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. Also, a number of the venous diseases do not endanger the limb or life of the patient as much as the arterial diseases more often do. In addition, because the anatomy and pathologic physiology of the veins is not well understood by the majority of surgeons, the surgical treatment is frequently inadequately performed, especially for the most common conditions, namely, the diseases of the veins of the lower extremity. Furthermore, few types of surgery require such meticulous, careful, nontraumatic and patient handling of tissues as the thin-walled venous channels. This may be especially true if a large ve­nous channel is inadvertently incised or torn during dissection of it. The control of venous bleeding under these conditions, especially if the vein must be preserved (e. g., as is necessary in freeing up the splenic vein in order to do a splenorenal venous shunt), will often require the utmost care and ingenuity that a surgeon can muster. As a result, many surgeons unfa­miliar with the technical difficulties of performing operative procedures for venous diseases become discouraged because of the poor results they obtain.

There is perhaps nothing more terrifying than the welling up of venous blood, especially in a deep wound, from injury to a large thin-walled ve­nous structure such as the inferior vena cava, the common iliac, the exter­nal iliac, the hypogastric, the femoral, the popliteal, the subclavian or the axillary veins. This is because venous hemorrhage at a low pressure is much more difficult to control than arterial hemorrhage that spurts out at high pressure. Although the loss of blood may be large from these venous injuries, the most serious complication in obtaining control (of the large veins especially) is the damage that may be done to contiguous structures such as arteries, ureters and nerves. However, if the basic rules of venous surgery are understood, the bleeding can be readily controlled, frequently with salvage of the vein and preservation of adjacent structures. It is of some significance also that almost all veins in the human body with the ex­ception of the superior vena cava, the inferior vena cava proximal to the renal veins and the portal vein are expendable in that they can be ligated without too serious consequences, which of course is not true of the aorta and many major arteries. These and other facts and methods of therapy will be demonstrated in the following pages.

Varicose veins of the lower extremity are one of the most common vascular diseases affecting the human race, and undoubtedly are the result of man’s assuming the erect position as a biped, because this subjects the veins of the lower extremity at the ankle level to a high intravenous pres­sure that approaches arterial systolic pressure. This is especially true in the standing stationary position. The superficial veins which lie between the skin and the deep fascia in the subcutaneous tissues have little if any support and, as a result, they tend to become dilated and varicosed. There have been many theories advanced to explain the etiology of varicose veins, some of which seem far-fetched, such as constipation or sitting in chairs. These certainly do not explain why it is not unusual to find the con­dition in one leg and not the other in the same individual. It seems of signif­icance that in obtaining a history from a patient with varicosities it is frequently found that the mother, father, aunts, uncles and siblings are or have been afflicted; in fact, it is rare that such a familial history is not en­countered. There seems little doubt that the condition of varicose veins is an inherited characteristic, probably the result of incompetence of the ve­nous bicuspid valves in the superficial and communicating system of veins in the lower extremity.

In order to understand the pathologic physiology of the lower extrem­ity veins, it should be remembered that there are three venous systems: (1) The superficial veins lie between the skin and the deep fascia in the subcu­taneous tissues. These consist of the internal or long saphenous vein and the external or short saphenous vein. They oscillate through their many branches so that frequently pathological conditions of one may involve the other. (2) The deep veins of the lower extremity lie between the muscles of the lower leg and the thigh and are protected from dilatation by the deep fascia, a tough fibrous envelope surrounding all the musculature of the ex­tremity. These consist of the common, the superficial and the deep femoral veins in the thigh; the popliteal vein at the knee; the anterior tibial, the pos­terior tibial and the peroneal veins in the lower leg. (3) The third system is made up of the communicating veins that connect the deep and superficial systems. Most surgeons call these vessels “the perforators,” which in­dicates only that they perforate the deep fascia. It is my opinion that the term “communicating veins” denotes their true function, and so for this reason it would be best to drop the former and maintain the latter. These are most numerous in the lower leg, but they also are present in the thigh. They play an extremely important role in the etiology of varicose veins of the superficial system and are even more important in the postthrombotic extremity.

These three systems of veins with their bicuspid valves, the muscles of the leg, and the deep fascia surrounding them constitute what is known as the venous heart of the lower extremity. By muscular action blood is pumped back to the heart through these vessels. A knowledge of this basic physiology of the lower extremity is extremely important in understanding the pathological diseases that result from a derangement of these venous systems with decompensation of the venous heart of varying degree in order that adequate therapy can be performed to correct any condition that develops.

Even though the deep veins are protected from dilatation, they may become diseased as a result of deep venous thrombosis. Recanalization of them invariably occurs with restoration of the venous lumen but with de­struction and incompetence of the venous valves. This results in decom­pensation of the venous heart, with an increase in the venous pressure in the lower limb during muscular contraction so that a state of ambulatory venous hypertension develops in the lower limb.

This results in increased intravenous pressure in the communicating veins, especially of the lower leg, and causes dilatation of them so that their valves become incompetent. As a result, the increased pressure is transmitted to the superficial system of the saphenous veins so that they, in turn, become dilated and incompetent. These changes in the three systems of veins, if untreated, result in the postphlebitic or the postthrombotic state. The characteristics of this condition are capillary hemorrhages in the skin, with brownish pigmentation. A condition of stasis cellulitis develops later, as evidenced by fibrous replacement of the subcutaneous tissues most frequently seen on the medial side of the lower leg and ankle. The in­volved area is characteristically indurated, slightly swollen and exquisitely tender. An abrasion of the area usually results in a chronic ulcer which has been given various names, such as postphlebitic, postthrombotic or stasis ulcer, but which could more accurately be termed a “venous hypertensive ulceration,” the result of decompensation of the venous heart of the lower extremity.

Many operative procedures have been described for centuries, even as far back as the time of Hippocrates, for eradication of varicose veins and cure of chronic ulcers of the lower extremity. It appears from the surgical literature that one method is in vogue for a short period of time, then is discarded for another. In fact, the treatment has apparently gone around in circles, coming back many years later to one of the earlier forms of treatment. For example, at the Massachusetts General Hospital in 1840 patients were admitted to the surgical wards for the injection of their vari­cose veins with a solution of ferric chloride solution. The results of this form of therapy were never published and presumably it was abandoned because of serious complications. The use of different sclerosing solutions and aseptic techniques was commenced again about 100 years later in the 1920′s as an ambulatory form of treatment but again discontinued after a few years because of poor results.

The surgical treatment of varicose veins and the chronic postthrom­botic syndrome with and without ulcerations of the lower leg still leaves much room for improvement, in part, it is believed, because of failure to understand the basic pathologic physiology and how these conditions can be corrected. Another reason for poor results is that the operative proce­dures are often turned over to the youngest members of the surgical house staff of the major hospitals for training surgeons. This has been going on for generations because the senior surgeons are not interested in the metic­ulous type of surgery that is required for the majority of these conditions. As a result, the training in this field is passed on from one young surgeon to another with such poor results that both patients and surgeons become dis couraged with the surgical treatment of these conditions.

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