SURGICAL THERAPY FOR DEEP VALVE INCOMPETENCE
Original author: Seshadri Raju
Abstracted by Gary W. Lemmon
Deep vein valvular incompetence happens when the valves in the veins (tubes that deliver the blood from your leg back to your heart) of your leg stop working well allowing blood to run backward into the leg after it has been pushed forward. These veins run along side the major arteries (blood vessels that bring the blood from your heart to the legs) and both travel deep within the muscles of the leg. The veins split below the knee into the three paired tibial veins of the calf. Within the veins are valves at the level of the groin, near the middle of the thigh, behind the knee and in the smaller veins in the calf. When working well, venous blood flow travels in one direction towards the heart pushed forward by the muscle in the foot, calf and thigh. Valvular reflux occurs when valves quit working and allows blood to flow in the reverse direction. Venous insufficiency can cause a number of problems from leg swelling to skin changes, including ulcers. Venous valves are made of two thin leaflets lying within the leg vein which meet in the middle of the vessel for proper closing. The valves are similar in structure to a heart valve although on a much smaller and thinner scale. Generally, deep vein valve surgery is done only for those people in whom compression stocking therapy and removing the problems of the superficial veins (saphenous vein ablation) have failed to take care of symptoms. These people usually have skin changes and ulceration associated with the venous incompetence.
A good history can help your doctor to know if the reflux and valvular incompetence is due to primary disease, which happens because the vein itself enlarges resulting in the valve leaflets not being able to meet or from venous thrombosis, which means the valve itself was damaged by blood clotting and scarring. Approximately one-half of the patients will be found to have either primary disease or post-phlebitic valve damage. A good physical examination shows the effect the venous incompetence is having on your leg: varicose veins are present, swelling is present, skin changes have occurred or an ulcer is present. A very detailed ultrasound study gives a road map of the entire anatomy of the leg veins. Swelling of the leg with standing and during walking using an air boot (air plethysmography) to measure the changes can give the doctor data of leg swelling and venous reflux. An evaluation of any blood clotting disorders is also useful to determine if previous venous thrombosis might be a problem during and shortly as surgery.
In general, there are three ways to fix vein valve reflux. The goal of each method
is to put a working valve back into lower leg vein system and by so doing to
prevent further reflux. The method used depends on what your surgeon believes
is best as well as the location in the leg of valve incompetence and whether the
valve leaflets are damaged or not. Several studies have shown that fixing or
placing a working valve in the femoral (or groin) location works well (Figure 1).
Repair of the popliteal vein valve which is located behind the knee can be a
second option. First described by Dr. Kistner in 1968, directly fixing the valve is
very successful and lasts a long time. Venous valve repair requires
magnification to do the best job and it is a very demanding work which must be
done perfectly. The direct valve repair (Figure 1) of Dr. Kistner requires
opening the vein to allow the surgeon to look at the valve leaflets and then to
place sutures to “cinch” or tighten up the valve. Once this is done, the vein is
closed so blood can flow normally again. This tightening of the valve parts
allows for proper closing. If one is familiar with sailing, it is much like the
cinching of a sail to allow it to catch more wind. Fine filament sutures smaller
than a human hair are used to retack or cinch the valve to the correct tightness. A
simple test done by pushing blood from below to above the valve while still
holding any more blood form coming from the leg and seeing if the valve now
works (the “strip test”) shows that the repair is working well. The patient is
given blood thinners (heparin) during the operation to make sure no blood clots
occur and is continued during the short hospital stay while changing to blood
thinner (warfarin) that can be taken by mouth which is continued for eight to
twelve weeks. Those patients having prior venous damage from venous
thrombosis (blood clotting) may need longer term anticoagulant (blood
Other ways to place a good valve into the refluxing lower leg vein system may
also work. One can cut the main vein in the incompetent veins and suture it into
place below one of the other veins in the lower leg that has a working valve (this
is called a valve transposition and involves a vein relocation) (Figure 1). There
may not be such a valve present in the lower leg making this approach impossible
and there is some concern that overtime the extra work this valve must do might
cause the vein to dilate causing this valve to also fail.
Axillary vein valve transfer (Figure 1) originally described by Dr. Raju in 1981
is used when direct vein valve repair or vein relocation is not possible. The
axillary veins near the armpit are of similar size to the femoral veins in the thigh.
A segment of vein with a good functioning valve is taken from the arm veins
through a small incision in the armpit. This valve segment is then placed into the
lower leg incompetent vein system by suturing it to both ends of the cut deep leg
vein. Occasionally a plastic cover is placed over the valve repair site to prevent
late vein dilation.
Complications or problems occurring during the operative experience involve
approximately ten percent of patients. These are most commonly hematomas or
bleeding in the area of operation or collection in the wound of other bodily fluids.
A re-operation to drain these fluids may be needed to make sure the valve
continues to work well. Thrombosis (clotting) of the valve repair site occurs in
roughly five percent of patients despite anticoagulant treatment.
Improvement in symptoms including stopping pain and swelling can be found in
sixty to eighty percent of patients who have venous reflux due to primary valve
dysfunction. Most patients are able to stop or limit stocking use after successful
operation. The results are not as good for those people who have valve surgery
because of prior vein thrombosis and extensive post-phlebitic (scarring)
changes. Nonetheless, two-thirds of patients can be found to have complete ulcer
healing at twelve years following successful surgery. Best outcomes can be seen
in those centers which have the surgeons, tools and skills needed for these
demanding operations available.
Vein valves that do not work will cause blood to flow backward in the veins into
the legs. This leads to problems with swelling, skin changes and even
breakdown of the skin (ulcers). There are ways to stop this abnormal backward
flow of blood by fixing the vein valves. If the valve is still present but just not
meeting properly, the valve can be fixed with fine sutures. If the valve is totally
damaged, one must place the refluxing system below a working valve in another
part of the leg veins (transposition) or must take one from the arm as a
transplant. Other techniques are being investigated but so far these are the more
common ways to fix the problem.
Commonly asked questions by patients
When such I ask my doctor about deep vein valve surgery?
Not all patients with valve reflux and venous insufficiency or who have had
prior episodes of venous thrombosis need deep vein valve reconstruction.
More commonly done and less invasive methods such as compression stocking
therapy and treatment of all superficial vein reflux is considered before
recommending valve reconstruction. The majority of patients can be managed
with these methods to provide for ulcer healing and reduction of leg swelling. If
these methods fail, direct valve surgery would be considered. Knowing the exact
cause of the venous reflux, whether it be primary valve dysfunction or
secondary to venous clot damage, is important to know so that the surgeon can
give the patients a good idea of the possible success and durability of the
procedure. This conversation should occur after the appropriate workup and the
diagnosis has been completed.
How long will I need to be on Warfarin treatment?
The length of time necessary for chronic anticoagulation (blood thinning drugs)
after valve repair is dependent on the surgeon’s thoughts, type of repair, and the
reason for valve incompetence in the first place. Anticoagulation for eight to
twelve weeks is standard for direct open vein repair. Longer duration of therapy
may be necessary for those individuals who have a history of prior clotting
What happens to the arm if the vein is taken from that location to be
transplanted to the leg veins?
Removal of the axillary vein from the arm surprisingly causes little problems in
most cases. There are many collaterals (small veins) within the arm that allow for
continued drainage of blood from the arm without significant swelling or pain.
Rarely some arm swelling is seen but is very manageable.
Figure 1: The artist has drawn pictures that show different ways of surgically
placing a work valve in the lower leg deep veins to prevent problems with deep
venous reflux. The picture of the leg shows a cut in the groin in many of these
veins repairs are preformed. The picture to the left of the leg shows a direct repair
of a floppy valve using very fine sutures to tighten the valve edges and make it
work again (direct valve repair). The picture in the upper right shows taking a
working valve from the arm and sewing it into the lower leg deep vein to prevent
reflux in that system (vein transplantation). The picture in the bottom right shows
placement of the non-working or incompetent major vein below a working valve
in another part of the lower leg deep veins (vein relocation or transposition).