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. For this reason, an oblique incision is made as shown. It is impos­sible to pinpoint the exact location of the communicating veins or to know for certain how many will be found. The keynote to success is to find all the incom­petent veins and to interrupt them beneath the deep fascia. The subfascial ap­proach and interruption make it possible to perform this much more effectively and completely than ligation superficial to the deep fascia; in fact, it would be impossible to find all those superficial to the fascia.
  • Blunt dissection with the forefinger of the left hand between the deep fascia and the calf muscles is readily carried out because there is only loose areolar tis­sue and the communicating veins between them. As this cleavage plane is devel­oped, the enlarged incompetent communicating veins are readily located. The dis­section can easily be carried to the midline posteriorly. The only structure to be avoided is the sural nerve, or the median component of it. Many surgeons persist in calling these perforating veins, presumably because they pass through the deep fascia. The term is otherwise meaningless, and the term “communicating vein” is much more significant since it indicates that the veins connect the deep and super­ficial systems. When the communicating veins become incompetent they play an exceedingly important role in the etiology of varicose veins and the pathological changes that develop in the leg. Furthermore, without the eradication of these veins the varicosities and the stasis dermatitis and ulcers will persist. Instead of diagnosing them as recurrent varicose veins, they should be called persistent when they are observed a year or longer postoperatively. Their presence under these conditions is evidence that an incomplete operation had been performed.

the subfascial interruption of incompetent medial calf communicating veins

    • This demonstrates the forefinger dissecting through the areolar tissue be­tween the deep fascia and the muscles and hooking one of the communicating veins with the end of the finger. Traction on a structure in this location, where it passes through the deep fascia, if it is a communicating vein, will always cause the skin to dimple as shown. Because these vessels are often hidden from view some distance from the incision, this dimpling of the skin is important confirmatory evi­dence that the subfascial structure encountered is a communicating vein, since no other structure beneath the deep fascia with tension on it will cause this.
    • After the communicating vein has been located by this maneuver, it is brought into view with retractors so that its point of emergence from the gastroc­nemius and soleus muscles is clearly visualized.
    • The vessel is then doubly clamped and divided between the clamps. Each end is ligated separately with 3-0 plain catgut ligatures. It is important to make certain that the proximal end coming out of the muscle is tied adequately because, if not, subfascial hemorrhage may occur. This is really the “high pressure” end of the vein, whereas the other end going through the deep fascia, although also better ligated, probably would not bleed postoperatively since it is the “low pressure” end. After completion of the ligatures, further exploration is carried out with the forefinger because there may frequently be several incompetent communicating veins; as many as four have been found on occasion. The complete eradication of these veins by ligation and division is necessary if a complete cure of the varicosi­ties is to be obtained, since if one is left intact it is certain there will be residual su­perficial varicosities.

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