Femoro-Saphenous Anastomosis

FEMORO-SAPHENOUS ANASTOMOSIS, an operation proposed in 1809 by Pierre Delbet for the treatment of varicose veins of the lower extremities, consisting in the transplantation of the great saphenous vein of the leg (vena saphena magna) using a vascular suture 15-20 cm below its original entry into the femoral vein (see figures 1 and 2), whereby the incompetent valve apparatus of the saphenous vein falls under the protection of the always functioning valves of the femoral vein. Hesse and Schaak proved that in the femoral vein above the entry of the saphenous vein, valves are absent in 13% of cases. Below the entry of the saphenous vein into the femoral vein, ^Fig. ^1. valves are always present (in 73%--2 pairs, in 18%--3 pairs). The valves protect the saphenous vein system from blood pressure fluctuations and prevent the retrograde flow of blood. It is essential that a single pair of competent valves can protect the saphenous vein from nodular dilation (Delbet, Hesse, and Schaak); therefore, the operation is physiologically grounded. The literature describes 229 cases of this operation (51 cases by Delbet, 115 cases by Hesse and Schaak, and 63 cases by other authors). Mortality is one case, 0.57%. The immediate surgical result of femoro-saphenous anastomosis is good in 88.7%, and unsuccessful in 11.3%. Long-term results were followed up by Hesse in 37 cases for up to 8 years, with a good result in 61.7% and relapse in 33.3%. Work capacity was restored in 74.4%, edema disappeared in 89.1%, and dilated veins disappeared in 74.4%. Relapses are explained, according to Hesse and Schaak, by the formation of collaterals. Therefore, it is necessary to ligate the saphenous vein at its very entry into the femoral vein, and all collaterals must be resected. 60% of failures fall on bilateral dilation; therefore, femoro-saphenous anastomosis in such cases should be performed only if a systemic disease is ruled out. 79.3% of all failures concern ulcerous forms, in which femoro-saphenous anastomosis is poorly indicated. After the rupture of a varicose node, which indicates a complete loss of elasticity, femoro-saphenous anastomosis is contraindicated. Failure to strip a second saphenous vein during the operation leads to relapse. Histological studies by Hesse and Schaak showed that the saphenous vein after transplantation is capable of regenerating elastic elements. Femoro-saphenous anastomosis is contraindicated if the venous dilation does not belong to the system of the great saphenous vein, in the absence of valvular incompetence, and in inflammatory phenomena in the region of the veins and lymphatic pathways. Femoro-saphenous anastomosis yields the best results in the ramuscular type of venous dilation with sharp signs of incompetence (Trendelenburg's, Hackenbruch's, and Hesse's signs). Delbet's operation yields incomparably better results than the ligation of the saphenous vein according to Trendelenburg. Compared with the excision of the saphenous vein according to Madelung, the results are approximately the same. According to the latest studies by Hesse and Schaak (1921), very narrow indications must be established for femoro-saphenous anastomosis. However, with the correct selection of cases, femoro-saphenous anastomosis yields an excellent result.

Figure 2.