Axillary vein transfer in trabeculated postthrombotic veins

Systematic review and meta-analysis of deep venous reflux correction in chronic venous insufficiency

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.

Chronic Venous Disease of the Lower Extremities: A State-of-the Art Review

Chronic venous disease is a common disease, the prevalence of which increases with age, and can cause debilitating symptoms that adversely affect the quality of life. The risk factors include family history, female sex, obesity, pregnancy, parity, and history of deep vein thrombosis. Moreover, it is associated with venous obstruction, reflux, or both, which, in turn, leads to ambulatory venous hypertension. Chronic venous disease is the leading cause of leg ulcers, which place a significant cost burden on the health care system. Compression therapy remains the cornerstone of treatment, particularly for more advanced disease. Superficial saphenous vein reflux can be associated with significant symptoms. Catheter techniques, both thermal and nonthermal, have demonstrated efficacy and safety in successful closure and symptom improvement. Deep vein obstruction can be broadly divided into thrombotic and nonthrombotic and can lead to symptomatic chronic venous disease. Recanalization using balloons and stents has been increasingly used and studied in such patients. It is critical to develop training opportunities and guidelines to improve evidence-based and appropriate care for cardiologists treating chronic venous disease.

Antigen removal process preserves function of small diameter venous valved conduits, whereas SDS-decellularization results in significant valvular insufficiency

Chronic venous disease (CVD) is the most common reported chronic condition in the United States, affecting more than 25 million Americans. Regardless of its high occurrence, current therapeutic options are far from ideal due to their palliative nature. For best treatment outcomes, challenging cases of chronic venous insufficiency (CVI) are treated by repair or replacement of venous valves. Regrettably, the success of venous valve transplant is dependent on the availability of autologous venous valves and hindered by the possibility of donor site complications and increased patient morbidity. Therefore, the use of alternative tissue sources to provide off-the-shelf venous valve replacements has potential to be extremely beneficial to the field of CVI. This manuscript demonstrates the capability of producing off-the-shelf fully functional venous valved extracellular matrix (ECM) scaffold conduits from bovine saphenous vein (SV), using an antigen removal (AR) method. AR ECM scaffolds maintained native SV structure-function relationships and associated venous valves function. Conversely, SDS decellularization caused significant changes to the collagen and elastin macromolecular structures, resulting in collagen fibril merging, elimination of fibril crimp, amalgaming collagen fibers and fragmentation of the inner elastic lamina. ECM changes induced by SDS decellularization resulted in significant venous valve dysfunction. Venous valved conduits generated using the AR approach have potential to serve as off-the-shelf venous valve replacements for CVI. STATEMENT OF SIGNIFICANCE: Retention of the structure and composition of extracellular matrix (ECM) proteins within xenogeneic scaffolds for tissue engineering is of crucial importance, due to the undeniable effect ECM proteins can impose on repopulating cells and function of the resultant biomaterial. This manuscript demonstrates that alteration or elimination of ECM proteins via commonly utilized decellularization approach results in complete disruption of venous valve function. Conversely, retention of the delicate ECM structure and composition of native venous tissue, using an antigen removal tissue processing method, results in preservation of native venous valve function.

Closed incisional negative pressure therapy may reduce surgical site infection rate following endophlebectomy with complementary polytetrafluoroethylene arteriovenous fistula of the common femoral vein

OBJECTIVE

Surgical desobliteration or endophlebectomy of the common femoral vein during deep venous recanalization with complementary polytetrafluoroethylene (PTFE) arteriovenous fistula (AVF), may lead to higher rates of surgical site infection (SSI). It has been reported that closed incisional negative pressure wound therapy (cINPT) may decrease SSI rates after different surgical procedures. The aim of this study was to determine the potential effect of cINPT on the SSI rate of femoral endophlebectomy with a complimentary PTFE AVF.

METHODS

Patients with recanalization of the femoral-iliac veins and femoral endophlebectomy with a complementary PTFE AVF and postoperative cINPT were identified. SSI, patency, and complication rates were analyzed.

RESULTS

This study included 65 patients with a mean age of 41 ± 14 years. The mean procedure time was 240 ± 11.9 minutes. Primary patency rate was 69.2% and secondary patency rate was 78.4%. SSI classified as Szilagyi I, II, and III occurred in 7.6% (n = 5), 3% (n = 2), and 7.6% (n = 5), respectively, with an overall SSI rate of 18.2%. Surgical wound revision with the application of a vacuum pump was required in 10.7% (n = 7). A multivariate analysis showed that the duration of the surgical procedure (P = .003) as well as lymphatic fistulas (P = .044) to have a significant impact on the SSI rate.

CONCLUSIONS

Endophlebectomy with complementary PTFE AVF of the femoral vein is related to an increased rate of lymphatic leakage and SSI. Lymphatic fistula and the duration of surgery could be assessed as relevant influencing factors of SSI. Application of cINPT in this surgical setting may reduce the SSI rate. Despite this potential improvement, SSI rates still limit the clinical success of a deep venous recanalization.

Report of the Society for Vascular Surgery and the American Venous Forum on the July 20, 2016 meeting of the Medicare Evidence Development and Coverage Advisory Committee panel on lower extremity chronic venous disease

On July 20, 2016, a Medicare Evidence Development and Coverage Advisory Committee panel assessed the benefits and risks of currently used lower extremity chronic venous disease (CVD) treatments and their effects on health outcome of the American adult population. The main purpose of the meeting was to advise the Centers for Medicare & Medicaid Services on coverage determination for interventions used for treatment of CVD. A systematic review of the Agency for Healthcare Research and Quality was presented, followed by lectures of invited experts and a public hearing of representatives of professional societies and the industry. After discussing critical issues, the panel voted for key questions. This report summarizes the presented evidence to support recommendations of the Society for Vascular Surgery/American Venous Forum coalition and the presentations on selected discussion topics. These included important venous disease evidence gaps that have not been sufficiently addressed, venous disease treatment disparities and how they may affect the health outcomes of Medicare beneficiaries, and mechanisms that might be supported by the Centers for Medicare & Medicaid Services to improve the evidence base to optimize the care of patients with lower extremity CVD.

Latest Innovations in the Treatment of Venous Disease

Venous disease is more common than peripheral arterial disease. Pathophysiologically, venous disease can be associated with obstruction, reflux, or both. A common feature in chronic venous disease is ambulatory venous hypertension. Inflammatory and pro-thrombotic mechanisms can be activated. The current therapies, including compression, ablation, and recanalization are discussed.

Editor's Choice - Reconstruction of the femoro-ilio-caval outflow by percutaneous and hybrid interventions in symptomatic deep venous obstruction

OBJECTIVE/BACKGROUND

Deep venous obstruction is relatively prevalent in patients with chronic venous disease. Endovascular treatments and hybrid interventions can be used to relieve venous outflow obstructions. This paper assesses mid-term clinical outcomes and patency rates in a large cohort after percutaneous and hybrid interventions.

METHODS

This was a prospectively analysed cohort study. Patients with symptomatic deep venous obstruction who presented at a tertiary referral hospital were divided into three groups: patients who underwent percutaneous stenting for non-thrombotic iliac vein compression syndrome (IVCS group); patients with post-thrombotic syndrome (PTS) treated by percutaneous stent placement (P-PTS group); and PTS patients with obstruction involving the veins below the saphenofemoral junction in which a hybrid procedure was performed, combining stenting with open surgical disobliteration (H-PTS group). Patency rates, complications, and clinical outcomes were analysed.

RESULTS

A total of 425 lower extremities in 369 patients were treated. At 60 months, primary patency, assisted primary patency, and secondary patency rates were 90%, 100%, and 100% for IVCS, and 64%, 81%, and 89% for the P-PTS group, respectively. The H-PTS group, showed patency rates of 37%, 62%, and 72%, respectively, at 36 months. Venous claudication subsided in 90%, 82%, and 83%, respectively. At the 24 month follow-up, mean Venous Clinical Severity Score decreased for all patients and improvement in Villalta score was seen in post-thrombotic patients. The number of complications was related to the extent of deep venous obstruction in which patients in the H-PTS group showed the highest complication rates (81%) and re-interventions (59%).

CONCLUSION

Percutaneous stent placement to treat non-thrombotic iliac vein lesions, and post-thrombotic ilio-femoral obstructions are safe, effective, and showed patency rates comparable with previous research. Patients with advanced disease needing a hybrid procedure showed a lower patency rate and more complications. However, when successful, the clinical outcome was favourable at mid-term follow-up and the procedure may be offered to selected patients.

Endophlebectomy of the common femoral vein and arteriovenous fistula creation as adjuncts to venous stenting for post-thrombotic syndrome

Background

Good results have been reported for angioplasty and stenting of post-thrombotic lesions of the iliac and proximal femoral veins. If lesions at the origin of the superficial femoral and profunda veins are stented, the intraluminal synechiae can be pushed against the orifices of inflow vessels, potentially decreasing stent inflow. Surgical disobliteration of the common femoral vein (endophlebectomy) has been suggested to mitigate this problem. Because of a temporary increase in thrombogenicity, this procedure may be accompanied by arteriovenous fistula creation.

Methods

Data on consecutive patients treated by hybrid venous reconstruction, between December 2010 and May 2015, were analysed. Standard recording consisted of clinical scoring systems (including Villalta scale) and imaging. Patency was assessed with duplex ultrasonography.

Results

Seventy-six legs (70 patients) were included. Median follow-up was 379 (range 73–1508) days. Primary, assisted primary and secondary patency rates at 12 months were 51, 70 and 83 per cent respectively. Sixty per cent of loss of primary patency (24 of 40 legs) was related to common femoral vein stenosis, and the rest to rethrombosis. Other complications included wound infection (29 per cent) and lymphatic leak (39 per cent). The Villalta score had decreased by a median of 7 points at 1-year follow-up.

Conclusion

The combination of venous stenting, endophlebectomy and arteriovenous fistula creation for patients with extensive post-thrombotic vein damage and severe post-thrombotic syndrome is feasible.

Multimodal Therapy for Acute and Chronic Venous Thrombotic and Occlusive Disease

Critical deep venous thrombosis and occlusion constitutes a small percentage of patients with venous disease. However, these patients exhibit severe symptomatology including pain and extensive edema that may progress to limb-or life-threatening complications such as phlegmasia cerulea dolens and superior vena cava syndrome. This paper reviews the different multimodal percutaneous interventions currently available for the treatment of complex critical venous thrombotic and occlusive disease.

Valve reconstructions

The history of venous valve reconstruction extends back to 1968 when Robert L Kistner performed the first internal valve plasty to treat deep venous axial reflux. Throughout the past 50 years other techniques of reconstructive deep venous surgery (RDVS) were developed, not only to repair but also to replace venous valves. And the fact that several surgeons and centers have undertaken RDVS in the treatment of chronic venous insufficiency (CVI) reporting outcomes, has added knowledge to define more clearly the role of this kind of specialized surgery. Patients who may benefit from RDVS are among those where conventional treatment with compression stockings combined with superficial surgery has failed. Ulcer-healing rates of up to 70% have been reported after RDVS and ulcer-free periods of up to 36 months have been generated. But during five-year follow-up, freedom from ulceration period and clinical improvement rates were reduced significantly. This raises then the issue and challenge of durability of RDVS since the average age of patients who can benefit from it is about 50 years.

Open surgical treatment for postthrombotic syndrome

The postthrombotic syndrome counts as a frequent long-term complication after deep vein thrombosis with approximately 20%–50% of affected patients after deep vein thrombosis. The earliest that diagnosis of postthrombotic syndrome can be made is 6 months after deep vein thrombosis. Most patients suffer from swelling and chronic pain. In all, 5%–10% of patients may even develop venous ulcers. The complex etiology consists of limited venous drainage because of chronic occlusions and secondary insufficiencies of venous valves inducing non-physiological venous reflux. Conservative management, first of all compression therapy, is of crucial importance in treatment of postthrombotic syndrome. Endovascular and open surgical techniques can additionally be used in a small subgroup of patients. Although rarely performed, this article illuminates the open surgical techniques in treatment of postthrombotic syndrome such as venous bypass surgery, valve repair and varicose vein surgery.

Indications for endophlebectomy and/or arteriovenous fistula after stenting

Endovenous recanalization with percutaneous transluminal angioplasty and stenting in post-thrombotic syndrome patients with iliocaval obstruction is a treatment modality quickly gaining popularity. Studies show good patency and clinical success rates. If the obstruction extends distally, below the inguinal ligament, stenting remains controversial. Without adequate inflow, the patency of stented iliocaval segments drops dramatically. This suggests that treatment of diseased common femoral, femoral and profunda femoral veins is required to ensure adequate inflow. Endophlebectomy, the removal of synechiae and septae from the common femoral vein, is a viable option in these cases. Another option, which can be done concurrently with the endophlebectomy, is the creation of an arteriovenous fistula. Selecting patients for these interventions however remains difficult, as precise preoperative prediction of inflow into the stented segments is difficult. In this paper we describe our experience in using duplex ultrasonography, magnetic resonance venography and conventional venography to assess the patency of the inflow trajectory. We believe this approach is essential in dealing with cases of complex post-thrombotic disease extending below the inguinal ligament. There is a great need to establish criteria to accurately assess pre- and postinterventional flow through treated vein segments.

Incidence and Risk Factors of the Post-thrombotic Syndrome

Annually 1–2 in every 1000 adults will develop a deep venous thrombosis of the lower extremity. A third to half of these patients will develop the post-thrombotic syndrome (PTS). However, predicting which patients will develop the PTS remains elusive. Ipsilateral thrombosis recurrence seems to be the most important risk factor. Moreover, residual venous occlusion and valvular reflux seem to predict PTS incidence to some degree. Laboratory parameters, including D-dimers and inflammatory markers, have shown promise in predicting development of the PTS in patients and are currently under investigation. Creating a model based on all combined risk factors and patient characteristics might aid in risk stratification in individual patients.

Postthrombotic syndrome: surgical possibilities

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.

An update on etiology, prevention, and therapy of postthrombotic syndrome

Postthrombotic syndrome is a common sequelae resulting from deep venous thrombosis. The primary interventions are prevention and treatment, both of which many vascular specialists may not always recognize. We review the definition, epidemiology, the basic pathophysiology, and preventative management for postthrombotic syndrome. The current primary medical and interventional treatment modalities to decrease the occurrence of postthrombotic syndrome are also highlighted. Many of these treatments are currently available and simply need to be adhered to, whereas others are a shift in the paradigm, focusing on active thrombus removal.

Primary chronic venous disorders

Primary chronic venous disorders, which according to the CEAP classification are those not associated with an identifiable mechanism of venous dysfunction, are among the most common in Western populations. Varicose veins without skin changes are present in about 20% of the population while active ulcers may be present in as many as 0.5%. Primary venous disorders are thought to arise from intrinsic structural and biochemical abnormalities of the vein wall. Advanced cases may be associated with skin changes and ulceration arising from extravasation of macromolecules and red blood cells leading to endothelial cell activation, leukocyte diapedesis, and altered tissue remodeling with intense collagen deposition. Laboratory evaluation of patients with primary venous disorders includes venous duplex ultrasonography performed in the upright position, occasionally supplemented with plethysmography and, when deep venous reconstruction is contemplated, ascending and descending venography. Primary venous disease is most often associated with truncal saphenous insufficiency. Although historically treated with stripping of the saphenous vein and interruption and removal of major tributary and perforating veins, a variety of endovenous techniques are now available to ablate the saphenous veins and have generally been demonstrated to be safe and less morbid than traditional procedures. Sclerotherapy also has an important role in the management of telangiectasias; primary, residual, or recurrent varicosities without connection to incompetent venous trunks; and congenital venous malformations. The introduction of ultrasound guided foam sclerotherapy has broadened potential indications to include treatment of the main saphenous trunks, varicose tributaries, and perforating veins. Surgical repair of incompetent deep venous valves has been reported to be an effective procedure in nonrandomized series, but appropriate case selection is critical to successful outcomes.

F. Válvulas da veia braquial comum: estudo anatômico

CONTEXTO: Boa parte das insuficiências venosas é devida à incompetência de suas válvulas. Como uma das alternativas cirúrgicas, temos os enxertos venosos valvulados no segmento insuficiente. OBJETIVO: Descrever a anatomia das válvulas da veia braquial comum. MÉTODOS: Foram selecionados 30 cadáveres do sexo masculino, independentemente de raça, que tinham seus membros superiores articulados ao tronco. Os mesmos estavam formolizados e foram mantidos em conservação com solução de formol a 10%. Utilizamos como critério de exclusão a existência de desarticulação de um dos membros ou de alterações deformantes em topografia das estruturas estudadas. RESULTADOS: O número total de válvulas identificadas foi de 28 em membro superior direito e de 33 em membro superior esquerdo, sendo 15 no segmento proximal direito e 21 no segmento proximal esquerdo. Mais de 91% das válvulas foram do tipo bicúspide e parietal. CONCLUSÃO: Conclui-se que a veia braquial comum apresenta freqüentemente válvulas do tipo bicúspide e parietal.

[Surgery for deep venous reflux in the lower limb]

Surgery for deep venous reflux (DVR) in the lower limb had displayed, for various reasons a much more limited development than arterial surgery including endovascular techniques. Importance and frequency of DVR in chronic venous disease and particularly in chronic venous insufficiency (CVI) has been fully identified only in the last 20 Years, thanks to the development of duplex-scanning. Despite its effectiveness, deep reconstructive surgery remains controversial which probably explains why this specific surgery is performed by few units worldwide. Furthermore as deep reconstructive surgery is usually combined with superficial and perforator surgery, assessment of its specific benefit is difficult. In patients with severe CVI, venous valvular reflux involves deep vein as an isolated abnormality in less than 10%, but is associated with superficial reflux or/and perforator incompetence in 46%. The most common etiology in DVR is post-thrombotic syndrome accounting for an estimated 60-85% of patients with CVI. Primary reflux is the result of structural abnormalities in the vein wall and the valve itself. A very rare cause of reflux is the absence of valves secondary to agenesis. Surgical techniques for treating DVR can be classified into two groups: those that do and those that do not involve phlebotomy. The first group includes internal valvuloplasty, transposition, transplantation, neo valve and cryopreserved allograft. The second group involves wrapping, Psathakis II procedure, external valvuloplasty (transmural and transcommissural) angioscopy assisted or not, external valve construction and percutaneous placed devices. There are some clinical features that enable distinguishing superficial venous insufficiency from deep venous insufficiency but they are not reliable enough as both are frequently combined. In addition primary reflux is difficult to identify from secondary deep reflux.

INVESTIGATIONS

Duplex scanning provides both hemodynamic and anatomic information. Photoplethysmography as air plethysmography can help when superficial and deep venous reflux are combined to identify the predominant pathological component. It would seem logical to go beyond these investigations only in those patients in whom surgery for DVR may be considered. That means that the decision to continue investigations is dominated by the clinical context and absence of contraindication (uncorrectable coagulation disorder, ineffective calf pump). When surgery is considered, complementary investigations must be carried out: ambulatory venous pressure measurement and venography including ascending and descending phlebography. The goal of DVR surgery is to correct the reflux related to deep venous insufficiency at the subinguinal. But it must be kept in mind that DVR is frequently combined with superficial and perforator reflux, consequently all these mechanisms have to be corrected in order to reduce the permanent increased venous pressure. As mentioned previously, surgery results for DVR are somewhat difficult to assess as superficial venous surgery and/or perforator surgery have often been performed in combination with DVR surgery. Valvuloplasty is the most frequent procedure used for primary deep reflux. On the whole, valvuloplasty is credited with achieving a good result in 70% of cases in terms of clinical outcome defined as a freedom of ulcer recurrence and the reduction of pain, valve competence and hemodynamic improvement over a follow-up period of more than 5 years. In all series, a good correlation was observed between these three criteria. External transmural valvuloplasty does not seem to be as reliable as internal valvuloplasty in providing long-term valve competence or ulcer free-survival. In PTS, long-term results are available for transposition and transplantation. In terms of clinical result and valve competence, a meta-analysis demonstrates that a good result is achieved in 50% of cases over a follow-up period of more than 5 years, with a poor correlation between clinical and hemodynamic outcome. Results with others techniques including Psathakis II technique, neovalve and cryopreserved valves are less satisfactory. DVR surgery indications for reflux rely on clinical severity, hemodynamics and imaging: most of the authors recommend surgery in patients severe disease graded C4 and C 5-6. When superficial and perforator reflux are associated, they must be treated, for some Authors as a first step, for others shortly before DVR surgery in the same hospitalization stay. Contraindications as previously stipulated have to be kept in mind. Hemodynamics and imaging criteria: only reflux graded 3-4 according to Kistner are usually treated with DVR surgery. It is generally recognized that, to be significantly abnormal, venous refill time must be less than 12 s, and the difference between pressure at rest and after standardized exercise in the standing position must be less than 40%. The decision to operate should be based on the clinical status of the patient, not the non-invasive data, since the patient's symptoms and signs may not correlate with the laboratory findings. Indications according to etiology: the indications for surgery can be simplified according to the clinical, hemodynamic and imaging criteria described above. In primary reflux, reconstructive surgery is recommended after failure of conservative treatment and in young and active patients reluctant to wear permanent compression. Valvuloplasty is the most suitable technique, with Kistner, Perrin and Sottiurai favoring internal valvuloplasty and Raju transcommissural external valvuloplasty. In PTS, obstruction may be associated with reflux; most of the authors agree that when significant obstruction is localized above the inguinal ligament, obstruction must be treated first. Secondary deep venous reflux, mainly post-thrombotic syndrome may be treated only after failure of conservative treatment as the results achieved by subfascial endoscopic perforator surgery associated or not with superficial venous surgery are not convincing. It is recommended that this procedure might be carried out in combination with deep reconstructive surgery. The techniques to be used, given that valvuloplasty is rarely feasible, in order of recommendation, are: transposition, transplantation, neovalve and cryopreserved allograft. Patients must be informed that in PTS surgery for reflux has a relatively high failure rate.

CONCLUSION

as large randomized control trials comparing conservative treatment and DVR surgery for DVR shall or should be difficult to conduct we must rely on the outcome of present series treated by DVR surgery. Analysis of those series provides recommendation grade C. Better results are obtained in the treatment of primary reflux compared with secondary reflux. Such surgery is not however, often indicated, and the procedure must be performed on specialized and high-trained centers.

Surgical disobliteration of postthrombotic deep veins—endophlebectomy—is feasible

OBJECTIVE

Partial obstruction of postthrombotic veins is caused by endovenous scar tissue, which creates synechiae and septae that narrow and sometimes block the lumen. We have performed surgical disobliteration, or endophlebectomy, of chronically obstructed venous segments during various kinds of deep venous reconstructions to increase the flow through previously obstructed segments. In this article we describe the endophlebectomy technique, and report the availability of this procedure as an adjunct to deep venous reconstructions for the treatment of postthrombotic chronic venous insufficiency. Patients and methods Between July 1996 and February 2003, surgical disobstruction of 23 deep venous segments was performed in 13 patients in association with 14 deep venous reconstructions to treat advanced postthrombotic chronic venous insufficiency. Postthrombotic veins were surgically exposed, and a longitudinal venotomy was carried out at a variable length. The synechiae and masses attached to the intimal layer were carefully excised. Mean duplex scanning follow-up was 10.8 +/- 8.2 months (median, 8 months; range, 1-28 months).

RESULTS

In 10 patients (77%) the treated segments remained primarily patent at median follow-up of 8 months (range, 1-28 months). Early thrombosis near the endophlebectomy site occurred in 3 patients, at 2, 5, and 12 days, respectively, after surgery. In 2 patients with early thrombosis further interventions were carried out with success. In a third patient with early postoperative thrombosis the final outcome was recanalization and reflux. These results yielded an overall secondary patency rate of 93%. No perioperative pulmonary embolism was observed.

CONCLUSION

This series demonstrates that surgical disobliteration of postthrombotic deep veins is technically feasible, and led to patency of the segments for the duration of follow-up for up to 28 months (mean, 10.8 +/- 8.2 months). We used this technique with the objective of disobstructing postthrombotic veins, to increase flow through a previously narrowed lumen. Postoperative thrombosis at the site of endophlebectomy occurred in 23% of patients. Although this early experience is encouraging, further studies and longer follow-up are necessary to assess the durability of the procedure.

Endovascular management of venous thrombotic and occlusive diseases of the lower extremities

Acute complications of deep vein thrombosis (DVT) of the lower extremities include pulmonary embolism and venous ischemia. Delayed complications include a spectrum of debilitating symptoms referred to as postthrombotic syndrome (PST). Anticoagulation therapy is recognized as the mainstay of therapy in acute DVT. However, there are few data to suggest any major beneficial effect on PTS, which is thought to be mediated by valve damage and/or occlusive chronic thrombus and venous scarring. Endovascular catheter-directed thrombolysis techniques with pharmacologic thrombolytic agents, used alone or in combination with mechanical thrombectomy devices, have been proven highly effective in clearing acute DVT, which may allow the preservation of venous valve function and prevention of subsequent venous occlusive disease. Definitive management of underlying anatomic occlusive abnormalities can also be undertaken.

Venous reflux repair with cryopreserved vein valves

PURPOSE

The purpose of this study was to evaluate the immediate and short-term outcome of inserted cryopreserved vein valve allografts and the clinical outcome of treated limbs.

METHOD

Twenty-seven cryovalves were inserted in 25 postthrombotic limbs because of active leg ulcer (20 limbs) or severe disabling leg pain (five limbs) as a procedure of last resort. Previous venous surgery had been performed in 80% of the limbs. Main stem superficial reflux and iliac venous outflow obstruction were controlled before cryovalve insertion. The most common insertion site was the superficial femoral or popliteal vein. Patients were followed up with clinical examination and with intermittent duplex Doppler scanning or ascending venography to assess patency and competency of the valve station.

RESULTS

After thawing, but before insertion, 74% of the cryovalves were incompetent and needed repair with transcommissural valvuloplasty. After insertion, mortality was zero. Morbidity was 48%, mainly because of seroma formation and deep wound infection. One cryovalve was explanted because of acute rejection. Six cryovalves occluded early (<6 weeks), and five occluded late. Cumulative rates of patent cryovalves and both patent and competent cryovalves at 24-month follow-up were 41% and 27%, respectively. Cumulative ulcer recurrence-free rate at 36 months was 50%. Pain relief was poor, and degree of swelling remained the same.

CONCLUSION

Compared with autologous vein transfer, cryovalve insertion is associated with high morbidity, high occlusion rate, poor cumulative midterm rate of patent graft with competent valve, and poor clinical results. The procedure should not be used as a primary technique for valve reconstruction, and it is questionable whether it is useful even in patients in whom autologous reconstruction techniques have been exhausted. The basis of the high failure rate is unclear; it may be immunologic or due to loss of endothelial cover after implantation. If cryovalves are to be a viable valve repair alternative, improved cryopreservation technique, immunologic modifications, or better matching must be achieved.

Outcome of venous stasis ulceration when complicated by arterial occlusive disease

OBJECTIVE

to report the outcome of patients with venous stasis ulceration (VSU) and severe arterial occlusive disease (AOD).

DESIGN

retrospective study.

METHODS

using the International Classification of Diseases (ICD-9), codes for VSU and AOD were cross-matched to identify patients from 1989 to 1999 at two tertiary hospitals. Entry into the study required the presence of a VSU and an ipsilateral procedure to improve AOD or major amputation during the same hospitalisation.

RESULTS

fourteen patients (15 extremities) with a mean age of 80 years (range: 47-93) were identified as having VSU and AOD. Mean duration of VSU up to the time of revascularisation or amputation was 6.4 years (range: 4 months-21 years). The mean number of VSUs per extremity was 2.1 and mean wound area was 71 cm(2). Mean ankle-brachial index was 0.46 (range: 0.10-0.78). Nine extremities (60%) had a bypass procedure, 3 (20%) had an interventional procedure, 1 (0.6%) had a lumbar sympathectomy, and 2 (13%) had an amputation. Over a mean follow-up of 2.8 years, 3 extremities (23%) healed of which 2 recurred. On last review, 11 patients with 12 afflicted extremities had expired. Nine of the remaining 10 extremities were not healed at the time of death. Eight of nine bypass grafts remained patent in follow-up or at death and subsequent limb salvage was 100%.

CONCLUSIONS

combined VSU and AOD represents a rare condition predominantly found in elderly patients with multiple comorbidities. Few patients had complete healing despite an arterial inflow procedure and mortality was high over the short term.

Current concepts in chronic venous ulceration

OBJECTIVES

despite numerous reports on the distribution of reflux in patients with venous ulceration, there is no consensus on the contribution of each venous system. This study was performed to evaluate the distribution of reflux in this group of patients.

METHODS

a literature search from 1980 to 1998 was performed. Because duplex scanning is the best method for detecting venous reflux, we only included reports that used this diagnostic modality. All studies with less than 30 ulcerated limbs were excluded. Since most reports did not give detailed data on perforator veins, reflux in these veins was combined with the superficial and deep veins. Documented episodes of superficial or deep vein thrombosis were noted.

RESULTS

thirteen studies that included 1249 ulcerated limbs fulfilled the inclusion criteria. The mean age of patients was 59 years (95% CI: 54-63, range: 14-93). Reflux was detected in 1153 (92%) of limbs. Reflux confined to the superficial veins alone was seen in 45% of limbs, in the deep veins alone in 12% and in both the superficial and deep veins in 43% of limbs. The overall involvement of the superficial veins was 88% and of the deep veins 56% (p <0. 0001). A documented episode of deep vein thrombosis was reported in only six of the 13 studies and the incidence was found to be 32%.

CONCLUSIONS

reflux in the superficial veins is seen in 88% of limbs with venous ulcers (CEAP classes 5 and 6). Isolated superficial vein incompetence is detected in 45%, while reflux in the deep venous system alone is seen in only 12%. These data have significant clinical implications, since reflux in the superficial system can be easily eliminated by excision of the affected veins.

Popliteal venous aneurysms: report of an unusual presentation and literature review

Aneurysms of the popliteal vein represent a rare clinical finding. Most patients with popliteal venous aneurysms present with pulmonary emboli. We describe a case report of a 69-year-old female who presented with popliteal fossa pain. A popliteal venous aneurysm was detected following extensive diagnostic work-up that included magnetic resonance imaging (MRI), venous duplex, and venography. At operation, the aneurysm was found to be compressing the tibial nerve. Tangential aneurysmectomy and lateral venorrhaphy was performed. A PTFE sleeve was placed around the site of venous repair to prevent recurrence of the aneurysm and to keep the tibial nerve free of the repair site. The postoperative course was uneventful, and duplex studies at 18 months after the procedure remain normal. The etiology of popliteal venous aneurysms is discussed here, and presentation, diagnostic work-up, and treatment options are reviewed. We demonstrate that pain in the popliteal fossa should be considered a presenting symptom for venous aneurysms.