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.

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.

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

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.

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.

Content Reviewed by – Dr. Jaisom Chopra