[Postoperative recurrence of varicosities at the level of the popliteal fossa. Anatomic data guiding the ultrasonographic exploration and surgical sequelae]

Abstract

The results of surgery of the short saphenous vein are less consistent than those of the long saphenous vein. The difference has been clarified by anatomo-physio-pathological studies which, as a complement to clinical examination, first used the different phlebography techniques and now benefit from pulsed colour echodoppler. They have shown that, in varicose veins considered to be of the short saphenous system, incompetence at its termination, with its anatomical variations, does not account for all the findings. Thus, imaging and the findings at surgery, have revealed a genuine venous complex in the popliteal fossa situated in four areas: in the sapheno-aponeurotic area with a variable point of termination of the short saphenous vein and important tributaries along its convexity; in the area of the medial head of the gastocnemius muscle with a voluminous trunk formed by the medial gastrocnemial veins which may run towards the termination of the short saphenous vein or even drain into its concavity; in the deep plane of the popliteal vein, which is sometimes double; in the short saphenous network with its very variable vein in the popliteal fossa and the lateral gastrocnemial veins. In practice, this classification helps to identify congenital reduplications, abnormal of aberrant veins and to perform planned surgery aimed at preventing postoperative recurrences. This is so because the latter are due, albeit less frequently than at the saphenofemoral junction, to a "new vein" which is in fact simply a missed tributary. Recurrences are mainly associated with : a duplication of the terminal part of the vein which has been missed; a short saphenous stump fed by a trunk from the medial gastrocnemial veins which has a termination into the popliteal vein common with the short saphenous vein; incompetent large medial gastrocnemial veins draining separately; an incompetent popliteal fossa perforator. The last two occur not uncommonly together and it has also been noted that failure to strip the short saphenous trunk increases the likelihood of postoperative recurrences. Repeat surgery is indicated in the presence of recurrences when there are important sources of reflux which are fully identified and precisely located by imaging, which is essential to prevent recurrent failure.