Controlled ischemia for complex venous surgery: The technique of choice

Transcription

1 From the American Venous Forum TECHNICAL NOTE Controlled ischemia for complex venous surgery: The technique of choice J. Leonel Villavicencio, MD, a David L. Gillespie, MD, b and Peter Kreishman, MSII, c Bethesda, Md Surgery under controlled ischemia has been extensively practiced by cardiac, plastic, orthopedic, vascular, and general surgeons. During the past 20 years, we have routinely used this technique to operate on a clean, bloodless field in complex cases of congenital vascular malformations. Based on our favorable experience, we have extended the use of the pneumatic tourniquet to complex cases of primary varicose veins. The use of the tourniquet has dramatically decreased the blood loss and operating time in complex venous surgery without complications secondary to its use. This technique represents a welcome alternative to the bloody, tedious, and time-consuming traditional varicose vein surgery of the past. Complex venous surgery for extensive varicose veins of the extremities can be safely and expeditiously performed under controlled ischemia. It should be the technique of choice. (J Vasc Surg 2001;34: ) Surgery under controlled ischemia has been practiced for several centuries. Currently, it is used in orthopedic, plastic, vascular, and general surgery. Fischer 1 in Switzerland first described the use of a tourniquet in varicose vein surgery. In the United States, Bernhard et al 2 reported the use of the pneumatic tourniquet in 40 patients to avoid clamping calcified, distal popliteal and tibial vessels in reconstructive bypass surgery. Since then, several reports describing the advantages of the technique have contributed to entice vascular surgeons to use the tourniquet in a variety of surgical procedures, 3-6 including subfascial endoscopic perforator division. 7-9 After Fisher and Lorge s report, surgery for varicose veins using the Löfqvist rolling tourniquet 10 or other forms of controlled ischemia 11 has been practiced throughout Europe and other areas of the world Based on our positive experience with the use of controlled ischemia in the surgical management of complex congenital vascular malformations, 16,17 we have extended the use of the tourniquet to patients with severe primary varicose veins. Our experi- From the *Department of Surgery, Uniformed Services University of the Health Sciences, the Department of Surgery and Vascular Surgery, Walter Reed Army and National Naval Medical Centers, a the Division of Vascular Surgery, Uniformed Services University of the Health Sciences, Vascular Surgery Service, Walter Reed Army Medical Center, b and the F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences. c Competition of interest: nil. Presented at the Thirteenth Annual Meeting of the American Venous Forum, Fort Myers, Fla, Feb 22-25, Reprint requests: J. Leonel Villavicencio, MD, FACS, Department of Surgery, USUHS, 4301 Jones Bridge Rd, Bethesda, MD ( jvillavicencio@usuhs.mil). Copyright 2001 by The Society for Vascular Surgery and The American Association for Vascular Surgery /2001/$ /6/ doi: /mva ence includes 220 patients with primary varicose veins, grade 3 of the Venous Clinical Severity Score, 18 (Fig 1, A) operated on at our institutions between January 1995 and December PREOPERATIVE EVALUATION With the patient in the upright position, a careful physical examination of the lower extremities is performed to assess the distribution of the diseased venous systems. The competency/incompetency of the saphenofemoral and saphenopopliteal junctions is investigated using continuous wave Doppler scanning. Color-flow duplex scanning should be performed to evaluate the hemodynamic and anatomic status of the saphenous trunks. This information will determine whether stripping of the greater or lesser saphenous veins needs to be performed and will assist the surgeon in tailoring the operation to the patient s hemodynamic findings. OPERATIVE TECHNIQUE Immediately before the operation, with good illumination, the varicose trunks and incompetent perforators are carefully marked with the patient in the upright position. A permanent marker that will not wash off during the extremity preparation is used. In addition to the standard venous surgery instruments, an assortment of crochet vein hooks, an Esmarch bandage, and a pneumatic tourniquet are necessary. The operation is usually performed under regional anesthesia, although in apprehensive patients, general anesthesia may be necessary. Technique. With the patient in Trendelenburg position, saphenofemoral junction division is performed in the routine fashion. In cases in which stripping of the greater saphenous vein is considered, the vein stripper is passed 947

2 948 Villavicencio, Gillespie, and Kreishman November 2001 A B Fig 1. A, Preoperative marking of a 48-year-old man with large primary varicose veins. There was a 3 4 cm greater saphenous vein aneurysm at the saphenofemoral junction, and a second 2 2 cm aneurysm at the upper third of the thigh. After resecting the aneurysms and dividing the saphenofemoral junction, the large varicosities were easily excised in 55 minutes in a bloodless field using a two-team approach. The pneumatic tourniquet was inflated at 250 mm Hg. Blood loss was minimal. B, Same patient 4 weeks after surgery. There were no complications secondary to the tourniquet. There were no hematomas and minimal ecchymosis. The saphenous trunk below the knee was preserved. All wounds healed uneventfully. from the groin to just below the knee. All varicosities on the proximal third of the thigh, involving the area where the tourniquet is going to be placed, are excised and the wounds closed. A tourniquet cuff is applied over a thick layer of soft cotton roll padding and connected to a microprocessor-controlled tourniquet system with an internal electrical pump (ATS 1500, Zimmer, Ohio). The tourniquet cuffs have a shell and dual-port single-bladder. Our preferred type is a 10-cm wide, 24-in to 34-in long, curved thigh cuff, but the selection depends on the patient s limb characteristics. The extremity is exsanguinated by tightly wrapping an Esmarch bandage from the foot to the level of the tourniquet. The tourniquet is inflated from 250 to 300 mm Hg depending on the thigh thickness and the patient s blood pressure. At this point, the Esmarch bandage is removed. The operation is performed in a clean, bloodless field using ministab incisions and crochet vein hooks. When necessary, slightly larger incisions (2-3 cm) are made to remove large clusters of dilated varicosities or to divide incompetent perforators. In cases of extensive thigh and lower-leg varicosities, a two-team approach is used to fur-

3 Volume 34, Number 5 Villavicencio, Gillespie, and Kreishman 949 ther decrease the tourniquet time. All wounds are closed, and, when indicated, invaginated stripping is performed under the inflated tourniquet. A thick layer of padding is placed over the operated areas, and a snug elastic bandage applied over the entire extremity. The tourniquet is deflated and the return of color and pulses to the extremity carefully verified. Patients spend 4 to 5 hours in the recovery room. After this time, the snug bandages are reapplied less tightly, and the patient is discharged fully ambulatory with instructions to walk smartly for 10 minutes every hour during daytime and to return the next day for a dressing change. Mild analgesics are prescribed for the first 48 hours. DISCUSSION Even though controlled ischemia has been used for many years in several surgical disciplines, its use in the commonly practiced surgery for varicose veins has not gained wide acceptance. In a recent survey of current practice of surgery for varicose veins in the United Kingdom, 19 it was found that 69.5% of general surgeons never use the tourniquet for varicose vein surgery, arguing that it confers no advantage, that its application is time consuming and cumbersome, and that it compromises the sterility of the operating field. Those using the tourniquet (18%) used it regularly, and 12.5% used it occasionally. The figures were similar among vascular surgeons, with 70% never using a tourniquet and 19% using it routinely. The authors considered that nearly 50,000 patients in the United Kingdom are submitted every year to varicose vein surgery. Based on the survey s findings, it is assumed that the majority of these patients are operated upon without the use of the tourniquet despite the benefits that those who have used it strongly proclaim. The advantages of controlled ischemia in arterial surgery have been clearly described in the large series of Collier 3 and Wagner et al. 4 It minimizes the vessel dissection necessary for anastomosis, avoids the trauma of vascular clamps, and greatly facilitates the visualization of the surgical procedure, which is performed in a clean, bloodless field. In varicose vein surgery, randomized studies have demonstrated the benefits of controlled ischemia There is a reduction in blood loss, more satisfactory operating field conditions, and improved cosmesis. One of the most important arguments against the tourniquet has been the fear of the potential complications attributed to its use. In an elegant article, Snyder 24 described the advantages of the method and its potential complications, which are not a clinical problem as long as the occlusion time is kept short. Complete nerve conduction block is observed within 15 to 45 minutes of tourniquet compression. However, with tourniquet times less than 120 minutes, distal nerve conduction is restored within 30 minutes of tourniquet deflation. Intracellular ph decreases during the first 30 minutes of ischemia, but despite an increase in technetium pyrophosphate uptake suggestive of skeletal muscle injury, there are no histologic changes, and metabolic recovery is observed in less than 20 minutes. 25 One should keep in mind that nerves and skeletal muscle directly beneath the tourniquet are susceptible to pressure necrosis. 26 The degree of potential complications with the use of the tourniquet depends on several factors, including the clinical conditions of the patient, the nature of the procedure (knee arthroplasty, arterial reconstruction, varicose vein surgery), the pressure applied, the type of cuff, and the time of tourniquet occlusion. Recognizing all of these factors, in our series of patients operated on for complex varicose veins, we have kept the tourniquet time relatively short (range, min; mean, 55 min) and have used a tourniquet pressure of between 250 and 300 mm Hg. The exact pressure at which a tourniquet should be inflated has not been determined. The minimum pressure that will produce a bloodless field should be used. For the upper extremity, add 70 mm to the patient s systolic blood pressure. For the lower extremity, it is recommended to inflate the tourniquet at twice the systolic pressure. 27 The use of a wide, curved thigh cuff at the lowest effective pressure further diminishes the potential for injury. To prevent the potential complications of the use of the pneumatic tourniquet, guidelines and recommended practices for its use were developed and approved by the Association of Operating Room Nurses Board of Directors in Curved tourniquets specifically designed for conical limbs occlude arterial flow at lower pressures than straight cuffs of equal width. 29 Following these guidelines, we have not observed any complications secondary to the use of the tourniquet. The low incidence of saphenous neuritis observed in our series (3%) may be a result of the excellent visualization of the distal saphenous trunk obtained in a bloodless field and the easy identification of the saphenous nerve trunk. The careful attention to an effective local compression of the surgical areas using thick padding under the snug elastic bandages applied during the first 24 to 48 hours of the postoperative period has resulted in a diminished incidence of hematomas and ecchymosis (Fig 1, B). Using our previous large experience with the traditional extensive surgical procedure described by the Mayo Clinic as a historical control, 30 the use of the tourniquet in our series of complex varicose vein surgery has dramatically decreased blood loss and operating time. It has allowed for a cleaner, faster, and more precise venous dissection and a better wound closure. It represents a welcome and elegant alternative to the tedious, time-consuming, and bloody varicose vein surgery of the past. For the indications described, it should be the technique of choice. REFERENCES 1. Fischer R. Erfahrungen mit der Blutleere oder Blutsperre bei Varizenoperation. Phlebologie 1994;23: Bernhard VM, Clark HB. Towne JB. Pneumatic tourniquet as a substitute for vascular clamps in distal bypass surgery. Surgery 1980;87: Collier PE. Atraumatic vascular anastomosis using tourniquet. Ann Vasc 1992;6: Wagner WH, Treiman RL, Cossman DV, Cohen JL, Foran RF, Treiman GS, et al. Tourniquet occlusion technique for tibial artery reconstruction. J Vasc Surg 1993;18:

4 950 Villavicencio, Gillespie, and Kreishman November Manship LL, Moore WM, Bynoe R. Differential endothelial injury caused by vascular clamps and vessel loops in atherosclerotic vessels. Am Surg 1985;7: Ciervo A, Dardik H, Qin F, Silvestri F, Wolodiger F, Hastings B, et al. The tourniquet revisited as an adjunct to lower limb revascularization. J Vasc Surg 2000;31: Gloviczki P, Cambria RA, Rhee RY, Canton LG, McKusick MA. Surgical technique and preliminary results of endoscopic subfascial division of perforating veins. J Vasc Surg 1996;23: Hauer G. The endoscopic subfascial division of the perforating veins preliminary report [in German]. Vasa 1985;14: Wittens CHA, Pierik RGJ, van Urk H. The surgical treatment of incompetent perforating veins. Eur J Vasc Endovasc Surg 1995;9: Löfqvist J. Chirurgie in Blutleere mit Rollmanschetten. Chirurg 1998;59: Shindo S, Tada Y, Kamiya K, Suzuki O, Kobayashi M, Iyori K, et al. Automatic sequential pneumatic tourniquet (pneumatic stocking) for distal bypass [letter]. J Vasc Surg 1993;21: Meyer TH, Weber H, Lang W. Varizenoperationen in Blutleere. Vorteile der konventionellen Technik mit ener Standardmanschette. Vasomed 1997;9: Streichenberger R, Barjoud H, Konieczny M, Elias W. Surgical management of major varicose veins of the lower limb using a pneumatic tourniquet. Ann Vasc Surg 1991;5: Langer C, Fischer R, Fratila A, Kaufmann R, Kluess HG, Ull G, et al. Leitlinien zur operativen Behandlung von Venenkrankheiten. Phlebologie 1998;27: Lahl W, Albrecht G. Optimierung der Varizenchirurgie durch Anwendung der Blutleere. Phlebologie 2000;29: Villavicencio JL. Treatment of varicose veins associated with congenital vascular malformations. In: Bergan JJ, Goldman MP, editors. Complex problems involving varicose veins. Part 4. Varicose veins and telangiectasias. St Louis (MO): Quality Medical Publishing Company; p Villavicencio JL. Congenital vascular malformations of venous predominance: Klippel Trenaunay Syndrome. In: Raju S, Villavicencio JL, editors. Surgical management of venous disease. Media (PA): Williams and Wilkins; p Rutherford BR, Padberg FT, Comerota AJ, Kistner RL, Meissner MH, Moneta GL. Venous severity scoring: an adjunct to venous outcome assessment. J Vasc Surg 2000;31: Tsavellas G, Ranboldo C. Tourniquet use during varicose vein surgery: a survey of current practice among Wessex surgeons. Ann R Coll Surg Engl 2000;82: Tsavellas G, Ranaboldo C. Varicose veins made easy! Ann R Coll Surg Engl 2000;82: Corbett R, Jayakumar KN. Clean-up varicose vein surgery use a tourniquet. Ann R Coll Surg Engl 1989:71: Thompson JF, Royie GT, Farrands PA, Najmaldin A, Clifford PC, Webster JHH. Varicose vein surgery using a pneumatic tourniquet: reduced blood loss and improved cosmesis. Ann R Coll Surg Engl 1990;72: Farrands PA, Royle G, Najmaldin A, Webster JHH. Varicose veins surgery: effect of tourniquet on intra-operative blood loss and postoperative cosmesis. Br J Surg 1987;74: Snyder SO. The pneumatic tourniquet: a useful adjunct in lower extremity distal bypass. Semin Vascular Surgery 1997;10(1): Pedowitz RA. The clinical problem. Acta Orthoped Scand 1991;62: Pedowitz RA, Gershuni DH, Schmidt AH, Friden J, Rydevik BL, Hargens AR. Muscle injury induced beneath and distal to a pneumatic tourniquet: a quantitative animal study of effects of tourniquet pressure and duration. J Hand Surg 1991;16A: Dawes BS. Orthopedic surgery. In: Rothrock JC, editor. Perioperative nursing care planning. 2nd ed. St Louis (MO): Mosby; p Association of Operating Room Nurses Board of Directors. Recommended Practices Committee. Recommended practices for the use of the pneumatic tourniquet. AORN J 1998;68: Pauers RS, Carocci MA. Low pressure pneumatic tourniquet: effectiveness at minimum recommended inflation pressures. J Foot Ankle Surg 1994;33: Villavicencio JL, Gillespie DL, Pikoulis E, Rich NM. Superficial varicose veins: therapeutic options. In: Raju S, Villavicencio JL, editors. Surgical management of venous disease. Media (PA): Williams and Wilkins; p Submitted Apr 18, 2001; accepted May 30, DISCUSSION Dr Simon Simonian (Annandale, Va). Good morning, Dr Wakefield, Dr Coleridge-Smith, members of the American Venous Forum, ladies and gentlemen. I want to thank the program committee of the American Venous Forum for asking me to discuss this important paper by Dr Leonel Villavicencio and his colleagues. I want to thank Dr Villavicencio for sending me the manuscript and the video ahead of time so that I could evaluate it. Certainly this technique of controlled ischemia for complex varicose vein surgery that you have introduced, Dr Villavicencio, is a new one to the American Venous Forum, and it is a method that probably others have not yet used in the United States. It was first used by Dr R. Fisher in 1965, in Switzerland, for varicose vein surgery, 35 years ago, but its use seems to have spread slowly. In a recent survey last year, only about 18% in the United Kingdom were using this technique on a regular basis, so that over 70% were never using it. They were rather afraid of the complications that this cuff, inflated for 30 minutes to 90 minutes, might produce to tissues other than the varicose veins such as the muscles and the nerves. Certainly it is a significant contribution. The cuff was used on 222 patients in the last 6 years; that makes about three patients a month or 37 a year. Out of a total of how many patients in the last 6 years have you selected these patients with complex vascular venous varicose veins? Certainly it is an effective technique, in that you have been able to reduce the blood loss, as you had intended to, and you state that you lost about 20 to 30 ml. That was lost only during the initial part of the operation when you explored the saphenofemoral junction and performed ambulatory phlebectomy or hook extraction of varicose veins in the proximal third of the thigh. After applying the tourniquet, you had no blood loss. How much was the blood loss in patients who did not get the tourniquet? You have stated that the operating time was dramatically reduced. What is your normal operating time in patients in whom the tourniquet was not used? With the cuff, the neuritis rate was 3%, which is low. What was the neuritis rate without the cuff? The hematoma around the track of the greater saphenous vein was found in only 6%. What was the hematoma in those without the tourniquet? The ecchymosis was minimal. How was that measured? How did it compare with the control patients? The pain was 3 to 4 on a scale of 0 to 10, 10 being the maximal. How was that measured? A questionnaire? The stripper was threaded from the groin to below the knee, which is similar to the technique of Oesch. In what percent were you successful in getting it below the knee to incorporate the Boyd perforator? The patients were in the recovery room for 3 to 4 hours to recover from general or epidural anesthesia. Is there any alternative method such as local tumescent anesthesia and intravenous sedation to reduce the PACU time? There were no complications, after using the tourniquet. What about nerves, that are known to lose their conduction time after ischemia of 20 to 30 minutes and then have to recover? Does

5 Volume 34, Number 5 Villavicencio, Gillespie, and Kreishman 951 this have any permanent effect in perhaps older patients? The muscles under the tourniquet, might they have had subclinical pressure necrosis? The ph is known to fall from 7.4 to pathological levels of metabolic acidosis. What about deep vein injury and subclinical thrombosis with this 250 to 300 mm Hg compression of the superficial femoral vein for up to 90 minutes? Have there been any studies with labeled fibrinogen to see if there was any deep vein thrombosis starting there? What about patients who have had deep vein thrombosis? Would you avoid the tourniquet in them? Certainly, it is indicated in complex congenital vascular malformations. However, with the use of preoperative sclerosing agents, it is easier to excise them when they are contracted. Dr Coleridge-Smith. Dr Simonian, I believe you have asked a very large number of questions of our speaker. Perhaps we can Dr Simonian. If I may close. I would suggest there is an effective alternative method to controlled ischemia, in excision of complex varicose veins and incurring minimal blood loss. It is the local tumescent epinephrine-containing anesthesia modification of Dr Klein. Desirable controlled ischemia is achieved to the varicose veins and the adjacent subcutaneous tissues only. Ischemia is avoided to the nerves, muscles, deep veins, and arteries. I greatly appreciate the opportunity of discussing this interesting paper. I thank the program committee and I greatly appreciate your kind attention. Dr J. Leonel Villavicencio. I think I need another paper to answer all those questions. Probably, Dr Simonian, I would be very happy to answer all those questions if I meet with you after the end of this session. Regarding the operating time. When you operate in a teaching hospital, the residents are the ones who operate, and obviously that extends the surgery time. This surgery is always done by the residents, and we just hold their hands. In general, this technique has provided a minimum of recurrence. I have a historical control of a large group of patients that we have operated on with the technique described at the Mayo Clinic, so comparing that technique, which is a historical reference, with this one here, I find a great deal of difference. Even though there are a number of techniques at the present time to operate on varicose veins, for these complex types of veins, this is the technique of choice. Thank you very much. O N THE MOVE? Send us your new address at least six weeks ahead Don t miss a single issue of the journal! To ensure prompt service when you change your address, please photocopy and complete the form below. Please send your change of address notification at least six weeks before your move to ensure continued service. We regret we cannot guarantee replacement of issues missed due to late notification. JOURNAL TITLE: Fill in the title of the journal here. OLD ADDRESS: Affix the address label from a recent issue of the journal here. NEW ADDRESS: Clearly print your new address here. Name Address City/State/ZIP COPY AND MAIL THIS FORM TO: OR FAX TO: OR PHONE: Mosby Subscription Customer Service Outside the US, call 6277 Sea Harbor Dr Orlando, FL, 32887