Influence of the profunda femoris vein on venous hemodynamics of the limb

Transcription

1 Influence of the profunda femoris vein on venous hemodynamics of the limb Experience from thirty-one deep vein valve reconstructions Ingvar Eriksson, M.D., and Bo Almgren, M.D., Uppsala, Sweden Venous valve reconstruction in 31 limbs (28 patients) with chronic deep venous insufficiency is analyzed. The indications for operation were primary or secondary deep valvular incompetence with severe reflux and venous hypertension. Valvuloplasty was performed on a proximal valve of the superficial femoral vein (SFV) in 17 limbs and on a common femoral vein valve in two limbs; transplantation of a valve-bearing segment of the axiuary vein was made to the common femoral vein in two limbs, to the SFV in seven limbs, and to the popliteal vein in three limbs. The results of valxafloplasty were satisfactory, with six failures observed during a follow-up period extending to 84 months (mean, 44 months). Eight of 12 valve transplant reconstructions failed within 2 years. Patency and competence of the reconstruction were obtained in 27 limbs at the 6-month postoperative control period. The effects on venous pressure were analyzed regarding the presence or absence of reflux into the profunda femoral vein (PFV) with preoperative retrograde phlebography. The results showed si~iflcant reduction of the ambulatory venous pressure (p <.5) and increase in venous recovery time (p <.1) in limbs with PFV competence. In limbs in which the PFV was incompetent the pressure values remained unchanged. These findings suggest that the functional state of the PFV is of great importance to the venous hemodynamics of the limb. This study also indicates that the principle of onelevel repair in the SFV seems appropriate in limbs with a competent PFV. (J VAse SURG 1986; 4:39-5.) Success in the treatment of deep venous insufficiency is often related to the degree of severity of the symptoms and to the rate of progression of the disease. In mild cases compression therapy alone will generally suffice. In more advanced stages surgical treatment, including ligation of perforating veins and skin grafting of leg ulcers, may be necessary. In addition, removal of the great saphenous vein may improve venous hemodynamics of the limb in selected cases. Despite these efforts, failures are not uncommon and constitute a therapeutic challenge. The introduction of methods for direct venous valve reconstruction la has implied new possibilities for active surgical treatment of deep venous insufficiency. These methods are based on the assumption that the construction of a competent valve in the femoral vein will reduce ambulatory venous hyper- From the Department of Surgery, University Hospital. Reprint requests: Ingvar Eriksson, M.D., Assoc. Professor of Surgery, Department of Surgery, University Hospital, S Uppsala, Sweden. 39 tension in the limb. The clinical results after such procedures have been difficult to evaluate as there is often a discrepancy between reported subjective improvement and objective findings) -8 The profunda femoral vein (PFV) is a vessel of considerable size, sometimes as large as the superficial femoral vein (SFV). The construction of a competent valve in the SFV in cases of deep venous incompetence by valvuloplasty or vein valve transplantation provides an opporttmity to assess the impact of the PFV on peripheral venous hemodynamics. The present study investigates the influence of the PFV on the hemodynamics of the limb after surgical venous reconstruction. In addition, we report our clinical experience with valvuloplasty and valve transplantation. PATIENTS AND METHODS Thirty-one limbs in 28 patients underwent venous valve surgical reconstruction between March 1978 and July 1985 in the treatment of deep venous insufficiency. There were 13 men and 15 women,

2 Volume 4 Number 4 October 1986 with a mean age of 48 years (range, 32 to 64 years). The indications for valve reconstruction were longstanding symptoms of venous disease, massive reflux to the midcalf or ankle level at descending phlebography, and ambulatory venous pressure values pointing to severe venous dysfunction. Preoperative investigations. The diagnosis of deep valvular incompetence was made with a 5 MHz directional Doppler flowmeter. Ascending phlebography after puncture of a dorsal foot vein was used for anatomic evaluation of the deep venous system. Descending phlebography from the common femoral vein was performed preoperatively in all patients in a 7-degree standing position. Spontaneous reflux and reflux after the Valsalva maneuver were classified as proposed by Kistner. x Measurements of the ambulatory venous pressure were performed to grade the severity of venous dysfunction. The maximal pressure reduction during exercise was calculated in percentage of the resting standing value. The venous recovery time (VRT) determined after exercise was also recorded. Venous volume and venous emptying were determined by strain-gauge plethysmography9 in 27 limbs. Operative procedures. In 19 limbs (18 patients) the origin of the disease was primary deep venous insufficiency with reflux of grade 3 to 4.1 Postthrombotic changes were lacking in all limbs except in one, which showed such changes in the deep veins of the calf. Direct valve repair, according to the method described by Kistner, 1 was performed on the most proximal valve in the SFV situated just below its junction with the PFV (Fig. 1) in 17 limbs and on the common femoral vein valve in two limbs. In the remaining 12 limbs (1 patients) the origin of deep venous insufficiency was a postthrombotic syndrome occurring after massive thrombosis with recanalization of the involved deep veins and destruction of the valves. A valve-bearing segment of the axillary veins was transplanted to the common femoral vein in two limbs, to the SFV in seven limbs, and to the popliteal vein above the knee joint in three limbs. Venous surgery before valve reconstruction. In both the valvuloplasty and the valve transplant groups a possible influence of incompetence of the superficial and perforator venous systems was eliminated before valve reconstruction. The long and short saphenous veins were removed (25 limbs) and the perforator veins were ligated (3 limbs) in all cases in which these vessels were incompetent. Follow-up. The duration of follow-up varied from 6 to 84 months. The patency of the deep veins Profunda femoris vein and venous hemodynamics 391 Fig. 1. Descending phlebograms in two limbswith primary deep insufficiency.arrows indicate position of most proximal valve in the superficial femoral vein. A, Competent PFV; B, incompetent PFV. and the competence of the reconstructed valves were repeatedly evaluated during the follow-up period. Venous pressure recordings and Doppler examinations were performed at 1 and 6 months postoperatively and then repeated once a year. Early postoperative plethysmography was repeated in 27 limbs.

3 m 392 Eriksson and Almgren Journal ot VASCUI~AR SURGERY Fig. 2, Descending phlebograms in a patient before (A) and after (B) valvuloplasty. Arrow indicates reconstructed valve. Note leakage in small branch of the profunda femoris vein. Table I. Clinical outcome of venous valve reconstruction Follow-up (too) Symptoms < Valvuloplasty Marked improvement Modest improvement Unchanged No. of limbs Valve transplantation Marked improvement Modest improvement Unchanged 3 5 No. of limbs Ascending phlebography was done in three cases in which plethysmography and Doppler findings suggested postoperative thrombosis of the reconstruction. Descending phlebography was repeated in all patients in whom Doppler examination indicated deep venous incompetence after operation. In addition, descending phlebograms were obtained in six limbs as a routine postoperative examination (Fig. 2). RESULTS Early results. In the valvuloplasty group the early clinical results (6 months) were favorable, with regression of swelling in most limbs (Table I). All nine leg ulcers healed within 2 months. The corresponding results in the valve transplant group were not so obvious as in the valvuloplasty group, al- though pain and swelling were reduced in most limbs. Three of five leg ulcers healed within 2 months. Four early failures were due to thrombosis (two limbs in the transplant group) and valve incompetence (one in each group). Minor postoperative complications occurred in nine patients, consisting of wound hematoma (five limbs), slight lymphedema (three limbs), and transient saphenous neuralgia (one limb). Late results. Late follow-up in the valvuloplasty group (mean, 44 months) showed satisfactory clinical results with lasting improvement of the symptoms in patients with persistent competence of the reconstructed valve. Preoperative valve incompetence at the popliteal level showed spontaneous correction in four limbs with competent PFVs. Late recurrence of symptoms occurred in five limbs at 11, 25, 36,

4 Volumc 4 Number 4 October 1986 Profunda femoris vein and venous hemodynamics 393 Profunda femoris system incompetency competency Profunda femoris system incompetency competency t- O = 6 " o= o3 o3 Q. O3 t- ed > 4 -~ 2 X ~ 1 ffl -- n.s. T t p <.5 > 25._~ 2 m> 15 -~ 1 X ~ 5 R.S. t t P<.1 Preop Postop Preop Postop (~ Preop Postop Preop Postop Fig. 3. Effects of venous valve reconstruction on venous pressure reduction (A) and venous refilling time (B) after exercise in limbs with competent or incompetent profunda femoris veins. 48, and 49 months after operation. Descending phlebography showed complete incompetence of the reconstructed valves in these cases, and the venous pressure reduction as well as the VRT returned to preoperative levels. Valve transplantation was started in April 1983 and therefore the follow-up period is short. Eight failures occurred during this time (Table I) because of thrombosis (five limbs) and valve incompetence (three limbs). A moderate clinical improvement (i.e., less pain and swelling) was noted in limbs with preserved competence of the reconstruction. Six failures occurred in the valvuloplasty group and eight occurred in the valve transplant group during the follow-up period. None of these limbs became worse than before operation, but the symptoms and pressure values subsequently returned to preoperative levels. Effect on venous pressure. At the 6-month control period 27 reconstructions altogether were found to be patent with preserved valve function. The postoperative reduction in ambulatory venous pressure (46% _+ 13.8%) did not differ from that found preoperatively (39.9% _ 19.2%), whereas VRT increased from sec to sec (p <.1). For evaluation of the results of valve reconstruction, the presence or absence of reflux into the PFV at preoperative retrograde phlebography was recorded in these 27 limbs (Fig. 1). Incompetence of the PFV, usually severe, was observed in 11 limbs in the valvuloplasty group and in four limbs in the valve transplant group. Twelve reconstructions were considered PFV-competent (seven valvuloplasties and five valve transplantations), although a minimal reflux was found in four limbs with a heavy Valsalva maneuver. When the limbs were categorized according to these phlebographic findings, the following observations were made (Fig. 3, A and B): (1) In PFV-incompetent limbs no change was observed in venous pressure reduction or VRT; and (2) PFVcompetent extremities showed a significant reduction in venous pressure (p <.5) and an increase in VRT (p <.1). In the total series the increase in VRT seems to be solely attributable to the increase observed in the PFV-competent group. DISCUSSION Valvular dysfunction in the perforating and deep venous systems is a well-known finding in limbs with deep venous insufficiency, either primary 1 or secondary (i.e., postthrombotic). Incompetence of these veins usually results in ambulatory venous hypertension and secondary changes in the distal tissues with pigmentation, skin atrophy, and ulceration. In addition, abnormal valve function in the saphenous vein may contribute to the severity of the symptoms. 1~'12 In the present study the influence of the superficial and perforating veins was eliminated by surgical removal of incompetent veins in these systems before valve reconstruction was performed. In the follow-up of patients with competent and

5 _ L _ 394 Eriksson and Almgren Journal of VASCULAR SURGERY SFV Fig. 4. Sketch outlines presence of reflux before (A and C) and after (B and D) valve reconstruction. Postoperative absence of profunda femoris vein reflux (B) causes decreased venous hypertension, whereas remaining profunda femoris vein reflux (D) does not result in objective improvement. patent deep valve reconstructions the interesting observation was made that the functional state of the valves in the PFV determined the objective result of valvular reconstruction (Fig. 4). Methods for separate evaluation of the influence of the PFV on venous hemodynamics have not previously been available. The introduction of venous valve reconstruction has implied an "experimental" model that fulfills some prerequisites of analyzing the hemodynamic impact of this vein. Beneficial effects of rerouting venous flow through a competent PFV have previously been noted after SFV ligation. Thus Linton and Hardy H found marked improvement in some cases, and Flanigan and Williams ~3 observed no effect on VRT in patients with PFV incompetence. Thrombosis occurring after venous valve transposition may also result in a marked improvement in VRT in the presence of a competent PFV, as noted by Queral et al.4 These observations, together with our own, indicate that more attention should be given to the state of PFV in studies of deep venous insufficiency. After femoral vein thrombosis occurs, direct or indirect venous collateral channels from the deep leg veins and the popliteal vein connect with the branches of the PFV. Mavor and Galloway ~4 found that in the postthrombotic state the PFV may act as a potential bypass collateral pathway to the femoropopliteal or lower segment in 86% of the limbs. These wide channels can easily be observed with retrograde phlebography in postthrombotic limbs with massive reflux and also, but to a lesser extent, in limbs with primary deep venous insufficiency. Therefore, anatomic prerequisites exist of prompt reflux into the parallel SFV and PFV systems. Defective valvular fimction in the PFV may result in rapid transmission of pressure changes down the collateral veins, causing permanent venous hypertension. Therefore, the PFV system may, by analogy with the arterial relationship, be more important for venous hemodynamics than has previously been considered. Preoperative valve incompetence at the popliteal level became spontaneously corrected in 4 of 12 limbs with a competent PFV. The same was noted by Queral et al. 4 in some of their patients after valve transposition. In all limbs with PFV incompetence the popliteal vein remained incompetent after valve reconstruction in the present study. Shun et al. is have emphasized the poor prognosis resulting from incompetence at the popliteal vein level in postthrombotic limbs. In the present series hemodynamic improvement was observed despite residual popliteal vein incompetence in most limbs with competent PFVs. This finding suggests that valve competence is essential at least at one level along the SFV-popliteal system. The clinical results after valvuloplasty, ~,:,6 valve transposition, 46 and valve transplantation 4'7 have been considered quite good, but objective methods have largely failed to verify these findings. In addition, very few studies have been extended to a longterm follow-up. Ferris and Kistner 6 reported good or excellent results after valvuloplast T in 8% of 32 patients followed up for 1 to 13 years (mean, 6 years). The corresponding figures in our series were 67% (8 of 12 limbs) 2 to 5 years after operation. The durability of the good results after this procedure seems to be consistent with previous observations. Taheri et a1.16 reported good or excellent results after valve transplantation in 75% of 43 limbs followed up to 4 years. Patency and competence of the transplanted valves were observed in 26 of 29 re-

6 Volume 4 Number 4 October 1986 Profunda femoris vein and venous hemodynamics 395 constructions. The results from our rather small series are contradictory to that report, because 8 of 12 transplants failed during a 2-year period. Some of these failures might be due to faulty surgical technique with use of transplants that were too narrow, but the early appearance of incompetence of some transplants with descending phlebography suggests the development of secondary changes in the valves or vein walls of the transplanted segments. On the basis of these experiences fair or good early clinical results may be achieved after valve transplantation whereas the long-term effects are definitely less good. The findings in the present investigation seem to have implications regarding operative strategy in deep venous surgical reconstruction. Patients in whom there are indications for surgical intervention should undergo reconstruction not only in the SFVpopliteal system but also in the PFV system (or in the common femoral vein) if massive reflux is observed in the two parallel systems. The present study also indicates that the principle of one-level repair in the SFV seems appropriate in patients with a competent PFV. REFERENCES 1. Kismer RL. Surgical repair of the incompetent femoral vein valve. Arch Surg 1975; 11: Kismer RL, Sparkuhl MD. Surgery in acute and chronic venous disease. Surgery 1979; 85: Taheri SA, Lazar L, Elias SM, Marchand PA, Heffner R. Surgical treatment of postphlebitic syndrome with vein valve transplant. Am J Surg 1982; 144: Queral LA, Whitehouse Jr WM, Flinn WR, Neiman HL, Yao JST, Bergan JJ. Surgical correction of chronic deep venous insufficiency by valvular transposition. Surgery 198; 87: Johnson ND, Queral LA, Flinn WR, Yao JST, Bergan JJ. Late oblective assessment of venous valve surgery. Arch Surg 1981; 116: Ferris EB, Kismer RL. Femoral vein reconstruction in the management of chronic venous insufficiency. Arch Surg 1982; 117: Raju S. Venous insufficiency of the lower limb and stasis ulceration. Changing concepts and management. Ann Surg 1983; 197: Eriksson I, Almgren B, Nordgren L. Late results after venous valve repair, lnt Angiol 1985; 4: Hallb66k T, G6thlin J. Strain-gauge plethysmography and phlebography in diagnosis of deep vein thrombosis. Acta Chir Scand 1971; 137: Bauer G. The etiology of leg ulcers and their treatment by resection of the popliteal vein. J Int Chir 1948; 8: Linton R_R, Hardy IB. Postthrombotic syndrome of the lower extremity. Treatment by interruption of the superficial femoral vein and ligation and stripping of the long and short saphenous veins. Surgery 1948; 24: Bjordal RI. Pressure patterns in the saphenous system in patients with venous leg ulcers. Acta Chir Scand 1971; 137: Flanigan DP, Williams LR. Venous insufficiency of the lower extremities: New methods of diagnosis and therapy. Surg Annu 1982; 14: Mavor GE, Galloway JMD. Collaterals of the deep venous circulation of the lower limb. Surg Gynecol Obstet 1967; 125: Shull KC, Nicolaides AN, Fernandes ~ Fernandes JF, Miles C, Homer J, Needham T, Cooke ED, Eastcott FH. Significance of popliteal reflux in relation to ambulatory venous pressure and ulceration. Arch Surg 1979; 114: Taheri SA, Heffner R, Meenaghan MA, Budd T, Albini B, Elias SM, Pollack LH, Pendergast DR, Shores RM. Technique and results of venous valve transplantation. In: Bergan JJ, Yao JST, eds. Surgery of the veins. Orlando: Grune & Stratton, Inc, 1985: