45

VARICOSE VEINSSome Comments on the Repair of Surgical Failures

By R. ROWDEN FOOTESurgeon in Charge of Varicose Vein Department, Harrow Hospital

There is no operation which is capable ofrestoring a normal physiology to a limb which isthe seat of varicose disease. So, in actual fact, noform of surgical approach is capable of producingperfection. The word 'failure,' when applied tothe results of surgery, must, for the purposes ofthis article, be used only when the diseased limb iseither not improved or has become worse sinceoperation.

Varicose disease is a progressive conditionshowing a steady deterioration over the years.For this reason the prognosis regarding cure isbetter amongst our older patients, who willobviously need the use of their legs for a shortertime than will those who are their juniors. Again,surgical success is more noticeable in those casespresenting a marked incompetence of the valvesof the superficial venous system associated witha gross dilatation and tortuosity of the affectedveins. It has been said by others that beforeconsidering surgery for a gastric ulcer the patient'has to earn his operation.' This remark can beapplied with equal truth to the sufferer fromvaricose disease. If this fact be remembered,mild cases will not be submitted to unnecessarysurgery performed purely from the cosmetic angleand we shall have fewer failures with which tocontend.There has been an unremitting struggle by

surgeons throughout the ages against the almostuncanny persistence of varicose disease, and thosewho care to read will find great interest in studyingthe varied angles of attack which have been levelledagainst the varix since the days when Hippocratespractised acu-puncture and Galen, a hundred orso years later, tore these pernicious weeds fromthe limb by means of a hook. The first glimmerof the development of our modern surgical attackdirected at the roots of the internal saphenousvein was given to us by Paul of Aegina who, somethirteen hundred years ago, recognized a suf-ficiency regarding the anatomy of the longsaphenous vein and its tributaries to secure, as he

thought, the main trunk from which all thebranches arise. These great men of the past allfailed to produce a cure, and it is doubtful whether,in most cases, they produced an improvement.As a result, throughout the centuries there hasbeen a recurrence of various forms of surgeryoccurring in cycles-becoming fashionable for aperiod of time and then being buried in oblivion,to be recalled a few hundred years later as a newstep in the progress of the surgical attack.

It is only in recent times that we have beenable to emphasize that we are able to benefit thevast majority of our patients. Furthermore, wecan now offer them a safe operation which, if initself is not Ioo per cent. satisfactory, is anywaynon-lethal and helps the vast majority of ourpatients. In spite of these facts, however, thereare still those amongst us who revert to the daysof Galen in their enthusiasm to eradicate thevarix. Many of such patients come to us at alater date as failures. Their lot, with a history ofmultiple massive incisions, .together with pro-longed hospitalization, is a- sorry- one, and torestore their confidence regarding further treat-ment is frequently a difficult problem. Thesepatients are apt to approach the clinic with a degreeof hopelessness. Many of them have been toldby their doctors that nothing more can be donefor them, and they need sympathetic handlingand reassurance.The author has for many years noted the more

frequent types of operative failure which havepresented themselves at a varicose clinic. Thosewho come to see us usually fall into one of tencategories, although some may present some signsof being in one or more of the groups which weare about to outline. In other words, many casescannot be definitely placed in a pigeonhole, andall of them require careful examination and assess-ment in order to determine the reasons why theirprevious operative tleatment has met with nosuccess. We now come to the list of the commonertypes of surgical 'failure.'

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46 POSTGRADUATE MEDICAL JOURNAL yanuary I95:

I. Branches at the sapheno-femoral junction havebeen missed at the time of the original operation.

This is the most frequent finding and it is notunusual to discover that it is the external super-ficial circumflex vein which has escaped resection,since this branch is often difficult to define inobese subjects (Fig. i). Another branch whichit is only too easy to miss is the accessorysaphenous vein which sometimes joins the mainsaphenous vein deep to the saphenous opening(see Figs. 2 and 3). This vein may often be largeand, since it lies on top of and parallel with thefemoral vein, may be mistaken for the deep veinwhen stripping up the saphenous stump. How-ever, it must be recognized that any branch whichis missed at the sapheno-femoral junction iscapable of bypassing the resected portion of theinternal saphenous vein and causing in due coursea complete recurrence of the original varicosecondition. Patients who suffer fiom this type offailure usually give the history of a period ofdefinite benefit subsequent to the primary opera-tion, recurrence as a rule appearing withineighteen months.

2. Cases in which the internal saphenous vein hasnot been ligated at all and the internal superficialfemoral vein has been ligated in error.

This error is fortunately not common and itshould be noted in the history that these patientsshow no benefit after operation and that, onexamination, the saphenous bulb is usually easilypalpableThe majority of those cases in the first two

categories, in other words those cases in whichtributaries of the sapheno-femoral junction havebeen missed or that group in which the saphenousvein is still intact, should be given the opportunityof surgical exploration and a further examinationof the sapheno-femoral junction. They should bewarned that perfect results can in no way beguaranteed, however. With these patients it isusually possible to feel the saphenous bulb eitherabove or below the original scar and, in those whoare not too fat, the by-passing branches can alsobe palpated. These branches may be definedsometimes by the impulse conveyed by coughing.The surgeon would be wise to make a largerincision than is usual when operating on thevirgin field and must place the line of his incisioneither above or below the original scar, choosingwhichever position he feels may give him thewidest exposure. Special care must be taken,since the old scar tissue may be attached to thefemoral vein and tears may result from any roughhandling. Once the sapheno-femoral junction hasbeen exposed, a flush ligation and a resection ofall adjacent branches should be performed. If

::!iiM !iBi~ii i~.ii.. .....

,ii.i !:.ii. .....:....

FIG. i.-Certain branches at the sapheno-femoraljunction have not been ligated and a severe recur-rence of varices has occurred eighteen months afteroperation.

thought advisable, a further small incision can bemade lower down in the course of the internalsaphenous vein so that a nutmeg grater needlemay be introduced at this point. Sclerosant maybe delivered through this needle if thought to benecessary. Always remember that the usualbranches at the sapheno-femoral junction mayjoin the femoral vein high up, going directly intothis deep vein. For this reason, when repairingcases of recurrence, it is wise to inspect thefemoral vein above the junction with theinternal saphenous vein.

3. Those cases in which the external saphenousvein is either incompetent at the time of the originaloperation or has become so subsequently.At the time of the first operation on the internal

saphenous vein, it is essential to note the conditionof the external saphenous vein and to deal with itat the same time if it is found to be incompetent.

Sclerosant therapy may be all that is requiredwith these patients since, as is well known, the

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48 POSTGRADUATEIMEDICAL JOURNAL January I952

last inch or so of the external saphenous vein justimmediately before it joins the popliteal vein isencased in a sheath of fascia. This fascia may actin much the same way as does a valve and probablyto some extent controls the backward pressure ofblood in the short saphenous vein. For thisreason it is always worth while trying injectiontreatment before resorting to surgery, especiallysince recurrences after surgical treatment arecommon, owing to the difficulty of isolating allthe branches at the junction.

4. Cases which have received adequate treatmentat the sapheno-femoral junction but in which ' blow-outs' (incompetent communicating veins) in thelower third of the leg have either developed since orhave not been dealt with at the time of the originaloperation.

Experience shows that it is usually necessary toresect these ' blow-outs' when they occur in thelower part of the leg at the time that the highresection operation is performed. Similar 'blow-outs' in the upper part of the leg and in the thighcan usually be dealt with by means of scarificationof the venous intima and do not require separateexcisions. Under local anaesthesia these 'blow-outs' in the lower third of the leg should beexposed and the communicating veins under-lying them should be resected.

5. Cases which develop multiple varices on theinner side of the lower leg after the original operation.

Such cases as a rule need the 'ankle tie'operation and the retrograde injection of a sclero-sant, delivered through a plastic tube. Thissimple procedure may be done painlessly underlocal anaesthesia. It is important that the tubebe withdrawn as the injection is being given, sothat the risks of sclerosant entering the deepveins may be minimized (see Fig. 4).

6. Cases which have been operated on correctlyfor varicose ulceration but who have not beenadequately instructed regarding the subsequent pro-longed bandage compression treatment which isusually necessary.The combination of surgery with localized

compression treatment is essential for the properhealing of gravitational ulceration and for theremoval of the accompanying oedema. If this isnot done the frequent result is that the ulcers willheal and then break down at intervals. Advice isneeded regarding the correct type of bandagesupport. With the majority a two-way stretchbandage, correctly applied before leaving bedin the morning, is all that is required in orderto remove the oedema and to cause healing. TIhe

Femoral vein

I .

si--Deep fascia

allosofantonn

l

/ --SpkenousI e

- Accessoryds saphednous

FIG. 2.-The usual method by which the accessorysaphenous vein jo insthe main trunk. This unionoccurs superficially to the deep fascia and thereforeallows of an easy ligation.

bandage should be reapplied during the day andpersisted with until a less bulky type of support,such as adequate elastic stockings, may be all thatis required for the control of the oedema. Forthe less intelligent patients, however, it is farbetter to use one of the sticky bandages of theElastoplast type, since the lazy patient may notpersist with a two-way stretch bandage oncehealing has occurred.

7. Cases presenting oedematous legs which havedeveloped shortly after operation.Such patients are usually suffering from deep

vein thrombosis. The causation can be tracedeither to immobilization of the limb after opera-tion, to the use of an over-all excess of sclerosant,to the injection of too much sclerosant into oneplace, or to the injection being made over a wide-open incompetent communicating vein. Sclero-sants should only be delivered in small multipledoses, in the right amountt nd in the right place.

In such cases prevention is far better than cure.

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January 1952 FOOTE: Varicose Veins: Some Comments on the Repair of Surgical Failures 49

I

c Accessorys s s I heisase tein

*1 -Z^eo fascia,

vein. This arrangement at the sapheno-femoral

i

FIG. 3.-A not uncommon method of union of theaccessory saphenous vein. In this case the unionwith the parent trunk is deep to the superficialfascia and the vein lies parallel with the femoralvein. This arrangement at the sapheno-femoraljunction may, in some cases, lead to a failure toligate this branch.

As has already been mentioned, this unfortunatehappening can be prevented by an immediatemobilization of the limb after operation. Thecontrol in the amount of sclerosant used is of theutmost importance and, in fact, the completeavoidance of all sclerosant is essential in thosecases in which the intima of the deep veins hasbeen previously sensitized-as in the case in whicha history of vwhite leg is present.Once the condition has developed, however, it

is essential to apply T.W.S. bandages correctlyand advise the patient to take plenty of exercisewhile these bandages are in place. If they areapplied so that the pressure is maximum in thelower third of the limb and is relaxed in its up-ward ascent until it is comparatively loose justbelow the knee, the oedema will be steadilyremoved in a majority of cases. Neglect to giveactive treatment of this type may lead to ulcerationor intractable oedema, whereas early treatmentwill cause the deep veins to take over their full

. .:.s ..j.A..1)

,. ,.

'"1';

1 , . :.- j: -A

t .;-'|;

:t i.*"....r

FIG. 4.-This diagram represents the author's methodof scarifying the venous intima from above bymeans of a nutmeg grater needle. In additionthere is shown the usual method of performing anankle tie and introducing a plastic tube throughwhich sclerosant may be delivered.

means of a nutmeg g~~ratrnel.Idiinthe~~~·jre ssonteuulmehdo efrig

ankle~· t ia n ntouin latc uethogwhichsclrosnmybedlivered

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50 POSTGRADUATE MEDICAL JOURNAL Janua3ya 1952

work in quite a high percentage of cases. Adequateexercises, physiotherapy and massage are alladjuncts to treatment which should not beforgotten.Another possible cause for deep vein throm-

bosis after operation should be considered.Damage to the femoral vein may be caused in someinstances by the use of a clamp at the sapheno-femoral junction. Nipping of the deep vein mayoccur (Fig. 5), and this point should be remem-bered at the time of operation.

CLa?O

FIG. 5.-Diagram illustrating a too close clamping ofthesaphenous' stump. Damage may be done to theanterior wall of the femoral vein by this procedure.This may be followed by a deep vein throm-bosis.

8. Cases which have been operated upon in thepresence of a deep vein thrombosis.

These patients, whilst suffering from a deepvein thrombosis, develop compensatory super-ficial varicosities. Unless the superficial varicesare forming an added embarrassment to the cir-culation of the limb, surgery should be avoided.Experience is required in selecting such cases forsurgical treatment. When surgery has beenwrongly applied to those who already suffer froma deep vein thrombosis, we are not able to do agreat deal, but we can instruct them regardingselected exercises, the use of elastic com-pression bandages and the avoidance whereverpossible of all those things which increase thegravitational factor.

9. Persistence of varicose ulceration after adequatesurgical treatment, due to the general health of thepatient.

It is not uncommon to see persistent ulceration

after an efficient surgical procedure. Many ofthese patients, when examined carefully, may befound to be suffering from a severe anaemia.Correction of this condition will in many casescause healing to occur. The syphilitic ulcer isnow a rarity but tineal infection is always with usand this infection can cause 'failures' to occurafter adequate surgical treatment.

10. That very large group of cases which havenot been submitted to a proper follow-up afteroperation.

All patients should be seen at the least everyyear after operation-whether they be better orworse. No patients should be promised a cure.They should all realize that varicose disease isa progressive condition and that the surgeon inmany cases can but retard this progress. Hispatients must give him the opportunity of seeingthem at regular intervals if their limbs are to bekept in order.

It is not always the fault of the patient thatthey have failed to attend, since many of themstate that they were told that the operation wouldcure their veins and they are often indignant overthe most minor recurrences. Adequate explana-tion to these patients regarding the progressivecharacter of the varicose state, and the injectionor ligation of branches where necessary, is oftenall that is required. Remember that, when dealingwith large branches, excision is often less painfulthan is the use of a sclerosant. The removal oflarge branches through small incisions under localanaesthesia is less painful and more lasting in itsresults.The purpose of these few comments on our

'failures' is to stimulate interest in their repairand is offered in no critical spirit, since the authorof these notes is humbled all too frequently byhis own 'failures.' The treatment of varicoseveins is an ever-fascinating subject, and' failures'and their repair add to its interest. Were thefishzrman to land a large trout with every cast ofhis fly, he would soon become bored! No caseis too hopeless for us not to be able to offer atleast some alleviation. Remember, however, thatprior to planning such repair, a careful andthorough examination and assessment of thelimbs is essential. A clear conception as to thecauses of the original surgical failure is neces-sary. As in the treatment of all sufferers fromvarices, the age, physical condition and stressesimposed on the patient by his particular type ofwork must all receive a careful consideration.Added to this the longevity or outlook regardingthe length of life is of importance. The surgicalhand should be held when dealing with theelderly who follow sedentary lives. Extensive

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January 1952 FOOTE: Varicose Veins: Some Comments on the Repair of Surgical Failures 51

surgery, when all that may be needed is a pair ofelastic stockings, is to be condemned. Now thatthe varicose patient is receiving more specializedtreatment in our hospitals, surgical failures arefortunately becoming less frequent. Just as beforethe days of Robert Jones, fractures were the' Cinderella' of general surgery, so in our timesthe varicose patient has received his measure ofneglect. The segregation of the varix into aspecial department in our hospitals is now happen-ing throughout the country and it will not be longbefore we shall cease to talk of the ' failures'of varicose surgery.

SummaryI. Some of the causes of our ' failures' in the

surgery of virices are discussed.2. There are but few of these cases which

cannot be bettered by treatment.3. A plea for the careful assessment of the cause

of each case of failure is made.4. Some suggestions for the repair of these

cases are offered for consideration.

AcknowledgmentThe author is indebted to Messrs. Butterworth

for permission to use certain of the illustrations.

BIBLIOGRAPHY

FOOTE, R. ROWDEN (1949), 'Varicose Veins,' Butterworth,London.

PRATT, G. H. (1946), 'Treatment of Varicose Veins,' J. Amer.med. Assoc., 132, 70i.

OBSTETRICS & GYNAECOLOGYPostgraduate Medical Journal

Price: 2s. 9d., post freeForeword Pelvimetry in Obstetrics

Sir Eardley Holland, M.D., F.R.C.S., F.R.C.P. H. Cecil Bull, M.R.C.P.Obstetrics in the National Health Service Analgesia and Anaesthesia in Modern Obstetrics

Sir William Gilliatt, K.C.V.O., M.D., M.S. G. C. Steel, M.R.C.S., L.R.C.P., D.A.(Lond.), F.R.C.P., F.R.C.S. An Evaluation of the Various Factors in Infertility

Modern Views on the Management of Placenta John Stallworthy, M.A., F.R.C.S., M.R.C.O.G.Praevia The Sympathetic Nervous System in Obstetric andC. H. G. Macafee, M.B., F.R.C.S., F.R.C.S.I., Gynaecological PracticeF.R.C.O.G. Albert Davis, M.D., Ch.M., F.R.C.S.,

The Modem Practice of Caesarean Section- M.R.C.O.G.Some Controversial Views The Present Position of Radiotherapy in theS. G. Clayton, M.D., M.S., F.R.C.S., Treatment of Malignant Disease of the PelvisM.R.C.O.G. M. Lederman, M.B., D.M.R.E.

Published byTHE FELLOWSHIP OF POSTGRADUATE MEDICINE

60, Portland Place, London, W.1

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