Arteriovenous communications in varicose veins localized by thermography and identified by operative microscopy

Abstract

By thermography the hottest spots of varicosities were localized. At surgery they were found to correlate well to the sites of small pulsating arteries joining the varicosities but did not show correspondence to incompetent perforating veins. At peroperative measurements these arteriovenous communications (AVC) ranged from 0.1-2 mm. Most of them (79%) were within 0.2-0.8 mm with a median value of 0.6 mm. Unexpectedly, direct communication of an arteriovenous nature between perforating veins and adjacent arteries was frequently seen at the fascial level or immediately beneath it. AVC to varicose and perforating veins were demonstrated in 64% (100/157) of explorations performed. The continuity of the suggested AVC was visually confirmed by microscopical anatomical isolation of the affluent artery or by observation of pulsatile bleeding on the inadvertent division of such a vessel. Operative microscopy was performed in 35 and magnifying glasses were used in a further 16 patients. Overall 79% of subfascially isolated perforating veins were equal to or smaller than 2.4 mm and 61% equal to or smaller than 1.8 mm. Perforating veins were missing in totally 47% (74/157 explorations) which means a frequent occurrence of clearly well-defined hot varicosities which could not be explained by retrograde flow through either incompetent perforating veins or by saphenous trunk insufficiency. The unexpected incongruity between the occurrence of well-defined hot varicosities and incompetent perforating veins discredits the traditional concept of their import with respect to varicose development. The only plausible explanation to the pooling of hot varicose blood was the identified arteries, inevitably supporting the role of arteriovenous communication in varicose development.