Alternative greater saphenous vein-sparing surgery: valvuloplasty combined with axial transposition of a competent tributary vein for the treatment of primary valvular incompetence---18-month follow-up.

Abstract

The greater saphenous vein (GSV) is one of the best grafts for vascular reconstruction, and a variety of sparing methods in patients with primary varicose veins have been performed. Of these, valvuloplasty of the subterminal valve is useful, but reflux in the proximal GSV via a competent tributary vein still remains. To minimize the subsequent reflux, we propose a new method, "valvuloplasty combined with axial transposition of a competent tributary vein" for the treatment of GSV incompetence. To compare this new method with single valvuloplasty. Seventy-eight limbs in 65 patients with GSV incompetence were included. Of these limbs, 38 underwent angioscopic valvuloplasty of the subterminal valve alone (V group). The remaining 40 were treated by angioscopic valvuloplasty combined with axial transposition of a competent tributary vein (V + T group). A competent tributary vein was identified by duplex scan in the thigh before surgery. After angioscopic valvuloplasty had been done, a competent tributary vein was exposed, and was cut 1.5 cm distal to its insertion. The distal cut end of the vein was then transposed to the GSV and end-to-side anastomosis was performed using 8-0 nylon under magnification. The incompetent GSV was ligated between the insertion and the anastomosed region. Venous hemodynamic changes were analyzed using air plethysmography (APG). Values obtained by9 APG included venous volume (VV), venous filling index (VFI), ejection fraction (EF), and residual venous function (RVF). The follow-up period was 18 months. Intergroup differences were analyzed with the Wilcoxon ranked sum test for nonparametric distribution. There were no statistical differences in age, gender, or clinical presentation between the two groups. In the V group, 27 limbs had reflux in the proximal GSV (67.4%). On the other hand, only 6 limbs (13.3%) showed minor reflux in the V + T group. A significant difference was seen in VFI at 1 year, and a continuous increase was observed in the V group during the follow-up examinations (P =.0035, VFI = 2.50 plus minus 1.21, 1.14 plus minus 0.42 at 18 months, respectively). Valvuloplasty combined with axial transposition of a competent tributary vein gives a better result than valvuloplasty alone at the 18-month follow-up. A competent valve in this location can be expected to improve VFI to a normal range.