Bypass graft to Lateral Tarsal Artery. Click to enlarge.

Evaluation and Surgical Management of Chronic Venous Insufficiency

Charles O. Brantigan MD FACS

The sores of poor people....are often mended by rest, a horizontal position, fresh provisions and warmth in hospitals...John Hunter

Venous reconstructive surgery is one of the new and particularly interesting aspects of vascular surgery. The generally satisfactory results of compression therapy for venous insufficiency, however, limits the number of patients for whom surgical reconstruction is an appropriate option. As a result, the number of venous reconstructive cases seen in any large vascular surgical practice is similarly limited. My goal in this presentation is to discuss the physiology of the venous system, available tests of venous physiology, and consider the role of venous reconstruction and destruction in the management of the postphlebitic leg. This discussion is limited, by necessity, by lack of large numbers of cases or extended follow up in mine or reported series.

The physiology of the post-phlebitic leg is reasonably well understood, although there are uncertainties as to the best way to quantify the magnitude of the disorder. Obviously any operation for arterial or venous disease must be based on an understanding of the pertinent physiology. Clearly, not all anatomically demonstrable lesions either on the arterial or venous side need to be repaired. In order to define a rational treatment plan, the physiology of chronic venous insufficiency must be considered on both a macro and a micro basis.

On a macro basis, one must begin with the anatomy of the lower extremity and consider, in descriptive terms, what components make up the venous system, and how each contributes to its overall function.

There are three venous systems in the leg, the superficial veins, the deep veins, and the perforator veins. Each has a different function. The superficial veins collect blood from the skin subcutaneous tissue and from the foot and convey it to the deep system. Preferential drainage of the foot into the superficial system explains why edema of the foot is a common complication of saphenous vein harvest. The superficial system is made up of collecting veins and the greater and lesser saphenous veins. All of these veins are protected by one way valves insuring flow in the proper direction. The blood collected in the superficial system either drains through the perforating veins into the deep system or directly from the greater and lesser saphenous veins into the femoral or popliteal veins respectively. The perforating veins are protected by one way valves which insure flow into the deep system. Generally speaking, the perforating veins are small and cannot be well visualized either on venography or using duplex scanning. The deep system serves as a pump conveying blood through a low pressure system against the force of gravity and into the heart. There are multiple veins within the soleus and gastrocnemius muscle, in particular, which serve as collecting chambers. These soleal sinuses passively fill with blood while the calf muscle is relaxed. When the calf muscle contracts, blood is forced out of the soleal sinusoids into the tibial veins and from thence uphill . Retrograde flow is prevented by the presence of one way valves. This pumping mechanism allows blood to flow uphill against gravity in spite of the fact that pressure in the system is less than the hydrostatic forces imposed by gravity.

As can be presumed by this functional anatomic description, there are only two things that can go wrong with the venous system: One or more of the veins can become obstructed, or segments of the system can become incompetent. Incompetence and/or obstruction lead to venous hypertension, and venous hypertension leads to the post phlebitic leg.

The abnormal calf pump. There is deep vein obstruction and
valvular incompetence. With contraction blood is forced toward
the skin. From Sumner, op cit

The incidence of post phlebitic changes in venous stasis ulcers is roughly related to the pattern of disease which is, in turn, roughly related to the degree of venous hypertension which can be measured directly. The data in the associated tables, modified from Dr. Browse's work is particularly valuable in answering questions concerning the prognosis of patients with chronic venous insufficiency.

Venous Disorders of the Legs
Pathology, Ambulatory Pressure and Ulceration
(modified from various papers by Browse)

On a micro, or cellular level, the pathophysiology of the venous stasis ulcer has been explained by multiple theories. The most credible theory is the one expounded by Browse . He postulated that venous hypertension causes leaky vessels through separation of endothelial cells. Relatively low degrees of separation produce extravasation of fluid. As the pressure becomes higher, the pores become relatively larger, and larger things are extravasated, eventually large proteins such as fibrinogen, and eventually red cells. The red cells decompose in the extravascular space, releasing hemoglobin pigment. This eventually becomes the hemosiderin which discolors the affected area in most patients with the postphlebitic leg. The fibrinogen is polymerized into fibrin and this fibrin coats the capillaries surrounding the areas most affected by high pressure. These fibrin cuffs have been demonstrated microscopically by selective staining. The effect of coating the capillaries is to decrease diffusion of oxygen across cell membranes. This means that the capillary bed serves functionally as a shunt, conveying blood without transporting oxygen. This makes the venous effluent from the area of a venous stasis ulcer abnormally high in oxygen content. The resulting tissue hypoxia stimulates new vessel formation. The new vessels eventually become coated with fibrin as well. Thus, an ischemic ulcer is created in the presence of exuberant capillary proliferation and increased oxygen tension. There is an intense fibrotic reaction both to the deposition of fibrin and the deposition of hemosiderin pigment leading to the badly damaged and fibrous appearing tissue that appears under the bleeding base on the venous stasis ulcer. In addition, for some unknown reason, these patients have a deficit of naturally occurring fibrinolytic activity in the area of the ulcer, and this encourages deposition rather than dissolution of fibrin.

The Browse theory of pathogenesis of venous stasis
ulceration.. See text.

If we are to deal with chronic venous insufficiency on a surgical basis, we must begin by correcting problems of venous incompetence and obstruction. Before we can correct them, we must identify the location of obstructions and incompetent valves. Many tests have been proposed for the evaluation of venous stasis disease. Each test is, of course, embraced enthusiastically by its advocate. Instead of discussing all available tests, I prefer to discuss the tests which have proven valuable to us in Denver.

To begin with, many venous tests are too imprecise to provide much help in evaluating the post phlebitic leg. Certainly, impedance plethysmography and radioisotope venography are basically useless in planning possible surgical therapy. Our experience has been that venous reflux testing, although widely advocated, produces such variable results that it is of no value either. We rely on Color Duplex Scanning and ascending and descending venography to make surgical decisions, although we are still not sure how to deal with the discrepant data which is occasionally produced by the three tests.

We begin our evaluation with Color Duplex Scanning. In most patients the most accurate evaluation of the patency of the venous system, including the tibial veins and the perforators, is accomplished in this way. In order to accomplish this, however, state of the art equipment is required, well trained and interested technologists, and more time than will ever be paid for by insurance companies, or particularly, by Medicare. Although there are technical limitations to the study, primarily due to obesity or massive edema, in most patients we can see and evaluate the six named tibial veins and the venous system up to and through the external iliac vein. Information about the common iliac vein and the vena cava is attainable as well, although it appears to be somewhat less reliable. Color Duplex Scanning appears to be our most important test because we are able to determine which segments are occluded and which segments are incompetent. Considerable experience is required, however, because many times following deep vein thrombosis, the occluded segments become partially recanalized and it is then up to the technologist to determine if the vein is still functionally occluded. When we are able to visualize specific venous valves, it makes an impressive picture which displays well at meetings. Unfortunately, however, we are generally able to demonstrate venous valvular competence or incompetence by the absence or presence of venous reflux seen using the low flow settings of the Color Duplex Scanner.

It must be noted that Duplex Scanning provides information about the superficial system and the perforating veins which is available in no other way. Contrast venography is generally carried out by obstructing flow through the superficial system in order to force the dye into the deep system. As a result, the opacification of the saphenous veins generally occurs only through incompetent perforators. Likewise, since there are many incompetent perforators, they can be identified with contrast venography, but not with the precision required to specifically interrupt these perforators using limited incisions.

Ascending venography is useful in that it provides an anatomic roadmap of the entire deep venous system. Contrast venograms are generally assigned to the lowest level of radiology resident and are often do not provide the amount of information that could be provided had they been done by someone who understood the importance of visualizing all tibial veins and visualizing the iliac veins as well. Successful surgery requires a quality roadmap. Ascending venography also provides us with roadmap information concerning the location of venous valve sinuses which, in turn, allows us to identify valve sinuses which we may not be able to see grossly at the time of surgery when the veins are not distended.

Descending venography is accomplished by introduction of dye into the iliac vein from above and watching the progress of its reflux down the leg . The degree of reflux is generally measured using the Kistner classification. Descending venography is also useful in identifying valve sinuses for possible surgical repair. The valve cusps which are incompetent are commonly identified in descending venography and provide some information to the surgeon concerning the most likely valve cusp to repair.

It is important to remember that the duplex scan and the contrast studies must be used together. Recanalized veins pose particular problems in evaluation. This recanalization often occurs in a sponge-like fashion which can be characterized as cavernous transformation. A vein that has undergone cavernous transformation will often be identified on ascending venography as an open vein and on descending venography as a competent vein when, in fact, the vein is functionally occluded. Making this assessment on duplex scanning is not easy, but it is more precisely done than with contrast studies.

Surgical modalities of interest in the management of the post phlebitic leg are many and varied. Each appears to have its own usefulness. Beginning with the most simple and proceeding to the most complex, I would like to comment on the role of the various surgical techniques.

Ligation and stripping of incompetent varicose veins is a time honored treatment. Unfortunately, it is commonly considered primarily for patients who have cosmetic problems or aching and swelling associated with varicose veins and is seldom considered as part of the treatment for patients with a post phlebitic leg. A surgical attack on the superficial system, when carried out, needs to be done completely. Ligation and stripping of the greater saphenous vein is often not sufficient. Secondary veins should be obliterated as well. Particular attention must be paid to the posterior arch vein, when present. It begins behind the medial maleolus and extends upward to join the greater saphenous vein below the knee. The lesser saphenous vein should be removed when it is incompetent, and the number and severity of scars made on the leg to achieve ligation and stripping of the superficial system in the context of the chronic venous ulcer is less important than it is in young women with a cosmetic problem or swollen legs. Operating on the patient with the leg elevated will markedly decrease the blood loss associated with these procedures, and some surgeons have even advocated using a tourniquet for hemostasis as one works through multiple incisions below the knee. Obviously, destruction of the incompetent portions of the superficial system will be effective in treatment of venous disease only if physiologic studies demonstrate that it is the principal defect. This occurs on occasion, but it is uncommon. There is a role for such destruction of an incompetent superficial system in the presence of deep vein incompetence, but its role in patients who have an obstructed deep system is uncertain, and according to some reporters, contraindicated.

Interruption of perforators has been carried out in the past using the Linton flap procedure or similar procedures . In my opinion, this procedure is outmoded and has no place in clinical medicine because of the massive nature of the operation and the high incidence of wound healing complications which are associated with it. Interruption of perforators is important, however. The perforators are generally marked using Duplex Scanning and are interrupted by making a number of small incisions under local anesthesia directly over the perforator. The perforator is identified where it comes through the fascia and is ligated in a subfascial manner. Again, if the patient's only problem is an incompetent perforator, then ligating the perforator under local anesthesia and day care surgery will be of great physiologic benefit. The role of the SEPS procedure or subfascial endoscopic perforator ligation remains to be determined. The procedure has some usefulness, but is limited by subcutaneous fibrosis in severe cases and by the location of the perforators in others.

Ligation of an incompetent profunda femoris vein can be immensely beneficial to some patients. In some patients, descending venography will show that the superficial femoral vein (part of the deep system) is competent but that the profunda femoris vein is incompetent and feeds incompetent perforators below the knee. It is difficult to thoroughly evaluate the profunda femoris vein using Duplex Scanning. In addition, there may be more than one profunda femoris vein, and ligation of the wrong one will not produce any benefit. Likewise duplications in the deep system will occasionally be identified in which one limb is incompetent and the other limb competent. In this case, ligation of the incompetent limb will markedly improve the patient's physiology.

In some patients with an incompetent venous system, it is possible to identify a venous valve either in the profunda femoris vein or in the greater saphenous vein which is competent. It is a relatively straightforward surgical procedure to transpose this valve into the incompetent superficial femoral vein . Our experience has been that these transposed valves tend to fatigue with time. Particularly if the patient is non compliant with the need for elastic support stockings in the postoperative period, venous valve fatigue will be a common problem. We use a wide mesh Dacron fabric to wrap these transposed valves, as our experience has shown that one of the common ways that these valves fatigue is for the transposed segment is to dilate making the annulus larger and the valve incompetent. Note that use of wide mesh material rather than a section of a vascular graft is selected because it offers less resistance to ingrowth of blood vessels into the vein itself.

Venous valve transplantation, as proposed by Taheri , has been successful in selected patients. In this procedure a competent venous valve is identified from elsewhere, generally one of the duplicated axillary veins. The valve bearing segment of vein is then excised and transplanted into the deep system of the leg. The size match is generally best in the popliteal vein. When we performed this operation, we prefer to reinforce the transplanted segment with wide mesh Dacron fabric for the same reason that we reinforce transposed valves.

Venous valve repair, as proposed by Kistner , has been our most reliable technique. The venous valves are then repaired directly by plicating either the annulus or the valve leaflet itself using magnification. The technical details are described in Kistner's articles, but resemble an annuloplasty of the tricuspid valve. We prefer to reinforce the plicated valve with Dacron mesh because of problems of dilation of the annulus. Our patient population must be significantly different from that of Kistner's, reflecting a higher incidence of post phlebitic legs rather than patients with primary valvular incompetence. In our experience, a relatively small number of patients have been candidates for this procedure.

Valve repair. Use of micro sutures to
tighten leading edge of valve

Bypassing obstructed venous segments can be carried out as well. The time honored operations, the Palma crossover procedure and the Husni saphenopopliteal bypass , are not procedures that we have had a great deal of experience with. While many physicians have reported good results with these operations, their role is yet to be defined. There is some question about whether they should be "protected" by doing a simultaneous AV fistula which is subsequently ligated. There is usually little morbidity associated with these procedures even if they fail.

Our best results with obstructed veins has been to use the spiral vein graft . This technique appears to be particularly useful in bypassing an obstructed iliac vein segment or a superficial femoral vein segment. This is a tedious and time consuming procedure whose charm will decrease in our eyes as soon as other people are willing to invest the time and effort required to construct these conduits. We are currently investigating the use of cryopreserved iliac veins for these conduits.

Patient selection for evaluation and for vascular surgical procedures on the venous system is complicated. My own inclination is to say that everyone with a post phlebitic leg who has stasis pigmentation or ulceration should undergo a complete evaluation, at least using Duplex Scanning. There will be a significant number of patients discovered whose problem is principally an incompetent superficial system and/or incompetent perforators. Since ligation and stripping of the superficial system is a relatively straightforward operation with a long, successful track record, I would be inclined to recommend this operation for whom the primary cause of their venous stasis ulcer is incompetence of the superficial system. Likewise, when patients have a prominent problem with incompetent perforators, ligation of these perforators under limited anesthesia using limited incisions will make a significant improvement in the patient's physiology and should be considered in most patients. Destruction of the superficial system in the face of deep system incompetence is a judgement call based on the surgeons assessment of the relative contribution of each component and I am unable to provide specific guidance in making this judgment.

On the other hand, the various venous bypass procedures and valve reconstructions should be considered in patients whose problems and symptoms are refractory to good elastic compression care, for patients for whom elastic support is not a consideration, or for the occasional patient with venous claudication. As with arterial disease, chronic venous insufficiency is an ongoing process, and there are many more things that can go wrong in the post operative patient who has venous disease than in one who has arterial disease. Since elastic compression is the most important way of preventing many of these problems, all postoperative patients are advised to wear elastic compression stockings for the rest of their lives. Under these circumstances, it is sometimes difficult to determine whether the patient's improvement following venous surgery is the result of more compulsive attention to elastic compression, or whether the patient is benefiting from the operation. Obviously if patients are required to wear elastic support post operatively, most of the surgical options are not appropriately offered to patients whose symptoms are already controlled with elastic support. In addition, the durability of these repairs and the long term results are not well known because the numbers of patients upon whom they have been performed is small and long term follow up is incomplete.

The surgical management of venous disease is particularly rewarding for the interested physician. The physiology is complex and fun to elucidate. Patients respond well to therapeutic regimens which are well conceived and well carried out, and the patients, particularly ones who have had long standing venous stasis ulcers, are very grateful when the problem is solved.

Dr Brantigan wrote the original version of this paper in 1992 and has presented this information at many medical meetings. This version was created in 1998 as a syllabus for such a presentation.

References:

1 Hunter, J Palmer, JF (ed) The works of John Hunter. London, Longman, Reese, Orme, Brown, Green and Longman 1837

2 Lofgren, EP, Myers, TT, Lofgren, KA, Kuster, G, The Venous Valves of the Foot and Ankle, Surg Gynec Obstet 289-290 (1968). Reese, Orme, Brown, Green and Longman 1837

3 Lofgren, EP, Myers, TT, Lofgren, KA, Kuster, G, The Venous Valves of the Foot and Ankle, Surg Gynec Obstet 289-290 (1968).

4 Criado, E, Johnson, G, Jr, Venous Disease, Current Problems in Surgery XXVIII (5) May 1991 p345.

5 Sumner, DS, Venous dynamics--varicosities, Clinical Obstet Gynec 24:743-760 (1981)

6 Browse, NL, The pathogenesis of venous ulceration, in Bergan, JJ and Yao JST, Surgery of the veins, Grune and Stratton, New York 1985 p25 ff.

Taheri, SA, Sheehan, F, Elias, S, Descending Venography, Angiology 34: 299-326 (1983).

7 Kistner, RL, Ferris, EB, Randhawa, G, Kamida, C, A method of performing descending venography, J Vasc Surg 4:464-8 (1986).

Linton, RR, Postthrombotic ulceration of ht lower extremity: Its etiology and surgical management, Ann Surg 138:415-32 (1953).

8 Queral, LA, Whitehouse, WM Jr, Flinn, WR, Neiman, HL, Yao, JST, Bergan, JJ, Surgical correction of chronic deep venous insufficiency by valvular transposition, Surgery 87:688-695 (1980).

9 Meadox Dacron Mesh catalog number 019206

10 Taheri, SA, Lazar, L, Elias, S, Marchand, P, Heffner, R, Surgical treatment of postphlebitic syndrome with vein valve transplant, Am J Surg 144:221-224 (1982).

11 Kistner, RL, Surgical repair of the incompetent femoral vein valve. Arch Surg 110:1336-42 (1975).

12 Bergen, JJ, Yao, JST, Venous Problems, Yearbook Medical Publishers, Inc, 1978.

13i Palma, EC, Esperon, R, Vein transplants and grafts in the surgical treatment of the postphlebitic syndrome, J Cardiovasc Surg 1:94-107 (1960).

14 Husni, EA, In situ saphenopopliteal bypass graft for incompetence of the femoral and popliteal veins, Surg Gynec Obstet 130:279 (1970).

15 Smith, ER, Brantigan CO, Bypass of superior vena cava obstruction using spiral vein graft, J Cardiovasc Surg 24:259-61 (1983).

© 2003-2004 Dr. Charles Brantigan,  Vascular Surgery Practice
2253 Downing Street, Denver, CO 80205
303.830.8822 fax: 303.830.7068 or 800.992.4676  inquiries@drbrantigan.com

Last Updated: 07/15/2004