Chirurgie du reflux veineux profond

Reconstructive surgery for deep vein reflux

DVR is defined as a reflux affecting the deep venous system. DVR essentially arises from two etiologies, primary deep valve incompetence (PDVI) and posthrombotic syndrome (PTS), knowing that axial reflux is correlated with severe chronic venous insufficiency. DVR correction aims at reducing the increased ambulatory venous pressure, which results from reflux in deep veins in orthodynamic conditions.

The results of DVR surgery are not easy to assess, as it is mostly combined with surgery for superficial venous system and/or perforators insufficiency.

In cases of primary insufficiency, valvuloplasty, the operation of choice, is credited at 5 years follow-up with a 70 % success rate in terms of clinical outcome and improved hemodynamic performance. In PTS, a meta-analysis of transpositions and transplants at more than 5 years estimates successful clinical outcome and improved hemodynamic performance at approximately 50 %. The Maleti neovalve construction technique has achieved by far better results.

Indications for DVR surgery are based on clinical, hemodynamic and imaging data. Etiology is a decisive factor in the choice of the technique.

The hypothesis of patho-physiological correlation between chronic cerebrospinal venous insufficiency and multiple sclerosis: rationale of treatment

BACKGROUND

The possible role of the venous system in the pathogenesis of chronic neurodegenerative diseases has been hypothesized for decades. Quite recently, the description of a venous condition defined as chronic cerebrospinal venous insufficiency (CCSVI) and its strong association with multiple sclerosis (MS) has brought back the attention of the scientific community to the hypothesis of an aetiological or concomitant role of an altered venous function in the occurrence of this pathology. CCSVI is identified by sonographic criteria, thus the indication for its possible treatment is based on ultrasound findings.

METHOD

We retrospectively examined 167 consecutive patients affected by clinically defined MS and CCSVI, identified by ultrasound assessment by the presence of at least two sonographic criteria. Ultrasonographic diagnosis of CCSVI was then integrated by venography and intravascular ultrasound examination (in 43 patients). Patients were all submitted to endovascular procedure (venoplasty).

RESULTS

In 37% of cases there was no correspondence between the preoperative ultrasound assessment and the venographic findings. In the event of incongruity between venography and sonography, the intravascular ultrasound examination investigation, when performed, confirmed ultrasound findings in 42% of cases and venography results in 58%. At one month in 12% of cases ultrasound assessment showed the persistence of altered flux. In 67% of cases patients reported subjective amelioration, regarding non-specific symptoms.

CONCLUSION

The pathophysiology of CCSVI is yet to be defined. The superior cava venous system is highly complex in terms of anatomy and possible anomalies, as well as its haemodynamic mechanisms. Further studies are required to define the parameters of diagnosis and treatment of CCSVI.