Deep Venous Incompetence and Valve Repair

Abstract This chapter deals with deep venous valve reconstructions aimed to provide a competent valve in the lower leg deep venous system and thereby prevent free reflux of blood into the lower leg when standing. Normal venous anatomy with some expected variations, particularly in relation to adjacent muscle bundles to allow for proper exposure, is discussed in addition to basic normal physiology and hemodynamics. The causes of and pathology of deep venous valvular disease highlight the difference between primary and secondary conditions. The resultant pathophysiology is common to both conditions and the aim of repair is to ameliorate the abnormal physiology sufficient to control a patient’s symptoms to a tolerable degree. The clinical evaluation required to define your specific patient’s condition in terms of clinical presentation, etiology, affected anatomy, and pathophysiologic consequences (CEAP) is detailed. Advanced imaging as regards to noninvasive and invasive techniques (venography) is required to plan an operative approach in a patient with deep venous valvular disease. If this imaging finds venous valves that are architecturally preserved, direct valve repair is possible by virtue of external banding, external valvuloplasty, or internal valvuloplasty. If no valve leaflets amenable to repair are present, valve transposition, valve transplantation, or valve substitutes such as the recently described neovalve are potential operative options. Details regarding these repairs are the essence of this technical-oriented textbook. Postoperative care and early and late outcomes are provided from a review of the literature.