O'Donnell, T F Jr

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THE ROLE OF ANGIOSCOPIC VALVEREPAIR FOR PRIMARY VALVEINCOMPETENCE (PVI)Thomas F. O’Donnell, Jr., MDNew England Medical CenterBoston, Massachusetts, USAThe treatment of deep venous valvular reflux for advanced chronicvenous insufficiency (CVI) has been cyclical in nature. During thelate 1 960s and early 1 970s there was enthusiasm for ablation of thesuperficial venous system — saphenous and its branches as well asperforating veins, as the sole management for venous ulcer withdeep venous reflux.’ Both the ulcer recurrence rate and woundmorbidity associated with this approach dampened interest in thetreatment of venous ulcer by superficial venous system ablationalone.2 Direct deep venous reconstruction pioneered by Kistner3sparked interest in the later approach. Recently, minimally invasivesurgery for treatment of incompetent perforating veins (SEPS)however, has refocused the treatment strategy for grade IV throughVI CVI back on superficial ablation rather than deep venous reconstruction due to the low wound morbidity rate of the former. Theimportant work ofGloviczki and his North American SEPS Registryhas shown that superficial venous ablation works better in patientswith primary valvular incompetence than those with a post-thrombotic etiology for their deep venous reflux.4 This data suggests thata staged approach to deep venous reflux due to primary valvularincompetence is the appropriate strategy. Although primary valvular incompetence has traditionally been related to a fibro-elasticdegeneration of the valve with resultant valvular insufficiency,3there is increasing evidence that volume overload from a capaciousvaricose superficial system can cause dilation of the deep venoussystem and secondary deep venous valvular incompetence.5 Thevalves in this situation are intact, but the dilation of the venousannulus prevents them from appropriately coapting. Superficialsystem surgery which removes the volume overload has shown torestore both normal venous diameter and valve competence. It hasbeen our approach to treat the incompetent superficial venoussystem first in patients with primary valvular incompetence andrestrict direct deep venous reconstruction to those patients who failthis therapy.One of the hosts of this conference, Dr. Robert Kistner, was thefirst surgeon to describe a direct approach to rendering a valvecompetent rather than replacing the incompetent segment withcompetent valve “borrowed” from either a local or distant venoussegment.3 His initial report in 1968 stimulated interest in thesurgical repair of primary valvular incompetence. Our case reportwill detail the diagnosis, surgical technique and postoperativeresults of surgery for primary valvular incompetence.Diagnostic MethodsClinical Examination: Patients with deep venous valvular refluxcharacteristically have pain, which is described as a heaviness ratherthan the intense bursting pain experienced by patients with deepvenous obstruction.7 The pain or heaviness develops upon risingfrom bed and worsens after prolonged standing. Calf heavinessoccurs irrespective of whether the patient is walking which is indistinct contrast to the situation with obstructive venous disease andvenous claudication. Edema is a constant finding in patients withdeep venous reflux and is of a mild to moderate degree. Cutaneoussequelae, lipodermatosclerosis and pigmentary changes occur frequently in these patients in association with incompetent perforatingveins. In our experience, the skin changes may not be as severe asthose encountered in patients with post-thrombotic syndrome.Noninvasive Assessment of Venous Reflux: Duplex scanning isour preferred diagnostic study, because it answers several questions:1) What is the pathologic process in the deep venous system, 2) whatlevels are involved, and 3) who are surgical candidates based on thedegree of reflux? Quantitative evaluation of venous valvular refluxis performed by the technique described by van Bemmelen. Whilecolor flow analysis provides qualitative determination of deepvenous valvular reflux, spectral analysis is recorded to quantify thedegree of reflux by duration.Air plethysmography provides hemodynamic information ondeep venous valvular incompetence. The venous filling index (VFI)relates directly to the degree of venous reflux and is independent ofthe venous volume reservoir. Christopolous8as well as our vascularlaboratory9have shown that patients with popliteal vein reflux instage IV — CVI have VFIs in the range from 7—28 ml/seconds versusthe normal 2 ml/seconds. We per-form both of these noninvasivestudies prior to consideration for valve reconstruction as well asemploying it as a method for documenting hemodynamic resultspostoperatively. In a prospective trial comparing quantitativeduplex scanning and air plethysmography to the gold standard ofdescending phlebography in patients with stage V/VI chronic venousinsufficiency, we demonstrated that the combination of valve closure times at the superficial femoral and popliteal vein levelsaccurately discriminated mild from severe reflux with a sensitivityof 90% and a specificity of 94%9Phleboraphy: In all surgical candidates, ascending phlebographyis performed with multiple tourniquets to maximize visualization ofthe deep system.7 With the superficial system occluded the contrastmaterial is injected by hand forcefully into a foot vein. In additionto indicating the presence and level of incompetent perforating vein,valve sites may be seen in the superficial femoral vein. The diameterof the veins helps distinguish relative deep venous valvular insufficiency from true PVI.Descending phlebography is then performed under fluoroscopywith the patient on a 75 degree tilt table. The contrast material ishand injected while the patient performs a Valsalva maneuver.Reflux of contrast material is followed by fluoroscopy and cut filmsare taken. As it slips past, the contrast material usually will outlinethe valve structure much as frost on a windowpane.Surgical Procedure: The common femoral, superficial femoral,profunda femoris, and greater saphenous veins (if the latter ispresent) are approached through a longitudinal incision placed overthe common femoral vein. Raju and Fredericks’0prefer to performthe dissection with a scalpel rather than with scissors in order toavoid venospasm. As opposed to veins that have been involved bya previous episode of thrombophlebitis, the veins of a patient withHAWAW MEDOAL JOURNAL, VOL 59, JUNE 2000266PVI usually do not have the intense penvenous scarring unique topost-thrombotic veins. The various branches of the major veins areligated so that approximately 4 cm of superficial femoral vein isisolated. The proximal valve is identified by its characteristic bulgein the upper superficial femoral vein. The vein is then milked ofblood to test its competence. An incompetent valve will permitblood flow down to the clamp placed distal to the valve. Followingheparinization, soft, noncrushing clamps are placed on the commonfemoral, profunda femoris, and superficial femoral veins below thevalve.There are three open approaches to exposure of the valve commissure. Kistner originally described a longitudinal venotomy,3whileRaju advocated a transverse venotomy placed above the valve)0Finally, Sottiurai used a combination of a transverse and longitudinal venotomy. We, however, prefer the closed angioscopic technique first described by Gloviczki.’2Angioscopic Technique: Fourteen patients have undergoneangioscopic evaluation of the valve before and after repair. Thescope is inserted through a large tributary of the proximal greatersaphenous vein which was invariably absent or via a branch of thefemoral vein down into the superficial femoral vein.13 Salinesolution is infused through the angioscope, and the valve leaflets areobserved for incompetence, which, when present, is both obviousand dramatic. The pathology of PVI usually demonstrates a wispygossamer-like valve with redundant valve margins.The Closed Angioscopic Valve Repair Technique: After placingtwo or three 7-0 monofilamant sutures on each side of the valve fromoutside the vein under angioscopic guidance, the repair was testedfor competence by infusing saline solution through the scope.Common to the patients who have undergone angioscopy is the useof the angioscope to judge the competence of the repair rather thanthe strip test. If the valves are incompetent, additional sutures areadded. By contrast, if the repair is narrowed sutures may beremoved.Results: Table I demonstrates the preoperative demographics forseven series in the literature which total 254 limbs. All series exceptours were carried out by the open technique. The indication forsurgery varied but averaged 75% for stage V/VT disease. Kistner’ 14series has the longest follow-up period. In general patients do quitewell regarding ulcer recurrence with rates varying from 35% to 19%.Several series such as Kistner’s and the recent one of Perrin’5 showthat valvular incompetence is related to the duration of ulcer-freesurvival. The value of angioscopic repair of primary valvularincompetence lies in the determination while in the operating roomthat the repair is competent. In the absence of further valvulardegeneration in the postoperative period, this finding should becorrelated with a good outcome.References1 O’Donnell TF, Shepard AD. Chronic venous insufficiency. In: Jarrett F, Hirsch J, Eds. Vascularsurgeryof the lower extremities. St. Louis: CV Mosby, 1985:206.38,2. Burnand KG, O’Donnell TF, Lea Thomas M, Browse NL. The relative importance of incompetentcommunicating veins in the production of varicose veins and venous ulcers, Surgery. 1977;82:9-14.3. Kistner R. Surgical repair of the incompetent femoral vein valve, Arch Surg. 1975;1 10:1336-1342.4, Gloviczki P, Bergan JJ, Rhodes JM, Canton LG, Harmsen 5, llstrup D. Mid-term results of endoscopicperforator vein interruption for chronic venous insufficiency: lessons learned from the North AmericanSubfascial Endoscopic Perforator Surgery registry, J Vasc Surg. 1999;29:489-502.5. Eriksson E. Plethysmographic studies of venous diseases of the leg, Acta Chir Scand, 1969;(suppl398).6. Kisfner R. Surgical repair of a venous valve, Straub Clin Proc. 1968;34:41-43.7. O’Donnell TF. Surgical management of deep venous valvular incompetence. In: Rutherford RB, ed.Vascular Surgery. 3ded. Philadelphia: WB Saunders, 1989; 1612-26.8. Christopoulos DG, Nicolaides AN, Szendro G, Irvine AT, et al. Air plethysmography and the effect ofelastic compression on venous hemodynamics of the leg, J Vasc Surg. 1987;5:148-59.9. Welch HJ, Faliakou EC, McLaughlin RL, et al. Comparison of descending phlebography withquantitative photoplethysmography, air plethysmography, and duplex quantitative valve closure timein assessing deep venous refluu, J Vasc Surg. 1992;16:913-20.10. Raju 5, Frededcks R. Valve reconstruction procedures for non-obstructive venous insufficiency:rationale, techniques, and results in 107 procedures with 2-8 year follow-up, J Vasc Surg. 1 988;7:301-10.11. Sottiurai VS. Surgical correction of recurrent venous ulcer, J Cardiovasc Surg. 199132:104-9.12. Gloviczki P, Merrell SW, Bower TC, Femoral vein valve repair under direct vision without venotomy: amodified technique with use of angioscopy, J Vasc Surg. 199114: 645-8.13. Welch HJ, McLaughlin RL, O’Donnell TF. Femoral vein valvuloplasty: irltraoperative angioscopicevaluation and hemodynamic improvement, J VascSurg. 1992; 16:694-700.14. Masuda EM, Kistner RL. Long term results of venous valve reconstruction: a four-to twenty-one-yearfollow-up, J Vasc Surg. 1994: 19:391-403.15. Perrin M, Hiltbrand B, Bayon JM. Results of valvuloplasty in patients presenting deep venousinsufficiency and recurdng ulceration, Ann Vasc Surg. 1999; 13:524-532.16. En ksson I. Vein valve surgery for deep valvular incompetence. In: Controversies in the managementof venous disorder, Eklof, Gjores, Thulesius. Berquist, EDS. Butterworths: London. 1989.17. Simkin R, Esteban JC, Bulb) R. By-pass veno-venosos y valvuloplastas anal tratamiento quirurgicodel sindrome post-trombotico, Angiologia. 1988;1:30-4.Table 1.— Summary of Preoperative Demographics for the Surgical Treatment of Primary Valvular Incompetence by ValvuloplastyPreoperative DemographicsHAWAII MEDICAL JOURNAL, VOL 59, JUNE 2000267Series Country Institution Year #Limbs Indicat Technique(% ulcers)Kistner14’ USA Straub Clinic 1992 51 (48 pts) 57% Open tPerfsRaju° USA Mississippi 1987 107 (42 pts) 71% Open ±_SFJ hgPerrin05 France Clinique Grand Large 1999 5233 (28 pts) 100% Open PerfsEriksson16 Sweden Uppsa)a Univ Hosp 1989 22 (20 pts) ?? % Open ÷PerfsSottiurai USA L.S.U. 1987 20 (12 pts) 100% OpenSimkin1171 Argentina Clinica Quintana 1988 7 (7 pts) 100% Open (3) Phication (4)O’Donnell USA NEMC 1992 14(l4pts) 100% l4openTable 2.— Summary of Postoperative Results for the Surgical Treatment of Primary Valvular Incompetence by ValvuloplastyPostoperative ResultsRange of follow, as well as (mean follow-up). Imaging refers to the percent of patients who were free of reflux on phlebography or duplex.Remodynamics refers to the percent of patients who had normalization of their APG or VRT#.*Angioscopically guided valvuloplastyINTERNAL VALVULOPLASTYMichel Perrin, MDUniversity de GrenobleGrenoble, FranceIn case of primary deep venous reflux and when deep venousreconstructive surgery is planned internal valvuloplasty looks to bein our experience the recommended surgical procedure.The rationale for recommending Internal Valvuloplasty (IV):First of all because other techniques have not yet provided long termresults as good as IV.-Valve transfer (transposition, transplantation) has been mostlyused to treat secondary deep vein reflux and generally their resultsare not as satisfactory as those obtained by IV (Perrin, Raju,Sottiurai).-Psathakis operation II had given excellent results to his promoterbut disappointing in small series reported by others (Perrin, Scurr).-Several authors (Belcaro, Lane, Raju, and Schanzer) had performed external wrapping (Veno-cuff, banding with Gore-Tex orDacron sleeve). Results are difficult to assess as various materialsand techniques had been used, indications were different accordingto authors and long-term results are not available. Furthermore, Icannot clearly understand how shrinking of the vein diameter maywork to correct reflux when the free borders of the valve areelongated and already in contact.-Plagnol and Raju had used neovalve. The former had reported onlymid-term results (average 18 month) in 44 extremities including 32-graded C6. Ulcer had recurred in 3/32(9.4%) and hemodynamicfailure in 6 /44(13.6%).-Hoshino, Kistner, Gloviczki, O’Donnell and Raju had used external valve repair, but again we have only short- or mid-term results.The advantages of the external valvuloplasty (EV) compared to IVare: EV is quicker than IV, allowing multivalve repair and avoidsphlebotomy. In our unit we have only performed EV in addition toIV at the popliteal level without using angioscopy. Angioscopy iscertainly very helpful as recommended by Gloviczki, Hoshino, andO’Donnell. I would add that in EV, the vein needs to be peeled off,and that might be detrimental to the vein wall vascularization.-Internal Valvuloplasty: Kistner, Raju, and Sottiurai have describedthree techniques. We used the latter with minor modificationsbecause it seems easier to perform valve repair through the T-shapedphlebotomy.The ideal site for performing valvuloplasty is still under discussion:Sottiurai recommends popliteal level and Raju termination of thesuperficial femoral vein. In our series the latter has been chosen.One of the potential hazards in IV is postoperative thrombosis. Allour patients have had a postoperative ascending phlebography (24to 36 hr. after surgery) to assess this complication. In IV (#65) forprimary vein reflux we have recorded 5 (7.6%) limited thrombosisin situ or distal to the valve repair. Our results are summarized inTables 1,11,111, and IV. Table V displays results gathered through thepublished literature. Until updated data on others’ techniques withlong follow-up results assessment will be presented, IV seems themore reliable surgical technique to correct deep venous reflux.Series Follow-up(mos) Imaging Hemodynam Clinical ResultsKistner 48-252 (108) 86% 67% (PVI) 60% 35% ulcerRaju 24-96 85% 1 year 7% DVT75% 2 years 5% bleed63% 3 years 5% infecPerrin 24-96 85% 68% 19.2% ulcer(58 months) recurrence77.8% ulcerfree survivalEriksson 6-84 100% 64% 6 mos 30% ulcer62% 84 mosSottiurai 10-73 80% ?Simkin 50%O’Donnell 12-62 100% 85% remain healedHAWAN MEDICAL JOURNAL, VOL 59, JUNE 2000268

The role of angioscopic valve repair for primary valve incompetence (PVI).

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The role of angioscopic valve repair for primary valve incompetence (PVI).

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