in diameter with reasonable success. For matting and telangiectasias under 0.5-mm diameter, the

flashlamp pumped dye laser (595-nm wavelength) is well studied.287 The potassium titanyl phosphate

(KTP) laser of wavelength 532 nm is applicable to those 0.7 mm or less.288 Since melanin is the prime

competing light absorber to hemoglobin in the body, the increased epidermal melanin in the tanned skin

risks long-lasting hyperpigmentation and, therefore, percutaneous laser therapy should not be

performed in those with a sun-tan.

Sclerotherapy (needle injection of caustic solutions directly into superficial veins with or without

fluoroscopic guidance) has long been advocated for treating varicosities remaining after saphenous

ablation, small isolated varicosities, telangiectasias, and reticular veins.289–291 Sclerotherapy alone

appears an effective treatment for branch varicosities in patients without major saphenous reflux and

appears effective when combined with GSV ablation to control branch varicosities.292–294 The FDAapproved sclerosing agents are sodium tetradecyl sulfate, sodium morrhuate, polidocanol, and

glycerine. Hypertonic saline (23.4%), although not approved for sclerotherapy in the United States, has

been used for many years. Pilodocanol used extensively in Europe is now commercially available in the

United States and has rapidly been adopted as the workhorse for venous sclerotherapy because of very

low allergic and anaphylactic reaction rates while being essentially painless with a low risk of tissue

necrosis. All act to damage the vein endothelium-inducing inflammation and scarring with ultimate

lumen collapse.289,295 Foam sclerotherapy is the addition of air or other gases, such as carbon dioxide, to

liquid sclerosing agents, particularly detergent sclerosants, to allow a more protracted contact of the

sclerosing agent to the vein wall. This modification adds a component to the agent that converts its use

to off-label. The most popular technique uses two syringes and a three-way stopcock to allow the gas to

be aspirated into one of the syringes, while the other syringe contains a detergent sclerosant, which

results in a 1 part of drug to 4/5 parts of gas. Pushing the mixture from one syringe to the next 20 times

results in desired bubble size.296 This technique is favored by many phlebologists especially for the

treatment of larger veins, such as the saphenous vein.292,297 Leg elevation is often employed to decrease

the risk of systemic embolization during injection. The exact concentration of sclerosant, liquid or foam,

used for sclerotherapy is dependent on vein size and agent used.289,295 These interventions are generally

outpatient procedures. Burning, stinging, itching, and muscle spasm are commonly observed with

sclerotherapy injections.298–300 Extravasation of the agent can cause fat or skin necrosis, ulcerations,

and/or hyperpigmentation of the surrounding skin.298,300 Posttreatment veins are often a brown color as

opposed to the blue-red pretreatment color. Microthrombectomy of clotted blood trapped in treated

veins appears to reduce postsclerotherapy pigmentation especially in veins 1 mm or less in diameter.301

Other potential complications of sclerotherapy include allergic reactions and toxicity if too much agent

is used at one sitting.289,298,300 Therefore, a limited amount of sclerosing agent is typically injected

during a single setting. Rarely ocular events or even cerebrovascular events have been observed

following foam sclerotherapy and, therefore, must be discussed with the patient prior to its use.299,302

The thought is that the sclerosing agent gets into the systemic circulation and potentially even the eye

or brain. The presence of a patent foramen ovale is associated with a higher frequency of transient

neurologic events.303 The use of CO2 as the mixing gas used for foam sclerotherapy appears to decrease

the risk of such adverse events.302 On the basis of the available data, the SVS/AVF Guidelines

Committee recommends that liquid or foam sclerotherapy be used to treat telangiectasia, reticular

veins, and varicose veins (grade 1B).126

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Algorithm 98-1. Treatment of chronic venous insufficiency.

Phlebectomy (ambulatory phlebectomy, stab avulsion, stab phlebectomy, microphlebectomy, and

microextraction are synonymous terms) is a technique in which varicose veins are removed through

small stab incisions with hooks or small mosquito clamps used to pull the vein from its bed. There are a

number of phlebectomy instruments available.304 It can be performed in an ambulatory setting with

local anesthesia or in conjunction with a more invasive procedure. One small randomized controlled

study suggests that this approach may have improved results over sclerotherapy.305 Which approach is

best remains a point of contention in the literature and is often physician choice. Complications are

generally minor and of low risk (<2%), including development of telangiectasia, blistering,

hyperpigmentation, and missed varix.306 Tumescent anesthesia has allowed for extensive interventions

with little pain and on an ambulatory basis.307 Such field anesthesia allows for another method of

phlebectomy, powered phlebectomy, involving a modified arthroscopic shaver with transillumination

that allows venous clusters to be illuminated, morcellized, and aspirated. When compared to ambulatory

phlebectomy, there is no benefit in patient cosmetic scores or satisfaction and the recurrence rate at 1

year is 15% higher.308 The added cost and lack of patient preference will likely prevent this technique

from becoming widely adopted.

Saphenous Vein Stripping/Ablation. Saphenous preservation can lead to good results in the hands of

very skilled interventionalist willing to interpret detailed preoperative imaging (proper patient

selection) and a detailed technical approach.309–311 It involves removal of only selected branch

varicosities resulting in improved saphenous function or at least preservation of the saphenous vein

without an unacceptable rate of recurrent varicosities over time. Because of the technical demands and

limited data available to compare results with more standard treatments, treating saphenous veins

reflux and associated varicose veins with such techniques is only suggested as appropriate in the hands

of skilled interventionalists (grade 2B/C) by the SVS/AVF Guidelines Committee.126

If widespread saphenous insufficiency is present, some method of eliminating reflux is required for

best results. Entirely removing the refluxing vein from the venous system is the current best and most

studied solution. The vein can be stripped from its bed and discarded. The procedure is called saphenous

vein high ligation and stripping. Lower leg deep venous occlusive disease is not an absolute

contraindication to removal of the saphenous system and may actually be indicated in patients with

mixed obstruction/reflux disease and is often the first step in cases of combined deep and superficial

insufficiency.312,313 Preoperatively, with the patient standing to fully dilate the veins, the varicosities

are marked with a permanent marker for later operative visualization. The operation includes ligation

and disconnection of the GSV at the SFJ via open incision followed by complete removal of the vein to

the knee by one or more distal incisions centered over the vein. If the below-knee greater saphenous

2814

vein is incompetent based on preoperative diagnostic studies, it may also be excised. The method of

vein removal may involve the introduction of long metal or plastic stripping wires with removable

heads of varying size or various others devices aimed at pulling the vein from the leg.314,315 There is

even a long probe that is placed down the saphenous after cephalad exposure and to the caudal area of

desired vein removal that, when activated, freezes the vein to the probe that is then pulled from the leg

with the vein attached (cryostripping).316 Both GSV and SSV can be treated by these methods taking

into account required patient positioning and anatomic variability especially of concern in the case of

the SSV.314 In particular, protection of the sural nerve by limited deep dissection is helpful. Among

properly selected patients undergoing GSV high ligation and stripping, recurrent saphenous varicosities

will be noted in less than 25% of cases at 2 years but increases to 41% at 5 years and 62% at 11 years,

depending on the rigor of patient evaluation.315,317,318 These results serve to highlight the chronicity of

varicose vein disease and place in perspective the expectations for other forms of saphenous ablation.

With the addition of new ablation technology, this approach to saphenous insufficiency has been largely

replaced in the United States, but certainly not so in less wealthy healthcare systems throughout the

world.

A more recent advancement that allows the saphenous vein to be removed from the venous

circulation without being extracted from the body is called endovenous thermal ablation. It uses a

variety of devices to ablate (burn) and permanently scar the vein such that it does not act as the conduit

for venous blood (therefore no reflux of blood can take place). The two most common methods use

radiofrequency-generated heat319,320 or a laser fiber (with or without cap) that generates heat to cause a

thermal injury to the vein.321–323 Placed percutaneously or rarely by venous cut down, the respective

probe is advanced into the vein to about 2 cm below the junction with the deep vein and sequentially

heated throughout the length of the GSV as it is pulled back to the entrance site. Tumescent anesthesia

is administered within the saphenous compartment providing anesthesia, a heat sink, and some venous

compression during the procedure. The precise parameters for heating the radiofrequency ablation

(RFA) probe is standardized for each pullback length (7 cm) at 120 degrees for each 20-second cycle

with two treatment cycles used in the more proximal segment of the vein. The time for ablation is

significantly decreased from the original device that involved a slow pull-back process and at 6 months

this new technique was effective demonstrating 99.6% of veins remaining ablated.324 This data mimics

the results of the older technique which demonstrated results comparable and, in some respects,

superior to open surgery.325–329 Laser energy of various wavelengths (810 to 1,470 nm) delivered via

bare-tipped fiber will cause a localized thermal injury to the vein wall.321–323 The laser probe technique

is more physician directed and involves a pullback of 1 to 2 mm/second for the first 10 cm and then 2

to 3 mm/second for the remaining vein length to deliver a 50 to 80 joules/cm when using the 810-nm

diode laser. This technique rivals RFA and surgery results in the treatment of saphenous vein

reflux.330–335 Several other innovative methods of ablating the saphenous vein include, but are not

limited to, steam, pharmacomechanical methods, cyanoacrylate plugs, and likely others to come which

still require study to determine how each will fit into our interventional armamentarium.

Hamel-Desnos et al.297 found GSV ultrasonography directed foam sclerotherapy to be 84% effective in

eliminating reflux for 1 year. Midterm results in 175 patients reported a 2-year primary success rate of

55% with a 77% secondary success rate in preventing recurrent reflux.336 The long-term results of the

VEDICO trial would suggest that substantially more veins are present at 10 years when foam is used as

a single modality than when surgery or surgery and foam are used.292 If recurrence without

reintervention is the goal, sclerotherapy appears to be at a disadvantage. Meta-analysis would suggest

that over time sclerotherapy loses its advantage to other more long-lasting interventions as would select

individual experiences.289,292,293,297,337,338 Newer techniques of sclerotherapy lack long-term evaluation.

Complications of GSV surgery are rare but include wound infection, DVT, nerve damage, and

hematoma formation to mention the most common.317,339,340 Saphenous nerve injury can result in an

area of numbness around the knee or foot but is often clinically irrelevant.119,138 Complications from

SSV stripping are also typically rare but include bleeding, hematoma formation, sural nerve damage,

DVT, and wound infection.341 These same complications are reported for radiofrequency and laser

ablations possibly at a slightly lower incidence for some, such as nerve paresthesia. DVT risk is about

1% for all procedures.317,320,323,339,340,342 A complication unique to the radiofrequency and laser

procedures is thermal damage to adjacent structures, such as nerve or skin, that appear to be mitigated

by tumescent anesthesia.319 Complications as well as short- and midterm freedom from recurrence for

both radiofrequency and laser saphenous vein ablation compare favorably with standard stripping and

both may provide patient benefit.320,323,342

2815

5 Based on the previous data in addition to other publications, which can be found in a recent metaanalysis sponsored by the SVS and AVF and a consensus document, the following guidelines have been

proposed regarding the treatment of C2

(patients with varicose veins) to improve QOL and to prevent

recurrence.343 High ligation and stripping of the GSV to the knee are suggested for incompetent GSVs

(grade 2B) with a 1-week period of postoperative compression (grade 1B). For the incompetent SSV, the

recommendation is high ligation of the vein at the knee crease about 3 to 5 cm distal to the

saphenopopliteal junction with selective stripping of the incompetent portion (grade 1B). In addition,

the consensus was that endovenous thermal ablation (RFA and laser) was recommended over surgery

for saphenous incompetence treatment based on reduced convalescence, pain, and morbidity (grade 1B)

and over foam sclerotherapy due to improved efficacy (grade 1B). The elimination of saphenous reflux

has also been found useful in treating the more advance stages of CVD (C6

), the venous ulcer. A

commissioned SVS/AVF systemic review and meta-analysis of surgical interventions versus conservative

therapy favored surgery over compression alone for ulcer healing with the quality of evidence low

resulting in a suggestion favoring ablation over compression therapy alone to improve ulcer

healing.270,276 While the same analysis demonstrated that surgery was statistically better than

compression in preventing recurrence but some design and baseline imbalances in the two instrumental

RCTs decreased the level of evidence resulting in a recommendation in favor of surgery of grade 1B. In

addition, in patients with a healed ulcer, ablation in addition to standard compression therapy is

recommended to prevent recurrence (grade 1C) and in patient with skin changes at risk of venous

ulceration, the same treatment is suggested (grade 2C).

Perforator Vein Ablation. Although effective in eliminating perforating vein reflux, open344 or even

endoscopic ligation345 has been replaced with percutaneous methods of ablation due to decreased

morbidity associated with the less invasive procedures. A systematic review of pertinent guidelines and

RCTs suggests that there is no benefit in treating patients with mild/moderate venous disease by the

addition of perforation ablation (ligation) and, in fact, some perforator veins revert to normal function

after superficial incompetence is corrected.346 The pertinent available data have resulted in an SVS/AVF

guideline, which recommends that incompetent veins in patients with varicose veins should not be

treated (grade 1B).126 No matter the ablating energy delivered (radiofrequency, laser or chemical)

during percutaneous perforator vein ablation, ultrasonographic access, operative monitoring, and

confirmation of results are routine and the procedure can be accomplished under local anesthesia. The

ablating device is inserted into the pathologic perforator and is serially pulled back during activation to

burn the perforator for its length or the sclerosant injected into it with a similar result. Prevention of

energy delivery to the deep system prevents unwanted thrombosis and is most often accomplished by

positioning the ablation device (when used) or properly compressing the vein when using sclerotherapy

at or just slightly below the fascia. Various sclerosing agents have been used with minimal risk of DVT,

skin infection, and an immediate success of 90% to 98% and a 2-year maintenance of occlusion of nearly

80%.347–349 RFA demonstrates a greater than 90% early ablation rate with > 80% free of reflux at 1

year and 5 years.350–353 Laser energy of various wavelengths has been used for this procedure with

reports of ∼100% occlusions immediately and 85% to 90% occlusion rate in mid-term follow-up.351,354

The addition of perforator ablation to superficial vein incompetence ablation in patient with venous

ulcers and pathologic perforator veins appears to improve healing rates and reduces

recurrence.268,346,355,356 The available data have been interpreted by the SVS/AVF Guidelines Committee

to allow four basic recommendations.276 In patients with active ulcers and both superficial and

perforator incompetence to the pertinent ulcer bed, it is suggested that both are ablated to aid in ulcer

healing and to prevent recurrence (grade 2C) but in patients without active ulcers the addition of

perforation ablation can be simultaneous or staged on the basis of outcome (grade 2C). It is suggested

that isolated “pathologic” perforators are ablated (grade 2C). It is recommended that “pathologic”

perforation ablation be percutaneous rather than an open procedure to eliminate the need for incisions

in areas of compromised skin (grade 1C).

Iliac Stenting and Venous Bypass. Endovascular stenting of iliac vein stenosis/obstruction involves

percutaneous access of a nondiseased caudal vein (popliteal, femoral, common femoral vein) with

guidewire/catheter access across the lesion under fluoroscopic guidance and generally intravascular

ultrasonographic confirmation of stenosis >50%. If confirmed, dilation with 12- to 18-mm diameter

percutaneous balloons, depending on the iliac to common femoral vein involved, with subsequent selfexpanding stent deployment to maintain the dilation. This is accomplished from normal outflow

(generally IVC) to distal normal vein even to less trochanter location within the common femoral vein if

2816

needed to ensure good inflow. Extension to below the inguinal ligament is acceptable in the treatment

of venous occlusive disease.357 Eliminating significant outflow obstruction in symptomatic patients has

decreased edema, pain symptoms, and improved QOL parameters.127,152,197,358–360 It will often result in

venous ulcers healing, many of which have associated untreated lower leg venous insufficiency, at an

initial rate of 68% with only 8 of 101 healed ulcers recurring within 5 years, whether preformed for

primary or postthrombotic occlusion.360 Parameters of venous reflux are not worsened following

resolution of the occlusive iliac vein occlusive disease.360 The primary and assisted primary stent

patency rates at 3 years is 75% and 92% and at 6 years 69% and 89%, respectively (Fig. 98-2).360,361

Many studies in multiple centers now confirm these earlier results with a cumulative patency rate of

90% and ulcer healing rates of 60% to 80%.362–367 This intervention has been performed for significant

clinical symptoms (C3 or C2 with pain) and based solely on a greater than 50% morphologic stenosis

found on transfemoral venography or intravascular ultrasonography.152,360,361 Potential complications

include DVT, access site complications, retroperitoneal hematoma, and other catheter- and balloonrelated problems with essentially no mortality associated with the procedure.225,360,361,368 When

technically feasible, endovascular intervention has replaced more invasive approaches. As a result of

accumulating data, the SVS/AVF Guidelines Committee has recommended venous angioplasty and stent

recanalization in addition to standard compression therapy to aid in venous ulcer healing and prevention

of ulcer recurrence in patients with proximal venous occlusion/severe stenosis and C4b

, C5

, and C6

disease (grade 1C).

Figure 98-2. Life-table presentation demonstrates the patency rates of iliac venous stents placed for symptomatic occlusive venous

disease. (After Neglén P, Hollis KC, Olivier J, Raju S. Stenting of the venous outflow in chronic venous disease: long-term stentrelated outcome, clinical and hemodynamic results. J Vasc Surg 2007; 46:979–990.)

The open surgical procedures used to relieve proximal IVC or iliac vein occlusions utilize the native

saphenous vein or polytetrafluoroethylene (PTFE) graft material as the conduit to bypass from a

nondiseased distal vein to a disease-free proximal or collateral axial vein. Vena cava or bilateral iliac

veins occlusion reconstructions often use PTFE grafts to allow a proper size match.369,370 If a single iliac

vein is severely stenosed or occluded and percutaneous methods have failure, cross-femoral venous

bypass or direct repair of the iliac vein can be performed.217,371 Patient survival should be considered

prior to aggressive intervention if iliac vein compression is due to a cancerous encroachment. The crossfemoral venous bypass (Palma procedure) is performed by passing a vein graft or graft material via a

suprapubic subcutaneous tunnel to the contralateral femoral vein. The saphenous vein or prosthetic

graft is then connected to the unaffected femoral vein by an end-to-side technique after anastomosis on

the affected side. The key to success of this surgery may be graft diameter. If the native vein is less than

4.5 mm in diameter, better success may be achieved with a 10-mm diameter PTFE graft, although

others would question whether PTFE is superior to vein in this location.369,372 An arteriovenous fistula is

generally used to increase flow through the graft in the immediate postoperative period. This fistula can

then be ligated in 1 to 3 months or left open long term if no unwanted sequelae are noted. In one series,

venous reconstruction for ileofemoral and IVC obstruction reported a 62% 3-year patency with the

Palma procedure demonstrating the overall best patency (83% 4-year).369 Mortality was minimal and

wound complications rare. Based on the limited current available data, the guideline for treating

2817

bilateral proximal venous occlusion/stenosis in patients with recalcitrant venous ulceration and no

endovascular option is a suggested open intervention using externally supported PTFE graft in addition

to standard compression therapy (grade 2C).193 In the same scenario, but with unilateral iliofemoral

venous disease, the suggested therapy is an open surgical bypass using saphenous vein if available and

sufficiently large with the alternative being a synthetic graft (grade 2C). When inflow is an issue during

open operation, a distal adjunctive arteriovenous fistula (4 to 6 mm in diameter) is suggested (grade

2C).

Indications for a saphenopopliteal vein bypass are symptomatic patients with isolated femoral or

popliteal vein occlusion, a patent common femoral and iliocaval system, a nonvaricosed saphenous vein,

and femoral phlebitis inactive for at least 1 year. In addition, conservative therapy must have failed,

and venous hypertension must be documented. These distal to proximal venous bypasses use autogenous

vein as the conduit of choice and bypasses extend from distal to proximal nondiseased segments.372 This

operation is rarely performed.

Although not yet proven as a method of treating occlusive venous disease due to prior thrombosis,

some data suggest that endophlebectomy (operative removal of synechiae and septa) of iliac, femoral,

popliteal, and even tibial veins is possible and can result in a 77% primary patency rate at 8 months.373

Venous Valve Repair or Replacement

The goal of venous valve repair or replacement is the prevention of deep venous reflux and, therefore, a

decrease in prolonged distal venous hypertension. These interventions are considered only after all

other more easily treated venous pathology has been addressed by the surgeon in charge. During the

conduct of these operations, several observations influence what the surgeon can offer a given patient.

If operative handling of the suspect valve results in vasoconstriction and secondary competence (often

determined by a standard “strip test”), an external valvuloplasty or a prosthetic sleeve technique may

be viable options.374 For a valve station requiring an in situ repair, careful adventitial dissection of the

valve attachment lines facilitates proper venotomy when required and helps to verify the feasibility of

valve repair.180 A lack of valve attachment lines may signify the destruction of the valve as a

postthrombotic sequela, prompting something other than an in situ repair.180 Valvuloplasty of any sort

is most commonly performed in the femoral or popliteal location due to size and hemodynamic

considerations.

Figure 98-3. Open valvuloplasty to repair an insufficient valve can be accomplished by various venotomy incisions. A: The method

of Kistner. B: The method of Raju. C: The method of Sottiurai. D: The method of Tripathi and his colleagues.

An internal valvuloplasty or an open direct valve repair has been the mainstay for the repair of

primary venous valvular reflux for decades. This technique involves venotomy and suturing of the

elongated valve leaflets under direct visualization with fine polypropylene suture (7 or 6 to 0) to

2818

tighten the valve cusps. Kistner and colleagues

154 reported success with a longitudinal venotomy

extending through the valve commissure in 1968 (Fig. 98-3). Raju375 championed a supracommissural

approach involving a transverse venotomy at least 2.5 cm above the valve. Sottiurai376 devised a hybrid

approach (a “T”-shaped venotomy), using a supravalvular transverse venotomy with distal extension

into the valve sinus. A “trapdoor” approach involving two transverse incisions (supravalvular and

infravalvular) connected by a single vertical incision through the commissure has been described by

Tripathi and Ktenidis (see Fig. 98-3).377 Plication of approximately 20% of the valve leaflet length tends

to restore valve competency in the majority of cases.378

The technique of external valvuloplasty offers the advantage of valve repair without venotomy.379 It

is performed by placing sutures transmurally through the valve attachment lines and, when tied,

reduces the commissural angle and vein diameter, resulting in a competent valve. The valve leaflets are

generally not captured or reefed by this method. Reported results suggest that it may be less durable

than the more precise open valvuloplasty, but patient selection plays a key role.379 A modification

(limited anterior plication) involves only anterior vein dissection and then reefing of the cusps using a

running mattress suture.380 It has been described in conjunction with saphenous vein stripping and

limited to the femoral vein valve. Another modification of this technique features the use of an

angioscope.381 A side branch of the GSV allows introduction of an angioscope, which is advanced into

the femoral vein to a position above the incompetent valve and external sutures are then placed under

direct vision.381 Following a learning curve while using the angioscope, Raju et al.382 demonstrated

good clinical and competency data with the “transcommissural” technique without the use of the

angioscope with 30 months of follow-up. In these last two methods, the venous valve cusps are actually

engaged with the suture and, therefore, the cusps are tightened directly much like the open method of

repair.

External banding has been employed when dissection vasospasm renders a valve spontaneously

competent. The technique uses an external sleeve made of synthetic material wrapped circumferentially

around the vein at the site of the valve and tightened to diminish the size of the vein lumen until the

valve is competent. The sleeve is then anchored in place to the adventitia by sutures to avoid slippage.

It has achieved good results when used in select patients.229,383,384 One group of investigators has been

more aggressive with this approach, utilizing the technique in patients with more severe valvular reflux

and often placing multiple external cuffs.383

Venous valve transplantation is an option when the valve is absent or destroyed. This procedure was

first reported clinically by Taheri385 in 1982. A 2- to 3-cm segment of upper extremity vein containing a

competent valve (or a reparable one) is first removed. The incompetent femoral vein is opened below

the takeoff of the profunda femoris vein, and the axillary vein segment is sutured into place following

the removal of an appropriate length of femoral vein. The popliteal location may be more appropriate if

the femoral location does not control all axial reflux into the leg, for example, if the profunda femoral

vein system is also incompetent. The proximal anastomosis may be accomplished first to confirm the

competence of the newly transplanted valve and to allow distention and lengthening of the vein/valve

to facilitate the distal anastomosis. For vein transplantation in trabeculated postthrombotic veins,

investigators

386 have excised intraluminal synechiae to create one acceptable lumen for transplantation.

Interrupted sutures are preferred to avoid suture line stenosis.378 Valve competence is determined by

the intraoperative strip test. An external sleeve can then be placed to prevent late dilatation of the

repaired segment and because approximately 40% of axillary vein valves are incompetent at explant, a

bench repair may be required to restore competency.180,378,387

A less common option for the PTS is valve transposition. If a venous valve is competent in one of the

major thigh venous systems, then a transposition procedure can be performed placing the incompetent

venous system below the competent valve. Most commonly, the femoral system is incompetent and the

profunda femoris valve remains competent. Here, the incompetent femoral vein can be transected and

reimplanted distal to the competent valve in the profunda femoris vein. Alternatively, the incompetent

femoral system can be placed below a competent valve in the GSV or when the profunda femoris venous

system is incompetent, it may be placed distal to a competent valve in either the femoral vein or the

GSV. A technique has been described for transposition of the ipsilateral valve-competent GSV to the

femoral vein and subsequent ligation of the femoral vein proximally, yet distal to the takeoff of the

profunda femoris vein to escape problems with diameter mismatch.388 At 10 years, 55% of the patients

were reported to be ulcer-free.

Aggressive venous valve surgery requires appropriate consideration of perioperative adjunctive care:

prophylactic antibiotics, intraoperative heparin use especially if the vein is opened, the use of pneumatic

2819