Vein Valve Incompetence Research Articles

A response: Internal jugular vein valve incompetence: A key consideration in patients with exercise-induced headache

A response: Internal jugular vein valve incompetence: A key consideration in patients with exercise-induced headache

Surgery for deep venous insufficiency.

Surgery for deep venous insufficiency.

Inferior selective crossectomy for great saphenous vein incompetence: Our experience.

To describe the mid-term outcome after inferior selective crossectomy in a subset of patients with symptomatic chronic venous disease and both great saphenous vein and suprasaphenic valve incompetence.Methodsː Retrospective analysis of prospectively collected data was conducted. During an eight-year period, 1095 ligations of all saphenofemoral junction inferior tributaries and great saphenous vein stripping were performed in 814 Clinical, Etiology, Anatomy, Pathophysiology C2-C6 patients. Duplex ultrasound follow-up examinations were performed after 30 days, 6 months, and 2 years, and saphenofemoral junction hemodynamic patterns and varicose veins recurrence rates were evaluated. Two hundred and twenty patients completed the two-year follow-up period. At the 30-day Duplex ultrasound evaluations, two different hemodynamic patterns were described. Type 1, with physiological drainage of saphenofemoral junction superior tributaries, was observed in 214 patients. Type 2, without flow in saphenofemoral junction superior tributaries, was observed in six patients. Overall varicose vein recurrence rates were 0, 2.3, and 2.7% at the 30-day, 6-month, and 2-year follow-up examinations, respectively. At the two-year follow-up, Type 1 patients showed 0% varicose vein recurrence, while Type 2 patients showed 100%.Conclusionsː Inferior selective crossectomy seems to be a valid and safe option in case of both suprasaphenic valve and great saphenous vein incompetence. Duplex ultrasound evaluation, according to our protocol, allows us to identify two different saphenofemoral junction hemodynamic patterns that could predict varicose vein recurrence at mid-term. An optimal stump washing after inferior selective crossectomy, warranted by patency and large caliber saphenofemoral junction superior tributaries, seems to be the key point in preventing varicose vein recurrence in this context. However, large prospective studies regarding saphenofemoral junction modifications and varicose vein recurrence are needed to confirm these preliminary observations.

Clinical Implications of Sexual Dimorphism in Gonadal Vein Valves

The clinical significance of valves within gonadal veins is controversial. In males, the absence of valves in the left testicular vein (compared to the right) has been cited as a potential mechanism for varicocele formation in the pampiniform plexus in the scrotum. In females, ovarian vein valve absence or incompetence may lead to pelvic congestion syndrome, a disputed explanation for pelvic, abdominal, and/or flank pain of unknown etiology. One study suggests that females have incompetent valves in dilated veins more frequently than males due to past pregnancies. Furthermore, inconsistencies exist in the reported incidence of gonadal vein valves, though pelvic insufficiency is more thoroughly documented and diagnosed in males than in females.This study assesses the presence, number, and location of gonadal vein valves in male and females. The right and left gonadal veins were evaluated in 13 embalmed cadavers (7 males, 6 females; mean age = 86.3 +/− 6.2 years). Twenty‐four veins were available for dissection; two veins were lost to dissection and therefore omitted. The veins were dissected from the ovary (females) or deep inguinal ring (males) to the point of drainage into the inferior vena cava (right gonadal vein) or left renal vein (left gonadal vein). The veins were incised along the entire length of this course, and the number and location of valves was noted and photographed. Anatomical variation and pathological dilation in the vasculature was also documented. A total of 8 valves were found among the 24 dissections. Valves were present in four of the six females (67%) compared to one out of seven males (14%). The valve in the male was located in the left gonadal vein; the bilateral distribution in females was more randomly patterned. The majority of the valves (87.5%) in females were located distally, adjacent to the ovary, while a single valve was located adjacent to the left renal vein confluence. No dilation was noted in any of the specimens.The male population in this study had a lower incidence of gonadal vein valves than in previous studies. However, the number of valves in female gonadal veins was considerably greater than in males. This finding has not been reported previously, perhaps due to the emphasis on male pelvic congestion as a risk for infertility versus attributing the condition in females to a psychosomatic etiology. The primary limitation of this research is the small sample size. Future work will explore the clinical implications of these preliminary findings in a patient population. Clinical correlation with patients who are suspected or known to suffer from pelvic congestion syndrome may shed further light on the role of gonadal vein valves in vein sufficiency and inform more effective treatment for this poorly understood condition in the female patient population.

Incidence of Internal Jugular Vein Valve Incompetence through High versus Low Approach for IJV Cannulation

Incidence of Internal Jugular Vein Valve Incompetence through High versus Low Approach for IJV Cannulation

Femoral vein valve incompetence as a risk factor for junctional recurrence.

Background Recurrent varicose veins occur up to 80% of procedures. The sapheno-femoral junction can be involved in more than 50% of cases. A detailed pathophysiological explanation of the phenomenon is still missing. The aim of the present work is to evaluate the role of femoral vein incompetence as risk factor for sapheno-femoral junction recurrence. Methods Three-hundred-eighty-one patients presenting an incompetent great saphenous vein system and eventually also an incompetent femoral tract (C2-6EpAsdPr) underwent a great saphenous vein high ligation with flush ligation also of the incompetent tributaries along the leg, sparing the saphenous trunk. Pre-operatively, all patients underwent a sonographic evaluation assessing the superficial and deep venous systems, including a detailed analysis of the iliac-femoral vein tract above the sapheno-femoral junction. A retrospective statistical analysis assessed the recurrence risk associated with iliac-femoral vein tract incompetence. Results In a 5.5 ± 1.9 years follow-up, great saphenous vein trunk reflux recurrence was detected in 45/381 (11.8%) cases. The reflux source was found in a reconnected sapheno-femoral stump in 11/45 cases (24.5%), in the pelvic network in 8/45 cases (17.8%), in a neovascularization process in 7/45 (15.5%) and in a newly incompetent great saphenous vein tributary in 19/45 (42.2%). At the pre-operative assessment, iliac-femoral vein tract reflux was present in 7 (26.9%) of the 26 cases who developed a sapheno-femoral junction recurrence and in 25 (7%) of the 355 patients who did not demonstrate sapheno-femoral junction recurrence (odds ratio: 4.8; confidence interval 95%: 1.8-12.6; p < .003). Discussion Despite many technical diagnostic and therapeutic refinements, varicose veins recurrence remains a frequent event. The present investigation points out the association among iliac-femoral vein tract incompetence and sapheno-femoral junction recurrences after high ligation.

Proceedings in Percutaneous Valvuloplasty

Experience in vein shaping by perivenous fluids led to the invention and first presentations of percutaneous valvuloplasty (PVP) by ultrasound-monitored perivenous injection in 2013. Meanwhile, ultrasound criteria have been improved, a simple test by perivenous saline injection has been established, and two pilot series with different cross-linked hyaluronan gels have been completed including a 1-year follow-up. Now, a comparison of those two studies is presented. Patients with proximal great saphenous vein valve incompetence but preserved and mobile valve structures according to 8 to 16 MHz ultrasound analysis were included. In series A, 23 patients (15 women, 8 men; 38-67 years; diameter, 7.0-11.5 mm [mean, 8.6 mm]) underwent PVP with hyaluronan gel consisting of large particles (>1 mm, Macrolane; Q-Med, Surrey, UK). In series B, a smooth hyaluronan gel (particles <0.2 mm, prototype approved for aesthetic use) was chosen for 18 patients (12 women, 6 men; 34-69 years; great saphenous vein diameter, 7.0-11.8 mm [mean, 8.9 mm]; Fig 1). Orthograde flow was established in 22 of 23 cases in series A (95.6%) and 18 of 18 cases in series B (100%; Fig 2). Gel volumes were 12 to 35 mL (mean, 19.4 mL, A) vs 4 to 9 mL (mean, 6.9 mL, B). There were no adverse reactions. At 1-year follow-up, orthograde flow was present in 15 of 22 cases (68.2%, A) vs 14 of 18 cases (78.6%, B). Cases with recurring reflux successfully received supplementary hyaluronan injections of 2 to 6 mL. At 1-year follow-up, the assisted success rate was 97.6%. Both substances decreased with time, but correlation with the vein diameter was not clear. Meanwhile, 5 of 11 initial cases with >2 years of follow-up still showed orthograde flow without additional injection, but hyaluronan was no longer able to be depicted. PVP is the first minimally invasive method to eliminate venous reflux while fully preserving the target vein. It is successfully feasible as well with large-particle hyaluronan as with smoother gels. Small-particle gels may be placed more precisely but are much more expensive when designed to be long-lasting. Efforts are now on the manufacturers to provide a definite substance for PVP approval.Fig 2Incompetent GSV, pre and post valvuloplasty.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

LIPODERMATOSCLEROSIS AS A VARIANT OF LOBULAR PANNICULITIS: COURSE AND OUTCOMES

Objective: to study the course and outcomes of lipodermatosclerosis (LDS) as a variant of lobular panniculitis. Patients and methods. Examinations were made in 38 patients (37 women and one man) aged 54±13 years who had been diagnosed with LDS lasting 2 weeks to 20 years and followed up at the V.A. Nasonova Research Institute of Rheumatology in 2009–2016. In addition to general clinical examination, the patients underwent immunological studies and lower extremity venous Doppler ultrasonography (DUSG). Outcomes were assessed as a significant improvement (complete regression of indurations), an improvement (regression of indurations was achieved, but there was one recurrence of LDS in the follow-up period), a slight improvement (regression of indurations was achieved, but there was more than one recurrence of LDS, which needed to change treatment policy), no effect of the therapy (no regression of indurations was achieved), and deterioration of health. Results. The 38 patients with LDS were noted to have subcutaneous fat inflammation in the leg (100%) and asymmetric inflammation (55%) on its medial surface (92%). If the body mass index (BMI) was normal, LDS regressed more rapidly (p=0.04). During the entire follow-up period, 16 (42%) patients were observed to have recurrent LDS; the median time to recurrence was 3 [1; 6] months. The development of a recurrence was associated with node merging into conglomerates [odds ratio (OR), 4.33; 95% confidence interval (CI), 1.05–17.8; p=0.037] and with the use of hydroxychloroquine (HCQ) agents at a dose &lt;400 mg/day (OR, 5.25; 95% CI, 1.26–21.96; p=0.019). Regression of indurations was achieved in 39.5% of cases, the likelihood of its development was higher when the duration of LDS was ≤3 months before therapy initiation (OR, 14.67; 95% CI, 1.5–139.8; p=0.006) and in the absence of perforating vein valve incompetence, as evidenced by DUSG (OR, 4.1; 95% CI, 1.0–17.0; p=0.045). Conclusion. In the study group, LDS was more common in middle-aged women with increased BMI and chronic venous insufficiency. The elevated clinical and laboratory parameters of inflammatory activity were not typical of LDS. Higher BMI values contributed to a longer regression of indurations. Recurrences were more frequently observed after stress and due to non-compliance with prescribed therapy. Node merging into conglomerates and use of HCQ&lt; 400 mg/day for ≥6 months after therapy initiation are risk factors of recurrent LDS. The likelihood of regression of indurations was higher in patients, in whom the duration of the underlying disease was ≤3 months before therapy initiation and perforator vein valve incompetence was absent, as evidenced by DUSC.

Surgery for deep venous incompetence.

Chronic deep venous incompetence (DVI) is caused by incompetent vein valves and/or blockage of large-calibre leg veins and causes a range of symptoms including recurrent ulcers, pain and swelling. Most surgeons accept that well-fitted graduated compression stockings (GCS) and local care of wounds serve as adequate treatment for most patients, but sometimes symptoms are not controlled and ulcers recur frequently, or they do not heal despite compliance with conservative measures. In these situations, in the presence of severe venous dysfunction, surgery has been advocated by some vascular surgeons. This is an update of the review first published in 2000. To assess the effects of surgical management of deep venous incompetence in terms of ulcer healing, ulcer recurrence and alleviation of symptoms. For this update, the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched October 2014) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 9). Randomised controlled trials of surgical treatment for patients with DVI. For this update, two review authors (RRG and SCH) extracted data independently. All included studies required full risk of bias assessment in line with current procedures of The Cochrane Collaboration. Two review authors (RRG and SCH) independently assessed risk of bias and consulted with a third review author (AA) when necessary. Four studies with 273 participants were included. All included studies reported clinical outcomes following valvuloplasty. We found no studies investigating other surgical procedures for the treatment of patients with DVI. All included studies investigated primary valve incompetence. We found no trials that investigated the results of surgery for secondary valvular incompetence or the obstructive form of DVI. Because different outcome measures were used, it was not possible to pool the results of included studies. The methodological quality of the included studies was low, mainly because information regarding randomisation and blinding was missing, or because data were incomplete or were presented poorly. Ulcer healing and ulcer recurrence were not reported in one study, and the remaining three studies did not include participants with ulcers or with active ulceration. Three studies reported no significant complications of surgery and no incidence of DVT during follow-up. One study did not report on the occurrence of complications. Clinical changes were assessed by subjective and objective measurements, as specified in the clinical, aetiological, anatomical, and pathophysiological (CEAP) classification score. This requires vascular laboratory measurements of lower limb haemodynamics before and after surgery. Tests include an overall evaluation of venous function with venous refilling time (VRT) or ambulatory venous pressure (AVP). Two small trials comparing external valvuloplasty using limited anterior plication in combination with ligation of incompetent superficial veins against ligation alone (L) showed that ligation plus limited anterior plication produced significant improvement in AVP: The mean difference was -15 mm Hg (95% confidence interval (CI) -20.9 to -9.0) at one year and -15 mm Hg (95% CI -21 to -8.9) at two years. Sustainable statistically significant improvement in AVP and VRT was achieved by ligation and limited anterior plication at 10 years in one study. However, AVP values after surgery remained relatively high, causing its benefit to be questioned. Similarly, another study including participants who were deteriorating preoperatively showed sustained mild clinical improvement for seven years in those subjected to valvuloplasty compared with participants undergoing superficial venous surgery alone. However, this benefit was lost when the condition of participants was stable preoperatively. One small study (n = 40) with grade 3 reflux and no participants with ulcers reported that external valvuloplasty of the femoral vein combined with surgical repair of the superficial venous system improved the haemodynamic status of the lower limbs, restored valvular function more effectively and achieved better outcomes than surgical repair of the superficial venous system alone. No evidence was found for benefit or harm of valvuloplasty in the treatment of patients with DVI secondary to primary valvular incompetence. The individual trials included in this review were small; they used different methods of assessment and overall were of poor quality. They did not include participants with severe DVI. Trials investigating the effects of other surgical procedures on deep veins are needed. Until the findings of such trials become available, the benefit of valvuloplasty remains uncertain.

Guidewire advancement is interrupted by an internal jugular vein valve with a restricted opening: an ultrasound image

To the Editor, Anesthesiologists have generally paid relatively little attention to the internal jugular vein valve (IJVV) during central venous catheter insertion. Interruption of guidewire insertion by the IJVV is known to occur; however, very few related images appear in the published literature. Recently, a 73-yr-old male with a bicuspid aortic valve and a history of hypertension presented to our hospital for aortic valve replacement. Following induction of anesthesia, we attempted an ultrasound-guided placement of the Sheath Introducer (Multi-lumen access catheter, ARROW ) into the patient’s right internal jugular vein (IJV). We rotated the patient’s head to the left while slightly extending his neck, and we then confirmed that the IJV was lying parallel to the right carotid artery which had no evidence of stenosis. Ultrasound imaging was used to confirm the location of the needle tip within the vessel and backflow of blood. Next, we attempted to introduce a guidewire into the right IJV; however, we were unable to advance the guidewire more than 8 cm due to resistance. During ultrasound-guided indwelling of the guidewire, a large membranous structure was detected protruding from the posterior wall of the IJV. Although we attempted to advance the guidewire with the assistance of ultrasound imaging, the wire could only push the bottom of membranous structure (Figure, Panel A). The guidewire was caught by the membranous structure, and we could not advance the wire further. After several failed attempts, we placed the Sheathe Introducer into the left IJV instead. Internal jugular vein valves are the only barrier between the brain and the heart that prevent retrograde venous blood flow when the intrathoracic pressure increases. Malfunction of the IJVV may include restriction of the opening and valve incompetence. As was the case here, a restricted opening may impede insertion of the catheter or guidewire during central venous catheterization, while valve incompetence may be a complication of catheterization. A guidewire is introduced along the posterior wall of the IJV. In this case, the patient’s IJVV was a bicuspid valve which consisted of a large posterior leaflet and a small anterior leaflet. Advancement of the guidewire was obstructed by the bottom of the posterior leaflet with a restricted opening. Based on our experience, we suggest assessing any malfunctioning opening movement of the IJVV with a preprocedural ultrasound scan. Macchi et al. reported that IJVV incompetence may be considered a normal finding; however, a pressure gradient develops in this valve during coughing. Catheterization of the IJV involves a risk of injury to the IJVV. Wu et al. reported that IJVV incompetence is more commonly caused by cannulation and catheterization at the proximal site of the IJV than at the distal site. Internal jugular vein valve incompetence causes an increase in retrograde

Cerebrovascular Risk Factors and Triggers in Transient Global Amnesia Patients with and without Jugular Valve Incompetence: Results from a Sample of 243 Patients

Background/Aims: Different etiologies for transient global amnesia (TGA) have been proposed, such as venous flow abnormalities, spreading depression and migraine-related mechanisms like focal ischemia. Jugular vein valve incompetence (JVI) is commonly described in TGA patients, but its contributing role in TGA pathogenesis is still unknown. We investigated the possible relationship between JVI and pathogenetic mechanisms in TGA. Methods: 243 TGA patients underwent clinical and neurological assessment. Demographic characteristics, TGA-precipitating factors and vascular comorbidities were carefully recorded. In each patient, JVI was assessed by Doppler ultrasonography. Results: TGA patients were grouped according to the presence (n = 171, 70.4%) or absence (n = 72, 29.6%) of JVI. TGA patients with JVI showed a higher presence of precipitating factors, namely a Valsalva-like maneuver (JVI-positive vs. JVI-negative, 35.8 vs. 17.1%, p = 0.004) and emotional stress (36.6 vs. 21.4%, p = 0.023), but had fewer vascular comorbidities, namely hypertension (37.2 vs. 51.4%, p = 0.047) and carotid arteriosclerosis (20.5 vs. 31.9%, p = 0.050). Conclusions: These findings support the argument for the existence of at least 2 different TGA-associated mechanisms defined by JVI. On the one hand, JVI associated with a Valsalva-like maneuver and emotional stress supported the venous blood congestion hypothesis, and on the other, the JVI-negative group may have another vascular basis, unrelated to venous congestion.

Internal Jugular Vein Valve Incompetence in Transient Global Amnesia

See related article, pages 67–71. Transient global amnesia (TGA) was generally believed to have a psychogenic, epileptic, or thromboembolic etiology until the frequent comorbidity with migraine and the common accompanying symptoms (headache and dizziness) pointed toward cortical spreading depression as a pathogenic suspect.1,2 More recently, based on evidence that Valsalva-like activities may represent the precipitating factors in most TGA patients, cerebral venous congestion leading to venous ischemia was hypothesized as a possible pathophysiologic mechanism.3 Corroborating this hypothesis, the prevalence of internal jugular vein (IJV) valve incompetence, as assessed by ultrasound, was found to be more prevalent in patients with TGA than in controls.4–8 In all of these studies, IJV valve incompetence was detected in 97 of 131 patients (74%) and in 65 of 191 controls (34%). In this issue of Stroke, Cejas and coauthors9 confirmed these findings in a larger population, reporting IJV valve insufficiency in 113 patients with TGA (79.5%) and in 10 controls (25%). Apparently, this could solve …

Internal jugular vein valve incompetence in COPD and primary pulmonary hypertension

Under physiologic conditions, intact internal jugular vein valves (IJVVs) efficiently prevent retrograde venous flow during intrathoracic pressure increase. Chronically elevated central venous pressure found in patients with chronic obstructive pulmonary disease (COPD) and primary pulmonary hypertension (PPH) might lead to IJVV incompetence (IJVVI). The aim of this study was to analyze the prevalence of IJVVI in patients with COPD and PPH using duplex sonography (DUS). We included 30 COPD patients, 5 PPH patients, and 100 healthy controls in the study. IJVVI was diagnosed if retrograde jugular blood flow was seen on DUS during a Valsalva maneuver. Retrograde venous flow intensity was evaluated and graded according to extent and duration of reflux. IJVVI was found in 18 (60%) COPD patients and in all 5 (100%) PPH patients, which was significantly different from the controls (27%; p < 0.005). The intensity of venous retrograde flow correlated with the pulmonary artery pressure. Compared with healthy controls, COPDand PPH patients demonstrated a significantlygreater prevalence of IJVVI, which seems to be caused by the elevated central venous pressure. These patients may be at higher risk to develop central nervous system diseases related to cerebral outflow obstruction.

Incompetence of Internal Jugular Valve in Patients with Primary Exertional Headache: A Risk Factor?

The pathophysiology of primary exertional headache (EH) is unknown. Physical exertion is associated with Valsalva-like manoeuvres (VM). VM leads to increased intrathoracic pressure and reduces cerebral venous drainage. Internal jugular vein valve incompetence (IJVVI) leads to retrograde venous flow during VM with transient increase of intracranial pressure. We analysed the prevalence of IJVVI in EH patients using duplex ultrasound. Bilateral measurements were performed at rest and during VM in 20 patients and 40 controls. Incompetence was concluded if retrograde venous flow could be seen in the jugular Doppler spectrum during repeated VM. Seventy percent of EH patients and 20% of controls demonstrated IJVVI, yielding a significant difference (P = 0.0004). IJVVI was always observed on the dominant venous drainage side. Our study suggests that intracranial venous congestion caused by retrograde jugular venous flow might play a role in the pathophysiology of EH with IJVVI as a risk factor.

Internal jugular vein valve incompetence and intracranial venous anatomy in transient global amnesia

Background: Recently a causal relation between internal jugular vein valve incompetence (IJVVI) and transient global amnesia (TGA) has been suggested. IJVVI is postulated to provoke a transient mesiotemporal ischaemia by...

Treatment of severe chronic venous insufficiency using the subfascial endoscopic perforator vein procedure

Before 1985, corrective surgical procedures for patients with chronic venous insufficiency and venous ulcers were performed using long incisions through diseased skin and subcutaneous tissues. The procedure, involving ligation of incompetent perforator veins, known as "the Linton operation," often was complicated by wound infections and poor healing. This changed in 1985 when G. Hauer demonstrated a new surgical technique for direct visual identification of the incompetent perforator veins using an endoscope in the subfascial space. This seminal contribution marked the advent of subfascial endoscopic perforator vein surgery (SEPS). From 1996 to 2004, the authors group prospectively collected data on 110 patients with chronic venous insufficiency who underwent a SEPS procedure. Preoperative assessment of the limb's vascular status consisted of color-flow duplex ultrasound imaging and ascending and descending phlebography to locate vein valve incompetence, along with venous mapping. The ages of the patients ranged from 42 to 82 years (mean, 60 years). A total of 128 limbs underwent the SEPS procedure in the cohort of 110 patients. According to CEAP classification for venous limb disease, 60 limbs belonged to group C5 (skin changes, pigmentation, venous eczema, lipodermatosclerosis, healed ulcer) and 68limbs to group C6 (skin changes and active ulceration). The 110 patients underwent 128 SEPS procedures without significant morbidity. Of the 68 limbs in class C6, 54 showed ulcer healing within the follow-up period of 12 weeks. The remaining 14 limbs in class C6 achieved ulcer healing within 24 weeks. In this latter group, 10 patients had venous ulcers larger than 4 cm in diameter. These patients underwent a split-thickness skin graft at the time the SEPS procedure was performed. The grafts remained healed during a 2-year follow-up period. This study demonstrated the effectiveness of the SEPS procedure when incorporated into the overall treatment strategy for patients with chronic venous insufficiency. Minimal postoperative complications accompanied by ulcer healing and relief of lower extremity symptoms were achieved for all the patients, underscoring the important role of incompetent perforator veins in the formation of chronic venous insufficiency.

Surgery for deep venous incompetence.

Chronic deep venous incompetence (DVI) is caused by incompetent vein valves and/or the blockage of large calibre leg veins, with a range of symptoms including recurrent ulcers, pain and swelling. To establish the effectiveness of various surgical procedures for treating DVI. Trials were identified through the Cochrane Peripheral Vascular Diseases Group's trials register, reference lists of relevant studies, and contact with principal investigators of identified trials and world experts in deep venous surgery. Randomised controlled trials of surgical treatment for patients with DVI. Reviewers extracted data independently. Outcome measures included ambulatory venous pressure (AVP) and venous refill time (VRT). Three trials were included, one trial was excluded. Two trials compared external valvuloplasty using limited anterior plication (LAP) in combination with ligation (L) of incompetent superficial veins (L+LAP) against ligation only (L). The other trial compared external valvuloplasty and ligation (V+L) of incompetent superficial veins against ligation only (L). Trial participants had primary valvular incompetence with mild to moderate symptoms but no venous ulcers.L+LAP produced significant improvement in AVP: the mean difference between L+LAP and L groups was -15 mm Hg (95% confidence interval (CI) -20.9 to -9.0) at one year and -15 mm Hg (95% CI -21 to -8.9) at ten years.AVP values after surgery remained relatively high. Nine of eleven valves repaired remained competent after two years of follow up. No complications occurred. The overall mean score for clinical outcome was +2 (moderate improvement) in the L+LAP group compared with +1 (mild improvement) in the L group. Patients with deteriorating clinical dynamics over the five years preceding surgery had a significantly higher rate of improvement in clinical condition in V+L compared to L (81% versus 51%; p < 0.05) after seven years follow-up. Patients with stable preoperative clinical dynamics demonstrated a similar rate of improvement in both groups (96% versus 90%; p> 0.1). AVPs were not performed. These results indicate that ligation and valvuloplasty may have produced a moderate and sustained improvement for seven to ten years after surgery, in patients with mild to moderate DVI caused by primary valvular incompetence. However, there is insufficient evidence to recommend the treatment to this subgroup of patients, as the trials were small, used different methods of valvuloplasty and different methods of assessment.

Regarding “Venous reflux repair with cryopreserved vein valves”

The timely article by Neglén and Raju (J Vasc Surg 2003;37:552-7) describes their experience in treating deep venous reflux with cryopreserved vein implantation because repair with autogenous vein was not possible. They noted that, in a large number of patients with thrombophilia, the transplanted cryopreserved vein became occluded despite aggressive anticoagulation therapy. We were surprised that 74% of the supplied cryovalves were incompetent when thawed, requiring transcommisural repair before implantation. To treat primary incompetence of the common femoral vein, we have used glutaraldehyde-preserved bovine pericardial monocusp patches, and more recently cryopreserved monocusp patches made from allograft pulmonary arteries.1García-Rinaldi R. Revuelta J.M. Martínez M.J. et al.Femoral vein valve incompetence treatment with a xenograft monocusp patch: preliminary report.J Vasc Surg. 1986; 3: 932-935PubMed Scopus (19) Google Scholar, 2García-Rinaldi R. Soltero E.R. Carballido J. et al.Implantation of cryopreserved pulmonary allograft monocusp patch to treat nonthrombotic femoral vein incompetence.Tex Heart Inst J. 2002; 29: 92-99PubMed Google Scholar Even though these patients were not “thrombosis prone,” none of our repairs has thrombosed.2García-Rinaldi R. Soltero E.R. Carballido J. et al.Implantation of cryopreserved pulmonary allograft monocusp patch to treat nonthrombotic femoral vein incompetence.Tex Heart Inst J. 2002; 29: 92-99PubMed Google Scholar The fundamental difference between our approach and that of Neglén and Raju is that we retain the posterior aspect of the patient's own vein. This concept originated after we repaired femoral veins damaged during extracorporeal membrane oxygenator support by patching them with polytetrafluoroethylene. Those repairs in which the posterior aspect of the patient's vein was retained remained patent without thrombosis. Patency was confirmed at duplex scanning and venography. In patients with primary reflux in whom we have implanted glutaraldehyde-preserved monocusp patches of bovine pericardium or cryopreserved allograft pulmonary arteries, we do not use warfarin anticoagulation therapy. Our maintenance regimen is 75 mg of clopidogrel and 81 mg of aspirin, after a loading dose of 300 mg of clopidogrel. This is clearly an indicator that our group of patients is quite different from the “thrombosis-prone” patients described by Neglén and Raju. It is important to note that the cause of venous ulceration was primary in more than 95% of our patients, which is different from what was noted in other reported series, in which there is a prevalence of deep venous valvular insufficiency secondary to venous thrombosis. Use of our technique for treatment of secondary deep venous valvular insufficiency will probably require a radically different type of anticoagulation protocol to overcome the tendency for development of thrombosis. ReplyJournal of Vascular SurgeryVol. 38Issue 5Preview Full-Text PDF Open Archive

Surgery for deep venous incompetence.

Chronic deep venous incompetence (DVI) is a troublesome condition with a range of symptoms in the legs including recurrent ulcers, pain and swelling. It is caused by incompetent vein valves and/or the blockage of large-calibre leg veins. To establish the effectiveness of various surgical procedures for treating DVI. Trials were identified from the Cochrane Peripheral Vascular Diseases Group's Specialised Trials Register, reference lists of relevant studies, and through contact with principal investigators of identified trials and world experts in deep venous surgery. Randomised controlled trials of surgical treatment for patients with DVI. Trials were selected by AA and checked by SCH. The reviewers extracted the data independently. A variety of outcome measures were reported including ambulatory venous pressure (AVP) and venous refill time (VRT). Only one trial met the inclusion criteria, none was excluded. The trial compared external valvuloplasty using limited anterior plication (LAP) in combination with ligature of incompetent superficial veins (ligation and LAP) against ligation only. The trial participants had primary valvular incompetence with mild to moderate symptoms but no venous ulcers. Ligation and LAP produced significant improvement in AVP: the mean difference between the Ligation and LAP group and the Ligation only group was -15 torr (weighted mean difference [WMD] -20.9, -9.0, confidence interval [CI] 95% fixed) at one year and -15 torr (WMD -21, -8.9, 95% CI fixed) at two years. However, there was no statistically significant improvement in VRT, the mean difference between the groups at one year was 2 seconds (WMD -2.7, 6.7; 95% CI fixed) and at two years was 4 seconds (WMD -0.7, 8.7; 95% CI fixed). AVP values after surgery remained relatively high. Nine out of eleven valves repaired remained competent after two years of follow up. No complications occurred. The overall mean score for clinical outcome was +2 (moderate improvement) in the Ligation and LAP group. This compared with +1 (mild improvement) in the Ligation only group. The results of one small trial showed that ligation and LAP produced a moderate improvement for two years after surgery, in patients with mild to moderate DVI caused by primary valvular incompetence. However, there is not sufficient evidence to recommend the treatment to this subgroup of patients with DVI.

The development of valvular incompetence after deep vein thrombosis: A 7 year follow-up study with Duplex scanning

To study the development and progression in time of deep venous valve incompetence with Duplex ultrasonography in combination with distal cuff deflation in patients with a history of deep venous thrombosis (DVT) and to evaluate symptoms of chronic venous insufficiency (CVI). Prospective cohort study. In a long term follow-up study the deep venous system of 24 patients (7 men, 17 women, mean age 51 years) of an initial group of 27 with phlebographically documented deep venous thrombosis were examined with Duplex scanning at two intervals (mean 34 and 86 months) after DVT. All but one segments recanalised. Deep venous incompetence occurred exclusively in post-DVT segments. At first follow-up 48% of the post-thrombotic segments showed valve incompetence, while at second follow-up this had increased to 60% (p < 0.001). Venous segments of the upper leg mainly contributed to this increase. Our group of 24 patients was too small to find any significant correlation between symptoms, thrombosis and valvular incompetence. The development of deep vein valve incompetence after deep vein thrombosis is a progressive process over more than 5 years.