Ischemie dolních končetin jako komplikace operace křečových žil – přehled literatury

Overview

Objectives: Each surgeon is concerned about the potential for periprocedural injury. While severe complications during varicose vein surgery are uncommon, they can have significant consequences, including prolonged disability or even mortality. This paper presents a review of the literature on ischaemic complications following varicose vein procedures.

Method: Review of literature data available in online database (PubMed, Medline, 1970–2021).

Results: A total of 33 cases of severe ischaemia were identified following the procedure of great saphenous vein ligation and stripping, with a minimum of 100 cases observed following the sclerotherapy. These were primarily attributable to peripheral embolization or thrombosis, and 16 cases of brain ischaemia were documented following sclero­therapy. No mortality was reported, and 22 amputations were documented in the open surgery cohort, compared to no mortality deaths and 56 amputations in the sclerotherapy group.

Conclusion: In order to prevent ischaemic injury during a lower limb varicose vein procedure, it is essential that the surgeon has provided a comprehensive preoperative examination, has a detailed understanding of the anatomy, has gained significant experience in performing the procedure, and has developed the requisite surgical skills. In the event that an injury does occur, it is of the utmost importance that the repair procedure is carried out by an experienced vascular surgeon, as the time is crucial in such cases.

Keywords:

sclerotherapy – ischaemia – complication – varicose vein – vein stripping

Introduction

Lower limb varicose vein surgery is an elective procedure. The majority of patients present with mild symptoms, or the indication for surgery is purely cosmetic [1]. Consequently, any complications are perceived as highly unfavourable outcomes [2]. These operations are less technically demanding and carried a lower risk of complications [3]. Consequently, it is frequently performed by surgical trainees. The procedure of ligation and stripping of the great saphenous vein is associated with a relatively low incidence of complications. The overall risk is stated as 17%, with a risk of major complication of 0.8%. However, serious complications can result in tragic and lifelong consequences. One such complication is limb or tissue ischaemia [1,4–6]. No relevant statistical data is available. It is not possible to provide an exact figure for the incidence of ischaemic complications following variceal surgery. Based on the statements of various authors, the estimated incidence is less than 0.06% [6]. Another option for the treatment of lower limb varices is sclero­therapy. The underlying principle is well established, and the procedure is relatively straightforward, with minimal time commitment and cost. Furthermore, general anaesthesia is not required. This has resulted in an increase in the number of outpatient procedures being carried out. Nevertheless, sclerotherapy has the potential to result in significant complications [3,7–9]. One of the most harmful complications is tissue, organ or limb ischaemia. This is caused by the occlusion of arteries with the sclerosing agent, either by direct injection or embolism [3,4]. The incidence of this type of complication following sclerotherapy is reportedly higher than that observed after great saphenous vein stripping, with an estimated prevalence of 0.25% [3,4,10]. It is essential to possess an understanding of these consequences and the underlying mechanisms to prevent them, recognise their symptoms and administer appropriate treatment [5,11,12]. Otherwise, the morbidity rate is high (85% for great saphenous vein stripping vs. 95% for sclerotherapy) and the amputation rate is also elevated (34 vs. 45%) [3,6,13]. There have been no reported deaths due to this type of complication in either group.

Method

The data were collected from the available literature. A ­search was conducted on PubMed and Medline for full-text articles published in English or German between 1970 and 2021 using the key words varicose vein, surgery, vein stripping, sclerotherapy, complication, ischaemia, defect, and injury. From these, only papers identifying ischaemic complications and/or soft tissue defects and loss as a consequence of varicose vein surgery were selected for further analysis. The collected data were analysed, but no statistical analysis was conducted due to the heterogenous and incomplete nature of the data.

Results

The results of the study demonstrated that the majority of articles describing ischaemic complications after varicose vein surgery were case reports, publications describing single-centre experiences, and a few review articles.

The incidence of severe ischaemic complications in the single-centre experiences and review articles was found to be comparable and relatively low, with a rate below 0.25%. Following great saphenous vein stripping, the incidence is 0.06%, while after sclerotherapy, it is up to 0.3% [3,4,6]. Up to 33 cases of ischaemic complications following great saphenous vein stripping were published (Tab. 1), and over 100 cases following sclerotherapy (limb ischaemia, stroke or TIA, and cardiac; Tab. 2). The morbidity rate was high in both groups, with 85% of patients in the great saphenous vein stripping group and 95% of patients in the sclerotherapy group experiencing complications. The necessity of minor amputation or necrectomy was less prevalent in the great saphenous vein stripping group, as was major amputation (34 vs. 45%) [3,6,13].

A delay in the diagnosis of the ischaemia was frequently observed [6,14,15]. It is noteworthy that none of the complications associated with great saphenous vein stripping resulted in mortality. In the sclerotherapy group, there were no fatalities associated with the inadvertent intra-arterial application of the agent.

The majority of ischaemic complications following great saphenous vein stripping exhibited notable similarities. The young, non-obese woman was most frequently affected in terms of demographics [6,16]. These women exhibited no evidence of atherosclerotic lesions. The anatomical variety, whereby the superficial femoral artery crosses the veins, was not the cause of the erroneous interpretation of the anatomical structures in the groin. The artery was erroneously identified as a vein. It is possible that the pulses were weakened as a result of vasoconstriction. The prognosis was more favourable in cases where the injury involved a transection or ligation of the artery, provided that this was promptly identified and corrected by reanastomosis or interposition with a Dacron or venous grafts [4,11,17]. These patients exhibited uncomplicated recovery. Patients who underwent inadvertent stripping of the superficial femoral artery or either the popliteal or crural artery experienced a significantly poorer outcome, accompanied by severe limb ischaemia (Fig. 1). This type of injury necessitated a complex bypass procedure, utilising either a venous or, most frequently, a composite graft (vein + Dacron), with a vein harvested from the contralateral leg or upper extremity. The position of the distal anastomosis was determined on a case-by-case basis. Occlusions and re-do surgery were not uncommon [1,18,19]. The incidence of limb loss was 34% [6,19]. The prognosis for patients with such injuries is dependent on the duration of ischaemia. It is regret­table that the symptoms of severe ischaemia were frequently identified with a delay, in some cases after several days. This resulted in the development of compartment syndrome and severe motor and neurological deficits, which persisted permanently. The most unfavourable outcome was observed when incorrect stripping of the great saphenous vein was combined with the inappropriate intra-arterial application of sclerotherapy [18].

Another mechanism of arterial injury during the great saphenous vein ligation was the blind placement of ligations and sutures to stop bleeding in the groin during preparation. In the majority of cases, such errors were identified and rectified at an early stage, frequently during the initial procedure [17]. These errors were not exclusive to less experienced surgeons; even those with considerable expertise were susceptible to making similar mistakes [11,14,19].

The underlying causes of tissue, organ, or limb ischaemia following sclerotherapy are evident. This is a conse­quence of the occlusion of an artery with the sclerosing agent, which is then followed by vasoconstriction and thrombosis [3,7,8]. Such occurrences may result from the application of the agent in an incorrect manner, directly into the arterial system. An alternative pathway is the embolisation of the agent through preformed arteriovenous fistulas and connections, or the systemic embolisation to the brain or coronary arteries when a foramen ovale is patent or there is another intracardial defect [13,20,21]. This pathway is challenging to predict and prevent. The sole potential method of prevention is echocardiography, which is advised for patients exhibiting a right-to-left intracardial shunt. It is contraindicated to perform sclerotherapy on a patient with severe pulmonary hypertension [22]. The utilisation of ultrasound guidance for the administration and monitoring of the procedure may prove an effective method of preventing the intra-arterial injection [8,23]. In the majority of patients, the recovery from a systemic embolisation (transient ischaemic attack, stroke, myocardial ischaemia) was uncomplicated and complete restitution of the symptoms was achieved [8,20,24,25]. The remaining ischaemic events, irrespective of the administered substance, had a more deleterious outcome, necessitating a necrectomy, minor amputation, or amputation of the affected extremity [3,10,12,26,27]. The treatment modalities included hyperbaroxic oxygen therapy, vasodilating therapy, intra-arterial thrombolysis, and thrombembolectomy. Asubstantial number of papers have been published on the complications of sclerotherapy. A comparison of the various forms and sclerosing agents reveals no statistical inferiority with regard to the incidence of ischaemic events. How­ever, foam sclerotherapy appears to exhibit a slightly higher incidence of transient vision disorders [3,8,22–24,27,28]. In recent decades, alternative methods have emerged for varicose vein surgery, employing high temperatures for the destruction of the main superficial veins in the limbs. These are known as endovenous methods. The requisite temperature is generated by dedicated laser catheters or catheters for radiofrequency ablation. These catheters may be utilised as a standalone intervention or in conjunction with sclerotherapy. As described in the literature, it can be stated that these less invasive methods do not result in ischaemia [22,29,30].

A tight compressive bandage may also be a rare cause of limb ischaemia or compartment syndrome, particularly in cases of significant oedema or haematoma formation [4,31].

Discussion

The published data do not provide precise figures or the incidence rate of ischaemic events following lower limb varicose vein surgery. Such estimates can be derived from published case reports, small series, single-centre experiences, and reviews, which are inherently limited in scope. It is evident that this report, as well as previous reviews, is influenced by a certain degree of bias. It is not always possible to identify all events or patients clearly in the literature, which introduces the possibility that some may be included in reviews on more than one occasion. It must be noted that the incidence, mortality, and morbidity rate or risk ratio stated in this article are only estimated values.

Some of the more severe complications have never been published, due to the evident reasons for doing so. There are only a few special registries in existence, and participation is voluntary. The published data are incomplete, with a paucity of information regarding the history, treat­ment, follow-up controls, and other pertinent details. The comparative studies concentrate on the recurrence of the disease, the level of pain experienced, the cosmetic effect, and the duration of the inability. A comparison is made of the incidence of less severe but more frequent complications. The prospective study design would be challenging to implement due to the low incidence rate of this type of injury.

It is possible that the symptoms of an ischaemic event may be overlooked due to the presence of postoperative pain [4,6]. Prior to the operation, the patient must be informed about the expected peri- and post-operative course, symptoms, and possible complications in order to obtain their confidence and cooperation [2,32]. It is of greater consequence that the surgeon is experienced and informed. Although the procedure itself appears straightforward and uncomplicated, potential risks do exist. Each procedure for the treatment of lower limb varicose veins must be performed by an experienced surgeon or under their supervision [33]. A systematic follow-up of the patients is essential to facilitate the early recognition of any potential complications [5].

The most common direct injury to the artery occurs during crossectomy in the groin area. However, the injury caused by stripping was more severe. The introduction of the stripper may be conducted in either an antegrade or retrograde manner. Both options have advantages and disadvantages. It is preferable to limit the stripping of the main veins. The safest method of introducing the stripper is under manual and/or ultrasound control throughout the length of the vein, as this can prevent the wire from passing into arteries or deep veins. It is also important to control the position of the laser and radiofrequency catheter [22].

Ultrasound is now a standard tool in the armamentarium of all specialities. It is a tool that surgeons frequently utilise in the operating room. Duplex ultrasound mapping of the venous system of the lower limbs is of critical importance and is recommended for the decision-making process regarding the treatment of varices, as well as for the surgical procedure itself [3,7,8]. This approach should be employed in order to prevent the aforementioned complications. If the procedure is planned and performed in accordance with the results of ultrasound, it may be reasonably expected that the incidence of recurrence and complications will be lower [22]. None of the studies describing sclerotherapy or endovenous methods have had ischaemia as their primary objective. It is not possible to confirm or refute the hypothesis that duplex ultrasound or endovenous methods have a beneficial effect on the incidence of ischaemic complications. The utilisation of ultrasound description facilitates more efficacious surgical procedures, frequently with a reduced extent of intervention. In select cases, the stripping of the great saphenous vein may be unnecessary. The vein may retain importance in the future, should the development of deep venous thrombosis occur or if bypass is required.

Conclusion

Ischaemic complications following varicose vein operations are uncommon, yet they have a profound impact on the patient. Such cases are not widely documented. It is of the utmost importance to prevent severe complications such as ischaemia. The role of the experienced surgeon, who performs the operation or has the supervision in the operating room, is of paramount importance. It is of great importance that the surgeon possesses both the requisite skills and anatomical knowledge. It is incumbent upon each surgeon to adhere to the established guidelines, recommendations, indications, and contraindication criteria.

The follow-up and post-operation control must be consistent in order to recognise any complications early. An experienced vascular surgeon should manage any ischaemia immediately.

Conflict of interests

The authors declare that they have no conflict of interest related to the creation of this article, and that this article has not been published in any other journal with access to congress abstracts.