Surgical Treatment

Ligation, stripping and venous phlebectomy

  • High ligation of saphenofemoral junction and stripping of the LSV is standard for many patients with CVI.
  • The cluster of veins arising from the LSV is avulsed by stab phlebectomy.
  • Transilluminated power phlebectomy (TriVex) removes clusters of veins by fewer stab incisions and in quicker time.
  • Lighting and stripping of the LSV can be performed in all CEAP classes 2 – 6 with venous reflux and improve the venous hemodynamics, eliminating deep venous reflux, providing symptomatic relief of advanced stages of CVI and helping ulcer to heal.
  • In a large study with superficial and deep venous reflux, surgery + compression was compared to compression alone and found the results to be 28% to 12% improvement.

Subfascial endoscopic perforator surgery

  • The importance of perforator incompetence contributing to CVI cannot be overlooked.
  • Surgery has often been performed to ligate perforators contributing to the superficial reflux and CVI. It is often not easy to perform this surgery due to the pre-existing tissue damage in the affected area.
  • Subfascial Endoscopic Perforator Surgery (SEPS) can ligate the incompetent perforators in areas of lipodermatosclerosis of ulcers by entering from a remote site with normal tissue.
  • A study using the SEPS technique found that 88% ulcers healed at 1 year but there was a recurrence rate of 28% at 2 years.
  • SEPS has also been used along with superficial vein ablation and found that 91% ulcers heal at a mean of 2.9 months with significant improvement in symptoms.
  • In another large series of > 800 patients with CEAP clinical classes 4-6 for 9 years 55% underwent surgical ligation with stripping + SEPS – 92% ulcers healed with only 4% recurrence rates.

Valve reconstruction

  • Venous valve injury may lead to the progression of CVI.
  • Venous valvuloplasty has been shown to provide 59% competency and 63% ulcer free time at 30 months.
  • Complications are:

bleeding as patients are anticoagulated

DVT

PE

Ulcer recurrence

wound infection.

  • Valves destroyed by post-phlebitic valve destruction cannot have venous valvuloplasty and need transposition of the profound femoris vein or saphenous vein valve and axillary vein valve to the damaged popliteal or femoral segments.
  • Cryopreserved vein valves allografts have been used. There is a high incidence of early thrombosis and poor patency and competence and increased patient morbidity. That is why this is not used now.

Summary

  • Chronic Venous Disease is a common problem and has a major impact on the individual and the health system.
  • A normal venous function needs axial veins with a series of venous valves and perforating veins to allow communication between the deep and the superficial systems and the venous muscle pump.
  • Dysfunction of any of these may lead to venous hypertension and CVI.
  • The manifestations of CVI range from pain and swelling to venous ulceration.
  • There are a number of invasive and non-invasive techniques that aid in the diagnosis and treatment.
  • The commonest used is the venous color doppler to confirm the diagnosis and provide anatomic details.
  • Air-plethysmography is needed to assess the severity of CVI.
  • Treatment of CVI is based on the severity of the disease and guided by anatomic and pathophysiologic considerations.
  • Graded compression stockings are the mainstay of the treatment of CVI.
  • Surgical and endogenous techniques are required with unsatisfactory medical (non-operative) treatment.
  • Recently early use of endogenous techniques is being recommended.