Deep venous valve reconstruction for non-healing leg ulcers: techniques and results

The purpose of the present paper was to report clinical and imaging results of a 5 year experience of deep venous valve surgery with evaluation of end-points at 2 year follow up for the management of non-healing venous leg ulcers in 137 patients.

Between October 1994 and November 1999, 137 patients (169 limbs) underwent deep vein reconstructions for non-healing venous leg ulcers of clinical, etiological, anatomical, pathological classification (CEAP) C6 class, as a 'last resort' treatment. End-points of the study were post-valve reconstruction, freedom from leg ulceration, vein valve patency and competency at 2 years. Primary refluxive disease was present in 96 patients (118 limbs). External valvuloplasty was performed in 12 limbs (19 valves) and internal valvuloplasty was performed in 90 limbs (144 valves). External supports were used in 16 limbs (16 valves). Multilevel (2-3) reconstructions were performed in 37 limbs. Forty-one patients had secondary valvular defects involving 51 limbs. Axillary-femoral vein or saphenofemoral vein valve transplant was performed for 29 patients (35 limbs) and three patients (three limbs), respectively, saphenofemoral venous transposition was performed in three patients (four limbs), and femoral/popliteal vein ligation was carried out in six patients (nine limbs).

Two year results of external valvuloplasty showed ulcer healing in 50% of limbs with maintenance of competency at only 31% of valve stations. Internal valvuloplasty was the most durable valve repair procedure with 2 year leg ulcer healing rates of 67% and valve station competency of 79%. For secondary incompetence, valve transplants had a significant deterioration in valve patency and competence at 2 years: 58% and 47%, respectively, with 55.3% leg ulcer healing. It was also noted that single-level repairs or single valve transplants had lower ulcer healing rates than multilevel repairs or valve transplants with multiple valve stations.

In a 2 year follow up, valvular reconstruction for refluxive disease is effective in healing venous ulcers that defy conservative management and superficial/perforator venous surgery. Furthermore, these procedures appear more promising for primary than for secondary incompetence. Multilevel or multivalve reconstructions yield superior results to single-level repairs in medium-term follow up.