Open Surgical Treatment of Chronic Venous Insufficiency

The term chronic venous insufficiency (CVI) refers to a progression in the broad category of chronic venous disorders. In terms of the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, it refers to progression beyond uncomplicated varicose vein disease (C2) to swelling (C3) and onward to skin changes (C4) and ulceration (C5–C6).

These venous problems seriously affect the quality of life in of approximately 15% of the adult population, who experience progression to late-stage chronic venous disorder. Midlife workplace disability and later-life disability in activities of daily living ensue as the chronic venous disorder progresses along its cascade from minor varicose veins or initial deep vein thrombosis to disabling pain and swelling with dependency of the extremity and overt skin changes, culminating in ulceration of the lower leg. This transition can occur over a period of a few years in post-thrombotic disease or over multiple decades in primary venous insufficiency.

The present role of open surgery should be interpreted to refer to deep vein reconstruction in the light of recent advances in minimally invasive treatment of venous insufficiency. With the reality of thermal and chemical means to treat reflux in the superficial saphenous and perforator veins and treatment of iliac vein obstruction with endovascular minimally invasive techniques, great progress has occurred in simplifying the management of a large percentage of patients with clinical venous disease.

There are venous problems not addressed by these advances, which include cases of skin ulceration and dense scarring of the subcutaneous tissues in the gaiter area of the lower leg (C4–C6 disease) secondary to deep vein reflux and obstruction below the inguinal ligament, and bursting calf pain with venous claudication typically caused by obstruction in the femoral–popliteal veins. Surgical interventions exist to treat and prevent these debilitating venous states.

For the most part there is agreement that open surgical reconstructive procedures are reserved for more difficult cases of chronic vein disease in which conventional measures of compression and the simpler surgical procedures of vein ablation and perforator interruption have proved inadequate to control the CVI syndrome. When patients with this situation are encountered, the management alternatives faced by the physician are to accept the limitation of activity and lifestyles imposed by venous disease or perform open surgery to reverse deep vein abnormalities and preserve functional capacity for the patient. It becomes a matter of whether the disease can be altered to improve the patient’s way of life or if the lifestyle needs to be modified to suit the limitations imposed by the disease.

The pathology encountered in C4 to C6 cases is a result of either primary or secondary reflux or obstruction. The third cause of venous insufficiency are congenital malformations. The more common entity is primary venous insufficiency, in which the physiologic finding is pure reflux and treatment requires restoring competence in the axial veins of the lower extremity. The less common form is postthrombotic disease leading to secondary CVI, in which the physiologic state begins as obstruction and morphs into a spectrum of mixed obstructive and reflux states in the involved veins. Surgical treatment of secondary CVI is more complicated because of the need to overcome both obstruction and reflux that occurs in stiff-walled veins whose valves and intimal linings have been deformed or totally destroyed.

The individual operative techniques of deep reconstruction are well described in the literature, and new innovations continue to appear. There are a number of available surgical and endovenous techniques to treat advanced cases of CVI ( Box 1 ). Recent advances that include autogenous neovalve creation in the postthrombotic vein and the demonstration that angioplasty and stenting in the iliac vein have favorable long-term patency with few complications provide new alternatives for selected patients.