Stefano Ricci
AbstractEndovenous laser ablation (EVLA) has two pitfalls: endovenous heat-induced thrombosis (EHIT) and
great saphenous vein (GSV) recanalization. Trying to avoid these pitfalls, the authors developed a novel
method of ultrasonography-guided high ligation (UGHL) as an adjunct to EVLA. After positioning a 5-F introducer sheath over a guidewire by a venous catheter above or blow the knee, the GSV at 2 cm distal to the SFJ was located by US, and 2 small 2–3-mm skin incisions were made next to the GSV under local anesthesia. The bilateral aspects of the GSV were dissected using mosquito forceps under duplex scanning guidance. The dorsal aspect of the GSV was then dissected using a Deschamps aneurysm needle, appearing as a strong echo behind the GSV. The needle, advanced to the other incision hooked a 2-0 silk thread which was pulled through to the first incision, encircling the dorsal aspect of GSV. The Deschamps needle was then advanced on the anterior aspectof the GSV for dissection, and led to the other incision carrying the thread, encircling the GSV. After EVLA of the GSV was completed the thread was tied around the GSV. Skin incisions were closed with Steri-strips.The procedure was performed in 20 patients who were scheduled for EVLA for incompetent GS. The mean GSV Diameterat 2 cm distal to the saphenofemoral junction (SFJ) in the standing position, was 5.1–11.5 mm. The CEAP clinical class was C2–C5. EVLA and UGHL were performed without complications. The time needed for UGHL was 191–853 s). UGHL took longer than 360 s (6 min) in 4 patients in the first 10 cases and in 1 patient in the last 10 cases. In the case with a deeply located GSV, encircling of the GSV was fairly difficult, and surrounding tissue could be caught during ligation. Successful GSV ligation was immediately confirmed by US. The postoperative courses were uneventful in all cases.
|
This is a very interesting method for GSV ligation with a limited surgical action. Probably not all the cases are simple, in particular when subcutaneous tissues are particularly thick or peri venous layers are sclerotic for inflammation. Excessive dilatation may cause difficulties too. However, considering the reduced rate of the two pitfalls reported in EVLA outcome, it may be questioned whether such approach to the GSV terminal part is really necessary in association to EVLA or not, if we consider the possible (although rare) occurrence of complications of this same procedure (vein rupture, hematomas, infection), when performed by non skilled surgeons. Much more interesting, instead, could be the use of this kind of GSV obstruction in association with GSV sclerotherapy, to guarantee a higher rate of GSV closure, or in association with saphenous vein sparing methods (CHIVA), in order to avoid the GSV surgical high ligation.
[TOP]