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any valve reconstruction in the popliteal vein location (48,57,58). One group of
investigators feels that multiple valve repairs in the same axial system (e.g., two in the
femoral vein) may decrease the risk of long-term failure (59), but most surgeons use
solitary valve repair with similar success. One investigator has even performed multiple
tibial vein valve repairs to correct axial reflux (59).
TREATMENT OPTIONS AND RESULTS
Perforator Vein Ligation
Perforator vein ligation can be performed via an open or minimally invasive endoscopic
technique. A Linton type procedure utilizes an incision along the medial or posterior lower
leg and the creation of subfascial flaps to allow exposure of the perforators (60–62). The
perforating veins are directly ligated and divided. The best scenario allows for healing of
any ulceration prior to operation to minimize the risk of infection in the flap area, but if
a skin ulcer is recalcitrant, it will likely require simultaneous debridement. If a large
amount of soft tissue and/or fascia is involved, a skin graft can aid in healing. DePalma
used multiple incisions orientated along skin lines and the development of bipedicle flaps
between each to allow ligation of perforating veins (63). Possibly a historical preamble to
endoscopic perforator surgery was Edwards use of a phlebotome placed subfascially via
a proximal, medial knee incision utilizing blind advancement to the medial malleolus to
disrupt encountered perforator veins (64). Infection concerns or lack of visualization
resulted in a technical switch with advancements in technology.
An endoscopic technique (SEPS or Subfascial Endoscopic Perforator Surgery) can
be employed (65,66). Following slight knee flexion, two small (10–15 mm) incisions are
made on the medial aspect of the lower leg near the knee proximal to areas of induration
and inflammation. Subfascial dissection is performed using sharp and blunt balloon
dissection. Some surgeons place a tourniquet on the upper leg to be inflated prior to
subfascial insufflation of carbon dioxide (CO
2
), which is used to improve visualization and
to prevent CO
2
emboli. Other surgeons feel this step unnecessary because the venous
system is better visualized with blood within the perforator veins and because the risk of
embolism is minimal. Under video enhanced imaging, the perforating veins are ligated
with clips and divided. Some physicians have utilized mediastinoscopes and long clip
applier to obviate the need for second incision (67,68). The closeness of the light source
and clipping mechanism within the same port can sometimes make it difficult to dissect
with three-dimensional clarity. Most surgeons preoperatively mark the perforating veins
with duplex scanning to assure that all offending veins are identified at the time of surgery.
Recognizing the impact of paratibial perforator veins, which require a fascial incision to
visualize, has prevented the need for subsequent operations to address missed
perforators (19). Recent adventures into subfascial endoscopic perforating vein surgery
for laterally located veins with associated venous ulceration have been reported with some
but less impressive clinical success (69,70). Venous ulceration in this locale accounts for
less than 10% of cases but can be a problem when encountered and awareness of potential
treatments is useful.
Safety and early efficacy of SEPS has been demonstrated (65,66). A mid-term
evaluation of patients undergoing SEPS demonstrated the patients to have decreased
symptoms and a near 90% ulcer healing rate at two years (71). Information on current
SEPS literature reports that wound complications are less common after the SEPS
(0–10%) than the open method (12–53%) with comparable outcomes (72). These findings
were confirmed by the only prospective, randomized study comparing SEPS with the
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Linton procedure (68). 53% of patients undergoing the Linton procedure had wound
complications while none in the SEPS group experienced this complication. At four years
of follow-up, 22% of the patients in the Linton group had recurrent venous ulceration
while 12% were so affected in the SEPS cohort (73). Whether SEPS is required in addition
to saphenous surgery for advanced chronic venous disease when both systems demonstrate
insufficiency remains debatable but a trend to more aggressive use to control all potential
venous hypertension is being seen in the literature (72).
Deep Venous Reconstructions
General Comments
During the performance of deep venous reconstruction, several observations influence
what the surgeon can do for a given patient. If manipulation of an in situ valve results in
vasoconstriction and secondary competence (the “strip test” becomes normal), then an
external valvuloplasty or a prosthetic sleeve technique may be a good repair for the
patient (74). If a valve requires an in situ repair, careful adventitial dissection of
the valve attachment lines facilitates appropriate venotomy, preventing damage to the
delicate valve leaflets, and helps to verify the feasible of an in situ repair (75). A lack of
clear valve attachment lines can signify valve destruction as a component of the post-
thrombotic syndrome prompting other than an in situ repair (75).
Prophylactic antibiotics should be given prior to skin incision, generally a first-
generation cephalosporin, and continued postoperatively for two to three days. Intra-
operative heparin is administered (2,000 to 10,000 units) based on the need to open
the vein and duration of clamping. Heparin is generally not reversed at the end of the
procedure. Pneumatic compression devices may be helpful postoperatively to decrease
swelling and may increase flow over the valve repair during inactivity. Low molecular
weight heparin or low-dose intravenous heparin should be started immediately
postoperatively and may influence the use of closed drainage to avoid hematoma
formation. Warfarin is generally begun on postoperative day one to help decrease the
hospital length of stay. A target INR of 2.0 to 2.5 is applied for the first six weeks with
a decreased to 1.7 to 2.0 for four months at which point it is stopped with adjustments for
any increased risk of thrombosis. One suggested long-term regiment of anticoagulation is
“minidose” warfarin using daily doses of 1 mg to 2.5 mg to prevent thrombosis (75,76).
Many surgeons encourage the use of compressive support following surgery but many
patients fail to comply and yet have a good clinical result (21,26).
Internal Valvuloplasty
An internal valvuloplasty, open direct valve repair, has been a mainstay for the repair of
primary venous valvular reflux for over 40 years. This technique requires a venotomy and
suturing of the floppy valve leaflets under direct visualization with 7-0 or 6-0
polypropylene suture to tighten the valve cusps. Kistner reported success with
a longitudinal venotomy extending through the valve commissure in 1968 (77). Raju
uses a supracommissural approach involving a transverse venotomy beginning atleast
2.5 cm above the valve (78). Sottiurai devised a hybrid “T”-shaped venotomy using
a supravalvular transverse venotomy with distal extension into a valve sinus (79). Tripathi
and his associates now champion a “trapdoor” approach involving two transverse incisions
(80). One incision is above and one below the valve connected by a single vertical incision
through the commissure (80). The suturing of the valve leaflets remains essentially the
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same no matter what opening in the vein is made and plication of about 20% of the valve
leaflet length seems to restore valve competency in most cases (81).
External Valvuloplasty
The technique of external valvuloplasty offers the advantage of valve repair without
venotomy (82). It is performed by placing sutures completely through the valve
attachment lines such that when the sutures are tied the commissural angle is narrowed
and the valve becomes competent. Although some reports suggest that it may be less
durable than the more precise open valvuloplasty, patient selection likely plays a key role
in success realized (48). A modification uses a limited anterior plication which involves
only anterior vein wall dissection and reefing of the cusps using a running mattress
suture. The suture is begun at a point 3–4 mm above the angle of the valve cusp insertion
lines and progresses to the angle of valve cusp insertion (83). About 3 mm of the vein
wall is incorporated into the stitch to narrow the cusps. The aim is to decrease the
vein wall dissection and therefore to hopefully reduce the progressive dilatation of
the vein sometimes noted after valvuloplasty. It has been described in conjunction with
saphenous vein stripping and limited to the femoral vein valve station. Results after ten-
year follow-up demonstrated improved venous refilling time and decreased ambulatory
venous pressures in patients with moderate deep venous valvular incompetence (83).
Thus, it shows promise as a mode of therapy for highly selected patients. Another
modification of the external technique features the use of an angioscope which therefore
adds a component of intralumenal visualization (84). A side branch of the GSV allows
introduction of an angioscope, which is advanced into the femoral vein above the
incompetent valve allowing external sutures to be placed under direct vision (84).
Following a learning curve which involved use of the angioscope, Raju and colleagues
demonstrated good clinical and competency data with the “transcommissural” technique
without the use angioscopy in a study with 30 months of follow-up (85).
External Banding
External banding has been employed when dissection vasospasm renders a valve
spontaneously competent. The technique uses an external sleeve made of synthetic
material [polytetraflouroethylene (PTFE) or polyester (Dacron)] wrapped circumferen-
tially around the vein at the valve and tightened to diminish the vein diameter until the
valve becomes competent. The sleeve is anchored to the adventitia by sutures to prevent
slippage. It has achieved good results when used in very select patients (48).
Venous Valve Transplantation
Venous valve transplantation is sometimes the onlyoption when an in situ valve is absent or
destroyed. This procedure was first reported clinically by Taheri early in the 1980’s (86).
A 2–3 cm segment of upper extremity vein containing a valve is first removed. Approxi-
mately 40% of axillary vein valves are incompetent at the time of explant and therefore
require bench repair prior to implant (75,81). Should a bench repair be necessary, the
transcommissural external valvuloplasty technique appears to have better results than
the standard external valvuloplasty (75), and some success has been achieved with internal
valvuloplasty (87). The incompetent femoral vein is exposed in routine fashion from below
the takeoff of the profunda femoris vein and for at least several centimeters distally to allow
removal of appropriate femoral vein such that the axillary vein segment can be sutured into
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place without tension or laxity. The popliteal location may be more appropriate if the
femoral location does not completely control axial reflux, for example, if the profunda
femoral vein system is also incompetent. The proximal anastomosis may be accomplished
first to allow distention and lengthening of the vein and to confirm competence of the
valve prior to and as an aid to completing the distal anastomosis. Trabeculated post-
thrombotic veins were once thought unacceptable for valve transplantation but investigators
have described excision of intraluminal synechiae to create an acceptable lumen for
transplantation (88). An interrupted sutures technique is recommended by most surgeons to
avoid suture line stenosis (81). Valve competence is determined by intraoperative strip
testing. An external sleevecan then be placed around the segment to prevent later dilationof
the segment.
Valve Transposition
Valve transposition is another option in management of patients with the post-thrombotic
syndrome. If a venous valve is competent in one of the axial thigh venous systems, then a
transposition procedure can be used to place the incompetent venous system below the
competent valve. Most commonly, the femoral system is incompetent and the profunda
femoris valve remains competent. The incompetent femoral vein can be transected and
reimplanted distal to the competent valve in the profunda femoris vein. Alternatively, the
incompetent femoral system can be reimplanted below a competent greater saphenous vein
valve. When theprofunda femoris venous system is dysfunctional, it may be placed distal to
a competent valve in either the femoral vein or the greater saphenous vein. A technique has
been described for transposition of the ipsilateral valve-competent greater saphenous vein to
the femoral vein with subsequent ligation of the femoral vein proximally yet distal to the
takeoffof theprofunda femorisvein toescape problems with diameter mismatch (89). At ten
years, 55% of the patients were reported to be ulcer-free (89).
Results of Standard Methods of Deep Venous Reconstructions
Valve repair procedures have a low morbidity and essentially zero mortality in most series
(9). Hematoma and seroma formation is seen in up to 15% of cases, with some expected
variation in the rate of hematoma formation dependent on the intensity of anticoagulation
(26,81,90,91). Deep venous thrombosis occurs in less than 10% of cases in most series
(26,75,81,90,91). Although one series had an incidence of thrombosis (often not occlusive
nor extensive) in the extremity of repair of approximately 20% as detected by ascending
venogram two days postoperatively. These events did not appear to have an impact on
clinical results (92). Wound infections have been seen in 2–4% of cases (26,75,81).
In general, reported results have been separated by the method of deep venous
reconstruction. Kistner and colleagues have followed their patients requiring internal
valvuloplasty for decades and have reported their results in life-table format with excellent
results (93,94). Valve competency is approximately 70% at five years in most series
(21,26,48,54,78,80,92–97). A patent and competent valve translates into clinical
improvement and a healed ulcer in general, while recurrent reflux is associated with
clinical failure. A similar commentary can be made about all types of venous
valvular reconstruction.
Valve transposition has reported clinical improvement of 50–60% of patients so
treated with three to five years of follow-up (9,26,89,96). The valve competency rate
varies from 30–80% and is clearly reflected in the clinical improvement noted
(9,26,89,96).
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Valve transplantation operations are performed in patients with the most difficult
anatomy and most damaged deep venous system. Clinical improvement is seen in about
50% of patients even at eight years of follow-up, and remains a viable and acceptable
option in cases where other techniques are not possible (8,9,81).
There does not appear to be a difference between reported competency rates or
clinical results when considering the location of valve transplantation (femoral verses
popliteal) but, in general, the competency rates reported for all other repairs are inferior
to internal valvuloplasty (57,58,77,96,98–102). Some of the difference in results can
be attributed to the more severe disease (damage inflicted by DVT) noted in patients
requiring transplantation or a transposition operation when compared to those requiring
valvuloplasty (generally a primary etiology) (26). Although Raju and associates find little
difference between the post-thrombotic and primary patient results in their series (48),
this may simply reflect a delay in the appearance of ulceration following valve failure.
These same investigators are one of a few with sufficiently high volume in a variety of
venous valve repairs to report a difference in valve competence based on method of repair.
It would appear that there is decreasing durability as one progresses from internal
valvuloplasty, to external valvuloplasty, and finally, to a need for transplantation (48).
Valve Substitutes
For those end-stage patients with chronic deep venous insufficiency and no autogenous
valve available, the only option is a valve substitute. Ingenious and creative methods
have been invented to address these patients. Dr. Raju and associates have reported
a small series of patients receiving de novo valve reconstruction procedures with rather
good clinical results (75). These procedures involve the use of donor vein wall from
which semilunar cusps are made after trimming adventitia and part of the media. The
valve “cusps” are sutured into the recipient vein with the nonendothelial surface directed
intralumenally to hopefully decrease the risk of thrombosis. Another attempt to use
autogenous vein as a valve substitute has been reported by Plagnol et al. (103). This
approach invaginates a stump of the greater saphenous vein into the femoral vein to
form a bicuspid valve. The invaginated component of the greater saphenous vein is
tacked to the opposite femoral vein wall with prolene suture to maintain its structure.
They report 19 of 20 reconstructions to be patent and competent at a mean of ten months
(103). One valve demonstrated reflux. The invagination of an adventitial surface into the
venous lumen is of some concern, a fear not upheld in this one report. Pushing the limits
even further, an Italian vascular surgeon has reported a series of bicuspid or monocusp
venous valves made from dissecting the intimal/medial wall from the thickened post-
phlebitic vein to form cusps. The initial seven cases were reported in 2002 with
acceptable preliminary results (104). A more robust report was given at the recent
American Venous Forum meeting in 2005 (105). Eighteen venous valves were
constructed in 16 patients with recurrent or non-healing venous ulcers due to post-
thrombotic chronic deep venous insufficiency. The patients were anticoagulated for six
months. Early thrombosis below the valve occurred in two patients and there was one
late occlusion after beginning oral contraceptives. Therefore, 83.3% of treated segments
at a mean 22 months of follow-up remained patent primarily with significantly improved
duplex and air plethysmographic results. This technique certainly seems promising
if others can duplicate these results.
Psathakis and Psathakis reported on a substitute “valve” operation using a Silastic
tendon designed to produce an external compression of the popliteal vein and thereby
prevent reflux with relaxation of the calf muscles (106). Perrin has attempted this
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procedure in nine patients but poor clinical and hemodynamic results were obtained.
He stopped using this procedure after one year (92). The technique has not gained
wide acceptance.
Many experimental attempts using allografts and synthetics have been unsuccessful
(107,108). A cadaveric cryopreserved pulmonary monocusp patch has been described with
reasonable clinical results in a very small group of patients (109). None of these valve
substititutes have been proven clinically useful to date.
Most recently, a bioprosthetic (small intestinal submucosa architecture), bicuspid
square stent-based venous valve was developed and placed percutaneously in the external
jugular vein of sheep (110). The valve appears to be somewhat resistant to thrombosis and
does become repopulated with recipient endothelial cells following implantation
(110,111). This technique shows promise as a minimally invasive synthetic valve and
continues in research and development (personal communication).
SUMMARY
The surgical treatment of CVI is a maturing field with various options available to the
patient based on specific preoperative evaluation. The majority of patients treated have
C
5,6
clinical disease, but with improving results some surgeons have extended the
indications to symptoms disabling to the patients in their daily lives. Noninvasive studies,
most notably duplex imaging, can provide detailed information about perforator and deep
venous valvular insufficiency. Perforator venous insufficiency is recommended in patients
with advanced disease, with or without associated superficial or deep disease, either as
primary treatment or to prevent recurrence due to missed perforator disease. In many
cases, descending venography provides an invasive but easy visualization of options
available for the treatment of deep venous insufficiency. Primary deep vein valve
incompetence is most commonly treated by internal valvuloplasty due to its adaptability
and long track record, followed by external banding or external valvuloplasty in select
patients. Transcommissural valvuloplasty may achieve superior results to a standard
external valvuloplasty. For management of the post-thrombotic syndrome, valve
transplantation is the most versatile option with transposition remaining useful in a select
patient cohort. Some autogenous valve substitutes have reached very limited clinical use,
most probably in cases where all other options were simply not possible. The search for
off-the-shelf valve substitutes continues with little success to date. Proper follow-up with
appropriate measurement tools to analyze success must be the goal of future study to
determine the best treatment for any given cohort of patients.
KEY POINTS
† Chronic venous disease affects 30 millions U.S. citizens with 2% experiencing
the disability of venous ulceration.
† Although the majority are affected primarily by superficial venous insufficiency,
approximately 30% have primarily deep venous insufficiency with associated
perforator disease in both, especially if the symptom is venous ulceration (60%).
† Patients with disabling symptoms unresponsive to compression or less invasive
treatments (i.e., superficial saphenous ablation) are candidates for perforator or
deep venous insufficiency surgery.
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† The etiology of primary venous valvular insufficiency is dilation of valve cusps
or the vein wall with preservation of valve architecture, while secondary valvular
insufficiency is generally the result of the scarring and fibrosis of deep venous
thrombosis. Differentiating the impact of each is blurred in individual patients.
† An accurate picture of the patient’s condition is critical to develop a proper
treatment plan and evaluate it. The CEAP classification, severity scores, and
quality of life surveys aid in this task and in wide spread acceptance of
any treatment.
† Currently, the two most useful non invasive diagnostic studies to clarify the
location and impact of venous insufficiency are the Duplex venous imaging study
and air plethysmographic (APG) evaluation.
† Descending venography is still utilized by many surgeons prior to deep venous
reconstruction to determine reflux degree and clarify valve anatomy.
† Perforator vein insufficiency surgery is warranted when demonstrated objectively
(generally by duplex imaging) and the patient has advanced disease especially
venous ulceration.
† Deep venous reconstruction is warranted when other less invasive methods have
failed and disabling symptoms remain (often recalcitrant or recurrent venous
ulceration).
† SEPS (Subfascial Endoscopic Perforator Surgery) is currently the recommended
method of treating perforator disease due to less wound complications than
Linton type procedures with equivalent clinical results.
† Internal Valvuloplasty is the best studied and most versatile technique for
treating primary deep venous valvular insufficiency with a 70% valve
competence rate, which translates into a similar rate of clinical success. Various
techniques of external valvuloplasty and external banding are useful for select
patients and when chosen well are also effective.
† Venous valve transplantation is the most versatile method of treating secondary
deep venous insufficiency while the transposition operation has limited appli-
cation. Clinical success is about 50% at five to eight years.
† In the treatment of deep venous insufficiency, the location and number of valve
reconstructions must aim to eliminate all major axial reflux into the calf.
† Preliminary reports using autogenous valve substitutes in difficult cases show
quite acceptable early results.
† Nonautogenous valve substitutes have fared poorly to date in the clinical arena.
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