VARICOSE
VEIN SURGERY IN LYMPHEDEMATOUS LIMBS
A.Cavezzi
The European J. of Lymphology and related problems, Vol.7,n.25, 1999, pag.27
Patients affected by lymphedema (LYM)
and associated saphenous varicose veins (VV) may need surgical treatment, which
has to be the least aggressive possible for the lymphedematous lower limb (LLL).
Selective indications to interventions in these patients may be ascending or recurrent
varicophlebitis, varicose ulcers, advanced dermohypodermitis, large and symptomatic
VV in phlebolymphedema.
We reviewed our last two years of surgical activity, examining the procedure and
results of saphenous stripping and/or phlebectomies in patients with LLL.
Pre-operative echo-colour-doppler investigation and mapping was carried out to
guide the surgical approach, both for a radical-cosmetic operation and to spare
healthy segments of saphenous trunk.
Surgery was always performed in local anaesthesia, favouring the ambulation of
the patients 1 hour after the operation; the surgical procedure consisted of:
a) enlarged crossectomy, when necessary (in 25% of the patients the sapheno-femoral
or sapheno-popliteal junction was competent, resulting in a "peripheral" VV disease),
b) short (sometimes 15-20 cm) saphenous stripping by invagination technique, c)
phlebectomies by mini-incisions (sometimes by means of a 18G needle) for varicose
tributaries, d) very rarely ligations of perforating veins.
The conservative approach, as we performed in LLL with VV, was based on: a)careful
dissection in the inguinal or popliteal area, sparing any lymph node from trauma,
b) the invagination method for the stripping and c) the limited avulsion of the
long or short saphenous vein (LSV) (SSV), which largely reduces the peri-saphenous
lymphatics damage, furthermore d) mini-incisions.
Moreover in these patients we used a multi-layer adhesive bandage for the first
7 post-operative days and we usually performed an intensive combined physical
therapy (manual lymphatic drainage, pressotherapy, elastic bandages and stocking)
before and after surgery, administering coumarin-rutin for 2-3 months peri-operatively.
32 patients suffering from LYM (st.II-III) were operated on for saphenous VV;
30 patients (94%) had no worsening of the LYM, 2 patients (6%) showed a slight
and transient increase in edema (one for SSV stripping and one for anterior saphenous
vein, ASV, stripping). All the patients had an improvement of the VV related symptoms,
without major or subsequent venous complications. The patients with ulcers had
an acceleration in the healing and phlebolymphedematous limbs improved the clinical
conditions.
In LLL we mainly prefer echosclerotherapy in case of VV due to incompetence of:
a) ASV, frequently passing through a lymph node, b) SSV, c) recurrent VV arising
from inguino-popliteal cavernoma (where re-do surgery may cause lymphatic problems).
VV surgery in LLL, if adequately and carefully performed in expert hands, may
be a useful procedure in selective cases, in order to prevent complicatons and
to improve the phlebo-lymphodynamic compensation.
