The role of angioscopic valve repair for primary valve incompetence (PVI).

The treatment of deep venous valvular reflux for advanced chronic venous insufficiency (CVI) has been cyclical in nature. During the late 1 960s and early 1 970s there was enthusiasm for ablation of the superficial venous system — saphenous and its branches as well as perforating veins, as the sole management for venous ulcer with deep venous reflux.’ Both the ulcer recurrence rate and wound morbidity associated with this approach dampened interest in the treatment of venous ulcer by superficial venous system ablation alone. 2 Direct deep venous reconstruction pioneered by Kistner 3 sparked interest in the later approach. Recently, minimally invasive surgery for treatment of incompetent perforating veins (SEPS) however, has refocused the treatment strategy for grade IV through VI CVI back on superficial ablation rather than deep venous recon struction due to the low wound morbidity rate of the former. The important work ofGloviczki and his North American SEPS Registry has shown that superficial venous ablation works better in patients with primary valvular incompetence than those with a post-throm botic etiology for their deep venous reflux. 4 This data suggests that a staged approach to deep venous reflux due to primary valvular incompetence is the appropriate strategy. Although primary valvu lar incompetence has traditionally been related to a fibro-elastic degeneration of the valve with resultant valvular insufficiency, 3 there is increasing evidence that volume overload from a capacious varicose superficial system can cause dilation of the deep venous system and secondary deep venous valvular incompetence. 5 The valves in this situation are intact, but the dilation of the venous annulus prevents them from appropriately coapting. Superficial system surgery which removes the volume overload has shown to restore both normal venous diameter and valve competence. It has been our approach to treat the incompetent superficial venous system first in patients with primary valvular incompetence and restrict direct deep venous reconstruction to those patients who fail this therapy. One of the hosts of this conference, Dr. Robert Kistner, was the first surgeon to describe a direct approach to rendering a valve competent rather than replacing the incompetent segment with competent valve “borrowed” from either a local or distant venous segment. 3 His initial report in 1968 stimulated interest in the surgical repair of primary valvular incompetence. Our case report will detail the diagnosis, surgical technique and postoperative results of surgery for primary valvular incompetence.