Abstract
Objective: To evaluate the results of venous valvular repair in the treatment of 16 cases of chronic venous insufficiency (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 were refractory to prolonged conservative care and removal of incompetent superficial and perforating veins. Investigation included ascending and descending venography, air plethysmography (APG) and colour flow duplex scanning (CFDS). All patients had class 4, 5 or 6 CVI and all demonstrated deep venous reflux from the groin to below the knee on descending venography.
Interventions: Superficial femoral vein valvuloplasty (12 operations) and venous valve transfer from the axillary vein to the above-knee popliteal vein (4 operations).
Main outcome measures: Healing of ulcers, relief of edema and improvement in symptoms were clinical criteria of success. An attempt was made to correlate preoperative and postoperative APG, CFDS and descending venography.
Results: Ninety-two percent of the valvuloplasty patients and 75% of the valve transfer patients were clinically improved. In this series no statistical association existed between preoperative and postoperative changes noted on APG.
Conclusion: This series suggests that deep vein valvular reconstruction for CVI refractory to conservative management and superficial surgery offers a good chance of clinical improvement.
Chronic venous insufficiency (CVI) is a common, debilitating, recidivistic problem that is stressful for both the attending physician and the patient because of its extremely refractory nature. In the United States, 500 000 people suffer from venous ulceration.1 Between $3 million and $1.2 billion are spent on venous ulcer care in the United Kingdom annually.2
With the introduction of colour flow duplex scanning (CFDS), air plethysmography (APG) and more liberal use and understanding of ascending as well as descending venography, the anatomy, pathological and physiologic features of venous reflux, venous hypertension and soft-tissue changes in the hypertensive area of the calf have been defined.3 There is no doubt that the underlying problem in every case of CVI is venous hypertension in the gaiter area of the calf.4 Venous hypertension may arise from either venous obstruction or valvular reflux. All patients in this series had extensive valvular reflux.
Reflux may occur in the superficial, perforator or deep system of veins,5,6 and the exact location is determined for each patient. Deep valvular repair should be reserved for patients whose condition is refractory to conservative care and after elimination of incompetent superficial and perforator veins. This management should markedly relieve symptoms and heal ulcers in 80% of cases.7 The remaining 20% should be considered candidates for deep valvular repair if significant deep reflux is documented.
This paper examines the clinical outcome in 16 consecutive operations (15 patients) for deep venous valvular repair because of refractory CVI.
Patients and methods
Fifteen patients (12 women) had deep venous valvular reconstruction between 1991 and 1992. One patient had a bilateral reconstruction. All patients were operated on by a single surgeon.
The preoperative investigation of all cases included history-taking and physical examination, ascending and descending venography, CFDS and APG. The preoperative classification of CVI used in this series is the one recommended by Porter and Rutherford8 (Table I). In this series 5 patients had class 4 disease, 3 patients had class 5 disease and 8 patients had class 6 disease.
Classification of Chronic Venous Insufficiency
The classification for the findings of reflux on descending venography used in this series is similar to the one proposed by Kistner and associates in 19869 (Table II).
Classification of Reflux on Descending Venography
All patients in this series had class 3 or 4 reflux.
In 12 cases there was primary valvular insufficiency (Fig. 1), and in these cases external valvuloplasty was done (Fig. 2). One valve in the superficial femoral vein was repaired in 9 cases, 2 valves in 2 cases and 1 valve in 1 case; 1 valve was repaired in the deep femoral vein.
Primary valvular insufficiency.
Technique of external valvuloplasty.
Technique of valvuloplasty
The common femoral, superficial and deep femoral veins are exposed and completely mobilized. Loupe magnification is used and careful attention is paid to removal of all fibrous tissue from the vein wall. Valves are identified by observation and stripping. Heparin is used for anticoagulation. The repair is done with 7-0 Prolene sutures, approximating the sides of the valve insertion (Fig. 2). Five to 7 interrupted sutures are used on each side. When the repair is complete, the strip test is done again with the patient in anti-Trendelenburg position to assure valve competence. The valve is encircled with polytetrafluoroethylene, which is loosely sutured with interrupted sutures in an attempt to discourage dilatation and deterioration of valve function.
In 4 cases, the leg had recanalized postphlebitic deep femoral veins and had an axillary vein segment containing a valve transferred to the popliteal vein (Fig. 3).
Technique of valve transfer.
Technique of venous valve transfer
The vein segment, approximately 6 to 7 cm long, is taken from the axillary vein. Three transfers contained 1 valve and 1 transfer contained 2 valves in the transferred segment in this series. A 3- to 4-cm segment of above-knee popliteal vein is removed and the axillary vein sewn in place with 8 interrupted Prolene sutures at each anastomosis. The vein is loosely wrapped with polytetrafluoroethylene.
All patients received heparin intraoperatively and for 5 days postoperatively. Warfarin was started on postoperative day 1 and continued for 3 months.
In all cases, a sequential venous pump was applied in the recovery room, and this was carried on until the patient was completely ambulatory, usually at 2 to 4 days.
Each patient was discharged with a panty hose type garment providing support of 20 to 30 mm Hg.
Patients were followed up 3 weeks, 2 months and 6 months postoperatively, by a clinical examination that assessed symptomatic relief and ulcer healing. CFDS and APG were done on all patients postoperatively, and 4 patients had descending venography.
The minimum final follow-up was 2 years, and clinical changes were observed and recorded using the post-surgical reporting standards.10
Statistics were tested by the Wilcoxon 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 with valve transfer are shown in Table III. Clinical improvement was present in 14 of 16 legs (88%) (p > 0.05), and good and excellent results were present in 9 of the 16 (56%).
Postoperative Classification and Results
Four patients had postoperative descending venography: 3 post-valvuloplasty patients and 1 post-transfer patient. The 3 post-valvuloplasty cases showed no reflux on descending venography; 1 of these patients had an excellent result and 2 had a good result. The postoperative venogram of the patient who had valve transfer showed gross reflux across the transplanted valve. This patient had a poor result.
CFDS was done postoperatively in all patients. In 8 of 9 cases with an excellent or good result there was no reflux at the valve site on CFDS. In 3 of the 5 cases with no clinical improvement there was no reflux at the repair site.
There was no significant statistical correlation between good and poor clinical results and preoperative and postoperative APG results.
All patients made a smooth recovery from surgery and were discharged between 5 and 7 days postoperatively. There were no deaths and no major complications. One patient had a hematoma at the donor site in the arm and another had a superficial suture infection in the groin. There were no cases of severe bleeding at the venous repair site and no major thrombosis postoperatively.
Discussion
CVI presents a frustrating management problem for patient and physician. Complete healing of the ulcer is difficult because of uncontrolled venous hypertension in the gaiter area of the leg, superimposed infections and poor patient compliance with compression hosiery. Most patients are young and middle aged, most work, and standing enhances the degree of venous hypertension.
Modern vascular laboratory techniques associated with refined ascending and descending venography have clarified many pathophysiologic aspects of the problem. CFDS has allowed investigators to examine valve function and location and to quantitate the degree of reflux from each valve.6,11 APG, a noninvasive easily repeatable test developed by Christopoulos and associates,12 analyses reflux, muscle pump function and residual volumes. This test is used extensively in preoperative and postoperative physiologic evaluation of patients with CVI. Concern has been expressed, however, with the lack of correlation of postoperative clinical results and laboratory measurements, especially APG.13,14 This finding was present in this series.
CVI is a complex hemodynamic problem that manifests itself clinically as lipodermatosclerosis with or without an ulcer in the gaiter area of the leg. It is probably a combination of large-vessel malfunction and additional microcirculatory disease. These complexities in pathogenesis could explain the noted discrepancies in preoperative and postoperative noninvasive measurements and the changes in clinical classification after surgery as documented by Iafrati and associates.13
Ascending venography determines patency of veins as well as the presence of incompetent perforating veins and the degree of superficial varicosities. Descending venography is extremely helpful in demonstrating both superficial and deep venous valvular reflux. Kistner and associates9 have classified the extent of reflux (Figs. 4 and 5). All patients in this series either had grade 3 (19%) or grade 4 (81%) venous reflux. Management decisions in the series were decided primarily on the basis of descending venography and clinical findings. APG and CFDS were not the prime determinants of valvular surgery but were analysed both in the preoperative and postoperative phases.
Descending venogram showing caudad “cascade” of dye in the superficial femoral and deep femoral veins. Note that there is no evidence of previous deep venous thrombosis (DVT). The diagnosis was primary valvular insufficiency.
Descending venography showing caudad free flow of dye into calf veins (Kistner grade III).
All patients in this series had CVI secondary to venous reflux. None had obstructive venous occlusion. Venous reflux is caused by destruction of valves in patients with deep venous thrombosis and recanalization, or by primary valvular insufficiency (Fig. 1). A history of phlebitis followed by months or years of symptoms of the post-thrombophlebitic syndrome, associated with venographic evidence of thickened veins, absent veins and areas of obvious recanalization (tree barking) are helpful in making the diagnosis of reflux due to deep venous thrombosis.
Primary valvular insufficiency, described by Kistner15 in 1968 is a distinct entity that must be recognized in the preoperative period when these valves are amenable to valvular repair.16 The valves show no evidence of previous inflammatory disease such as thickening or scarring of the valve cusps. The valve cusps are elongated, prolapsed and become incompetent (Fig. 1). No cause for this condition is known.17,18 The diagnosis is confirmed by descending venography (Figs. 4 and 5) showing significant reflux and no evidence of recanalized fibrotic veins and valves.18
All cases in this series were refractory to conservative management. Our initial management in treating new cases of CVI is conservative, including elevation of the foot of the bed, leg elevation whenever possible, local attention to the ulcer bed, and a below-knee support stocking, usually starting with one that provides support of 20 to 30 mm Hg, emphasizing “donning” the stockings first thing in the morning. Extensive walking is encouraged to increase the efficacy of the calf muscle pump, and local care of the ulcer is provided with saline and betadine soaks followed by dry dressing under the support stockings. Antibiotics are used locally and systemically if bacterial infection is present in the ulcer. Weight reduction is encouraged if the patient is obese, although no evidence exists that obesity plays a role in the pathogenesis of chronic venous ulceration.14
Recently, early management of cases of CVI, with or without ulceration, has changed. On physical examination the physician looks for reflux at the saphenofemoral junction (Trendelenberg test), Hunterian perforating veins, Boyd, Dodd or Cockett perforating veins and short saphenous popliteal reflux. CFDS is done to map out the venous anatomy in the area of the medial calf to aid in subsequent sclerotherapy. Major areas of transfacial reflux — saphenofemoral, saphenopopliteal and Hunterian, Boyd and Dodd perforating veins — are ligated as an in-office ambulatory procedure and remaining perforator areas, Dodd, Boyd, Cockett, are treated with sclerotherapy with the aid of CFDS of the veins in the gaiter area. Four-layer compression bandages are used after sclerotherapy.19
No deep valvular reconstruction was done in any patient who had superficial or perforating vein incompetence as evidenced by careful clinical examination, venography and duplex scanning. If all investigations demonstrate incompetence, as is often the case,5 early attention is given to alleviating the reflux in the superficial and perforating systems.7
In this series of 16 consecutive cases of CVI managed surgically with a minimal 2-year patient follow-up, 12 cases were primary valvular insufficiency and 4 were valve destruction due to deep venous thrombosis.
Our current policy in valvuloplasty is to repair all the obvious valves in the extent of the femoral canal, usually 2. Success of valvular repair at surgery was indicated by a positive strip test (Fig. 6).
Technique for the intraoperative strip test.
The results are encouraging. In 12 cases of valvuloplasty repair, the result was excellent in 1, good in 5 and fair in 5; there was no improvement in 1 case. In the 4 cases of valve transfer there was no excellent result, but it was good in 3 cases and unchanged in 1. Overall, 14 patients (92%) were improved with deep venous valvular repair (p = 0.05).
Long-term venous follow-up valve repairs20,21 indicate that cases of primary valvular insufficiency result in a higher number of good results than cases of valvular incompetence secondary to recanalized valves after deep venous thrombosis. Deep venous valve surgery results in long-term improved clinical results. Masuda and Kistner21 reported a 60% long-term clinical improvement and noted that when there was CFDS evidence of competent valves, the improved results were 86%.
Bry and associates22 and O’Donnell23 found a 93% clinical improvement in 14 patients with valve transfer to the popliteal vein, with a mean follow-up of 5.3 years.
Conclusions
Valvular repair and valve transfer are reasonable options in the management of CVI refractory to both conservative care and superficial venous surgery. Sixteen cases of CVI treated by deep valvular surgery resulted in 92% improvement with an excellent or good result in 56% of cases.
Acknowledgments
We thank Dr. Gordon Doig, Analytical Epidemiologist, Biostatistical Support Unit, University of Western Ontario, for reading an earlier manuscript and making many worthwhile suggestions.
Footnotes
↵* Supported by the A.D. McLachlin professorship
- Accepted April 9, 1997.