Extra-fascial ligation of incompetent perforators via mini-incisions, under local anaesthesia

Reflux of the venous blood outwards through incompetent perforators may be primary or secondary [post-thrombotic], with resultant liposclerosis, eczematization, pigmentation, edema and ulceration. The main objective of managing these cases is preventing the transmission of deep venous pressure to affected skin areas by perforator interruption. Initially this was achieved by long incisions whether medial lateral or posterior and direct perforator ligation subfascially. Pre-operative color duplex localization and skin marking of the incompetent perforators, followed by assessement of the efficacy, convenience and wound complications of a simplified method to ligate them extrafacially through mini incisions under local anaesthesia. Eight hundred incompetent perforators in 184 limbs in 102 patients with chronic venous insufficiency with ulceration. Inclusion criteria was the presence of non liposclerotic skin at the skin mark or within 2 cm of it. Local infiltration of the chosen skin site with Xylocaine 2%, 2-2.5 cm incision is made in the skin. Using small retractors with gentle dissection to find the perforator, aided by gentle finger dissection. Following the perforator down to the fascia to make sure it has no other branches. Ligation and division of the perforator. A compression bandage is applied from toes up to knee level. Follow up of the patient for 12 month post operative for ulcer healing and for wound complications. It was observed that the site of incompetent perforators in 22.3% of limbs did not match the location of ulcer in the same compartment. Such a phenomenon may result from its connection with another muscular vein branch [a deep communicator] with a remote surface emergence in another compartment. Early procedure complications were incision wound break down [5.38%], and sepsis [7, 88%]. It was observed that there is an individual variability in patient's tolerance to venous congestion sequalae, also edma, after ligation of all incompetent perforators, may be responsible for incomplete ulcer healing without any new perforator incompetence. Extra-fascial ligation of incompetent perforators under local anaesthesia has the advantage of; patient satisfaction is high, post operative ambulation is fast and most of them could resume daily activity within 3-4 days. It is also economic and a large number of cases can be done within a short time

Subfascial endoscopic perforator surgical ligation [SEPS]: single versus double port

SEPS is on the rise in treating chronic venous insufficiency. Limitations of the two entry ports technique, to find the incompetent perforators and interrupt them, are due to the narrow subfascial space. The situation is made more difficult whenever dense overlying liposclerotic skin does not allow enough distensibility to create a subrfacial plane sufficient for viewing and manipulating the perforator veins via the two ports. Single port double channel laparoscopes were meant to overcome those difficulties. Was to compare the difference in technicality, and results between the single and double port scope, on performing SEPS. All cases were C 6 [open ulcer] according to CEAP classification. They were divided into two groups; fifty patients underwent SEPS using double port, and fifty Patients underwent SEPS using single port. Both groups were matched for age, sex, risk factors, medial and lateral distribution of the ulcer, and size. The first group that underwent SEPS using single port had the upper hand in reducing the operative time, ease of maneuverability within the leg compartment, ease of accessibility of the posterior compartment from a medial or lateral entry approach. Regarding the intra-operative findings in comparison to pre-operative duplex findings as regards perforators, results were more satisfactory in the first group. Hematoma, wound infection, and neuralgia of saphenous and sural nerves were not different lwith the single port SEPS, however, small patches of superficial skin gangrene over areas of extensive septum dissection to reach perforators lying, within it was observed in some diabetic cases. The progressive ulcer healing following primary SEPS was -96% using the single port in comparison to 84% for the doble port [statistically significant]. Repeat SEPS for ligation of the missed perforators was feasible and much easier using the single port. The advantage of the single port due to its better maneuverability leading to significantly shorter operative time and better accessibility to posterior compartment perforators after piercing of the intramuscular septum, and higher venous ulcer healing rate can be clearly shown

Alternative saphenous vein graft pathway from the femoral or supragenicular popliteal artery down to anterior tibial or dorsalis pedis artery

The classically described methods of a pathway from a supragenicular artery down to anterior tibial or dorsalis pedis artery graft routing are the medial [pre-tibial], the lateral [around the fibula neck], and the transosseous [through a window in the interosseous membrane]. In both medial and lateral approach, the graft is- vulnerable to compression around the knee joint bony elements. Regeneration of the interosseous membrane may narrow the arterial pathway. In the anterior leg compartment, the graft should ideally avoid compression as that induced by ischemia reperfusion edema, and be protected from exposure should a wound break down happens. Was to study efficacy and safety of modifications of saphenous graft routing, and minimizing number of incisions for distal artery and vein exposure, in anterior tibial or dorsalis pedis bypass. All study and control groups had critical foot ischemia. They consisted of two groups. Group I: consisted of reversed vein graft [42 patients underwent the modified anatomical pathway, the graft was tunneled from the medial supragenicular incision, crossing above the interosseous membrane, pursuing the natural arterial pathway to the anterior compartment, passing deep to the muscles. A closed fasciotomy of the anterior compartment was performed to minimize the graft compression by the ischemia-revascularization edema, then performing the anastomosis to anterior tibial artery [ATA], or dorsalis pedis artery [DPA], and 10 controls underwent the subcutaneous lateral approach. Group II consisted of 20 cases done by in-situ saphenous vein bypass, using a single skin incision midway between the course of great saphenous vein [GSV] and [ATA] or [DPA] to serve both exposure of the artery, and harvesting of the distal segment of the GSV, and 10 controls, using double parallel incisions. The primary patency for the modified anatomical tunneling technique was, 85.71%, with no need for further surgery to assist patency. The limb salvage was 84.3%. Meanwhile, for the lateral subcutaneous tunneling the primary patency was 60%. Three cases during the follow up period needed revision with resultant success of only two cases making the cumulative patency 50% and with limb salvage rate of 50%. Eighty four% of the patients were diabetics, follow up time was 2-7 years. Using a single incision for distal artery exposure and saphenous vein release when using the in-situ technique in this study yielded infection rate of 5% compared to 20% in the double incision technique. Also, the patency rate was 80% compared to 60% in the double incision technique. The relative safety and efficiency of the alternative saphenous vein graft pathway in achieving a good patency rate and less complications in anterior tibial or dorsalis pedis bypass can be shown in this study

Limited resection of infected puncture site potion of hemodialysis arteriovenous access graft [whether natural or synthetic], with replacement by an ex-situ saphenous vein bridge graft, for access salcage

Infection in a hemodialysis access graft is a serious complication that can lead to loss of the dialysis access. If the whole graft is involved, the only way is to remove it under appropriate antibiotic cover, and reconstruct another fistula. But, f only a localized segment As involved as in puncture site infection, trials have been made to excise this involved segment and replace the lost segment ex-situ by a substitute. Relative resistance of the autogenous saphenous vein to infection may present a more durable segment substitute. Study the efficacy of an ex-situ bridge segment of saphenous vein in replacing an injected localized segment of hemodialysis access; its resistance to infection and access salvage up to 3 months post operatively. Forty patients with ESRD having localized hemodialysis access puncture site infection. Twenty six had a PTFE access. Fourteen had a natural autogenous arm vein access. Follow up of the repaired access for 3 months for re-infection and access salvage and patency. The overall early access salvage rate was 36/40 cases [90%]. For ePTFE, it was 23/26 [88.46%] and for autogenous A-V fistula was 13/14 [92.9%]. The re-infection rate by the end of 3 months was 2.78%, with 4.3% for ePTFE grafts and 0% for auto genous A-Vfistulas. The overall access salvage and patency by the end of 3 months was 87.5%, with an overall access loss of 12.5%. The overall salvage for synthetic grafts was 84.6%, and for the autogenous vein was 92.85%. Each dialysis access should be preserved for use for as long as possible. Using a saphenous bridge ex-situ seems superior in late access salvage than using a bridge of PTFE and we recommend Its use In cases of puncture site localized infections

Distal revascularization-interyal ligation [DRIL] versus banding for simulataneous correction of steal, and preservation of A-V hemodialysis access

Ischemic steal syndrome secondary to a hemodialysis arteriovenous access is a potentially serious complication. Two types of the syndrome are recognized; the immediate, and delayed type. This condition occurs due to marked decrease or reversal of flow in the arterial segment distal to the A-V fistula, induced by the low resistance of the fistula outflow. Of the work: To compare the efficacy of two methods used in managing A-V dialysis access steal; DRIL, versus banding. Twenty six patients presenting with manifestations of steal following creation of a function A V shunt access. Fourteen patients underwent DRIL, and twelve patients underwent banding of the first 3-4 cm of the access beginning, adjacent to the A-V shunt Pre and post operative color Duplex for measuring the flow rates in proximal and distal arterial segment, and the flow rates in the access. Intraoperative pressure measurement were recorded before and after correction in the proximal and distal arterial segment using an invasive line. Acute steal cases were 26.9% compared to 73.1% delayed presentation. The sudden loss of part of the arterial flow into the access, in the presence of inefficient colla might be responsible for that. The distal arterial pressure improved significantly postoperatively in both groups. The major difference between the 2 groups was in the patency rate measured at 6 months postoperatively. It was 66.7% for banding, compared to 92.9% for DRIL although the results did not reach stastical significance. Thrombosis in a case occurred on third postoperative day, the others thrombosed between 2-6 months post correction. Diabetes effect on steal was well demonstrated in this aeries [88.5%] as well as female predominance [69.2%]. Banding had good results when the venous limb was dilated with associated compensatory proximal arterial hypertrophy which allowed narrowing of the outflow venous tract to 6-7 mm, with good palpable distal pulse, and good thrill at the fistula site. However, if infection is excluded, the DRJL results might have approached 100%, still, it showed higher patency trend

Thrombophlebitis of the proximal great saphenous vein: hazard of extension into the deep venous system and management

Superficial thrombophlebitis [STP] of the proximal great saphenous vein [GSV] has long been considered a benign and self limiting disease. Possible extension into the deep system alerted authors to be cautious about proximal STP. Incidence of deep system extension varies between 7-44%. Another hazard of STP is pulmonary embolism [PE] with rates ranging between 3-33%. To study the incidence of direct extension of GSV proximal thrombophlebitis into the deep system in a group of patients having above knee GSV thrombophlebitis together with the efficacy and safety of direct thrombectomy of this extension. Two hundred cases of acute above knee GSV thromhophlebitis. Color Duplex of the venous system of the limb to show the position of the thrombus within the GSV, and its extension into the deep system, and if it is a fresh thrombus was done. Thrombectomy of all the cases [using fogarty catheter], that showed extension into the deep venous system, under protection of a high positive end expiratory pressure [PEEP] anesthesia to guard against intra-operative PE using 20 cm water pressure, with SFJ ligation, and GSV stripping, if that was varicosed. The cases were put on anticoagulation for 3 months post operatively. Ventilation/perfusion lung scan for the operated cases were performed Post operative venous duplex at 10 days, 1, 3 months, to study patency, flow and reflux in the deep system at the CFV, SFV and rest of the deep system. The propagation of thombosis form the proximal saphenous vein via SFJ into the deep system was noticed in 11% of the studied 200 cases. It was also thought that the thrombus has to extend to the deep system before being able to cause pulmonary embolism. 3% had probability result for PE. The use of positive end expiratory pressure [PEEP] was meant to prevent pulmonary embolism. The post operative color duplex survey showed normal venous morphology and function in 90.9% of cases, and accepted reasonable results in 9.1%. the use of direct thrombectomy of STP of the GSV in such described circumstances to improve deep venous patency, and lessen the post deep venous thrombosis sequalae