Skip to main content

Deep Venous Reflux

  • Chapter
  • First Online:
Venous Disorders
  • 660 Accesses

Abstract

Chronic venous insufficiency (CVI) encompasses an extensive range of clinical manifestations from limb swelling to non-healing ulcers. Etiologies for CVI in the deep venous system include reflux, venous obstruction, or a combination of the two. Of these, reflux alone or in combination with obstruction is the contributing factor in the overwhelming majority (70–90%) of instances [1–7]. Such reflux involving the deep vein (DVR) can result from primary or secondary etiologies. The occurrence of DVR varies in different populations. While the precise number is hard to determine due to difference in metrics used, an excess of 30–60% of DVR is believed to be primary in origin [8–12]. Secondary DVR arises as a result of deep vein thrombosis (DVT) involving the extremity. Often the two can coexist in the same patient [13]. Primary DVR arises due to stretching/elongation of the valve cusps or dilation of the affected venous segment. A developmental etiology has also been recognized due to symptoms predating the age of actual presentation, often as early as teenage years [14]. Trauma has also been presented as a cause. Degeneration of the fibroelastic tissue of the valve that gradually develops over time is deemed the most plausible cause in a majority of patients [14]. This chapter explores the pathophysiology and management of DVR.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 109.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 139.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Moore DJ, Himmel PD, Sumner DS. Distribution of venous valvular incompetence in patients with the postphlebitic syndrome. J Vasc Surg. 1986;3(1):49–57.

    Article  CAS  Google Scholar 

  2. Shull KC, Nicolaides AN, Fernandes é Fernandes J, Miles C, Horner J, Needham T, et al. Significance of popliteal reflux in relation to ambulatory venous pressure and ulceration. Arch Surg. 1979;114(11):1304–6.

    Article  CAS  Google Scholar 

  3. Hanrahan LM, Araki CT, Rodriguez AA, Kechejian GJ, LaMorte WW, Menzoian JO. Distribution of valvular incompetence in patients with venous stasis ulceration. J Vasc Surg. 1991;13(6):805–11. discussion 11–2

    Article  CAS  Google Scholar 

  4. Danielsson G, Arfvidsson B, Eklof B, Kistner RL, Masuda EM, Satoc DT. Reflux from thigh to calf, the major pathology in chronic venous ulcer disease: surgery indicated in the majority of patients. Vasc Endovasc Surg. 2004;38(3):209–19.

    Article  Google Scholar 

  5. Johnson BF, Manzo RA, Bergelin RO, Strandness DE Jr. Relationship between changes in the deep venous system and the development of the postthrombotic syndrome after an acute episode of lower limb deep vein thrombosis: a one- to six-year follow-up. J Vasc Surg. 1995;21(2):307–12. discussion 13

    Article  CAS  Google Scholar 

  6. Neglen P, Thrasher TL, Raju S. Venous outflow obstruction: an underestimated contributor to chronic venous disease. J Vasc Surg. 2003;38(5):879–85.

    Article  Google Scholar 

  7. Raju S, Darcy MD, Neglen P. Unexpected major role for venous stenting in deep reflux disease. J Vasc Surg. 2009;51(2):401–8.

    Article  Google Scholar 

  8. Eriksson I, Almgren B. Influence of the profunda femoris vein on venous hemodynamics of the limb. Experience from thirty-one deep vein valve reconstructions. J Vasc Surg. 1986;4(4):390–5.

    Article  CAS  Google Scholar 

  9. Cheatle TR, Perrin M. Venous valve repair: early results in fifty-two cases. J Vasc Surg. 1994;19(3):404–13.

    Article  CAS  Google Scholar 

  10. Raju S, Fredericks R. Valve reconstruction procedures for nonobstructive venous insufficiency: rationale, techniques, and results in 107 procedures with two- to eight-year follow-up. J Vasc Surg. 1988;7(2):301–10.

    Article  CAS  Google Scholar 

  11. Sottiurai VS. Comparison of surgical modalities in the treatment of recurrent venous ulcer. Int Angiol. 1990;9(4):231–5.

    CAS  PubMed  Google Scholar 

  12. Masuda EM, Kistner RL. Long-term results of venous valve reconstruction: a four- to twenty-one-year follow-up. J Vasc Surg. 1994;19(3):391–403.

    Article  CAS  Google Scholar 

  13. Kistner RL, Eklof B, Masuda EM. Deep venous valve reconstruction. Cardiovasc Surg. 1995;3(2):129–40.

    Article  CAS  Google Scholar 

  14. Kistner RL. Primary venous valve incompetence of the leg. Am J Surg. 1980;140(2):218–24.

    Article  CAS  Google Scholar 

  15. Shami SK, Sarin S, Cheatle TR, Scurr JH, Smith PD. Venous ulcers and the superficial venous system. J Vasc Surg. 1993;17(3):487–90.

    Article  CAS  Google Scholar 

  16. Caps MT, Manzo RA, Bergelin RO, Meissner MH, Strandness DE. Venous valvular reflux in veins not involved at the time of acute deep vein thrombosis. J Vasc Surg. 1995;22(5):524–31.

    Article  CAS  Google Scholar 

  17. Brittenden J, Bradbury AW, Allan PL, Prescott RJ, Harper DR, Ruckley CV. Popliteal vein reflux reduces the healing of chronic venous ulcer. Br J Surg. 1998;85(1):60–2.

    Article  CAS  Google Scholar 

  18. Rosfors S, Lamke LO, Nordström E, Bygdeman S. Severity and location of venous valvular insufficiency: the importance of distal valve function. Acta Chir Scand. 1990;156(10):689–94.

    CAS  PubMed  Google Scholar 

  19. Neglen P, Egger JF, Olivier J, Raju S. Hemodynamic and clinical impact of ultrasound-derived venous reflux parameters. J Vasc Surg. 2004;40(2):303–10.

    Article  Google Scholar 

  20. Raju S, Fredericks RK, Hudson CA, Fountain T, Neglén PN, Devidas M. Venous valve station changes in “primary” and postthrombotic reflux: an analysis of 149 cases. Ann Vasc Surg. 2000;14(3):193–9.

    Article  CAS  Google Scholar 

  21. Welch HJ, Young CM, Semegran AB, Iafrati MD, Mackey WC, O’Donnell TF. Duplex assessment of venous reflux and chronic venous insufficiency: the significance of deep venous reflux. J Vasc Surg. 1996;24(5):755–62.

    Article  CAS  Google Scholar 

  22. Neglen P, Raju S. A rational approach to detection of significant reflux with duplex Doppler scanning and air plethysmography. J Vasc Surg. 1993;17(3):590–5.

    Article  CAS  Google Scholar 

  23. Labropoulos N, Delis K, Nicolaides AN, Leon M, Ramaswami G. The role of the distribution and anatomic extent of reflux in the development of signs and symptoms in chronic venous insufficiency. J Vasc Surg. 1996;23(3):504–10.

    Article  CAS  Google Scholar 

  24. Sarin S, Scurr JH, Smith PD. Medial calf perforators in venous disease: the significance of outward flow. J Vasc Surg. 1992;16(1):40–6.

    Article  CAS  Google Scholar 

  25. Lurie F, Kistner RL, Eklof B, Kessler D. Mechanism of venous valve closure and role of the valve in circulation: a new concept. J Vasc Surg. 2003;38(5):955–61.

    Article  Google Scholar 

  26. Marston WA, Brabham VW, Mendes R, Berndt D, Weiner M, Keagy B. The importance of deep venous reflux velocity as a determinant of outcome in patients with combined superficial and deep venous reflux treated with endovenous saphenous ablation. J Vasc Surg. 2008;48(2):400–5. discussion 5–6

    Article  Google Scholar 

  27. Szendro G, Nicolaides AN, Zukowski AJ, Christopoulos D, Malouf GM, Christodoulou C, et al. Duplex scanning in the assessment of deep venous incompetence. J Vasc Surg. 1986;4(3):237–42.

    Article  CAS  Google Scholar 

  28. van Bemmelen PS, Bedford G, Beach K, Strandness DE. Quantitative segmental evaluation of venous valvular reflux with duplex ultrasound scanning. J Vasc Surg. 1989;10(4):425–31.

    Article  Google Scholar 

  29. Masuda EM, Kistner RL, Eklof B. Prospective study of duplex scanning for venous reflux: comparison of Valsalva and pneumatic cuff techniques in the reverse Trendelenburg and standing positions. J Vasc Surg. 1994;20(5):711–20.

    Article  CAS  Google Scholar 

  30. Araki CT, Back TL, Padberg FT, Thompson PN, Duran WN, Hobson RW. Refinements in the ultrasonic detection of popliteal vein reflux. J Vasc Surg. 1993;18(5):742–8.

    Article  CAS  Google Scholar 

  31. Sarin S, Sommerville K, Farrah J, Scurr JH, Coleridge Smith PD. Duplex ultrasonography for assessment of venous valvular function of the lower limb. Br J Surg. 1994;81(11):1591–5.

    Article  CAS  Google Scholar 

  32. Masuda EM, Kistner RL. Prospective comparison of duplex scanning and descending venography in the assessment of venous insufficiency. Am J Surg. 1992;164(3):254–9.

    Article  CAS  Google Scholar 

  33. Labropoulos N, Giannoukas AD, Delis K, Mansour MA, Kang SS, Nicolaides AN, et al. Where does venous reflux start? J Vasc Surg. 1997;26(5):736–42.

    Article  CAS  Google Scholar 

  34. Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011;53(5 Suppl):2S–48S.

    Article  Google Scholar 

  35. Neglen P, Raju S. A comparison between descending phlebography and duplex Doppler investigation in the evaluation of reflux in chronic venous insufficiency: a challenge to phlebography as the “gold standard”. J Vasc Surg. 1992;16(5):687–93.

    Article  CAS  Google Scholar 

  36. Baker SR, Burnand KG, Sommerville KM, Thomas ML, Wilson NM, Browse NL. Comparison of venous reflux assessed by duplex scanning and descending phlebography in chronic venous disease. Lancet. 1993;341(8842):400–3.

    Article  CAS  Google Scholar 

  37. Raju S, Fredericks R, Lishman P, Neglen P, Morano J. Observations on the calf venous pump mechanism: determinants of postexercise pressure. J Vasc Surg. 1993;17(3):459–69.

    Article  CAS  Google Scholar 

  38. Kistner R. Surgical repair of a venous valve. Straub Clin Proc. 1968;34:41–3.

    Google Scholar 

  39. Raju S, Berry MA, Neglen P. Transcommissural valvuloplasty: technique and results. J Vasc Surg. 2000;32(5):969–76.

    Article  CAS  Google Scholar 

  40. Sottiurai VS. Technique in direct venous valvuloplasty. J Vasc Surg. 1988;8(5):646–8.

    Article  CAS  Google Scholar 

  41. Gloviczki P, Merrell SW, Bower TC. Femoral vein valve repair under direct vision without venotomy: a modified technique with use of angioscopy. J Vasc Surg. 1991;14(5):645–8.

    Article  CAS  Google Scholar 

  42. Kistner R. Surgical technique of external venous valve repair. Straub Clin Proc. 1990;55:15–6.

    Google Scholar 

  43. Hoshino S, Satakawa H, Iwaya F, Igari T, Ono T, Takase S. External valvuloplasty under preoperative angioscopic control. Phlebologie. 1993;46(3):521–9.

    CAS  PubMed  Google Scholar 

  44. O’Donnell TF Jr. The role of angioscopic valve repair for primary valve incompetence (PVI). Hawaii Med J. 2000;59(6):266–8.

    PubMed  Google Scholar 

  45. Welch HJ, McLaughlin RL, O’Donnell TF Jr. Femoral vein valvuloplasty: intraoperative angioscopic evaluation and hemodynamic improvement. J Vasc Surg. 1992;16(5):694–700.

    Article  CAS  Google Scholar 

  46. Raju S, Hardy JD. Technical options in venous valve reconstruction. Am J Surg. 1997;173(4):301–7.

    Article  CAS  Google Scholar 

  47. Raju S, Fredericks RK, Neglen PN, Bass JD. Durability of venous valve reconstruction techniques for “primary” and postthrombotic reflux. J Vasc Surg. 1996;23(2):357–66. discussion 66–7

    Article  CAS  Google Scholar 

  48. Eriksson I. Reconstructive surgery for deep vein valve incompetence in the lower limb. Eur J Vasc Surg. 1990;4(3):211–8.

    Article  CAS  Google Scholar 

  49. Ma T, Fu W, Ma J. Popliteal vein external banding at the valve-free segment to treat severe chronic venous insufficiency. J Vasc Surg. 2016;64(2):438.e1–45.e1.

    Article  Google Scholar 

  50. Camilli S, Guarnera G. External banding valvuloplasty of the superficial femoral vein in the treatment of primary deep valvular incompetence. Int Angiol. 1994;13(3):218–22.

    CAS  PubMed  Google Scholar 

  51. Nash T. Long term results of vein valve transplants placed in the popliteal vein for intractable post-phlebitic venous ulcers and pre-ulcer skin changes. J Cardiovasc Surg. 1988;29(6):712–6.

    CAS  Google Scholar 

  52. Iafrati M, O’Donnell TF. Surgical reconstruction for deep venous insufficiency. J Mal Vasc. 1997;22(3):193–7.

    CAS  PubMed  Google Scholar 

  53. Taheri SA, Lazar L, Elias S, Marchand P, Heffner R. Surgical treatment of postphlebitic syndrome with vein valve transplant. Am J Surg. 1982;144(2):221–4.

    Article  CAS  Google Scholar 

  54. Raju S, Neglen P, Doolittle J, Meydrech EF. Axillary vein transfer in trabeculated postthrombotic veins. J Vasc Surg. 1999;29(6):1050–62. discussion 62–4

    Article  CAS  Google Scholar 

  55. Eklof BG, Kistner RL, Masuda EM. Venous bypass and valve reconstruction: long-term efficacy. Vasc Med. 1998;3(2):157–64.

    Article  CAS  Google Scholar 

  56. Bry JD, Muto PA, O’Donnell TF, Isaacson LA. The clinical and hemodynamic results after axillary-to-popliteal vein valve transplantation. J Vasc Surg. 1995;21(1):110–9.

    Article  CAS  Google Scholar 

  57. Johnson ND, Queral LA, Flinn WR, Yao JS, Bergan JJ. Late objective assessment of venous value surgery. Arch Surg. 1981;116(11):1461–6.

    Article  CAS  Google Scholar 

  58. Pavcnik D, Uchida B, Kaufman J, Hinds M, Keller FS, Rösch J. Percutaneous management of chronic deep venous reflux: review of experimental work and early clinical experience with bioprosthetic valve. Vasc Med. 2008;13(1):75–84.

    Article  Google Scholar 

  59. Weber B, Hafner J, Willenberg T, Hoerstrup SP. Bioengineered valves for the venous circulation. Expert Rev Med Devices. 2016;13(11):1005–11.

    Article  CAS  Google Scholar 

  60. Raju S, Darcey R, Neglen P. Unexpected major role for venous stenting in deep reflux disease. J Vasc Surg. 2010;51(2):401–8. discussion 8

    Article  Google Scholar 

  61. Seager MJ, Busuttil A, Dharmarajah B, Davies AH. A systematic review of endovenous stenting in chronic venous disease secondary to iliac vein obstruction. Eur J Vasc Endovasc Surg. 2016;51(1):100–20.

    Article  CAS  Google Scholar 

  62. Neglen P, Hollis KC, Olivier J, Raju S. Stenting of the venous outflow in chronic venous disease: long-term stent-related outcome, clinical, and hemodynamic result. J Vasc Surg. 2007;46(5):979–90.

    Article  Google Scholar 

  63. Kurklinsky AK, Bjarnason H, Friese JL, Wysokinski WE, McBane RD, Misselt A, et al. Outcomes of venoplasty with stent placement for chronic thrombosis of the iliac and femoral veins: single-center experience. J Vasc Interv Radiol. 2012;23(8):1009–15.

    Article  Google Scholar 

  64. de Graaf R, de Wolf M, Sailer AM, van Laanen J, Wittens C, Jalaie H. Iliocaval confluence stenting for chronic venous obstructions. Cardiovasc Intervent Radiol. 2015;38(5):1198–204.

    Article  Google Scholar 

  65. Padberg FT Jr, Pappas PJ, Araki CT, Back TL, Hobson RW. Hemodynamic and clinical improvement after superficial vein ablation in primary combined venous insufficiency with ulceration. J Vasc Surg. 1996;24(5):711–8.

    Article  Google Scholar 

  66. Sales CM, Bilof ML, Petrillo KA, Luka NL. Correction of lower extremity deep venous incompetence by ablation of superficial venous reflux. Ann Vasc Surg. 1996;10(2):186–9.

    Article  CAS  Google Scholar 

  67. Walsh JC, Bergan JJ, Beeman S, Comer TP. Femoral venous reflux abolished by greater saphenous vein stripping. Ann Vasc Surg. 1994;8(6):566–70.

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer Nature Singapore Pte Ltd.

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Jayaraj, A. (2018). Deep Venous Reflux. In: Khanna, A., Jindal, R. (eds) Venous Disorders. Springer, Singapore. https://doi.org/10.1007/978-981-13-1108-6_3

Download citation

  • DOI: https://doi.org/10.1007/978-981-13-1108-6_3

  • Published:

  • Publisher Name: Springer, Singapore

  • Print ISBN: 978-981-13-1107-9

  • Online ISBN: 978-981-13-1108-6

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics