Does surgical correction of the superficial femoral vein valve change the course of varicose disease?

PURPOSE

We tested the hypothesis that the course of primary chronic venous insufficiency can be changed by correction of the incompetent valve in the superficial femoral vein.

METHODS

This was a prospective, randomized, controlled study. A total of 125 extremities with reflux in greater saphenous and superficial femoral veins and belonging to clinical classes C2-C4 were analyzed. During the first 5 years, the type of clinical dynamics and changes in valvular function were determined in each patient. Patients were stratified according to the type of clinical dynamics and randomly assigned to treatment groups. Phlebectomy was performed in all extremities. In each of 64 extremities (the study group), the proximal incompetent superficial femoral vein valve was corrected as a part of the primary intervention. Patients were followed up for 7 to 8 years after surgery.

RESULTS

The clinical dynamics of the extremity significantly depended on reflux changes. Increase in superficial femoral vein reflux was found in 74% of the extremities with progressive clinical dynamics but in only 47% of extremities with stable clinical dynamics (chi(2) = 9.71; P <.01). After surgical treatment, 65% of the extremities in the control group showed stable improvement; in 11%, recurrent varicosity was found; in 24%, the disease was aggravated. Of the extremities in the study group, 86% had stable improvement, 5% had recurrent varicosity, and 10% were aggravated (P <.05). Extremities with the progressive type of clinical dynamics were main contributors to this difference (chi(2) = 7.86; P <.05). In 92% of the extremities with corrected valves and in 50% of the extremities with increase in reflux after valvuloplasty, clinical improvement was observed (chi(2) = 11.5; P <.01). Extremities with corrected valvular function demonstrated superior results in comparison with extremities with stable valvular function in the control group (clinical improvement in 92% and 66% of extremities, respectively; P <.005).

CONCLUSIONS

In patients with chronic venous insufficiency, two types of clinical dynamics, stable and progressive, can be identified. The progressive type is associated with the presence of superficial femoral vein reflux and increasing greater saphenous vein reflux. Superficial vein surgery neither corrects superficial femoral vein reflux nor prevents it from progressing further. Correction of a single superficial femoral vein valve during primary intervention significantly improves the long-term results of superficial venous surgery. This improvement is associated with the prevention of reflux progression. Surgical correction of the incompetent superficial femoral vein valve changes the course of primary chronic venous insufficiency.

Expanded polytetrafluoroethylene in external valvuloplasty for superficial or deep vein incompetence

The authors evaluated the long-term safety of expanded polytetrafluoroethylene (ePTFE) implants used in external valvuloplasty for treatment of incompetence of the long saphenous and common and superficial femoral veins. During a 15-year period patients with superficial and/or deep venous disease and hypertension due to pure superficial or deep vein incompetence underwent an external valvuloplasty with ePTFE sutures, or an ePTFE cardiovascular patch placed as a sleeve around the incompetent vein segment, or an ePTFE tubular graft placed around the venous segment. Postoperative follow-up evaluations consisted of clinical examinations, high-resolution ultrasonography, and color duplex scanning, and a complete blood count performed at 1, 3 and 6 months, and repeated for at least 4 years, every 2 years after the procedure. A total of 101 patients (38 men and 63 women; mean [+/- sd] age, 44+/-12 years) underwent external valvuloplasty between January 1983 and December 1998; 82 of them completed the 4-year follow-up. Forty of the 82 patients had been operated on for superficial vein incompetence, 42 for deep vein incompetence. Overall, the mean follow-up time was 7.8+/-3.6 years (range, 4 to 13). There were no infections, thromboses,foreign-body reactions to the ePTFE implants, or other prosthesis-related complications requiring explantation. One granuloma (noninfected) developed in association with a tubular ePTFE implant around a long saphenous vein, but it did not necessitate implant removal. Seven patients required (at least after 4 years) a second procedure for recurrent or new venous incompetence. Therefore, in this observational study, ePTFE implants used to treat or correct venous incompetence were well tolerated on a long-term basis.

Superficial vein valve repair with a new external valve support (EVS). The IMES (International Multicenter EVS Study)

The aim of this international multicenter trial was to evaluate the effects of a new surgical device (Gore External Valve Support-EVS) and technique for external valvuloplasty of the long saphenous vein (LSV). Patients with superficial venous disease and venous hypertension due to pure superficial venous incompetence were randomized into two treatment groups, the first treated with "conventional treatment" (ligation or stripping) and the second with external valvuloplasty with the EVS. Patients with uncomplicated varicose veins within the age range of 35-65 years were included. Incompetence with presence of functional cusps at the saphenofemoral junction (SFJ), with vein dilatation were the main inclusion criteria. The EVS comprised of a GORE-TEX patch material (including a nitinol frame) that is placed around the vein, producing a reduction in the caliber of the vein. Also the vein section becomes elliptical. These combined actions are aimed to reduce incompetence, allowing a better closure of the cusps. The EVS was placed at the SFJ after limited dissection of the vein and ligation of collaterals. The procedure was randomized as an alternative to simple ligation or stripping (according with the procedure commonly used in the center). The associated ligation of distal incompetent veins was allowed. The main outcome measures of the study were evaluated by color-duplex (morphologic findings and evaluation of reflux) and with ambulatory venous pressure (AVP) or air-plethysmography (APG). Main endpoints of the first year of the study and main subject of this report (mainly concerning safety within the first year of follow-up) were considered presence/absence of reflux; patency of the veins; mobility/function of vein cusps; occurrence of thrombosis; tolerability of the device; and increased complexity and operating time needed for the EVS. At 1 year 30 patients had been randomized (14 EVS implanted, 16 controls). Reflux was absent in all EVS patients, all treated veins were patent, and all cusps were mobile. No thrombosis had been observed and the tolerability of the device was very good. The increased complexity required by placing the EVS was limited (5-12 minutes more). In conclusion results of the first year show efficacy and tolerability of the EVS. In selected patients (superficial LSV incompetence, reflux-dilatation, functional SFJ cusps, incompetence mainly due to enlargement of the vein), the EVS could be an effective alternative to "destructive" ligation and/or stripping of the vein. Prolonged follow-up will indicate the clinical potentials of the EVS.

External femoral vein valvuloplasty with limited anterior plication (LAP): a 10-year randomized, follow-up study

The aim of this study was to evaluate the effects after 10 years of external valvuloplasty of the femoral vein (limited anterior plication or LAP). After informed consent patients with venous hypertension due to deep and superficial venous incompetence were randomized into two treatment groups. Both groups were treated with superficial vein surgery (ligation and section of the major incompetent superficial veins). Group 2 was treated with the same procedure and with LAP. External valvuloplasty of the superficial femoral vein was performed with plication of the anterior vein wall after limited dissection of the vein. Results were evaluated with color-duplex scanning and ambulatory venous pressure (AVP) measurements. Endpoints were AVP, refilling time (RT), presence/absence of reflux at the superficial femoral vein, the variation in the diameter of the vein, and quality of life score (QLS). No complications were observed. All femoral veins treated with LAP were competent after 10 years. Significantly lower AVP and longer RT were observed in the LAP group. Also the average diameter of the vein was smaller in the LAP group. Moreover, QLS was significantly better in the LAP group after 10 years. In conclusion, in selected subjects, with moderate deep venous incompetence, functional cusps, or incompetence mainly due to relative enlargement of the femoral vein, LAP may be an effective alternative to external valvuloplasty.

Laser Doppler Flux in the Venous Wall

Objectives:

To evaluate in vivo the perfusion of the venous wall in normal veins, varicose veins and in femoral veins of post-phlebitic limbs recording wall flux with laser Doppler flowmetry. As there is some evidence that both structure and microcirculatory dynamic responses are altered in the abnormal vein wall, we also aimed to study the response of vein wall perfusion to locally induced vasodilatation following papaverine infusion.

Design:

Open prospective study in patients with venous insufficiency and in patients undergoing coronary revascularization with a normal venous system.

Setting:

Cardiovascular Institute, Chieti University, Pierangeli Clinic, Italy and Irvine Laboratory, St Mary's Hospital, London, UK.

Patients:

Twenty-four normal long saphenous veins and 11 common femoral veins (35 normal veins, 35 subjects) and 42 varicose veins (42 patients).

Measurements:

Venous wall flux was measured on the external surface of normal long saphenous veins and common femoral veins. Measurements were also made on varicose veins before ligation of the sapheno-femoral junction. All measurements were made when at least three-quarters of the adventitia and periadventitia tissue were still intact for a length of 3 cm.

Results:

Flux in the normal vein wall was higher ( t = 5.88; p<0.05) than in varicose veins and in veins of post-phlebitic limbs. There was no difference in flux between varicose veins and post-phlebitic veins. After intravenous papaverine injection in a subgroup of eight normal and eight varicose veins, in the wall of normal veins there was a significant increase in flux (from 8.5 (SD 5.1) units to 13.2 (SD 3.8) units; p<0.05) which was not observed in varicose veins.

Conclusions:

A higher vein wall perfusion was observed in normal veins compared with varicose veins and post-phlebitic limb veins. Greater vascular reactivity to intraluminal papaverine injection was observed in normal veins.