Servier – Phlebolymphology

Deep venous reconstructive surgery for CVI. New procedures and tricks.
O. Maleti

Postthrombotic deep vein incompetence is an incapacitating disease, which, in most cases, can lead to severe chronic venous insufficiency.

The author proposed a question: What do we mean by deep venous reconstructive surgery for chronic venous insufficiency (CVI)? In answering, surgery aimed at repairing one or more venous valves, or aimed at reconstructing a nonrefluxing segment. Repair is frequently possible in CVI due to primary reflux, rarely possible in secondary reflux, never possible in valve agenesis. Reconstruction is possible in secondary reflux and valve agenesis. The main repair technique is valvuloplasty, which consists of shortening the free edge of the cusps. The modified technique is lifting the free edge of the cusps. In the secondary reflux, postthrombotic syndrome (PTS) valvuloplasty is rarely feasible because the cusps are ticketed and the sinus is modified. In such cases, the creation of a new nonrefluxing segment is preferable. We have several options; the first option is transposition, meaning to transpose a devalvulated segment into a valvulated segment, using various techniques (transposition on the profunda vein, saphenous vein, or distal femoro-profunda vein).

The neovalve is the second preferable option. This technique has been submitted for improvement. Neovalves create a competing flow. The advantage is to create a wash action into the pocket and a mobile flap.

The reconstruction in valve agenesis (absence of the valves affects the femoral and the profunda district. In these cases, the author prefers the endophlebectomy (removing the fibrosis that determines an obstruction) associated with stent insertion.

In conclusion, the author reminded the audience that severe CVI is an incapacitating disease and has a high social cost. Patients with a Clinical, Etiologic, Anatomic, and Pathophysiologic classification of C3-C6 must be investigated due to the limits of the US in making an exhaustive diagnosis. Additional investigations (air plethysmography, venography, and intravascular ultrasound, are needed. When a proximal obstruction is detected it must be treated first, and if the re-equilibrium of the leg is obtained, our mission is accomplished, if not, open surgery can be advisable to correct possible obstruction at the common femoral level and to correct noncompensated obstruction at the femoral level. Regardless of technique, we must abolish the reflux.

Do we need to treat leg perforator veins? Pros.
O. Nelzen

According to the author, incompetent perforators (IPs), together with superficial venous insufficiency (SVI) and deep venous insufficiency (DVI), contribute to global venous incompetence. The number of IPs increases with the amount of reflux. Perforator incompetence is an independent factor contributing to venous disease severity.

The author related the myth that IPs are of importance only if combined with DVI; that would perhaps be true if we were standing still like statues, but we do walk, which changes the situation. In fact, IPs are connected more to SVI rather than DVI.

Most IPs are found in association with superficial venous reflux; if the venous reflux is left untreated, new IPs may develop. Missed IPs are strongly correlated with nonhealing or recurrent leg ulcers.

The second myth is that IPs become competent because of superficial vein surgery in ulcer patients? Only one out of three IPs normalize, thus, two out of three remained incompetent.

In series of a hard to heal venous ulcers, unresponsive compression, and 76 ablations of superficial venous incompetence, 66 IP treatments with radiofrequency (RF) ablation were additionally performed with a 6-month healing rate of 76%. Ablation of all refluxing superficial or perforating veins was recommended.

The indications are venous ulcer disease or eczema/sclerosis, size of perforator >3 mm, number of IPs, inflammation in the area of the perforator and severe edema.

In conclusion, the author proposes treating IPs in patients with: (i) Clinical, Etiologic, Anatomic, and Pathophysiologic classification (CEAP) classes C4-C6; (ii) in certain cases, with severe edema (C3) or recurrent varicose veins with several IPs; and (iii) clinical observation in patients with primary varicose veins (C2-C3).

Reference:
Harlander-Locke et al. J Vasc Surg. 2012;55:458-464.

Do we need to treat leg perforator veins? Cons.
J-J. Guex

The author proposed that we do not need to treat medial leg perforator veins (MLPVs), but that we do need to treat other incompetent perforator veins (IPVs) and to do something.

The reasons for not treating MLPVs are because they are a phenomenon of great saphenous vein (GSV) insufficiency, they usually disappear after treatment of the GSV, they are not usually responsible for skin changes, their treatment does not improve clinical results or reduce recurrences and are not satisfactory. The criteria for possible treatment of MLPVs are a diameter >5 mm, reflux >0.5 sec, or the reflux of MLPVs that is not accompanied by an incompetent GSV and is above a significant varicose cluster.

The possible treatments are ultrasound-guided foam ablation (not in PVs since a small collateral artery may be injected), thermal ablation with special probes under ultrasound guidance, in selected cases after treatment of a superficial network in IPVs remain.

In conclusion, the author proposed treating the superficial network, defering treatment of incompetent MLPVs, evaluating outflow obstruction, and considering iliocaval angioplasty and deep valve repair.