Surgical Treatment of Lower Extremity Deep and Perforator Vein Incompetence

Deep Venous Valve Surgery

Indications for deep vein valve surgery include venous valve reflux in the presence of intractable, advanced symptoms of lower extremity chronic venous insufficiency (CEAP classes C4-C6), or the presence of significant pain that interferes with quality of life. Typically, intervention follows long-standing compressive therapy and the correction of iliac or iliofemoral venous outflow obstruction, and superficial or perforator vein reflux. Lower extremity axial reflux is present that extends from groin to calf, along with an incompetent deep venous valve, which is amenable to direct surgical repair, or a postthrombotic vein segment that is suitable for indirect repair or replacement.

Subfascial Endoscopic Perforator Surgery

The role of perforating vein surgery in treating symptoms of venous insufficiency remains controversial. Chronic venous insufficiency (CEAP C4-C6) with a medially located leg ulcer in association with perforator vein reflux of greater than 3.5 seconds on duplex scan are usually present. Appropriate candidates for intervention are those patients with low operative risk and acceptable ambulatory status without significant peripheral arterial occlusive disease, calf pump failure, morbid obesity, or a hypercoagulable state.

Deep Venous Valve Surgery

• Preoperative diagnostic workup should include lower extremity arterial and venous duplex studies.

• Ascending and descending venography is performed to identify the sites of reflux and obstruction. When proximal venous obstruction is suspected in the iliac system, intravascular ultrasound should be performed, because it is often superior to conventional venography at diagnosing venous stenoses.

• Duplex imaging of the axillary veins can be performed to evaluate its suitability as a donor segment for lower extremity valve transplantation.

• Assessment for underlying thrombophilia is indicated to guide postoperative anticoagulation.

• A sequential compression device is applied at the time of anesthesia to decrease the risk of deep vein thrombosis (DVT) and postoperative edema.

Subfascial Endoscopic Perforator Surgery

• Duplex imaging is performed preoperatively to identify the number, location, and size of incompetent perforators and to evaluate the superficial and deep venous systems.

• The day before surgery perforators are marked on the skin with a semipermanent marker.

• Preoperative and postoperative strain gauge or air plethysmography may be used as a physiologic tool to evaluate the impact of treatment on the degree of valve incompetence, calf muscle pump function, outflow obstruction, and related hemodynamic changes.

• Prophylactic low-molecular-weight heparin may be considered during the perioperative period, especially in patients with a prior history of DVT.

Deep Venous Valve Surgery

• Deep vein thrombosis. The risk of DVT in deep vein valve surgery is less than 5%, but may involve the site of repair, the distal venous system, or the opposite unoperated limb. Sequential pneumatic boots, heparin prophylaxis, and perioperative anticoagulation may help diminish the risk of DVT. Lower extremities should be elevated in the postoperative period until the patient is ambulatory to decrease venous stasis and edema.

• Hematoma. Meticulous hemostasis is required and a drain left at the operative site, particularly, if postoperative anticoagulation will be instituted.

• Incompetent reconstructed valve. The construction of a neovalve or vein valve transfer can be considered if direct repair is unsuccessful.

Subfascial Endoscopic Perforator Surgery

• Missed perforators. Failure to identify incompetent perforators that may be located in the intermuscular septum, paratibial, or retromalleolar region may contribute to delayed ulcer healing or a recurrent ulcer. The medial insertion of the soleus muscle may need to be exposed to visualize proximal paratibial perforators. Retromalleolar, lower posterior tibial perforators cannot be reached by current endoscopes and, if incompetent, may need to be interrupted by an open technique.

• Nerve injury. Damage to the saphenous nerve, which runs along the saphenous vein below the knee, can cause dysesthesia and a loss of sensation along the medial aspect of the lower leg. In addition, the tibial nerve runs posterior to the medial malleolus into the foot and is also at risk of injury. Tibial injury may present as dysesthesia and weakeness of the foot and toes.

• Infection. The risk of a surgical site infection is increased in the presence of an open ulcer, even if remote from the surgical incision. The procedure should be deferred in the presence of active cellulitis and prophylactic antibiotics considered routine.

• Deep vein thrombosis

• Hematoma

Deep Venous Valve Surgery

Direct valve repair is used more often for patients who present with primary valvular incompetence, whereas deep vein valve reconstruction, such as vein valve transfer, is most often performed for those with postthrombotic syndrome.