Journal of Experimental Medical & Surgical Research Cercetãri Experimentale & Medico-Chirurgicale Year XVII Nr.2/2010 Pag. 81-86 JOURNAL Experimental Medical of Surgical R E S E A R C H THE RESULTS OF THE SURGICAL TREATMENT OF SUPERFICIAL VENOUS THROMBOSIS J. Avram 1, F. Cãdariu 1, M. Pasztori 1, S. Manciu 1, M. Avram 1, I. Avram 1 Received for publication: 03.03.2010 Revised: 14.05.2010 Summary: The thrombosis of the great saphenous vein (GSV) and its crossa is a frequent complication of neglected varicose disease reported to the surgical patients. The thrombosis may be located at the collateral varicose veins, at the trunk of the GSV or also at the trunk associated with the crossa of the GSV. The pulmonary embolia is possible in some situations: thrombosis extended to deep veins, after sclerotherapy or at operated cases. In the First Clinic of Surgery Timisoara, we followed 138 cases with GSV thrombosis in the period 01.01.2000-31.06.2009. In cases with extended venous thrombosis we applied initially NSAI and anticoagulant treatment with heparin or LMWH and continued with surgical treatment as a delayed emergency and we performed a short saphenectomy and phlebectomies (44 cases), crossectomy with varicous thrombectomies (79 cases - in 2 case bilateral crosectomy), femoral-iliac thrombectomy (5 cases) and 5 non-operated. Postoperative we continued the anticoagulant treatment for 3 months with oral anticoagulant drugs at the patients with deep venous thrombosis respectively aspirin 100 mg/day, anti-inflammatory and phlebotonic treatment in cases with superficial thrombophlebitis. The postoperative recovery was good in 131 cases; the only signifficant complications were two non-lethal pulmonary embolia, for which the patients were transferred to the cardiology unit. The postoperative follow-up exam (at 3 to 24 month, mean 14 month) showed good results, without relapse of disease, edema or any complaints from the patients. The 2 non-operated cases were patients with digestive malignancies and saphena magna thrombosis extended to femural and iliac vein with late presentation to surgeon. Surgical treatment of extensive GSV thrombosis is needed as a delayed emergency and consists in high ligature of the crossa and thrombectomy. Stripping or phlebectomies are electively indicated, depending on the patients condition. Pulmonary embolia is a possible complication after superficial thrombophlebitis operated. Key Words: superficial venous thrombosis, DVT, pulmonary embolia, phlebectomy 1. - First Surgical Clinic, Univesity of Medicine and Pharmacy "Victor Babeº" Timiºoara BACKGROUND Thrombosis in the superficial varicous or nonvaricous veins may develop with or without known etiologic factors. The superficial venous thrombosis (SVT) was considered a benign disease with good evolution spontaneously or under treatment. But the risk of major complications as deep venous thrombosis (DVT) or pulmonary embolia (PE) is present. The compression ultrasonography (CUS) can easily visualize the presence of DVT associated or secondary to SVT. Therefore the high risk of PE is present. The SVT, mainly the extensive form, is now evaluated as a complex medical issue and is integrated in the venous thromboembolism (VTE) (1.). Correspondence to: The management of the SVT must be re-evaluated. The SVT is a complex condition, considered a syndrome rather than a disease, because it has a multitude of etiologies. The management of patients with SVT is controversial, especially regarding the usefulness of surgery, the timing and duration of anticoagulation and the best treatment methods. The guidelines are incomplete in recommendations. The NSVT group is complex and heterogeneous but venous parietal inflammation or hypercoagulability are present, in different proportions more or less important. In a prospective analysis of risk factors for NSVT Gillet (2004) revealed neoplasia in 4.8 % of cases, systemic disease in 9.5 %, and thrombophilia in 48 % of cases out I. Avram (iavram@yahoo.com), str. Toplita 2a, 300012 Timisoara, Romania 81
Tab. 1. The etiologic classification of SVT Varicose (VSVT): Primary: varicose disease, Secondary: varicose disease associated with other trigger factors Non-varicose SVT (NSVT): Primary: Mondor disease Secondary: thrombophilia, paraneoplastic syndrome, physical or chemical iatrogenous trauma, infection. 5 cases 10 cases 79 cases 44 cases saphenectomy + phlebectomies crossectomy + thrombectomy ilio-femoral thrombectomy non-operated Fig. 1. Treatment of extended SVT in the First Surgical Clinic Timisoara. of a total of 42 patients. The SVT is important because its incidence increased over the last 20 years, possibly due to the rising presence of hormones in environment and nutrition, or due to the higher incidence of cancer, obesity and thrombophilia (2.). SVT progresses through perforans veins and the sapheno femoral or sapheno popliteal junction and may involve the adjacent deep veins. Superficial phlebitis may be accompanied by occult deep vein thrombosis in non-contiguous veins in the same leg or even in the controlateral leg due to hypercoagulable states producing thrombosis simultaneously at multiple sites in both superficial and deep venous systems. Recurrence of SVT is up to 15%. Bilancini S. (3.) considered several clinical forms of SVT as follows: centrifugal SVT centripetal SVT perforans thrombosis plus SVT ( shirt buttons ) ascendant SVT: GSV /LSV trunk up to SFJ / SPJ localised junction thrombosis LSV thrombosis axillary SVT In the varicous veins by action of synergic factors the local thrombosis can extend progressively or creeping jumping from collaterals to the GSV trunk. Then the thrombus can obstruct the SFJ, SPJ or incompetent perforans veins. The risks of PE increases when the developing of thrombus involves the junction, perforans, and femoral, popliteal or iliac veins and practically it has the evolution of a DVT. Later, neglected DVT and SVT can lead to chronic venous insufficiency (CVI). The SVT can extend to the deep venous system through perforans veins in 30% of cases or through junction in 22.5% of cases. Association of SVT and PE is present in 5.4% of cases. PE is present in 47.3%cases of DVT without SVT and in 52.6% of cases of DVT associated with SVT. The true real incidence of deep veins system involvement in clinically isolated SVT is not known, published data estimate it from 7% to 57% (4.) MATERIAL AND METHOD Our study included 138 cases with SVT which were treated in the Phlebology Department of the First Surgical Clinic, University of Medicine and Pharmacy Timisoara between 01.01.2000 and 31.06.2009. The topography of SVT was as follows: calf limited in 42 patients, 59 patients had thrombosis extended to thigh, 32 patients had thrombosis of the crossa extended to the femoral vein, and 5 cases had femoral thrombosis extended to the iliac vein. We applied initially NSAI and anticoagulant treatment with heparin or LMWH and continued with surgical treatment as a delayed emergency. We performed a short saphenectomy and phlebectomies (44 cases), 82
Fig. 2 a, b. Ultrasound examination and intraoperative aspect: high SVT with thrombosis 1 cm proximal to the of the GSV junction. crossectomy with varicous thrombectomies (79 cases - in 2 case bilateral crosectomy), femoral-iliac thrombectomy (5 cases) and 5 non-operated (Fig. 1.). Patients were referred to our department by their general practicioner or were admitted directly through the emergency department. The selection of the hospitalized patients was performed by a surgeon from the phlebology department. We performed compression ultrasound (CUS) to all patients, the standard laboratory investigations, chest x-ray, EKG, and then we ordered special investigations for thrombophilia, neoplasia, chronic diseases, cardiac ultrasound examination, pulmonary CT-scan or pulmonary scintigraphy (Fig. 2.). The time interval from thrombosis onset to admission in surgery clinic was variable: 2-4 weeks for limited forms 1-4 weeks for femoral extended forms 3-10 days for junctions thrombosis 3 21 days for ilio-femoral thrombosis In the last year we performed in the Phlebology department by day surgery 14 phlebectomies and / or venous puncture and thrombus extractions. In the VSVT group we diagnosed associated neoplasia in 3 patients: rectal, uterine and renal cancer. RESULTS: The operations were performed without important incidents. The postoperative recovery was good with 2 local minor hematoma (1.4 %). When Fogarty thrombectomy was associated with stripping we registered 2 nonlethal pulmonary embolia on day 5-14 after surgery during therapy with LMWH. The postoperative follow up exam at 3 24 months, with mean 14 months registered good results, no relapse, and reduced edema and no subjective complaints. The distal great saphena remained obliterated distally. The mortality was 0%. DISCUSSIONS: In Romania the vascular surgeons or the general surgeons treat the VSVT, because angiology or phlebology is not recognized as a distinct medical specialty. The NVSVT are investigated by internists, haematologists, surgeons, dermatologists and in these cases the treatment is non-surgical. In our Phlebology Department we treated SVT as day-cases or inpatient hospitalization. In the limited forms of SVT the treatment is as follows: anti-inflammatory drugs (oral and local); ointments with hyaluronidase, MPS (mucopolysaccharide polysulfate); liposomal heparin spray; LMWH were not recommended? surgical treatment transcutaneous thrombectomy; elastic stockings. In extended VSVT we performed surgical crossectomy and excision of the proximal 5-10 cm of the GSV and phlebectomies as a delayed emergency. We do not performed stripping in the extensive VSVT because of the high risks of PE. P. Poredos (2010) considered that there is no preferential treatment of SVT because there is lack of evidence-based data; the choice of therapy is influenced by symptoms and by the evolution of the disease, patient s preference, cost, available medical resources and insurance reimbursement (5.). We can add to these factors the experience and preference of the treating doctor and the system of hospitalization. 83
CONCLUSIONS: The prophylaxis of VSVT is the early treatment of varicose disease. The VSVT is a common complication of the non-operated varicose disease. Both VSVT and NSVT require mandatory CUS investigation and the search for the risk trigger factors. The NSAI drugs, the local heparinoid ointment and the anticoagulants are used in both varicose and non-varicose SVT. The major surgical procedures as crossectomy and proximal saphenectomy / stripping and extraction of the thrombus from the junction are useful in VSVT management. The minor surgical procedures as distal phlebectomies, puncture and thrombus extraction are also useful for an effective management of the disease. In VSVT involving only the superficial veins the surgical results are very good. In the thrombectomy with Fogarthy catheter through the junction from the femoral and iliac vein there is a high risk of PE. The anticoagulant therapy is mandatory for 3 weeks 3/6 months after surgery. We consider that the VSVT (DSS) has a surgical solution and anti-inflammatory or anticoagulant solution. The NVSVT is a medical disease and anticoagulation is mandatory in association with the specific treatment. b a c d e Fig. 3. Extended SVT with thrombosis of the GSV junction. a. - preoperative aspect; b., c. - intraoperative aspect - thrombosed crossa, d., e. - excisev GSV 84
a. b. c. d. e. f. Fig. 4. M.N., male, 37 years; extended SVT a. - preoperative aspect b. - postoperative aspect at 3 weeks c. - preopeartive ultrasound examination, complete thrombosis of the GSV d., e., f. - intraoperative aspects: thrombosed SFJ, thrombectomy and partial excision of the prosimal GSV. 85
a. b. c. d. e. f. Fig. 5. G.S., female, 73 years; neglected varicose disease with extended SVT a. - preoperative aspect b. - postoperative aspect at 2 weeks c. - preopeartive ultrasound examination, thrombosis of the GSV d., e., f. - intraoperative aspects: thrombosis of the GSV up to 1 cm from the SFJ, thrombectomy and partial excision of the proximal GSV. References: 1. J.Avram, Simona Manciu, Mihaela Pasztori et al. - EXTENSIVE SAPHENA MAGNA VEIN THROMBOSIS. Cercetãri Experimentale & Medico-Chirurgicale, year XIII, nr. 1/2006, p. 18-21 2. Gillet JL, Allaert FA, Perrin M. - Superficial thrombophlebitis in non varicose veins of the lower limbs. A prospective analysis in 42 patients. J Mal Vasc. 2004; 29(5): 263-272. 3. Bilancini S, Lucchi M - Les Thromboses Veineuses Superficielles sont-elles polymorphes? Phlebologie, 1999, 52:41-43 4. Kalodiki E, Nicolaides AN. - Superficial thrombophlebitis and low-molecular-weight heparins. Angiology. 2002;53:659-63. 5. P. Poredos - Superficial thrombophlebitis what it is and how to manage. VII th CEVF Congress, Timisoara, may 2010. 86