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Initial experience of subfascial endoscopic perforator vein surgery in patients with severe chronic venous insufficiency
D. Casian, E. Gutu, S. Moroz (Chirurgia, 102 (4): 415-419)

Introduction
According to contemporary conception, severe chronic venous insufficiency (CVI) is considered to be in patients in CEAP classes C4, C5 and C6, other words, in patients with trophic skin changes: pigmentation, venous eczema, lipo-dermatosclerosis, healed and active ulceration.
Treatment of severe CVI is an important problem of angiology and vascular surgery, first of all because of high prevalence and incapacitating nature of CVI and on the other hand due to the difficult choice of optimal method of its management.
Surgery allows eliminating of basic pathogenic mechanisms of development of severe CVI - truncal saphenous and perforating veins refluxes. According to recent medical studies, quitting of pathological blood flotation through incompetent perforating veins is the most important component of successful surgical treatment of severe CVI (1, 2).
At the same time, carrying-out of surgical manipulation close to leg venous ulcer is associated with considerable alteration of pathologically changed tissues and high rate of postoperative necrotic and suppurative wound complications. Introduced in clinical practice in the middle eighties, Subfascial Endoscopic Perforator Surgery (SEPS) is a foolproof method of treatment of perforating veins reflux without direct surgical manipulation in the area of trophic disturbances (3).
In this paper, we present initial case series, consisted of 5 patients with severe CVI, SEPS being used in complex treatment.
Case series
The criteria used for selection of the patients for SEPS were presence of incompetent perforating veins in the area of trophic disturbances, confirmed by imagistic diagnostic methods and clinical manifestations of CVI in CEAP classes C4 - C6.
Determination of C-class according to CEAP classification was based on the results of physical examination of patients. Calculation of points according to venous clinical severity score (VCSS) was performed also (4).
Preoperative clinical investigation of patients, besides standard examination and routine laboratory tests, included duplex scanning of the venous system in the lower limbs performed with the Philips HDI 3500 (Philips ATL, USA) using linear array multifrequency transducers 5-12 MHz. Truncal saphenous blood reflux, perforating veins reflux and deep veins reflux were found and assessed during duplex scanning. Axial or segmental venous reflux consistently exceeding 0,5 s in duration was considered as abnormal. Perforating vein was considered to be incompetent in case of bidirectional blood flow and diameter 4 mm and more at the fascia perforating level. Skin marking of projection of the incompetent perforating veins was performed in all cases. The etiology of CVI (varicose disease, posthrombotic disease) was determined too.
Five consecutive patients have been selected for surgical treatment, including SEPS, according to the foregoing criteria since May 2005. Clinical characteristics of all the patients and the results of duplex scanning are presented in the table 1.
Surgical procedure in all cases was performed under general anesthesia. Cefuroxim in dose of 1500 mg was introduced intravenously during premedication. Presence of truncal reflux and the reflux through incompetent sapheno-femoral junction contributed to high ligation and below-knee stripping of long saphenous vein, being the first step of intervention. The endoscopic stage was performed with the patient leg moderately flexed in the knee-joint, external rotated and elevated. Two 10 mm trocars were placed in the posteromedial subfascial compartment of calf. The first one was placed at the merge of upper and middle third of calf, 3-4 cm from medial edge of tibia. So called "american technique", with using of space-maker (General Surgical Innovations Inc., Cupertino, CA, USA; model DBD 900 REF) with balloon volume of 900 ml aimed to form the working space and insufflation in the operative space of carbon dioxide (CO2), was performed.
After that, a 0-degree 10 mm telescope was introduced through the first port. The second port was placed under visual control 4-5 cm lower and behind from the first one. All surgical interventions were performed without reduction of arterial blood flow in the operative area. The technical details of endoscopic stage of the procedure are presented in the table 2.
Only one patient had intraoperative hemorrhage from perforating vein due to its monopolar coagulation. Hemorrhage was easy stopped after ports extraction by application of elastic bandage. No early postoperative complications related to SEPS were noted. The median period of hospital treatment after surgery was 5 days, varying from 3 to 8 days.
All patients underwent the follow-up examination in different period after surgery (2-13 months) with determination of C class and clinical severity score. The results of repeated clinical examination are presented in the table 3.
Therefore, in all patients in CEAP class C6 healing of venous ulcer after surgical treatment was noticed. There were no signs of trophic disturbances in patients N1 and N2 at the time of repeated examination 8 and 13 months after surgical procedure correspondingly (Fig.1a, b). Skin grafting was performed in patient N3 two weeks after surgery because of huge dimension of venous ulcer. There was no change in C class in patients N4 and N5, but the clinical severity score decreased for 5 and 2 points respectively.

Figure 1A
Figure 1B

Discussion
The occurrence of CVI with leg edema and skin trophic changes is rather high in population and achieves 3.0 - 11.0%. Although there is no accurate data of CVI epidemiology in Republic of Moldova, according to SEPIA research, enrolling 6674 patients, performed in Romania in 2004, CVI was discovered in 2135 (32%). Moreover, the rate of severe forms was high - 19% (C4 - 16%, C5 - 2.5%, C6 - 0.5%) (6).
Election of the optimal treatment protocol in case of severe CVI is still open to question, in spite of considerable progress achieved recently in the treatment of vascular pathology. Nonsurgical management of severe CVI contributes only to short-term clinical improvement, conditioned by the following factors: insufficient accessibility of qualitative elastic stockings or irregularities of it use by patient; hot climate, which embarrasses wearing of elastic stockings or wraps and relative high cost of effective phlebotonic medications.
Operative quitting of pathological venous reflux remains the main method of radical correction of CVI, although there are some researches being evidence of rather effective conservative treatment (7, 8).
Classic methods of perforating vein disconnection such as Cockett's or Linton's procedures are accomplished by considerable number of necrotic and suppurative wound complications, and are often technically unrealizable in conditions of lipodermatosclerosis, large or circular venous ulcer (9).
Widely spread nowadays, endoscopic surgery makes possible avoiding manipulation in the area of trophic disturbances and active venous ulcer in case of severe CVI. Skin marking of incompetent perforating veins location, using duplex scanning, is one of the obligatory components of preoperative management. We consider that visual estimation of perforating vein incompetence during SEPS, based on indirect signs (the diameter more than 2 mm, kinking, tenseness) is greatly less evident than the results of preoperative duplex scanning.
Thus, we believe that it is not necessary to examine all subfascial space to find the incompetent perforating veins. We performed mobilization and dissection only preoperatively diagnosed and marked incompetent perforating veins in the all presented cases.
There are two basic methods of SEPS: dual-port technique and single-port technique. Using first method, the working space usually is achieved by special balloon, so called space-maker, introduced into the subfascial space. After initial inflation and achieving of "working space", the balloon is removed having been deflated and the obtained space is filled with carbon dioxide (CO2). In this study the described method was used in four cases. From our experience use of space-maker greatly facilitates manipulations in the subfascial space and reduces bleeding from small vessels. High cost of disposable space-maker is the single disadvantage of this method. Using single-port technique, working space is achieved mechanically due to introduction of multi-channel operative telescope with large diameter. This method is technically easier, but it requires a special designed instrument. Furthermore the field of view is considerably reduced in nongaseous method that, according to some investigators data, may cause the increasing rate of intraoperative errors and complications (9).
It is recommended by some authors to perform SEPS after application of pneumatic haemostatic tourniquet such as the Lofqvist roller cuff on the middle one-third of calf in order to improve the visualization and obtain a bloodless operative field (10). We didn't use reduction of blood flow in the presented series of patients, since we consider, that this method do not allow intaoperative control of hemostasis and, to the other hand, ischemia reduces the time available for performing of operation.
Election of optimal mode of disconnection of the perforating vein (mono- or bipolar coagulation, clipping), providing for a good hemostasis, is a very important part of SEPS. Monopolar coagulation was used for disconnection of perforating vein in two patients, evolving with bleeding in one case. We refrained from this method later on, using it only for dissection of perforating veins. Clipping of incompetent perforating vein, seems to be a more effective method and is usually recommended if the perforating vein is larger than 6 mm. We believe, that the indications for clipping should be enlarged, taking in consideration, that it is rather difficult to determine the diameter of perforating vein during surgery, and because the diameter of insufficient perforating veins is usually 5 mm and more.
It is possible to perform clipping of incompetent perforating vein without its transsection in case of presence of only one incompetent perforating vein. According to some data, this method allows to reduce duration of procedure, pain syndrome and edema in postoperative period (11).
High effectiveness of SEPS in treatment of patients with CVI is proved by a large clinical experience. Use of SEPS contributes to a stable decrease of C-class of CEAP classification and statistically significant reducing of venous clinical severity score (12). The results of treatment in presented case series agrees with majority opinion about high effectiveness of SEPS in severe CVI, being a complication of varicose disease or deep vein thrombosis.
Endoscopic method of quitting of blood pathologic reflux through incompetent perforating veins allows achieving of encouraging early- and late-postoperative results, reduces postoperative morbidity and contributes to improvement of quality of life in patients with severe CVI.

References
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2. TAWES, R.L., BARRON, M.L., COELLO, A.A. - Optimal therapy for advanced chronic venous insufficiency. J. Vasc. Surg., 2003, 37:545.
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4. RUTHERFORD, R.B., PADBERG, J.R.F.T., COMEROTA, A.J., KISTNER, R.L., MEISSNER, M.H., MONETA, G.L. - Venous severity scoring: an adjunct to venous outcome assessment. J. Vasc. Surg., 2000, 31:1307.
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7. MAYBERRY, J.C., MONETA, G.L., TAYLOR, L.M., PORTER, J.M. - Fifteen year results of ambulatory compression therapy for chronic venous ulcers. Surgery., 1991, 109:575.
8. PHILLIPS, T.J. - Current approaches to venous ulcers and compression. Dermatol. Surg., 2001, 27:611.
9. SHISHIN, K.V., STREKALOVSKII, V.P., STARKOV, IU.G., SVETUKHIN, A.M., ASKEROV, N.G., SAPELKIN, S.V. - Endoscopic subfascial dissection of venous perforants in treatment of venous trophic ulcers of the legs. Khirurgiia (Mosk)., 2005, 5: 9.
10. LOFQVIST, J. - Surgery in a bloodless field with roll cuffs. Chirurg., 1988, 59:853.
11. KIANIFARD, B., PRICE, S., WHITELEY, M.S. - Clipping perforators without dividing them could reduce postoperative pain and swelling following subfascial endoscopic perforator surgery. Ann. R. Coll. Surg. Engl., 2002, 84:210.
12. CIOSTEC, P., MYRCHA, P., NOSZCZYK, W. - Ten years experience with subfascial endoscopic perforator vein surgery. Ann. Vasc. Surg., 2002, 16:480.


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