Open surgical treatment for postthrombotic syndrome

Abstract

The postthrombotic syndrome counts as a frequent long-term complication after deep vein thrombosis with approximately 20%–50% of affected patients after deep vein thrombosis. The earliest that diagnosis of postthrombotic syndrome can be made is 6 months after deep vein thrombosis. Most patients suffer from swelling and chronic pain. In all, 5%–10% of patients may even develop venous ulcers. The complex etiology consists of limited venous drainage because of chronic occlusions and secondary insufficiencies of venous valves inducing non-physiological venous reflux. Conservative management, first of all compression therapy, is of crucial importance in treatment of postthrombotic syndrome. Endovascular and open surgical techniques can additionally be used in a small subgroup of patients. Although rarely performed, this article illuminates the open surgical techniques in treatment of postthrombotic syndrome such as venous bypass surgery, valve repair and varicose vein surgery.

Keywords

Postthrombotic syndrome venous bypass valvuloplasty venous ulcers varicose vein surgery

Introduction

The postthrombotic syndrome (PTS) counts as a frequent long-term complication after deep vein thrombosis (DVT). Approximately 20%–50% of patients with DVT develop a PTS, most commonly at a time period of a few months to a few years after DVT.^1–6 The earliest that diagnosis of PTS can be made is 6 months after DVT. PTS is characterized by symptoms including swelling and chronic pain. A total of 5%–10% of patients may even suffer from venous ulcers.^1,5,7,8 Patients are characterized by severe psychological strain, as PTS reduces the quality of life (QoL).^2,9–11 Thereby, it also causes a burden for healthcare system.^12–14

The etiology of the PTS can be explained on one hand by an occlusion-limited drainage of the venous blood and thus increasing venous pressure: intraluminal thrombus material leads to changes of the venous adventitia followed by a total blockage of the vein or at least growth of obstructing septae. The incomplete recanalization of the thrombotic occlusion results in a chronic drainage disorder. On the other hand, secondary insufficiencies of venous valves or even their complete degeneration can lead to a non-physiological reflux known in primary varicose veins.

PTS is diagnosed by clinical presentation, a gold standard does not yet exist. Various clinical tools may be useful for the diagnosis and classification of PTS, e.g. Ginsberg Measure, Villalta Scale, Brandjes Scale as well as CEAP Classification, the VCSS and the Widmer Classification. To objectify the diagnosis of PTS compression ultrasonography can visualize (post)thrombotic alterations.

The treatment of PTS generally requires a multimodality approach. Conservative management, including compression therapy with elastic compression stocking (ECS) as well as pharmacotherapy, ulcer management, lifestyle changes and exercise training, is of upmost importance. However, recurrent ulceration cannot always be treated adequately by conservative measures on a long-term basis. Additionally, endovascular and open surgical techniques can be provided to a selected therapy-refractory group of patients. Endovascular treatment, which is the more common approach, mainly focusses on recanalization of chronically obstructed veins. This article concentrates on the open surgical techniques, which although rarely performed, in a very small and well selected cohort, aim to treat the obstruction (bypass surgery or disobliteration), the secondary varicose or the insufficiency of the deep veins (deep venous valve repair, transfer or transposition). Deep valve reconstruction is reserved for a small group of patients who have failed conservative or endovascular treatment.

Evidence for both approaches – particularly for the open surgical treatment – is very low due to the lack of high-quality trials available. Commonly the use of the last named techniques is based on the experiences of a few specialists in centers of excellence.

Varicose vein surgery

Patients with a PTS can be treated by varicose vein surgery in case of severe secondary varicosis. Especially when deep veins are occluded, varicose vein surgery needs to focus only on the segments of insufficiency. For instance, the classic stripping of the greater saphenous vein (GSV) is not performed in total but concentrates on areas connected to ulceration. A crossectomy also is rarely indicated in these patients.

In PTS vein surgery the interruption of insufficient perforator veins is of prime importance. Traditional open surgical techniques (i.e. Linton procedure, Hach procedure) are passed by minimal-invasive techniques as subfacial endoscopic perforator vein surgery (SEPS).¹⁵

Endovenectomy (venous disobliteration)

If the symptoms of a patient with PTS derive mainly from chronic blockage of the venous drainage and occlusion only occurs in a relatively short and localized area, an option is to resect the intraluminal obstructing alterations. In the venous system, a disobliteration of almost occluded or insufficiently recanalized segments can be done similarly to the treatment of stenotic arterial vessels by thromboendarterectomy.¹⁶ The difference between both treatments is that in veins the therapy aims to remove thrombotic septae and synechiael structures caused by the thrombus. A resection of parts of wall tissue thus freeing deeper layers shall be prevented since those layers are thrombogenic causing re-thrombosis. A small study by Puggioni et al.¹⁷ showed that this occurred to 33% of the patients. The venotomy should be sealed with a venous patch to prevent stenosis (by suturing) – another predisposing factor for re-thrombosis. This procedure is especially suitable for operative accessible venous segments such as the Vena femoralis communis.

Venous valve reconstruction (Valvuloplasty)

The profound venous system is equipped with bicuspid venous valves that are important for the physiologic “anti-reflux system” of the human body. Its function prevents the reflux of steady venous blood against the flow to the heart within the healthy person. Therefore malfunctions of venous valves can lead to a volume overload of the venous system and thus result in ulcerations. If a (secondary) malfunction of valves is diagnosed as part of the PTS, operative reconstruction may be a suitable therapeutic method to heal or reduce the consequences of PTS in selected patients. There are several procedures, e.g. internal or external valvuloplasty, which enable a repair usually within the Vena femoralis communis or Vena femoralis profunda.

The internal valvuloplasty (see Figure 1) starts with the clamping of the concerned segment of the vein followed by a longitudinal venotomy. The insufficient valve will be tightened by anterior transcommissural suture after it has been exposed and prepared. The procedure was first described by Kistner in 1968.^18,19 The external valvuloplasty (see Figure 2) consists of the tightening of insufficient valves by through-and-through sutures at the valve-carrying segment. Overall it is characterized by a transmural suture and therefore an adaptation of the valvular cusps. Kistner et al.²⁰ has invented this procedure as well. Advantages are the prevention of venotomy and the clamping of the vein.²⁰ Some vascular surgeons claim that the lack of visual control and less precision doing the valve reconstruction are disadvantages. The third technique relies on the principle of extravasal compression of valve-carrying segments by a PTFE or Dacron prosthesis to achieve a good adaptation of valve leaflets. This treatment also called “banding” (see Figure 3) can also be done with a pericard patch.²¹

Figure 1.

Internal valvuloplasty: longitudinal venotomy at the insufficient venous valve. Tucking transcommissural sutures shortening the cusp edge to restore competence of insufficient venous valve (Kistner^18,19).

Figure 2.

External valvuloplasty: after visualizing the insufficient venous valve through-and-through transluminal sutures are placed and the incompetent valve cusps are tightened. The sutures are performed in both commissures (anterior and posterior vein wall) (Kistner²⁰).

Figure 3.

Venous banding: extravasal compression of valve-carrying segments by PTFE, Dacron or pericard patch to restore competence of insufficient venous valve (Us et al.²¹).

Valve transposition and valve transplantation

Valve transplantation and valve transposition are options for patients with irreversible destruction of their venous valves. In these cases it is impossible to reestablish the native valve function with the above mentioned procedures due to altered anatomical situations by post-infectious changes and/or scar tissue.

Valve-carrying segments of the Vena axillaris^22,23 and the Vena brachialis can be used as donor material for an autogenous transplantation. Usually insufficient valve segments will be replaced by donor material en-bloc with end-to-end-anastomosis. An additional external banding as mentioned above can be done to prevent secondary dilatation and therefore a relapse of valve insufficiency. The first to mention this technique were Taheri et al.²⁴

The method of transposition of a postthrombotic vein can be used if the valve of intersection of the Vena femoralis superficialis is insufficient but the valves of the GSV are still intact. Due to the transposition of the Vena femoralis superficialis with end-to-side technique to the GSV the venous blood flow will be changed via intact valves and a reflux into the Vena femoralis superficialis can be stopped. Alternatively, a transposition can be done distal of an intact valve of the Vena femoralis profunda.

Other techniques for reflux correction are cryopreserved vein valve,²⁵ autogenous valve reconstruction by inverting the saphenous vein²⁶ or neovalve construction by using vein wall dissection.^27,28

Prosthetic valve

In the last two decades, several artificial valves for venous replacement have been tested on an experimental basis. For instance, Pavcnik et al.²⁹ investigated valves made of synthetic or biological materials with different types of leaflets in sheep. These experiments were only carried on a catheter-based technique and mainly tested in animals. Nevertheless, the first Phase-I-studies have been published.³⁰

Venous bypass for long-segment chronic occlusions

Open surgical bypass treatment is available for selected patients with PTS in order to relieve symptoms and strain when conservative compression therapy or endovascular treatment is not successful. In general, in case of infrainguinal venous obstruction, saphenopopliteal³¹ or saphenotibial bypass may be used. Femorofemoral,³² femoroiliac, iliocaval or femorocaval^33,34 bypass surgery are treatment options in iliofemoral or iliacocaval venous obstruction (see Figure 4).

Figure 4.

Examples for different prosthetic venous reconstructions.

Examples of venous bypass grafting

Saphenopopliteal bypass

If the superficial or profunda femoral vein is faced by a long-segment occlusion the creation of a saphenopopliteal bypass is an elegant treatment option. This surgery was developed by May and Husni in the 1970s, an in-situ end-to-site anastomosis of the distal GSV can be done with the Vena poplitea distal of the occlusion.³¹ The venous outflow of the lower leg therefore takes place via the GSV (see Figure 5). In a small study with an average follow up of 103 months, 82% of the patients treated by this surgery showed an improvement of symptoms, three out of five chronic ulcerations could be healed. The authors assess the technique as “satisfying and reliable.”³⁵ A very recent publication by Shaydakov et al.³⁶ reports similar results in a case study with 12 patients.

Figure 5.

Sapheno-popliteal-femoralis bypass: the venous outflow of the lower leg takes place via the GSV to bypass the long-segment occlusion of the Vena femoralis (Husni³¹).

Femorofemoral bypass

Unilateral chronic occlusion of the pelvic vascular bed can be avoided open surgically by the creation of a femoral cross-over bypass (Palma-Operation, see Figure 6). This method was one of the first surgeries invented in order to treat the PTS: the contralateral GSV is dissected throughout the segment and the distal end sutured in an end-to-site anastomosis to the Vena femoralis communis in the area of the chronic pelvic vascular occlusion after it has been subcutaneously tunneled within the lower belly.³² In case the GSV is not useful for bypass, the surgery can also be performed with reinforced PTFE prosthetic graft (see Figure 4). To prevent the occlusion of the bypass in low-flow venous systems, some vascular surgeons prefer the construction of a temporary arteriovenous fistula distal of the bypass. The patency rates of these bypasses are indicated to be 70%–83% for venous grafts and 44%–100% in synthetic grafts.³⁷ The possible creation of an iliaco-iliacal cross-over bypass (high Palma Bypass according to Vollmer) shall also be mentioned even though it has lost its importance with the increasing number of endovascular procedures in this vascular field.

Figure 6.

Palma-Operation: femoral cross-over bypass to redirect the venous blood flow around the chronic pelvic occlusion. Contralateral GSV is used as autogenous graft (Palma and Esperon³²).

Discussion

This article shows that there is a broad surgical spectrum that can relieve PTS patient’s symptoms and pain. Experiences with the individual methods are partially limited and the evaluation of the different treatment options that enable recommendations based on evidence-based medicine is difficult since there are no large randomized studies due to few case numbers. This result is also confirmed by the systematic review of Bond et al.³⁸ concerning operative treatment options of the PTS. Only 12 studies with 349 patients were included in the survey paper after all research findings since 1980 have been cited. It seems favorable though that 11 out of 12 studies indicated a relief of symptoms due to operative methods whilst healing rates of ulcer were said to be between 50% and 100%.

The latest guideline of the German Society of Vascular Medicine can be considered outdated and needs to be reviewed and revised regarding new research findings. Regarding operative methods, the American Heart Association recommends its use slightly (Level of Evidence C) in its recent guideline of 2014.³⁹ The indication and choice of treatments thus remain an adjusted decision regarding the individual patient’s case. More studies and investigations are necessary to expand the knowledge on a long-term basis for the operative treatment of PTS and the associated repertoire of vascular surgery.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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