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238 Ultrasound Guidance for Endovenous Treatment
A
B
C
veins under lipodermatosclerotic plaques and under venous ulcers (Figure
17-11).
30
Ultrasound monitoring should confi rm the fact that these vessels
are fi lled with foam during treatment.
Ultrasound guidance is also used in treatment of incompetent perforat-
ing veins. Direct cannulation and controlled injection of the SF under
direct visualization are effective.
27
Often, superfi cial peripheral veins can
FIGURE 17-11 Ultrasound sonography has confi rmed the presence of a tangled
network of varicose veins of small caliber, reticular varices, and incompetent perforating
veins under lipodermatosclerotic plaques and under venous ulcers.
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Ultrasound Guidance for Endovenous Treatment 239
be directly injected with the objective of obliteration of the attached per-
forator and its network of incompetent veins.
DISCUSSION
Compression therapy and surgery have been the cornerstone of
CVI treatment for years, and they are still useful. New, minimally inva -
sive techniques, including radiofrequency ablation of saphenous veins,
EVLT, and venous ablation with sclerofoam, have been demonstrated to
be safe, effective, and more acceptable to patients.
16
The contribution of
ultrasound in general and duplex technology in particular has given reli-
ability to the diagnosis of CVI and has enhanced the development of
minimal treatments. Intraprocedural and postprocedural US duplex ultra-
sound monitoring provides the best control of the entire procedure. This
provides early prevention of complications and minimizes the chance of
failure.
CONCLUSIONS
Duplex ultrasound is essential in every phase of CVI patient care and
has played a pivotal role in the recent revolution in venous therapy. Experi-
ence, critical thinking, uniform testing, and insight in the pathology are
necessary to achieve satisfactory results.
REFERENCES
1. Labropoulos N, Leon LR Jr. Duplex evaluation of venous insuffi ciency. Semin Vasc
Surg. 2005;18(1):5–9.
2. Ballard J, Bergan J, Delange M. Venous imaging for refl ux using duplex ultrasonogra-
phy. In: Aburahma AF, Bergan JJ, eds. Noninvasive Vascular Diagnosis, 1st ed. London:
Springer-Verlag, 2000:339–334.
3. Depalma RG, Kowallek DL, Barcia TC, Cafferata HT. Target selection for surgical
intervention in severe chronic venous insuffi ciency: Comparison of duplex scanning and
phlebography. J Vasc Surg. 2000;32(5):913–920.
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ciency. J Endovasc Ther. 2002;9(2):229–233.
5. Mekenas L, Bergan J. Venous refl ux examination: Technique using miniaturized ultra-
sound scanning. J Vasc Tech. 2002;2(26):139–146.
6. Kistner RL, Eklof B, Masuda EM. Diagnosis of chronic venous disease of the lower
extremities: The “CEAP” classifi cation. Mayo Clin Proc. 1996;71(4):338–345.
7. Eklof B, Rutherford RB, Bergan JJ, et al. Revision of the CEAP classifi cation for
chronic venous disorders: Consensus statement. J Vasc Surg. 2004;40(6):1248–1252.
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240 Ultrasound Guidance for Endovenous Treatment
8. Lynch TG, Dalsing MC, Ouriel K, Ricotta JJ, Wakefi eld TW. Developments in diagnosis
and classifi cation of venous disorders: Non-invasive diagnosis. Cardiovasc Surg.
1999;7(2):160–178.
9. Labropoulos N, Tiongson J, Pryor L, et al. Defi nition of venous refl ux in lower-extremity
veins. J Vasc Surg. 2003;38(4):793–798.
10. Masuda EM, Kistner RL, Eklof B. Prospective study of duplex scanning for venous
refl ux: Comparison of Valsalva and pneumatic cuff techniques in the reverse Trendelen-
burg and standing positions. J Vasc Surg. 1994;20(5):711–720.
11. Markel A, Meissner MH, Manzo RA, Bergelin RO, Strandness DE Jr. A comparison
of the cuff defl ati on method w ith Valsalva’s ma neuver a nd limb compression i n detecting
venous valvular refl ux. Arch Surg. 1994;129(7):701–705.
12. Delis KT, et al. Enhancing venous outfl ow in the lower limb with intermittent pneumatic
compression. A comparative haemodynamic analysis on the effect of foot vs. calf vs.
foot and calf compression. Eur J Vasc Endovasc Surg. 2000;19(3):250–260.
13. Vasdekis SN, Clarke GH, Nicolaides AN. Quantifi cation of venous refl ux by means of
duplex scanning. J Vasc Surg. 1989;10(6):670– 677.
14. Pichot O, et al. Role of duplex imaging in endovenous obliteration for primary venous
insuffi ciency. J Endovasc Ther. 2000;7(6):451–459.
15. Min RJ, Khilnani N, Zimmet SE. Endovenous laser treatment of saphenous vein refl ux:
Long-term results. J Vasc Interv Radiol. 2003;14(8):991–996.
16. Sadick NS. Advances in the treatment of varicose veins: Ambulatory phlebectomy, foam
sclerotherapy, endovascular laser, and radiofrequency closure. Dermatol Clin. 2005;
23(3):443–455, vi.
17. Puggioni A, Kalra M, Carmo M, Mozes G, Gloviczki P. Endovenous laser therapy and
radiofrequency ablation of the great saphenous vein: Analysis of early effi cacy and
complications. J Vasc Surg. 2005;42(3):488–493.
18. Caggiati A, Bergan JJ, Gloviczki P, Jantet G, Wendell-Smith CP, Partsch H. Nomencla-
ture of the veins of the lower limbs: An international interdisciplinary consensus state-
ment. J Vasc Surg. 2002;36(2):416–422.
19. Delis KT, et al. In situ hemodynamics of perforating veins in chronic venous insuffi -
ciency. J Vasc Surg. 2001;33(4):773–782.
20. Caggiati A, Bergan JJ, Gloviczki P, Eklof B, Allegra C, Partsch H. Nomenclature of the
veins of the lower limb: Extensions, refi nements, and clinical application. J Vasc Surg.
2005;41(4):719–724.
21. Weiss RA. Comparison of endovenous radiofrequency versus 810 nm diode laser occlu-
sion of large veins in an animal model. Dermatol Surg. 2002;28(1):56–61.
22. Weiss RA, Weiss MA. Controlled radiofrequency endovenous occlusion using a unique
radiofrequency catheter under duplex guidance to eliminate saphenous varicose vein
refl ux: A 2-year follow-up. Dermatol Surg. 2002;28(1):38–42.
23. Morrison N. Saphenous ablation: What are the choices, laser or RF energy. Semin Vasc
Surg. 2005;18(1):15–18.
24. Pichot O, et al. Duplex ultrasound scan fi ndings 2 years after great saphenous vein
radiofrequency endovenous obliteration. J Vasc Surg. 2004;39(1):189–195.
25. Goldman MP. Mechanisms of action of sclerotherapy. In: Goldman MP, ed. Sclerother-
apy: Treatment of Varicose and Telangiectatic Leg Veins, 2nd ed. St. Louis, MO: Mosby,
1995:244–279.
26. Cabrera J. Dr J. Cabrera is the creator of the patented Polidocanol microfoam. Dermatol
Surg. 2004;30(12, Pt 2):1605; author reply, 1606.
27. Coleridge Smith P. Saphenous ablation: Sclerosant or sclerofoam? Semin Vasc Surg.
2005;18(1):19–24.
28. Tessari L, Cavezzi A, Frullini A. Preliminary experience with a new sclerosing foam in
the treatment of varicose veins. Dermatol Surg. 2001;27(1):58–60.
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Ultrasound Guidance for Endovenous Treatment 241
29. Cabrera J, et al. Ultrasound-guided injection of Polidocanol microfoam in the manage-
ment of venous leg ulcers. Arch Dermatol. 2004;140(6):667–673.
30. Bergan JJ, Pascarella L. Severe chronic venous insuffi ciency: Primary treatment with
sclerofoam. Semin Vasc Surg. 2005;18(1):49–56.
31. Guex JJ. Foam sclerotherapy: An overview of use for primary venous insuffi ciency.
Semin Vasc Surg. 2005;18(1):25–29.
32. Guex JJ, Allaert FA, Gillet JL, Chleir F. Immediate and midterm complications of
sclerotherapy: Report of a prospective multicenter registry of 12,173 sclerotherapy ses-
sions. Dermatol Surg. 2005;31(2):123–128; discussion, 128.
33. Bergan JJ, Weiss RA, Goldman MP. Extensive tissue necrosis following high-
concentration sclerotherapy for varicose veins. Dermatol Surg. 2000;26(6):535–541;
discussion, 541–542.
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243
18
Repair of Venous Valves
in Severe Chronic
Venous Insuffi ciency
Michel R. Perrin
INTRODUCTION
According to the CEAP classifi cation “the term chronic venous insuf-
fi ciency (CVI) implies a functional abnormality of the venous system and
is usually reserved for patients with more advanced disease including those
with edema (C3), skin changes (C4) or venous ulcers (C5–6).”
1
Severe CVI is harder to defi ne. For example, the transient edema that
occurs with primary varices would not qualify a patient for this designation,
while permanent edema due to deep venous refl ux or obstruction would.
With regard to skin disorders, the updated CEAP classifi cation divides
class C4 into subgroups C4a and C4b. We suggest that only patients with
class C4b disease and higher be deemed to have severe CVI.
Because repair of superfi cial venous valves is performed primarily in
patients without severe CVI,
2–7
only repair of deep valves will be addressed
in this chapter.
Deep vein valve dysfunction may be due to a variety of causes. The
most common etiology of CVI is secondary in nature; post-thrombotic
syndrome (PTS) accounts for an estimated 60% to 85% of patients
with severe CVI.
8–10
Post-thrombotic syndrome is the result of deep vein
thrombosis and the subsequent infl ammation of the valve cusps and vein
wall during the process of recanalization. This leads to scarring and short-
ening of the cusps, which in turn results in failure of the cusps to achieve
normal coaptation and the attendant refl ux. Refl ux secondary to the PTS
is not amenable to direct surgical repair of the damaged or destroyed
valve.
Venous Ulcers
Copyright © 2007 by Academic Press, Inc.
All rights of reproduction in any form reserved.
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244 Repair of Venous Valves in Severe Chronic Venous Insuffi ciency
Primary refl ux is the result of structural abnormalities in the vein wall
and valve itself. Redundant, malopposed cusps and venous dilation permit
valve prolapse and refl ux. In primary refl ux, unlike PTS, there is no evi-
dence of previous thrombosis or infl ammation near the valve. It is possible,
however, to have both proximal primary refl ux and distal PTS in the same
leg. A rare cause of congenital refl ux is the complete or partial absence of
valves secondary to agenesis.
RATIONALE FOR REPAIR OF
DEEP VENOUS VALVES
The goal of therapy is to correct the deep venous refl ux (DVR) below
the level of the inguinal ligament. Infrainguinal refl ux leads to permanent
venous hypertension, unmitigated by the activity of the calf venomuscular
pump. It is important to note, however, that DVR frequently occurs in
association with superfi cial and perforator refl ux and that all these abnor-
malities must be addressed in order to correct the venous hypertension.
METHODS
Valve repair techniques for treating DVR can be classifi ed into two
groups: those that involve phlebotomy and those that do not involve
phlebotomy.
TECHNIQUES WITH PHLEBOTOMY
Internal Valvuloplasty
Since the fi rst procedure using a longitudinal phlebotomy (Figure 18-1)
described by Kistner
11
in 1968, various procedures have been proposed.
Raju
12
advocated a supravalvular transverse venotomy, while Sottiurai
13
utilized a hybrid T-shaped, supravalvular incision (Figure 18-2). In 2002,
Tripathi
14
proposed an internal trap-door valvuloplasty. In all cases the
redundant valve cup is plicated to the vein wall using multiple interrupted
or continuous 7-0 prolene reefi ng sutures. It has been estimated that plica-
tion of approximately 20% of the leafl et length should restore competence,
although the best gauge remains visual inspection.
Venous Segment Transfer
The venous segment transfer procedure was designed for patients with
a competent great saphenous or deep femoral vein valve in their proximal
segment (Figure 18-3) and DVR in the femoro-popliteal axis related to
post-thrombotic changes. The purpose of venous segment transfer is to
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Repair of Venous Valves in Severe Chronic Venous Insuffi ciency 245
FIGURE 18-1 Internal valvuloplasty according to Kistner. Using a longitudinal phle-
botomy, each valve is repaired by interrupting a series of sutures placed at the commissures.
Each suture progressively shortens the leading edge of the cusp.
FIGURE 18-2 Internal valvuloplasty according to Sottiurai. After T-shaped phlebot-
omy, the valve cusp is repaired.
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246 Repair of Venous Valves in Severe Chronic Venous Insuffi ciency
transpose a competent valve-bearing venous segment into the axial deep
venous system (i.e., the femoro-popliteal axis at the groin level). Several
surgical variations of venous segment transfer have been employed using
end-to-end or side-to-end anastomosis, depending on the competence of
the various valves in the veins of the inguinal area.
15
Unfortunately, this
technique can be used only in approximately 20% of patients with PTS,
because the remaining 80% do not have a competent valve in the proximal
segment of the great saphenous or deep femoral vein.
Vein Valve Transplantation
Figure 18-4 shows a vein valve transplantation. A 2–3-cm segment of
axillary vein is inserted as an interposition graft at the termination of the
femoral vein just below the junction of the deep femoral vein with the
femoral vein or at the popliteal vein.
Neo Valve
Various techniques for creating a neo valve have been developed.
Plagnol
16
constructed a neo bicuspid valve by invagination using the ter-
FIGURE 18-3 A. Venous segment transfer. The refl uxive femoral vein (c) may be
transposed into the great saphenous vein (d) or the profunda femoral vein (b) provided they
have a competent proximal valve above the transposition. B. (a) common femoral vein; (b)
profunda femoral vein; (c) femoral vein; (d) great saphenous vein.
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Repair of Venous Valves in Severe Chronic Venous Insuffi ciency 247
mination of the great saphenous vein, while Maleti
17
created a valvular
cusp by dissecting the femoral venous wall to obtain a single or a bicuspid
valve (Figure 18-5). Both of these techniques have been used in PTS.
Allograft Cryopreserved Valve
Femoral vein allografts with competent valve(s) removed from qualifi ed
donors have been prepared, stored, and implanted in appropriate hosts.
18
TECHNIQUES WITHOUT PHLEBOTOMY
Wrapping, Banding, Cuffi ng, and External Stenting
Wrapping, banding, cuffi ng, and external stenting techniques were ini-
tially developed to treat saphenous incompetence and later applied to the
treatment of primary deep vein incompetence.
19,20
External Valvuloplasty
The fi rst step in external valvuloplasty consists in adventitial dissection
until the valves’ insertion lines are clearly identifi ed as an inverted V. The
commissural angle is normally acute but is widened in a refl uxing valve.
Transmural Valvuloplasty
Kistner introduced external valvuloplasty in 1990.
21
In the transmural
valvuloplasty technique, an external row of sutures is placed along the
diverging margins of the valve cusp in the vein wall. Sutures for external
repair are begun at each commissure on both sides of the vein. The inter-
FIGURE 18-4 Valve transplant. Above-knee or below-knee axillary vein-to-popliteal
vein transplantation end-to-end anastomosis.
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