Open Surgical Treatment of Chronic Venous Insufficiency



Open Surgical Treatment of Chronic Venous Insufficiency



Robert L. Kistner


The term chronic venous insufficiency (CVI) refers to a progression in the broad category of chronic venous disorders. In terms of the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, it refers to progression beyond uncomplicated varicose vein disease (C2) to swelling (C3) and onward to skin changes (C4) and ulceration (C5–C6).


These venous problems seriously affect the quality of life in of approximately 15% of the adult population, who experience progression to late-stage chronic venous disorder. Midlife workplace disability and later-life disability in activities of daily living ensue as the chronic venous disorder progresses along its cascade from minor varicose veins or initial deep vein thrombosis to disabling pain and swelling with dependency of the extremity and overt skin changes, culminating in ulceration of the lower leg. This transition can occur over a period of a few years in post-thrombotic disease or over multiple decades in primary venous insufficiency.


The present role of open surgery should be interpreted to refer to deep vein reconstruction in the light of recent advances in minimally invasive treatment of venous insufficiency. With the reality of thermal and chemical means to treat reflux in the superficial saphenous and perforator veins and treatment of iliac vein obstruction with endovascular minimally invasive techniques, great progress has occurred in simplifying the management of a large percentage of patients with clinical venous disease.


There are venous problems not addressed by these advances, which include cases of skin ulceration and dense scarring of the subcutaneous tissues in the gaiter area of the lower leg (C4–C6 disease) secondary to deep vein reflux and obstruction below the inguinal ligament, and bursting calf pain with venous claudication typically caused by obstruction in the femoral–popliteal veins. Surgical interventions exist to treat and prevent these debilitating venous states.


For the most part there is agreement that open surgical reconstructive procedures are reserved for more difficult cases of chronic vein disease in which conventional measures of compression and the simpler surgical procedures of vein ablation and perforator interruption have proved inadequate to control the CVI syndrome. When patients with this situation are encountered, the management alternatives faced by the physician are to accept the limitation of activity and lifestyles imposed by venous disease or perform open surgery to reverse deep vein abnormalities and preserve functional capacity for the patient. It becomes a matter of whether the disease can be altered to improve the patient’s way of life or if the lifestyle needs to be modified to suit the limitations imposed by the disease.


The pathology encountered in C4 to C6 cases is a result of either primary or secondary reflux or obstruction. The third cause of venous insufficiency are congenital malformations. The more common entity is primary venous insufficiency, in which the physiologic finding is pure reflux and treatment requires restoring competence in the axial veins of the lower extremity. The less common form is postthrombotic disease leading to secondary CVI, in which the physiologic state begins as obstruction and morphs into a spectrum of mixed obstructive and reflux states in the involved veins. Surgical treatment of secondary CVI is more complicated because of the need to overcome both obstruction and reflux that occurs in stiff-walled veins whose valves and intimal linings have been deformed or totally destroyed.


The individual operative techniques of deep reconstruction are well described in the literature, and new innovations continue to appear. There are a number of available surgical and endovenous techniques to treat advanced cases of CVI (Box 1). Recent advances that include autogenous neovalve creation in the postthrombotic vein and the demonstration that angioplasty and stenting in the iliac vein have favorable long-term patency with few complications provide new alternatives for selected patients.



BOX 1   Interventions to Treat Reflux and Obstruction in Chronic Venous Insufficiency




Candidates for surgery are patients who are unable to maintain their way of life because of disabilities imposed by their venous condition and in whom a surgical procedure can reasonably be expected to restore part or all of that capacity. For younger patients, the clinical need can relate to strenuous activity to earn their living or to enjoy a way of life such as outdoor hiking and hunting, whereas elderly persons may be incapacitated when they cannot manage self-care because they are unable to reach their ankles to don stockings or to change bandages. Open venous reconstruction is used to preserve quality of life rather than to save life or limb. It strives to alter the pathological condition to fit the patient’s way of life as opposed to altering the patient’s way of life to fit the pathological condition.



Indications for Detailed Venous Evaluations


The three conditions that qualify patients for deep vein reconstruction are a repairable deep vein defect, serious lifestyle limitations imposed by the venous disease, and good enough health that the patient will benefit by improved function after successful repair. Usually the clinical picture includes limited tolerance for ambulation plus pigmentation and sclerotic skin changes with or without ulceration. Some postthrombotic patients have superficial veins that are entirely normal and skin that is normal, but the deep vein reflux or obstruction causes bursting pain and venous claudication. Any one of these symptoms or signs can be severely limiting and sufficient to warrant deep vein intervention.


Deep vein reconstruction requires a thorough diagnostic evaluation sufficient to map the distribution of reflux and obstruction in the vein segments from the diaphragm to the calf. From this information, one can determine which surgical alternatives are applicable in a given case of advanced CVI.


Patients who fit the criteria for deep vein surgery are a selected few among the 30% of the population with chronic venous disease but they are destined to lead a life of significantly impaired activity imposed by their disease if it goes uncorrected (Box 2). The actual symptoms can be pain or swelling and congestion; the signs may be swelling of marked degree and skin changes, especially ulceration, that cannot be controlled with simpler measures. Surgical treatment to correct significant reflux or obstruction in these instances can relieve symptoms.



Box 2   Clinical Conditions that Warrant Consideration for Open Deep Vein Surgery



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Aug 25, 2016 | Posted by in CARDIOLOGY | Comments Off on Open Surgical Treatment of Chronic Venous Insufficiency

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