[Surgery for deep venous reflux in the lower limb]

The effectiveness of the deep venous reconstructive surgery (DVRS) for reflux remains controversial. The more common etiology in deep venous reflux (DVR) is the postthrombotic syndrome, but primary deep vein insufficiency is frequently overshadowed. Valve agenesis is very rare. Clinical examination frequently does not allow distinguishing between superficial and deep venous insufficiency. In addition primary reflux is difficult to identify from secondary deep reflux.

Duplex scanning provides etiologic, anatomic and hemodynamic information. Plethysmography gives information on the overall severity of the venous disease, but not on the etiology and is not reliable for identifying the predominant component when superficial and deep insufficiencies are combined. It would seem logical to go beyond these investigations only in those patients in whom surgery for DVR may be considered. In absence of contraindication (uncorrectable coagulation disorder, ineffective calf pump) complementary investigations must be carried out: ambulatory venous pressure measurement and venography including ascending and descending phlebography. The goal of DVR surgery is to correct the reflux related to deep venous insufficiency at subinguinal level. But it must be kept in mind that DVR is frequently combined with superficial and perforator reflux, consequently all these mechanisms have to be corrected in order to reduce the ambulatory venous pressure. Surgical techniques can be classified into 2 groups: those with phlebotomy and those without. Outcomes DVRS for reflux are difficult to assess as this surgery is frequently combined with superficial and perforator vein surgery, but both have been usually performed before as first step. Indication for DVRS relies on clinical, hemodynamic and imaging criteria. Etiology is also a decision factor as surgery is more often proposed in primary reflux. DVRS must be performed on specialized and high-trained centers.