicondyle. Of the 30 limbs dissected, 70% of SPJs were normal, 23% low and 7% high. Direct measurement from the SPJ to anatomical landmarks showed a higher interquartile range (IQR) in low compared with normal terminations; however, the vertical distance from the SPJ to the fibula head showed an increase in IQR from low to normal terminations (7.1-14.2). The mean distances between the SPJ and CPN in low and normal terminations were 23.3 and 16.7 mm, respectively. Comparison of the IQR showed values very similar to low terminations having a slightly higher IQR compared with normal terminations (7.15-6.0).
Significant anatomic variation was observed in the termination of the SSV, with 67% located within 66 mm above the lateral femoral epicondyle. The risk of damaging the CPN during saphenopopliteal ligation may be higher for SPJs located above the lateral femoral epicondyle because of the proximity of the two structures and variability of SPJ.
A retrospective analysis of 26 consecutive cases of traumatic common peroneal nerve palsy seen during a four-year period in the Department of Rehabilitation Medicine at New York Medical College was carried out. Fifteen were complete lesions, nine were incomplete lesions, and there were two cases of neurapraxia. Among the factors studied were etiology, age, sex, associated injuries, electrodiagnostic findings, and prognosis for recovery. The ultimate functional status of the patients was evaluated up to three years following injury. Of the patients, 19.2% recovered fully, and 26.9% showed partial recovery. The maximum time of recovery was achieved in 15.5 months in complete lesions and 9.5 months in incomplete lesions. The relationship of peronneal nerve injury to fractures of the femur is emphasized. The indications for medical, surgical and rehabilitative management are discussed.
In a series of 70 patients (75 cases of common peroneal nerve palsy) the common causes were trauma about the knee or about the hip, compression, and underlying neuropathy. A few palsies occurred spontaneously for no apparent reason. The prognosis was uniformly good in the compression group; recovery was delayed but usually satisfactory in patients who had suffered stretch injuries. In the acute stage, when clinical paralysis appears to be complete, electrophysiological studies are a useful guide to prognosis. They may also indicate an underlying neuropathy and they detect early evidence of recovery. The anatomical peculiarities of the common peroneal nerve are noted and aspects of the clinical picture, management, and prognosis of palsy are discussed.
Stripping of the long saphenous vein (LSV) may prevent recurrence of varices, although this has not been demonstrated using objective criteria. The aim of this study was to determine whether the addition of LSV stripping, from groin to upper calf, to saphenofemoral junction (SFJ) ligation prevents residual reflux, and whether LSV stripping to the upper calf results in greater neurological complications. Sixty-nine patients with primary varicose veins, LSV reflux and SFJ incompetence, confirmed by duplex ultrasonography and photoplethysmography, were studied. A total of 105 limbs were treated by SFJ ligation and avulsion of varices; patients were randomized to undergo stripping of the LSV to the upper calf (n = 49) or no additional treatment (n = 56). Three months after surgery all patients were examined clinically, by duplex ultrasonography and by photoplethysmographic tests of venous function, to establish the extent of persisting varices. Fewer persisting incompetent LSVs in the calf were found when the LSV was stripped (n = 9) than after SFJ ligation alone (n = 25) (P < 0.01). Photoplethysmographic refilling times were improved to a similar extent in both groups after surgery but were lower in those who had residual LSV reflux (P < 0.05). Six limbs developed paraesthesia in the distribution of the saphenous nerve: two in the group that were stripped and four in those that were not. These data suggest that LSV reflux is more completely abolished by combining LSV stripping with SFJ ligation; stripping the LSV to the upper calf does not result in a higher incidence of injury to the saphenous nerve.
Eleven patients had either repair (two) or nerve graft reconstruction (nine) of the common peroneal nerve or its superficial or deep divisions about the knee. The average follow-up period was 29.1 months. A good or excellent result was achieved in six (54.5%) patients. The results appeared best when direct nerve repair was possible or when a defect of 6 cm or less required grafting. Peroneal nerve exploration and repair or reconstruction as required seem indicated for known nerve disruption or unknown nerve continuity if there is no suggestion of continuing recovery by three to six months after the injury.
A questionnaire was sent to 363 members of the Vascular Surgical Society of Great Britain and Ireland about their use of deep vein thrombosis (DVT) prophylaxis at the time of varicose vein surgery. Replies were received from 289 surgeons (80 percent), of whom only 29 percent regarded varicose veins as an important risk factor for DVT. Only 12 percent used subcutaneous heparin prophylaxis routinely, while 71 percent did so selectively, being influenced by a history of thromboembolism (95 percent), obesity (47 percent), age (35 percent), recurrent varicose veins (22 percent) and inpatient status (16 percent). At the end of the operation 52 percent applied crepe bandages, 25 percent other bandages, 13 percent stockings and 10 percent Tubigrip. Subsequently, antiembolism stockings were prescribed by 55 percent. There is a wide variation in opinion regarding DVT prophylaxis for patients having varicose vein surgery, which has both clinical and medicolegal implications.
Investigation of the diagnostic and technical problems of redo surgery of the lesser saphenous vein for primary varicose veins.
Design: a retrospective study.
Section of Vascular Surgery in a University Hospital.
Fifteen lower extremities were operated upon (13 patients, 3 males and 10 females, ages ranging from 43 to 65 years with a mean of 53.2).
Each case was assessed by clinical examination, duplex scanning and venography (ascending venography and/or varicography). Surgical procedure was carried out via a longitudinal approach over the popliteal region or the posterior aspect of the thigh. Each case presented with a stump of the lesser saphenous vein.
Hemodynamic (correction of reflux of the lesser saphenous vein) and clinical (improvement of clinical state in the operated lower limb and complications) results were evaluated.
Reflux at the ostium of the lesser saphenous vein was corrected in 15/15 (100%) cases. Clinical result was good in 15/15 (100%) cases. Postoperative edema was observed in 7/15 (46.7%) cases. Lesion of the common peroneal nerve with paresis of the foot dorsal flexion was found in 1/15 (6.7%) cases. Hypertrophic scar was observed in 4/15 (26.7%) cases.
Redo surgery of the lesser saphenous vein is requested less frequently than other surgical procedures for superficial venous diseases. This surgery requires two essential features: a) accurate diagnosis of the lesser saphenous vein insufficiency; b) adequate surgical technique. For the former purpose, venography is a fundamental method of assessment. Surgical technique should be cautious and gentle. A longitudinal approach leads to a wide exposure of the structures in the popliteal fossa.
We describe the neurophysiological and ultrasound (US) findings in two patients with right sural nerve lesions following stripping of the small saphenous vein for varicose vein treatment. In the first case, US showed a tear of the nerve proximal to the lateral malleolus and a hypoechoic swelling of the proximal stump, likely related to a terminal bulb neuroma. A sural conduction study performed distally and proximally to the lesion through a near-nerve needle technique showed absent responses. In the second case, US showed a deep subcutaneous extension of a postsurgical scar placed behind the lateral malleolus close to the sural nerve, but no nerve discontinuity. Sural conduction study showed absent responses distal to the scar. Sural stimulation immediately above the scar yielded a small response at the sciatic nerve. A subsequent investigation performed 15 months after the operation showed absent proximal and distal responses. The combination of US and sural conduction study, including recording at the sciatic nerve, to our knowledge has not been described previously, and may yield important complementary information in the diagnosis of sural nerve lesions.
Five cases of sural nerve lesion linked to small saphenous vein pathology are reported. They were due to vein stripping (4 cases) and to thrombophlebitis (1 case). The diagnosis was especially delayed in the first 4 cases, as this pathological field is quite unknown. In all the cases, only electrodiagnosis allowed to assess the diagnosis and medical care was sufficient to control the pain of these patients.
The complication rate in varicose vein surgery has not been viewed separately for the sapheno-femoral and the saphenopopliteal junction. From 1.10.1988 to 31.12.99 we prospectively registered the major vascular and neural complication rate. A total of 31,838 ligations of the saphenofemoral junction and 6,152 ligations of the saphenopopliteal junction were performed. There were seven major vascular injuries (0.017%) and three major neural injuries (0.0074%). The specific risk at the saphenofemoral junction amounts to: major venous injury n = 4 (0.013%) without development of a postthrombotic syndrome (PTS); no arterial injury and no major neural injury. At the saphenopopliteal junction we found three major venous injuries (0.049%) with development of PTS in all cases. There were three major neural injuries (0.049%) with complete regeneration in two cases and one permanent paresis of digit V. Since operations on the saphenopopliteal junction show a higher risk of major vascular und major neural injury, flush ligation of the saphenopopliteal junction should not be forced in every case.
The aim of surgical therapy of varicose veins is the elimination of reflux from the deep to superficial system at the saphenous crosse and perforant vessel and conservation of the superficial venous system due to possible surgical procedures for arterial revascularization. This latter condition leads to an extension of indications for short stripping procedures, although the venous distal segment may undergo hypoplastic degeneration not compatible for revascularization purposes. Another important reason is the minor incidence of neurologic complication due to saphenous nerve lesion which may occur during long saphenous stripping.
From January 1994 to June 1999, we considered 233 patients (182 women, 51 men); 180 cases underwent long saphenous stripping procedures, whereas 53 a short stripping of GSV. The incidence of neurologic complications of the saphenous nerve were recorded in 11.6% of the patients treated with the standard procedure, whereas no such complication was observed in all cases treated with the short stripping procedure.
ECD follow-up performed for a period of three months from the surgical procedure revealed the patency of the residual saphenous vein, with a minimum diameter of 3 mm, in 28 patients (56.6%).
Our opinion is to extend the indication for short stripping of the saphenous vein to all cases where the distal saphenous trunk is not involved, when the ECD shows a pathological ostial reflux, a truncular reflux limited to the thigh, which may be associated with incontinence of the perforant vein of Dodd.
The outcome of short saphenous vein surgery is often unsatisfactory and the high litigation rate reflects this. The aim of this study was to explore the current management of short saphenous varicose veins in Great Britain and Ireland.
This was a postal questionnaire survey of the surgical members of the Vascular Surgical Society of Great Britain and Ireland. Of 532 questionnaires 379 were returned (71.2%).
There was diversity of opinion about the management of short saphenous veins. Eighty nine per cent of surgeons requested duplex imaging for all patients and over 50% arranged additional duplex marking of the saphenopopliteal junction preoperatively. Only 10.4% formally exposed and identified the popliteal vein during saphenopopliteal ligation, the majority (75.7%) dissected down the short saphenous vein to visualise the junction. The short saphenous vein was stripped routinely by 14.5% of surgeons, the majority preferring to excise a proximal segment of up to 10 cm (55.1%). Compared with long saphenous vein surgery, surgeons were generally more likely to warn patients of nerve damage but equally likely to warn of deep vein thrombosis. A small number of surgeons failed to warn patients of these complications.
The variation in management of short saphenous veins may be explained by the lack of definitive clinical trials in this area.
Common peroneal nerve (CPN) injuries represent the most common nerve lesions of the lower limb and can be due to several causative mechanisms. Although in most cases they recover spontaneously, an irreversible damage of the nerve is also likely to occur. Nerve regeneration following CPN repair is poorer if compared to other peripheral nerves and this can explain the reluctant attitude of many physicians towards the surgical treatment of these patients. Among the several factors advocated to explain the poor outcome following surgery, it has been suggested that reinnervation might be obstacled by the force imbalance between the functioning flexors and the paralysed extensors that eventually results in the fixed equinism of the foot, due to the excessive contracture of the active muscles and the shortening of the heel cord. Therefore the early correction of these forces might favour nerve regeneration. Following such hypothesis, the authors treat irreversible CPN injuries performing a one-stage procedure of nerve repair and tibialis tendon transfer. We report our experience, describing the indications to surgical treatment, the operative technique and the postoperative clinical outcome correlated with the causative mechanisms of the injuries.
A 62-patient series controlled over a period of 15 years with a post-traumatic palsy of the CPN is reported. All the patients underwent surgery. In open wounds, when a nerve transection was suspected, surgery was performed at emergency (2 cases). In closed injuries, operative treatment was advised when no spontaneous regeneration occurred 3-4 months after the injury. From 1988 till 1991, 9 patients were elected for surgery : in 6 cases treatment consisted of neuroma resection and nerve repair by means of a graft. In 3 patients it was performed only a CPN decompression at the fibular neck. Since 1991, surgical treatment has always consisted of nerve repair associated with a tendon transfer during the same procedure. Fifty-three patients were elected for surgery. Nerve repair was achieved by direct suture in 1 case and by means of a graft in 46 patients. Decompression of the CPN at the fibular neck was performed in 6 patients where nerve continuity was demonstrated.
In the first group of patients, nerve repair outcome was highly disapponting: no recovery in 5 cases, reinnervation occurred in 1 patient only (M1-2). CPN decompression was followed by complete recovery in 2 cases, no improvement was observed in 1 case. Nerve repair associated with tibialis tendon transfer dramatically improved the postoperative outcome: at 2 year follow-up, neural regeneration was demonstrated in 90% of the patients. Surgical outcome depends on the causative mechanisms of the lesion: sharp injuries and severe dislocations of the knee had an excellent recovery, while in crush injuries and gunshot wounds good recovery was less common.
Surgical treatment of CPN injuries can nowadays be highly rewarding. CPN palsies in open wounds should undergo surgical exploration at emergency. In close injuries with no spontaneous recovery within 4 months after the injury, patients should be advised to seek surgical treatment regardless the causative mechanism of the lesion. According to our experience, the association of a transfer procedure to nerve repair enhances neural regeneration, dramatically improving the surgical outcome of these injuries.
The aim of this study was to identify the incidence and distribution of nerve damage in patients undergoing primary venous surgery.
Patients undergoing primary great saphenous vein surgery between February and November 2003 were enrolled. In all cases the great saphenous vein was 'flush' ligated at the sapheno-femoral junction and stripped to the knee by inversion without using a stripper head; multiple phlebectomies were performed using an Oesch hook. A vascular nurse followed up patients 6 weeks post-operatively. Those reporting altered sensation and/or pain were examined by a doctor to provide an objective assessment of any neurological damage. These patients were again followed up by telephone at 6 and 12 months.
Sixty-three limbs from 54 patients were enrolled. Numbness or paraesthesia was identified in 17 (27%) limbs at 6 week follow-up. 11 (17%) limbs were affected below the knee and 7 (11%) limbs were affected at the thigh or groin. One of the limbs was affected above and below the knee. Of these 17 limbs there was resolution in six limbs at 6 months and nine limbs at 12 months. Two patients with persistent nerve lesions regretted undergoing surgery. Patients undergoing bilateral surgery were more likely to report abnormal sensation (chi(2) test, p=0.006). There was no significant difference between the incidence of nerve injury for consultant, SpR or SHO as first operator (chi(2) test, p=0.9).
This study demonstrates the frequency of nerve injury during primary great saphenous vein surgery. It will be useful for clinicians providing informed consent and may provide a benchmark for comparison with newer techniques.
The study was conducted to assess the efficacy and rate of complications of endovenous laser treatment (EVLT) of the short saphenous vein (SSV).
During a 17-month period, 210 (187 patients) with SSV incompetence documented by duplex ultrasound studies were treated with EVLT using a 980-nm diode laser. Duplex ultrasound examinations were performed on the day of the procedure, within the first week, and 2 to 11 months after the procedure (mean follow-up, 4 months). Clinical examinations were performed at 2 weeks and 6 weeks. Patients were assessed for deep venous thrombosis (DVT), nerve injury, and resolution of symptoms.
All procedures were technically successful, and in the 126 patients (60%) who completed final follow-up scanning, 96% of SSVs remained closed. Three patients (1.6%) had numbness at the lateral malleolus at the 6-week follow-up. DVT, defined as a tail of thrombus protruding into the popliteal vein, was not detected in any limbs at the initial duplex study, but was noted in 12 limbs (5.7%) at the 1-week follow-up examination. Nine patients were treated with 3 days to 3 months of fractionated heparin and Coumadin (Bristol-Myers Squibb, Princeton, NJ), and there were no DVT extensions or pulmonary emboli. The anatomic configuration of the saphenopopliteal junction was the only factor predictive of DVT.
Intermediate-term results of EVLT of the SSV demonstrate that the technique is effective at eliminating SSV reflux and affording symptomatic relief. The incidence of nerve injury is low, but the incidence of DVT is higher than reported for the great saphenous vein. Anatomic features of the SSV may predict patient risk for DVT.
Anatomic variation study of small saphenous vein termination using color Doppler ultrasound
- A Oliveira
- Ea Vidal
- Franç
- Gj
de Oliveira A, Vidal EA, Franç GJ, et al. Anatomic variation study of small saphenous vein termination using color Doppler ultrasound. J Vasc Bras 2004;3:223e30.
Anatomia m edico-cir urgica do sistema venoso dos membros inferiores
- M Garrido
- Maffei Fh
- Rollo S Ha Lastoria
Garrido M. Anatomia m edico-cir urgica do sistema venoso dos membros inferiores. In: Maffei FH, Lastoria S, Rollo HA, Yoshida WB eds. Doenç vasculares perif eri-cas, Vol. 1. Rio de Janeiro, Brazil: Medsi, 2002. pp 133e67.
Anatomia médico-cirúrgica do sistema venoso dos membros inferiores.
- Garrido M.
Garrido M. Anatomia m edico-cir urgica do sistema venoso
dos membros inferiores. In: Maffei FH, Lastoria S,
Rollo HA, Yoshida WB eds. Doenças vasculares perif ericas, Vol. 1. Rio de Janeiro, Brazil: Medsi, 2002. pp
133e67.