Chinese Medical Journal 2013;126(3):405-408
Combined subfascial endoscopic perforator surgery and endovenous laser treatment without impact on the great saphenous vein for management of lower-extremity varicose veins

GAN Shu-jie,  QIAN Shui-xian,  ZHANG Ci,  MAO Jie-qi,  LI Ke ,  TANG Jing-dong

GAN Shu-jie (Department of Vascular Surgery, Shanghai First People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200080, China)

QIAN Shui-xian (Department of Vascular Surgery, Shanghai First People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200080, China)

ZHANG Ci (Department of Vascular Surgery, Shanghai First People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200080, China)

MAO Jie-qi (Department of Vascular Surgery, Shanghai First People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200080, China)

LI Ke (Department of Vascular Surgery, Shanghai First People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200080, China)

TANG Jing-dong (Department of Vascular Surgery, Shanghai First People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200080, China)

Correspondence to:TANG Jing-dong,Department of Vascular Surgery, Shanghai First People’s Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200080, China (Tel: . Fax:. E-mail:drtangjingdong@126.com)
Keywords
varicose veins; perforator; subfascial endoscopic perforator surgery; endoscopic perforator surgery; endovenous laser treatment; endovenous laser treatment
Abstract
Background  Conventional high ligation and stripping of the great saphenous vein (GSV) has a good curative effect but is highly traumatic with a considerable relapse rate. Subfascial endoscopic perforator surgery (SEPS) plus endovenous laser treatment (EVLT) could be applied as individual therapy. This study aimed to evaluate the feasibility of performing combined SEPS and EVLT without impacting GSV in the management of valvular insufficiency of the lower-limb venous perforators.
Methods  Placement of lower-limb venous perforator insufficiency was marked by ascending phlebography in 83 affected limbs from September 2010 to June 2011. After randomization, SEPS was performed on 41 limbs to address the insufficiency of the venous perforators under the deep fascia, in combination with EVLT to close the superficial varicose veins without impacting the GSV. The remaining 42 limbs were treated using traditional GSV phlebectomy as controls.
Results  Postoperatively, all varicose veins were resolved, with lightening of the pigmentation and healing of the ulcer. Within a follow-up period of 5–11 months, no symptoms had recurred. Compared with the control group, the operation time, the number of incisions sutured, and the in-hospital time decreased on average by 1.5 hours, 4.7, and 6.8 days, respectively (P <0.01 in all cases).
Conclusion  Combined SEPS and EVLT for treatment of valvular insufficiency of the lower-limb venous perforators offer the advantages of microtrauma and rapid cure.
Conventional high ligation and stripping of the great saphenous vein (GSV) has a good curative effect but is highly traumatic with a considerable relapse rate. Hauer1 proposed subfascial endoscopic perforator surgery (SEPS) for venous diseases of the lower limbs in 1985. Over recent years, there has been considerable progress in the diagnosis and treatment of venous disease of the lower limbs, including in China. According to clinical experience, it appears that some cases of lower-limb varicosity were predominantly caused by incomplete venous valve function of the perforator veins, with anterograde phlebography of the veins of the lower limbs.2-4 Without irreversible change of the affected GSV, SEPS plus endovenous laser treatment (EVLT) could therefore be applied as individual therapy. This approach had a good curative outcome, while preserving the unaffected GSV and causing less trauma. The specific diagnosis and treatment process is reported herein.
 
METHODS
 
Subjects and study design
Patients admitted to our hospital between September 2010 and June 2011 with incomplete venous valve function of the perforator veins in the lower limbs were randomized to SEPS plus EVLT (experimental group) or conventional stripping of the GSV (control group).
 
Patients from experimental group received epidural anesthesia in the supine position with the affected knee in a slightly bent position. A 1.5-cm transverse incision was made 4 cm inside the tibial tuberosity. Subcutaneous tissue was detached until the deep fascia was revealed. An incision was made on the deep fascia, and a Trocar and lens were inserted via the incision until they reached the position between the deep fascia and muscular layer. The subfascial space was insufflated with CO2 to 15 mmHg (1 mmHg=0.133 kPa), and then an endoscope was inserted into the same gap, 4 cm inside the first incision and 3 cm below the second incision, by observing the screen. Dissecting forceps were inserted through the channel of the endoscope for blunt dissection of loose connective tissue under the deep fascia. Perforating veins with variable thickness were dissected at the site of the label. The tiny perforating veins were burnt off by electric coagulation. Larger perforating veins were clipped using a titanium clamp and burnt off by electric coagulation at the distal end. Next, laparoscopic devices were withdrawn, followed by removal of subcutaneous gas by squeezing. The two incisions were sutured intermittently. EVLT was performed for superficial varicose veins using Leifukang semiconductor laser-treatment apparatus (810 nm) for 80–500 pulses (mean, 205). Points of varicose vein branches were punctured, and a laser fiber was inserted for multi-direction treatment. With a laser power of 12–18 W in continuous pulse mode, the laser was emitted and the laser fiber was slowly and continuously withdrawn at a speed of 1–3 mm/s. An elastic bandage was applied at the site of surgery of the affected limb under pressure. A stretch sock was used to support the affected limb in discharged patients with incomplete function of the valve of the lower-limb deep vein. In the control group, all patients received conventional stripping of the GSV. The curative effect and relapse rate were observed during the follow-up visit.
 
Statistical analysis
SPSS 11.5 (SPSS Inc., USA) software was used for all analysis. A t-test was performed to compare operation time, number of incisions made, and length of hospital stay between the two groups. Statistical significance was defined as P <0.05. Results were expressed as mean ± standard deviation (SD), and statistical significance was determined using the two samples t test.
 
RESULTS
 
Study population
From September 2010 to June 2011, a total of 69 patients (83 limbs) with incomplete venous valvular function of the perforator veins in the lower limbs were admitted to our hospital. Thirty-six of these patients were male and 33 were female, with an average age of (53.4±13.5) years (range, 35.0–68.0 years) and a disease course of approximately 3–20 years. According to the 1994 CEAP classification of chronic lower-limb venous diseases by the American Vein Association,5 17 limbs were classified as grade 2 varicosity, 19 as grade 3 varicosity (edema), 13 as grade 4 varicosity (skin pigmentation, eczema, and skin hardening), 18 as grade 5 varicosity (healed ulcer), and 15 as grade 6 varicosity (attacking ulcer). The longest duration of any unhealed ulceration was 5 years. Thirty-five cases (41 limbs) were randomly selected as the experimental group, including 18 male and 17 female patients having varicosity of all grades. This group received SEPS plus EVLT. The remaining 34 patients (42 limbs), including 24 male and 10 female patients having varicosity of all grades, formed the control group. The control group received conventional stripping of the GSV. Deep vein valve function of all affected limbs was below grade 2 according to the Kistner classification.5 Fourteen cases were combined with primary hypertension, and eight cases were combined with diabetes.
 
Thirty-five patients in the experimental group and 34 patients in the control group were diagnosed with insufficiency of the perforating venous valve below the knee and subordinate superficial varicose veins. The affected perforating vein and superficial varicose vein were labeled.
 
Treatment outcomes
The incisions in the 83 limbs in 69 cases all recovered well, without infection or bleeding. The varicose veins of all affected limbs were resolved with alleviation of local pain. Pigmentation in the medial malleolus of 13 limbs was alleviated and the ulcers of 18 limbs were fully recovered within 2 to 4 weeks, without relapse or new ulceration. Tissue edema did not appear after surgery. The follow-up visit, performed after a period of 5–11 months, included 67 limbs with a follow-up rate of 80.7%. During the follow-up visit, no relapse of varicosity or aggravation of subcutaneous congestion was observed. Thirteen limbs suffered from subcutaneous congestion, which disappeared within 1 week. Skin numbness was reported in 14 limbs in the area of surgery on the inner side of the lower leg. Compared with the control group, the operation time of the experimental group was reduced by an average of 1.5 hours (P <0.01); the number of incisions sutured was reduced by an average of 4.7 (P <0.01); and the length of hospital stay was reduced by an average of 6.8 days (P <0.01; Table 1).
 

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Table 1. Comparison of outcomes between the experimental group and the control group
 
DISCUSSION
 
Perforating vein surgery reported in the early literature was mainly performed for the treatment of lower leg ulcers. Conventional types of surgery require large incisions, which may damage soft tissue on a large scale. The practice of perforating vein dissection by inserting a blunt dissection apparatus into the superficial fascia can reduce the complication rates. Hauer1 proposed SEPS in 1985, in which perforating vein dissection is achieved in the subfascial space, with visual access provided by use of an endoscope inserted from the proximal end of the limb. This approach could make the surgery minimally invasive,6-8 and may be used to treat incomplete function of the perforating vein. The advantage of this technology is the high localization precision, which is not affected by local skin dystrophy or ulceration. With SEPS, perforating veins can be clipped selectively in the subfascial space, reducing the high relapse rate and the probability of unsatisfactory efficacy of first treatment, which are common in the conventional approach. The incision is made inside the proximal end of the upper leg, which could reduce the occurrence of incision-recovery failure. These advantages explain why SEPS has been promoted in China since 1999.
 
According to the data presented in this study, we can draw the following conclusions. First, the incisions made on the lower leg should be kept at a distance apart. Specifically, the incisions should be made at a distance of 4 cm on the inner side and 3 cm at the distal end under the lens, so that the apparatus can be inserted into the subfascial space under direct vision from the monitor. This technique can also help keep the apparatus ahead of the lens. Second, according to the contrasting results in our study, the reflux of perforating veins in the affected limb occurs predominantly in the Cockett I, II, and III vein along Linton’s line and 24 cm along the perforating vein from the foot. The appropriate positioning of the two incisions facilitates the dissection of these perforating veins. At the same time, EVLT is employed to treat superficial varicose veins, a technique that is easy to perform. For superficial varicose vein branches, a multiple-point puncture is suggested. The clipping of superficial veins has a good curative effect, requires no incision, and requires only the application of an elastic bandage on the area of surgery under pressure. In the control group, conventional stripping of the GSV was performed, and therefore high ligation of the early section of the GSV was required as the first step. Then the trunk of the GSV as well as the superficial varicose veins was stripped by sectioning. The conventional approach requires multiple incisions, is traumatic, requires time for the incisions to slowly recover, and increases the risk of subcutaneous hemorrhage after surgery, which could damage the well-functioning GSV. It is thus clear that SEPS plus EVLT is superior to conventional SEPS.
 
The principal diagnosis of cases in this study was incomplete venous valve function of the perforator veins in the lower limbs. Therefore, positioning of the perforating veins with reverse flow was highly important. Linton’s line provides guidance for the positioning of the main perforating veins in the lower leg. Using a simple touching approach, a depression in the deep fascia could be identified; and this depression is a relatively fixed point for the positioning of the perforating vein on Linton’s line. Color Doppler ultrasound is now commonly used in the positioning of perforating veins.9-12 Anterograde phlebography of the veins of the lower limbs used in this study not only anatomically positions the perforating veins, but more importantly, identifies reverse flow in the perforating veins. This can not be realized simply by touching or using of color Doppler ultrasound. We believe that anterograde phlebography of the veins of the lower limbs can accurately identify the position and function of the perforating veins.
 
Incomplete function of the lower-limb deep veins, perforating veins, and superficial veins may result in venous diseases of the lower limbs, which should be treated using different therapies.13,14 Incomplete function of perforating veins may increase reflux in the deep veins and result in “blowout” change.15 Treatment of reflux in perforating veins can effectively prevent varicosity in superficial veins, as also confirmed by our study. We performed anterograde phlebography in the patients of the experimental group and found that the GSV and its valve functioned well. In the experimental group, the healthy full-length GSV was preserved in case of future need for vein transplant. Data showed that blockage only occurred in a small number of cases with a preserved healthy full-length GSV, which confirmed the rationality of such a procedure. The operation time of the combined SEPS and EVLT procedure was shorter than that of the conventional SEPS, which effectively reduced subcutaneous congestion. Furthermore, this procedure has the advantages of minimum invasiveness and preservation of the function of the GSV. At the same time, the clogging of the venous blood is prevented at the site of ulceration and pigmentation, which promotes ulceration healing and the reduction of pigmentation. In general, SEPS plus EVLT is a safe and effective procedure, allowing rapid recovery after the procedure.8,10-13 and is recommended as individualized therapy for the treatment of venous diseases.
 
REFERENCES