Venous Disorders of the Legs: Principles and Practice

142 Pages·1999·5.9 MB·English

by  Lawrence L. Tretbar MD (auth.)

Venous Disorders of the Legs
Springer
London
Berlin
Heidelberg
New York
Barcelona
Budapest
Hong Kong
Milan
Paris
Santa Clara
Singapore
Tokyo
L. L. Tretbar
Venous
Disorders
of the Legs
Principles and Practice
With 93 Figures
including 16 Color Plates
, Springer
Lawrence L. Tretbar, MD, Professor, Clinical Surgery, University of Missouri - Kansas
City School of Medicine
Phlebologic Institute of the Midwest, 8787 Ballentine, Shawnee Mission, Kansas 66214,
USA
Cover illustrations: The insets show: Figure 7.3 (the Miiller hook, the Oesch, the Ramelet, and the Tretbar hook);
Figure 1.4 (the deep venous plexus of the foot outlined with dye).
British Library Cataloguing in Publication Data
Tretbar, Lawrence 1.
Venous disorders of the legs: principles and practice
1. Veins - Diseases 2. Veins - Diseases - Treatment 3. Leg - Blood-vessels - Diseases
I. Title
616.1'4
Library of Congress Cataloging-in-Publication Data
Tretbar, Lawrence 1., 1933-
Venous disorders of the legs: principles and practice 1 1. 1. Tretbar
p. cm.
Includes bibliographical references and index.
ISBN-13: 978-1-4471-1203-7 e-ISBN-13: 978-1-4471-0795-8
DOl: 10.1007/978-1-4471-0795-8
1. Leg - Blood-Vessels - Diseases. 2. Varicose Veins. I. Title. [DNLM: 1. Varicose Veins.
2. Leg -blood supply. 3. Venous Insufficiency. 4. Veins - physiopathology. WG 620 T799v 1998]
RC695.T74 1998
616.1'4 - dc21
DNLM/DLC 98-6341
for Library of Congress CIP
Apart from any fair dealing for the purposes of research or private study, or critism or review, as permitted
under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or
transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case
of reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing
Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers.
© Springer-Verlag London Limited 1999
Softcover reprint of the hardcover 1s t edition 1999
The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific
statement, that such names are exempt from the relevant laws and regulations and therefore free for general
use.
Product liability: The publisher can give no guarantee for information about drug dosage and application thereof
contained in this book. In every individual case the respective user must check its accuracy by consulting other
pharmaceutical literature.
Typeset by The Midlands Book Typesetting Company, Loughborough
28/3830-543210 Printed on acid-free paper
Foreword
Within the last five years a number of new books on venous disorders have been produced.
Previously the study of venous disease was well-served by the classic texts of Foote,
Anning, Dodd and Cockett, and Hobbs, but these texts are now out of print and out of
date. How does Larry Tretbar's book equate with its competition? Those of you who pick
up or purchase this delightful little book will not be disappointed. It is a single author
text which is clearly written and succinct. In just over 100 pages Tretbar distils the work
of many of his larger competitors without losing any vital information along the way. He
also provides new insights and ideas in many areas. Contents are set out in a standard
format but the writing is pithy and the line drawings (mostly by the author himself) are
clear and helpful. It excels in the management and treatment of varicose veins where the
author has made his major contribution. The book contains many of the classic venous
references though these of necessity cannot be comprehensive in the interest of brevity.
Linton pointed out that diseases of the veins of the lower extremities are one of the
commonest of human ailments that can be remedied by surgical measures. These disorders
are often poorly managed by junior doctors who fail to acquaint themselves with the
anatomy and pathophysiology of these disorders. For this reason I have no doubt that
this monograph will find its way to the bookshelves of all those who are interested in the
treatment of venous diseases, and I can specially recommend it to those who are starting
to treat patients for the first time as it provides a comprehensive but readable guide to all
that they need to know.
Professor K.G. Burnand
Professor of Vascular Surgery
St Thomas' Hospital
London
v
Preface
The preface to a book presents a wonderful opportunity for the author to let his hair
down, to speak in ordinary English, to tell the story of his literary achievement and to
let his supporters know just how much he appreciates them.
Although I have lectured and written journal articles on the topic of venous disease
for many years, this book is the feature-length publication. It has allowed me to combine
more than 30 years' of personal experience with that of others to create a primer with
some depth and, I hope, a balanced view of this unique medical specialty.
My first real contact with the vascular system came during a year in my general surgery
residency in which I worked as a Research Fellow for Dr Willem Kolff in his Department of
Artificial Organs. Among the many medical devices Dr Kolff invented, the most famous is
the artificial kidney which permits renal dialysis. With another young surgeon my year-long
project was to design, build and implant an artificial heart into the chest of a calf Here I
quickly learned that the venous system was just as important to the organism as were its
arteries. I learned about vis a tergo, vis a !onte, venous hypertension and the problems of
venous return. Dr Kolff challenged us to create new approaches or concepts to solve a
problem ... and to make them work. It was a year of profound vascular experience.
My mentor during those years of residency was Dr George "Barney" Crile, the son of
one of the founders of the Cleveland Clinic. Not only did he introduce modified radical
mastectomy into American surgery but he inspired us to "question the time-honored
ideas". He believed that any medical viewpoint more than five years old needed thorough
re-evaluation. This concept has helped me place a new perspective on the traditional
American attitudes toward varicose vein treatment.
My first contact with sclerotherapy was at the West Middlesex University Hospital in
London during a year spent there as a Senior Registrar. The hospital's vein clinic, which
I had to manage, was performing the Fegan technique of injection/compression for large
varicose veins. I learned the technique and brought it back to the US, where it received
little interest. Thirty years later almost every American doctor seems to be interested in
sclerotherapy.
Mr George Fegan, the remaining "godfather" of contemporary phlebology, is still
challenging us to consider the role of incompetent perforators in the treatment of varicose
veins. I treasure his friendship and support.
Thanks are also due to Kathy, Kirsten and Eric who have spent many hours listening
to tedious talk about veins and waiting for me to revise and edit; to my office staff, Marsha
Stillions, Christa Stillions, Amy Hellige and my associate Dr Marcus Stanbro, who have
adjusted their schedules to give me more time at the word processor. I appreciate Dr
Ricardo Majia's diplomatic proof reading. Of course the staff at Springer-Vedag London
have done their best to keep me in line and on time. Thanks Nick and Nick, Chris, Deirdre
and Robin for your help.
L.L. Tretbar
vii
Contents
1 Anatomy of the Leg Veins ............................................... 1
Configuration of the venous system ........................................ 1
Histology .............................................................. 2
Venous innervation ..................................................... 3
Embryology ............................................................ 3
Venous systems of the foot ................................................ 3
Superficial venous system ................................................ 4
Greater (long) saphenous vein ............................................. 5
Lesser (short) saphenous vein ............................................. 8
Reticular vein system ................................................... 10
Accompanying nerves .................................................. 11
Deep venous system .................................................... 11
Intermuscular veins (venae comites) ....................................... 12
Intramuscular veins .................................................... 13
Perforating veins ....................................................... 14
Valves ............................................................... 16
Comments ............................................................ 18
References ............................................................ 18
2 Venous Function, Dysfunction and Venous Insufficiency .................... 21
Return of blood to the heart .............................................. 21
Venous pressure ....................................................... 24
Chronic venous insufficiency ............................................. 26
Chronic venous hypertension ............................................. 28
Comments ............................................................ 31
References ............................................................ 31
3 Clinical Phlebologic Evaluation ......................................... 33
History of present illness ................................................ 33
Past medical history .................................................... 34
Physical examination ................................................... 35
Comments ............................................................ 40
References ............................................................ 40
4 Venous Testing, Non-Invasive and Invasive ................................ 41
Non-invasive vascular testing: ultrasound ................................... 41
Venous Doppler examination ............................................. 44
Duplex ultrasonography ................................................. 51
Plethysmography ....................................................... 53
ix
x Venous Disorders of the Legs
Magnetic resonance imaging ............................................. 57
Thermography ........................................................ 57
Invasive vascular testing ................................................. 58
Comments ............................................................ 60
References ............................................................ 61
5 Patterns of Varicose Vein Development/Principles of Treatment .............. 63
Common patterns of varicose vein development ............................. 63
Non-saphenous veins ................................................... 66
Principles of treating varicose veins ....................................... 68
Greater saphenous vein incompetence ..................................... 69
Lesser saphenous vein incompetence ...................................... 69
Microincisional phlebectomy ............................................. 70
Comments ............................................................ 70
References ............................................................ 70
6 History of Medical and Surgical Treatment of Varicose Veins ................. 71
Early surgical treatments ................................................ 71
British experience ...................................................... 72
German experience ..................................................... 72
Post-Trendelenburg experience ........................................... 74
American school of surgery .............................................. 75
Later American experience ............................................... 76
Follow-up ............................................................ 79
Comments ............................................................ 80
References ............................................................ 80
7 Contemporary Medical and Surgical Treatment of Varicose Veins ............. 81
Overview ............................................................. 81
Greater saphenous vein incompetence ..................................... 82
Lesser saphenous vein incompetence ...................................... 85
Microincisional phlebectomy ............................................. 85
Valvuloplasty ......................................................... 86
Surgical techniques ..................................................... 86
New varicose veins ..................................................... 92
Comments ............................................................ 93
References ............................................................ 93
8 Injection Sclerotherapy ................................................ 95
Mechanism of action of sclerotherapy ...................................... 95
Types of sclerosant solutions ............................................. 95
Complications ......................................................... 96
Side-effects ........................................................... 97
Clinical applications ................................................... 101
Clinical approaches .................................................... 102
Clinical techniques .................................................... 102
Compression ......................................................... 105
Comments ........................................................... 106
References ........................................................... 107
9 Complications of Chronic Venous Insufficiency ........................... 109
Cutaneous complications ............................................... 109
Treatment of chronic venous ulcers ....................................... 113
Comments ........................................................... 119
References ........................................................... 120
Contents xi
10 Venous Thromboembolic Disease ..................................... 121
Pathogenesis of deep venous thrombosis .................................. 121
Clinical experience .................................................... 123
Establishing a diagnosis of deep venous thrombosis ......................... 124
Pulmonary embolism .................................................. 125
Treatment of venousthromboembolism ................................... 126
General medical care .................................................. 129
Prevention of thromboembolism ......................................... 129
Comments ........................................................... 130
References ........................................................... 130
Color Plate Section .................................................... 133
Index ............................................................... 139
CHAPTER 1
Anatomy of the Leg Veins
T
he structure and function of the completely revolutionized Galen's concept of
venous system have been of special circulation. He not only described the contraction
interest to anatomists for centuries. of the heart and its pulmonary circulation but
The veins are easily seen when diseased, especially explained the role of the veins in returning blood
those of the superficial system, and easily accessible to the heart and the need for valves in maintaining
to the anatomist. Nevertheless the true nature of the unidirectional blood flow. Harvey is shown in Fig.
venous system remained a mystery for hundreds of 1.1 as he appeared at the time of publication of de
years. mortu cordis. [1,2)
Galen in the 2nd century AD had clear insights Today our knowledge of venous disease is
into venous diseases and described treatments equally dependent on an understanding of the
for venous ulcers and varicose veins. Unfortunately anatomy and function of the leg veins. Because many
his erroneous views of the nature and function generations of anatomists have redefined the
of blood pervaded scientific thought for 15 centuries. structure and configuration of the venous system
Galenic physiology held that blood was created there are many different names used to describe the
in the liver where it received "natural spirits". veins of the leg. We use nomenclature generally
It then was attracted, as if by centrifugal force, agreed upon by English-speaking phlebologists. [3)
to the periphery of the body. Although it now However, because much of the phlebological
seems simple to understand the function of the literature is in German and French their equivalents
veins and their valves, it remained until the 17th are provided for clarity.
century for the true nature of the venous system to Special attention is paid to those veins and
be revealed. anatomic features which are frequently associated
With vivid and sometimes colorful imagination with venous disease but which may not be adequately
Vesalius, Fallopius and Leonardo da Vinci described described in regular anatomical texts. Also, many
the venous system. But it was Hieronymus Fabricius anatomic variations are found in the leg's venous
of Aquapendente, a student of Fallopius and himself system which are not often described in texts.
a teacher of anatomy at the University of Padua,
who gave the first accurate description of the venous
valves. He knew that the valves helped regulate the
Configuration of the venous system
flow of blood in veins but still held to Galen's
mistaken notion of circulation. Nevertheless
Fabricius' description of the valvular arrangement
helped Harvey develop and support his own theory If we visualize the vascular system as seen from the
of circulation. skin surface, the first structures are the capillary loops.
William Harvey, an English physician studying in Lying just beneath the epidermis, the series of loops
Padua with Fabricius, finally explained the circu begin as arterioles which ascend from the deeper
lation of blood in 1628. In his famous explication, dermis. At the top of the loop the tiny vessel becomes
Exercitatio anatomica de mortu cordis et sanguinis a venule. Gas and fluid exchanges occur here as the
in animalibus (Anatomic Treatise on the Motion blood begins its journey back to the heart.
of the Heart and Blood in Animals) Harvey Post-capillaryvenules measure about 12-30!lm and