Some new considerations on venous valvuloplasty: an international on line debate

Abstract

venous valvuloplasty and an intriguing discussion took
place on VASCULAB, a well known network on line with
about 1300 expert members in phlebology guided by F.
Passariello as conceiver and coordinator.
The valvuloplasty attempts to reduce blood reflux and
venous hypertension in chronic venous disease (CVD). The
technique requires a skilled and experienced surgeon and a
careful patient evaluation and selection. It could be a good
approach in selected cases with post thrombotic syndrome
(PTS).
Some studies indicate in the nineties that valvuloplasty
or valvular replacement is an effective treatment for venous
incompetence in selective cases. After a concise valvuloplasty story from Kistner to Maleti, despite the advances in
valvuloplasty, we point out that the surgical mainstay to
correct CVD, deep and superficial or both, or primary varicose veins is great saphenous vein (GSV) ligation and stripping but also various conservative or endovascular treatments. Nevertheless actually some clinical studies have
reported achieving long-term, effective competence of deep
venous system, as well as the superficial venous system,
both after valvuloplasty or by implanting an external vein
support device.
J. Opie identified as an optional surgical solution for the
large underserved patient group of PTS a new technique:
« monocusp surgery ». He presented a new surgical method
to replace a dysfunctional aplastic / dysplastic / absent
venous valve using the full thickness viable native vein wall
tissue (the monocusp) and covered the defect with an ultrathin synthetic e-PTFE vascular closure patch (iVenaTMe-PTFE
patch) to successfully reverse venous insufficiency and its
effects both early and long-term with limited complications. The description on monoscusp valvuloplasty by Opie
in Vasculab was accurate.
At the same time S. Camilli presented his technique of
external stretching valvuloplasty with a new device is « oval
shaped external support « (OSES), made by a Nitinol net-like
framework, very smooth, elastic and flexible, available in
different size. The OSES device is suitable for the terminal
and pre-terminal valves of the GSV and virtually for any
peripheral venous valve, on superficial and deep system,
also without ligation of the possible present competent collaterals.
The discussion was ample and very interesting with the
contributes of C. Recek, B.B. Lee, C. Franceschi, O. Maleti and
others, included J. Opie and S. Camilli.
In general, R. Kistner considerations about Maleti’s technique are true for all valvuloplasties: « I find no fault with
valvuloplasty and I am anxious to see if others can duplicate
the experience. Points that need to be expanded in these
experiences are how many cases were evaluated and found
not to be candidates for this procedure, the length of the
learning curve for producing a reliably competent valve, and
whether there is any sign that these new valves will degenerate with time. If this technique can be successful, the
next question will be whether it can be achieved in a more
minimally invasive method »