CASE REPORTS LEG ULCERATION ASSOCIATED WITH INCOMPETENCE OF THE GASTROCNEMIUS VEIN A CASE REPORT MARIAN SIMKA

Transcription

1 POLSKI PRZEGLĄD CHIRURGICZNY 2008, 80, 4, /v CASE REPORTS LEG ULCERATION ASSOCIATED WITH INCOMPETENCE OF THE GASTROCNEMIUS VEIN A CASE REPORT MARIAN SIMKA Out-patient Department of Angiology, Private Medical Institution Sana in Pszczyna Kierownik Zakładu: lek. A. Simka This paper presents a case of the patient with leg ulcers resulting from incompetence of the gastrocnemius vein with refluxing variety referred to as the enigma of the gastrocnemius vein. The operation consisted of the selected ligature of incompetent perforator joining the gastrocnemius vein and the small saphenous vein. After the operation ulcers healed and reflux in the system of the gastrocnemius vein disappeared. Surgical tactics of operations for varicose veins accompanied by incompetence of the gastrocnemius vein is also discussed. Key words: chronic venous insufficiency, gastrocnemius vein, leg ulcers Varicose veins situated on the posterior aspect of a leg result predominantly from the incompetence of the small saphenous vein. However, a relatively frequent pathology is also an incompetence of the gastrocnemius vein (1, 2, 3). Yet, the actual prevalence of varicose veins associated with the incompetence of this vein remains unknown because very few surgeons perform ultrasonic examination prior to surgery for varicose veins, and the reflux in the gastrocnemius vein is assessed even less frequently. It is possible that the incompetence of the gastrocnemius vein is far more common than is suspected. Misdiagnosis of this pathology results in a high frequency of recurrence of varicose veins in the small saphenous vein because surgical management of patients with coexisting incompetence of the gastrocnemius vein should completely differ from that performed for a simple, small saphenous vein incompetence (4, 5, 6). Due to the specific hemodynamics of this anatomical variety of varicose vein (venous reflux transmits the pressure directly from intramuscular veins to the skin), incompetence of the gastrocnemius vein is likely accompanied by an enormously high ambulatory venous hypertension, although this hypothesis has not yet been proven. Nevertheless, a high frequency of this pathology should be expected in a group of patients with non-healing venous ulcers that are localized in the posterior and lateral aspects of the leg. CASE REPORT A 49-year-old male patient with an 8-month history of two ulcers localized at the posterior and medial aspect of left leg (fig. 1) was exami- Fig. 1. Leg ulcers. The localization of incompetent perforator joining the the gastrocnemius vein with the small saphenous vein is marked with the arrow

2 218 M. Simka ned. The diameters of the ulcers were 5 and 3 cm, respectively. There was a history of deep venous thrombosis and several recurrences of leg ulcerations. Coexisting pathologies included arterial hypertension and epilepsy. A typical compression therapy with lowstretch bandages and local treatment with hydrocolloid dressings (Comfeel ) and tulle gras dressings (Bactigras ) were carried out for 2 months. An improvement of the ulcers, however, was not achieved. On the contrary, a new ulcer with a 1 cm diameter developed. Ultrasonic color-doppler examination revealed that the only pathology in the superficial venous system was of the refluxing variety, which has been previously described by Hobbs (7), referred to as the enigma of the gastrocnemius vein. In this variety, the reflux originates in the incompetent gastrocnemius vein and enters the distal part of the small saphenous vein via a wide incompetent perforator (fig. 2). In this patient, there were separate junctions of the small saphenous vein and the gastrocnemius vein with the popliteal vein (fig. 3), a pathological reflux in the gastrocnemius vein, physiological flow in the proximal part of the small saphenous vein, an incompetent perforator that joined the gastrocnemius vein with the small saphenous vein, and pathological reflux in the small saphenous vein distally from this perforator. The patient was referred for surgical treatment. The operation consisted of a selected ligature of the incompetent perforator (5, 8). A quick healing of the ulcers was observed after the surgery. The ulcers, with the exception of one several-millimeter-wide wound, healed within 4 weeks. The patient was managed with compression therapy and hydrocolloid (Comfeel ) and povidone iodine (Inadine ) dressings. Ulcers healed completely 9 weeks after the surgery. Two months later, a new 1 cm diameter ulcer localized at the posterior aspect of the leg developed. Ultrasonic examination revealed dilated incompetent veins at the lateral aspect of the leg in the suprafascial compartment (R3 system, shunt type 6 according to the Tempitz classification) (9). These veins were not found prior to the operation. Physiological flow in the proximal part of the small saphenous vein and in the gastrocnemius vein in the absence of pathological refluxes or improper dilations of these veins was also revealed. There was an outflow from the distal part of the small saphenous vein through the competent perforator localized distally from the site of previous operation (fig. 6). Varicose veins were obliterated with 1% sodium tetradecyl sulphate (Fibrovein ) foamed with the Tessari method (10, 11, 12). The ulcer healed after two months. It was recommended that the patient wear under-the-knee, class 2 compression stockings. There was no further recurrence of ulcers during 6 months of follow-up. Fig. 2. Described by Hobbs the enigma of the gastrocnemius vein Fig. 3. Sonographic picture of junction of the gastrocnemius vein with the popliteal vein. Small saphenous vein joins the popliteal vein more proximally

3 Leg ulceration associated with incompetence of the gastrocnemius vein a case report 219 Fig. 4. Sonographic picture of incompetent perforator joining the the gastrocnemius vein with the small saphenous vein P perforator, VG vena gastrocnemia, VSP vena saphena Fig. 5. Sonographic picture of incompetent gastrocnemius vein (transverse section) Fig. 6. Sonographic picture 4.5 months after the operation. Distal part of small saphenous vein with a perforator that drains this vein to the deep venous system. The place of previous ligature of the perforator is marked with arrow VSP vena saphena DISCUSSION The gastrocnemius vein can be an initial source of pathological reflux and also of venous thrombosis. Current literature, however, very rarely deals with anatomy and pathophysiology of this vein (3-6). Consequently, this vein is infrequently assessed by ultrasonic examination, and this leads to improper tactics during the operative treatment for varicose veins that are accompanied with an incompetence of the gastrocnemius vein. Sometimes, in a patient with an incompetent gastrocnemius vein, varicose veins are not visible and the only clinical signs are pain and discomfort in the calf in an upright position. In such cases, only precise ultrasonic examination can uncover the exact cause of patient s complaints. Leg ulcers resulting from the incompetence of the gastrocnemius vein usually require surgical treatment, as compression therapy alone cannot manage venous hypertension. An incompetent gastrocnemius vein can be connected with the small saphenous vein and also with deep veins lying under the triceps muscle of the calf. There are two anatomical variants of the connection of the gastrocnemius vein with the popliteal vein, separate junctions of the gastrocnemius vein and the small saphenous vein with the popliteal vein, and a less frequently seen variety with a short common venous trunk. As far as hemodynamic features are concerned, several types of reflux exist. There can be

4 220 M. Simka an incompetence of the gastrocnemius vein coexisting with incompetent small saphenous vein, and varicose veins with isolated incompetence of the gastrocnemius vein. Of course, coexisting incompetence in the territory of the great saphenous vein is also possible (1-5, 13). Re-entry points can be localized exclusively in the gastrocnemius vein system, or there could be an additional perforator connected to incompetent small saphenous vein (fig. 7 and 8). The enigma of the gastrocnemius vein is a unique type of reflux (fig. 2) (5). Precise ultrasonic examination prior to surgery is a must, and the surgical strategy should depend on anatomical and hemodynamic relationships of the veins (4,8). Of course, an incompetent gastrocnemius vein cannot be excised and should be managed hemodynamically (similarly to the CHIVA surgery) (5, 14). Surgical intervention in these patients should be as non-invasive as possible, and a wide incision in the popliteal fossa should be avoided because of very bad postoperative cosmetic results. Limited ligatures of the veins according to the type of venous reflux should be the principle of surgical treatment. As a consequence of the operation, recirculation of blood and venous ambulatory hypertension should disappear. Dissection of the vessels in popliteal fossa is required only in two of the reflux types with a common junction. In the first one (the variety with two re-entry points), the proximal small saphenous vein should be disconnected from the popliteal vein, and the perforator joining the small saphenous vein with the gastrocnemius vein should additionally be ligated (fig. 9). In the second variety (reflux only in the gastrocnemius vein), the proximal part of the gastrocnemius vein should be cut off (fig.10). Other patients, including those with Fig. 7. Types of reflux in the system of the gastrocnemius vein. Anatomical variety with common junction with the popliteal vein Fig. 8. Types of reflux in the system of the gastrocnemius vein. Anatomical variety with separate junctions with the popliteal vein Fig. 9. Plan of the operation in a patient with common junction and two re-entry points Fig. 10. Plan of the operation in a patient with common junction and isolated reflux in the gastrocnemius vein

5 Leg ulceration associated with incompetence of the gastrocnemius vein a case report 221 the enigma of the gastrocnemius vein, should be managed with a simple ligature of the perforator joining the small saphenous vein with the gastrocnemius vein (5). In these cases, sclerotherapy of this incompetent perforator could be an alternative method to the surgical treatment. However, there is a relatively high risk of post-sclerotherapy thrombosis of the gastrocnemius vein. Therefore, prophylactic administration of low-molecular-weight heparins after the sclerotherapy seems to be unavoidable in these patients. REFERENCES 1. Aragão JA, Reis FP, Pitta GB et al.: Anatomical study of the gastrocnemius venous network and proposal for a classification of the veins. Eur J Vasc Endovasc Surg 2006; 31: Aragão JA, Reis FP, Poli de Figueiredo LF et al.: Anatomia das veias e troncos gastrocnemios em cadáveres humanos adultos. J Vasc Br 2004; 3: Urigo F, Pischedda A, Mocci M et al.: Incompetence of the m. gemellus veins in varicose veins: its incidence and phlebographic study. Radiol Med (Torino) 1992; 84: Juhan C, Barthélémy P, Alimi Y et al.: Prevalence of gastrocnemius vein insufficiency using color-coded Doppler ultrasound (modifications of the therapeutic strategy). Bull Acad Natl Med 1993; 177: Simka M, Palma de M: Operacje hemodynamiczne w leczeniu żylaków kończyn dolnych. Przegl Flebol 2007; 15: Juhan C, Barthélémy P, Alimi Y et al.: Récidives après chirurgie des veines jumelles. J Mal Vasc 1997; 22: Hobbs JT: The enigma of the gastrocnemius vein. Phlebology 1988; 3: Palma de M, Carandina S, Zamboni P: Surgical resolution of the enigma of the gastrocnemius vein (abstract). Phlebology 2006; 21: Simka M: Anatomia i patofizjologia refluksu żylnego u chorych z żylakami kończyn dolnych. Przegl Flebol 2006; 14: Bergan J, Pascarella L, Mekenas L: Venous disorders: treatment with sclerosant foam. J Cardiovasc Surg 2006; 47: Cabrera J, Redondo P, Becerra A et al.: Ultrasound-guided injection of polidocanol microfoam in the management of venous leg ulcers. Arch Dermatol 2004; 140: Whiddon LL: The treatment of venous ulcers of the lower extremities. Proc Bayl Univ Med Cent 2007; 20: Caggiati A, Bergan J, Gloviczki P et al.: Nomenclature of the veins of the lower limbs: An international interdisciplinary consensus statement. J Vasc Surg 2002: 36: Juan J, Escribano JM, Criado E i wsp: Haemodynamic surgery for varicose veins: surgical strategy. Phlebology 2005; 20: Received: r. Adress correspondence: Pszczyna, ul. Wodzisławska 89 COMMENTARY I read with great interest the publication describing how calf muscle venous insufficiency can be responsible for the poor healing of lower limb ulcerations. The problem mentioned by the Authors is rarely presented, even by phlebological specialists. The reason for this might be related to diagnostic difficulties, as well as the fact that the eventual pathology is not taken into consideration. As a formality I would like to remind all readers that there are four calf muscle veins, two medial and two lateral, which drain the medial and lateral head of the muscle. Normally, these veins are abundant in valves. Calf muscle veins branch off at the level of the popliteal vein. In the days when ultrasonography was not available, phlebography through direct injection of the popliteal vein was the only method enabling the visualization of these venous pathologies. Treatment of calf muscle venous insufficiency is not easy since it requires good knowledge of the anatomical conditions of the popliteal fossa. It seems that the only ideal method of treating this pathology is the embolization of the insufficient venous segment or connecting perforator under fluoroscopic control. This procedure requires good radiological equipment and a physician experienced in endovascular procedures. The Author should be congratulated on their elegant presentation of this interesting clinical case. Prof. dr hab. Zbigniew Rybak Katedra i Klinika Chirurgii Ogólnej, Naczyniowej i Transplantacyjnej AM we Wrocławiu