Chapter 19: Surgery

INTRODUCTION

The surgical approach to correct venous insufficiency depends upon precise diagnostic tools and innovative operative techniques. How far venous surgery has come can be better appreciated by a glimpse at the attempts over the ages to treat leg pain, swelling, and ulcers, as described in Chapter 22.

The modern vascular surgeon has powerful tools to evaluate the anatomy and function of the venous system. Here, color-flow duplex ultrasound has become the diagnostic gold standard. Scanning vascular function during the operative procedure is possible using high resolution B-mode ultrasound.

In the leg, blood flow in superficial, perforator, and deep veins can be observed using ultrasonometry. The valves themselves can be seen as they open and close. The surgeon also has a new generation of very fine needles, sutures, and other materials to minimize operative trauma on veins and their valves. In addition, postoperative care has improved substantially with thrombus-preventing interventions as well as drugs to delay blood clotting and to reduce inflammation.

This chapter is meant to give an outline of indications for surgery and a brief overview of the operative procedures currently available. It includes the surgical approach to the superficial, perforator, and deep venous systems.

INDICATIONS FOR SURGERY

There are situations in caring for the patient with venous insufficiency in which surgical intervention is indicated:

1. When symptoms (especially pain) persist and limit activities despite properly applied compression and leg elevation practices.

2. Alleviation of venous hypertension in the superficial system to control complications of venous ulcer, dermatitis, and recurrent cellulitis.

3. Easing of venous claudication in selected cases of deep valvular insufficiency, especially in the active person who would be excessively encumbered by the restrictions required of physical measures.

4. Management of recalcitrant venous ulcers by operating on perforating veins with major reflux, most notably when ulcers recur and when reflux from superficial axial and varicose veins has been addressed.

5. Correction of appearances for cosmetic purposes when unsightliness is caused by varicose veins and spider veins.

6. Debridement of necrotic and infected tissues in and around venous ulcers.

While the indications for surgical intervention are generally reserved for those conditions proving resistant to medical treatment, rapid development in efficacy of these procedures promises an ever-expanding application.

INTERVENTIONS BY THE SURGEON

Sclerotherapy

In this procedure, a substance is injected into a vein to seal off that section of the vessel. One method is to use a caustic solution to create a strong inflammatory reaction in the inner wall, causing the opposing sides to stick together. The vein then becomes a solid, shrunken cord. The name of the procedure comes from skleros, the Greek word for “hard.”

Sclerotherapy has become highly refined since 1853 when the French physician E. Chassaignac injected an iron salt into ...