OBJECTIVE: To evaluate the results of venous valvular repair in the treatment of 16 cases of chronic venousinsufficiency (CVI).DESIGN: A retrospective analysis of 16 venous valve repair operations (15 patients) with a minimum follow-up of 2 years.SETTING: A 650-bed university-affiliated teaching hospital.PATIENTS: Fifteen consecutive referred patients who had CVI had deep vein valve surgery. All cases wererefractory to prolonged conservative care and removal of incompetent superficial and perforating veins. In-vestigation included ascending and descending venography, air plethysmography (APG) and colour flowduplex scanning (CFDS). All patients had class 4, 5 or 6 CVI and all demonstrated deep venous refluxfrom the groin to below the knee on descending venography.INTERVENTIONS: Superficial femoral vein valvuloplasty (12 operations) and venous valve transfer from theaxillary vein to the above-knee popliteal vein (4 operations).MAIN OUTCOME MEASURES: Healing of ulcers, relief of edema and improvement in symptoms were clinicalcriteria of success. An attempt was made to correlate preoperative and postoperative APG, CFDS and de-scending venography.RESULTS: Ninety-two percent of the valvuloplasty patients and 75% of the valve transfer patients were clini-cally improved. In this series no statistical association existed between preoperative and postoperativechanges noted on APG.CONCLUSION: This series suggests that deep vein valvular reconstruction for CVI refractory to conservativemanagement and superficial surgery offers a good chance of clinical improvement.
OBJECTIF : Évaluer les résultats d’une réparation des valvules veineuses dans le traitement de 16 cas d’in-suffisance veineuse chronique (IVC).CONCEPTION : Analyse rétrospective de 16 interventions de réparation de valvules veineuses (15 patients)avec suivi d’une durée minimale de deux ans.CONTEXTE : Hôpital d’enseignement de 650 lits affilié à une université.PATIENTS : Quinze patients consécutifs atteints d’insuffisance veineuse chronique qui ont subi une inter-vention chirurgicale aux valvules veineuses profondes. Tous les cas étaient réfractaires à des soins de conser-vation prolongés et à l’ablation de veines superficielles et perforantes insuffisantes. Les examens ont inclusune phlébographie ascendante et descendante, une pléthysmographie gazeuse (PGG) et une scanographieduplex couleur. Tous les patients étaient atteints d’une IVC de catégorie 4, 5 ou 6 et une phlébographiedescendante a révélé un reflux veineux profond de l’aine jusqu’au-dessous du genou.INTERVENTIONS : Valvuloplastie de la veine fémorale superficielle (12 interventions) et transfert de valvulesveineuses de la veine axillaire à la veine poplitée au-dessus du genou (4 interventions).PRINCIPALES MESURES DES RÉSULTATS : La guérison des ulcères, le soulagement de l’dème et l’améliorationdes symptômes ont été les critères cliniques de réussite. On a essayé d’établir un lien entre la pléthysmogra-phie gazeuse avant et après l’intervention, la scanographie duplex couleur et la phlébographie descendante.RÉSULTATS : L’état clinique de 92 % des patients qui ont subi une valvuloplastie et de 75 % de ceux qui ont
Chronic venous insufficiency(CVI) is a common, debilitat-ing, recidivistic problem that
is stressful for both the attendingphysician and the patient because ofits extremely refractory nature. In theUnited States, 500 000 people sufferfrom venous ulceration.1 Between $3million and $1.2 billion are spent onvenous ulcer care in the United King-dom annually.2
With the introduction of colour flowduplex scanning (CFDS), air plethys-mography (APG) and more liberal useand understanding of ascending as well as descending venography, theanatomy, pathological and physiologicfeatures of venous reflux, venous hyper-tension and soft-tissue changes in thehypertensive area of the calf have beendefined.3 There is no doubt that the un-derlying problem in every case of CVIis venous hypertension in the gaiter areaof the calf.4 Venous hypertension mayarise from either venous obstruction orvalvular reflux. All patients in this serieshad extensive valvular reflux.
Reflux may occur in the superficial,perforator or deep system of veins,5,6
and the exact location is determinedfor each patient. Deep valvular repair
should be reserved for patients whosecondition is refractory to conservativecare and after elimination of incompe-tent superficial and perforator veins.This management should markedlyrelieve symptoms and heal ulcers in80% of cases.7 The remaining 20%should be considered candidates fordeep valvular repair if significant deepreflux is documented.
This paper examines the clinicaloutcome in 16 consecutive operations(15 patients) for deep venous valvularrepair because of refractory CVI.
PATIENTS AND METHODS
Fifteen patients (12 women) haddeep venous valvular reconstruction be-tween 1991 and 1992. One patient hada bilateral reconstruction. All patientswere operated on by a single surgeon.
The preoperative investigation ofall cases included history-taking andphysical examination, ascending anddescending venography, CFDS andAPG. The preoperative classificationof CVI used in this series is the onerecommended by Porter and Ruther-ford8 (Table I). In this series 5 patientshad class 4 disease, 3 patients had class
5 disease and 8 patients had class 6disease.
The classification for the findingsof reflux on descending venographyused in this series is similar to the oneproposed by Kistner and associates in19869 (Table II).
All patients in this series had class 3or 4 reflux.
In 12 cases there was primaryvalvular insufficiency (Fig. 1), and inthese cases external valvuloplasty wasdone (Fig. 2). One valve in the super-ficial femoral vein was repaired in 9cases, 2 valves in 2 cases and 1 valve in1 case; 1 valve was repaired in thedeep femoral vein.
Technique of valvuloplasty
The common femoral, superficialand deep femoral veins are exposedand completely mobilized. Loupemagnification is used and careful at-tention is paid to removal of all fibroustissue from the vein wall. Valves areidentified by observation and strip-ping. Heparin is used for anticoagula-tion. The repair is done with 7-0 Pro-lene sutures, approximating the sidesof the valve insertion (Fig. 2). Five to7 interrupted sutures are used on eachside. When the repair is complete, the
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subi un transfert de valvule s’est amélioré. Dans cette série, on n’a établi aucun lien statistique entre leschangements préopératoires et postopératoires révélés par la pléthysmographie gazeuse.CONCLUSION : Cette série indique que dans les cas d’insuffisance veineuse chronique réfractaire à un traite-ment de conservation et à une chirurgie superficielle, la reconstruction des valvules veineuses profondes of-fre de bonnes chances d’amélioration clinique.
5 Skin changes, as defined above, with healed ulceration
6 Skin changes, as defined above, with active ulceration
Table II
Classification of Reflux on DescendingVenography
Class
0
1
2
3
4 Reflux to the ankle
Reflux to the calf
Reflux to the knee but not below
Reflux to the mid-thigh
No reflux
Description
strip test is done again with the patientin anti-Trendelenburg position to as-sure valve competence. The valve isencircled with polytetrafluoroethyl-ene, which is loosely sutured with in-terrupted sutures in an attempt to dis-courage dilatation and deteriorationof valve function.
In 4 cases, the leg had recanalizedpostphlebitic deep femoral veins andhad an axillary vein segment contain-ing a valve transferred to the poplitealvein (Fig. 3).
Technique of venous valve transfer
The vein segment, approximately 6to 7 cm long, is taken from the axil-lary vein. Three transfers contained 1valve and 1 transfer contained 2 valvesin the transferred segment in this se-ries. A 3- to 4-cm segment of above-knee popliteal vein is removed and theaxillary vein sewn in place with 8 in-terrupted Prolene sutures at eachanastomosis. The vein is looselywrapped with polytetrafluoroethylene.
All patients received heparin intraop-eratively and for 5 days postoperatively.Warfarin was started on postoperativeday 1 and continued for 3 months.
In all cases, a sequential venouspump was applied in the recoveryroom, and this was carried on until thepatient was completely ambulatory,usually at 2 to 4 days.
Each patient was discharged with a
panty hose type garment providingsupport of 20 to 30 mm Hg.
Patients were followed up 3 weeks,2 months and 6 months postopera-tively, by a clinical examination thatassessed symptomatic relief and ulcerhealing. CFDS and APG were doneon all patients postoperatively, and 4patients had descending venography.
The minimum final follow-up was2 years, and clinical changes were ob-served and recorded using the post-surgical reporting standards.10
Statistics were tested by theWilcoxon signed rank sum test (a non-parametric version of the paired t-test).
RESULTS
Postoperative clinical results in 12
legs with valvuloplasty and 4 legs withvalve transfer are shown in Table III.Clinical improvement was present in14 of 16 legs (88%) (p > 0.05), andgood and excellent results were pre-sent in 9 of the 16 (56%).
Four patients had postoperative de-scending venography: 3 post-valvulo-plasty patients and 1 post-transfer pa-tient. The 3 post-valvuloplasty casesshowed no reflux on descending venog-raphy; 1 of these patients had an excel-lent result and 2 had a good result. Thepostoperative venogram of the patientwho had valve transfer showed gross reflux across the transplanted valve. This patient had a poor result.
CFDS was done postoperatively in allpatients. In 8 of 9 cases with an excel-lent or good result there was no reflux
at the valve site on CFDS. In 3 of the 5cases with no clinical improvement therewas no reflux at the repair site.
There was no significant statisticalcorrelation between good and poorclinical results and preoperative andpostoperative APG results.
All patients made a smooth recov-ery from surgery and were dischargedbetween 5 and 7 days postoperatively.There were no deaths and no majorcomplications. One patient had ahematoma at the donor site in the armand another had a superficial sutureinfection in the groin. There were nocases of severe bleeding at the venousrepair site and no major thrombosispostoperatively.
DISCUSSION
CVI presents a frustrating manage-ment problem for patient and physi-cian. Complete healing of the ulcer is
difficult because of uncontrolled ve-nous hypertension in the gaiter area ofthe leg, superimposed infections andpoor patient compliance with com-pression hosiery. Most patients areyoung and middle aged, most work,and standing enhances the degree ofvenous hypertension.
Modern vascular laboratory tech-niques associated with refined ascend-ing and descending venography haveclarified many pathophysiologic aspectsof the problem. CFDS has allowed in-vestigators to examine valve functionand location and to quantitate the de-gree of reflux from each valve.6,11
APG, a noninvasive easily repeatabletest developed by Christopoulos andassociates,12 analyses reflux, musclepump function and residual volumes.This test is used extensively in preoper-ative and postoperative physiologicevaluation of patients with CVI. Con-cern has been expressed, however, with
the lack of correlation of postoperativeclinical results and laboratory measure-ments, especially APG.13,14 This findingwas present in this series.
CVI is a complex hemodynamicproblem that manifests itself clinicallyas lipodermatosclerosis with or with-out an ulcer in the gaiter area of theleg. It is probably a combination oflarge-vessel malfunction and additionalmicrocirculatory disease. These com-plexities in pathogenesis could explainthe noted discrepancies in preoperativeand postoperative noninvasive mea-
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Table III
VRT = venous refill time, AVP = ambulatory venous pressure
Postoperative Classification and Results
Class
+3
+2
+1
0 Unchanged. No change clinically or byvascular laboratory test results
Mild improvement. Clinical improvement orimprovement in vascular laboratory testresults (VRT or AVP)
Moderate improvement. Mild symptoms ofchronic venous disease, improvement ofVRT to normal or at least +5 s, improvementin AVP to normal or at least -10 mm Hg
Asymptomatic. No symptoms of chronicvenous disease, improvement of VRT tonormal or at least +5 s, improvement inAVP to normal or at least -10 mm Hg
Description
1
5
5
1
Valvuloplasty
Cases, no.
1
0
3
0
Valve transfer
-1 Mild worsening. Worsening of symptoms ofchronic venous disease or by vascularlaboratory test results (VRT or AVP) 0 0
-2 Significant worsening. Worsening ofsymptoms and vascular laboratory testresults (VRT or AVP) 0 0
-3 Marked worsening. Same as -2 accompaniedby new or worsening ankle claudication 0 0
FIG. 4. Descending venogram showing caudad“cascade” of dye in the superficial femoral anddeep femoral veins. Note that there is no evi-dence of previous deep venous thrombosis(DVT). The diagnosis was primary valvular insuf-ficiency.
surements and the changes in clinicalclassification after surgery as docu-mented by Iafrati and associates.13
Ascending venography determinespatency of veins as well as the presenceof incompetent perforating veins andthe degree of superficial varicosities.Descending venography is extremelyhelpful in demonstrating both superfi-cial and deep venous valvular reflux.Kistner and associates9 have classifiedthe extent of reflux (Figs. 4 and 5). Allpatients in this series either had grade3 (19%) or grade 4 (81%) venous re-flux. Management decisions in the se-ries were decided primarily on the ba-sis of descending venography andclinical findings. APG and CFDS werenot the prime determinants of valvularsurgery but were analysed both in thepreoperative and postoperative phases.
All patients in this series had CVIsecondary to venous reflux. None hadobstructive venous occlusion. Venousreflux is caused by destruction of valvesin patients with deep venous thrombo-sis and recanalization, or by primaryvalvular insufficiency (Fig. 1). A history
of phlebitis followed by months oryears of symptoms of the post-throm-bophlebitic syndrome, associated withvenographic evidence of thickenedveins, absent veins and areas of obviousrecanalization (tree barking) are help-ful in making the diagnosis of refluxdue to deep venous thrombosis.
Primary valvular insufficiency, de-scribed by Kistner15 in 1968 is a distinctentity that must be recognized in thepreoperative period when these valvesare amenable to valvular repair.16 Thevalves show no evidence of previous in-flammatory disease such as thickeningor scarring of the valve cusps. The valvecusps are elongated, prolapsed and be-come incompetent (Fig. 1). No causefor this condition is known.17,18 The di-agnosis is confirmed by descendingvenography (Figs. 4 and 5) showingsignificant reflux and no evidence of re-canalized fibrotic veins and valves.18
All cases in this series were refrac-tory to conservative management.Our initial management in treatingnew cases of CVI is conservative, in-cluding elevation of the foot of thebed, leg elevation whenever possible,local attention to the ulcer bed, and abelow-knee support stocking, usuallystarting with one that provides sup-port of 20 to 30 mm Hg, emphasiz-ing “donning” the stockings firstthing in the morning. Extensive walk-ing is encouraged to increase the effi-cacy of the calf muscle pump, and lo-cal care of the ulcer is provided withsaline and betadine soaks followed by
dry dressing under the support stock-ings. Antibiotics are used locally andsystemically if bacterial infection ispresent in the ulcer. Weight reductionis encouraged if the patient is obese,although no evidence exists that obe-sity plays a role in the pathogenesis ofchronic venous ulceration.14
Recently, early management of casesof CVI, with or without ulceration, haschanged. On physical examination thephysician looks for reflux at the saphe-nofemoral junction (Trendelenbergtest), Hunterian perforating veins, Boyd,Dodd or Cockett perforating veins andshort saphenous popliteal reflux. CFDSis done to map out the venous anatomyin the area of the medial calf to aid insubsequent sclerotherapy. Major areasof transfacial reflux — saphenofemoral,saphenopopliteal and Hunterian, Boydand Dodd perforating veins — are lig-ated as an in-office ambulatory proce-dure and remaining perforator areas,Dodd, Boyd, Cockett, are treated withsclerotherapy with the aid of CFDS ofthe veins in the gaiter area. Four-layercompression bandages are used aftersclerotherapy.19
No deep valvular reconstruction wasdone in any patient who had superficialor perforating vein incompetence as ev-idenced by careful clinical examination,venography and duplex scanning. If allinvestigations demonstrate incompe-tence, as is often the case,5 early atten-tion is given to alleviating the reflux inthe superficial and perforating systems.7
In this series of 16 consecutive
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FIG. 5. Descending venography showing caudadfree flow of dye into calf veins (Kistner grade III). FIG. 6. Technique for the intraoperative strip test.
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cases of CVI managed surgically witha minimal 2-year patient follow-up, 12cases were primary valvular insuffi-ciency and 4 were valve destructiondue to deep venous thrombosis.
Our current policy in valvuloplastyis to repair all the obvious valves in theextent of the femoral canal, usually 2.Success of valvular repair at surgerywas indicated by a positive strip test(Fig. 6).
The results are encouraging. In 12cases of valvuloplasty repair, the resultwas excellent in 1, good in 5 and fairin 5; there was no improvement in 1case. In the 4 cases of valve transferthere was no excellent result, but itwas good in 3 cases and unchanged in1. Overall, 14 patients (92%) were im-proved with deep venous valvular re-pair (p = 0.05).
Long-term venous follow-up valverepairs20,21 indicate that cases of primaryvalvular insufficiency result in a highernumber of good results than cases ofvalvular incompetence secondary to re-canalized valves after deep venousthrombosis. Deep venous valve surgeryresults in long-term improved clinicalresults. Masuda and Kistner21 reporteda 60% long-term clinical improvementand noted that when there was CFDSevidence of competent valves, the im-proved results were 86%.
Bry and associates22 and O’Don-nell23 found a 93% clinical improve-ment in 14 patients with valve trans-fer to the popliteal vein, with a meanfollow-up of 5.3 years.
CONCLUSIONS
Valvular repair and valve transferare reasonable options in the manage-ment of CVI refractory to both con-servative care and superficial venoussurgery. Sixteen cases of CVI treatedby deep valvular surgery resulted in92% improvement with an excellent orgood result in 56% of cases.
We thank Dr. Gordon Doig, Analytical Epi-demiologist, Biostatistical Support Unit, Uni-versity of Western Ontario, for reading an ear-lier manuscript and making many worthwhilesuggestions.
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5. Shami SK, Sarin S, Cheatle TR, ScurrJH, Coleridge Smith PD. Venous ul-cers and the superficial venous sys-tem. J Vasc Surg 1993;17:487-90.
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