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Jornal Vascular Brasileiro

versão impressa ISSN 1677-5449versão On-line ISSN 1677-7301

J. vasc. bras. vol.8 no.1 Porto Alegre jan./mar. 2009  Epub 13-Mar-2009

http://dx.doi.org/10.1590/S1677-54492009005000004 

CASE REPORT

 

Surgical treatment of varicose veins of the lower limbs in liver transplant recipients: case report

 

 

Jorge R. Ribas TimiI; Carlos Eduardo Del ValleII

IHead, Department of Vascular Surgery, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brazil. Vascular and endovascular surgeon, Núcleo Integrado de Cirurgia Endovascular do Paraná (NICEP), Curitiba, PR, Brazil
IIMSc. in Surgical Clinic, UFPR, Curitiba, PR, Brazil. Surgeon, Vascular Surgery Service Prof. Dr. Elias Abrão Curitiba, PR, Brazil

Correspondence

 

 


ABSTRACT

Liver transplantation is having progressively better outcomes, and quality of life is being more often addressed. Varicose veins of the lower limbs are common in the general population and cause symptoms in a significant number of cases, impairing quality of life. For patients in good clinical condition, with adequate graft function, surgical treatment for varicose veins of the lower limbs can be a safe option, with more effective and longer lasting outcomes. The authors report two cases of liver transplant recipients who had symptomatic varicose veins of the lower limbs and were submitted to varicose vein surgery following authorization from the liver transplantation team. Operations were uneventful, with good follow-up results. Surgery for varicose veins of the lower limbs can be safely performed in liver transplant recipients, and it is an effective and long lasting treatment for chronic venous insufficiency in these patients.

Keywords: Varicose veins, lower limbs, liver transplantation, venous insufficiency.


 

 

Introduction

Liver transplantation has had constant progress over the past decades and has become the treatment of choice for a large number of patients with liver failure of varied causes. Survival rates of transplanted patients has improved, reaching 67-72% in 4-5 years in some series1-3 thanks to improvement in surgical technique, selection of patients and postoperative care. A cohort study showed mean survival rate of 22 years after the procedure.4 In addition to survival rates, another important factor that has received more attention is the quality of life of patients that were submitted to liver transplantation.5-7

Varicose veins of the lower limbs are common in the general population, with clinical symptoms in a significant number of cases.8-12 As symptoms become more significant, there is a proportional worsening in the patient's quality of life.

Some drug treatments for symptoms of chronic venous insufficiency are inadequate for liver transplant recipients. This is a result of liver toxicity of certain oral phlebotropics, especially coumarin, which can cause increase in liver enzymes.13 Coumarin is found in the market in its purified form, combined with troxerutin, and as an active component in herbal extracts, such as Melilotus officinalis.

A significant part of patients that received liver transplantation have clinical condition to be submitted to surgical treatment of varicose veins of the lower limbs. This is a treatment modality that has a more definite nature, with even more significant improvement in quality of life.

 

Case reports

Case 1

A 52-year-old female patient was submitted to liver transplantation (graft from cadaver) due to liver cirrhosis secondary to infection by hepatitis B virus (HBV). She already had varicose veins of the lower limbs before being submitted to transplantation. Fifty months after the transplantation, which had progressed uneventfully, the patient had symptoms of pain, weight, tiredness and edema, with impairment in her quality of life. There was no clinical contraindication against being submitted to surgical repair of varicose veins, and there was no reflux in the deep venous system. Partial right saphenous vein stripping was then performed and collaterals were removed, under peridural anesthesia, uneventfully and using paracetamol for postoperative analgesia. There was no change in graft function. The patient has been followed for 18 months and has no symptoms of venous or liver failure.

Case 2

A 52-year-old male patient, 48 months after liver transplantation, due to cirrhosis secondary to hepatitis C virus received a graft from a cadaver. He had large-diameter varicose veins of the lower limbs before transplantation. The deep venous system was not affected. Symptoms of venous insufficiency were responsible for impairment of quality of life. Surgical treatment was chosen due to the reasons mentioned above. The procedure was authorized by the liver transplant team, as the patient had not had events and the graft had proper functioning. The patient required total great saphenous vein stripping to the left and bilateral excision of varicose collateral veins. The procedure was performed under peridural anesthesia, and paracetamol was used for postoperative analgesia. The patient had satisfactory postoperative course both from the perspective of liver graft and lower limb symptoms. He is now in the 60-month follow-up after varicose vein surgery.

 

Discussion

The authors performed a wide review of the Brazilian and international literature and found no reports of liver transplant recipients that had been submitted to surgical treatment of varicose veins of the lower limbs. Patients were indicated for varicose vein surgery because they had significant symptoms and because the intervention had low morbidity rate. In addition, they had consent from the transplant team. The procedure can be performed under peridural regional block, which has good safety levels, little bleeding and little postoperative pain. Patients whose graft have good function should not have their surgery contraindicated. Postoperative analgesia was performed using paracetamol due to its lower risk of liver lesion in relation to non-hormonal anti-inflammatory and opioids.14Paracetamol toxicity is dose-dependent, therefore it is safe in low doses,15,16 while non-hormonal anti-inflammatory may have idiosyncratic reactions.17 Both procedures were uneventful. There was no change in operative technique in relation to non-transplanted patients. Partial segments of the saphenous vein were removed according to clinical assessment using Doppler ultrasound as usual. Hospital discharge occurred 12 hours after the end of the procedure, as in most patients. Surgery is planned according to color Doppler ultrasound findings, and segmental or total saphenous vein stripping is performed according to reflux topography. Thus, the great saphenous vein can be preserved in case it is competent, because its proximal segment, adjacent to the saphenofemoral junction, can be used as peritoneal venous shunt if the patient has refractory ascites in the future.18-20

 

Conclusion

When consented by the transplant tram, varicose vein surgery improves quality of life of transplant patients, and the successful transplant is not a barrier against such procedure.

 

References

1. Busuttil RW, Farmer DG, Yersiz H, et al. Analysis of long-term outcomes of 3200 liver transplantations over two decades: single-center experience. Ann Surg. 2005;241:905-16.         [ Links ]

2. Tector AJ, Mangus RS, Chestovich P, et al. Use of extended criteria livers decreases wait time for liver transplantation without adversely impacting posttransplant survival. Ann Surg. 2006;244:439-50.         [ Links ]

3. Morioka D, Egawa H, Kasahara M, et al. Outcomes of adult-to-adult living donor liver transplantation: a single institution's experience with 335 consecutive cases. Ann Surg. 2007;245:315-25.         [ Links ]

4. Barber K, Blackwell J, Collett D, Neuberger J; UK Transplant Liver Advisory Group. Life expectancy of adult liver allograft recipients in the UK. Gut. 2007;56:279-82.         [ Links ]

5. Parolin MB, Rabinovitch I, Urbanetz AA, Scheidemantel C, Cat ML, Coelho JC. Impact of successful liver transplantation on reproductive function and sexuality in women with advanced liver disease. Transplant Proc. 2004;36:943-4.         [ Links ]

6. Erim Y, Beckmann M, Valentin-Gamazo C, et al. Quality of life and psychiatric complications after adult living donor liver transplantation. Liver Transpl. 2006;12:1782-90.         [ Links ]

7. Karam VH, Gasquet I, Delvart V, et al. Quality of life in adult survivors beyond 10 years after liver, kidney, and heart transplantation. Transplantation. 2003;76:1699-704.         [ Links ]

8. França GJ, Timi JRR, Vidal EA, Oliveira A, Secchi F, Miyamotto M. O eco-Doppler colorido na avaliação das varizes recidivadas. J Vasc Bras. 2005;4:161-6.         [ Links ]

9. França LHG, Tavares V. Insuficiência venosa crônica: uma atualização. J Vasc Bras. 2003;2:318-28.         [ Links ]

10. Carpentier PH, Maricq HR, Biro C, Ponçot-Makinen CO, Franco A. Prevalence, risk factors, and clinical patterns of chronic venous disorders of lower limbs: a population-based study in France. J Vasc Surg. 2004;40:650-9.         [ Links ]

11. Ruckley CV, Evans CJ, Allan PL, Lee AJ, Fowkes GR. Chronic venous insufficiency: clinical and duplex correlations. The Edinburgh Vein Study of venous disorders in the general population. J Vasc Surg. 2002;36:520-5.         [ Links ]

12. Evans CJ, Fowkes FG, Ruckley CV, Lee AJ. Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study. J Epidemiol Community Health. 1999;53;149-53.         [ Links ]

13. Adama BS, Pentza R, Siegers CP, Strubelt O, Tegtmeier M. Troxerutin protects the isolated perfused rat liver from a possible lipid peroxidation by coumarin. Phytomedicine. 2005;12:52-61.         [ Links ]

14. Tolman KG. Hepatotoxicity of non-narcotic analgesics. Am J Med. 1998;105:13S-19S.         [ Links ]

15. Lee WM. Acetaminophen toxicity: changing perceptions on a social/medical issue. Hepatology. 2007;46:966-70.         [ Links ]

16. Larson AM, Polson J, Fontana RJ, et al. Acetaminophen-induced acute liver failure: results of a United States multicenter, prospective study. Hepatology. 2005;42:1364-72.         [ Links ]

17. Pérez-Gutthann S, García-Rodríguez LA, Duque-Oliart A, Varas-Lorenzo C. Low-dose diclofenac, naproxen, and ibuprofen cohort study. Pharmacotherapy. 1999;19:854-59.         [ Links ]

18. Vadeyar HJ, Doran JD, Charnley R, Ryder SD. Saphenoperitoneal shunts for patients with intractable ascites associated with chronic liver disease. Br J Surg. 1999;86:882-5.         [ Links ]

19. Vizsy L, Beznicza H, Batorfi J. Our experiences with saphenoperitoneal shunts in the treatment of intractable ascites. Hepatogastroenterology. 2005;52:920-2.         [ Links ]

20. Deen KI, de Silva AP, Jayakody M, de Silva HJ. Saphenoperitoneal anastomosis for resistant ascites in patients with cirrhosis. Am J Surg. 2001;181:145-8.         [ Links ]

 

 

Correspondence:
Jorge Ribas Timi
Rua Bruno Filgueira, 369/201
CEP 80240-220 - Curitiba, PR, Brazil
Email: jorgetimi@terra.com.br

Manuscript received March 20, 2008, accepted December 26, 2008.

 

 

No conflicts of interest declared concerning the publication of this article.

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