Recurrence Rates Following External Valvular Stenting of the Saphenofemoral Junction: A Comparison with Simultaneous Contralateral Stripping of the Great Saphenous Vein

Functional repair of the great saphenous vein by external valvuloplasty reduces the vein's diameter: 6-month results of a multicentre study

Objectives

External valvuloplasty (eVP) is a reconstructive surgical method to repair the function of the terminal and preterminal valves. We evaluated the 6-month outcomes of eVP regarding the diameter of the great saphenous vein (GSV).

Methods

Patients from five vein centres were included in this observational study. Follow-up involved detailed duplex sonography of the GSV. The venous clinical severity score (VCSS) and the C class of the clinical, aetiologic, anatomic and pathophysiologic (CEAP) classification were recorded.

Results

We enrolled 210 patients, with a follow-up rate of 58%; eVP was sufficient in 95.24% of the patients. The GSV diameters decreased significantly from 4.4 mm (standard deviation (SD): 1.39) to 3.9 (SD: 1.12), 4 cm distal to the saphenofemoral junction (SFJ); from 3.7 mm (SD: 1.10) to 3.5 mm (SD: 1.02) at the mid-thigh; from 3.6 mm (SD: 1.14) to 3.3 mm (SD: 0.94) at the knee and from 3.1 mm (SD: 0.99) to 2.9 mm (SD: 0.78) at the mid-calf. VCSS decreased significantly from 4.76 (SD: 2.13) preoperatively to 1.77 (SD: 1.57) 6 months postoperatively.

Conclusions

GSV function can be restored by eVP; diameters over the total length of the GSV decreased significantly.

External valvuloplasty of the saphenofemoral junction in insufficient great saphenous veins - six weeks results of a prospective multicentre trial

Background: Varicosis of the great saphenous vein (GSV) is a common disease. Most of the therapeutic concepts attempt to remove or destroy the truncal vein. However, the absence of the GSV could be harmful for further treatments of artherosclerotic disease as the GSV is often used as bypass graft in lower extremity or coronary artery revascularisations. External valvuloplasty (EV) is one of the vein-sparing treatment options. The aim of this clinical study was to describe the outcome, safety and complications of this procedure in a prospective multicentre trial. Patients and methods: The function of the terminal and preterminal valve was restored by external valvuloplasty. Furthermore, multiple phlebectomies of tributaries were performed. Patients were reinvestigated six weeks after surgery. Primary endpoint was the function of the external valvuloplasty measured by diameter of the GSV and the prevalence of reflux in the GSV. The eligibility of the vein as a potential bypass graft was noticed. CEAP class and VCSS scores were analysed. Results: A total of 359 patients were included in the study. After six weeks 297 patients could be reinvestigated. The function of the external valvuloplasty was sufficient in 284 patients (95.6%). Treatment failed in 8 patients (2.6%) due to an occlusion or junctional reflux despite valvuloplasty. The GSV was estimated as suitable as a bypass graft in 261 patients (87.8%). Reflux at the saphenofemoral junction was significantly reduced after treatment and the diameter of the GSV near the saphenofemoral junction significantly decreased from 4.4 mm to 3.8 mm (p < 0.05). The VCSS was significantly reduced from 4.6 preoperatively to 2.6 postoperatively. Conclusions: External repair of the great saphenous vein can reduce venous symptoms and may preserve the great saphenous vein as a bypass graft. Nevertheless, this treatment option is only suitable for a limited number of patients.

Repair of Saphenofemoral Transition: Reşat Operation for Patients With Venous Reflux

Objective:

To develop a new solution superior to the current surgical interventions in patients with venous reflux in the great saphenous vein (GSV).

Materials and Methods:

Patients with the symptoms of venous incompetence in their legs like pain, edema, and cramp were also examined with color Doppler ultrasonography (CDU). One hundred ninety-one extremities with venous reflux at the saphenofemoral transition (SFT) were subjected to surgery over 8 years. A newly designed operation, the Reşat operation, was performed in all of the patients. The Reşat Operation was performed only in the patients with continuous reflux at their saphenofemoral transition during the entire Valsalva maneuver. The follow-up time spanned more than 8 years. The patients' complaints, physical examinations, and CDU findings were evaluated.

Results:

All of the patients had continuous reflux at the SFT for the duration of the entire Valsalva maneuver preoperatively. However, 67.88% of the patients had no reflux postoperatively (P &lt; 0.001). Additionally, 95.76% of the patients recovered to different degrees in the early postoperative period ultrasonographically (P &lt; 0.001). All of the patients reported being satisfied with the result in the early postoperative period (P &lt; 0.001). In the late postoperative period, although the CDU reports of some patients showed reflux at the GSV, no patient complained about their condition.

Conclusion:

The Reşat operation is a well-tolerated operation and reconstitutes the saphenofemoral transitions successfully. Its early and late postoperative results are satisfactory. The Reşat operation should be the first-choice surgical treatment in patients with venous reflux at the saphenofemoral transition.

The effect of pregnancy on venous valve repair to the sapheno-femoral junction for varicose veins

Objectives:

Pregnancy represents a special situation where both the mechanical and hormonal instigating factors of varicose veins are reversible with the venous valve cusps preserved. Exostent venous valve repairs are a physiological alternative which minimises stimulus to collateral growth (recurrence). The study purpose was to assess the effect of pregnancy on the durability of valve repairs.

Methods:

In a prospective study of 36 limbs, 20 young females (30 ± 4.7 years) had an exostent implanted to the terminal valve of the saphenofemoral junction for varicose veins. At routine long-term follow up (9.7 ± 3.8 years), 38 pregnancies were completed (mean: 1.8, range: 1–4). The controls were a non-pregnant group of limbs ( n = 386).

Results:

At 9.7 years, the internal diameter of the greater saphenous vein (GSV) changed from 7.8 ± 2.8 mm preoperatively to 4.5 ± 1.4 mm post-operatively. Recurrence was associated with reflux, preoperative deep system and ovarian vein involvement. Pregnancy induced 33.3% recurrences compared with non-pregnant controls (4.7%) similarly treated or 22.8% compared with non-pregnant ablative controls. At 9.7 years, symptomatic improvement continued with significantly better CEAP status (described later) (31CSEAP preoperative to 6CSEAP) with no further truncal ablation (strip, laser) required.

Conclusions:

Venous valve repairs can withstand the special stresses of pregnancy. There is no need to ablate the GSV. This approach is contrary to the traditional dictum; the treatment of varicose veins should be delayed until the family is completed.

[Modern varicose vein surgery]

Varicose vein operations belong to the most commonly performed surgical procedures in Germany. Besides the classic operation employing modern technology, which shows manageable recurrence rates with good cosmetic results and must be considered as the established standard therapeutic procedure, endoluminal treatment methods (endovenous radiofrequency therapy, endoluminal laser therapy) have been increasingly used in recent years. The endoluminal treatment methods offer patients reduced post-operative pain and a shorter recovery time compared to traditional surgery. Unfortunately due to limitations caused by vessel diameter and the ability to probe the vessel, they are only available to a limited range of patients. It remains to be seen how these procedures compare to the classical techniques, in particular in regards to improving the long-term quality of life and recurrence rates. A further therapeutic option is chemical endoluminal therapy, catheter-assisted foam sclerotherapy. It can be used as a safe treatment option with good postoperative results in some cases. However, the primary closure rates are inferior to surgery and endoluminal procedures.