ANZ J. Surg. 2004; 74: 34–39 ORIGINAL ARTICLE ORIGINAL ARTICLE DEEP VENOUS VALVE RECONSTRUCTION FOR NON-HEALING LEG ULCERS: TECHNIQUES AND RESULTS RAMESH TRIPATHI,* † KISHORE SIEUNARINE,* MANZOOR ABBAS † AND NAZISH DURRANI † *Department of Vascular Surgery, Royal Perth Hospital, Perth, Australia and † Department of Vascular Surgery, M. S. Ramaiah Medical College, Bangalore, India Background: The purpose of the present paper was to report clinical and imaging results of a 5 year experience of deep venous valve surgery with evaluation of end-points at 2 year follow up for the management of non-healing venous leg ulcers in 137 patients. Methods: Between October 1994 and November 1999, 137 patients (169 limbs) underwent deep vein reconstructions for non- healing venous leg ulcers of clinical, etiological, anatomical, pathological classification (CEAP) C6 class, as a ‘last resort’ treatment. End-points of the study were post-valve reconstruction, freedom from leg ulceration, vein valve patency and competency at 2 years. Primary refluxive disease was present in 96 patients (118 limbs). External valvuloplasty was performed in 12 limbs (19 valves) and internal valvuloplasty was performed in 90 limbs (144 valves). External supports were used in 16 limbs (16 valves). Multilevel (2–3) reconstructions were performed in 37 limbs. Forty-one patients had secondary valvular defects involving 51 limbs. Axillary–femoral vein or saphenofemoral vein valve transplant was performed for 29 patients (35 limbs) and three patients (three limbs), respectively, saphenofemoral venous transposition was performed in three patients (four limbs), and femoral/popliteal vein ligation was carried out in six patients (nine limbs). Results : Two year results of external valvuloplasty showed ulcer healing in 50% of limbs with maintenance of competency at only 31% of valve stations. Internal valvuloplasty was the most durable valve repair procedure with 2 year leg ulcer healing rates of 67% and valve station competency of 79%. For secondary incompetence, valve transplants had a significant deterioration in valve patency and competence at 2 years: 58% and 47%, respectively, with 55.3% leg ulcer healing. It was also noted that single-level repairs or single valve transplants had lower ulcer healing rates than multilevel repairs or valve transplants with multiple valve stations. Conclusion : In a 2 year follow up, valvular reconstruction for refluxive disease is effective in healing venous ulcers that defy conservative management and superficial/perforator venous surgery. Furthermore, these procedures appear more promising for primary than for secondary incompetence. Multilevel or multivalve reconstructions yield superior results to single-level repairs in medium-term follow up. Key words: deep vein valvular reflux, leg ulceration, valvuloplasty. Abbreviations: CEAP, clinical, etiological, anatomical, pathological classification; DVT, deep venous thrombosis; PTFE, polytetrafluorethylene; VCT, valve closure time. INTRODUCTION Venous ulceration in the gaiter area of legs occurs as a con- sequence of unabated, persistent chronic venous insufficiency. This is due to valvular deficiency of superficial, perforator or deep veins alone or in combination. Most venous ulcers heal rapidly after superficial vein surgery if the deep venous system is not involved, but the results are not good when deep veins are involved. 1,2 Treatment options to correct deep venous insuf- ficiency, therefore, must be investigated. There is evidence that surgical treatment of deep vein valvular reflux leading to severe chronic venous insufficiency provides long-term relief of symptoms and heals venous leg ulcers in 65–80% of patients at 5 years following operation. 1,3–5 Venous valve reconstruction for chronic venous insufficiency was introduced by Kistner as early as in 1968. 6 However, deep venous valvular reconstructions have not become popular and maintain an aura of controversy due to a lack of comparative studies between conservative and surgical therapy. Furthermore, previous studies have included patients with valvular surgery performed with additional superficial and perforator vein surgery, making it difficult to assess whether the benefits of such therapies were due to valve repairs or superficial/perforator surgery. The present study was undertaken to further justify the role of deep venous valvular reconstructions in chronic venous insuf- ficiency, in patients who had recalcitrant non-healing leg ulcer as a ‘last resort treatment’, despite multiple superficial/perforator vein surgeries, compression therapy and medical management. METHODS Between October 1994 and November 1999, of 162 patients who underwent deep vein reconstructions 137 patients (169 limbs) were included in the present study as having satisfied the inclu- sion criteria. The mean age of the present patient group was 38.7 years (range: 17–75 years) with a male:female ratio of 2.18:1. In the 169 limbs there were a total of 411 previous super- ficial/perforator operations performed in the past. Twenty-four Presented at the 14th Annual Meeting of the American Venous Forum, La Jolla, California, 21–24 February 2002. R. Tripathi FRCS(Ed); K. Sieunarine FRACS; M. Abbas MS; N. Durrani MB BS. Correspondence: Mr R. Tripathi, Department of Vascular Surgery, Royal Perth Hospital, Perth, WA 6000, Australia. Email: tripathi@iinet.net.au Accepted for publication 20 January 2003.