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Brahma B, Yamamoto T, Panigoro SS, Haryono SJ, Yusuf PA, Priambodo PS, Harimurti K, Taher A. Supermicrosurgery lymphaticovenous and lymphaticolymphatic anastomosis: Technical detail and short-term follow-up for immediate lymphatic reconstruction in breast cancer treatment-related lymphedema prevention. J Vasc Surg Venous Lymphat Disord 2024; 12:101863. [PMID: 38428499 DOI: 10.1016/j.jvsv.2024.101863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 02/05/2024] [Accepted: 02/12/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE We describe the feasibility and short-term outcome of our surgical technique to repair the lymph vessel disruption directly after axillary lymph node dissection during breast cancer surgery. This procedure is called immediate lymphatic reconstruction to prevent breast cancer treatment-related lymphedema (BCRL), which frequently occurs after axillary lymph node dissection. The surgical technique consisted of lymphaticovenous anastomosis (LVA) or lymphaticolymphatic anastomosis. We named the procedure lymphatic bypass supermicrosurgery (LBS). METHODS This study used a retrospective cohort design of patients with breast cancer between May 2020 and February 2023. LBS was performed by making an intima-to-intima coaptation between afferent lymph vessels and the recipient's veins (LVA) or efferent lymph vessels lymphaticolymphatic anastomosis. RESULTS A total of 82 patients underwent lymphatic bypass. The mean age of patients was 50 ± 12 years, and most had stage III breast cancer (n = 59 [72%]). LVA was the most common type of lymphatic bypass (94.6%). The median number of LVA was 1 (range, 1-4) and 1 (range, 1-3) for lymphaticolymphatic anastomosis. The median follow-up time was 12.5 months (range, 1-33 months). The 50 patients who had postoperative indocyanine green lymphography described arm dermal backflow stage 0 in 20 (40%), stage 1 in 19 (38%), stage 2 in 2 (4%), and stage 3 in 9 (18%) cases. The proportion of BCRL was 11 (22%), and subclinical lymphedema was 19 (38%) in this period. Most cases were in stable subclinical lymphedema (10, 58.8%). The 1-year and 2-year BCRL rates were 14% (95% confidence interval, 4%-23.9%) and 22% (95% confidence interval, 10.1%-33.9%), respectively. CONCLUSIONS Along with the emerging immediate lymphatic reconstruction, LBS is a feasible supermicrosurgery technique that may have a potential role in BCRL prevention. A randomized controlled study would confirm the effectiveness of the technique.
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Affiliation(s)
- Bayu Brahma
- Doctoral Program in Medical Sciences, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, National Center for Global Health and Medicine, Tokyo, Japan.
| | - Sonar Soni Panigoro
- Oncology Division, Department of Surgery, Faculty of Medicine, Universitas Indonesia - Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Samuel Johny Haryono
- Department of Surgical Oncology, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia
| | - Prasandhya Astagiri Yusuf
- Department of Medical Physiology and Biophysics/Medical Technology IMERI, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Purnomo Sidi Priambodo
- Department of Electrical Engineering, Faculty of Engineering, Universitas Indonesia, Jakarta, Indonesia
| | - Kuntjoro Harimurti
- Division of Geriatrics/Clinical Epidemiological Unit, Department of Internal Medicine, Universitas Indonesia - Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
| | - Akmal Taher
- Department of Urology, Faculty of Medicine, Universitas Indonesia - Dr. Cipto Mangunkusumo General Hospital, Jakarta, Indonesia
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Maleti O, Orso M, Lugli M, Perrin M. Systematic review and meta-analysis of deep venous reflux correction in chronic venous insufficiency. J Vasc Surg Venous Lymphat Disord 2023; 11:1265-1275.e5. [PMID: 37453548 DOI: 10.1016/j.jvsv.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 06/27/2023] [Accepted: 07/01/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the technical feasibility, operative techniques, safety, and efficacy outcomes of procedures aimed at correcting deep venous reflux, in patients with chronic venous insufficiency. METHODS We performed systematic literature searches in PubMed, Embase, and Web of Science from databases' inception to February 2022. We included systematic reviews, randomized controlled trials, and observational studies describing surgical procedures to treat patients with deep reflux due to primary and secondary incompetence, post-thrombotic syndrome (PTS). Proportion meta-analyses were performed for all the efficacy and safety outcomes. RESULTS We included 57 studies in the quantitative synthesis: three randomized controlled trials including 252 patients and 54 case series including 4004 patients. Studies included a median of 38 patients, with a mean age of 51 years; 52% of them were males. Forty percent of studies included 2291 patients with primary incompetence, 29% of studies included 595 patients with PTS, and 31% of studies included 1118 patients with both diseases. As for primary incompetence, pooled estimates for all procedures showed an 89% (95% confidence interval [CI], 82%-94%) of ulcer healing, 10% (95% CI, 4%-18%) ulcer recurrence, 98% (95% CI, 93%-100%) valve patency, 84% (95% CI, 78%-90%) valve competence, 0.05% (1/1904 patients) pulmonary embolism, 1% (95% CI, 0%-3%) wound infections, 5% (95% CI, 1%-9%) hematoma, 2% (95% CI, 0%-6%) lymphocele, 2% (95% CI, 1%-4%) thrombosis, 85% (95% CI, 74%-94%) pain improvement, 89% (95% CI, 65%-100%) edema improvement, and 85% (95% CI, 73%-93%) lipodermatosclerosis improvement. Patients with PTS showed less favorable outcomes: 82% (95% CI, 71%-91%) of ulcer healing, 18% (95% CI, 5%-36%) ulcer recurrence, 88% (95% CI, 78%-96%) valve patency, 78% (95% CI, 66%-88%) valve competence, no pulmonary embolism, 6% (95% CI, 0%-22%) wound infections, 6% (95% CI, 3%-10%) hematoma, 5% (95% CI, 1%-12%) lymphocele, 7% (95% CI, 1%-16%) thrombosis, 79% (95% CI, 59%-94%) pain improvement, 75% (95% CI, 61%-88%) edema improvement, and 64% (95% CI, 9%-100%) lipodermatosclerosis improvement. CONCLUSIONS The number of studies included in each meta-analysis are limited, and knowing how this element can affect the statistical power, as well as the absence of comparative control groups, it is not possible to draw definitive conclusions. Nevertheless, deep venous reconstructive surgery for reflux may increase the probability of clinical improvement in patients affected by chronic venous insufficiency. Outcomes appear to be satisfactory even if possible adjunctive procedures may be required over the course of the patient's lifetime. Consequently, a strict follow-up protocol is required to maintain outcomes. Further studies are required to evaluate deep venous reconstructive surgery for reflux particularly as to how it compares with the more recently introduced endovenous approaches.
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Affiliation(s)
- Oscar Maleti
- National reference Training Center in Phlebology, UEMS, Vascular Surgery, Cardiovascular Department Hesperia Hospital, Modena, Italy
| | - Massimiliano Orso
- Istituto Zooprofilattico Sperimentale dell'Umbria e delle Marche 'Togo Rosati', Perugia, Italy
| | - Marzia Lugli
- National reference Training Center in Phlebology, UEMS, Vascular Surgery, Cardiovascular Department Hesperia Hospital, Modena, Italy.
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Stanek A, Mosti G, Nematillaevich TS, Valesky EM, Planinšek Ručigaj T, Boucelma M, Marakomichelakis G, Liew A, Fazeli B, Catalano M, Patel M. No More Venous Ulcers-What More Can We Do? J Clin Med 2023; 12:6153. [PMID: 37834797 PMCID: PMC10573394 DOI: 10.3390/jcm12196153] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/12/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023] Open
Abstract
Venous leg ulcers (VLUs) are the most severe complication caused by the progression of chronic venous insufficiency. They account for approximately 70-90% of all chronic leg ulcers (CLUs). A total of 1% of the Western population will suffer at some time in their lives from a VLU. Furthermore, most CLUs are VLUs, defined as chronic leg wounds that show no tendency to heal after three months of appropriate treatment or are still not fully healed at 12 months. The essential feature of VLUs is their recurrence. VLUs also significantly impact quality of life and could cause social isolation and depression. They also have a significant avoidable economic burden. It is estimated that the treatment of venous ulceration accounts for around 3% of the total expenditure on healthcare. A VLU-free world is a highly desirable aim but could be challenging to achieve with the current knowledge of the pathophysiology and diagnostic and therapeutical protocols. To decrease the incidence of VLUs, the long-term goal must be to identify high-risk patients at an early stage of chronic venous disease and initiate appropriate preventive measures. This review discusses the epidemiology, socioeconomic burden, pathophysiology, diagnosis, modes of conservative and invasive treatment, and prevention of VLUs.
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Affiliation(s)
- Agata Stanek
- Department of Internal Medicine, Angiology and Physical Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Batorego 15 Street, 41-902 Bytom, Poland
- Vascular Independent Research and Education, European Foundation, 20157 Milan, Italy; (G.M.); (A.L.); (B.F.); (M.C.); (M.P.)
- VAS-International Consortium—International No More Venous Ulcers Strategic Network, 20157 Milan, Italy; (G.M.); (T.S.N.); (E.M.V.); (T.P.R.); (M.B.)
| | - Giovanni Mosti
- VAS-International Consortium—International No More Venous Ulcers Strategic Network, 20157 Milan, Italy; (G.M.); (T.S.N.); (E.M.V.); (T.P.R.); (M.B.)
- Angiology Department, MD Barbantini Clinic, Via del Calcio 2, 55100 Lucca, Italy
| | - Temirov Surat Nematillaevich
- VAS-International Consortium—International No More Venous Ulcers Strategic Network, 20157 Milan, Italy; (G.M.); (T.S.N.); (E.M.V.); (T.P.R.); (M.B.)
- Department of Specialized Surgery, Central Hospital of Ministry of Internal Affairs, Chimboy St. 2 A, Almazar District, Tashkent 100095, Uzbekistan
| | - Eva Maria Valesky
- VAS-International Consortium—International No More Venous Ulcers Strategic Network, 20157 Milan, Italy; (G.M.); (T.S.N.); (E.M.V.); (T.P.R.); (M.B.)
- Department of Dermatology, Venereology and Allergology, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60596 Frankfurt am Main, Germany
| | - Tanja Planinšek Ručigaj
- VAS-International Consortium—International No More Venous Ulcers Strategic Network, 20157 Milan, Italy; (G.M.); (T.S.N.); (E.M.V.); (T.P.R.); (M.B.)
- Dermatovenereological Clinic, University Medical Centre Ljubljana, Gradiskova 10 Street, 1000 Ljubljana, Slovenia
| | - Malika Boucelma
- VAS-International Consortium—International No More Venous Ulcers Strategic Network, 20157 Milan, Italy; (G.M.); (T.S.N.); (E.M.V.); (T.P.R.); (M.B.)
- Department of Internal Medicine, University of Algiers, Bachir Mentouri Hospital, Algiers 16208, Algeria
| | - George Marakomichelakis
- Vascular Independent Research and Education, European Foundation, 20157 Milan, Italy; (G.M.); (A.L.); (B.F.); (M.C.); (M.P.)
- VAS-International Consortium—International No More Venous Ulcers Strategic Network, 20157 Milan, Italy; (G.M.); (T.S.N.); (E.M.V.); (T.P.R.); (M.B.)
- 4th Department of Internal Medicine, General Hospital of Evangelismos, 16676 Athens, Greece
| | - Aaron Liew
- Vascular Independent Research and Education, European Foundation, 20157 Milan, Italy; (G.M.); (A.L.); (B.F.); (M.C.); (M.P.)
- VAS-International Consortium—International No More Venous Ulcers Strategic Network, 20157 Milan, Italy; (G.M.); (T.S.N.); (E.M.V.); (T.P.R.); (M.B.)
- Department of Medicine, Portiuncula University Hospital, University of Galway, H91 TK33 Galway, Ireland
| | - Bahar Fazeli
- Vascular Independent Research and Education, European Foundation, 20157 Milan, Italy; (G.M.); (A.L.); (B.F.); (M.C.); (M.P.)
- Support Association of Patients of Buerger’s Disease, Buerger’s Disease NGO, Mashhad 9183785195, Iran
| | - Mariella Catalano
- Vascular Independent Research and Education, European Foundation, 20157 Milan, Italy; (G.M.); (A.L.); (B.F.); (M.C.); (M.P.)
- VAS-International Consortium—International No More Venous Ulcers Strategic Network, 20157 Milan, Italy; (G.M.); (T.S.N.); (E.M.V.); (T.P.R.); (M.B.)
- Department of Biomedical, Clinical Sciences L Sacco Hospital, Inter-University Research Center on Vascular Disease, University of Milan, 20157 Milan, Italy
| | - Malay Patel
- Vascular Independent Research and Education, European Foundation, 20157 Milan, Italy; (G.M.); (A.L.); (B.F.); (M.C.); (M.P.)
- VAS-International Consortium—International No More Venous Ulcers Strategic Network, 20157 Milan, Italy; (G.M.); (T.S.N.); (E.M.V.); (T.P.R.); (M.B.)
- Department of Vascular Surgery, Apollo CVHF, Heart Institute, Ahmedabad 380059, India
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Us MH, Ugur M. Has external banding become a historical technique during venous valve repair? Rev Assoc Med Bras (1992) 2021; 67:1676-1680. [DOI: 10.1590/1806-9282.20210721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 09/03/2021] [Indexed: 11/21/2022] Open
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Fernández-Colino A, Jockenhoevel S. Advances in Engineering Venous Valves: The Pursuit of a Definite Solution for Chronic Venous Disease. TISSUE ENGINEERING PART B-REVIEWS 2020; 27:253-265. [PMID: 32967586 DOI: 10.1089/ten.teb.2020.0131] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Native venous valves enable proper return of blood to the heart. Under pathological conditions (e.g., chronic venous insufficiency), venous valves malfunction and fail to prevent backward flow. Clinically, this can result in painful swelling, varicose veins, edema, and skin ulcerations leading to a chronic wound situation. Surgical correction of venous valves has proven to drastically reduce these symptoms. However, the absence of intact leaflets in many patients limits the applicability of this strategy. In this context, the development of venous valve replacements represents an appealing approach. Despite acceptable results in animal models, no venous valve has succeeded in clinical trials, and so far no single prosthetic venous valve is commercially available. This calls for advanced materials and fabrication approaches to develop clinically relevant venous valves able to restore natural flow conditions in the venous circulation. In this study, we critically discuss the approaches attempted in the last years, and we highlight the potential of tissue engineering to offer new avenues for valve fabrication. Impact statement Venous valves prosthesis offer the potential to restore normal venous flow, and to improve the prospect of patients that suffer from chronic venous disease. Current venous valve replacements are associated with poor outcomes. A deeper understanding of the approaches attempted so far is essential to establish the next steps toward valve development, and importantly, tissue engineering constitutes a unique toolbox to advance in this quest.
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Affiliation(s)
- Alicia Fernández-Colino
- Department of Biohybrid & Medical Textiles (BioTex), AME-Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany
| | - Stefan Jockenhoevel
- Department of Biohybrid & Medical Textiles (BioTex), AME-Institute of Applied Medical Engineering, Helmholtz Institute, RWTH Aachen University, Aachen, Germany.,AMIBM-Aachen-Maastricht-Institute for Biobased Materials, Maastricht University, Geleen, Netherlands
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Leckie KE, Dalsing MC. Open Surgical Reconstruction for Deep Venous Occlusion and Valvular Incompetence. Surg Clin North Am 2018; 98:373-384. [PMID: 29502778 DOI: 10.1016/j.suc.2017.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
This article considers the potential options for open deep venous reconstructions based on pathologic complication (obstruction vs insufficiency), anatomic location, presence of disease-free venous architecture, and patient need. Other things being equal, less invasive techniques and disease locations will be attempted as first-line therapy. When other options fail and symptoms persist, open venous surgery by means of bypass for obstructive disease and valve repair or replacement for deep venous insufficiency remains a viable option. The basic techniques available and overall success rates of each are considered.
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Affiliation(s)
- Katherin E Leckie
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, 1801 North Senate Boulevard, Suite 3500, Indianapolis, IN 46202, USA.
| | - Michael C Dalsing
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, 1801 North Senate Boulevard, Suite 3500, Indianapolis, IN 46202, USA
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Boersma D, Vink A, Moll FL, de Borst GJ. Proof-of-Concept Evaluation of the SailValve Self-Expanding Deep Venous Valve System in a Porcine Model. J Endovasc Ther 2017; 24:440-446. [DOI: 10.1177/1526602817700120] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To evaluate the SailValve, a new self-expanding deep venous valve concept based on a single polytetrafluoroethylene cusp floating up and down in the bloodstream like a sail, acting as a flow regulator and allowing minimal reflux to reduce thrombogenicity. Methods: Both iliac veins of 5 pigs were implanted with SailValve devices; the first animal was an acute pilot experiment to show the feasibility of accurately positioning the SailValve via a femoral access. The other 4 animals were followed for 2 weeks (n=2) or 4 weeks (n=2) under a chronic implantation protocol. Patency and valve function were evaluated directly in all animals using ascending and descending phlebography after device placement and at termination in the chronic implant animals. For reasons of clinical relevance, a regimen of clopidogrel and calcium carbasalate was administered. Histological analysis was performed according to a predefined protocol by an independent pathologist. Results: Deployment was technically feasible in all 10 iliac veins, and all were patent directly after placement. No perioperative or postoperative complications occurred. Ascending phlebograms in the follow-up animals confirmed the patency of all valves after 2 or 4 weeks. Descending phlebograms showed full function in 5 of 8 valves. Limited reflux was seen in 1 valve (4-week group), and the function in the remaining 2 valves (2-week group) was insufficient because of malpositioning. No macroscopic thrombosis was noted on histology. Histology in the follow-up groups revealed a progressive inflammatory reaction to the valves. Conclusion: This animal study shows the potential of the SailValve concept with sufficient valve function after adequate positioning and no (thrombogenic) occlusions after short-term follow-up. Future research is essential to optimize valve material and long-term patency.
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Affiliation(s)
- Doeke Boersma
- Department of Vascular Surgery, University Medical Centre, Utrecht, the Netherlands
- Department of Surgery, Jeroen Bosch Ziekenhuis, Den Bosch, the Netherlands
| | - Aryan Vink
- Department of Pathology, University Medical Centre, Utrecht, the Netherlands
| | - Frans L. Moll
- Department of Vascular Surgery, University Medical Centre, Utrecht, the Netherlands
| | - Gert J. de Borst
- Department of Vascular Surgery, University Medical Centre, Utrecht, the Netherlands
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9
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Popliteal vein external banding at the valve-free segment to treat severe chronic venous insufficiency. J Vasc Surg 2016; 64:438-445.e1. [DOI: 10.1016/j.jvs.2016.03.412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 03/05/2016] [Indexed: 11/20/2022]
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Wittens C, Davies AH, Bækgaard N, Broholm R, Cavezzi A, Chastanet S, de Wolf M, Eggen C, Giannoukas A, Gohel M, Kakkos S, Lawson J, Noppeney T, Onida S, Pittaluga P, Thomis S, Toonder I, Vuylsteke M, Kolh P, de Borst GJ, Chakfé N, Debus S, Hinchliffe R, Koncar I, Lindholt J, de Ceniga MV, Vermassen F, Verzini F, De Maeseneer MG, Blomgren L, Hartung O, Kalodiki E, Korten E, Lugli M, Naylor R, Nicolini P, Rosales A. Editor's Choice - Management of Chronic Venous Disease: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2015; 49:678-737. [PMID: 25920631 DOI: 10.1016/j.ejvs.2015.02.007] [Citation(s) in RCA: 501] [Impact Index Per Article: 55.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Abstract
Venous leg ulceration (VLU) is one of the most predominate medical disorders worldwide and in the western hemisphere it affects around 1.5% of the general population and up to 5% of the elderly population. Unfortunately, this trend will only increase given the growth of an aging population worldwide. Understanding its pathophysiology that begins with venous hemodynamic abnormalities and leads to inflammatory alterations with microcirculatory changes is critical to delivering effective curative therapy. As such, the main component to treatment is reversing the underlying venous hypertension and pro-inflammatory milieu using compression treatment along with various adjuvant therapies. Given its impact, a comprehensive multi-pronged approach to care, treatment and prevention is required to reverse the increasing trend that is observed worldwide.
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Affiliation(s)
- Yung-Wei Chi
- Department of Internal Medicine, Section of Cardiovascular Medicine, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Joseph D Raffetto
- Vascular Surgery Division, VA Boston Healthcare System, West Roxbury, MA, USA
- Division of Vascular and Endovascular Surgery, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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O'Donnell TF, Passman MA, Marston WA, Ennis WJ, Dalsing M, Kistner RL, Lurie F, Henke PK, Gloviczki ML, Eklöf BG, Stoughton J, Raju S, Shortell CK, Raffetto JD, Partsch H, Pounds LC, Cummings ME, Gillespie DL, McLafferty RB, Murad MH, Wakefield TW, Gloviczki P. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery ® and the American Venous Forum. J Vasc Surg 2014; 60:3S-59S. [PMID: 24974070 DOI: 10.1016/j.jvs.2014.04.049] [Citation(s) in RCA: 377] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Postthrombotic syndrome: surgical possibilities. THROMBOSIS 2011; 2012:520604. [PMID: 22084674 PMCID: PMC3206373 DOI: 10.1155/2012/520604] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Accepted: 08/28/2011] [Indexed: 11/30/2022]
Abstract
Postthrombotic syndrome
(PTS) is a late outcome of deep vein thrombosis characterized by
cramping pain, swelling, hyperpigmentation, eczema,
lipodermatosclerosis, and ulceration in the leg due to increased
venous outflow resistance and reflux venous flow. Newer surgical
and endovascular interventions have a promising result in the
management of postthrombotic syndrome. Early surgical or
endovascular interventions in appropriately selected patients may
decrease the incidence of recurrent ulceration and skin changes and
provide a better quality of life. Duplex and IVUS (intravenous
ultrasound) along with venography serve as cornerstone
investigative tools for assessment of reflux and obstruction.
Venous obstruction, if present, should be addressed earlier than
reflux. It requires endovenous stenting, endophlebectomy, or open
bypass procedures. Venous stripping, foam sclerotherapy,
radiofrequency, or laser ablation are used to abolish superficial
venous reflux. Valvuloplasty procedures are useful for incompetent
but intact deep venous valves, while transposition or axillary
vein autotransplantation is done for completely destroyed
valves.
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Longevity and Outcomes of Axillary Valve Transplantation for Severe Lower Extremity Chronic Venous Insufficiency. Ann Vasc Surg 2011; 25:496-501. [DOI: 10.1016/j.avsg.2011.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Revised: 12/17/2010] [Accepted: 02/08/2011] [Indexed: 11/22/2022]
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Raju S, Darcey R, Neglén P. Unexpected major role for venous stenting in deep reflux disease. J Vasc Surg 2010; 51:401-8; discussion 408. [DOI: 10.1016/j.jvs.2009.08.032] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Revised: 08/11/2009] [Accepted: 08/14/2009] [Indexed: 10/20/2022]
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Affiliation(s)
- Seshadri Raju
- University of Mississippi Medical Center, Jackson, USA.
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Abstract. Vascular 2008. [DOI: 10.2310/6670.2008.00025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Lehtola A, Oinonen A, Sugano N, Albäck A, Lepäntalo M. Deep Venous Reconstructions: Long-term Outcome in Patients with Primary or Post-thrombotic Deep Venous Incompetence. Eur J Vasc Endovasc Surg 2008; 35:487-93. [DOI: 10.1016/j.ejvs.2007.09.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2007] [Accepted: 09/01/2007] [Indexed: 10/22/2022]
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Meissner MH, Eklof B, Smith PC, Dalsing MC, DePalma RG, Gloviczki P, Moneta G, Neglén P, O’ Donnell T, Partsch H, Raju S. Secondary chronic venous disorders. J Vasc Surg 2007; 46 Suppl S:68S-83S. [DOI: 10.1016/j.jvs.2007.08.048] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2006] [Revised: 08/15/2007] [Accepted: 08/19/2007] [Indexed: 11/16/2022]
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Pavcnik D, Yin Q, Uchida B, Park WK, Hoppe H, Kim MD, Keller FS, Rösch J. Percutaneous autologous venous valve transplantation: Short-term feasibility study in an ovine model. J Vasc Surg 2007; 46:338-45. [PMID: 17664108 DOI: 10.1016/j.jvs.2007.04.060] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Accepted: 04/22/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND Limited experience with bioprosthetic venous valve percutaneously inserted into femoral veins in 15 patients has been promising in short-term results only to show disappointing long-term results. Percutaneous autogenous venous valve (PAVV) transplantation was explored in an ovine model as a possible alternative treatment. METHODS PAVV consisted of a vein segment containing a valve that was attached to a stent template. The stent templates (n = 9) were designed and hand made in our research laboratory. They consist of two stainless steel square stents 13 or 15 mm in diameter to fit the ovine jugular veins (JV), which ranges from 10 to 15 mm in diameter. A valve-containing segment of JV was harvested and attached with sutures and barbs inside the stent template (n = 9). The valve devices were then manually folded and front loaded inside the 4 cm chamber of the 13F delivery sheath and delivered into the contralateral JV by femoral vein approach. Transplanted PAVVs were studied by immediate and 3 months venograms. Animals were euthanized at 3 months, and jugular veins harvested to perform angioscopic evaluations in vitro. RESULTS PAVV transplantation was successful in all nine animals. Good valve function with no reflux was observed on immediate and 3 months venograms in eight valves. The transplanted maximal JV diameter ranged from 10.2 mm to 15.4 mm (mean 13.1 +/- 1.5 mm). Venoscopic examination revealed intact, flexible, nonthickened valve leaflets in eight specimens. One PAVV exhibited normal function of one leaflet only; the other cusp was accidentally cut during the transplantation procedure. All transplanted autologous valves were free of thrombus and incorporated into the vein wall of the host vessel. CONCLUSION This study demonstrated that autogenous valve transplants remained patent and competent without long-term anticoagulation for up to 3 months. The percutaneous autogenous venous valve may provide in future minimally invasive treatment for patients with chronic deep venous insufficiency, but long-term studies need to be done to document its continued patency and function.
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Affiliation(s)
- Dusan Pavcnik
- Oregon Health and Science University, Dotter Interventional Institute, Portland, OR 97239, USA.
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Us M, Basaran M, Sanioglu S, Ogus NT, Ozbek C, Yildirim T, Selimoglu O, Kaya Z. The Use of External Banding Increases the Durability of Transcommissural External Deep Venous Valve Repair. Eur J Vasc Endovasc Surg 2007; 33:494-501. [PMID: 17239634 DOI: 10.1016/j.ejvs.2006.11.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2006] [Accepted: 11/26/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND The use of external banding during transcommissural external valvuloplasty has the theoretical advantage of increasing the durability of surgical procedure. The aim of this study was to assess the durability of this combined approach and compare its long-term results with those of external valvuloplasty procedure applied alone. METHODS We retrospectively reviewed data on 144 patients with combined superficial and deep venous reflux who underwent transcommissural external valvuloplasty procedure alone or transcommissural external valvuloplasty plus external banding procedure over a 7-year period from September 1998 to November 2005. The clinical study included only the patients who have completed at least 48 months of follow-up period. Seventy-six patients who have completed the necessary follow-up period were divided into 2 groups according to the surgical procedure performed. Group A consists of 40 patients in whom transcommissural external valvuloplasty was the procedure of choice and Group B consists of 36 patients in whom an external banding has been added to external valvuloplasty repair. The outcomes assessed are venous clinical severity scores of patients, ulcer recurrence and competency rates. RESULTS In both groups, median preoperative Venous Clinical Severity Scores were 3. The severity scores improved in both groups during the postoperative follow-up period. However, although the scores of Group B patients at 12 and 24 months were lower than those of Group A, the difference was not statistically significantly at these time points; but, reached a statistical significance at the end of 36 months. Ulcer-freedom rates at 48 months for groups A and B were 72% and 96%, respectively. The cumulative competency rates of 40 Group A patients were 85% at 6 months, 77.5% at 12 months, 69% at 24 months, 58% at 36 months, 55% at 48 months, and 48.5% at 60 months. The cumulative competency rates of 36 patients in Group B were 88% at 6 months, 80% at 12 months, 75% at 24 months, 71.5% at 36 months, 69% at 48 months, and 69% at 60 months. CONCLUSIONS Although external valvuloplasty procedure is an acceptable technique that can be used in patients with deep venous reflux, our study revealed that its durability may be limited and decreases over time. The addition of external banding provides more durable results with a lesser incidences of ulcer recurrence and valve incompetence.
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Affiliation(s)
- M Us
- Camlica Hayat Hospital, Cardiovascular Surgery Clinic, Istanbul, Turkey.
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Abstract
Over 7 million Americans suffer from chronic venous insufficiency (CVI), a disease that affects the venous system of the lower extremities. Problems associated with CVI include ulcerations, bleeding, swelling, and varicose veins, as well as deep vein thrombosis and pulmonary embolism. The presence of CVI is the result of incompetent, or malfunctioning, one-way vein valves in leg veins. There are few effective clinical therapies for treating CVI and there are currently no prosthetic vein valves commercially available. The purpose of this study was to define clinically relevant design requirements, develop functional tests for assessing a prosthetic vein valve, and design and fabricate a functional prosthetic vein valve for eventual clinical use. Engineering design methods were used to develop the valve, building a product based on well-defined consumer needs and design specifications. Emphasis was placed on creating a valve with potential clinical functionality. This clinical functionality was distilled into three major design criteria: that the valve (1) withstand backpressure of 300mmHg with less than 1.0mL∕min of leakage; (2) open with distal pressure gradients less than 5mmHg; and (3) meet criteria 1 and 2 after 500,000cycles of opening and closing. Hydrostatic testing was conducted to measure the opening pressure and reflux leak rate of the valve. Cyclic life functionality was assessed using a cyclic flow loop simulating physiologic conditions of cyclic flow and pressure found in leg veins. The valve opened with a pressure of 2.6mmHg±0.7mmHg, which matches physiologic vein valve function. The valve also withstood 300mmHg of backpressure with less than 0.5mL∕min of leakage, and maintained this performance even after 508,000cycles of opening and closing in simulated physiologic conditions. The valve’s burst pressure was a minimum of 530mmHg±10mmHg, six times greater than physiologic pressure natural vein valves experience. The valve continued to function well in an environment of vein-like tube expansion. The newly designed bi-leaflet prosthetic valve is comprised of a flexible, biocompatible material. Bench test results have shown that the valve is hydrodynamically functional and meets the mechanical design criteria for backpressure competency and opening pressure after 500,000cycles. Finally, the valve can be manufactured easily with low cost.
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Affiliation(s)
- Rahul D. Sathe
- George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA 30332-0405
| | - David N. Ku
- George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA 30332-0405
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Rosales A, Slagsvold CE, Kroese AJ, Stranden E, Risum Ø, Jørgensen JJ. External Venous Valve Plasty (EVVP) in Patients with Primary Chronic Venous Insufficiency (PCVI). Eur J Vasc Endovasc Surg 2006; 32:570-6. [PMID: 16919978 DOI: 10.1016/j.ejvs.2006.04.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2005] [Accepted: 04/02/2006] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To evaluate the patency of EVVP and its effect in symptom relief, ulcer healing and ulcer-free period in patients with PCVI. METHODS Between 1993 and 2004, 1800 patients with CVI were evaluated and seventeen with PCVI were selected for EVVP. They were all investigated with ambulatory venous pressure measurement (AVP), colour duplex ultrasound (CDU), ascending venography and descending video venography. The CEAP classification was used to group the patients. Six patients were C4, four C5 and seven C6. All had deep reflux and high levels of AVP. RESULTS All procedures were technically successful. The ulcer healing rate was 4/7 (57%) within 3 months. All C4 patients experienced symptom improvement postoperatively and had a median recurrence free period of 72 (range 60-122) months. The C5 group had an median ulcer free period of 61 months (12-72) and the C6 of median 48 (12-72) months. Single valve plasties (4) reached a median competence period of 48 months (12-72), 12 multiple valve plasties at the same level show a median 78 months (63-122) and 10 multilevel repairs median 54 months (12-96). Multiple valve plasties at the same level (multi-station plasties) performed on the C4 group seemed to yield the longest durability with a median of 103 months (84-122). CONCLUSION EVVP with an ulcer healing rate of 57% and satisfactory symptom improvement seems to be an alternative of surgical treatment for selected patients with PCVI. The durability of this technique seems to be related to clinical severity and the multiplicity of repairs.
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Affiliation(s)
- A Rosales
- Oslo Centre for Vascular Surgery, Aker University Hospital, Oslo, Norway.
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25
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Maleti O, Lugli M. Neovalve construction in postthrombotic syndrome1 1Additional material for this article may be found online at www.jvascsurg.org. J Vasc Surg 2006; 43:794-9. [PMID: 16616239 DOI: 10.1016/j.jvs.2005.12.053] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2005] [Accepted: 12/05/2005] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate a new neovalve construction technique in postthrombotic syndrome. The surgical procedure is described, and preliminary results of the first case series are given. METHODS From December 2000 to June 2004, neovalve construction in 18 limbs was performed on 16 patients (8 male and 8 female; median age, 55.5 years; range, 34-79 years) to treat severe chronic venous insufficiency in cases of postthrombotic syndrome. Surgical treatment was recommended in cases of nonhealing or recurrent ulcers (CEAP classification class C6). Preoperative duplex scanning, ascending/descending venography, and air plethysmography were routinely performed. Valvular cusps were created by dissecting the thickened venous wall to obtain material with which to fashion a new monocuspid or bicuspid valve. Mean follow-up was 22 months (range, 1-42 months). Postoperative duplex scanning and air plethysmography were performed in all patients. Descending venography was performed after surgery in 15 limbs. RESULTS In 16 lower extremities (89%), the ulcer healed within 4 to 25 weeks (median, 12 weeks), and no recurrences occurred. Neovalve competence was confirmed in 17 cases (95%). Postoperative duplex scan and air plethysmography showed a significant improvement in hemodynamic parameters (P < .001), especially in younger patients with good muscle pump function. In 17 limbs (95%), the treated segments remained primarily patent at median follow-up of 22 months. Early thrombosis below the neovalve site occurred in two patients (12%). No perioperative pulmonary embolism was observed. A late occlusion occurred in one patient (6%), 8 months after surgery. Minor postoperative complications occurred in three patients (17%). CONCLUSIONS Neovalve construction seems to be effective in restoring femoral competence in postthrombotic reflux. Although these preliminary results are encouraging, long-term follow-up and a larger series are required to validate the technique.
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Affiliation(s)
- Oscar Maleti
- Department of Cardiovascular Surgery, Hesperia Hospital, Modena, Italy.
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26
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Elias SM, Frasier KL. Minimally invasive vein surgery: its role in the treatment of venous stasis ulceration. Am J Surg 2004; 188:26-30. [PMID: 15223499 DOI: 10.1016/s0002-9610(03)00288-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Although traditional modalities used to treat venous disease and subsequent stasis ulceration have proved to be effective, they can have associated morbidities, such as postoperative pain, limited mobility, wound infection and dehiscence, as well as missed varicosities and/or incompetent perforator veins resulting in additional procedures. Recent advances have been made in minimally invasive vein surgery (MIVS) techniques that can decrease operative morbidity, number and size of incisions, recovery time, as well as operative time. These techniques are as durable as open procedures. The following procedures will be discussed: transilluminated powered phlebectomy, radiofrequency ablation of the greater saphenous vein closure, subfascial endoscopic perforator surgery, and percutaneous vein valve bioprosthesis. The advent of MIVS techniques allows the surgeon to manage venous pathophysiology associated with all 3 venous systems. MIVS is proving to be an important complement in the overall care of venous stasis ulceration.
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Affiliation(s)
- Steven M Elias
- Center for Vein Disease, Englewood Hospital and Medical Center, 180 North Dean Street, Englewood, New Jersey 07631, USA.
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Teebken OE, Puschmann C, Aper T, Haverich A, Mertsching H. Tissue-engineered bioprosthetic venous valve: a long-term study in sheep. Eur J Vasc Endovasc Surg 2003; 25:305-12. [PMID: 12651167 DOI: 10.1053/ejvs.2002.1873] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE to develop a graft bearing an immunologically tolerated tissue-engineered venous valve (TE graft) that will be incorporated into a native vessel, and restore normal valve function for the treatment of chronic venous insufficiency. METHODS twenty-four TE grafts were grown using decellularised allogeneic ovine veins as donor matrix, which was subsequently repopulated with the future recipient's myofibroblasts (MFB) and endothelial cells (EC). TE grafts were implanted into the external jugular vein. Animals were sacrificed at 1, 6, and 12 weeks (n=4, each). Autografts served as controls (1 week, n=4; 6 weeks, n=4). Specimen for histology and immunohistochemistry were taken. RESULTS the matrix was successfully repopulated with MFB and EC (n=8). Patency on venography in the TE graft-group was44,44, and 34 at 1, 6, and 12 weeks, and44 (44) in autografts at 1 (6) weeks, respectively. Except for 2 TE grafts after 12 weeks, valves were competent (duplex ultrasound). Patent TE grafts were merely distinguishable from autografts with minor inflammatory reactions. Reflux was caused by neo-intima formation related to the basis of the TE graft. CONCLUSION acellularisation and consecutive in vitro autogeneic re-seeding of valved venous conduits can lead to immunologically acceptable, patent, and competent implants in sheep.
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Affiliation(s)
- O E Teebken
- Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany
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Sybrandy JE, van Gent WB, Pierik EG, Wittens CH. Endoscopic versus open subfascial division of incompetent perforating veins in the treatment of venous leg ulceration: long-term follow-up. J Vasc Surg 2001; 33:1028-32. [PMID: 11331845 DOI: 10.1067/mva.2001.114812] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE Subfascial division of incompetent perforating veins seems to be a successful treatment for patients with venous leg ulceration (CEAP 6). For postoperative wound complications, endoscopic techniques are more common than open subfascial division of incompetent perforating veins (Linton procedure). We investigated the long-term results of ulcer healing and recurrence rates and compared them with preoperative and postoperative duplex findings. METHODS Patients with venous ulceration on the medial side of the lower leg were randomly allocated to endoscopic exploration or open exploration by means of the modified Linton approach. Ulcer healing and recurrence rates were documented. RESULTS Thirty-nine patients were randomly allocated to exploration, 19 patients to open subfascial division of incompetent perforating veins (Linton group), and 20 patients to subfascial endoscopic division of incompetent perforating veins (SEPS group). During the follow-up period, four patients in the SEPS group died, all of causes other than the venous leg ulcer. Because of a squamous cell carcinoma that had developed in the venous ulcer, one patient in the SEPS group underwent a below-knee amputation. In a mean follow-up period of 50.6 months, the venous ulceration of all 18 patients in the Linton group who were available for follow-up initially healed. The recurrence rate in this group was 22% (4 patients). In the SEPS group, the mean follow-up period for 19 patients was 46.1 months, with the ulceration healing in 17 patients and a recurrence rate of 12% (2 patients). The presence of deep venous incompetence (DVI) did not influence the recurrence rates (P =.044, Fisher exact test), but it significantly influenced the development of new incompetent perforating veins (3 of 10 without DVI; 7 of 10 with DVI; P =.011, binomial test). CONCLUSION The long-term follow-up results of the endoscopic division of perforating veins are comparable with those of the open division of perforating veins (modified Linton procedure).
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Affiliation(s)
- J E Sybrandy
- Department of Vascular Surgery, Sint Franciscus Hospital, Rotterdam, The Netherlands
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29
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Abstract
PURPOSE The purpose of this study was to describe the technique of a variation of closed external venous valve repair (transcommissural valvuloplasty), its complication rate, and duplex scan durability. METHODS The "blind" transcommissural valve repair of the vein was performed by placing transluminal sutures along the valve attachment lines, which simultaneously closed the valve attachment angle and also tightened the valve cusps. A total of 179 successfully repaired valve sites of 141 limbs in 129 patients were followed up 1 to 42 months through clinical observation and with duplex Doppler ultrasound scan. RESULTS Postoperative complications (< 30 days) occurred in 12 (9%) of 141 limbs: superficial (1) and deep (1) wound infection, large wound hematoma (4), seroma (1), and deep vein thrombosis (5), with associated pulmonary embolus in one patient. Seventy-eight percent (reflux time </= 0.5 seconds) and 81% (reflux time </= 1.0 seconds) of valve sites were competent. The cumulative competency rate at 30 months was 59% and 63%, respectively. The cumulative ulcer recurrence-free interval was 63% at 30 months (n = 92). The pain score and swelling grade substantially improved. CONCLUSION Transcommissural valvuloplasty is a safe procedure with low morbidity. It is relatively rapid and simple to perform, and its competency rates are comparable to those of internal valvuloplasty. Advantages over the internal repair are that venotomy is not required, repair can be extended to small-caliber veins, and multiple valve stations can be repaired in a single stage.
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Affiliation(s)
- S Raju
- River Oaks Hospital, Kackson, MS, USA.
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30
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Raju S, Fredericks RK, Hudson CA, Fountain T, Neglén PN, Devidas M. Venous valve station changes in "primary" and postthrombotic reflux: an analysis of 149 cases. Ann Vasc Surg 2000; 14:193-9. [PMID: 10796949 DOI: 10.1007/s100169910035] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The purpose of this study was to analyze valve station changes noted during venous valve reconstruction and the associated outcome. One hundred and forty-nine valve reconstructions were available for analysis at the time of surgical exploration; the venous valve was graded according to valve station changes (VS grades) from zero through six. Ascending venography was analyzed by a similar grading system and the two methods were compared. The results of this analysis showed that valve station wall changes are frequently present in patients with deep venous reflux and pose technical challenges during valve reconstruction; the outcome, however, appears unaffected. Grade 0 to 1 valve station changes are predominantly due to "primary" reflux, with an occasional instance of postthrombotic etiology. Grade 2 or 3 valve station changes are roughly evenly divided between phlebosclerosis of primary reflux and postthrombotic etiologies. The mechanism of onset of reflux with preservation of valve cusps in the latter group of postthrombotic cases is probably different from currently accepted theories of evolution of postthrombotic changes. Postthrombotic valve damage is variable, and the valve station anatomy may be sufficiently preserved in some patients to allow direct valve repair.
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Affiliation(s)
- S Raju
- Department of Surgery, The University of Mississippi Medical Center, Jackson, MS, USA
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Neglén P, Raju S. Balloon dilation and stenting of chronic iliac vein obstruction: technical aspects and early clinical outcome. J Endovasc Ther 2000; 7:79-91. [PMID: 10821093 DOI: 10.1177/152660280000700201] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE To describe the technical aspects of percutaneous balloon dilation and stenting for the treatment of venous outflow obstruction in chronic venous insufficiency. METHODS Between March 1997 and December 1998, 94 consecutive patients (median age 48 years, range 14 to 80) with suspected iliac vein obstruction in 102 limbs were studied prospectively with the intent to treat any venous occlusion or stenosis verified during femoral vein cannulation. Data from the history, clinical examination, procedure, and follow-up were recorded. Preoperative indicators of obstruction were venographic evidence of occlusion, stenosis, or pelvic collateral vessels; increased arm-foot venous pressure differential; and abnormal hyperemia-induced venous pressure elevation. RESULTS Cannulation and technical success rates were 98% and 97%, respectively, with 118 Wallstents deployed in 77 veins. Primary, assisted primary, and secondary patency rates at 1 year were 82%, 91%, and 92%, respectively. Clinical improvement in pain and swelling was significant. CONCLUSIONS Stenting of benign iliac vein obstruction is a safe method with good short-term results. Venous lesions should always be stented; when treating iliocaval junction lesions, stents should be inserted well into the inferior vena cava. Absence of collateral vessels does not exclude the existence of significant obstruction, and their presence may indicate an obstruction not visualized. No gold standard for accurate pre- or intraoperative patient selection is currently available.
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Affiliation(s)
- P Neglén
- River Oaks Hospital, Jackson, Mississippi, USA.
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Neglén P, Raju S. Balloon Dilation and Stenting of Chronic Iliac Vein Obstruction:Technical Aspects and Early Clinical Outcome. J Endovasc Ther 2000. [DOI: 10.1583/1545-1550(2000)007<0079:bdasoc>2.3.co;2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Raju S, Neglén P, Doolittle J, Meydrech EF. Axillary vein transfer in trabeculated postthrombotic veins. J Vasc Surg 1999; 29:1050-62; discussion 1062-4. [PMID: 10359939 DOI: 10.1016/s0741-5214(99)70246-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE This study assessed whether axillary vein transfer can be successfully performed in trabeculated veins and whether patients with this severe form of postthrombotic syndrome can be helped by an aggressive approach. METHODS A total of 102 axillary vein transfer procedures were carried out in 83 limbs with trabeculated veins. More than one venous segment was repaired in 38 limbs with a second axillary valve in 19, and a different technique was used in the remainder. The superficial and deep femoral veins were the most common target sites. "Bench repair" of leaky axillary valves was performed before the transfer in 32 cases. Venous stasis dermatitis or ulceration was present in 90% of the limbs. The operability rate and chance of successful valve reconstruction was high, even in the presence of severe venographic appearance. RESULTS The actuarial transplant patency rate was 83% at 10 years. The actuarial freedom from recurrent ulceration rate was more than 60% at 10 years, similar to the results obtained in a matched group of axillary vein transfers to nontrabeculated veins. Severe preoperative ambulatory venous hypertension (venous filling time [VFT] of less than 5 seconds), which was present in 67% of patients, did not adversely affect outcome, but short VFTs that persisted after surgery did. VFT and VFI90 (venous filling index, air plethysmography) improved after valve transfer. Swelling disappeared or was significantly reduced in 55% of patients (11 of 20 patients) who had moderate or severe preoperative swelling. In 82% of patients (31 of 37 patients) who had mild or no preoperative swelling, the swelling remained stable after surgery, and in 18% of patients (6 of 37 patients), it became worse. Pain was significantly diminished in 70% of patients; 23% of patients with severe pain had complete resolution. CONCLUSION Axillary vein transfer, in combination with other antirefluxive procedures when indicated, is safe, effective, and durable in patients with trabeculated veins and severe forms of postthrombotic syndrome. It may be considered as an option when conservative therapy or other types of surgery fail.
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Affiliation(s)
- S Raju
- Department of Surgery, University of Mississippi Medical Center, Jackson, USA
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Abstract
PURPOSE To highlight a special subset of cases of venous stasis in which the profunda femoris vein enlarges to a variable extent (axial transformation) to compensate for severe postthrombotic changes in the accompanying superficial femoral vein. METHODS Among 500 consecutively treated patients with severe venous stasis, 57 patients had axial transformation of the profunda femoris vein. Venous obstruction and reflux were assessed by means of arm-foot pressure differential, ambulatory venous pressure measurement, air plethysmography, and duplex examination. Ascending and descending venograms also were obtained. A variety of valve reconstruction techniques were useful in correcting reflux in the enlarged profunda femoris vein and the companion postthrombotic superficial femoral vein. RESULTS In 55% of patients the profunda femoris vein was larger than normal and provided partial outflow from the leg through a profunda-popliteal connection, but the superficial femoral vein was still the dominant outflow tract (grades I and II). In 36% of patients the profunda femoris was the dominant outflow tract from the leg, and in another 9% it was the sole axial outflow tract (grades III and IV). The skin changes of advanced venous stasis were present among 92% of patients and frank ulceration among 88%. Antireflux operations on the profunda femoris vein and companion superficial femoral vein, including ligation and division in some instances, were well tolerated. Despite a postthrombotic cause, obstruction did not worsen after surgical treatment, and reflux improved according to most laboratory measurements. Complete ulcer healing was obtained with the surgical techniques described. The actuarial recurrence-free survival rates were 90% 1 year and 66% 5 years after treatment. CONCLUSION Axial transformation of the profunda femoris vein is present in a subset of instances in which severe postthrombotic changes are present in the companion superficial femoral vein. Profunda femoris reflux is invariably present in these instances because of compensatory dilatation and enlargement of this vessel. Simultaneous valve repair of the axially transformed profunda femoris vein and companion superficial femoral vein to abolish reflux yields excellent long-term results and healing of stasis ulceration.
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Affiliation(s)
- S Raju
- Department of Surgery, University of Mississippi Medical Center, Jackson, USA
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