title: Air plethysmographic assessment of external valvuloplasty in patients with valvular incompetence of the saphenous and deep veins.
abstract: OBJECTIVE
  The indications for deep venous valvuloplasty remain controversial in patients with incompetent deep vein valves associated with primary varicose veins. The purpose of this study was to evaluate the usefulness of external femoral valvuloplasty performed simultaneously with varicose vein surgery from the standpoint of venous function determined with air plethysmography.
  
  
  METHODS
  Thirty-one limbs of 25 patients (12 men, 13 women; mean age, 56.3 years; range, 33 to 80 years) with chronic venous insufficiency caused by valvular incompetence of both deep veins and saphenous veins were studied in a prospective, nonrandomized fashion. Descending phlebography showed moderate to severe reflux of grade 3 or 4 with Herman and Kistner classifications. Clinical severity of disease was CEAP classification 2S (in six limbs), classification 3 (in three limbs), classification 4 (in 16 limbs), classification 5 (in two limbs), and classification 6 (in four limbs). We performed superficial venous surgery alone in 14 limbs (control group), which consisted of stripping or ligation of incompetent saphenous veins and ligation of all incompetent perforators. In the remaining 17 limbs (study group), we performed superficial venous surgery simultaneously with external valvuloplasty of the femoral vein with intraoperative endoscopic observation. Venous reflux of the limbs was evaluated with air plethysmographic examination before surgery and at 1, 6, 12, and 24 months after surgery in both groups.
  
  
  RESULTS
  Preoperative venous filling index (mean +/- standard deviation) in the control and study groups was 9.4 +/- 3.8 mL/min and 8.8 +/- 3.5 mL/min, respectively (not significant), and it decreased to 7.0 +/- 3.6 mL/min (P <.01) and 2.8 +/- 1.0 mL/min (P <.01), respectively, 1 month after surgery. Postoperative index values in the study group were significantly lower than values in the control group (P <.01), and this difference continued for more than 2 years after surgery (P <.05). After a follow-up period of 12 to 37 months (average, 25 months), the venous clinical severity score was higher in the control group (3.4 +/- 1.7) than in the study group (2.1 +/- 0.3; P <.05), and the venous disability score was higher in the control group (1.4 +/- 0.6) than in the study group (0.8 +/- 0.8; P <.05).
  
  
  CONCLUSIONS
  Although further follow-up study is necessary, these results point to the functional and clinical usefulness of femoral valvuloplasty performed simultaneously with varicose vein surgery in patients with moderate to severe deep venous reflux. The venous filling index obtained with air plethysmography is an excellent predictor of the clinical severity of the disease and of postoperative clinical results.
authors.affiliation: Second Department of Surgery, Faculty of Medicine, University of the Ryukyus, Okinawa, Japan. sakuda-h@med.u-ryukyu.ac.jp
authors.forename: Hitoshi
authors.initials: H
authors.lastname: Sakuda
authors.forename: Moriyasu
authors.initials: M
authors.lastname: Nakaema
authors.forename: Shinobu
authors.initials: S
authors.lastname: Matsubara
authors.forename: Noboru
authors.initials: N
authors.lastname: Higa
authors.forename: Yoshihiko
authors.initials: Y
authors.lastname: Kamada
authors.forename: Yukio
authors.initials: Y
authors.lastname: Kuniyoshi
authors.forename: Kageharu
authors.initials: K
authors.lastname: Koja
mesh_terms: D016022:Case-Control Studies; D005260:Female; D005268:Femoral Vein / Q000601:surgery*; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010991:Plethysmography; D011446:Prospective Studies; D012501:Saphenous Vein / Q000601:surgery*; D013997:Time Factors; D014648:Varicose Veins / Q000175:diagnosis / Q000601:surgery*; D014689:Venous Insufficiency / Q000175:diagnosis / Q000601:surgery*