The sapheno-femoral junction valvuloplasty in the post-thrombotic syndrome: a proposal with the use of a new device

Abstract

Before developing deep venous thrombosis (DVT), most patients suffering from postthrombotic syndrome (PTS) have a normal great saphenous vein (GSV). After DVT, the GSV plays a vicarious function, but many patients develop secondary varicose veins (VVs) and the previous positive contribution of the GSV vanishes. In these cases the ablative strategy is generally implemented with positive results in the short-term, but commonly with late varicose recurrences. In two cases the authors preferred a different approach to preserve and recover the GSV vicarious function by sapheno-femoral junction (SFJ) valvuloplasty. Out of 43 cases we treated with SFJ stretching valvuloplasty performed with the new OSES device (V-OSES), we proposed this operation to two patients (A and B) suffering from PTS and secondary VVs at an early stage, classified as C3 and C4 (Clinical-Etiology-Anatomy-Pathophysiology classification, CEAP). In the V-OSES operation a gentle stretching force is applied onto the apex of the opposite valve commisures so that the valve cross-section becomes oval and the cusp's length excess is retrieved. The operation was performed on the SFJ valve having incompetent, but floating cusps visible on ultrasound (US) scan. This reparative technique was undertaken under local anesthesia and was combined with disconnection of the incompetent tributaries and/or perforators. The US-duplex scanning showed that the SFJ valves were competent at month 16 (B) and 20 (A) follow-up after surgery and the GSV vicarious function was preserved. The stretching valvuloplasty operation is intended to repair the SFJ valve incompetence and preserve the GSV vicarious function. This approach may be useful in primary VVs, but especially in PTS when superficial reflux appears and secondary VVs are at early stage. The SFJ reparative operation may be combined with the conventional GSV conservative strategies, including incompetent tributaries ablation/disconnection. This approach does not seem to have been already reported in the literature and needs further confirmation.