The subfascial interruption of incompetent medial calf communicating veins

  • This shows the lower leg with a group of large varicosities in the pos­teromedial aspect of the calf and an intraluminal stripper in the long saphenous vein. If only the long saphenous vein is removed, these varicosities will persist because they have developed as a result of the incompetence of the communicat­ing veins in this region and not primarily because the main saphenous vein is incompetent.
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The mode of production of iliofemoral thrombophlebitis

The mode of production of iliofemoral thrombophlebitis
  • Fortunately not all silent deep venous thrombi in the popliteal and femoral veins lodge in the pulmonary artery when they break off from their distal attach­ment; some lodge in the common femoral vein. It is significant that some patients have been known to complain of pain in the calf without much attention being paid to this complaint. Others may have had an unexplained concomitant rise in tem­perature, pulse and respirations, a complication not infrequently caused by deep venous thrombosis of one of the lower extremities and a minor pulmonary embolus.
  • Suddenly the patient experiences severe pain in the thigh. The leg often becomes pale in color and later cyanotic; the entire extremity to the groin becomes swollen in a matter of hours. It is believed that the long venous thrombus becomes impinged in the common femoral vein because in some patients the lumen of this vessel is uneven in outline, tending to entrap the thrombus at this site. Proximal thrombosis quickly develops to involve the external iliac vein, so that the outflow tract is markedly occluded. Temporarily at least, massive pulmo­nary embolism does not occur, but may develop from proximal propagating thrombi. In some patients after 72 hours a sterile inflammatory reaction develops between the thrombus and the venous endothelium, which causes it to become adherent in the iliofemoral region and results in the condition termed “occlusive thrombophlebitis.”
  • The above sequence of events should not occur if early surgical intervention by phlebotomy and thrombectomy is performed as soon as the diagnosis of an ob­structing thrombus in the femoral vein is made. Phlebography may be resorted to, but too often it may produce more thrombosis from the irritating effect of the radiopaque dye. From experience it has been observed that if the thrombus has been lodged in the femoral vein for less than 72 hours it can be extracted readily through a venotomy, similarly to an arterial embolus through an arteriotomy. The venous intima will still be smooth and shiny without adherent blood clot. Some surgeons favor closure of the venotomy to restore the continuity of the common femoral vein. It is my opinion, however, that interruption of it, as shown in this illustration, is preferable. Not only does this give immediate protection from a massive pulmonary embolus, but it also is the best insurance against emboli should phlebitis recur in the extremity. It also has the advantage that it helps to prevent the sequelae of the thrombotic state seen so commonly in the postthrom – botic limb with the uninterrupted femoral vein.

The mode of production of iliofemoral thrombophlebitis


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Superficial thrombophlebitis of the lower extremity

Superficial thrombophlebitis in the lower extremity is seen most frequently in middle-aged and elderly patients with longstanding varicose veins.

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Varicose veins – The Pathophysiology

Varicose veins – The Pathophysiology
    • A drawing showing the normal condition of the three venous systems of the lower extremity. The long and the short saphenous veins of the superficial system, and the femoral and posterior tibial veins of the deep system are shown with their competent bicuspid valves that permit blood to flow only toward the heart. The communicating system of veins between these two systems, the superficial and the deep, are shown with their competent valves that permit blood to flow only from the former to the latter.
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    Prophylaxis of deep venous thrombosis by ambulation in bed

    Prophylaxis of deep venous thrombosis by ambulation in bed
    • These drawings demonstrate the author’s method for ambulating patients who must remain in bed longer than 24 hours postoperatively.
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    Interruption of the inferior vena cava

    Interruption of the inferior vena cava
      • This shows the position of the patient on the operating table for the extraperi­toneal exposure of the infrarenal portion of the inferior vena cava through a right flank incision. The patient lies supine with the right side elevated approximately 15 degrees by blanket rolls under the right chest, hip and thigh.
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      Diseases of the Veins

      The diseases of the veins have never attracted the surgical attention that arterial diseases have for a number of reasons. The apparent lack of interest in this branch of vascular surgery, despite the frequency of disorders, especially of the veins of the lower extremity, may in part be because the results of treatment of some of the common conditions involving them have for the most part been unsatisfactory.

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      Inferior vena cava interruption and plication

      Inferior vena cava interruption and plication
      • The inferior vena cava may also be exposed retroperitoneally with relative ease through a right paramedian right rectus muscle-retracting incision. The in­cision should extend from the pubis to 3 or 4 cm. above the umbilicus.
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      The operative technique of ligation and stripping of the saphenous vein

      This shows an intraluminal stripper that has been inserted into the vein at the ankle and passed proximally in it to the popliteal space.

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      Thromboembolic disease – Proximal superficial femoral vein interruption

      Thromboembolic disease – Proximal superficial femoral vein interruption
            • The femoral artery must be treated with great care to prevent injury to it. Under no conditions should it be retracted with a rubber tube or catheter around it because of the danger of fracturing its wall, with resulting thrombosis and occlusion. (See Introduction, Plate 12 A.)
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