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[Post-thrombotic valvular lesions]
1Explorations fonctionnelles, CHU Côte de Nacre, Caen.
Insights
Deep vein thrombosis often leads to post-thrombotic valve destruction, impacting venous function. Early diagnosis and surgical repair are crucial for severe cases, though surgical outcomes have a high failure rate.
Area of Science:
- Vascular Surgery
- Venous Thromboembolism Research
- Diagnostic Imaging in Phlebology
Context:
- Deep vein thrombosis (DVT) can result in significant venous valve damage within months.
- Post-thrombotic valve destruction is diagnosed by venous reflux consequences.
- Current diagnostic methods like photoplethysmography and phlebography have limitations in sensitivity and specificity.
Purpose:
- To evaluate diagnostic methods for post-thrombotic venous valve destruction.
- To compare the impact of valve destruction versus non-repermeation on skin trophicity.
- To assess the efficacy and outcomes of surgical repair for severe cases.
Summary:
- Ultrasonography-Doppler is the preferred initial diagnostic tool for identifying, localizing, and quantifying venous reflux post-DVT.
- Dynamic popliteal phlebography in an upright position is considered a reference standard.
- Valve destruction leads to worse skin trophicity issues than non-repermeation, necessitating surgical consideration in young patients.
Impact:
- Ultrasonography-Doppler offers a reliable, accessible method for diagnosing venous reflux and guiding treatment decisions.
- Surgical interventions like transposition, transplantation, and valvuloplasty are options for severe cases unresponsive to medical treatment.
- Surgical repair success rates are around 50%, highlighting the complexity and challenges in managing post-thrombotic venous insufficiency.
Abstract:
A patent lumen after deep vein thrombosis can be achieved but at the cost of valve destruction which occurs in 50 to 75% of the cases within 6 to 12 months after the thrombotic event. The diagnosis of post-thrombotic valve destruction is made on the basis of direct consequences of venous back flow. Photoplethysmographic measurement of venous filling pressure while walking or after a Valsava manoeuvre lacks specificity and is insufficiently sensitive, especially in case of minimal back flow. Retrograde femoral phlebography can miss distal back flow if the femoral valves functions correctly. Dynamic popliteal phlebography in the upright position could be the reference examination. Ultrasonography-Doppler is however widely used as the first intention investigation providing a positive diagnosis, recognizing the localization and quantifying the back flow. The patient is placed in the upright position and reflux is checked after standardized distal compression. The ultrasonographic aspect (fibrosis, thick wall, tributary vessels) gives further arguments for differential diagnosis. The consequences of valve destruction on skin trophicity appear to be worse than non-repermeation after a thrombotic event. Surgical repair (transposition, transplantation, valvuloplasty) should be proposed for young patients with severe trophicity disorders which resist well-conducted medical treatment. The rate of failure is approximately 50% i.e. higher than for primary valve destruction.