Reconstructive Surgery for Deep Vein Reflux in the Lower Limbs: Techniques, Results and Indications

Maleti O, Perrin M. Eur J Vasc Endovasc Surg. 2011;41:837-848.

by Robert KISTNER, Hawaii, USA

ABSTRACT

The authors provide a concise authoritative appraisal of the techniques and results reported over the past 40 years in this specialized aspect of chronic venous disease (CVD). The article summarizes a large body of developmental literature that appeared during the 40+ years when deep reconstruction has been practiced. It digests the original literature into an understandable report that is quickly read and well referenced to provide an important contribution for anyone interested in the field, while also providing an attractive and highly readable introduction for the novice. There are exceptionally well chosen illustrations that clarify the written descriptions of the techniques. This is a valuable feature of this article since the precise anatomy involved in deep venous reconstruction is unfamiliar to the majority of surgeons, let alone readers who have not had the advantage of seeing the procedures performed.

The description of the differences between primary (pure venous reflux) and post-thrombotic (combined venous reflux and obstruction) CVD at the beginning of the article is especially important because the two processes are so different in their development and so similar in their long-term clinical manifestations. Differences between primary and secondary CVD persist through the diagnostic workup and the surgical techniques to the eventual long-term results. The long-term prognosis is better in the primary reflux cases where the pathologic damage to the normal venous structure is often less severe.¹

The clear presentation of surgical techniques is a reflection of the thorough understanding these authors have of the complexities of the details involved. Their presentation manages to dispel a great deal of the confusion that has occurred from successive reporting of treatment results during the past several decades and makes understandable recommendations for present-day usage. For example, they clearly identify the advantages of external valve repairs over internal repairs as being a safer but less precise and less durable technique. As such the surgeon can choose the external repair as a valuable adjunct for additional valves after a more definitive internal procedure on the chosen first valve, or use the external technique when exposure is difficult or the projected life-span of the patient is limited. Similar examples are found in their analysis of techniques for valve substitution in post-thrombotic cases where a choice between transposition and transplantation is often encountered.

The presentation of current techniques for creation of the neovalve by the Maleti/Lugli techniques is especially valuable. When these techniques and their longer term results have proven to be reproducible by other vascular surgeons, it is very possible they will answer the problem of a durable valve in many of the difficult postthrombotic cases. As the authors point out, the search for a long-term successful bioprosthetic substitute valve remains clinically unsuccessful, and even valve substitution techniques give disappointing long-term results.

With all of this, the article ascribes primary importance to elimination of proximal obstruction in the iliofemoral veins and notes that unresolved iliac vein obstruction may negate the positive effects of well performed distal vein reflux ablation. A point that has been cited by others is that positive clinical results in CVD are seen with many different procedures that improve the amount of reflux and obstruction encountered in primary and secondary CVD in both the superficial and deep veins. ²

At the present time the pendulum is swinging strongly in favor of multiple interventions in the superficial veins because of their simplicity and availability, but the suspicion lingers that deep vein obstructions or axial refluxes may be the cause of many of the recurrent phenomena in venous cases and a new enthusiasm for deep vein correction may develop in the future. ³ As greater maturity in understanding of venous pathophysiology evolves from the digestion of accumulated experience, perceptive articles such as this from acknowledged experts in deep venous problems will assume increased importance. ^4,5,6

References:
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2. Gillespie, DL. Venous ulcer diagnosis, treatment, and prevention of recurrences. J Vasc Surg. 2010;52(Suppl S):8S-14S.
3. Danielsson G, Eklof B, Grandinetti A, et al. Deep axial reflux, an important contributor to skin changes or ulcer in chronic venous disease. J Vasc Surg. 2003;38:1336-1341.
4. Raju S. Post-thrombotic syndrome: clinical features, pathology, and treatment. In: Bergan JJ, ed. The Vein Book. Burlington, MA: Elsevier Academic Press; 2007:599-608.
5. O’Donnell TF Jr. The present status of surgery of the superficial venous system in the management of venous ulcer and the evidence for the role of perforator interruption. J Vasc Surg. 2008; 48:1044-1052.
6. Meissner MH, Eklof B, Smith PC, et al. Secondary chronic venous disorders. J Vasc Surg. 2007;46(Suppl S):68S-83S.