Internal valvuloplasty combined with sleeve wrapping in the treatment of severe great saphenous vein insufficiency: A report of two cases

Introduction

Chronic venous insufficiency (CVI) of the lower extremities is the most common chronic venous disease in the population and has a significant impact on quality of life. ¹ And the valve insufficiency of the great saphenous vein (GSV) is one of the most important manifestations of CVI. ² Great saphenous vein dysfunction can lead to venous reflux and distal venous hypertension, the clinical manifestations of the affected limbs in the early stage of swelling, heaviness, soreness and pain, with the development of the disease, but also cause varicose veins, hyperpigmentation, venous ulcers and other skin changes, which seriously affects people’s quality of life and brings a greater socio-economic burden. ³ Medication and elastic compression stockings (ECSs) are often used clinically to treat early symptoms, while surgery is used to relieve advanced symptoms. To the best of our knowledge, various surgical techniques for the treatment of GSV insufficiency have been described in the literature, but this is the first time that an attempt has been made to treat GSV insufficiency using the internal valvuloplasty proposed by Kistner ⁴ in conjunction with the sleeve wrapping procedure proposed by Lurie et al. ⁵ We present two early cases of GSV insufficiency in which internal valvuloplasty combined with sleeve wrapping significantly relieved the patients’ discomfort. The patients consented to the publication of this case report.

Case report

Case 1

A 24-year-old man presented with hyperpigmentation of the medial ankle region of the bilateral lower limbs. Three years ago, he developed bilateral skin hyperpigmentation of the medial ankle area, with the right side more severe than the left, concentrated mainly behind the medial ankle. He had no bilateral lower limb pain, swelling or varicose veins. Increasing hyperpigmentation in the right ankle area 1 year ago, with gradual darkening of skin colour (Figure 1(a)). After admission, lower extremity venous ultrasound was perfected, suggesting significant regurgitation at the level of the bilateral GSV valves, with a duration of more than 10 s on the right side and more than 5 s on the left side. Retrograde venography of the right lower extremity, performed in conjunction with the patient’s Valsava manoeuvre, showed reflux of the right deep vein into the mid-thigh and reflux of the right GSV into the ankle. Level IV according to the Kistner grading method ⁶ (Figure 2(a)). Preliminary diagnosis of severe bilateral GSV valve shows insufficiency.OPEN IN VIEWER

Figure 1.

(a) Before surgery, the patient had significant hyperpigmentation in the ankle area of the right lower extremity, mainly behind the inner ankle. (b) Six months after surgery, the patient’s pigmentation in the medial ankle area of the right lower limb was reduced in extent and colour without further deterioration.

OPEN IN VIEWER

Figure 2.

(a) Venography of the right lower extremity with femoral vein reflux to the mid-thigh and GSV reflux to the ankle. (b) Venography of the left lower extremity with femoral vein reflux to the tibial plateau and GSV reflux to the proximal calf.

After completion of the relevant preoperative investigations, we performed internal valvuloplasty and sleeve wrapping of the right GSV in this patient. During surgery, the GSV was fully exposed and it was found that the GSV had a significant sinus dilatation about 5 cm from the confluence point and the wall of the vein was very thin. After incision according to the Kistner method, a double valve-like valve structure was seen, with an apparent redundant prolapse on one side of the valve (Figure 3(a)). The two confluences were suspended with one stitch each of 7-0 prolene suture, sutured to the vein wall and knotted extra-lumitorally. Then one additional suture was placed on one side to correct the redundant flap to the same length on both sides. The vein wall was closed continuously with 6-0 prolene sutures, and the venous valve function was restored by the strip test without significant regurgitation. In the natural state of the vein, a 1 × 7 cm artificial vascular patch was cut and wrapped around the GSV valve area to strengthen the vein wall, which was continuously closed with 5-0 prolene sutures (Figure 3(b)). The venous valve was then found to be patent and free of regurgitation by the strip test.OPEN IN VIEWER

Figure 3.

(a) During surgery, seen after incision of the GSV. (b) After Internal valvuloplasty combined with sleeve wrapping.

Post-operative treatment was successful. We gave the patient continuous pumping of sodium heparin and kept the APTT in the 60–80 s. Before discharge, the patient was switched to oral anticoagulation with rivaroxaban. We advised him to avoid prolonged standing and sitting after discharge, to wear ECS and to have regular venous ultrasound examinations.

At follow-up, the patient’s hyperpigmentation in the medial ankle area of the right lower limb had not only worsened but had become much smaller and less intense in colour (Figure 1(b)). Six months after surgery, the patient’s repeat venous ultrasound showed no significant regurgitation at the right GSV valve. Venous ultrasound was repeated 1 and 2 years after surgery and the results were still satisfactory.

Discussion

Currently, the majority of treatments for GSV disease aim to remove or ablate the unhealthy vein to relieve symptoms. However, because the preservation of the GSV as a potential graft for future lower limb or cardiovascular procedures, ⁷ valvuloplasty is worth considering as it can relieve the symptoms of GSV insufficiency and prevent varicose veins and ulcers without destroying the veins.

Valvuloplasty involves two types of surgery: Internal valvuloplasty and external valvuloplasty. External valvuloplasty has been shown to be safe and effective in the treatment of GSV regurgitation in several centres.^8–10 Since Kistner proposed internal valvuloplasty in 1975, this procedure has been used to correct deep vein valve insufficiency in the lower extremities with good results, but the efficacy of using this surgical procedure to improve GSV valves remains to be seen. Therefore, our centre tried to treat severe GSV regurgitation with internal valvuloplasty combined with sleeve wrapping. The indications for this procedure include patients experiencing lower limb soreness, heaviness, swelling and other symptoms without obvious varicose veins, severe saphenofemoral valve insufficiency identified by angiography. However, patients with significant deep venous valve insufficiency indicated by angiography will be excluded. It is crucial to strictly adhere to these indications as the primary goal of this procedure is to prevent further deterioration of lower limb venous disease.

In these two cases, we first used internal valvuloplasty to restore GSV valve function, with satisfactory restoration of valves function verified by the strip test after suturing the vein wall. Given the thin wall of the vein and its tendency to dilate, to prevent recurrence of valvular insufficiency due to venous dilatation in the post-operative period, we also combined sleeve wrapping.

The advantages of this new operation are as follows: Firstly, it caters to a wide range of patients who suffer significantly from lower limb symptoms and require treatment to improve their quality of life. Secondly, this operation is innovative based on repairing deep venous valves, and the operation method is novel and traceable. Most importantly, it addresses the aetiology by attempting to restore the function of the saphenofemoral valve before irreversible varicose veins occur in order to slow down or prevent disease progression. Lastly, this operation preserves the main trunk and branches of the GSV which can potentially serve as a graft for future cardiovascular surgeries while also playing a role in preventing reflux during deep venous thrombosis.

It is important to note that in the above cases, the artificial patch sleeve is not designed to allow the vein to contract in a non-spasmodic state, but rather to apply a non-contractile patch ring suture to reinforce the vein wall and prevent dilatation of the vein in a spasmodic state. ¹¹ Post-operative patient management is critical, and in order to prevent DVT of the lower limbs leading to post-thrombotic syndrome (PTS), ¹² which can destroy valve function and make this surgery a lost cause, special attention should be paid to the use of post-operative anticoagulant medications in the patient.

Conclusion

Internal valvuloplasty combined with sleeve wrapping is safe and feasible in the treatment of early GSV incompetence, with good short-term results; long-term results remain to be seen.