compression devices postoperatively, and the use of LMWH or IV heparin in the postoperative period.

Some use closed suction drainage of wounds to avoid hematoma and seroma formation. Warfarin should

have an initial target INR range of 2.0 to 2.5 for the first 6 weeks and some would advocate a

subsequent decrease to 1.7 to 2.0 until 4 months when it is discontinued. Adjustments are made to

accommodate those with an increased risk of thrombosis. One suggested that long-term regimen is

“minidose” warfarin, which utilizes daily doses of 1 to 2.5 mg to prevent thrombosis.180,389 Although

many surgeons encourage the use of compressive support, patients often do not comply but still have

acceptable clinical results.182,183

Valve repair procedures are well tolerated by most patients and have a low morbidity, as well as

essentially zero mortality in most series.154 Hematoma and seroma formation are noted in less than 15%

of cases, depending on the level of anticoagulation used.182,378,390–392 DVT occurs in less than 10% of

cases in most series and even if higher is not associated with clinical sequelae, while the pulmonary

emboli risk is well less than 1%.180–182,378,390–392 Wound infections have been seen in 2% to 7% of

cases.180,182,378,392

Kistner et al. reported long-term follow-up of internal valvuloplasty spans over decades and is

reported in life-table format (Fig. 98-4). Valve competency is 60% to 70% at 5 years in most

series.181–183,229,375,377,393–398 In general, a patent and competent valve translates into clinical

improvement and a healed ulcer, while the reverse is true with recurrent reflux. This is true for all types

of single station venous valvular reconstructions.

External valvuloplasty without direct cusp repair (isolated wall diameter reduction) appears to

perform less well in all aspects than open valvuloplasty.229,392 However, the “transcommissural”

technique that does directly repair the slack valve cusps performs much like open valvuloplasty with a

competency rate of more than 60% at 3 years and >70% ulcer free rate up to 5 years.382 External

banding performs adequately in select cases or as adjunctive procedures during other venous valve

surgery.229,383,384

Valve transposition demonstrates clinical improvement in 50% to 60% of patients after 3 to 5 years of

follow-up.154,181,182,388–391,393–397 The valve competency rate varies from 30% to 80% and is reflected in

the clinical improvement noted.154,181,182,388–391,393–397

Figure 98-4. Life-table demonstrates the cumulative clinical success rate based on type of valve reconstruction procedure. The

valve repair operation is valvuloplasty as performed by Kistner and associates via the Kistner technique. “Other operations” refer to

valve transpositions (n = 14), superficial femoral vein valve transplantations (n = 2), and combined valve repair and transposition

procedures (n = 3). Numbers in parentheses indicate the number of valve repairs remaining in the study at that time point.

Significant difference exists between valve repair and other operations. (After Masuda EM, Kistner RL. Long-term results of venous

valve reconstruction: a four to twenty-one year follow-up. J Vasc Surg 1994;19:391.)

Valve transplantation is undertaken in the most complex and difficult conditions. Clinical

improvement is seen in about 50% of patients even at 8 years of follow-up, and it remains a good

option in cases where other techniques are not possible.153,154,379 There does not appear to be a

difference between reported competency rates or clinical results when considering the location of valve

repair (femoral vs. popliteal), but overall the competency rates reported are inferior to internal

valvuloplasty.376,385,397,399–404 There are data to support that contention that repairing multiple valves in

the same axial system translates into longer clinical benefit, but this approach does, of course, add risks

at the initial operative intervention.382,383,392,405

In general, patients with postthrombotic reflux tend to have more problems maintaining healed ulcers

than those with a primary etiology of reflux, as noted from the results of internal valvuloplasty

(generally a primary etiology) versus those requiring transplantation or a transposition operative

2820

approach.182 Review of pertinent data has resulted in guidelines to reference when treating patients

with C4b

, C5, and C6 disease.276 It is suggested that in such patients with structurally preserved deep

venous valves, individual valve repair can be offered (grade 2C). If no structurally intact exists, then

valve transposition or transplantation is suggested treatment (grade 2C).

Valve Substitutes

Autogenous tissues appear to be the only material that currently can act as a substitute valve with some

hope of success in the clinical arena. Using donor vein, after trimming adventitia and part of the media,

to fashion semilunar cusps within the deficient recipient vein, Raju and Hardy180 have reported

acceptable clinical results. Another approach invaginates a stump of the long saphenous vein into the

femoral vein to fashion a bicuspid valve, 19 of 20 reconstructions were patent and competent at a mean

of 10 months with one valve demonstrating reflux.406 No other series have reproduced these findings to

date. The newest innovation has been to use an ophthalmic knife or other fine tool to dissect the

intima/media wall of the thickened postthrombotic vein wall into one or two sheets and thereby fashion

the valve cusp(s).407 This technique has been reproduced by another investigator.408 A recent

improvement has been to place two sutures on the cusp(s) to hold the valve in the semiopen position

and thereby to prevent valve collapse and improve neovalve competence. The results with this

modification include 21 operations (mean follow-up 11 months) with all valves competent, a 95% ulcer

healing rate and two recurrences (9.5%).409 In this highly select group of patients, the SVS/AVF

Guidelines Committee suggests consideration of autogenous valve substitutes in addition to standard

compression therapy to aid in venous ulcer healing and recurrence prevention (grade 2C).276

Venous Ulcer Wound Care

The quest to heal venous ulcers has generated a myriad of potential topical agents to aid in ulcer

healing. Topical antibiotics and dressings containing antimicrobials may retard wound healing and cause

allergic reactions and are not recommended for the treatment of venous ulcers.276,410 Growth factors

and cytokines in addition to compression when provided as isolated topically applied agents have not

demonstrated efficacy when compared to placebo. Review of the literature demonstrates inconsistent

results or studies with insufficient data to determine with any certainty the efficacy of such

adjuvants.411,412 A number of topical dressings applied on the ulcer bed and beneath the compression

dressing have been investigated to determine if ulcer healing could be improved. Hydrocolloids (e.g.,

DuoDerm), foams (e.g., Allevyn), alginates (e.g., Sorbsan), hydrogels (e.g., Intrasite Gel, or Debrican),

and others (e.g., Opsite) have been studied. Insufficient data is available to make firm conclusions, but

it is clear that the nature and amount of the exudates present may provide a rationale for the benefit of

one or the other of these dressings in a given patient.413–415 The SVS/AVF 33.Guidelines Committee

suggests that the wound dressing be selected, which absorbs wound exudates and protects the periulcer

skin from damage (grade 2B).276

Surgical debridement to healthy tissue, when required, benefits the rate of ulcer healing and does not

lead to a higher risk of systemic infection.410,416–418 It is especially beneficial when evaluated as

adjuvant care to the standard methods of venous ulcer wound care.414,419 The use of local anesthetic

during debridement of venous leg ulcers has been found statistically beneficial in lowering pain scores

in a Cochrane analysis of six trials.420 This and other pertinent data are the basis of recent guidelines for

optimal patient care.276 Surgical debridement is recommended to remove slough, nonviable tissue and

eschar (grade 1B) using local anesthesia to minimize discomfort (grade 1B).

Hydrosurgical, enzymatic, and larval therapy are effective methods of venous ulcer debridement, but

none have been found more effective than surgical debridement and can be more expensive. Current

guidelines suggest each as a potential alternative to surgical debridement when a trained practitioner is

not available to provide surgical debridement (grade 2B/C).276

For resistant venous ulcers, defined as those that fail to demonstrate improvement in a minimum of 4

to 6 weeks of standard wound therapy, adjuvant wound therapy options should be considered.276,421

These ulcers can be extensive, and skin grafting allows for coverage of raw surfaces to speed the healing

process. Once the ulcer has a clean base of granulation tissue, a split-thickness skin graft can be applied.

There are reports on improved healing with skin grafting for chronic venous ulceration.422 Skin grafting

is generally considered only when ulcer healing has not occurred following diligent conservative

management.423 An alternative or precursor to an autologous skin graft may be one of a variety of skin

substitutes. A number of skin substitutes have been used to aid in venous ulcer healing (e.g., fresh

allografts, porcine dermis) but for most there are insufficient data available to determine whether

2821

venous ulcer healing is improved.424 However, the biologically active bilayered human skin equivalent

with an allogenic epidermal and dermal layer has demonstrated more promise and statistically

improved the time to complete healing.414,424,425 Porcine small intestine submucosa (SIS) is primarily a

collagen-based extracellular matrix with retained biologically active components. In a study of SIS and

when adjusted for ulcer size, SIS was three times as likely to heal as the control group (P = 0.007) and

at 6 months there was no recurrence in the SIS group.419 This manuscript was included in a review of

the literature as an RCT demonstrating significance when used to heal venous ulcers.414 The use of these

skin substitutes is suggested as guideline adjuvant therapy in recalcitrant venous ulcer care (grade 2

A/B).276

The Pelvic Congestion Syndrome

This distressing clinical condition can result from gonadal vein and/or hypogastric vein reflux. Pelvic

pain is a constant complaint and can be disabiling. Gonadal vein reflux may be best managed with

gonadal vein excision due to its many areas of potential reflux, but an endovascular approach using

coils, sclerosants, or a combination can also be successful and is the most common approach

currently.426 Hypogastric vein reflux may be best managed by percutaneous embolization.427 When the

elimination of proximal reflux does not resolve superficial varicosities, the management involves

techniques used for saphenous vein branch varicosities.

2822

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