Deep Venous Reconstruction in Paradise

Aloha. In Hawaiian this word means hello but also welcome to our family. The latter was the most appropriate phrase to describe my visit to the Straub Clinic in Honolulu.

In the Autumn of 1999, the 3^rd Pacific symposium on venous disease was held on the Big Island of Hawaii. One of the doctors who attended, was a senior surgeon from Derby. He returned full of enthusiasm about the role of deep venous reconstruction in the management of patients with venous insufficiency. If he were younger, he would have wanted to introduce some of the concepts he had seen to surgical practice in the United Kingdom. At that time, his registrar was nearing the end of training, and it was to him that the infectious enthusiasm was transferred. I was that registrar and with the help of a supporting letter from the senior surgeon Mr Ken Callum and the generosity of the English and American Colleges of Surgery I was able to fund a sabbatical in Honolulu, Hawaii.

Honolulu is the capital city of the American State of Hawaii. The city is on Oahu, one of the 7 tropical Islands in the Pacific Ocean. The word Honolulu means ‘melting pot’ and it well describes the mix of the Polynesians, Japanese and Caucasians who make up the state’s population of 1.5 million. There are on the Islands, several hospitals and the Straub clinic is one of these. By United Kingdom Standards the hospital is small with 140 beds but it possesses more modern equipment than can be found in some of the larger hospitals in the UK. The clinic has an international reputation in the management of venous disease. In the mid to late 1960’s Dr Robert Kistner performed one of the first venous valve reconstructions on a patient with deep venous disease. To paraphrase his own words, he said that he did the operation because the presentation and signs of disease in that patient were so unusual that he did an exploratory operation to find out what was going on. Since then he has continued to investigate and operate on patients with severe venous disease. Patients are referred from all over the pacific and also from the continental united states. In the 1980s Dr Kistner was joined by Dr Eklof, a Swedish born surgeon, also with an international reputation in venous surgery. They continued to investigate and treat patients with venous disease and the department now consists of 4 surgeons, the latest appointments being Dr Elna Masouda and Dr Dean Sato, both of whom were trained by Dr Kistner. More recently, the Straub Foundation, the charitable section of the clinic has organised and hosted the Pacific Venous Forum.

The Vascular Clinic is based on the fifth floor of the outpatient’s department and comprises a waiting area for patients and a well designed series of investigative and treatment areas and offices. Each surgeon has their own nurse who co-ordinates the running of the clinic and is the first port of call for patient enquires. There are three vascular technicians trained in the use of duplex and plethysmography. There are 3 Duplex scanners, with some of the latest diagnostic software including B wave ultrasound that allows visualisation of flow without the ‘noise’ associated with colour flow duplex.

Before I left for Hawaii, I considered the reasons why deep venous reconstruction is rarely practiced in the United Kingdom and why in my higher surgical training had I been exposed to only two deep venous procedures. The following article is a summary of the ideas I had before my visit and the observations that I made.

One of the reasons why deep venous surgery in the United Kingdom may be different from that in Hawaii might be that the populations have  different patterns of venous disease. In Hawaii, the majority of patients are, as in the United Kingdom, women with superficial venous disease. Most of the venous ulcers, however, occur in men and the pathology is frequently primary valvular reflux. The majority of patients that I saw were of Polynesian descent, including one with a strong family history of leg ulceration. In the time that I was there, I only saw a small sample and it was not possible to obtain information on the ethnic origins of the patients with venous disease. There were however several men of European origin with deep venous impairment secondary to previous thrombotic disease. Whilst there, I observed the assessment and treatment of one man who had a combination of ouflow obstruction and deep reflux after an extensive iliofemoral deep vein thrombosis 30 years before presentation. His progress through the clinic and subsequent treament gave good insight into the multidisciplinary method for the evaluation and treatment of deep venous disease.

The patient, a 54 year old factory worker had been referred from a clinic in California with a history of a road accident subsequent to which he developed a deep vein thombosis in the right leg that was treated with oral anticoagulation. Although his leg remained more swollen than the left he was able to lead a relatively normal and productive life until two years before his presentation. When seen in Hawaii, he gave a history of deep calf pain almost immediately on standing, followed by pain and swelling of the ankle that meant he had to give up his job as a warehouseman. On examination he was well and had normal pulses in his right leg. There was a discrete are of lipodermatosclerosis above the medial malleolus. Continuous wave Doppler showed a patent long saphenous vein and a reflux signal in the popliteal vein. Of interest, Dr Kistner, examined the patient as he was supine on a couch and since then I have adopted the technique. It is more comfortable for patient and surgeon and avoids the need for squatting on the floor or asking the patient to stand on a platform. There was no place for the trendelenburg test in the clinical examination as the Doppler probe is much more accurate such that the former should perhaps be confined to the history books!

Following the clinical examination, the patient had a 45 minute examination by one of the highly trained technologists who used one of the latest Duplex Ultrasound machines that possess B wave technology. This new industry standard now allows clinicians to see laminar and turbulent flow within vessels and to calculate volumes of reflux. The latter measurements are yet to be verified but may lead the way for more accurate assessment of the success of intervention. The Duplex examination showed a combination of a tight external iliac vein stenosis with incompetence of the common, superficial and profunda veins. The long saphenous was patent and competent. The velocity and volumes of reflux were such that Dr Kistner felt able to recommend further investigation with a view to surgical intervention. Ascending and descending venography was then done to confirm the duplex findings and establish the site of any incompetent valve stations that might be amenable to repair. None of the latter were present when the venography was done by Dr Kamida.

The best management approach was angioplasty and stenting of the external iliac stenosis in addition to local endophlebectomy ( the equivalent of endarterectomy) of the common femoral vein. The latter was deemed to be required because of the risk of stent fracture if placed across the common femoral vein. These two procedures were aimed to relieve the obstructive component of the disease in the leg but would not correct the reflux disease in the deep system. It is still not known whether a sequential or all at one time approach should be used in this situation. Dr Kistner tends to favour the latter so in this case, a transpostion of the superifical femoral vein onto the long sphenous vein was planned. This approach utilised the remaining competent valves of the long saphenous vein. An arterivenous fistula was fashioned with saphenous vein so as to increase the flow of blood through the site of the endophlebectomy and reduce the risk of thrombosis.

Within five days of arriving in Hawaii, the patient had completed all of his investigations and had had his operation. The procedure was done in the main operating theatre and the stent was deployed at the same time. Three days later, Duplex showed no reflux in the patent superficial vein and good flow through the iliac vein. The patient commentated that his leg felt much less swollen and the pain had disappeared. He flew home one week after his operation.

It would be interesting to know how the patient has progressed in the last few months. One of the problems inherent in the location of the Straub and the patients that are treated there is the thoroughness of follow up. It has been argued that Deep venous surgery does not work and that in those in whom it does, the long term results are poor. With this in mind, I was encouraged to review the technical success of deep venous reconstruction done in the 1990s.

Some of the results have been published previously but without compromising future publications from the department, I noted that the success rates were.

Towards the end of my visit, I discussed many factors about deep venous disease and its management with the staff at the Straub. Apart from a few centres such as Jacksonville and Lyon there are few authorities on the subject. In the United Kingdom, only 190 operations appear to have been done in one year and those figures are subject to the fallability of the OPCS coding system in UK hospitals. One question that I felt needed to be answered was why hadn’t the techniques at the Straub been adopted by others. One comment from Dr Kistner amazed me when he said that I was the only surgeon who had been to Honolulu and spent time actually watching how the assessments and operations were done. Other distinguished surgeons had read the papers and then attempted the techniques but found the results disappointing. This is not to say that the Straub has no problems. The average success rate was about 50% but for those people the abolishion of leg pain and discomfort was worth the operation even is the progression of the venous disease in their leg progressed after such that they relapsed to their pre-operative state after only a few years or months.

Some of the other reasons for the lack of popularity of the technique might be explained by the need for meticulous and often prolonged dissection of deep veins. As those who have operated on deep veins will know, venous bleeding is much more difficult to control than arterial. Thus every tributary to the deep veins must be meticulously dissected free to preserve a blood free operative field. In a healthcare system such as that in the UK where it is difficult enough to operate on patients with life and limb threatening disease, it does seem rather odd to try and spend hours on operations that have a limited longevity and success rate when the alternative of compression stockings and a pat on the back is more appealing and apparently less costly or an NHS trust. This attitude may have to change in our increasingly consumer led healthcare system. Since my return from Hawaii, I have been referred nearly 20 young patients who may  be suitable for reconstructive venous surgery. I can see a time in the not too distant future when they demand, much like the citizens of the United States and France, for something to be done.

The Vascular Surgeons at the Straub clinic mange patients with acute deep venous disease. Although two patients presented with acute iliofemoral deep vein thromboses while I was there, neither were suitable for venous thrombolysis or venous embolectomy. The expertise for the techniques dose, however exist and good results can be obtained.

Fortunately, I was able to spend time studying wave forms other than those found in blood vessels. The beaches in Hawaii are beautiful but some of the most dangerous in the World because of the Rip tides and surf that can easily break bones or even necks. I was amazed to see that there are several different types of wave that can sweep an unsuspecting victim into the water. The waves on the famous Wakikki beach were however suitable for a surfing novice so I was able to spend more time on the board than in the water. One note of caution is that the Sharks like to feed early in the morning when most people have the opportunity to surf during the working week.

If anyone reading this article has an urge to travel to Hawaii then a visit to the other Islands such as Maui and Kaui are essential. It is not always sunny in paradise and rain falls almost daily especially on the North coast. When I was there, England had floods but on one day 22 inches of rain fell on the Big Island of Hawaii.