Surgery for deep venous incompetence

Deep venous incompetence (DVI) is a problem in the veins that can lead to leg ulcers (sores), pain and swelling. It may be caused by a problem in the valves of the vein, by a blockage of the veins or by a combination of these events. For most people, wearing special compression stockings and treating the ulcers is enough. When this does not ease the problem, surgery is sometimes tried. This review includes four studies with a total of 273 participants. All included studies reported on outcomes following surgical repair of venous valves (valvuloplasty). We did not identify studies investigating other surgical procedures for the treatment of patients with DVI. All included studies investigated primary valve incompetence (when valves do not close properly because of laxity of the vein wall or valve cusps). We found no trials that investigated the results of surgery for secondary valvular incompetence (when valves do not close properly, for example, when valves are damaged as a result of deep vein thrombosis) or for the obstructive form of DVI. As different outcomes were reported, it was not possible to combine the results of these studies. The methodological quality of the included studies was low, mainly because information regarding allocation of treatment and blinding was missing, or because data were incomplete or were poorly presented. Ulcer healing and ulcer recurrence were not reported in one study, and the remaining three studies did not include patients with ulcers or active ulceration. Three studies reported no significant complications of surgery or no incidence of DVT during follow-up. One study did not report on the occurrence of complications.

Clinical changes were assessed by subjective and objective measurements, as specified in the clinical, aetiological, anatomical, and pathophysiological (CEAP) classification score. This requires vascular laboratory measurements of lower limb haemodynamics before and after surgery. Tests include an overall evaluation of venous function with venous refilling time (VRT) or ambulatory venous pressure (AVP). Results show improvement in clinical symptoms and muscle pumping function and significant improvement in the haemodynamic status of patients who had external valvuloplasty along with surgery to the superficial venous system. In patients who had surgery to the superficial venous system only, clinical symptoms improved, but no improvement in muscle pumping function was reported.

Evidence is not sufficient to show the effects of surgery on the treatment of patients with DVI. The individual trials included in this review have demonstrated possible long-term benefit in certain groups of patients, but these trials were small, used different methods of assessment and overall were of poor quality. They did not include patients with severe DVI. Trials investigating the effects of other surgical procedures on the deep veins are needed. Until evidence from such trials becomes available, conventional conservative measures, such as high compression therapy or elasticated hosiery, remain the treatments of choice.

Authors' conclusions: 

No evidence was found for benefit or harm of valvuloplasty in the treatment of patients with DVI secondary to primary valvular incompetence. The individual trials included in this review were small; they used different methods of assessment and overall were of poor quality. They did not include participants with severe DVI. Trials investigating the effects of other surgical procedures on deep veins are needed. Until the findings of such trials become available, the benefit of valvuloplasty remains uncertain.

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Background: 

Chronic deep venous incompetence (DVI) is caused by incompetent vein valves and/or blockage of large-calibre leg veins and causes a range of symptoms including recurrent ulcers, pain and swelling. Most surgeons accept that well-fitted graduated compression stockings (GCS) and local care of wounds serve as adequate treatment for most patients, but sometimes symptoms are not controlled and ulcers recur frequently, or they do not heal despite compliance with conservative measures. In these situations, in the presence of severe venous dysfunction, surgery has been advocated by some vascular surgeons. This is an update of the review first published in 2000.

Objectives: 

To assess the effects of surgical management of deep venous incompetence in terms of ulcer healing, ulcer recurrence and alleviation of symptoms.

Search strategy: 

For this update, the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched October 2014) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2014, Issue 9).

Selection criteria: 

Randomised controlled trials of surgical treatment for patients with DVI.

Data collection and analysis: 

For this update, two review authors (RRG and SCH) extracted data independently. All included studies required full risk of bias assessment in line with current procedures of The Cochrane Collaboration. Two review authors (RRG and SCH) independently assessed risk of bias and consulted with a third review author (AA) when necessary.

Main results: 

Four studies with 273 participants were included. All included studies reported clinical outcomes following valvuloplasty. We found no studies investigating other surgical procedures for the treatment of patients with DVI. All included studies investigated primary valve incompetence. We found no trials that investigated the results of surgery for secondary valvular incompetence or the obstructive form of DVI. Because different outcome measures were used, it was not possible to pool the results of included studies. The methodological quality of the included studies was low, mainly because information regarding randomisation and blinding was missing, or because data were incomplete or were presented poorly. Ulcer healing and ulcer recurrence were not reported in one study, and the remaining three studies did not include participants with ulcers or with active ulceration. Three studies reported no significant complications of surgery and no incidence of DVT during follow-up. One study did not report on the occurrence of complications. Clinical changes were assessed by subjective and objective measurements, as specified in the clinical, aetiological, anatomical, and pathophysiological (CEAP) classification score. This requires vascular laboratory measurements of lower limb haemodynamics before and after surgery. Tests include an overall evaluation of venous function with venous refilling time (VRT) or ambulatory venous pressure (AVP). Two small trials comparing external valvuloplasty using limited anterior plication in combination with ligation of incompetent superficial veins against ligation alone (L) showed that ligation plus limited anterior plication produced significant improvement in AVP: The mean difference was -15 mm Hg (95% confidence interval (CI) -20.9 to -9.0) at one year and -15 mm Hg (95% CI -21 to -8.9) at two years. Sustainable statistically significant improvement in AVP and VRT was achieved by ligation and limited anterior plication at 10 years in one study. However, AVP values after surgery remained relatively high, causing its benefit to be questioned. Similarly, another study including participants who were deteriorating preoperatively showed sustained mild clinical improvement for seven years in those subjected to valvuloplasty compared with participants undergoing superficial venous surgery alone. However, this benefit was lost when the condition of participants was stable preoperatively. One small study (n = 40) with grade 3 reflux and no participants with ulcers reported that external valvuloplasty of the femoral vein combined with surgical repair of the superficial venous system improved the haemodynamic status of the lower limbs, restored valvular function more effectively and achieved better outcomes than surgical repair of the superficial venous system alone.

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