Single-leaflet reconstruction surgery for severe chronic lower limb venous insufficiency caused by post-thrombotic syndrome: a case report and literature review

Abstract

Background

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A considerable number of patients with deep vein thrombosis of the lower extremities will develop post-thrombotic syndrome even after receiving standardized anticoagulation therapy. Damage to the femoral vein valves caused by post-thrombotic syndrome can lead to severe chronic lower limb venous insufficiency and currently there is a lack of effective treatment.

Case presentation

We present a patient with pigmentation and itching due to post-thrombotic syndrome, where the anterior leaflet of the first set of valves in the superficial femoral vein was completely destroyed, while the posterior leaflet, although structurally intact, was adhered to the vessel wall. By reconstructing the posterior leaflet of the femoral vein valve and simultaneously narrowing the lumen where the anterior leaflet was located through suture ligation, we restored the valve’s function to prevent venous reflux. During a 12-month follow-up period, the patient’s quality of life significantly improved.

Conclusions

Single-leaflet reconstruction surgery may serve as a potential treatment option for patients with post-thrombotic syndrome.

Introduction

Post-thrombotic syndrome (PTS) of lower extremities refers to a series of manifestations of venous insufficiency that occur in patients 3 months to several years or even decades after deep vein thrombosis (DVT). These symptoms typically include leg swelling, pigmentation, itching, and even ulcers [1], which severely affect quality of life [2, 3]. For DVT patients, especially for those with proximal DVT [4,5,6], the risk of developing PTS remains as high as 20–50% even after receiving standard anticoagulation therapy, and the incidence of severe PTS, such as venous ulcers, is approximately 5% [7,8,9]. The mechanism behind PTS involves obstruction of the venous lumen caused by DVT or damage to the venous valves due to thrombus organization, leading to chronic venous insufficiency (CVI) [6, 10, 11]. Non-surgical treatment options include vasoactive drugs, compression therapy, and exercise training, but their effectiveness is limited [1, 12,13,14,15,16,17]. For patients with severe PTS, if there is an obstruction in the iliac veins, the first consideration should be endovascular treatments such as balloon angioplasty and stenting to eliminate the obstruction. If the iliac veins are confirmed to be patent, then attention should turn to correcting reflux in the femoral vein valves [18]. However, due to valve destruction and extensive adhesions around the valves caused by organized thrombi, restoring the morphology and function of the valves through surgery can be a big challenging [19]. We present a patient with severe lower extremity venous insufficiency caused by PTS, presenting with pigmentation and itching. This patient successfully underwent reconstruction of a single leaflet of the femoral vein valve, resulting in improved quality of life.

Case report

A 62-year-old male was admitted to our hospital due to severe lower extremity venous insufficiency. The patient first experienced sudden onset of persistent edema in the right lower limb 20 years ago, with the swelling affecting the right thigh and right calf. Through color Doppler ultrasound examination at a local hospital, acute deep vein thrombosis in both lower limbs was discovered, with the right side involving femoral vein, popliteal vein, and great saphenous vein thrombosis and the left side an isolated gastrocnemius vein thrombosis. No screening for risk factors of thrombosis was performed, and he was treated with anticoagulation therapy (oral warfarin) for one year. Six years ago, the patient gradually developed symptoms of bilateral lower limb soreness, swelling, and pigmentation in the foot and ankle area, which were more severe on the right side, accompanied by severe itching. The patient sought medical help (including oral medications, wearing compression stockings, and other unknown treatments), but symptoms did not improve. The patient had a 10-year history of hypertension and coronary heart disease. Two years ago, he underwent valve replacement surgery due to valvular heart disease and had been on long-term oral warfarin since then. He had no history of smoking, alcohol abuse, drug misuse, or recent trauma. There was no significant family history related to thrombotic disorders. The patient also had no recent history of fever, headache, chest tightness, abdominal pain, nausea, or vomiting. The patient didn’t exhibit any symptoms of shortness of breath or wheezing either after recent activities or at rest.

The physical examination revealed no varicose veins in the abdominal wall (including the lower and lateral abdominal walls), both thighs and legs. Corona phlebectatica was visible around both ankles (Fig. 1A). Hemosiderin deposition was observed on both lower legs, which was severe on the medial and posterior aspects of the right foot’s boot area, along with eczematous changes. There was no evidence of ulcers or signs of ulcer healing. Pitting edema was present in both lower legs. The circumference of the lower legs, measured 15 cm below the knee, was 38.5 cm on the left side and 39.5 cm on the right (Fig. 1B). Palpation of the dorsalis pedis and posterior tibial arteries showed normal bilaterally. Muscle strength in all four limbs was normal. The patient’s weight was 82 kg. The Villalta scale score was 15, and the revised Venous Clinical Severity Score (r-VCSS) was 12. Color Doppler ultrasound results showed chronic mural thrombi with patent blood flow and incomplete occlusion in the right common femoral vein, superficial femoral vein, popliteal vein, and great saphenous vein, confirming the previous occurrence of deep vein thrombosis. Incompetence of perforator veins in the right lower leg (non-pigmented area, Cockett II perforator, diameter 2 mm, reflux time greater than 0.5 s) was noted. Antegrade venography demonstrated good contrast filling in the iliac veins and proximal femoral veins, with no evidence of iliac vein compression. Multiple webs and stenoses were observed in the distal superficial femoral vein and popliteal vein, suggesting mild obstructive pathology in these segments. The venous blood flow from the foot and ankle to the right iliac vein and distal inferior vena cava remained patent (Fig. 1C and E), indicating that obstructive component in the distal veins may be minimal. An additional movie file provided further detail [see Additional file 1]. There were no significantly incompetent perforator veins around the pigmented area of the right foot’s boot region. Retrograde venography confirmed severe incompetence of the right femoral vein valve, with blood refluxing beyond the level of the right knee, as well as mild incompetence of a branch of the right deep femoral vein and the right femoral saphenous vein valve, with blood reflux reaching middle part of the thigh (Fig. 1D). Based on the above information, the patient was classified as C4cEsAdsPro [20], with grade III superficial femoral vein valve incompetence (Kistner classification) and grade II deep femoral vein valve incompetence (Kistner classification) [21]. We routinely performed an evaluation of both axillary veins under ultrasound, finding bilateral cephalic vein variations, both draining into the brachial vein. The echocardiogram didn’t reveal any abnormalities in cardiac structure and function, with an ejection fraction of 62%.

Fig. 1

Physical examination and venography. Legends: A Corona phlebectatica around the ankle; B Pigmentation in the foot and boot area; C Antegrade phlebography showed patent blood flow in the right popliteal vein, superficial femoral vein and common femoral vein, with no obstruction; D Retrograde phlebography showed reflux in the right common femoral vein (yellow arrow), the right superficial femoral vein (red arrow), the branches of the right deep femoral vein (white arrow), and the right great saphenous vein (black arrow). The most severe reflux occurred in the right superficial femoral vein, with the reflux extending beyond the knee joint level (red arrow); E Antegrade phlebography showed patent blood flow in the right iliac vein and the distal part of the inferior vena cava, with no pelvic collateral veins formation. Based on the aforementioned examination results, we believed that the symptoms and signs of PTS in the patient’s right lower limb weren’t not caused by cardiac factors or by obstructive factors in the lower limb veins, but were mainly due to reflux in the superficial femoral vein. We proceeded with a superficial femoral vein valve repair surgery for the patient

The surgical procedure was performed under general anesthesia. We performed surgery in the area of the right superficial femoral vein valve, exposed the superficial femoral vein valve, released the adhesions, and restored the morphology and function of the valve. The specific procedure was as follows. After anatomical exposure of the femoral vein, a strip test was first conducted, which confirmed significant reflux in the right superficial femoral vein. Following systemic heparinization and blocking, a longitudinal incision was made along the anterior wall of the superficial femoral vein, revealed numerous irregular fibrous cord-like proliferations inside, which were considered to be due to organized thrombi. Further exploration of the first set of valves in the superficial femoral vein revealed that the anterior leaflet was completely destroyed and almost absent, while the posterior leaflet was intact but elongated, with part of it adhered to the posterior venous wall by fibrous cord-like tissue (Fig. 2-A and -D). First, we carefully separated the posterior leaflet from the adhered fibrous cord-like tissue, excised the excess fibrous cord-like tissue, and restored the sinus structure of the posterior leaflet (Fig. 2-E). Then, we sutured at the two attachment points of the posterior leaflet on the venous wall toward the anterior leaflet direction to shorten the edge of the leaflet, preventing it from being too elongated. We then sutured a portion of the venous wall where part of the anterior leaflet was located, reducing the overall cross-sectional area of the lumen by approximately one-third (Fig. 2-B and -F). While ensuring that the lumen was not excessively narrowed, this procedure allowed the narrowed anterior wall of the vein to come into better apposition with the posterior leaflet when it is being expanded, ultimately creating a perfect single-leaflet structure and restoring the valve’s function to prevent venous reflux (Fig. 2-C). Finally, we used a vascular patch to create a tubular structure and wrapped it around the outer wall of the vein (Fig. 2-G) [22], and ligated a branch of the deep femoral vein (which had severe reflux during the preoperative angiography). After completing these steps, we repeated the strip test, confirming that the superficial femoral vein valve function was intact with no reflux (Fig. 2-G). The groin incision was then sutured, a drainage tube was left in place, and the surgery was completed.

Fig. 2

Surgical procedure. Legends: A Fibrous structure adhering between the posterior leaflet of the femoral vein valve and the wall of the femoral vein (white arrow), and the almost destroyed and disappeared anterior leaflet structure (red arrow); B The area where the anterior leaflet of the femoral vein valve was sutured; C Reconstructed single-leaflet structure of the femoral vein; D The posterior valve leaflet adhered to the posterior venous wall by fibrous cord-like tissue (white arrow); E Punctate bleeding (black arrow) on the venous wall after the fibrous cord-like tissue adhered to the posterior valve leaflet was dissected and removed and reconstructed sinus structure of the posterior valve leaflet (white arrow); F The partial lumen constricted by suturing (black arrow) where the anterior valve leaflet was located and the full state of the femoral vein lumen distal to the valve (white arrow) when filled with blood; G When wrapping a vascular patch around the outer wall of the vein (white arrow) and blocking the distal femoral vein and moving the blood in the proximal cavity towards the proximal direction, the empty lumen (white arrow) distal to the valve suggested that the single posterior valve leaflet was capable of preventing venous reflux

After the surgery, the patient was kept in a heparinized state for 3 consecutive days, with the activated partial thromboplastin time (APTT) monitored to be within 2.5 to 3.5 times the normal range. Three days later, the treatment was switched to a standardized oral anticoagulation rivaroxaban regimen. The patient received a total of three months of anticoagulation. Postoperatively, the swelling, soreness, and itching in the patient’s right lower limb gradually subsided. The patient continued to maintain pressure therapy with medical compression stockings.

Follow-up examinations through Color Doppler ultrasound at 1 month, 3 months, 6 months and 1 year post-surgery showed that the blood flow in the right femoral vein was unobstructed, with no new thrombus formation, and no reflux was observed in the right superficial femoral vein valve during the Valsalva maneuver (Fig. 3). Six months after the surgery, the swelling in the right lower limb had decreased, and the itching and soreness had disappeared, reducing the patient’s dependence on compression stockings and allowing a return to normal life. The Villalta scale score decreased to 4, and the r-VCSS decreased to 6. We obtained the patient’s consent for this publication.

Fig. 3

Venous Color Doppler ultrasound results. Legends: A Preoperative ultrasound showed significant reflux (white arrow) in the femoral vein when performing the Valsalva maneuver. B Postoperative venous ultrasound showed no reflux (white arrow) in the femoral vein distal to the reconstructed vein valve (red arrow) when performing the Valsalva maneuver

Discussion

PTS is a condition that occurs months to years after DVT, characterized by impaired venous return in the lower limbs due to deep vein obstruction and/or valve reflux. Current research indicates that early mechanical and pharmacological thrombectomy on the basis of adequate anticoagulation can reduce the long-term risk of PTS [23,24,25,26,27]. However, for PTS that has already developed, there are currently no effective treatment methods. Previous treatments for PTS have included venoactive drugs, compression therapy, exercise training, and surgical interventions, but the efficacy of those non-surgical treatments is not well established, making surgical treatment particularly significant [12,13,14,15,16,17]. For patients with proximal obstruction (such as iliac vein stenosis or occlusion), bypass surgery or endovascular angioplasty (such as iliac vein balloon dilatation and stenting) to relieve the obstruction can yield clear benefits [18]. For patients without proximal venous obstruction but with femoral vein reflux as the primary pathogenic factor, our treatment goal is to restore the normal structure and function of the venous valves at that site.

Transplanting a segment of the axillary vein with functional valves to the femoral vein affected by post-thrombotic valve insufficiency can improve lower limb venous insufficiency for a certain period, but the long-term outcomes are not ideal. Masuda and Kistner reported long-term follow-up results for PTS patients who underwent axillary vein transplantation or femoral vein valve transposition, finding that only 37% of PTS patients had good to excellent outcomes [19]. Loay and colleagues performed axillary vein valve transplants in 18 patients with severe CVI, 66% of whom had post-thrombotic femoral vein valve insufficiency, and found that the median duration of normal valve function after autologous axillary vein valve transplantation was only 15 months [28]. This may be primarily due to the fact that axillary vein valves are weaker than femoral vein valves and may be unable to withstand the high pressure in the lower limb veins over a long term, leading to the rapid loss of function of the transplanted axillary vein valves in the femoral vein.

In addition, for patients who are candidates for axillary vein transplantation, it is necessary to evaluate the course of the cephalic vein. Only in patients where the cephalic vein drains into the subclavian vein can the axillary vein on that side be considered for transplantation; otherwise, this could lead to severe upper limb swelling and thrombosis of the upper limb veins. In our case, both cephalic veins of the patient drained into the brachial veins, making axillary vein valve transplantation unfeasible.

Although valve repair and reconstruction can restore the structure and function of valves, this approach is primarily used as a surgical treatment for primary lower limb venous valve insufficiency. For patients with PTS, the difficulty in repairing the femoral vein valves significantly increases. This is mainly due to two factors. First, the organization of thrombi around the valves leads to the destruction of valve structures, making it difficult to perform symmetrical repair of the valve leaflets. Second, even if the valve structure is still intact, we need to release the adhesions caused by organized thrombi between the valves or between the valves and the vessel wall. This process can cause damage to the endothelium and expose subendothelial tissues to the lumen, leading to recurrent venous thrombosis [29], which ultimately results in the failure of valve repair and reconstruction surgery. Therefore, attempts at valve repair and reconstruction in PTS patients are rarely made. S. Raju et al. evaluated the durability of venous valve reconstruction techniques in primary reflux and post-thrombotic reflux, finding that in primary femoral vein valve reflux, the durability of valve reconstruction was superior to that in post-thrombotic femoral vein valve reflux [30].

Specific femoral vein valve repair techniques include intraluminal and extraluminal repairs. Intraluminal repair is a classic surgical technique for treating deep venous valve insufficiency, first proposed and applied clinically by Kisnter in the 1970s [21]. The general procedure involves occluding the vein and then making a longitudinal incision at the junction of the valve leaflets of the first pair of valves in the superficial femoral vein. Using a 7 − 0 non-traumatic suture, the surgeon performs a U-shaped stitch approximately 2 mm below each junction point of the valve leaflets, passing the needle from outside the venous wall through to the free edge of the valve leaflets and exiting the wall to tie the suture. The posterior wall is sutured in the same manner. After completing the suturing, it should be observed that both valve leaflets are semi-erect. Flushing with heparinized saline should show the elastic coaptation of the valve leaflets. Finally, the incision on the venous wall is closed and the lumen reopened. In contrast, the surgical method for extraluminal repair involves fully exposing the area of the first pair of valves in the superficial femoral vein, identifying the dilated angle formed by the grayish-white bilateral valve attachment lines and their intersection points on the venous wall. A 7 − 0 Prolene suture is used to make stitches at the intersection point of the valve leaflets and knots are tied. Starting from the intersection point, continuous sutures are made through both sides of the valve attachment lines to reduce the angle formed by the two valve leaflets below the intersection point. After narrowing, a Strip test is performed to observe the recovery of valve function and blood flow conditions. Previous studies have found that intraluminal repair is more effective than extraluminal repair, especially for patients with PTS [30, 31]. Regardless of the method, the goal is to simultaneously reconstruct both valve leaflets, shorten the edges of the anterior and posterior leaflets, and align them at the midline level of the vein, in order to restore good anti-reflux capability. For patients with PTS, the presence of residual thrombi within the lumen, valve adhesions, and valve damage varies significantly, highlighting the highly individualized nature of valve repair strategies, which may be the reason why patients with PTS are more suitable for intraluminal repair. There is no standardized surgical approach for valve repair in PTS patients; each case is reported as an individual instance. Similarly, for our patient, due to the erosion caused by organized thrombi, one of the leaflets in the first set of femoral vein valves was completely destroyed, making it impossible to perform a traditional double-leaflet repair. We had to adopt a combined approach of single leaflet reconstruction and suturing the venous wall on the opposite side where the other leaflet was located. The process of reconstructing the posterior leaflet was similar to the method proposed by Kistner. However, the technique of suturing the venous wall on the anterior leaflet side had not been previously reported—it was an innovative attempt. Using this method, we were able to bring the reconstructed posterior leaflet as close as possible to the anterior wall of the vein, thereby restoring its effective anti-reflux function. Although further research is needed to validate this, we believe that this surgical technique holds promise as a viable option for treating PTS patients.

It should be noted that releasing adhesions within the venous lumen can cause endothelial damage, increasing the risk of early postoperative venous thrombosis [29]. Therefore, we maintained the patient’s APTT level above 2.5 times the normal range for the first three days postoperatively, after which we switched to full-dose oral anticoagulants. Similarly, we did not address the right great saphenous vein. Although there was reflux present in this vein, it did not exhibit significant dilation, and the degree of reflux was mild. Therefore, we preserved it as a compensatory return vein following femoral vein thrombosis. With these measures, the patient did not develop new thrombi postoperatively, nor did they experience any bleeding-related complications. Additionally, the patient’s quality of life after surgery was significantly improved and was not affected by the preserved great saphenous vein.

In summary, the single leaflet reconstruction technique may be suitable for patients who meet the following criteria: those with severe PTS who have failed non-surgical treatments, significant reflux in the femoral vein, no obstructive venous disease and one of the two leaflets of the superficial femoral vein valve has been destroyed or significantly atrophied. Key points of the technique may include: selecting a structurally intact leaflet, carefully dissecting and removing fibrous bands adhered to the leaflet, suturing the two attachment points of the selected leaflet to pull and appropriately shorten the leaflet edge to prevent redundancy and simultaneously ligating a small portion of the vessel cavity where the contralateral leaflet resides to create a single-leaflet valve structure. This procedure may also restore anti-reflux function of vein valves. Furthermore, postoperative anticoagulation is crucial as it prevents early thrombosis within the lumen, which could lead to surgical failure.

In our review of previous studies, we did not find any reports of a similar surgical approach. During the 1 year follow-up period after the surgery, the patient’s superficial femoral vein valve maintained good function. This case suggests that for PTS patients, there is no standardized approach for valve repair; an individualized principle must be followed. Restoring valve function through the repair and reconstruction of a single leaflet in the superficial femoral vein may be feasible. This has significant implications. A large number of PTS patients who traditionally could not undergo simultaneous repair and reconstruction of both valve leaflets may have the opportunity to restore valve function through single-leaflet repair and reconstruction, thereby alleviating PTS symptoms and improving their quality of life.