Surgery for deep venous reflux in the lower limb

Surgery for deep venous reflux (DVR) in the lower limb had displayed, for various reasons a much more limited development than arterial surgery including endovascular techniques. Importance and frequency of DVR in chronic venous disease and particularly in chronic venous insufficiency (CVI) has been fully identified only in the last 20 Years, thanks to the development of duplex-scanning. Despite its effectiveness, deep reconstructive surgery remains controversial which probably explains why this specific surgery is performed by few units worldwide. Furthermore as deep reconstructive surgery is usually combined with superficial and perforator surgery, assessment of its specific benefit is difficult. In patients with severe CVI, venous valvular reflux involves deep vein as an isolated abnormality in less than 10%, but is associated with superficial reflux or/and perforator incompetence in 46%. The most common etiology in DVR is post-thrombotic syndrome accounting for an estimated 60-85% of patients with CVI. Primary reflux is the result of structural abnormalities in the vein wall and the valve itself. A very rare cause of reflux is the absence of valves secondary to agenesis. Surgical techniques for treating DVR can be classified into two groups: those that do and those that do not involve phlebotomy. The first group includes internal valvuloplasty, transposition, transplantation, neo valve and cryopreserved allograft. The second group involves wrapping, Psathakis II procedure, external valvuloplasty (transmural and transcommissural) angioscopy assisted or not, external valve construction and percutaneous placed devices. There are some clinical features that enable distinguishing superficial venous insufficiency from deep venous insufficiency but they are not reliable enough as both are frequently combined. In addition primary reflux is difficult to identify from secondary deep reflux. INVESTIGATIONS: Duplex scanning provides both hemodynamic and anatomic information. Photoplethysmography as air plethysmography can help when superficial and deep venous reflux are combined to identify the predominant pathological component. It would seem logical to go beyond these investigations only in those patients in whom surgery for DVR may be considered. That means that the decision to continue investigations is dominated by the clinical context and absence of contraindication (uncorrectable coagulation disorder, ineffective calf pump). When surgery is considered, complementary investigations must be carried out: ambulatory venous pressure measurement and venography including ascending and descending phlebography. The goal of DVR surgery is to correct the reflux related to deep venous insufficiency at the subinguinal. But it must be kept in mind that DVR is frequently combined with superficial and perforator reflux, consequently all these mechanisms have to be corrected in order to reduce the permanent increased venous pressure. As mentioned previously, surgery results for DVR are somewhat difficult to assess as superficial venous surgery and/or perforator surgery have often been performed in combination with DVR surgery. Valvuloplasty is the most frequent procedure used for primary deep reflux. On the whole, valvuloplasty is credited with achieving a good result in 70% of cases in terms of clinical outcome defined as a freedom of ulcer recurrence and the reduction of pain, valve competence and hemodynamic improvement over a follow-up period of more than 5 years. In all series, a good correlation was observed between these three criteria. External transmural valvuloplasty does not seem to be as reliable as internal valvuloplasty in providing long-term valve competence or ulcer free-survival. In PTS, long-term results are available for transposition and transplantation. In terms of clinical result and valve competence, a meta-analysis demonstrates that a good result is achieved in 50% of cases over a follow-up period of more than 5 years, with a poor correlation between clinical and hemodynamic outcome. Results with others techniques including Psathakis II technique, neovalve and cryopreserved valves are less satisfactory. DVR surgery indications for reflux rely on clinical severity, hemodynamics and imaging: most of the authors recommend surgery in patients severe disease graded C4 and C 5-6. When superficial and perforator reflux are associated, they must be treated, for some Authors as a first step, for others shortly before DVR surgery in the same hospitalization stay. Contraindications as previously stipulated have to be kept in mind. Hemodynamics and imaging criteria: only reflux graded 3-4 according to Kistner are usually treated with DVR surgery. It is generally recognized that, to be significantly abnormal, venous refill time must be less than 12 s, and the difference between pressure at rest and after standardized exercise in the standing position must be less than 40%. The decision to operate should be based on the clinical status of the patient, not the non-invasive data, since the patient's symptoms and signs may not correlate with the laboratory findings. Indications according to etiology: the indications for surgery can be simplified according to the clinical, hemodynamic and imaging criteria described above. In primary reflux, reconstructive surgery is recommended after failure of conservative treatment and in young and active patients reluctant to wear permanent compression. Valvuloplasty is the most suitable technique, with Kistner, Perrin and Sottiurai favoring internal valvuloplasty and Raju transcommissural external valvuloplasty. In PTS, obstruction may be associated with reflux; most of the authors agree that when significant obstruction is localized above the inguinal ligament, obstruction must be treated first. Secondary deep venous reflux, mainly post-thrombotic syndrome may be treated only after failure of conservative treatment as the results achieved by subfascial endoscopic perforator surgery associated or not with superficial venous surgery are not convincing. It is recommended that this procedure might be carried out in combination with deep reconstructive surgery. The techniques to be used, given that valvuloplasty is rarely feasible, in order of recommendation, are: transposition, transplantation, neovalve and cryopreserved allograft. Patients must be informed that in PTS surgery for reflux has a relatively high failure rate. CONCLUSION: as large randomized control trials comparing conservative treatment and DVR surgery for DVR shall or should be difficult to conduct we must rely on the outcome of present series treated by DVR surgery. Analysis of those series provides recommendation grade C. Better results are obtained in the treatment of primary reflux compared with secondary reflux. Such surgery is not however, often indicated, and the procedure must be performed on specialized and high-trained centers.     

Cardiac surgery in Jehovah's witnesses. Apropos of 47 cases]

47 cardiac defects in Jehova's witnesses were operated on without using any blood during the operation. In 9 cases the patients were under 15 years of age. 7 cases were of congenital heart defects in which the operation could be carried out with the heart still beating or by a closed heart technique: 4 of these were adults and 3 were children. In 40 cases, extracorporeal circulation was required: 19 valve defects, 8 coronary areterial cases, 10 congenital cardiac lesions, 2 valve defects associated with coronary artery disease, and 1 aneurysm of the thoracic aorta. Of these 40 patients, 4 died. The details and limits of this total haemodilution are analysed, as are the causes of failure and complications. This technique does not worsen the postoperative prognosis appreciably, but limits the scope of the surgery, and cannot be applied to a child of less than 10 kg.     

Vascular malformations of the limbs. Role of vascular and reconstructive surgery]

The progress made by noninvasive exploration for the assessment of vascular malformations now allows the therapeutic strategies to be better established. While observation and conservative methods are most often chosen, some venous or arteriovenous malformations lead to contemplating a palliative or curative treatment. Two therapeutic choices may thus be used: embolization through an arterial route or, most often, through direct puncture of the malformation, or exeresis surgery, sometimes associated to surgery for tissue reconstruction. These techniques may be used alone, but are most often associated within the scope of a multidisciplinary management of the condition.     

Prophylaxis of deep venous thrombosis in colorectal surgery

A group of 230 patients undergoing elective colorectal surgery was analyzed for the presence of deep venous thrombosis (DVT). Prophylaxis against DVT was practiced with low-dose heparin (either 5000 IU every eight hours, or 5000 IU every 12 hours for seven days) in 199 patients. Prevention of infection was attempted with preopetive administration of Enterobiotic^® in 155 patients and of Vibramycin^® in patiens. DVT was diagnosed in 46 patients. The frequency of DVT did not differ significantly between patients who underwent resections of the colon and those who underwent rectal surgery. DVT was diagnosed in 27 of the 73 infected patients, which was significantly higher than the incidence of 19 with DVT among the 157 uninfected patients. The frequency of DVT among patients in the two heparin regimens was 15 and 17 per cent respectively, which was significantly lower with untreated patients. No lethal pulmonary embolism was found and no patient showed clinical signs of embolism. It is assumed that measures aimed at reducing postoperative infection, combined with low-dose heparin, will reduce the incidence of postoperative DVT after colorectal surgery.     

Indications for reconstructive vascular surgery in gangrenous changes in the leg]

Proceeding from an experience in the treatment of 195 patients with obliterative athrosclerosis of the bifurcation of the abdominal aorta and the arteries of the lower extremities in the pre-gangrene or gangrene stage (reconstructive procedures on the vessels were performed in 151 patients), the authors conclude that such interventions should be considered procedures of choice. Amputation of the extremity may be considered in such patients only after an angiographic examination that is the main method that permits to determine the possibilities of performing a reconstructive vascular operation. Good immediate results of vascular interventions were achieved in 80% of the patients with stage III--IV ischaemia.     

Surgery in postphlebitic disease. Apropos of 157 surgical interventions

Surgery occupies only a restricted position in post-phlebitic illness. The authors analyse 157 surgical operations carried out on 138 patients between 1969 and 1983. A detailed report is always given pre-operatively as a matter of course by Functional examination and phlebography, in order to locate the predominant physiopathological disorder or disorders: superficial venous deficiency--reflux via the perforators--the obliteration syndrome or devalvulation syndrome of the deep venous system. After a short listing of the surgical methods, the results of these different operations are analysed. They are hard to assess. Where there is a relapsing ulcer, surgery of the perforators produces 70 percent good results. The therapeutic indications are discussed, finally, on the basis of recently published series and the authors' experience.     

Prevention of venous thrombosis in surgery. Very brief advice]

Avoid immobilization before and immediately after the operation : do not rely simply on raising of the legs but ensure that the patient walks as soon as po-sible. Apply elastic support bandages to the lower limbs before, during, and after the operation. Limit the duration of the operation and of the general anaesthesia. Reduce trauma of the vessels to a minimum during the operation. Give aspirin before and after the operation : 3 X 0,50 g.     

Functional exploration of the deep venous system by duplex]

The development of new direct methods for treatment of deep venous insufficiency requires improvement of the ultrasonographic investigation of valve function. The combination of imaging and pulsed Doppler provides more accurate diagnoses and can be used to establish deep venous hemodynamic cartography. Four essential rules must then be followed: an examination in standing position, proximal decompression tests, examination by one third segments and by thirds of each segment, analysis of the forgotten veins of the leg (soleus, gemellar) and thigh (profunda femoris, quadriceps, posterior ischiatic anastomotic flow) and of the deep muscular anastomoses. The hemodynamic direction of each feature of the venous map is then noted. This investigation enables the following in the context of disease: the diagnosis of deep venous pain affecting an apparently non-varicose area; precise monitoring of the post-thrombotic status of a deep vein, avoiding diagnostic errors related to a painful repermeation syndrome; preselection of cases of deep venous insufficiency suitable for anatomical surgical treatment or a hemodynamic technique (CHIVP) as indicated by the deep hemodynamic cartography which this investigation makes possible.