Current surgical approaches to venous hypertension and valvular reflux

Abstract

Venous hypertension in the lower extremity with and without ankle ulceration can be attributed to venous outflow obstruction, venous valve incompetence with massive reflux. Compression stocking and pneumatic pump cannot provide a long-term cure of this advance stage of venous pathology and ulcer recurrence is to be expected. Definitive treatment requires the following sequential order: (1) correction of potential underlying coagulopathy (deficiency in Protein C, Protein S, anthrombin III), (2) correction of venous outflow obstruction in the pop-fem-iliac or inferior vena cava with venous bypass (balloon angioplasty of venous stenosis has disappointing long-term results because fibrocollagen is resistant to dilation), (3) correction of valve incompetence in the following order of preference: valvuloplasty, vein transposition, and valve transplantation, (4) perforator ligation and saphenous vein stripping, (5) compression stocking and pneumatic pump to enhance venous return and reduce superficial venous congestion. In nonpostphlebitic venopathy, compression stocking + pneumatic boot pump can function as a substitute for perforator ligation + saphenous vein stripping. There is high incidence of incompetence in transplated valve (53%) that can be restored with open valvuloplasty.