Chapter 159 - Deep vein valve reconstruction Flashcards
Rate of deep venous obstruction or reflux in all CVD
55%
Primary venous insufficiency valves
1) floppy 2) redundant 3) elongated cusps 4) assymmetrical insertion 5) enlarged venous diameter
Secondary venous insufficiency causes
DVT and post-thrombotic disease
Cutoff for abnormal reversed flow (reflux) in femoropopliteal and deep femoral and tibial veins
1 sec for fem pop 0.5 s for profunda 0.4 s for tibial
Signs of venous insufficiency on duplex
1) reflux 2) thickened scarred constricted vein 3) valves with poor flow 4) diminished augmentation 5) respiratory variation lost (local or proximal obstruction/stenosis)
Air plethysmography cut off for venous insufficiency
Venous filling index > 2 ml/s Residual volume fraction > 35% Ejection fraction > 60%
Ascending and descending venography uses
Ascending - define anatomy and eliminate obvious obstruction Descending - determine valve leaflet integrity, location and degree of reflux to each segment
Treatment algorithm for venous ulcer
FIGURE 159.7
Indication for deep vein valve repair CEAP class
C4b, C5 and C6
Types of treatments for valve restoration
1) valve repair (internal/external valvuloplasty, banding) 2) valve transposition/transplantation 3) autologous valve substitute
Location of AT vein in relation to closest muscle
Deep to anterior tibialis Anterior compartment
Location of PT and peroneal vein in relation to closest muscle
Deep posterior compartment Covered by soleus and gastrocnemius - superficial posterior compartment
Number of valves in paired tibial and peroneal veins
3-12 in each
Number of valves in popliteal veins
1-3
Number of valves in femoral vein
1-5 (>90%)
Most constant valve location
proximal femoral vein 1-2 cm distal to confluence with profunda 90%
Number of valves in profunda
1-4 (88%)
Number of valves in CFV
>50% none can have 1-2 near inguinal ligament
Strip test
milking blood antegrade past valve with inflow occluded then pressure retrograde to fill vein again (reflux)
Internal valvuloplasty 4 exposure types
1) Kistner 1968 - longitudinal venotomy through valve commissure 2) Raju transverse venotomy supracommissural 2.5 cm above valve 3) Sottiurai combined approach T shape 4) Tripathi and Ktenidis trap door
External valvuloplasty methods
1) Kistner 1990 - transmural suture through valve attachment lines 2) transluminal sutures 3) angioscopic guidance 4) Raju - transcommissural valvuloplasty 5) limited anterior plication
External banding
External sleep of synthetic wrapped around vein at site of valve
Valve transplantation key points
Taheri described it 2-3 cm UE vein with valve harvested Replaces most proximal segment of FV Proximal anast first to confirm valve competence
Valve transposition key points
GSV, profunda and FV all can be used in various configurations
Neovalve creation techniques
1) Autogenous vein as donor cusp 2) GSV placed inside femoral vein as cusp 3) cutting intimal/medial wall to create valve 4) endo valve creation 5) endo valve replacement
Hematoma and seroma in valve repair
15%
DVT after valve repair
10%
Internal valvuloplasty long term competence
5 year 60-70%
External valvuloplasty long term competence
3 year 64%; 5 year 52%
External banding competency rate long term
78% at 50 months
Clinical improvement after valve transplantation and transposition
50% in 8-10 years
Neovalve long term competence
68% at 54 months
