Preliminary Report of a New Approach to Sparing the Greater Saphenous Vein for Grafting: Valvuloplasty Combined with Axial Transposition of a Competent Tributary Vein

New Concept: Different Types of Insufficiency of the Saphenofemoral Junction Identified by Duplex as a Chance for a More Differentiated Therapy of the Great Saphenous Vein

Even though the item ‘saphenofemoral junction’ (SFJ) is anatomically well defined, the incontinence of the SFJ is often incompetently described in clinical practice and studies. Especially with regard to the optimal therapy of the great saphenous vein, it might be of importance to have a more distinct regard to the SFJ as it is known that about 10–30% of the saphenous refluxes have no femoral origin. Considering the terminal and preterminal valve three types of incompetence of the SFJ may be differentiated: Type 1: Incompetent terminal, but competent preterminal valve; Type 2: Competent terminal, but incompetent preterminal valve; Type 3: Incompetent terminal and preterminal valve (complete incompetence). A review on prior studies and reports leads to the assumption that the differentiation of the distinct types of SFJ-incompetence allows a more individual and – perhaps – more effective therapy. Finally, studies are necessary to evaluate the here given new concept.

Great saphenous vein sparing surgery by angioscopic valvuloplasty combined with axial transposition of a competent tributary vein--5-year follow-up

OBJECTIVE

To evaluate the efficacy and haemodynamic effects of great saphenous vein (GSV) sparing surgery--valvuloplasty combined with axial transposition of a competent tributary vein (A-VACT).

MATERIALS AND METHODS

Eighty-five limbs in 74 patients with isolated GSV incompetence were selected for GSV sparing surgery. After angiographic valvuloplasty, the competent tributary vein was exposed and cut 1.5 cm distal to its insertion point on the GSV. The transected vein was anastomosed end-to-side to the GSV, which was ligated between the tributary insertion site and the anastomosis. Venous valve competence were screened by serial postoperative duplex examination, and venous haemodynamic changes were analyzed using venous filling index (VFI) measured by air plethysmograph pre- and postoperatively. The follow-up period was 5-years.

RESULTS

Sixty-seven patients were included in whom 76 limbs were treated. There was a statistically significant reduction in the vein diameter at the SFJ after 5-years (0.83 S.D. 0.29 cm to 0.46 S.D. 0.12 cm, p=0.0002, Wilcoxon). Similarly, significant reduction was found in the GSV at the 5-year follow-up point (0.63 S.D. 0.19 cm to 0.39 S.D. 0.11 cm, p<0.0001, Wilcoxon). On the other hand, there was significant increase in the diameter of the competent tributary vein postoperatively (0.22 S.D. 0.13 cm to 0.31 S.D. 0.12 cm, p<0.0001, Wilcoxon). Duplex scanning demonstrated reflux at the SFJ in 12 limbs (16%). Similarly, in the GSV, venous reflux was found in 13 limbs (17%). Reflux in the transposed tributary vein was found in 20 limbs (26%). But only 7 limbs (9%) had minor varicose veins' recurrence. VFI remained normal during the follow-up examination. The preoperative VFI confirmed the presence of venous reflux, but there were significant improvement in the VFI values at all postoperative examinations.

CONCLUSIONS

A-VACT procedure improves venous function, resolves varicose veins at 5-years follow-up as well as preserving the GSV for future grafting.

Varicose veins--an old dog and some new tricks

There are many new methods to treat varicose veins being tried and tested around the world, many using patented techniques. They would appear to demonstrate many of the features a military surgeon might deem beneficial for treating a service population, a rapid return to duties amongst them. There are some significant drawbacks. All of these modalities need to offer long-term evidence of efficacy to demonstrate advantage over current standard. The endovenous therapies utilise expensive equipment that limit their introduction and provide a potential for novel complications as well as novel therapy. Modified sclerotherapy as described here has many advantages; it is incredibly cheap, minimally invasive and easily repeatable--in fact planned re-intervention is used in some protocols. Until long-term results are available, it would seem premature to recommend any of these new treatments for use in service personnel with primary varicose veins. Military vascular surgeons will await these results with interest, as the service population would have much to gain from a modality that reliably treats the veins and ensures a swift return to service.

Alternative greater saphenous vein-sparing surgery: valvuloplasty combined with axial transposition of a competent tributary vein for the treatment of primary valvular incompetence---18-month follow-up

BACKGROUND

The greater saphenous vein (GSV) is one of the best grafts for vascular reconstruction, and a variety of sparing methods in patients with primary varicose veins have been performed. Of these, valvuloplasty of the subterminal valve is useful, but reflux in the proximal GSV via a competent tributary vein still remains. To minimize the subsequent reflux, we propose a new method, "valvuloplasty combined with axial transposition of a competent tributary vein" for the treatment of GSV incompetence.

OBJECTIVE

To compare this new method with single valvuloplasty.

METHODS

Seventy-eight limbs in 65 patients with GSV incompetence were included. Of these limbs, 38 underwent angioscopic valvuloplasty of the subterminal valve alone (V group). The remaining 40 were treated by angioscopic valvuloplasty combined with axial transposition of a competent tributary vein (V + T group). A competent tributary vein was identified by duplex scan in the thigh before surgery. After angioscopic valvuloplasty had been done, a competent tributary vein was exposed, and was cut 1.5 cm distal to its insertion. The distal cut end of the vein was then transposed to the GSV and end-to-side anastomosis was performed using 8-0 nylon under magnification. The incompetent GSV was ligated between the insertion and the anastomosed region. Venous hemodynamic changes were analyzed using air plethysmography (APG). Values obtained by9 APG included venous volume (VV), venous filling index (VFI), ejection fraction (EF), and residual venous function (RVF). The follow-up period was 18 months. Intergroup differences were analyzed with the Wilcoxon ranked sum test for nonparametric distribution.

RESULTS

There were no statistical differences in age, gender, or clinical presentation between the two groups. In the V group, 27 limbs had reflux in the proximal GSV (67.4%). On the other hand, only 6 limbs (13.3%) showed minor reflux in the V + T group. A significant difference was seen in VFI at 1 year, and a continuous increase was observed in the V group during the follow-up examinations (P =.0035, VFI = 2.50 plus minus 1.21, 1.14 plus minus 0.42 at 18 months, respectively).

CONCLUSION

Valvuloplasty combined with axial transposition of a competent tributary vein gives a better result than valvuloplasty alone at the 18-month follow-up. A competent valve in this location can be expected to improve VFI to a normal range.