I read with interest the article by Mendes and colleagues (J Vasc Surg 2003;38:891-5) because it provides an important contribution to an intriguing and controversial dilemma of venous surgery. They demonstrated, in the presence of normal deep veins, a significant clinical and hemodynamic improvement after correction of superficial insufficiency, without any perforator treatment. To the contrary, it has been demonstrated that ablative surgery of the perforating veins can significantly reduce the venous drainage of the leg. Illig1 unintentionally demonstrated this by means of photoplethysmography after subfascial endoscopic perforators surgical ablation procedures. Personally, I agree completely with the observation of Mendes et al, but my interpretation of such result is far from the speculations reported in their discussion. Basically, the study of Mendes measures a correct surgical application of the Perthes test, in which, by eliminating superficial reflux, the blood flows downward and therefore inward to the competent deep veins through the perforators. In such cases, we commonly observe bidirectional flow in the Cockett or other distal perforators at the time of preoperative duplex evaluation, but always with inward flow during muscular diastole. Surprisingly, this finding is considered pathologic by many investigators, despite the “net profit” proven both by the Perthes test and electromagnetic flowmetry. In my opinion, it is incorrect to consider insufficient those perforator veins that exhibit bidirectional flow without a critical evaluation of their hemodynamic significance in the context of an insufficient saphenous system. No distinction is made between perforating veins with regard to the flow direction during calf muscular contraction or relaxation. Coleridge Smith has reported that bidirectional flow is commonly found in the distal perforators of normal subjects and therefore cannot be considered diagnostic of insufficiency. The current criteria for duplex diagnosis of perforator incompetence are poorly defined, creating many limitations both in investigation and in treatment. Perforator vessels in certain limbs are useful for drainage and cannot simply be considered pathologic perforating veins. Careful assessment by color Doppler scan of inward flow during muscular diastole could correctly identify the perforators to disconnect and those to save because, as we should not forget, the aim of surgery in patients with chronic venous insufficiency is to improve venous emptying, not just to indiscriminately remove veins!

Regarding: Treatment of superficial and perforator venous incompetence without deep venous insufficiency: is routine perforator ligation necessary?

ZAMBONI, Paolo
2004

Abstract

I read with interest the article by Mendes and colleagues (J Vasc Surg 2003;38:891-5) because it provides an important contribution to an intriguing and controversial dilemma of venous surgery. They demonstrated, in the presence of normal deep veins, a significant clinical and hemodynamic improvement after correction of superficial insufficiency, without any perforator treatment. To the contrary, it has been demonstrated that ablative surgery of the perforating veins can significantly reduce the venous drainage of the leg. Illig1 unintentionally demonstrated this by means of photoplethysmography after subfascial endoscopic perforators surgical ablation procedures. Personally, I agree completely with the observation of Mendes et al, but my interpretation of such result is far from the speculations reported in their discussion. Basically, the study of Mendes measures a correct surgical application of the Perthes test, in which, by eliminating superficial reflux, the blood flows downward and therefore inward to the competent deep veins through the perforators. In such cases, we commonly observe bidirectional flow in the Cockett or other distal perforators at the time of preoperative duplex evaluation, but always with inward flow during muscular diastole. Surprisingly, this finding is considered pathologic by many investigators, despite the “net profit” proven both by the Perthes test and electromagnetic flowmetry. In my opinion, it is incorrect to consider insufficient those perforator veins that exhibit bidirectional flow without a critical evaluation of their hemodynamic significance in the context of an insufficient saphenous system. No distinction is made between perforating veins with regard to the flow direction during calf muscular contraction or relaxation. Coleridge Smith has reported that bidirectional flow is commonly found in the distal perforators of normal subjects and therefore cannot be considered diagnostic of insufficiency. The current criteria for duplex diagnosis of perforator incompetence are poorly defined, creating many limitations both in investigation and in treatment. Perforator vessels in certain limbs are useful for drainage and cannot simply be considered pathologic perforating veins. Careful assessment by color Doppler scan of inward flow during muscular diastole could correctly identify the perforators to disconnect and those to save because, as we should not forget, the aim of surgery in patients with chronic venous insufficiency is to improve venous emptying, not just to indiscriminately remove veins!
2004
Zamboni, Paolo
File in questo prodotto:
Non ci sono file associati a questo prodotto.

I documenti in SFERA sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.

Utilizza questo identificativo per citare o creare un link a questo documento: https://hdl.handle.net/11392/1211155
 Attenzione

Attenzione! I dati visualizzati non sono stati sottoposti a validazione da parte dell'ateneo

Citazioni
  • ???jsp.display-item.citation.pmc??? ND
  • Scopus 0
  • ???jsp.display-item.citation.isi??? 1
social impact