[Surgical method for correction of absolute valvular insufficiency in post-thrombophlebotic disease of the lower limbs].

A new technique has been worked out for intravasal autovenous valvuloplasty. It is based on the "ink-pot that does not spill" principle with creation of two cusps and is used in the treatment of patients with post-thrombophlebotic disease of the lower limbs induced by absolute valvular incompetence of the great veins. Criteria are offered for assessment of the efficacy of the technique for formation of venous valves. Altogether 54 operations were performed including those provided to 29 patients (the main group) operated on according to the technique proposed and those in 25 patients (control group) operated on the basis of the known technique reported in the literature. In 51 patients, these operations were accomplished in combination with different variants of procedures on the communicating and saphenous veins of the lower limbs. The time of some follow ups was as long as 7 years. The beneficial short-term results were obtained in 96.5% of cases whereas the long-term outcomes were positive in 92% of the basic group patients.

A new incision for subfascial ligation of perforating veins in chronic venous ulcers of the leg.

A new incision is described for subfascial ligation of perforating veins in patients with chronic venous ulcers of the leg. It avoids the complications encountered with the conventional midline posterior approach.

Surgical management of the post-phlebitic leg syndrome.

Twenty-five patients (32 limbs) with severe retrograde ejection venous syndrome (post-phlebitic leg syndrome) were surgically treated from 1971 to 1986 using a "very complete fasciotomy" with or without other individualized procedures. Clinical data, venographic findings, operative choices, and outcome were analyzed retrospectively. The theoretic benefit of adopting this new and conceptually accurate diagnostic label and the principle of "no incompetent perforators, no ulcers" is discussed. The patients generally had been managed for 10 to 20 years with conservative neglect or operative inadequacy. With correct conceptual understanding, anatomic stratification, defined indications for surgery, and individualization of procedures, an excellent result has been obtained with a low rate of serious complications. The very complete fasciotomy should be suitable for general use in treating this difficult and controversial syndrome.

Pathogenesis and pathophysiology of the post-thrombotic syndrome: clinical implications.

Anticoagulant therapy can successfully prevent pulmonary embolism and rethrombosis in most cases, but cannot affect either early morbidity or the late post-thrombotic sequelae. In carefully selected cases, early clot removal by thrombolysis or thrombectomy may be justified by improved outcome because of the significant role early and late outflow obstruction plays in determining the ultimate severity of post-thrombotic sequelae. Nevertheless, it is recognized that anticoagulant therapy will continue to be used in the majority of patients because of serious intercurrent disease, sedentary lifestyle, limited extent of thrombosis, lack of tissue loss and, unfortunately, delay in referral for treatment.

Long term results of vein valve transplants placed in the popliteal vein for intractable post-phlebitic venous ulcers and pre-ulcer skin changes.

Most patients with chronic venous ulceration or severe pre-ulcer damaged skin have incompetent popliteal valves and a high ambulant venous pressure (AVP). Competency can be restored by a vein valve transplant taken from the arm and placed in the popliteal fossa, with subjective and objective improvement. In this study 23 patients with post-phlebitic syndromes received 25 vein valve grafts as part of management. Seventeen patients had large recurrent ulcers after unsuccessful venous surgery: 6 patients had extensive pre-ulcer skin damage. Fifteen of 17 patients healed their ulcers, and all 6 patients with skin damage showed rapid improvement with relief of symptoms. Falls in the AVP, ranging from 10 to 40 mmHg occurred in 19 patients. All vein valve transplants were patent, after 18 months, but 5 grafted valves have evidence of venous reflux. These results suggest a functioning valve replacement in the popliteal fossa may lower the AVP sufficiently to heal intractable venous ulcers or severely damaged skin. Vein valve transplants function well long term, and the falls in the AVP are usually maintained. The popliteal fossa may be the ideal site since a component popliteal valve has been shown to limit adverse post-phlebitic changes.

Division of incompetent perforator veins and subfascial interposition of a polypropylene foil in post-thrombotic syndrome. Preliminary results.

AIM: The safety, feasibility and early efficacy of subfascial endoscopic perforator surgery was gradually accepted for patients who had severe chronic venous insufficiency but, in the literature, the recurrence rate of ulceration is about 10-40%, especially in patients with previous deep vein thrombosis (DVT). METHODS: From October 1998 to February 2002, 205 patients with 280 inferior leg ulcers were followed; 115 had venous ulcers but only 20 patients had chronic ulcers with previous DVT; 4 patients were excluded and only 16 patients (9 female, 7 male, mean age 61 years) with 18 chronic ulcers were included. These patients underwent sub-aponeurotic interruption of perforating veins with blind technique in association with subfascial interposition of a hand-made polypropylene foil. Eight of these patients had persistent non-healing ulcers at the time of surgery and 10 had chronic recurrent ulceration healed at the time of the surgical procedure. All patients were assessed clinically and with duplex scanning. RESULTS: The follow-up was done clinically and with eco-Doppler from 6 to 38 months with a mean follow up period of 23.2 months. The healing rate was 100%. The 2-year life table incidence of ulcer recurrence was 0%. Hospital stay ranged from 1-2 days, early operative complications included extensive ecchymosis in 1 patient, oedema in 3 patients. CONCLUSION: The division of perforating veins, with the subfascial support of a polypropylene foil give promising results in the treatment of venous ulcers in post-thrombotic syndrome with low morbidity and short hospital stay.

Robert May memorial lecture: Advances in reconstructive venous surgery.

During the last decade progress in reconstructive venous surgery is mainly based on improvements of preoperative diagnosis and on changed surgical techniques (e.g. intraoperative lumen control by vascular endoscopy or angiography; temporary arteriovenous fistulas as protective measure; external supported vascular prostheses as substitutes). The main indications include acute ilio-femoral phlebothrombosis, vein injuries and in selected cases the substitution of big veins in extended tumor surgery. The late results of venous thrombectomy in the ilio-femoral segment could be remarkably improved due to changed techniques of lumen restoration (combined ring- and balloon-disobliteration, temporary a.v. fistula in inguinal or popliteal position). In patients with persisting central occlusions in the iliac veins a second repair may be considered using a suprainguinal cross-over graft (external supported e-PTFE-prosthesis). For post-thrombotic syndrome with pronounced deep venous insufficiency reconstructive procedures afford a critical selection of patients (Palma-operation, Husni-May-operation, interposition of valve bearing venous segments in the superficial femoral vein). The remarkable contribution given by R. May to the advances in venous surgery is illustrated.

[Post-phlebothrombotic venous insufficiency of the lower limbs. Echo-guided targetted surgery]. / Insufficienza venosa post-flebotrombotica degli arti inferiori. La chirurgia mirata eco-guidata.

The post-phlebothrombotic syndrome surgery has always had a limited space within the limits of the venous lower limbs surgery. This, either for the distrust of surgeon to operate a limb with deep thrombotic phenomenon, or because the range of possible operations is rather limited and constituted by very cruent and devasting operations. The introduction of very accurate method in the preoperative diagnostic, as the echo-color-Doppler, enables an accurate mapping of the new venous post-phlebothrombotic situation and a careful haemodynamic study of the deep or superficial venous circle. Hence, the surgeon has a new and significant chance to perform a minimal surgery generally directed to the ligation of the perforans veins that has become incontinent after the phlebothrombotic insult. In this way, the wide and devasting dissection can be avoided as previous Linton-type interventions.

[Felder's intervention in the posphlebitic syndrome of the lower limbs]. / L'intervento di Felder nella sindrome post-flebitica degli arti inferiori.

Postphlebitic syndrome of the lower limbs is a consequence of chronic varices or the outcome of TVP leading to edema, eczema, stasis ulcers, etc. In these cases surgical treatment takes the form of ligating the perforating varices using a subfascial route according to Linton's technique, together with stripping the great and small saphenous vein. There are cases, however, in which the extent of cutaneous involvement does not allow a "safety incision" to be made. Felder's operation, using posterior surgical aggression in that area of the skin which generally remains healthy, therefore allows an easier ligation of the perforating varices and quicker cutaneous healing.

[Late results of the Palma operation]. / Palma-mütétek késöi eredményei.

Since 1981, 54 femoro-femoral crossover saphenous bypass (Palma-operation) were performed for chronic venous insufficiency caused by unilateral iliac vein occlusion. Long-term patiency rate and clinical results were evaluated by radioisotope venography and venous occlusion plethysmography. Plethysmography demonstrated significant improvement of maximal venous outflow after operation. Radioisotope venography showed remarkable long-term patency rate of Palma-bypass (of 42 operation, 29 patent graft). Long-term clinical results appeared to be excellent after operation of isolated iliac vein occlusion, whereas the results after operations performed with postthrombotic changes in more distal deep veins were not acceptable, therefore a more critical preoperative selection seems to be necessary.

[Treatment of post-phlebitic syndrome]. / Trattamento della sindrome post-flebitica.

The Authors report their experience in the treatment of the post phlebitic syndrome at ulceration stage. The therapy is based on three important points: a first medical treatment and later saphenous striping with a specific tying of the insufficient perforant veins to consolidate the results of scarification in the future; finally ther removal of plugs of fascia for the therapy of hypodermitis with a personal technique.

[The value of phlebography, USG-doppler and intraoperative tests in diagnosis of perforating venous insufficiency in the calf]. / Skutecznosc badan flebograficznych, USG-doppler i sródoperacyjnych w wykrywaniu niewydolnych zyl przeszywajacych goleni.

Accuracy of phlebography, color duplex sonography and intraoperative findings have been compared in a group of 29 patients operated for postphlebitic syndrome. The highest number of perforating veins was identified during the operation, fewer on phlebography and the fewest on color duplex sonography. However in the upper part of the calf both the latter were found to be inaccurate.

[Surgery for postthrombotic syndrome of the lower limbs]. / Chirurgie du syndrome post-thrombotique des membres inférieurs.

Advances have been made in surgery of the post-thrombotic syndrome of the lower limbs with work involving the pathophysiology of the syndrome. It can now be imputed to superficial venous insufficiency involving the saphenous network and (or) perforating veins of the leg, or to deep venous insufficiency which requires careful analysis of its obstructive and reflux components. Surgery addresses only clinical manifestations that are not managed by conservative treatment. In these cases, in superficial venous insufficiency, it appears preferable to excise the saphenous network and (or) to ligate the perforating veins using a subfascial approach, which gives favorable long-term results in 45 to 98% of cases. In deep venous insufficiency, surgery can either by pass the obstructive lesions, or valve transposition or transplantation can be performed at the sites of reflux. Results are less satisfactory, however, leading to healing of recurring ulcers (the reference criterium) in 42 to 60% of the cases. In all cases, surgical results will be better maintained with continued medical treatment, especially compression.

[Outpatient surgical treatment of chronic venous insufficiency of the lower extremities]. / Khirurgicheskoe lechenie bol'nykh khronicheskoi venoznoi nedostatochnost'iu nizhnikh konechnostei v poliklinike.

The results are analyzed for 30 surgical interventions on the legs for chronic venous insufficiency. Feasibility is considered of surgical correction of the function of the deep vein valvular apparatus, of retrograde circulation arrest by obturation of posterior tibial veins in varicosity and postthrombotic diseases.

[Pre- and postoperative treatment of trophic ulcers in a controlled germ-free environment]. / Pred- i posleoperatsionnoe lechenie troficheskikh iazv v usloviiakh upravliaemoi abakterial'noi sredy.

Pre- and postoperative treatment was conducted in 140 patients with trophic ulcers in a controlled abacterial medium in the period from 1985 to 1988. The etiological factor of the development of the trophic ulcer was primary varicosity in 86 (61.4%) and the post-thrombophlebitic syndrome in 54 (38.5%) patients. Venous hemodynamics improved both on the healthy and on the affected extremity. Besides, there was a tendency towards a decrease of the blood proteolytic activity near the focus of affection and an increase of that in the peripheral blood.

[Formation of subfascial lymphovenous anastomoses on the foot]. / Formirovanie subfastsialnykh limfovenoznykh anastomozov na stope.

The author suggests a new modification of operation for formation of subfascial lymphovenous anastomoses (LVA) on the dorsum of the foot in treatment of edema of the lower limbs. Sixty-two patients underwent operation. In 34 patients of the control group an epifascial LVA was formed on the dorsal surface of the foot. The operation for LVA anastomosis was combined with fenestration of the leg fascia. A positive effect of various degree was produced in the postthrombotic syndrome in 84% of the studied patients (in 29% of the controls) and in 94% of cases of II degree lymphedema (in 56% of the controls). The expediency of subfascial LVA is substantiated clinically and physiologically.

[The potential of conservative therapy and surgical treatment of microcirculatory distress in chronic venous insufficiency of the lower extremities in a stage of trophic disorders]. / Vozmozhnosti konservativnoi terapii i khirurgicheskogo lecheniia narushenii mikrotsirkuliatsii pri khronicheskoi venoznoi nedostatochnosti nizhnikh konechnostei stadii troficheskikh rasstroistv.

The present work describes the results of an all-round examination and treatment of 120 patients suffering from different forms of chronic venous insufficiency (CVI) of the lower extremities with trophic disorders of soft tissues. Of these, varicosis was present in 91 (75.8%) patients and postthrombotic disease - in 29 (24.2%), patients. Hemomicrocireulation was examined by laser Doppler flow-metry. Assessment was made of the functional activity of neutrophilic granulocytes of the microcirculatory bed. The data were obtained indicating the decrease of skin perfusion and activation of neutrophils in the hemomicrocirculatory bed of the involved extremity at venous outflow decompensation. Of the 120 persons, conservative treatment was provided to 23 patients, in 45 patients, the conservative measures represented a stage in the preoperative preparation. Ninety-seven patients were operated on. The studies of hemomicrocirculation carried out at different times after treatment have demonstrated that conservative treatment produces a beneficial effect on hemomicrocirculatory disorders in the lower extremities of patients with CVI. However, the effects of conservative therapy are unstable and not long-lasting. Surgical correction of the venous outflow in patients with decompensated forms of CVI of the lower extremities leads to a stable improvement of the functional parameters of microcirculation.

[The role of endoscopic ligation of the perforating veins in the treatment of chronic venous insufficiency under conditions of the one-day surgery center]. / Rol' éndoskopicheskoi pereviazki perforantnykh ven pri lechenii khronicheskoi venoznoi nedostatochnosti v usloviiakh tsentra khirurgii odnogo dnia.

The present work is concerned with the results of endoscopic ligation of the perforating veins (SEPS) in 179 patients with chronic venous insufficiency, class 4-6, performed at the one-day surgery center. In patients suffering from varicosity, SEPS was accomplished in combination with phlebectomy in 52 (29.1%) patients. The second stage after phlebectomy involved the combination of SEPS with microsurgical reconstruction of the femoral vein valve. SEPS alone was provided to 89 (49.7%) patients suffering from postthrombotic disease. No life-threatening complications or lethal outcomes were recorded. The postoperative events were observed in 20 (11.2%) patients. Good results were obtained in 128 71.5%) patients, satisfactory in 42 (23.5%) and unsatisfactory in 9 (5%) subjects. The data obtained allow to regard SEPS as an effective, drastic and little traumatic technique which can be used successfully under conditions of the one-day surgery center.

[The transfascial excision of indurated subcutaneous fat in the postthrombophlebitic syndrome]. / Chresfastsial'noe issechenie indurativno-izmenennoi podkozhnoi kletchatki pri posttromboflebiticheskom sindrome.

The authors came to the conclusion that in surgical treatment of the postthrombophlebitic syndrome it is necessary in some cases to excise the indurated fatty tissue on the leg during the operation on the veins. It should be carried out transfascially through a Felder incision in combination with ligatin of the perforating veins on the leg. The suggested method produces better results than those of excision of the changed fatty tissue through a cut made in the skin overlying it. Excision of the indurated fatty tissue removes the focus of chronic infection and autoallergy.

[Anatomo-topographic basis for operations of transposition of the superficial femoral vein in post-thrombophlebitic disease of the lower extremities]. / Anatomo-topograficheskoe obosnovanie operatsii transpozitsii poverkhnostnoi bedrennoi veny pri posttromboflebiticheskoi bolezni nizhnikh konechnostei.

Post-thrombophlebitic disease of the lower limbs may be occlusive, (2%), recanalized (54%), and mixed (44%) in character. Operations for restoration of the normal flow of blood cannot remove the retrograde flow in veins with destroyed valves. Many variants of valve restoration have been suggested. The simplest among them are transplantation of the superficial femoral vein, the lateral circumflex femoral vein, and the great saphenous vein. The anatomical structure of the lower limb venous system was studied on the corpses of humans without venous pathology. In most cases the deep femoral vein was found to have one valve (46.8%), two (30.6%), and three (12.8%) valves. Valves were found at a distance of 1.0 to 4.5 cm from the site of drainage of the deep femoral vein into the superficial vein in 48.35% of cases, 43.5% had a sufficient diameter (0.6 cm). Thus, implantation of the superficial femoral vein into the deep vein can be conducted in less than half of the patients. Study of the anatomy of the lateral circumflex femoral vein showed that the operation can be performed in 9.6% of cases. The great saphenous vein is the main route of blood drainage in post-thrombophlebitic disease. Its use as a valvular protection is very risky. It should also be taken into account that in post-thrombophlebitic disease the great saphenous vein is dilated and marked by relative venous incompetence. Though they are relatively simple, these operations, can be therefore, performed in less than half of the patients. Examination of patients should include ultrasonic angioscanning and retrograde transfemoral phlebography, which allow precise determination of the anatomical features of the lower limb venous system in each patient.