Five-Year Experience of Valvular Reconstructions for Nonhealing Leg Ulceration due to Deep Venous Reflux: Lessons Learned

Abstract

Deep venous reflux is responsible for considerable morbidity in the form of venous leg ulceration and remains a significant health problem. Deep venous reconstructions have been looked upon as controversial in the past. To clarify the role of deep vein valve surgery in venous surgery, we report the lessons learned from clinical and imaging results of a 5-year expe rience of deep venous valve reconstructions. From 1994 to 1999, 137 patients (169 limbs) underwent deep vein reconstructions for nonhealing venous leg ulcers of CEAP C6 class, as a "last resort" treatment. End points of the study were leg ulcer healing, and vein valve station patency and competency. All end points were looked at on a follow-up of a minimal 2-year period follow ing the valve reconstructions. External valvuloplasty showed ulcer healing in 50% of limbs with maintenance of competency at only 31% of valve stations. Internal valvuloplasty was the most durable valve repair procedure, with 2- year leg ulcer healing rates of 67% and valve station competency of 79%. For secondary incompetence, valve transplants showed a significant deterioration in valve patency (58%) and competence (47%) at 2 years, with 55.3% leg ulcer healing. Single-level repairs or single valve transplants had much lower ulcer healing rates than multiple-level repairs or valve transplants with mul tiple valve stations. Important lessons learned from this study are: 1) Valvular reconstruction for refluxive disease is effective in healing venous ulcers that defy conservative management and superficial/perforator venous surgery. 2) These procedures appear more promising for primary than for secondary incompetence. 3) Multiple-level or multiple-valve reconstructions yield superior results to single-level repairs, challenging the "gatekeeper" concept.