Transcommissural valvuloplasty: technique and results

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.

Stasis Dermatitis: The Burden of Disease, Diagnosis, and Treatment

Stasis dermatitis (SD), an inflammatory dermatosis occurring on the lower extremities, is a cutaneous manifestation of chronic venous insufficiency (CVI). SD is associated with a significant burden of disease. Symptoms such as pain, swelling, and itching can be debilitating for patients, leading to poor sleep, loss of mobility, and the inability to perform daily activities, and can interfere with work and leisure activities. Moreover, SD is a progressive disease with serious secondary complications such as ulcerations, which increase the patients' morbidity, reduce their quality of life, and increase health care burden. Challenges in diagnosing patients may have both short- and long-term sequalae for the patients due to unnecessary treatment and management. In addition, misdiagnosis may result in hospitalizations, placing additional burden on health care professionals in terms of time and financial burden on the health care system. Compression therapy and leg elevation represent the mainstay of treatment for CVI; however, it is also difficult to self-manage, which places a substantial burden on patients and caregivers. Moreover, compression therapy may cause discomfort and exacerbate itching. Subsequent nonadherence may result in disease progression that places additional burden on the physicians who manage these patients and the health care system in terms of resources required and costs incurred. A large proportion of patients with SD develop allergic contact dermatitis because of innate immune signals and altered skin barrier predisposing to sensitization to topical prescriptions, over-the-counter medications, and compression devices used to treat SD. Other than topical corticosteroids, there are no approved pharmacological options to treat inflammation in SD.

Clinical tolerance of untreated reflux after iliac vein stent placement

BACKGROUND

We have recently demonstrated in a large patient cohort that the prevalence and severity of reflux will improve in most limbs after stenting and that most limbs will not develop new-onset reflux. In the present report, we have focused on the long-term clinical outcomes associated with untreated reflux in the same patient cohort who had undergone iliofemoral venous stenting without correction of residual reflux.

METHODS

The clinical outcomes data from 1379 limbs treated with only iliac vein stenting without correction of superficial or deep reflux from 1997 to 2018 were analyzed (23-year follow-up period). Of the 1379 limbs, 632 (46%) had had preexisting reflux before stenting and 747 (54%) had did not. The reflux data (reflux segmental score, air plethysmography, ambulatory venous pressure) for these patients have been previously reported in detail. The subsets were compared perioperatively with each other using the following variables: grade of swelling, visual analog scale for pain score, venous clinical severity score, venous stasis dermatitis, ulceration, and quality of life measures.

RESULTS

Both groups demonstrated improvements in the venous clinical severity score, grade of swelling, visual analog scale score, and quality of life. No differences were found in ulcer healing (5% vs 3% for limbs with and without prestent reflux, respectively) and resolution of dermatitis (6% vs 5% for limbs with and without prestent reflux, respectively) between the two groups. Of the 632 limbs with preexisting reflux, 218 (34%) had had axial reflux and 414 had had nonaxial reflux (66%). The clinical outcomes were similar between the two groups. Using a multisegment reflux score, the limbs with prestent reflux (n = 632) were divided into two groups. A segmental score of ≥3 indicated severe reflux and a score of <3 indicated moderate reflux. Of these 632 limbs, 161 (25%) had severe reflux and 471 (75%) had moderate reflux. The two groups demonstrated similar outcomes for most clinical parameters. The post-thrombotic limbs and nonthrombotic limbs also showed similar outcomes.

CONCLUSIONS

The long-term follow-up of patients after iliac vein stenting showed that uncorrected reflux is well tolerated by most patients across most clinical measures.

Options in the treatment of superficial and deep venous disease in patients with Klippel-Trenaunay syndrome

OBJECTIVE

Klippel-Trenaunay syndrome (KTS) is a congenital mixed mesenchymal malformation syndrome that includes varicose veins, capillary and venous malformations, lymphatic abnormalities, and hypertrophy of various connective tissue elements. The purpose of the present study was to describe the clinical characteristics and outcomes in a subset of patients with KTS in whom venous interventions, including iliofemoral venous stenting, were performed after failure of conservative therapy.

METHODS

A single-center retrospective data review of 34 patients with KTS who had undergone interventions for venous disease between January 2000 and December 2020 was performed.

RESULTS

Their mean age was 38.4 ± 17.5 years (range, 12-80 years). No gender predilection was found. Of the 34 patients, 61% had had all three features of the classic triad for KTS. Varicose veins were present in all 34 patients (100%), and 30% had had a history of bleeding varicosities. Most patients (79%) had CEAP (Clinical, Etiology, Anatomy, and Pathophysiology) class ≥C4. Of the 34 patients, 30% had a history of deep vein thrombosis and/or pulmonary embolism. Factor VIII elevation was the most common thrombophilia condition (12%). The venous filling index was elevated at baseline (5.9 ± 5.1 mL/s) and did not normalize despite intervention (3.5 ± 2.3 mL/s; P = .04). The superficial venous interventions (n = 35) included endovenous laser therapy; stripping of the great saphenous vein, small saphenous vein, anterior thigh vein, or marginal vein; ultrasound-guided sclerotherapy; and stab avulsion of varicose veins. One coil embolization of a perforator vein was performed. Deep interventions (n = 19) included endovenous stenting (n = 15), popliteal vein release (n = 3), and valvuloplasty (n = 1). The venous clinical severity score had improved from 9.4 ± 4.5 to 6.2 ± 5.6 (P = .04). The visual analog scale for pain score had improved from 5.5 ± 2.7 to 2.5 ± 3.3 (P = .008). Healing of ulceration was noted in 75% of the patients. Significant improvements in the total pain (P = .04) and total psychological (P = .03) domains were noted in the 20-item chronic venous disease quality of life questionnaire.

CONCLUSIONS

Superficial and deep venous interventions are safe and effective in patients with KTS when conservative therapy has failed. Iliofemoral venous stenting is a newer option that should be considered in the treatment of chronic deep venous obstructive disease in patients with KTS in the appropriate clinical context. An aggressive perioperative deep vein thrombosis prophylaxis protocol should be in place to reduce thromboembolic complications in these patients.

Chronic venous insufficiency: Part 2 Diagnosis and treatment

Chronic venous insufficiency (CVI) is a common medical condition that results from venous hypertension of the extremities, leading to significant morbidity. The diagnosis of CVI is quite straightforward from patient history and obvious clinical manifestations. In the recent past, availability of various invasive and non-invasive modalities have assisted in evaluation of such cases. Although compression therapy is the mainstay of management, newer surgical and other interventional techniques are now being considered for patients who do not respond to conventional medical management. This review article will outline a diagnostic approach in cases of CVI and discuss the management principles encompassing conservative, pharmacological, and interventional options.

Open Surgical Reconstruction for Deep Venous Occlusion and Valvular Incompetence

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.

What is New in Venous Surgery

The aim of this article is to discuss recent developments in the management of venous disease. A literature search was done of English language journals from 1995 to 2000 to identify articles that discussed new innovations. In addition, the proceedings of specialist meetings were reviewed to include opinions of experts leading the field of venous practice. The article discusses the use of non-invasive investigations, thermal ablation of varicose veins, the economics of superficial and deep venous disease and the possible changes that might occur in the future management of patients with venous disease.

Successful tissue engineering of competent allogeneic venous valves

OBJECTIVE

The purpose of this study was to evaluate whether tissue-engineered human allogeneic vein valves have a normal closure time (competency) and tolerate reflux pressure in vitro.

METHODS

Fifteen human allogeneic femoral vein segments containing valves were harvested from cadavers. Valve closure time and resistance to reflux pressure (100 mm Hg) were assessed in an in vitro model to verify competency of the vein valves. The segments were tissue engineered using the technology of decellularization (DC) and recellularization (RC). The decellularized and recellularized vein segments were characterized biochemically, immunohistochemically, and biomechanically.

RESULTS

Four of 15 veins with valves were found to be incompetent immediately after harvest. In total, 2 of 4 segments with incompetent valves and 10 of 11 segments with competent valves were further decellularized using detergents and DNAse. DC resulted in significant decrease in host DNA compared with controls. DC scaffolds, however, retained major extracellular matrix proteins and mechanical integrity. RC resulted in successful repopulation of the lumen and valves of the scaffold with endothelial and smooth muscle cells. Valve mechanical parameters were similar to the native tissue even after DC. Eight of 10 veins with competent valves remained competent even after DC and RC, whereas the two incompetent valves remained incompetent even after DC and RC. The valve closure time to reflux pressure of the tissue-engineered veins was <0.5 second.

CONCLUSIONS

Tissue-engineered veins with valves provide a valid template for future preclinical studies and eventual clinical applications. This technique may enable replacement of diseased incompetent or damaged deep veins to treat axial reflux and thus reduce ambulatory venous hypertension.

Chronic Venous Insufficiency

Varicose veins are a common manifestation of chronic venous disease and affect approximately 25% of adults in the western hemisphere. The historical standard treatment has been surgery, with high ligation and stripping, combined with phlebectomies. In the past decade, alternative treatments such as endovenous ablation of the great saphenous vein (GSV) with laser, radiofrequency ablation, and ultrasonography-guided foam sclerotherapy have gained popularity. Performed as office-based procedures using tumescent local anesthesia, the new minimally invasive techniques have been shown in numerous studies to obliterate the GSV, eliminate reflux, and improve symptoms safely and effectively.

Thinking Outside the Heart: Use of Engineered Cardiac Tissue for the Treatment of Chronic Deep Venous Insufficiency

This article considers the use of autologous stem cell-derived cardiomyocytes as a novel means to aid venous return. The approach consists of creating external cuffs of engineered heart tissue around vein segments with incompetent or poorly competent valves. The engineered heart tissue cuff prevents distention of the impaired vein segments and aids unidirectional flow by its rhythmic contractions. There appear to be no fundamental limitations to this approach as feasibility of all of the individual components has already been shown. Here, we underline the clinical need for novel ways to treat chronic deep venous insufficiency, review previous research that enabled this approach, consider potential designs of engineered heart tissue cuffs, and outline its advantages and future challenges.

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.

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.

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.

Percutaneous autologous venous valve transplantation: Short-term feasibility study in an ovine model

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.

Treatment of chronic venous insufficiency

Chronic venous insufficiency (CVI) results from venous hypertension secondary to superficial or deep venous valvular reflux. Treatment modalities are aimed at reducing venous valvular reflux, thereby inhibiting the ensuing pathologic inflammatory process. Compression therapy using pumps, bandaging, and/or graded compression stockings is the mainstay of treatment for CVI. Compression therapy has been shown to be effective in reducing venous hypertension retarding the development of inflammation and pathologic skin changes. Pharmacologic agents such as diuretics and topical steroid creams reduce swelling and pain short term but offer no long-term treatment advantage. Herbal supplements may reduce the inflammatory response to venous hypertension, but are not licensed by the US Food and Drug Administration, and vary in their efficacy, quality, and safety. However, several randomized controlled trials using the herbal horse chestnut seed extract containing aescin have shown short-term improvement in signs and symptoms of CVI. Endovascular and surgical techniques aimed at treatment of primary and secondary venous valvular reflux have been shown to improve venous hemodynamics promoting healing of venous ulcers and improving quality of life. The newer endovascular treatments of varicose veins using laser, radiofrequency ablation, and chemical foam sclerotherapy show some promise.

The Use of External Banding Increases the Durability of Transcommissural External Deep Venous Valve Repair

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.

External Venous Valve Plasty (EVVP) in Patients with Primary Chronic Venous Insufficiency (PCVI)

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.

Neovalve construction in postthrombotic syndrome1 1Additional material for this article may be found online at www.jvascsurg.org

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.

[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.

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.