Preoperative Assessment of Small Saphenous-Type Varicose Veins by Three-Dimensional CT Venography with Dual-Route Injection / 日本心臓血管外科学会雑誌

The saphenopopliteal junction (SPJ) is found at various levels and has various patterns compared with the saphenofemoral junction. Although this can cause difficulty in the surgical treatment of varicose veins and affect the outcome, there have been few reports on preoperative assessment of the small saphenous vein (SSV) regarding this point. This study was undertaken to evaluate three-dimensional CT venography with dual-route injection for the preoperative assessment of a small saphenous-type varicose vein. We examined a total of 15 legs in 15 patients with a small saphenous-type varicose vein, which were preoperatively evaluated by CT venography and then surgically treated. The patients included 4 men and 11 women with ages ranging from 50 to 80 years old (mean age, 66 years). The grading of varicose veins according to the CEAP classification was C2, C3, C4, and C5 in 3, 4, 6 and 2 legs, respectively. The CT imaging was performed with contrast medium diluted ten-fold, which was injected into the great and small saphenous veins simultaneously. CT venography clearly visualized the lower extremity veins. Whereas the popliteal vein coursed deep above the level of the femoral intercondylar groove, it followed a shallow course below the level of the knee joint. In 11 legs (74%), the SPJ was located in the shallow portion, whereas it was in the deep portion in 4 legs (26%). Among the former group, the SSV was connected to the great saphenous vein via the Giacomini vein in 2 cases, and the gastrocnemius vein was connected to the SSV before the SPJ in 3 cases. Among the latter group, a localized large venous aneurysm with thrombus before its termination was found in one case. In another case, the SSV showed branched termination in the deep portion. Our three-dimensional CT venography with dual-route injection provides more accurate information on venous anatomy in the lower extremity. The accuracy of images acquired by CT venography with dual-route injection was verified by intraoperative findings. Although Doppler ultrasound is essential for examining the presence of regurgitation in the veins and locating the course of a varicose vein in the surgical field, all 15 cases had scheduled surgery under local anesthesia based on accurate preoperative diagnosis. This study suggests that CT venography with dual-route injection is beneficial in preventing undesired complications during surgery and avoiding additional procedures for recurrent varicose veins.

Femoro-Femoral Bypass Anterior to the Pubis and Inside of the Thigh Muscle for Treatment of Suspected Infected Aneurysm in the Ilio-Femoral Area / 日本心臓血管外科学会雑誌

Infected femoral artery aneurysm is difficult to treat because of the risk of reinfection and anastomosis. The treatment of choice has been a topic of much controversy. Revascularization is mandatory for limb salvage after excision of infected grafts. Revascularization requires various ingenious techniques such as retro-sartorius bypass and obturator bypass. We treated a patient with suspected infection of an aorta-femoral graft, using femoro-femoral crossover bypass in front of the pubis and inside of the thigh muscle. We performed complete debridement of infected tissue. After resterilization of the operative field once more and exchange of all the instruments we performed revascularization detouring around areas of focal infection, using autogenious vein graft through the front of the pubis and inside of the thigh muscle to reach the left superficial femoral artery.