Incompetent venous valves: Ultrasound imaging and exo-stent repair

Background: Lower limb venous disease remains a significant problem in our community today. The condition has been treated mainly with ablative procedures such as stripping and/or sclerotherapy. The aim of this study was to assess external valvular stenting (EVS) of incompetent venous valves as a reparative alternative to the management of patients with varicose veins. In addition, ultrasound examination of the superficial venous valves prior to surgery was also assessed for its ability to predict success with EVS. Methods: Valves considered for EVS were assessed with brightness-mode (B-mode), spectral pulsed Doppler (PD), color Doppler imaging (CDI) and brightness-flow (B-flow). The ultrasonic features of the great saphenous vein (GSV), terminal valve (TV) and sub-terminal valves (STV) were considered. Inclusion criteria were valvular ring dilation <12 mm in diameter, internal diameter (ID) <12 mm along the entire length of the trunk, symmetry of the valve sinuses, positive identification of two valve cusps, and symmetrical reflux flow patterns through the incompetent valve. There were 69 limbs included in the study. All repaired TVs were tested intraoperatively for competence after application of the EVS. If there was evidence of residual reflux, the STV was also repaired. The operated limbs were assessed clinically 3 months after the procedure at which time ultrasound was also used to test the repaired valves. Results: Of the 69 TVs that were examined preoperatively, a total of 50 were considered repairable by ultrasonic features. At operation, 44 of these valves were successfully repaired. In the 6 limbs that had residual TV reflux, the STV was repaired. All 6 had competence in the GSV trunk following the STV EVS. Of the 19 TVs that were considered by ultrasonic features to be unrepairable, 18 had gross reflux following EVS with 1 only being repaired successful. All limbs that were successfully repaired at operation were followed up 3 months later, and re-examined with diagnostic ultrasound. Of this group, 3 GSVs had residual reflux at the TV and STV, 1 GSV had major reflux and 1 GSV developed thrombophlebitis. The overall figures for the predictability of successful EVS based on ultrasonic features of the valve were sensitivity 97.8% (95% CI, 88.2 - 99.6), specificity 75% (95% CI 53.3 - 90.2) and accuracy 90.4%. Conclusions: In the treatment of varicose veins, a combination of ultrasound modalities accurately predicts EVS outcomes at the TV and STV of the GSV.