title: Reduction internal valvuloplasty is a new technical improvement on plication internal valvuloplasty for primary deep vein valvular incompetence.
abstract: OBJECTIVE
  We describe a new technique of valve leaflet closure, reduction internal valvuloplasty (RIVAL), to treat primary deep vein valvular incompetence in patients with C6 venous disease.
  
  
  METHODS
  The RIVAL method involves excision of redundant valve and suturing of the freshened edge to the wall of the valve station instead of plication at the commissural junctions. Since January 2008, RIVAL has been successfully performed on 44 incompetent deep vein valves in 18 consecutive patients (25 limbs). All patients had C6 venous ulcers of a minimum 3 months' duration.
  
  
  RESULTS
  On mean follow-up of 1 year (clinical assessment of venous ulcer healing and color-coded duplex scans at 1, 6, 12, 18, and 24 months) of the 44 valves repaired by reduction valvuloplasty, all 44 valves (100%) maintained full patency. Forty-two valves (95.4%) were competent, achieving a valve closure time <1 second with no reflux at the target valves on Valsalva maneuver in the reverse Trendelenburg and upright positions, and their intervalvular distances were reduced to >60% of preoperative levels. Eighty-eight percent of all ulcers (22 of 25) healed within 9 weeks of surgery without any recurrence in the follow-up period. There was no valve thrombosis or resorption seen with this method.
  
  
  CONCLUSIONS
  The RIVAL technique represents a significant advancement over the traditional existing valve plication techniques. It enables accurate anatomic fashioning and suturing of valve cusps and results in excellent competency and ulcer healing rates with fewer complications in our early experience. Further follow-up is anticipated to define its long-term role in the management of C6 venous disease.
authors.affiliation: Narayana Institute of Vascular Sciences, Bangalore, India.
authors.forename: Himanshu
authors.initials: H
authors.lastname: Verma
authors.affiliation: Narayana Institute of Vascular Sciences, Bangalore, India.
authors.forename: Rajesh
authors.initials: R
authors.lastname: Srinivas
authors.affiliation: Narayana Institute of Vascular Sciences, Bangalore, India.
authors.forename: Robbie K
authors.initials: RK
authors.lastname: George
authors.affiliation: Narayana Institute of Vascular Sciences, Bangalore, India. Electronic address: ramesh.tripathi@vascularsurgeon.org.
authors.forename: Ramesh K
authors.initials: RK
authors.lastname: Tripathi