"Quality of Life after Varicose Vein Surgery in Patients with High-ligation and Stripping, External Valvuloplasty and Sapheno-femoral Redo Surgery".

BACKGROUND: High-ligation and stripping (HL/S) and external valvuloplasty (eVP) with the implantation of an external device to restore the valve's function, are surgical methods to eliminate reflux at the saphenofemoral junction. Furthermore, redo-surgery (RedoS) can be performed in terms of same side groin recurrences. It is unclear, if there is a difference in quality of life (QoL) between these 3 surgical treatment options. Therefore, it was the aim of our study to elucidate QoL in patients before and after surgical treatment at the saphenofemoral junction by comparing HL/S, eVP, and RedoS. METHODS: A total of 303 participants (156 HL/S, 81eVP, 64 RedoS) were recruited during the daily clinical routine. QoL was measured at admission and 6 weeks after the surgical procedure by means of SF-12 (12 item short form health survey) and Aberdeen Varicose Vein Questionnaire. RESULTS: The mean value of Aberdeen Varicose Vein Questionnaire was 14.5 (SD 2.1) preoperatively and 4.9 (SD 3.3) postoperatively in the HL/S group, 16.4 (SD 1.4) preoperatively and 6.8 (SD 2.5) postoperatively in the eVP group and 15.5 (2.2) preoperatively and 5.8 (SD 4.2) postoperatively in the RedoS group, which was statistically significant (P< 0.05) in all groups. Postoperatively, the mean values were statistically significant within the groups. Concerning physical aspects of the SF-12 we found a significant improvement in the RedoS group, while mental aspects were significantly better in the HL/S and eVP group postoperatively. Nevertheless, the clinical relevance of these SF-12 differences is questionable under consideration of the minimal important difference. CONCLUSIONS: Varicose vein surgery leads to a significant improvement of QoL in all groups. The implantation of an external patch could have a negative influence in QoL.

The influence of age on valve disease in patients with varicose veins analysed by transmission electron microscopy and stereology.

BACKGROUND: The aim of this study was to investigate the influence of age on the ultrastructure of venous valve morphology in patients with C2 classified chronic venous disorders according to the CEAP classification. PATIENTS AND METHODS: The study population consisted of 16 consecutive patients with varicose veins (C2). The mean age was 49.8 years (30-66). The (pre-) terminal valve including the vessel wall was harvested within the proximal 2 centimetres of the great saphenous vein. The mean thickness (volume-to-surface ratio = V/S ratio) of elastin, collagen, endothelium and of the entire valve was determined. A blinded morphologist performed the examination by transmission electron microscopy and stereology. Analyses by Pearson's product moment correlation, Kendall's tau and Spearman's rank correlation were performed to investigate whether there is a correlation between age and the ultrastructural morphology. RESULTS: Stereological analysis of the valves demonstrated a mean V/S ratio (signifying a thickness estimation) for elastin of 0.87 µm3/µm2, for collagen of 18.0 µm3/µm2, for endothelium of 0.65 µm3/µm2, and for the entire valve of 25.2 µm³/µm². Statistical analyses showed no statistically significant correlation between age and the ultrastructural morphology in this patient group. CONCLUSIONS: The ultrastructural morphology of the venous valves in chronic venous disorders may not depend on age in patients presenting with C2 disease. This conclusion may or may not apply to all C classes as we investigated a homogenous group of patients with C2 limbs.

[Free autovenous graft with destructed valves in treatment of severe ischemia of lower extremities]. / Lechenie kriticheskoi ishemii nizhnikh konechnostei s ispol'zovaniem svobodnogo autovenoznogo transplantata s razrushennymi klapanami.

AIM: to improve treatment of patients with severe atherosclerotic lesion of lower extremities arteries followed by critical ischemia by optimization of femoropopliteal bypass surgery. MATERIAL AND METHODS: Treament and survey of 60 patients with severe atherosclerotic lesion of femoropopliteotibial segment and critical lower limb ischemia were analyzed. Patients were divided into 2 groups depending on technique of femoropopliteal bypass. Conventional in situ autovenous technique was used in group 1. In the second group we used original method of free autovenous graft with destructed valves. RESULTS: Technique of free autovenous graft with destructed valves decreases incidence of early postoperative complications by 13.3%, remote thrombosis of graft by 13.3%. Also it increases physical and mental components of health by 7.9% and 3.1% respectively. CONCLUSION: Use of free autovenous graft with destructed valves is reasonable and improves results of treatment.

Surgery for deep venous incompetence.

BACKGROUND: Chronic deep venous incompetence (DVI) is caused by incompetent vein valves and/or blockage of large-calibre leg veins and causes a range of symptoms including recurrent ulcers, pain and swelling. Most surgeons accept that well-fitted graduated compression stockings (GCS) and local care of wounds serve as adequate treatment for most patients, but sometimes symptoms are not controlled and ulcers recur frequently, or they do not heal despite compliance with conservative measures. In these situations, in the presence of severe venous dysfunction, surgery has been advocated by some vascular surgeons. This is an update of the review first published in 2000. OBJECTIVES: To assess the effects of surgical management of deep venous incompetence in terms of ulcer healing, ulcer recurrence and alleviation of symptoms. SEARCH METHODS: For this update, the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched October 2014) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 9). SELECTION CRITERIA: Randomised controlled trials of surgical treatment for patients with DVI. DATA COLLECTION AND ANALYSIS: For this update, two review authors (RRG and SCH) extracted data independently. All included studies required full risk of bias assessment in line with current procedures of The Cochrane Collaboration. Two review authors (RRG and SCH) independently assessed risk of bias and consulted with a third review author (AA) when necessary. MAIN RESULTS: Four studies with 273 participants were included. All included studies reported clinical outcomes following valvuloplasty. We found no studies investigating other surgical procedures for the treatment of patients with DVI. All included studies investigated primary valve incompetence. We found no trials that investigated the results of surgery for secondary valvular incompetence or the obstructive form of DVI. Because different outcome measures were used, it was not possible to pool the results of included studies. The methodological quality of the included studies was low, mainly because information regarding randomisation and blinding was missing, or because data were incomplete or were presented poorly. Ulcer healing and ulcer recurrence were not reported in one study, and the remaining three studies did not include participants with ulcers or with active ulceration. Three studies reported no significant complications of surgery and no incidence of DVT during follow-up. One study did not report on the occurrence of complications. Clinical changes were assessed by subjective and objective measurements, as specified in the clinical, aetiological, anatomical, and pathophysiological (CEAP) classification score. This requires vascular laboratory measurements of lower limb haemodynamics before and after surgery. Tests include an overall evaluation of venous function with venous refilling time (VRT) or ambulatory venous pressure (AVP). Two small trials comparing external valvuloplasty using limited anterior plication in combination with ligation of incompetent superficial veins against ligation alone (L) showed that ligation plus limited anterior plication produced significant improvement in AVP: The mean difference was -15 mm Hg (95% confidence interval (CI) -20.9 to -9.0) at one year and -15 mm Hg (95% CI -21 to -8.9) at two years. Sustainable statistically significant improvement in AVP and VRT was achieved by ligation and limited anterior plication at 10 years in one study. However, AVP values after surgery remained relatively high, causing its benefit to be questioned. Similarly, another study including participants who were deteriorating preoperatively showed sustained mild clinical improvement for seven years in those subjected to valvuloplasty compared with participants undergoing superficial venous surgery alone. However, this benefit was lost when the condition of participants was stable preoperatively. One small study (n = 40) with grade 3 reflux and no participants with ulcers reported that external valvuloplasty of the femoral vein combined with surgical repair of the superficial venous system improved the haemodynamic status of the lower limbs, restored valvular function more effectively and achieved better outcomes than surgical repair of the superficial venous system alone. AUTHORS' CONCLUSIONS: No evidence was found for benefit or harm of valvuloplasty in the treatment of patients with DVI secondary to primary valvular incompetence. The individual trials included in this review were small; they used different methods of assessment and overall were of poor quality. They did not include participants with severe DVI. Trials investigating the effects of other surgical procedures on deep veins are needed. Until the findings of such trials become available, the benefit of valvuloplasty remains uncertain.

[Perforating veins insufficiency in patients with varicose disease].

MATERIAL AND METHODS: It was analyzed the results of complex survey and treatment of 181 patients with varicose disease CEAP degrees C3-C6. Ultrasonic scanning was applied to define localization, severity and extension of blood reflux in venous system. RESULTS: Superficial reflux was revealed in all patients, perforating--in 59.7%, deep--in 22.8% of cases. We concluded that high-intensive total-subtotal blood reflux in superficial veins was main hemodynamic factor resulted perforating insufficiency in 42% of patients, high-intensive deep reflux--in 17.7% of cases additionally. In patients with subcompensated course of disease superficial reflux removal and large perforating veins (diameter 4.5±0.5 mm) ligation are advisable. Small perforating veins insufficiency (diameter 3.5±0.5 mm) is eliminated independently after superficial reflux removal. Two-staged treatment should be used in patients with decompensated course of disease and trophic disorders ofshin. Perforating veins sclerotherapy under ultrasonic control is advisable secondarily after superficial reflux removal.

Role of sinus in prosthetic venous valve.

BACKGROUND: The majority of bioprosthetic venous valves do not have a sinus pocket and, in practice, they are often placed in non-sinus segments of the veins. The aim of this study is to investigate the effect of the sinus pocket on the flow dynamics in a prosthetic valve. METHODS: A bench top in vitro experiment was set up at physiological flow conditions to simulate the flow inside a venous system. Bicuspid bioprosthetic valves with different leaflet lengths (5 and 10 mm) were tested in tubes with and without a sinus pocket and the flows around the valve were visualized by particle image velocimetry (PIV). Velocity data measurements were made and the vorticity was calculated in the with- and without-sinus set-ups. RESULTS: PIV measurements showed that vortex structure was maintained by the sinus. For the 10-mm leaflet length design with sinus, the jet width at the exit of the valve was 59% of that without sinus. For the 5-mm design with sinus, the jet width was 73% of the valve without sinus. Flow from the sinus region was entrained into the main jet observed near the exit of the sinus and altered the flow at the near wall region. CONCLUSIONS: The sinus pocket alters the flow around the valve and functions as flow regulator to smooth the flow pattern around the valve. The vortical structure inside the sinus is maintained at the valve leaflet tip during the valve cycle. For the prosthetic valve designated to be placed without a sinus, a shorter leaflet length is preferable and performs more closely to the valve with sinus.

Characterization of a bioprosthetic bicuspid venous valve hemodynamics: implications for mechanism of valve dynamics.

BACKGROUND: Chronic venous insufficiency (CVI) of the lower extremities is a common clinical problem. Although bioprosthetic valves have been proposed to treat severe reflux, clinical success has been limited due to thrombosis and neointima overgrowth of the leaflets that is, in part, related to the hemodynamics of the valve. A bioprosthetic valve that mimics native valve hemodynamics is essential. METHODS: A computational model of the prosthetic valve based on realistic geometry and mechanical properties was developed to simulate the interaction of valve structure (fluid-structure interaction, FSI) with the surrounding flow. The simulation results were validated by experiments of a bioprosthetic bicuspid venous valve using particle image velocimetry (PIV) with high spatial and temporal resolution in a pulse duplicator (PD). RESULTS: Flow velocity fields surrounding the valve leaflets were calculated from PIV measurements and comparisons to the FSI simulation results were made. Both the spatial and temporal results of the simulations and experiments were in agreement. The FSI prediction of the transition point from equilibrium phase to valve-closing phase had a 7% delay compared to the PD measurements, while the PIV measurements matched the PD exactly. FSI predictions of reversed flow were within 10% compared to PD measurements. Stagnation or stasis regions were observed in both simulations and experiments. The pressure differential across the valve and associated forces on the leaflets from simulations showed the valve mechanism to be pressure driven. CONCLUSIONS: The flow velocity simulations were highly consistent with the experimental results. The FSI simulation and force analysis showed that the valve closure mechanism is pressure driven under the test conditions. FSI simulation and PIV measurements demonstrated that the flow behind the leaflet was mostly stagnant and a potential source for thrombosis. The validated FSI simulations should enable future valve design optimizations that are needed for improved clinical outcome.

More great saphenous vein valves - less varicose veins?

BACKGROUND: In patients with chronic venous disease (CVD) the number of venous valves and the degree of valve deterioration have not been extensively investigated and are poorly understood. The aim of this prospective study was to quantitatively and qualitatively investigate the venous valves in CVD patients in view of their clinical classification. PATIENTS AND METHODS: Within two years a consecutive series of 152 patients (223 limbs) undergoing primary surgery for great saphenous vein varicose veins was investigated. In all patients the 'C' class according to the basic CEAP-classification was registered preoperatively (C2 to C6) for each limb. Both the quantity and quality of venous valves were assessed in the GSV's after removal. Qualitative evaluation of the valves was based on macroscopic appearance using a classification from 0 to 5 and described as 'valve disease class'. RESULTS: A negative correlation between age and the number of valves was detected (p = 0.0035). There was an increase of C-class with increasing age. No significant correlation between the average number of valves per meter and the C-class was detected. For all C-classes an average of between four and five valves per meter was counted. Valve disease class was positively correlated with the C-class although the valve disease class was never higher than the C-class (p < 0.05). CONCLUSIONS: The valve disease class of the great saphenous vein correlates with the C-class of the CEAP-classification. The number of valves did not correlate with the 'C'-class. With each increase in the CEAP class the age increased as well.

[Stages of development of surgical treatment for insufficiency of venous valves of lower limbs].

Insufficiency of the valvular apparatus of the lower-limb veins is one of the main causes of the development of chronic venous insufficiency. This disease is commonly prevalent in developed countries including Russia and is an urgent and socially significant problem. Insufficiency of the venous valves may be corrected by a wide variety of approaches and methods however they all are not universal or have low efficacy and in some cases cannot be applied at all. This article is dedicated to the review of the existing methods of surgical correction of valvular insufficiency of lower-limb veins, as well as a review of the studies of the most promising trend of this problem, i.e. prosthetic repair of venous valves.

[Restoration of valvular function of deep veins in lower-limb varicose disease].

The present work was based on analysing the results of a complex examination and surgical treatment of 16-to-78-year-old patients presenting with varicose disease during the period from 2006 to 2010. A total of 1,095 limbs were examined and operated on in 1,070 patients. Of these, 298 (29.6 %) were men, and 709 (70.4 %) women. The distribution of the patients according to the CEAP clinical classification was as follows: C1 - 3 patients, C2 - 215, C3 - 566, C4 - 203, C5 - 29, and C6 - 79 subjects. All patients underwent ultrasonic duplex scanning, with retrograde phlebography performed in 21 cases. 51.2% of patients were diagnosed as having pathological deep venous reflux. In the group of patients with valvular insufficiency of deep veins, a total of 93 operations aimed at correcting deep reflux were performed, including 12 interventions for congenital avalvulation of veins. The indications for restorative operations on the valvular apparatus of deep veins were determined in severe forms of chronic venous insufficiency combined with axial reflux along deep veins in cases of inefficiency of conventional methods of surgical and conservative treatment. The long-term outcomes of surgery were assessed after 18-48 months. The results were evaluated by means of clinical and instrumental methods of examination: the disease severity scale, patients quality of life questionnaire, ultrasonographic and roentgen contrast methods of examination, and legometry. The operations aimed at restoring the valvular function of the femoral veins turned out to be effective methods of correcting venous reflux and made it possible to restore the valvular function in 84% of cases. In the remote postoperative period valvular competence was observed in 74.6% of patients. Carrying out such operations significantly improve the course of the disease due to decreasing the malleolar volume (p<0.001), manifestations of symptoms of chronic venous insufficiency (p<0.001), and improving quality of life (p<0.001).

[The application of popliteal vein anatomy study and valve construction procedure].

OBJECTIVE: To analyze anatomy data of popliteal veins (PV), with the purpose of selection of popliteal venous valves construction segment via venography, and to evaluate the surgical results. METHODS: From February 1998 to November 2010, after analyzing the popliteal vessel anatomy data of 39 limbs and related phlebography research of 862 cases, 102 patients (69 male and 33 female patients, aged from 48 to 71 years, mean 59 years) with severe deep venous insufficiency were selected for popliteal venous valve construction procedures. Doppler ultrasound, continuous dynamic venography, and intraoperative venous pressure measurements were used to assess the hemodynamic changes pre- and postoperatively. Venous clinical severity score (VCSS) were used to evaluate long-term results of deep venous valve construction procedures. RESULT: In the 102 patients, 93.7% patients had one pair of valves in popliteal vein (PV), locating in the distal 1/3 segment of PV, with gastrocnemius veins (GV) joining with PV above PV valves. Postoperative blood flow volume of the PV was significantly higher than the preoperative volume (732.3 ml/min vs. 150.2 ml/min, t = 8.979, P < 0.001). The proximal pressure was significantly lower than the distal pressure ((12 ± 3) cm H(2)O vs. (15 ± 3) cm H(2)O, 1 cm H(2)O = 0.098 kPa, t = 8.049, P < 0.001). VCSS score was significantly lower after the surgery ((34 ± 15) cm H(2)O vs. (41 ± 14) cm H(2)O, t = 59.780, P < 0.001). Pre- and postoperative hemodynamic changes and VCSS scores were statistically significant (9.3 ± 1.9 vs. 1.8 ± 1.0, t = 59.780, P < 0.001). Mean follow-up were 8.9 years with an ulcer recovery rate of 96.3%, and a 3.7% ulcer recurrent rate. CONCLUSIONS: Popliteal vessel anatomy study and venography research provide critical information for the PV valve construction part selection, which stayed proximal to the communications of GV and PV. Restoration of gastrocnemius pump function and satisfactory long-term efficacy are received after valve construction.

[Artificial venous valves]. / Sztuczne zastawki zylne.

Venous diseases seem to be a large social problem. Chronic venous insufficiency, which is the most well-known venous disease, can be caused by high blood pressure in veins. The increase in pressure may cause the vein wall weakness and may even lead to damage venous valves. There are many different methods of treatment of chronic venous insufficiency: surgical and non-surgical. A new therapeutic approach is the use of artificial venous valves. Artificial venous valves can be classified into synthetics, xenografts and allografts. Different types of artificial venous valves are presented based on the analysis of literature reports. A variety of techniques have been used clinically. Improved venous hemodynamics and valve competency have been demonstrated. We presented advantages and disadvantages of described artificial venous valves. The majority of these valve studies await confirmation over extended periods of time. This paper also describes two types of artificial venous valves, which were analyzed by computer simulation.

Two-Year Results of a First-In-Human Study in Patients Surgically Implanted With a Bioprosthetic Venous Valve, the VenoValve in Patients With Severe Chronic Venous Insufficiency.

OBJECTIVE: Two-year follow-up results from a first-in-human study of patients implanted with the VenoValve are evaluated for supporting the long-term clinical safety and performance of the device. BACKGROUND: Chronic Venous Insufficiency (CVI) involves improper functioning of lower limb vein valves and inability of these valves to move blood back towards the heart. CVI symptoms include swelling, varicose veins, pain, and leg ulcers. Currently, there is no cure for this condition and treatment options are limited. This study provides 2-year outcomes for 8 patients who were implanted with the bioprosthetic VenoValve for treating severe CVI with deep venous reflux measured at the mid-popliteal vein. The 6-month and 1-year results were previously published. METHODS: Eleven patients with C5 & C6 CVI were implanted with VenoValve into the midthigh femoral vein and followed for 2 years. Assessed clinical outcomes include device-related adverse events, reflux time, disease severity, and pain scores. RESULTS: All 11 implant procedures were successful. Two-year follow-up data was obtained for 8 subjects: 1 patient died of non-device related causes, 1 was lost to follow-up, and 1 refused to follow-up due to the COVID-19 pandemic. No device-related adverse events occurred between the first and second years of follow-up. Reported 2-year clinical performance outcomes included significant decreases in mean reflux times of the mid-popliteal vein (61%), and significant improvements in mean scores for disease severity rVCSS (56%) and VAS pain (87%). CONCLUSIONS: Results from this study support long-term safety and effectiveness of the VenoValve for improving CVI severity by reducing reflux and thereby venous pressures in the lower extremities. With limited treatments for valvular incompetence involved in severe, deep venous CVI, the device may be considered as a novel therapy. A pivotal trial in the United States is currently being conducted to assess the device in a larger number of patients.

Percutaneous venous valve designs for treatment of deep venous insufficiency.

At present, no widely accepted surgical options exist for treating chronic deep venous insufficiency (CDVI). Experimental efforts to improve catheter-based management for CDVI have shown disappointing results, hindering application of these techniques in the clinical arena. A review of the literature focusing on technical aspects of valve stent design was conducted. Eight experimental studies were scrutinized to derive data on (1) stent design and configuration; (2) valve design, composition, and configuration; (3) delivery system; (4) functional outcome; and (5) histology to provide a basis for the design of a new prosthetic venous valve. The analysis of available experimental data found that all prosthetic valve designs currently under development/testing rely on some type of a stent to act as a carrier or frame for valve attachment. Most valve models reviewed were for the most part implanted safely and accurately, with good short-term patency and competency. The most commonly reported adverse event was thrombosis, which limited durability. It is assumed that valve configuration determines long-term results after repair. Hence, the newly proposed valve design consisted of 2 stent rings without barbs to fix the valve in the host vein. Because a little reflux might actually benefit the patency of the valve, the valve cusp in the new design forms a billowing "sail" that does not completely open or close, which also prevents the valve cusp from sticking to the wall. This technology remains of great interest to the interventionist and all physicians who are involved in the care for patients with advanced chronic venous disease. Valve design remains a challenge, but promising new valve substitutes such as the one outlined here are under evaluation.

Historical overview of venous valve prostheses for the treatment of deep venous valve insufficiency.

Almost 3% of people in the Western world will suffer from a venous disease at some time in their lives, but as yet there are very few effective treatments for the venous system. When the valves become incompetent, they allow backflow and subsequent pooling of blood in the lower extremities. Current clinical therapies for the elimination of deep reflux are very invasive and provide short-lasting results. Thus, there is an urgent need for technological evolution of implantable valves and, if possible, with minimally invasive techniques. This review provides a basic history of the discovery of deep vein valves and various designs of prosthetic vein valves that have been evaluated in animal models and clinical studies.

[State of crural perforating veins after sclerosurgical interventions for lower limb varicose disease].

Analysed herein are the findings obtained by comprehensive examination of 106 patients presenting with grade C3 chronic venous insufficiency according to the CEAP classification. Localization, intensity and extent of refluxes of blood in the venous system of the affected extremity were determined by means of ultrasonographic angioscanning. Based on the obtained results, the patients were subdivided into two groups. Group One was composed of 87 (82.1%) patients found to have their perforant venous insufficiency caused by superficial hypervolemia due to sharply pronounced varicosity of superficial veins. Group Two comprised 19 (17.9%) patients who had developed perforant insufficiency secondary to superficial and deep blood refluxes. In 82 (77.3%) Group One patients, the scope of the operations was limited to elimination of the superficial blood reflux, with only five (4.7%) patients at the second stage of management had their perforant blood reflux removed. Group Two patients were subjected to single-stage removal of both superficial and perforant blood refluxes. Excellent therapeutic outcomes were observed in 49.1% of cases, with good and satisfactory results obtained in 41.5% and 9.4% of patients, respectively.

Prosthetic venous valves: Short history and advancements from 2012 to 2020.

Chronic Venous Disease is estimated at 83.6% of the global population. Patients experience pain, discomfort and severe complications with few effective therapies being available. Current strategies for the treatment of malfunctioning venous valves are invasive with a high recurrence rate. A prosthetic venous valve replacement is imminent, possibly providing better outcomes and improved general quality of life. In this review, prosthetic venous valves history is presented and assesses the advantages and disadvantages of developed venous valves. Articles that discussed potential designs of prosthetic venous valves were examined. A systematic search produced thirty-five papers fitting the inclusion criteria. Our understanding of the ideal abilities required in prosthetic valves has evolved. Developed valves are reported for regurgitation, migration and leakage. Issues have been resolved, but we are still away from the ideal valve. Improvements within the last eight years provided information on the importance of sinuses and prosthetic to venous wall-size mismatch.

Has external banding become a historical technique during venous valve repair?

OBJECTIVE: In deep venous valve repair, transcommissural external valvuloplasty (TEV) is the commonly used technique. In some cases, external banding (EB) is combined with this procedure to improve the patency and durability of the surgical procedure. METHODS: We retrospectively analyzed patients who underwent deep venous valve repair from 1998 through 2018. Patients were divided according to the surgical procedure: Group A: TEV alone and Group B: TEV+EB. Early postoperative outcomes of the procedure were compared between the groups. RESULTS: There were 265 patients in Group A and 165 patients in Group B. The mean follow-up period was 4.2±3.7. The rate of recurrence of venous reflux, ulcer, and reoperation were 31.9 versus 30.9, 21.2 versus 21.8, and 16.7 versus 13.9 in Group A and Group B, respectively. There were 67 reoperations in the follow-up period. At reoperation, external valvuloplasty was performed in 64% of the reoperations in Group A, while this rate was 13% for Group B. CONCLUSIONS: There is no more need for EB during the venous valve repair with the increased experience of valvuloplasty techniques. TEV might be enough with acceptable long-term outcomes during deep venous reconstruction.

Endoscopically directed external support of femoral vein valves.

BACKGROUND: This study investigated the optimization of indications to external valve support using the Vedensky Spiral for primary deep venous reflux based on the femoral vein proximal (ostial) valve anatomy type. METHODS: The external Vedensky Spiral was used for correction of valvular insufficiency in 28 extremities of 24 patients (18 women, 6 men) during 1998 to 2002. Patients were a mean age of 54.6 years (range, 32-76 years). The clinical manifestation was C(4) in 10 limbs and C(5) in 18 limbs. Primary axial deep reflux was present in all 28 extremities, and axial superficial reflux was also present in 26. Duplex scanning and descending phlebography were used to estimate the functional condition of the deep vein valves. Fibrophleboscopy intraoperatively to study the anatomic status of the femoral vein valves and for checking the repaired valve function was used. RESULTS: Phleboscopy showed the following anatomy of ostial valves of the femoral vein: 16 valves had wide separation of cusps, 11 had elongation of cusps, and one had a monocusp. The competence of femoral vein ostial valves was completely restituted in all cases with wide separation of cusps. Multiple corrections were performed in cases with incomplete competence of the ostial valve (valve with elongation of cusps or monocusp). CONCLUSION: External valve support by the Vedensky Spiral is an effective and simple method of correction of incompetent femoral vein valves in limbs with primary deep venous reflux. The technical success of the intervention depends on the type of valve insufficiency and the correct choice of spiral diameter.

Neovalve construction in deep venous incompetence.

OBJECTIVES: The purpose of this study is to assess the outcome of neovalve construction in two consecutive series of patients affected by postthrombotic syndrome and valve agenesis. The technique was modified in the second series so as to correct a cause of failure. METHODS: Between December 2000 and June 2007, 40 neovalve constructions were carried out in 36 patients (19 males, 17 females, median age 57, range, 29-82) affected by deep venous insufficiency. Thirty-two patients were affected by postthrombotic syndrome and 4 by valve agenesis. The 32 patients with postthrombotic syndrome were selected from among 76 patients with resistant ulcers classified C (6,S) E (S) A (S,D,P) P (R,RO) and the 4 patients with valve agenesis were selected from among 28 affected by resistant ulcers classified as C (6,S) E (C) A (S,D,P) P (R). The patients were subdivided into 2 groups. The first group included 19 operations performed in the period between December 2000 and December 2004, with a median follow-up of 54 months (range, 31-78). The second group included 21 patients operated on between January 2005 and June 2007, with a median follow-up of 5 months (range, 2-29). In the second group, a surgical variation was applied in order to prevent flap collapse and to maintain the continence of the neovalve. RESULTS: In the first series, ulcer healing was observed in 16 cases out of 19 (84%). Recurrent ulcers were observed in one case after 3 years. Valve competence was ascertained in 13 cases per 803 patient-months (1.6/100 patient-months). With regard to the second series, competence was achieved in all cases with a cumulative rate of 21 per 228 patient-months (9.2/100 patient-months). In the second series, the ulcer failed to heal in one case and recurred in two cases, with an intention-to-treat ulcer recurrence rate of three cases per 209 patient-months. Postoperative deep-venous thrombosis was observed in 3 patients in the first series. None was detected in the second series. The mortality rate was 0 and in neither group was pulmonary embolism detected. CONCLUSION: The modified technique applied to the second group seemed to improve valve continence results significantly. However, a longer follow-up period is required for the latter group to validate this technical enhancement.