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PubMed1999

Use of ipsilateral greater saphenous vein as a valved transplant in management of post-thrombotic deep venous insufficiency: long-term results.

Incompetence of the deep venous valve is a common feature of post-thrombotic deep venous insufficiency. Various surgical techniques have been proposed to treat reflux. In this study we describe long-term results of a novel transposition technique using the ipsilateral greater saphenous vein. From 1984 to 1994 we used this procedure to treat 16 patients including 10 men and 6 women with a mean age of 56 years (range: 25 to 76 years). In all 16 cases the indication for surgery was incapacitating pain associated with recurring ulceration in 9 patients. From the results of using this technique we conclude that transposition using the ipsilateral greater saphenous vein is safe and effective with good mid-term results, especially for pain. For ulcers the primary success rate was 55% but this increased to 84% with proper surveillance and treatment of secondary insufficiency of the superficial venous system.

Female↗
PubMed1999

Autogenous valve reconstruction technique for post-thrombotic reflux.

Post-thrombotic reflux in deep veins of the lower extremities cannot be treated by in situ valvuloplasty because of valve degeneration. The outcome of transplantation and transposition of segments with valves is controversial. From feasibility tests in animals and fresh human cadavers we have developed an autogenous valve reconstruction technique. The valve is fashioned from the proximal end of the greater saphenous vein that is left attached to the femoral vein, invaginated, and fixed to the venous wall. This technique provides a competent bicuspid valve. In a series of 19 patients operated on in 1995 we performed 20 valve reconstruction procedures at the level of the femorosaphenous junction by invagination of a fragment from the proximal end of the greater saphenous vein in the common femoral vein. Mean follow-up time was 10 months. No complications were observed. All femoral veins were patent and competent except one in which mild reflux was observed because of insufficient valve size. Further follow-up is needed to confirm the efficacy of this simple, new technique.

Animals↗
PubMed1994

Venous reflux in patients with previous deep venous thrombosis: correlation with ulceration and other symptoms.

PURPOSE: Deep vein thrombosis (DVT) in many cases leads to chronic symptoms in the damaged leg, even though the affected veins have recanalized. The major hemodynamic defect in such recanalized veins is reflux. The incidence and extent of reflux has been studied in patients with proven DVT and correlated with concurrent symptoms. METHODS: Two hundred seventeen limbs in 183 patients were examined by duplex scanning from January 1989 to October 1992. All limbs had previous DVT diagnosed by venography. Sites and extent (proximal, distal, or both) of reflux were identified by meticulous duplex scanning of the whole venous system and correlated with presenting symptoms. RESULTS: The patients were classified into nine groups on the basis of the classification of the system involved (superficial, deep, or superficial and deep) and whether the reflux was found proximal or distal to the knee or both. Eight-one limbs belong to chronic venous insufficiency class 1, 92 belong to class 2, and 38 belong to class 3. Reflux was confined to the deep venous system in 84 limbs (38.7%), to the superficial system in 31 (14.3%) limbs, and to both systems in 102 (47%) limbs. It was confined to proximal veins only in 48 (22.1%) limbs, distal only in 56 (25.8%) limbs and throughout the limb in 113 (52.1%) limbs. The incidence of swelling was increased by distal or a combination of proximal and distal reflux regardless of which system was involved. In limbs with superficial venous insufficiency (SVI) or deep venous insufficiency (DVI) only, the incidence of skin changes was not affected by the extent of reflux. However, in limbs with combined SVI and DVI, it was increased in the presence of reflux throughout the limb. Absence of distal reflux was associated with a low incidence of skin changes even in the presence of DVI. Ulceration increased with an increased extent of reflux in the presence of SVI. Absence of superficial reflux was associated with a low incidence, even in the presence of DVI. CONCLUSIONS: The data suggest that as far as the skin changes and ulceration are concerned, distal reflux and reflux in the superficial veins are more harmful than reflux confined to the deep veins, even when such reflux extends throughout the deep venous system.

Adolescent↗
PubMed2005

Patterns of venous insufficiency after an acute deep vein thrombosis.

BACKGROUND: The purpose of this study was to investigate patterns of venous insufficiency during a 12-month period after an acute deep vein thrombosis. STUDY DESIGN: Seventy limbs in 67 patients with an acute deep vein thrombosis (DVT) involving 147 anatomic segments were evaluated with duplex scanning at 1 month, 3 months, 6 months, and 1 year. Venous segments were examined whether they were occluded, partially recanalized, or totally recanalized, and the development of venous reflux was evaluated. RESULTS: The segments investigated were the common femoral vein (38 segments), femoral vein (33 segments), popliteal vein (36 segments), and calf veins (40 segments). There were 35 limbs with isolated DVT and the remaining 35 had multisegment DVT. At 1 year, thrombi had fully resolved in 76% of the segments, 20% remained partially recanalized, and 5% were occluded. The venous occlusion was most predominant in the femoral vein (21%) at 1 year. On the contrary, rapid recanalization was obtained in calf veins than in proximal veins at each examination (p < 0.01). Deep vein insufficiency was detected as early as 1 month after development of DVT, and the reflux was most predominant in popliteal veins (56%), followed by femoral veins (18%). No reflux was found in calf veins. Multisegment DVTs had a significantly higher incidence of deep vein insufficiency than single segment DVTs at 1 year. Development of superficial venous insufficiency was found in 5 limbs (7%) and perforating vein insufficiency in 5 (7%). CONCLUSIONS: Lower extremity venous segments showed different proportions of occlusion, partial recanalization, and total recanalization. Calf veins showed more rapid recanalization than proximal veins. Venous reflux was noted as early as 1 month. The limbs involving multisegment DVTs on initial examination had a higher incidence of deep vein insufficiency and could require much longer followup studies.

Acute Disease↗
PubMed2005

Venous disorders: overview of current practice.

Venous disease often is overlooked until the problems it causes become severe. When patients present with concomitant diseases or disorders, those disorders may take priority both in the patient's mind and the caregiver's. Fortunately, there has been an increasing interest in the diagnoses and treatment of venous disorders and with this is a renewed interest in early diagnosis of venous problems and identification of individuals at risk for venous problems.

Bandages↗
PubMed2004

Surgical disobliteration of postthrombotic deep veins--endophlebectomy--is feasible.

OBJECTIVE: Partial obstruction of postthrombotic veins is caused by endovenous scar tissue, which creates synechiae and septae that narrow and sometimes block the lumen. We have performed surgical disobliteration, or endophlebectomy, of chronically obstructed venous segments during various kinds of deep venous reconstructions to increase the flow through previously obstructed segments. In this article we describe the endophlebectomy technique, and report the availability of this procedure as an adjunct to deep venous reconstructions for the treatment of postthrombotic chronic venous insufficiency. Patients and methods Between July 1996 and February 2003, surgical disobstruction of 23 deep venous segments was performed in 13 patients in association with 14 deep venous reconstructions to treat advanced postthrombotic chronic venous insufficiency. Postthrombotic veins were surgically exposed, and a longitudinal venotomy was carried out at a variable length. The synechiae and masses attached to the intimal layer were carefully excised. Mean duplex scanning follow-up was 10.8 +/- 8.2 months (median, 8 months; range, 1-28 months). RESULTS: In 10 patients (77%) the treated segments remained primarily patent at median follow-up of 8 months (range, 1-28 months). Early thrombosis near the endophlebectomy site occurred in 3 patients, at 2, 5, and 12 days, respectively, after surgery. In 2 patients with early thrombosis further interventions were carried out with success. In a third patient with early postoperative thrombosis the final outcome was recanalization and reflux. These results yielded an overall secondary patency rate of 93%. No perioperative pulmonary embolism was observed. CONCLUSION: This series demonstrates that surgical disobliteration of postthrombotic deep veins is technically feasible, and led to patency of the segments for the duration of follow-up for up to 28 months (mean, 10.8 +/- 8.2 months). We used this technique with the objective of disobstructing postthrombotic veins, to increase flow through a previously narrowed lumen. Postoperative thrombosis at the site of endophlebectomy occurred in 23% of patients. Although this early experience is encouraging, further studies and longer follow-up are necessary to assess the durability of the procedure.

Feasibility Studies↗
PubMed2003

Treatment and management of acute venous thromboembolic disease.

Venous thromboembolic (VTE) disease consists of deep vein thrombosis and/or pulmonary embolism. Either low molecular weight heparin given subcutaneously or unfractionated heparin administered intravenously are used for the initial treatment. Simultaneously, warfarin therapy is initiated. Thrombolytic therapy plays a limited role. Following the initial heparin treatment, anticoagulation clinics provide an excellent means of monitoring the oral anticoagulation. Patient education is important and patients should be well versed in the basic features of oral anticoagulation. The duration of oral anticoagulation is dependent on a number of factors including the presence of inherited risk factors, bleeding risk and patient reliability. Residual thrombus in the affected vein may indicate the need for prolonged anticoagulation. The low intensity oral anticoagulation (INR 1.5-2.0) is useful in preventing recurrent thrombosis following the initial treatment period with full intensity oral anticoagulation.

Acute Disease↗
PubMed1995

The clinical and hemodynamic results after axillary-to-popliteal vein valve transplantation.

PURPOSE: To evaluate the results of axillary vein to popliteal vein valve transplantation (VVTX), we reviewed the clinical, phlebographic, and noninvasive hemodynamic results in 15 patients. METHODS: All patients had postthrombotic destruction of deep venous valves as determined by ascending phlebography, whereas descending phlebography demonstrated grade III or IV reflux in all patients. A segment of valve-bearing axillary vein was transplanted to the popliteal vein in the affected limb. Postoperative evaluation was by clinical, noninvasive, and phlebographic means. RESULTS: Over a mean follow-up period of 5.3 years (1.25 to 11 years), 13 of 14 patients (93%) had symptomatic improvement with relief of swelling, whereas all 14 patients who were admitted with pain had relief after operation. Thirteen of 15 patients (87%) returned to work or household duties. Physical findings of edema, skin pigmentation, and lipodermatosclerosis improved in most patients. Only three patients (21%) had development of recurrent ulcers, with an average postoperative ulcer-free interval of 4 years by life-table analysis. The cumulative ulcer-free survival rate for the group averaged 62% at late follow-up. All three patients with ulcer recurrence had a functioning valve by descending phlebography, but recurrent perforating veins were found in two patients, and deep venous thrombosis above a patent VVTX was observed in the third. Late assessment of reflux by venous filling index and valve closure times for the entire sample demonstrated mean values of 4.9 seconds in the latter and 6.8 ml/sec in the former. Residual volume fraction, which correlates with invasive ambulatory venous pressures, was reduced to a mean of 31%. No deterioration in late sequential noninvasive values could be detected. CONCLUSION: VVTX is a durable procedure for preventing recurrent venous ulcers.

Adult↗
PubMed1998

Axial transformation of the profunda femoris vein.

PURPOSE: To highlight a special subset of cases of venous stasis in which the profunda femoris vein enlarges to a variable extent (axial transformation) to compensate for severe postthrombotic changes in the accompanying superficial femoral vein. METHODS: Among 500 consecutively treated patients with severe venous stasis, 57 patients had axial transformation of the profunda femoris vein. Venous obstruction and reflux were assessed by means of arm-foot pressure differential, ambulatory venous pressure measurement, air plethysmography, and duplex examination. Ascending and descending venograms also were obtained. A variety of valve reconstruction techniques were useful in correcting reflux in the enlarged profunda femoris vein and the companion postthrombotic superficial femoral vein. RESULTS: In 55% of patients the profunda femoris vein was larger than normal and provided partial outflow from the leg through a profunda-popliteal connection, but the superficial femoral vein was still the dominant outflow tract (grades I and II). In 36% of patients the profunda femoris was the dominant outflow tract from the leg, and in another 9% it was the sole axial outflow tract (grades III and IV). The skin changes of advanced venous stasis were present among 92% of patients and frank ulceration among 88%. Antireflux operations on the profunda femoris vein and companion superficial femoral vein, including ligation and division in some instances, were well tolerated. Despite a postthrombotic cause, obstruction did not worsen after surgical treatment, and reflux improved according to most laboratory measurements. Complete ulcer healing was obtained with the surgical techniques described. The actuarial recurrence-free survival rates were 90% 1 year and 66% 5 years after treatment. CONCLUSION: Axial transformation of the profunda femoris vein is present in a subset of instances in which severe postthrombotic changes are present in the companion superficial femoral vein. Profunda femoris reflux is invariably present in these instances because of compensatory dilatation and enlargement of this vessel. Simultaneous valve repair of the axially transformed profunda femoris vein and companion superficial femoral vein to abolish reflux yields excellent long-term results and healing of stasis ulceration.

Actuarial Analysis↗