Introduction

Conventional surgery for varicose veins has largely been replaced by endovenous techniques; however, open procedures such as great saphenous vein (GSV) stripping are still performed in selected patients. Although generally regarded as safe, conventional operations may occasionally result in severe complications, including nerve injury, bleeding, deep venous trauma, and limb-threatening postoperative edema.

Deep venous injury during superficial venous surgery is particularly rare, but its consequences may be dramatic [1, 2]. Delayed diagnosis may lead to venous outflow obstruction, compartment syndrome, peripheral nerve damage, chronic pain, and permanent functional impairment [2]. The present report describes a young woman with combined femoral and popliteal vein injury during GSV stripping, treated with urgent venous reconstruction and prolonged postoperative care.

Case report

A 34-year-old woman underwent right GSV stripping at a one-day surgery center. In the postoperative period, the patient reported severe pain, sensory disturbance, and massive swelling of the right lower limb. On the same day, groin exploration was performed and a compression dressing was applied. Because swelling and foot paresis persisted on the following day, the patient was transferred to our vascular surgery department.

On admission, the right lower limb was markedly swollen, with sensory loss and impaired foot movements; pedal pulses were preserved. Computed tomography angiography demonstrated a normal arterial system, marked soft-tissue edema, and absence of venous opacification below the groin (Figure 1).

Femoral vein ligation was suspected and the patient was qualified for urgent surgery.

Intraoperatively, loss of continuity of the femoral vein distal to the junction of the GSV was identified, whereas the GSV itself remained patent. A hematoma was present in the femoral vein bed (Figures 2 A, B).

Venography performed through a dissected posterior tibial vein demonstrated a patent popliteal vein segment below the knee joint line, with no contrast flow proximally (Figure 3).

After exploration of the popliteal fossa, rupture of the popliteal vein above the joint line was identified. The distal venous segment was anastomosed end-to-end to a 6-mm PTFE graft. The graft was then tunneled to the groin and anastomosed side-to-end to the GSV just below its junction with the femoral vein. Completion venography confirmed patency of the popliteal vein, graft, and iliac vein, with simultaneous contrast extravasation from injured collateral branches in the popliteal region (Figure 4).

A seton drain was placed in the popliteal fossa, and leg fasciotomy was performed. Because of ongoing bleeding, an arterio-venous fistula using the posterior tibial vessels was not created. On the following day, the seton was removed and thrombectomy of a partially thrombosed graft, causing approximately 80% luminal narrowing, was performed.

Postoperatively, the patient was treated with negative-pressure wound therapy, split-thickness skin grafting, and intensive rehabilitation. The total hospital stay was 40 days (Figures 5–7).

Anticoagulation with apixaban 5 mg twice daily was initiated. At 8-month follow-up, graft occlusion was detected; because the patient remained asymptomatic and the timing of occlusion was unknown, thrombectomy was not undertaken.

During further follow-up, the patient required continuous compression therapy and had persistent foot drop related to common peroneal nerve injury. She also developed chronic neuropathic pain syndrome requiring pharmacological treatment with pregabalin, duloxetine, and buprenorphine (Figures 8 A, B).

Discussion

Deep venous injuries during conventional varicose vein surgery are rare, but they may lead to severe and irreversible complications [1–5]. Available literature indicates that this type of complication is uncommon, with a reported incidence ranging from 0.0017% to 0.3% [2, 3]. Despite its rarity, it may occur in procedures performed by both less experienced and highly experienced surgeons.

In the present case, delayed recognition of the injury was likely one of the most important factors influencing the final outcome. A 24-hour interval between the primary procedure and definitive reconstructive treatment probably contributed to prolonged venous hypertension, extensive limb edema, compartment syndrome-related tissue injury, and permanent peripheral nerve dysfunction. This case therefore underlines the importance of maintaining a high index of suspicion whenever disproportionate pain, massive swelling, or new neurological deficits occur after varicose vein surgery.

The most plausible mechanism of injury was aberrant passage of the stripping device from the GSV through Hunter’s perforator into the femoral vein, followed by misidentification of the vessel in the groin, ligation and division of the femoral vein, and subsequent stripping of the femoral and popliteal veins together with a segment of the great saphenous vein. Although this mechanism cannot be proven with certainty, it best explains the intraoperative findings and the extent of venous destruction observed during reconstruction.

The interval from injury to restoration of venous continuity appears to be the key prognostic factor in such patients. In the present case, urgent reconstruction restored venous flow and allowed limb salvage, but it did not prevent long-term neurological sequelae. Even though graft occlusion was later documented, no further surgical intervention was required because the patient had no symptoms of critical venous outflow obstruction at that stage.

This case also has broader practical relevance. As endovenous techniques continue to reduce the frequency of conventional stripping procedures, surgeons may encounter such operations less often. Reduced procedural exposure should not reduce awareness of rare but catastrophic complications. Careful operative technique, accurate identification of venous anatomy in the groin, and prompt postoperative reassessment in cases of unexpected pain or swelling remain essential [2, 3, 5].

Conclusions

Combined femoral and popliteal vein injury during GSV stripping is an exceptionally rare but potentially devastating complication. Early diagnosis and immediate reconstructive surgery are critical for limiting irreversible limb damage. This case highlights that even routine superficial venous procedures may result in major deep venous trauma and permanent neurological disability.

Disclosures

1. Institutional review board statement: Not applicable.
2. Assistance with the article: None.
3. Financial support and sponsorship: None.
4. Conflicts of interest: None.

References