Severity and location of venous valvular insufficiency: the importance of distal valve function

Venous calf pump function was evaluated with special reference to distribution and severity of deep venous reflux at different levels. A combination of ultrasonography, foot volumetry and venous plethysmography was used in 100 consecutive patients, 32 of whom were also studied with phlebography and intravenous pressure measurements. A clear relationship was found between clinical stage of chronic venous insufficiency and number of segments with reflux. Clinically important deep venous insufficiency was found particularly in patients with reflux in the distal posterior tibial veins, even in the presence of competent popliteal valves. The results demonstrated the calf pump to be functionally divided into a series of pumps, with the distal part more important than the proximal. The importance of evaluating venous valvular function at different levels for adequate assessment of venous calf pump function is emphasized.     

Congenital absence of vein valves of the lower extremities]

Sixteen patients with congenital absence of venous valves in the deep veins of 18 lower limbs are reported. The disease limbs characterized by venous hypertension is frequently seen in teen-agers. Venographically, no valve is to be found in the deep venous system. Conservative treatment may be tried in those without pigmentation and ulcer formation in the goiter area. However, valvular reconstructive operation of the deep veins is the effective method of treatment.     

An objective assessment of the physiologic changes in the postthrombotic syndrome

To determine what physiologic changes might contribute to the development of the postthrombotic syndrome, venous outflow, venous refilling time, and valvular competence were assessed in 32 patients (39 limbs) with documented deep venous thrombosis. The follow-up ranged from nine to 144 months (mean, 41 months) after the acute deep venous thrombosis. Pain was noted by 49% of the patients, but more objective end points occurred less frequently (edema, 21%; pigmentation, 26%; ulceration, 3%). Venous outflow was lower in the affected limbs but was not a good indicator of those patients with or without symptoms. Venous refilling time after calf compression was markedly reduced in limbs with incompetent valves (mean +/- SD, 8.4 +/- 3.8 s v 25.3 +/- 12.1 s), as well as in those with edema, pigmentation, and ulceration. It appears that most of the sequelae of the postthrombotic syndrome can be attributed to the loss of valvular function.     

Congenital venous valvular aplasia of the lower extremities

A 10-year-old girl had bilateral, symmetrical swelling of the lower extremities, which had been present since the age of 1 year. Noninvasive vascular laboratory measurements of the ambulatory venous pressure, venous recovery time, and maximum venous outflow revealed profound bilateral lower extremity venous valvular incompetence. Duplex imaging of the veins of the lower extremities demonstrated no evidence of thrombosis, and no venous valves could be imaged. On phlebography, the patient was found to have no venous valves in the superficial and deep systems of the leg. We conclude that congenital absence of the venous valves of the lower extremities is almost certainly underdiagnosed and that the vascular laboratory can accurately and easily differentiate between lymphedema and venous valvular imcompetence. Such differentiation may have therapeutic implications.     

Trapdoor internal valvuloplasty--a new technique for primary deep vein valvular incompetence.

OBJECTIVES: to describe a new technique of exposure of the valve commissure, called the "Trapdoor" Internal Valvuloplasty (TIV), to treat primary deep vein valvular incompetence. MATERIAL AND METHODS: the TIV method involves partial transverse incisions which are joined together by a vertical incision to create a virtual "trapdoor" at the target vein valve, providing optimum access to repair the insufficient valve. In 17 consecutive patients (25 limbs) TIV has been successfully employed for 41 valvular repairs since August 1999. All patients had open non-healing or recurrent venous ulcers. RESULTS: on mean follow-up of six months (clinical assessment of venous ulcer healing and by colour-coded Duplex scans at 1, 3, 6, 9 and 12 months), of the 41 valves repaired by TIV technique, 39 valves (95%) maintained full patency. Thirty-four valves (85%) achieved primarily a VCT <0.5 s without reflux at the target valves on Valsalva manoeuvre in the upright position. Eighty-four percent of all ulcers (n=25) healed within 8 weeks of surgery without recurrence during the follow-up period. CONCLUSION: the Trapdoor Internal Valvuloplasty (TIV) represents a novel technique, which has the advantages of being both technically less demanding and anatomically better defined. Furthermore, TIV is physiologically acceptable and enables accurate localisation of valve cusp defects while allowing comprehensive, anatomical repair of valvular deficiencies.     

Status of the valves in the superficial and deep venous system in chronic venous disease

The relationship between the functional status of the venous valves in the superficial and deep veins and ulceration was evaluated in 42 patients. Twenty-five patients had ulcers, 12 of these patients had a history of previous deep venous thrombosis and 13 of these patients denied such an event. Seventeen patients had normal ankle skin, 10 of these patients had a documented history of deep vein thrombosis and seven of these patients had varicose veins only. An ultrasonic duplex scanner was used to document the presence of reflux in all segments of the superficial and deep system. In the entire group of 25 limbs with ulceration, valvular incompetence was noted in 22 limbs at levels involving segments that communicated with the ulcer-bearing area. Of the 17 limbs with normal ankle skin, in only two instances was a single segment of posterior tibial vein in midcalf found to be incompetent. For those patients with normal ankle skin and a history of varicose veins, the deep veins below the common femoral vein level were always competent.     

Distribution of venous valvular incompetence in patients with the postphlebitic syndrome

The records of 122 patients who underwent Doppler evaluation for the postphlebitic syndrome were reviewed to determine the relationship between location of venous valvular incompetence and severity of clinical signs. Categorized according to the most severe physical finding, there were 35 limbs with perimalleolar ulcers, 113 with stasis pigmentation, 26 with swelling, and 70 with no overt signs. Incompetent veins, either deep or superficial, were present in 93% of the symptomatic and 59% of the asymptomatic limbs. Proximal (iliofemoral) deep venous incompetence was not strongly correlated with disease severity (p less than 0.10), but distal (popliteotibial) deep venous and superficial venous incompetence were (both, p less than 0.0005). The relative frequency of isolated proximal incompetence appeared to diminish with increasing disease severity; whereas that of distal incompetence, with or without associated proximal venous incompetence, increased. Isolated proximal venous incompetence was found in only 5% of limbs with severe disease (ulcers or pigmentation). In limbs with severe signs, distal venous incompetence was present in 67% of those with proximal venous incompetence and in 57% of those in which the proximal valves were competent. These findings cast doubt on the potential value of proximal venous valvular reconstruction, especially in limbs with combined proximal and distal insufficiency.     

Relationship of venous reflux to the site of venous valvular incompetence: implications for venous reconstructive surgery

To evaluate the relationship of the site of venous valvular incompetence to the severity of venous reflux, legs of 71 patients with suspected chronic venous insufficiency were evaluated with Doppler ultrasonography and photoplethysmography. A venous recovery time (VRT) of less than 20 seconds after calf muscle exercise was considered indicative of significant reflux. Average VRTs were brief in 15 legs with stasis changes (10 +/- 7 seconds), longer in 42 legs with edema (26 +/- 23 seconds), and normal in 64 asymptomatic legs (37 +/- 24 seconds) and 16 legs with pain (53 +/- 19 seconds). Average VRTs in limbs with incompetent saphenous veins were abnormal. In limbs with competent superficial veins, only those with incompetent distal deep veins (popliteal and posterior tibial) had abnormal VRTs (14 +/- 10 seconds). VRTs in limbs with no detectable valvular incompetence and in those with incompetence limited to the proximal deep veins (common and superficial femoral) were normal (47 +/- 23 and 42 +/- 27 seconds, respectively). When superficial veins were incompetent, an ankle tourniquet normalized VRTs in 63% of legs with proximal deep venous incompetence and in only 33% of legs with distal deep venous incompetence. It is concluded that venous reflux is largely determined by saphenous and distal deep valvular function and that competence of the proximal valves has little effect. Decreased venous reflux would not be expected after proximal valvular reconstruction.     

Valve competence following experimental venous valve autotransplantation

In canine experiments, venous patency and valvular competence were evaluated following transposition of a valve-containing vein segment, with an without a distal arteriovenous (AV) fistula. The effects of distal fistula size on valvular function were also examined. Autogenous valve-containing venous segment grafts were placed in the femoral position. With no adjuncts, 90% of the grafts showed either occlusion, severe extrinsic narrowing, or intraluminal filling defects on early venograms, although 75% of valves were eventually competent at death. Veins that had undergone thrombosis and recanalization were routinely incompetent. With a distal AV fistula, all veins remained patent and 86% demonstrated valve competence. With both an AV fistula and dextran 40, all veins remained patent and all valves were component. Separately, graded size of AV fistulas did not result in loss of valve competence. Following venous segment transposition, continuous venous patency appears necessary for eventual valvular function, and this is enhanced by both a distal AV fistula and dextran.     

Spontaneous lysis of deep venous thrombi: rate and outcome

Ultrasonic duplex scanning was used to study the rates at which lysis of thrombi, valvular incompetence, and symptoms of the postthrombotic syndrome (edema) developed in 21 patients after deep venous thrombosis (DVT). Lysis of thrombi occurred rapidly in most patients. In 11 of 21 patients (53%), recanalization occurred in all segments by 90 days after presentation. In four patients, extension of the initial DVT occurred between 30 and 180 days, despite treatment with warfarin. Valvular incompetence developed in 13 patients during the study period. The number of patent venous segments with incompetent valves increased from the initial presentation to 180 days, at which time 25% of patent segments contained incompetent valves. Valvular incompetence developed in previously thrombosed segments that were initially competent after recanalization and in segments not previously thrombosed. This suggested that although incompetence may occur as a result of a direct effect of the thrombus on the valve, other mechanisms must also be involved. Patients with edema early after DVT (from 7 to 30 days) were more likely to have residual occlusion than valvular incompetence. The late development of edema (from 90 to 270 days) was more closely correlated with valvular incompetence.     

Air plethysmographic assessment of external valvuloplasty in patients with valvular incompetence of the saphenous and deep veins

PURPOSE: The indications for deep venous valvuloplasty remain controversial in patients with incompetent deep vein valves associated with primary varicose veins. The purpose of this study was to evaluate the usefulness of external femoral valvuloplasty performed simultaneously with varicose vein surgery from the standpoint of venous function determined with air plethysmography. PATIENTS AND METHODS: Thirty-one limbs of 25 patients (12 men, 13 women; mean age, 56.3 years; range, 33 to 80 years) with chronic venous insufficiency caused by valvular incompetence of both deep veins and saphenous veins were studied in a prospective, nonrandomized fashion. Descending phlebography showed moderate to severe reflux of grade 3 or 4 with Herman and Kistner classifications. Clinical severity of disease was CEAP classification 2S (in six limbs), classification 3 (in three limbs), classification 4 (in 16 limbs), classification 5 (in two limbs), and classification 6 (in four limbs). We performed superficial venous surgery alone in 14 limbs (control group), which consisted of stripping or ligation of incompetent saphenous veins and ligation of all incompetent perforators. In the remaining 17 limbs (study group), we performed superficial venous surgery simultaneously with external valvuloplasty of the femoral vein with intraoperative endoscopic observation. Venous reflux of the limbs was evaluated with air plethysmographic examination before surgery and at 1, 6, 12, and 24 months after surgery in both groups. RESULTS: Preoperative venous filling index (mean +/- standard deviation) in the control and study groups was 9.4 +/- 3.8 mL/min and 8.8 +/- 3.5 mL/min, respectively (not significant), and it decreased to 7.0 +/- 3.6 mL/min (P <.01) and 2.8 +/- 1.0 mL/min (P <.01), respectively, 1 month after surgery. Postoperative index values in the study group were significantly lower than values in the control group (P <.01), and this difference continued for more than 2 years after surgery (P <.05). After a follow-up period of 12 to 37 months (average, 25 months), the venous clinical severity score was higher in the control group (3.4 +/- 1.7) than in the study group (2.1 +/- 0.3; P <.05), and the venous disability score was higher in the control group (1.4 +/- 0.6) than in the study group (0.8 +/- 0.8; P <.05). CONCLUSION: Although further follow-up study is necessary, these results point to the functional and clinical usefulness of femoral valvuloplasty performed simultaneously with varicose vein surgery in patients with moderate to severe deep venous reflux. The venous filling index obtained with air plethysmography is an excellent predictor of the clinical severity of the disease and of postoperative clinical results.     

Pathogenesis of primary chronic venous disease: Insights from animal models of venous hypertension

BACKGROUND: Reflux of blood through incompetent venous valves is a major cause of the venous hypertension that underlies clinical manifestations of chronic venous disease, including varicose veins, lipodermatosclerosis, and venous ulcers. OBJECTIVE: To review published literature relating to animal models in which venous hypertension has been produced and which have yielded information on the mechanisms by which venous hypertension may trigger inflammation and cause changes in the skin and venous valves. METHODS: Medline searches, with additional papers identified from reference lists in published papers. RESULTS: At least three types of animal model were identified that have contributed to a better understanding of the trigger mechanisms and role of inflammatory processes in chronic venous disease. These models involve venous hypertension induced either by acute venular occlusion, placement of a chronic arteriovenous fistula, or ligation of several large veins. Model results suggest that elevated venous pressure and altered flow can trigger inflammatory cascades in the vein wall and venous valves which can cause progressive valvular incompetence and eventual valvular destruction, and which are also important in the skin changes associated with venous disease. Treatment with agents that reduce oxidative stress by scavenging free radicals and that inhibit the inflammatory cascade can prevent the progressive deterioration of function in valves exposed to elevated venous pressure and can prevent the development of reflux blood flow. CONCLUSIONS: Understanding these processes suggests potential therapeutic targets that could be effective in slowing or preventing progression, and could help promote a more positive and proactive attitude towards treatment of the underlying disease process, rather than the later manifestations of chronic venous disease.     

Percutaneous transpopliteal venography

The authors advocate percutaneous transpopliteal venography as a new method for evaluating the function of deep venous valves of the lower extremity. At the popliteal fossa, the popliteal vein was punctured and a catheter was inserted cephaladly for venographic study of the valves. By this method, not only the ilio-femoropopliteal vein was clearly visualized, also the competence of the valves in this venous segment may accurately be tested one by one, thus making up the shortcomings of the ascending and descending venography. It was found, through this venography, that even if the highest valve of the superficial femoral vein was competent distal valves in the femoral and popliteal veins may become incompetent resulting in primary valvular incompetence of the deep veins in the lower extremity.     

Percutaneous autologous venous valve transplantation: short-term feasibility study in an ovine model

BACKGROUND: Limited experience with bioprosthetic venous valve percutaneously inserted into femoral veins in 15 patients has been promising in short-term results only to show disappointing long-term results. Percutaneous autogenous venous valve (PAVV) transplantation was explored in an ovine model as a possible alternative treatment. METHODS: PAVV consisted of a vein segment containing a valve that was attached to a stent template. The stent templates (n = 9) were designed and hand made in our research laboratory. They consist of two stainless steel square stents 13 or 15 mm in diameter to fit the ovine jugular veins (JV), which ranges from 10 to 15 mm in diameter. A valve-containing segment of JV was harvested and attached with sutures and barbs inside the stent template (n = 9). The valve devices were then manually folded and front loaded inside the 4 cm chamber of the 13F delivery sheath and delivered into the contralateral JV by femoral vein approach. Transplanted PAVVs were studied by immediate and 3 months venograms. Animals were euthanized at 3 months, and jugular veins harvested to perform angioscopic evaluations in vitro. RESULTS: PAVV transplantation was successful in all nine animals. Good valve function with no reflux was observed on immediate and 3 months venograms in eight valves. The transplanted maximal JV diameter ranged from 10.2 mm to 15.4 mm (mean 13.1 +/- 1.5 mm). Venoscopic examination revealed intact, flexible, nonthickened valve leaflets in eight specimens. One PAVV exhibited normal function of one leaflet only; the other cusp was accidentally cut during the transplantation procedure. All transplanted autologous valves were free of thrombus and incorporated into the vein wall of the host vessel. CONCLUSION: This study demonstrated that autogenous valve transplants remained patent and competent without long-term anticoagulation for up to 3 months. The percutaneous autogenous venous valve may provide in future minimally invasive treatment for patients with chronic deep venous insufficiency, but long-term studies need to be done to document its continued patency and function.     

Mid-term results of endoscopic perforator vein interruption for chronic venous insufficiency: lessons learned from the North American subfascial endoscopic perforator surgery registry. The North American Study Group

PURPOSE: The safety, feasibility, and early efficacy of subfascial endoscopic perforator surgery (SEPS) for the treatment of chronic venous insufficiency were established in a preliminary report. The long-term clinical outcome and the late complications after SEPS are as yet undetermined. METHODS: The North American Subfascial Endoscopic Perforator Surgery registry collected information on 148 SEPS procedures that were performed in 17 centers in the United States and Canada between August 1, 1993, and February 15, 1996. The data analysis in this study focused on mid-term outcome in 146 patients. RESULTS: One hundred forty-six patients (79 men and 67 women; mean age, 56 years; range, 27 to 87 years) underwent SEPS. One hundred and one patients (69%) had active ulcers (class 6), and 21 (14%) had healed ulcers (class 5). One hundred and three patients (71%) underwent concomitant venous procedures (stripping, 70; high ligation, 17; varicosity avulsion alone, 16). There were no deaths or pulmonary embolisms. One deep venous thrombosis occurred at 2 months. The follow-up periods averaged 24 months (range, 1 to 53 months). Cumulative ulcer healing at 1 year was 88% (median time to healing, 54 days). Concomitant ablation of superficial reflux and lack of deep venous obstruction predicted ulcer healing (P <.05). Clinical score improved from 8.93 to 3.98 at the last follow-up (P <. 0001). Cumulative ulcer recurrence at 1 year was 16% and at 2 years was 28% (standard error, < 10%). Post-thrombotic limbs had a higher 2-year cumulative recurrence rate (46%) than did those limbs with primary valvular incompetence (20%; P <.05). Twenty-eight of the 122 patients (23%) who had class 5 or class 6 ulcers before surgery had an active ulcer at the last follow-up examination. CONCLUSIONS: The interruption of perforators with ablation of superficial reflux is effective in decreasing the symptoms of chronic venous insufficiency and rapidly healing ulcers. Recurrence or new ulcer development, however, is still significant, particularly in post-thrombotic limbs. The reevaluation of the indications for SEPS is warranted because operations in patients without previous deep vein thrombosis are successful but operations in those patients with deep vein thrombosis are less successful. Operations on patients with deep vein occlusion have poor outcomes.     

Surgical treatment of patients with chronic lower limb venous insufficiency and trophic disorders

The experience in surgical treatment of 326 patients with IV-VI degree chronic lower limb venous insufficiency (CEAP) is analyzed. Correction of disorders of venous hemodynamics was performed with surgical methods and sclerotherapy. The best clinical and functional results in long-term period were achieved in patients undergone surgery in an early stage of the disease without deep veins valves insufficiency and external trophic disorders. Pathology of deep veins required correction of valves function. It is concluded that these patients require complex approach to the treatment.     

下肢深静脉功能不全的检测与修复材料选择的研究

目的寻找下肢深静脉瓣膜包窄术最佳环包材料,了解彩色超声多普勒对深静脉瓣膜功能不全的诊断价值和月国静脉瓣膜功能。方法观察以自体大隐静脉片、自体阔筋膜和人造血管片作深静脉瓣膜包窄术的效果;彩色超声多普勒与经月国静脉插管造影结果对比;月国静脉瓣膜血液动力学检查。结果自体阔筋膜和大隐静脉片逐渐挛缩呈纤维化瘢痕增生,而人造血管的形态和结构无明显变化;彩色超声多普勒与经月国静脉插管造影检测下肢深静脉功能比较,前者与后者的符合率为９１．８６％;屏气时股、月国静脉瓣膜同时关闭,小腿三头肌收缩时月国静脉瓣膜开放程度明显大于股静脉瓣膜。结论以人造血管作环包材料效果最好;彩色超声多普勒以其无创性成为重要的检测手段;月国静脉瓣膜是保护小腿深静脉功能的最后屏障     

Valvular xenografts in the inferior vena cava

The unsolved problem of valvular incompetence is a common denominator to chronic venous insufficiency. Cardiac experience with tissue valves suggests the potential for their use in more peripheral locations. The current initial work evaluated 22 valvular xenografts placed in the inferior vena cavas of 22 dogs. Patency extended to 28 months in 12 valves. There was a plausible explanation for failure in 8 of the 10 unsuccessful units. Patent valves functioned with minimal pressure gradients at moderate flow with no evidence of pulmonary emboli. Retrograde valvulograms showed acceptable functional competence in six of eight units examined despite autopsy evidence of leaflet fibrosis and anatomic incompetence. The study establishes the feasibility of long-term patency of valvular xenografts in the inferior vena cava, but also raises questions concerning design requirements for prosthetic venous valves.     

Angioscopy-assisted valvuloplasty for primary deep venous valvular insufficiency

Primary deep venous valvular insufficiency causes reflux syndrome. Angioscopy permits the surgeon not only to ascertain that venous valves have not been destroyed but to perform external valvuloplasty under visual control with the valves under pressure. We have performed angioscopy-assisted venous valvuloplasty in three men (mean age 36 years; range 30 to 38 years) and one woman (age 58 years). All four patients had class 3 disease (SVS/ISCVS classification). Descending phlebograms showed grade 3 reflux in one patient and grade 4 reflux in three patients. In all patients angioscopy-assisted valvuloplasty of the superficial femoral vein was combined with wrapping with a segment of polytetrafluoroethylene prosthesis, stripping of incompetent superficial veins, and subfascial ligation of perforating veins. Mean follow-up was 12 months (range 6 to 17 months). In three patients ulcers healed and did not recur; in the remaining patient nearly complete healing was obtained after skin grafting. In all patients ambulatory venous blood pressure improved significantly and venous filling time returned to normal (> 15 seconds). At duplex ultrasonography and descending phlebography, no residual reflux was demonstrated. At final follow-up, all repaired valves were patent and competent. Our experience demonstrates that angioscopy-assisted venous valvuloplasty combines the accuracy of valvuloplasty by means of phlebotomy and the simplicity of external valvuloplasty and thus is preferred to either of these methods.     

Correlation of clinical findings with venous hemodynamics in 386 patients with chronic venous insufficiency

Deep venous insufficiency secondary to deep valvular incompetence predominated over superficial venous insufficiency in an unselected patient population with advanced chronic venous insufficiency. Venous obstruction was uncommon (5 percent), suggesting that venous bypass surgery may have limited applicability in the management of chronic venous insufficiency. Although the majority of patients (72 percent) with stage III venous disease (ulcer) had deep venous insufficiency alone and would be potential candidates for deep valvular reconstruction, 13 percent were found to have superficial venous insufficiency alone, and the remaining 15 percent, deep venous insufficiency with a hemodynamically significant component of superficial venous insufficiency. These findings suggest that not all patients with stage III disease have altered hemodynamics on the basis of deep venous valvular incompetency. Although most stage III chronic venous insufficiency is secondary to altered deep venous hemodynamics, as demonstrated by shortened venous refill time, there is a significant group of patients with severe chronic venous insufficiency having superficial venous insufficiency alone or in combination with deep venous insufficiency (28 percent). Thus, it is imperative that those patients with superficial venous insufficiency be identified by a widely available and reproducible method, such as light reflection rheography, since they may respond to surgery of the superficial venous system alone.