# Postthrombotic Syndrome: Surgical Possibilities

Authors: Ajay K. Khanna; Shivanshu Singh
Journal: Thrombosis
 (2012)

---

## Abstract

Postthrombotic syndrome
(PTS) is a late outcome of deep vein thrombosis characterized by
cramping pain, swelling, hyperpigmentation, eczema,
lipodermatosclerosis, and ulceration in the leg due to increased
venous outflow resistance and  reflux venous flow. Newer surgical
and endovascular interventions have a promising result in the
management of postthrombotic syndrome. Early surgical or
endovascular interventions in appropriately selected patients may
decrease the incidence of recurrent ulceration and skin changes and
provide a better quality of life. Duplex and IVUS (intravenous
ultrasound) along with venography serve as cornerstone
investigative tools for assessment of reflux and obstruction.
Venous obstruction, if present, should be addressed earlier than
reflux. It requires endovenous stenting, endophlebectomy, or open
bypass procedures. Venous stripping, foam sclerotherapy,
radiofrequency, or laser ablation are used to abolish superficial
venous reflux. Valvuloplasty procedures are useful for incompetent
but intact deep venous valves, while transposition or axillary
vein autotransplantation is done for completely destroyed
valves.


---

## Body

## 1. Introduction

Postthrombotic syndrome (PTS) affects nearly 23–60% of patients following an episode of deep vein thrombosis (DVT) [1]. Incidence of venous ulcers is around 3–5% [2]. Development of PTS is the principal determinant of health-related quality of life after DVT [3]. PTS is associated with worse physical quality of life and increased pain [4]. The annual health care cost of PTS in the United States is approximately $200 million [5]. The pathophysiology of PTS involves two key processes, namely, venous outflow obstruction as a result of partial recanalization of thrombus with decreased compliance of thrombotic vein and reflux venous flow due to valvular incompetence. Valve station fibrosis  leads  to  luminal  narrowing  and  valve  redundancy or widening of commissural valve  angle. These components result in distal venous stasis and venous hypertension in the lower limb. Reflux occurs not only in segments distal to postthrombotic stenosis but also in areas remote from them [6].Work-up includes meticulous clinical history and examination. Duplex sonography of affected limb has become the initial investigation of choice. It can qualitatively identify site of reflux and stenosis. Presence of echoic  lumen, reduced  compressibility,  impaired  augmentation  of  flow  on  distal  compression, and reduced  or  absent  phasity is qualitative parameters to identify venous thrombus  [7]. Quantitative assessment of overall severity of reflux when multiple segments are involved can be studied. At present, multisegment score or presence of axial reflux are the best available  measures [8]. Valve closure time has failed to have any clinical utility [9]. One of the  most important drawbacks of duplex is its inability to properly assess iliac vein thrombus. Intravascular ultrasound (IVUS ) provides better images of iliac vein and inferior vena cava thrombi [10]. It is  readily used during stent procedures. Ascending venography is an invasive method of getting a panoramic view of lower limb venous outflow in infrainguinal area. Efficient  collateralization  is  seen  in  femoropopliteal  postthrombotic stenosis  via  profunda  femoris  vein. Problem of distal venous hypertension occurs in iliac vein stenosis  due to poor collateral formation in the pelvic veins. This is the reason why iliocaval postthrombotic stenosis needs  intervention to reduce the impact of postthrombotic syndrome. Ambulatory venous pressure (AVP) provides  an  overall assessment  of venous dysfunction [11]. AVP is maximum in limbs having venous obstruction with reflux than having either of the two alone. Investigations  like  magnetic resonance imaging and computed tomography provide three-dimensional view of the venous tree.Compression therapy in the form of elastic stockings, unna boots, have been the traditional method of managing such patients. High level of noncompliance is a major limiting factor resulting in their failure [12]. Newer devices like Veinoplus have been tried to provide electrical stimulation to muscle calf pump. Contractions of calf muscle compress deep veins and improve the blood flow against resistance, decrease amount of reflux and the amount of venous stasis [13–15]. These all should  be  considered  complimentary  to  newer surgical  and  endovascular techniques. The type of surgical or endovascular intervention depends upon the site and type of pathology. Venous obstruction, if present, should  be  treated  earlier  than  reflux [3] with  iliofemoral stenting, endophlebectomy,  or venous  bypass  procedures. Venous  bypass  procedures  include  crossover  bypass  or  inline  bypass  procedure. Superficial  venous  reflux  is   managed  earlier  than  deep  reflux  with   stripping,  liquid  compression,  or  foam sclerotherapy; endovenous radiofrequency or laser ablation of saphenous vein. Deep vein valve repair is considered a second-stage operation when minimally invasive therapies have failed [3]. Though superficial reflux is managed earlier than deep reflux, it has been suggested  that both may be managed concomitantly [3]. Use of bioprosthetic valves (e.g., Portland valve), cryopreserved valves, gracilis sling procedure has been largely discouraging  [3]. The modified Italian neovalve  reconstruction seemed to improve valve continence result significantly  [16]. Still, strict guidelines or criteria  regarding who will be benefited most are not established [17]. Patients who are considered for surgical or  endovascular interventions  include  those who had (1) failure  of conservative  therapy, (2) recurrent complications  of postthrombotic syndrome, and (3) younger population suffering with this  syndrome. Stasis  skin changes are often the main indications of surgery [2].


## 2. Interventions for Iliofemorocaval Obstruction

### 2.1. Iliocaval Stenting

It has become the “procedure of choice” for the management of iliofemorocaval obstruction [18].  Compared  to  bypass  procedures  it  is  relatively  simple, has  lower risk,  it’s  an  OPD basis procedure, has excellent stent patency and better symptom improvement. Under ultrasound guidance, ipsilateral femoral vein  is accessed. Iliocaval thrombus is visualized by IVUS. The stenotic lesions are dilated by  15-16 mm balloon followed by placement of self-expanding stent. Intraoperative anticoagulation is done with  minimal dose of heparin followed by daily dosage with aspirin. Gianturco Z stent  has been used for stenting wide calibre vessels like inferior vena cava. Wallstent  has been used for inferior vena cava, pelvic veins, and larger veins of thigh region. For  medium-sized vessels, metallic stents  with smaller profile, self-expanding, and longitudinal flexibility are used. Commonly used diameters  are 12–14 mm. Hartung et al. found a technical success rate of stenting  procedure to be 95.5% [19]. Venous  clinical  severity  score  had  a median  improvement  from  8.5 to  2, and  median  venous  disability  score improved from 2 to 0. Cumulative primary, assisted primary, and secondary patency rates of the venous segments at 3 years were  73%, 88%, and 90%, respectively, in  intention to treat. The survival rate  was 100% at  1 year and 97.3% at 5 years [19].


### 2.2. Crossover Bypass Procedure (Palma-Dale Procedure [20])

These procedures are done in cases of unsuccessful stenting attempts, stent failure, and long occlusions where stenting may not be feasible. They are  more  invasive, risky interventions  and require longer anticoagulation therapy. According to Vollmar  [21], prerequisites for success of cross-femoral grafts are patent contralateral iliofemoral vein and caval run-off; a supine resting pressure gradient in excess of 4 to 5 mmHg between the femoral veins in the involved and contralateral limbs; adequate distal venous system (a patent profunda femoris vein, preferably with an open or partially recanalized superficial femoral vein ); a patent and competent greater saphenous vein on the recipient  [run-off] side with a minimal diameter of 4 to 5 mm and no varicosities. In  the  crossover bypass, the great saphenous vein  of the nonaffected  limb  (donor limb) is exposed and rotated at the saphenofemoral junction. An alternative to the use of autologous saphenous vein is use of a  10 mm  PTFE  (polytetrafluroethylene)  graft   for  femoro-femoral  bypass  procedure  when  adequate  calibre saphenous vein is not available.  The  PTFE graft  is more thrombogenic than the autologous  graft. Under general anaesthesia, vertical incisions are made in both the groin regions to expose the common femoral, proximal superficial femoral, profunda femoris  vein and other femoral tributaries. The saphenous vein graft from nonaffected limb is prepared. A deep tunnel in subcutaneous plane is made in suprapubic and subsartorial region. The saphenous vein is passed  through  these tunnels  towards  the  affected  side  taking  great  care to  avoid  twisting  of the  vessel. It  is anastomosed  in  an  end  to side  fashion  to  the common  femoral or proximal popliteal vein  distal to  the site  of iliofemoral obstruction. An arteriovenous fistula is made between posterior tibial artery and vein to increase flow through  the graft  thus  maintaining  graft  patency  [22]. The  fistula  is  usually  closed  4 to 8  weeks  after surgery. Anticoagulation therapy is given for at least 45 days in the postoperative period. In a study on 78 limbs, Husni reported a “clinical success”  rate of 74% and patency was 73% during 7 to 144 months of followup [23]. Halliday et al. reported a cumulative patency rate of 75% during 5 yrs of followup [24].


### 2.3. In-Line Bypass Procedure

This procedure may be performed in the femoroiliocaval obstruction associated with segmental obstruction. Expanded PTFE graft (ePTFE graft) is most commonly used. An arteriovenous  fistula is created  distally  to  maintain  adequate  inflow.  Life-long anticoagulation is usually required.  Jost et al. showed  a secondary patency rate of 54% at 2 years [25].


### 2.4. Endophlebectomy

It is an open surgical technique in which the postthrombotic vein is longitudinally exposed at various segments and the synechiae attached to the intimal layer are carefully removed with scissors  at  the base. Removal of the constricting bands increases the inflow in iliocaval stenting and outflow for vein valve transposition or transfer and increase calf outflow. Puggioni and Lurie [26] reported a case series of 13 patients  in which surgical disobliteration was performed in 23 deep venous segments with 14 deep venous reconstructions. In 77% of patients, the treated segments remained primarily patent at mean followup of 11 months. Overall, secondary patency rate was 93%.


## 2.1. Iliocaval Stenting

It has become the “procedure of choice” for the management of iliofemorocaval obstruction [18].  Compared  to  bypass  procedures  it  is  relatively  simple, has  lower risk,  it’s  an  OPD basis procedure, has excellent stent patency and better symptom improvement. Under ultrasound guidance, ipsilateral femoral vein  is accessed. Iliocaval thrombus is visualized by IVUS. The stenotic lesions are dilated by  15-16 mm balloon followed by placement of self-expanding stent. Intraoperative anticoagulation is done with  minimal dose of heparin followed by daily dosage with aspirin. Gianturco Z stent  has been used for stenting wide calibre vessels like inferior vena cava. Wallstent  has been used for inferior vena cava, pelvic veins, and larger veins of thigh region. For  medium-sized vessels, metallic stents  with smaller profile, self-expanding, and longitudinal flexibility are used. Commonly used diameters  are 12–14 mm. Hartung et al. found a technical success rate of stenting  procedure to be 95.5% [19]. Venous  clinical  severity  score  had  a median  improvement  from  8.5 to  2, and  median  venous  disability  score improved from 2 to 0. Cumulative primary, assisted primary, and secondary patency rates of the venous segments at 3 years were  73%, 88%, and 90%, respectively, in  intention to treat. The survival rate  was 100% at  1 year and 97.3% at 5 years [19].


## 2.2. Crossover Bypass Procedure (Palma-Dale Procedure [20])

These procedures are done in cases of unsuccessful stenting attempts, stent failure, and long occlusions where stenting may not be feasible. They are  more  invasive, risky interventions  and require longer anticoagulation therapy. According to Vollmar  [21], prerequisites for success of cross-femoral grafts are patent contralateral iliofemoral vein and caval run-off; a supine resting pressure gradient in excess of 4 to 5 mmHg between the femoral veins in the involved and contralateral limbs; adequate distal venous system (a patent profunda femoris vein, preferably with an open or partially recanalized superficial femoral vein ); a patent and competent greater saphenous vein on the recipient  [run-off] side with a minimal diameter of 4 to 5 mm and no varicosities. In  the  crossover bypass, the great saphenous vein  of the nonaffected  limb  (donor limb) is exposed and rotated at the saphenofemoral junction. An alternative to the use of autologous saphenous vein is use of a  10 mm  PTFE  (polytetrafluroethylene)  graft   for  femoro-femoral  bypass  procedure  when  adequate  calibre saphenous vein is not available.  The  PTFE graft  is more thrombogenic than the autologous  graft. Under general anaesthesia, vertical incisions are made in both the groin regions to expose the common femoral, proximal superficial femoral, profunda femoris  vein and other femoral tributaries. The saphenous vein graft from nonaffected limb is prepared. A deep tunnel in subcutaneous plane is made in suprapubic and subsartorial region. The saphenous vein is passed  through  these tunnels  towards  the  affected  side  taking  great  care to  avoid  twisting  of the  vessel. It  is anastomosed  in  an  end  to side  fashion  to  the common  femoral or proximal popliteal vein  distal to  the site  of iliofemoral obstruction. An arteriovenous fistula is made between posterior tibial artery and vein to increase flow through  the graft  thus  maintaining  graft  patency  [22]. The  fistula  is  usually  closed  4 to 8  weeks  after surgery. Anticoagulation therapy is given for at least 45 days in the postoperative period. In a study on 78 limbs, Husni reported a “clinical success”  rate of 74% and patency was 73% during 7 to 144 months of followup [23]. Halliday et al. reported a cumulative patency rate of 75% during 5 yrs of followup [24].


## 2.3. In-Line Bypass Procedure

This procedure may be performed in the femoroiliocaval obstruction associated with segmental obstruction. Expanded PTFE graft (ePTFE graft) is most commonly used. An arteriovenous  fistula is created  distally  to  maintain  adequate  inflow.  Life-long anticoagulation is usually required.  Jost et al. showed  a secondary patency rate of 54% at 2 years [25].


## 2.4. Endophlebectomy

It is an open surgical technique in which the postthrombotic vein is longitudinally exposed at various segments and the synechiae attached to the intimal layer are carefully removed with scissors  at  the base. Removal of the constricting bands increases the inflow in iliocaval stenting and outflow for vein valve transposition or transfer and increase calf outflow. Puggioni and Lurie [26] reported a case series of 13 patients  in which surgical disobliteration was performed in 23 deep venous segments with 14 deep venous reconstructions. In 77% of patients, the treated segments remained primarily patent at mean followup of 11 months. Overall, secondary patency rate was 93%.


## 3. Interventions to Correct Venous Reflux

Venous  reflux in  PTS can  occur at  three sites, namely, superficial venous system, deep, or at  perforator level.  The superficial reflux being easier to manage is attended earlier than more complicated deep venous reflux.  Even in the presence of concomitant deep venous reflux, superficial venous surgery has shown to abolish deep venous reflux in 50%  of such  limbs  and  a 77% ulcer healing  rate  at  12  months  [27]. Surgery  for deep  venous  reflux  includes valvuloplasty for intact but incompetent valves, valve transposition, or axillary vein autotransplantation for destroyed valves. The first open valvuloplasty was performed by Dr. Kistner in 1968 [28].


### 3.1. Ablation of Superficial Venous Reflux

Saphenous vein stripping is still the standard in managing truncal reflux in saphenous vein. Liquid or foam compression sclerotherapy, endovascular radiofrequency, or laser ablation  of the great saphenous vein have all been used and have been rewarding. Liquid compression sclerotherapy is effective for cases of superficial venectasias and nontruncal varicosities with competent great and small saphenous vein [29]. Clinical and hemodynamic follow-up results have shown that foam sclerotherapy is better than liquid compression sclerotherapy  for truncal reflux in  great  saphenous  vein  [30, 31]. Trials  comparing  stripping  with  endovascular radiofrequency ablation have shown lesser pain, shorter hospital stay, and earlier return to work in radiofrequency ablation  group. However, at the end of 4 months, no significant difference was found in the two groups  [32, 33]. Neglen and associates have combined iliofemoral stenting with obliteration of superficial venous reflux and found that it is safe, effective and minimally  invasive single-stage procedure  [34]. Ablation of superficial venous reflux along with subcutaneous fasciotomy for chronic and recurrent venous ulcers improves ulcer healing  or success of skin grafting [35].


### 3.2. Interventions  for  Perforator  Incompetence

Role  of  surgical  treatment  for  perforator  incompetence  in  the management of PTS has not been studied well. This is because incompetent perforators are rarely found in isolation in cases of postthrombotic syndrome [36]. The incompetent perforators are treated by SEPS (subfascial endoscopic perforator surgery) or ultrasound guided therapeutic radiofrequency ablation.


### 3.3. Interventions  for  Deep  Venous  Reflux

The  first  and  second  proximal  femoral  valve  stations  are surgically approached via an ipsilateral groin incision made in the direction of vessels. Profunda  femoris exposure, if required, needs dissection of sartorius muscle fascia. By performing positive and negative strip tests, reflux at the valve station is assessed. Reflux is demonstrated by venous refilling distally. The adventitia at the particular valve station is carefully dissected to expose the valve attachment lines. Failure to identify the attachment lines implies that the particular valve is completely destroyed, thus not suitable for valvuloplasty. Either transposition or autologous vein transfer may be required in such cases [37].


#### 3.3.1. Internal Valvuloplasty

Following venotomy, the redundant valve cusps are exposed and apposed to the vein wall under direct vision with the help of 7–0 polypropylene suture. Plication of approximately 20% of valve length is usually sufficient to prevent reflux [38]. Dr. Kistner used longitudinal venotomy approach and opened the valve through  anterior commissure  [39].  Other approaches  are supravalvular transverse venotomy  without  opening  the valve [40], T-shaped venotomy [41]. A novel technique of trapdoor internal valvuloplasty has been described by Dr. Tripathi and Ktenidis [42]. After commissure identification, transverse venotomy involving half the circumference is made from the axis of the centre of one commissure to the other, one centimetre above and below the target valve. With the help of specially designed angled retractors, the valve cusps are kept away from the commissural axis. The anterior ends of the two transverse venotomy incisions are connected by a longitudinal venotomy along the more anterior of the two commissures. This creates a trapdoor at the level of target valve. It has the benefits of being technically less demanding and anatomically better defined and physiologically acceptable. The basic aim of all techniques is one, that is, plication of the redundant valve.


#### 3.3.2. External  Valvuloplasty

This  technique  involves  transmural  suturing  through  the  valve  attachment  lines without  performing  a  venotomy.  It  results  in  narrowing  of  the  commissural  angles,  thus  making  the  valves competent. Several modifications  have been introduced since long-term results have shown it to  be less durable repair. Limited anterior plication involves continuous mattress suturing from a point 3 to 4 mm proximal to the valve cusp insertion lines up to the angle of valve cusp insertion [43]. The aim was to reduce the amount of vein dissection and reducing the risk of progressive venous dilatation which occurs in some cases of valvuloplasty. It has promising long-term follow-up results in terms of improved venous refilling and decreased ambulatory venous pressure [43]. In 1991,  Gloviczki  and  colleagues  [44]  described  femoral  vein  valve  repair  under  angioscopic  guidance  without performing  a venotomy. The  angioscope is introduced through the saphenous vein  or one  of its  tributaries  and navigated under vision through  the  common  femoral vein  to  the bifurcation  of femoral  vein.  If found  to  have primary valvular incompetence, repair of valve is done by external placement of 7–0 polypropylene sutures. Suture is  placed  lateral  to  the  site  of  insertion  of  each  valve.  The  elongated  valves   are  gradually  shortened.  Valve competency is checked by infusion of irrigation fluid via the angioscope. An external PTFE cuff of size 1 to 1.5 cm width is placed around the site of repair to prevent venous dilatation.


#### 3.3.3. Transcommissural Valvuloplasty

This technique offers the advantage of avoiding venotomy as well as need of an angioscope. Performed  in cases of intact but incompetent valves, it  is safe, simple, rapid, and  multiple valve stations can be repaired at the same setting. An inverted V-shape is formed by the apices of the cusps of bicuspid venous valve. After adventitial dissection and identification  of valve station, a through  and through transluminal resuspension suture is passed obliquely across the inverted “V”, traversing both the cusps near their attachment to the wall. Involvement of both the valve cusps is evident by puckering of the valve attachment lines. Further two to four more interrupted stitches are placed distally, each of them being less deep and less oblique. The last stitch is at one to two mm beyond the point of maximum bulge at the valve station. The aim is to shorten valve cusp length at each end of commissure  by  nearly  20%. Similar  procedure  is  repeated  at the other end of the  cusp.  Strip  test is performed cautiously  to  check  for  valve  competence.  The  internal  valvuloplasty  corrects  the  valve  cusps  only  without considering the commissural angles while the  external valvuloplasty only corrects the commissural angle  without considering the valve cusps. The advantage of transcommissural valvuloplasty is that it corrects both the redundant valve cusps as well as  commissural angles. The cumulative competency rates of 140 sites were 84% at 12 months, 72% at 24 months, and 59% at 30 months [28]. Median time to failure was 11 to 16 months (range 2–35  months) depending on the criteria used [28]. Among 36 multiple valves repaired, duplex scan revealed 11 failures. All  11 valves  were  single  failures  (i.e., only  one  of the  repaired  valves  in  the  individual  limb  failed,  with the other(s) remaining  competent)  [28].  The  cumulative  competency  rate  of  the  transcommissural  repair  is  59%  to  69% depending on reflux criteria used. It is comparable to those reported for internal and external repair [45–47].


#### 3.3.4. Neovalve  Reconstruction

The  Italian  neovalve  reconstruction  is  a  technique  of  creating  an   antireflux mechanism. In this  technique, the femoral vein is exposed via a 10 cm long longitudinal incision  on the lateral border  of sartorius  extending  up  to  10–15 cm below  the  inguinal  ligament.  Intraoperative identification  of incompetent valve station is most crucial though duplex and other preoperative tests may be used. A longitudinal or transverse venotomy of 2-3 cm length is performed. With the help of ophthalmic blade or microscissors, the intimal dissection  is performed  to  raise an intimal flap. The  depth of  dissection depends on the vein  wall thickness. A monocuspid or a bicuspid valve can be created in this fashion. The size of flap is properly assessed to prevent valve prolapse in case of excessive width. In a variation to the original technique, Lugli and associates stitched the free edge of the flap to the vein wall by 7/0 suture [16]. This prevents reattachment of the flap to the original vein wall that had resulted in failure of neovalve  within a short period after surgery in earlier series. Contraindications  to neovalve reconstruction include severely limited ambulation, thrombophilia, bleeding diathesis, severe comorbidity, possibility of other standard techniques like femoral transposition, or valve transplant [16].  Cumulative ulcer healing was 7.7/100 patient-months  (16 cases per 206 patient-months) in the first series and 30.7/100 patient-months  (20 cases per 65 patient-months) in the second [16]. The cumulative patency rates were 16 cases per 919 patient-months (1.7/100 patient-months) and  21 per 228 patient-months  (9.2/100 patient-months), respectively,  in  the  first  and second  series  [16].  Postoperative  duplex scan  and  air  plethysmography  measurements  showed  a  significant improvement (P<0.001) [48]. Thus, neovalve reconstruction seemed to be effective in restoring femoral competence in postthrombotic reflux.


#### 3.3.5. Prosthetic Venous Valves

The need for prosthetic venous valves arises in cases of end-state chronic  deep venous insufficiency afflicted with recurrent or resistant venous ulceration in which the available  medical therapy and  interventional procedures  like  superficial  venous  ablation  or perforator surgery  have  failed  to  provide  any clinical or hemodynamic benefit. Majority of the attempts of prosthetic venous valve repair have not shown good results. A  bioprosthetic  Portland  valve  (bicuspid  square  stent -based  venous  valve  made  from small  intestinal submucosa) has  been studied  after percutaneous placement  in  the  sheep  external jugular vein  [49]. It  has  88% patency and competency rate. Valve tilting led to occlusion and valve insufficiency in three experimental animals [49].  Variations  have  been  made  to  prevent tilting  and to provide  a longer cusp which  is supposed  to be  more hemodynamic structure. Valve thickening is another problem with the prosthetic valves. Cryopreserved valves are superficial femoral vein containing valve allograft made by Cryo Life, Inc,  Kennesaw, Georgia. They can prevent venous  reflux up  to  125 mmHg  of  retrograde  venous  pressure. They  may  require  valvuloplasty  at  the time  of implantation for optimal performance and competency [50]. The cryopreserved valve allografts have failed in early and midterm clinical trial and are not considered suitable for treating DVT [51]. Graft rejection is a concerning issue regarding graft failure. T-cell immunosuppressive drugs like cyclosporine and azathioprine may prevent graft rejection. Another technique of restoring deep venous valve competence involves intussusception of the vein into itself [52]. The bicuspid valve is made by two sutures placed at 180 degree to hold the inner vein wall in correct position. Short-term patency was good with competency rate of 90–100%. But hemodynamic results are not as fair as in the case of native valves. Modifications like thinning of the adventitia and partly of the media to decrease the thickness of these valves  have  been done  and studied  in  canine  model  [53]. Problem of valve  thrombosis  is  a limiting  factor  in prosthetic valve as compared to native valves. Repopulating a decellularized external vein containing valve allograft with donor smooth muscle cells and endothelial cells has been attempted to make the transplant quite similar to an autogenous vein in sheep experiments [54]. 75% of the valves (nine out of twelve) were patent and competent at 12 weeks. Two were affected by the neointimal growth and one had occluded [54]. Use of Z-type stent configuration with metal exoskeleton and a vein containing the valve lining inside has been used. The Z-configuration allows expansion in the area of valve which is considered essential for proper valve cleansing and long-term function [55].


#### 3.3.6. Axillary Vein Autotransplantation

First described in humans by Taheri in 1982 [56], this procedure is done in cases of deep venous reflux with destroyed valves. A 2-3 cm of axillary vein segment containing a competent valve or a reparable one is removed. The femoral vein is accessed, and the segment containing the incompetent valve is removed. Presence of intraluminal synechiae in the femoral vein near the site of anastomosis requires excision to create a sizeable lumen for proper anastomosis  [57]. If the axillary vein valve explant is incompetent (as seen in 40% of the axillary vein explants), a bench repair by transcommissural external valvuloplasty technique is done before anastomosis [37, 38]. With the help of interrupted sutures, the proximal anastomosis of femoral vein with the axillary vein segment is performed. Proximal anastomosis is done earlier than the distal anastomosis as this allows to  check  for  valvular  competence  and  causes  distension  and  lengthening  of  the  axillary  vein  segment,  thus facilitating better distal anastomosis. An external PTFE sleeve is placed over the axillary vein graft and secured in position by adventitial stitches. It prevents future dilatation of the graft segment.


#### 3.3.7. Valve Transposition

It is a technique in which the incompetent venous system with destroyed valves is placed distal to the competent valve. Prerequisite for this procedure is that at least a single axial venous valve in the groin area is  competent.  Examples  include  transaction  of incompetent  femoral  vein  and  reimplantation  distal to  the competent  valve  in  the  profunda  femoris  vein  or  distal to  the  competent  great  saphenous  vein. Similarly, the incompetent profunda femoris vein can be transposed distal to the competent femoral vein valve. From the results of using the ipsilateral great saphenous vein transposition, it has been found to be safe and effective with good mid-term results, especially  for pain. For ulcers, the  primary  success  rate  was  55% but  it  increased to  84% with  proper surveillance and treatment of secondary insufficiency of the superficial venous system [58].


## 3.1. Ablation of Superficial Venous Reflux

Saphenous vein stripping is still the standard in managing truncal reflux in saphenous vein. Liquid or foam compression sclerotherapy, endovascular radiofrequency, or laser ablation  of the great saphenous vein have all been used and have been rewarding. Liquid compression sclerotherapy is effective for cases of superficial venectasias and nontruncal varicosities with competent great and small saphenous vein [29]. Clinical and hemodynamic follow-up results have shown that foam sclerotherapy is better than liquid compression sclerotherapy  for truncal reflux in  great  saphenous  vein  [30, 31]. Trials  comparing  stripping  with  endovascular radiofrequency ablation have shown lesser pain, shorter hospital stay, and earlier return to work in radiofrequency ablation  group. However, at the end of 4 months, no significant difference was found in the two groups  [32, 33]. Neglen and associates have combined iliofemoral stenting with obliteration of superficial venous reflux and found that it is safe, effective and minimally  invasive single-stage procedure  [34]. Ablation of superficial venous reflux along with subcutaneous fasciotomy for chronic and recurrent venous ulcers improves ulcer healing  or success of skin grafting [35].


## 3.2. Interventions  for  Perforator  Incompetence

Role  of  surgical  treatment  for  perforator  incompetence  in  the management of PTS has not been studied well. This is because incompetent perforators are rarely found in isolation in cases of postthrombotic syndrome [36]. The incompetent perforators are treated by SEPS (subfascial endoscopic perforator surgery) or ultrasound guided therapeutic radiofrequency ablation.


## 3.3. Interventions  for  Deep  Venous  Reflux

The  first  and  second  proximal  femoral  valve  stations  are surgically approached via an ipsilateral groin incision made in the direction of vessels. Profunda  femoris exposure, if required, needs dissection of sartorius muscle fascia. By performing positive and negative strip tests, reflux at the valve station is assessed. Reflux is demonstrated by venous refilling distally. The adventitia at the particular valve station is carefully dissected to expose the valve attachment lines. Failure to identify the attachment lines implies that the particular valve is completely destroyed, thus not suitable for valvuloplasty. Either transposition or autologous vein transfer may be required in such cases [37].


### 3.3.1. Internal Valvuloplasty

Following venotomy, the redundant valve cusps are exposed and apposed to the vein wall under direct vision with the help of 7–0 polypropylene suture. Plication of approximately 20% of valve length is usually sufficient to prevent reflux [38]. Dr. Kistner used longitudinal venotomy approach and opened the valve through  anterior commissure  [39].  Other approaches  are supravalvular transverse venotomy  without  opening  the valve [40], T-shaped venotomy [41]. A novel technique of trapdoor internal valvuloplasty has been described by Dr. Tripathi and Ktenidis [42]. After commissure identification, transverse venotomy involving half the circumference is made from the axis of the centre of one commissure to the other, one centimetre above and below the target valve. With the help of specially designed angled retractors, the valve cusps are kept away from the commissural axis. The anterior ends of the two transverse venotomy incisions are connected by a longitudinal venotomy along the more anterior of the two commissures. This creates a trapdoor at the level of target valve. It has the benefits of being technically less demanding and anatomically better defined and physiologically acceptable. The basic aim of all techniques is one, that is, plication of the redundant valve.


### 3.3.2. External  Valvuloplasty

This  technique  involves  transmural  suturing  through  the  valve  attachment  lines without  performing  a  venotomy.  It  results  in  narrowing  of  the  commissural  angles,  thus  making  the  valves competent. Several modifications  have been introduced since long-term results have shown it to  be less durable repair. Limited anterior plication involves continuous mattress suturing from a point 3 to 4 mm proximal to the valve cusp insertion lines up to the angle of valve cusp insertion [43]. The aim was to reduce the amount of vein dissection and reducing the risk of progressive venous dilatation which occurs in some cases of valvuloplasty. It has promising long-term follow-up results in terms of improved venous refilling and decreased ambulatory venous pressure [43]. In 1991,  Gloviczki  and  colleagues  [44]  described  femoral  vein  valve  repair  under  angioscopic  guidance  without performing  a venotomy. The  angioscope is introduced through the saphenous vein  or one  of its  tributaries  and navigated under vision through  the  common  femoral vein  to  the bifurcation  of femoral  vein.  If found  to  have primary valvular incompetence, repair of valve is done by external placement of 7–0 polypropylene sutures. Suture is  placed  lateral  to  the  site  of  insertion  of  each  valve.  The  elongated  valves   are  gradually  shortened.  Valve competency is checked by infusion of irrigation fluid via the angioscope. An external PTFE cuff of size 1 to 1.5 cm width is placed around the site of repair to prevent venous dilatation.


### 3.3.3. Transcommissural Valvuloplasty

This technique offers the advantage of avoiding venotomy as well as need of an angioscope. Performed  in cases of intact but incompetent valves, it  is safe, simple, rapid, and  multiple valve stations can be repaired at the same setting. An inverted V-shape is formed by the apices of the cusps of bicuspid venous valve. After adventitial dissection and identification  of valve station, a through  and through transluminal resuspension suture is passed obliquely across the inverted “V”, traversing both the cusps near their attachment to the wall. Involvement of both the valve cusps is evident by puckering of the valve attachment lines. Further two to four more interrupted stitches are placed distally, each of them being less deep and less oblique. The last stitch is at one to two mm beyond the point of maximum bulge at the valve station. The aim is to shorten valve cusp length at each end of commissure  by  nearly  20%. Similar  procedure  is  repeated  at the other end of the  cusp.  Strip  test is performed cautiously  to  check  for  valve  competence.  The  internal  valvuloplasty  corrects  the  valve  cusps  only  without considering the commissural angles while the  external valvuloplasty only corrects the commissural angle  without considering the valve cusps. The advantage of transcommissural valvuloplasty is that it corrects both the redundant valve cusps as well as  commissural angles. The cumulative competency rates of 140 sites were 84% at 12 months, 72% at 24 months, and 59% at 30 months [28]. Median time to failure was 11 to 16 months (range 2–35  months) depending on the criteria used [28]. Among 36 multiple valves repaired, duplex scan revealed 11 failures. All  11 valves  were  single  failures  (i.e., only  one  of the  repaired  valves  in  the  individual  limb  failed,  with the other(s) remaining  competent)  [28].  The  cumulative  competency  rate  of  the  transcommissural  repair  is  59%  to  69% depending on reflux criteria used. It is comparable to those reported for internal and external repair [45–47].


### 3.3.4. Neovalve  Reconstruction

The  Italian  neovalve  reconstruction  is  a  technique  of  creating  an   antireflux mechanism. In this  technique, the femoral vein is exposed via a 10 cm long longitudinal incision  on the lateral border  of sartorius  extending  up  to  10–15 cm below  the  inguinal  ligament.  Intraoperative identification  of incompetent valve station is most crucial though duplex and other preoperative tests may be used. A longitudinal or transverse venotomy of 2-3 cm length is performed. With the help of ophthalmic blade or microscissors, the intimal dissection  is performed  to  raise an intimal flap. The  depth of  dissection depends on the vein  wall thickness. A monocuspid or a bicuspid valve can be created in this fashion. The size of flap is properly assessed to prevent valve prolapse in case of excessive width. In a variation to the original technique, Lugli and associates stitched the free edge of the flap to the vein wall by 7/0 suture [16]. This prevents reattachment of the flap to the original vein wall that had resulted in failure of neovalve  within a short period after surgery in earlier series. Contraindications  to neovalve reconstruction include severely limited ambulation, thrombophilia, bleeding diathesis, severe comorbidity, possibility of other standard techniques like femoral transposition, or valve transplant [16].  Cumulative ulcer healing was 7.7/100 patient-months  (16 cases per 206 patient-months) in the first series and 30.7/100 patient-months  (20 cases per 65 patient-months) in the second [16]. The cumulative patency rates were 16 cases per 919 patient-months (1.7/100 patient-months) and  21 per 228 patient-months  (9.2/100 patient-months), respectively,  in  the  first  and second  series  [16].  Postoperative  duplex scan  and  air  plethysmography  measurements  showed  a  significant improvement (P<0.001) [48]. Thus, neovalve reconstruction seemed to be effective in restoring femoral competence in postthrombotic reflux.


### 3.3.5. Prosthetic Venous Valves

The need for prosthetic venous valves arises in cases of end-state chronic  deep venous insufficiency afflicted with recurrent or resistant venous ulceration in which the available  medical therapy and  interventional procedures  like  superficial  venous  ablation  or perforator surgery  have  failed  to  provide  any clinical or hemodynamic benefit. Majority of the attempts of prosthetic venous valve repair have not shown good results. A  bioprosthetic  Portland  valve  (bicuspid  square  stent -based  venous  valve  made  from small  intestinal submucosa) has  been studied  after percutaneous placement  in  the  sheep  external jugular vein  [49]. It  has  88% patency and competency rate. Valve tilting led to occlusion and valve insufficiency in three experimental animals [49].  Variations  have  been  made  to  prevent tilting  and to provide  a longer cusp which  is supposed  to be  more hemodynamic structure. Valve thickening is another problem with the prosthetic valves. Cryopreserved valves are superficial femoral vein containing valve allograft made by Cryo Life, Inc,  Kennesaw, Georgia. They can prevent venous  reflux up  to  125 mmHg  of  retrograde  venous  pressure. They  may  require  valvuloplasty  at  the time  of implantation for optimal performance and competency [50]. The cryopreserved valve allografts have failed in early and midterm clinical trial and are not considered suitable for treating DVT [51]. Graft rejection is a concerning issue regarding graft failure. T-cell immunosuppressive drugs like cyclosporine and azathioprine may prevent graft rejection. Another technique of restoring deep venous valve competence involves intussusception of the vein into itself [52]. The bicuspid valve is made by two sutures placed at 180 degree to hold the inner vein wall in correct position. Short-term patency was good with competency rate of 90–100%. But hemodynamic results are not as fair as in the case of native valves. Modifications like thinning of the adventitia and partly of the media to decrease the thickness of these valves  have  been done  and studied  in  canine  model  [53]. Problem of valve  thrombosis  is  a limiting  factor  in prosthetic valve as compared to native valves. Repopulating a decellularized external vein containing valve allograft with donor smooth muscle cells and endothelial cells has been attempted to make the transplant quite similar to an autogenous vein in sheep experiments [54]. 75% of the valves (nine out of twelve) were patent and competent at 12 weeks. Two were affected by the neointimal growth and one had occluded [54]. Use of Z-type stent configuration with metal exoskeleton and a vein containing the valve lining inside has been used. The Z-configuration allows expansion in the area of valve which is considered essential for proper valve cleansing and long-term function [55].


### 3.3.6. Axillary Vein Autotransplantation

First described in humans by Taheri in 1982 [56], this procedure is done in cases of deep venous reflux with destroyed valves. A 2-3 cm of axillary vein segment containing a competent valve or a reparable one is removed. The femoral vein is accessed, and the segment containing the incompetent valve is removed. Presence of intraluminal synechiae in the femoral vein near the site of anastomosis requires excision to create a sizeable lumen for proper anastomosis  [57]. If the axillary vein valve explant is incompetent (as seen in 40% of the axillary vein explants), a bench repair by transcommissural external valvuloplasty technique is done before anastomosis [37, 38]. With the help of interrupted sutures, the proximal anastomosis of femoral vein with the axillary vein segment is performed. Proximal anastomosis is done earlier than the distal anastomosis as this allows to  check  for  valvular  competence  and  causes  distension  and  lengthening  of  the  axillary  vein  segment,  thus facilitating better distal anastomosis. An external PTFE sleeve is placed over the axillary vein graft and secured in position by adventitial stitches. It prevents future dilatation of the graft segment.


### 3.3.7. Valve Transposition

It is a technique in which the incompetent venous system with destroyed valves is placed distal to the competent valve. Prerequisite for this procedure is that at least a single axial venous valve in the groin area is  competent.  Examples  include  transaction  of incompetent  femoral  vein  and  reimplantation  distal to  the competent  valve  in  the  profunda  femoris  vein  or  distal to  the  competent  great  saphenous  vein. Similarly, the incompetent profunda femoris vein can be transposed distal to the competent femoral vein valve. From the results of using the ipsilateral great saphenous vein transposition, it has been found to be safe and effective with good mid-term results, especially  for pain. For ulcers, the  primary  success  rate  was  55% but  it  increased to  84% with  proper surveillance and treatment of secondary insufficiency of the superficial venous system [58].


## 3.3.1. Internal Valvuloplasty

Following venotomy, the redundant valve cusps are exposed and apposed to the vein wall under direct vision with the help of 7–0 polypropylene suture. Plication of approximately 20% of valve length is usually sufficient to prevent reflux [38]. Dr. Kistner used longitudinal venotomy approach and opened the valve through  anterior commissure  [39].  Other approaches  are supravalvular transverse venotomy  without  opening  the valve [40], T-shaped venotomy [41]. A novel technique of trapdoor internal valvuloplasty has been described by Dr. Tripathi and Ktenidis [42]. After commissure identification, transverse venotomy involving half the circumference is made from the axis of the centre of one commissure to the other, one centimetre above and below the target valve. With the help of specially designed angled retractors, the valve cusps are kept away from the commissural axis. The anterior ends of the two transverse venotomy incisions are connected by a longitudinal venotomy along the more anterior of the two commissures. This creates a trapdoor at the level of target valve. It has the benefits of being technically less demanding and anatomically better defined and physiologically acceptable. The basic aim of all techniques is one, that is, plication of the redundant valve.


## 3.3.2. External  Valvuloplasty

This  technique  involves  transmural  suturing  through  the  valve  attachment  lines without  performing  a  venotomy.  It  results  in  narrowing  of  the  commissural  angles,  thus  making  the  valves competent. Several modifications  have been introduced since long-term results have shown it to  be less durable repair. Limited anterior plication involves continuous mattress suturing from a point 3 to 4 mm proximal to the valve cusp insertion lines up to the angle of valve cusp insertion [43]. The aim was to reduce the amount of vein dissection and reducing the risk of progressive venous dilatation which occurs in some cases of valvuloplasty. It has promising long-term follow-up results in terms of improved venous refilling and decreased ambulatory venous pressure [43]. In 1991,  Gloviczki  and  colleagues  [44]  described  femoral  vein  valve  repair  under  angioscopic  guidance  without performing  a venotomy. The  angioscope is introduced through the saphenous vein  or one  of its  tributaries  and navigated under vision through  the  common  femoral vein  to  the bifurcation  of femoral  vein.  If found  to  have primary valvular incompetence, repair of valve is done by external placement of 7–0 polypropylene sutures. Suture is  placed  lateral  to  the  site  of  insertion  of  each  valve.  The  elongated  valves   are  gradually  shortened.  Valve competency is checked by infusion of irrigation fluid via the angioscope. An external PTFE cuff of size 1 to 1.5 cm width is placed around the site of repair to prevent venous dilatation.


## 3.3.3. Transcommissural Valvuloplasty

This technique offers the advantage of avoiding venotomy as well as need of an angioscope. Performed  in cases of intact but incompetent valves, it  is safe, simple, rapid, and  multiple valve stations can be repaired at the same setting. An inverted V-shape is formed by the apices of the cusps of bicuspid venous valve. After adventitial dissection and identification  of valve station, a through  and through transluminal resuspension suture is passed obliquely across the inverted “V”, traversing both the cusps near their attachment to the wall. Involvement of both the valve cusps is evident by puckering of the valve attachment lines. Further two to four more interrupted stitches are placed distally, each of them being less deep and less oblique. The last stitch is at one to two mm beyond the point of maximum bulge at the valve station. The aim is to shorten valve cusp length at each end of commissure  by  nearly  20%. Similar  procedure  is  repeated  at the other end of the  cusp.  Strip  test is performed cautiously  to  check  for  valve  competence.  The  internal  valvuloplasty  corrects  the  valve  cusps  only  without considering the commissural angles while the  external valvuloplasty only corrects the commissural angle  without considering the valve cusps. The advantage of transcommissural valvuloplasty is that it corrects both the redundant valve cusps as well as  commissural angles. The cumulative competency rates of 140 sites were 84% at 12 months, 72% at 24 months, and 59% at 30 months [28]. Median time to failure was 11 to 16 months (range 2–35  months) depending on the criteria used [28]. Among 36 multiple valves repaired, duplex scan revealed 11 failures. All  11 valves  were  single  failures  (i.e., only  one  of the  repaired  valves  in  the  individual  limb  failed,  with the other(s) remaining  competent)  [28].  The  cumulative  competency  rate  of  the  transcommissural  repair  is  59%  to  69% depending on reflux criteria used. It is comparable to those reported for internal and external repair [45–47].


## 3.3.4. Neovalve  Reconstruction

The  Italian  neovalve  reconstruction  is  a  technique  of  creating  an   antireflux mechanism. In this  technique, the femoral vein is exposed via a 10 cm long longitudinal incision  on the lateral border  of sartorius  extending  up  to  10–15 cm below  the  inguinal  ligament.  Intraoperative identification  of incompetent valve station is most crucial though duplex and other preoperative tests may be used. A longitudinal or transverse venotomy of 2-3 cm length is performed. With the help of ophthalmic blade or microscissors, the intimal dissection  is performed  to  raise an intimal flap. The  depth of  dissection depends on the vein  wall thickness. A monocuspid or a bicuspid valve can be created in this fashion. The size of flap is properly assessed to prevent valve prolapse in case of excessive width. In a variation to the original technique, Lugli and associates stitched the free edge of the flap to the vein wall by 7/0 suture [16]. This prevents reattachment of the flap to the original vein wall that had resulted in failure of neovalve  within a short period after surgery in earlier series. Contraindications  to neovalve reconstruction include severely limited ambulation, thrombophilia, bleeding diathesis, severe comorbidity, possibility of other standard techniques like femoral transposition, or valve transplant [16].  Cumulative ulcer healing was 7.7/100 patient-months  (16 cases per 206 patient-months) in the first series and 30.7/100 patient-months  (20 cases per 65 patient-months) in the second [16]. The cumulative patency rates were 16 cases per 919 patient-months (1.7/100 patient-months) and  21 per 228 patient-months  (9.2/100 patient-months), respectively,  in  the  first  and second  series  [16].  Postoperative  duplex scan  and  air  plethysmography  measurements  showed  a  significant improvement (P<0.001) [48]. Thus, neovalve reconstruction seemed to be effective in restoring femoral competence in postthrombotic reflux.


## 3.3.5. Prosthetic Venous Valves

The need for prosthetic venous valves arises in cases of end-state chronic  deep venous insufficiency afflicted with recurrent or resistant venous ulceration in which the available  medical therapy and  interventional procedures  like  superficial  venous  ablation  or perforator surgery  have  failed  to  provide  any clinical or hemodynamic benefit. Majority of the attempts of prosthetic venous valve repair have not shown good results. A  bioprosthetic  Portland  valve  (bicuspid  square  stent -based  venous  valve  made  from small  intestinal submucosa) has  been studied  after percutaneous placement  in  the  sheep  external jugular vein  [49]. It  has  88% patency and competency rate. Valve tilting led to occlusion and valve insufficiency in three experimental animals [49].  Variations  have  been  made  to  prevent tilting  and to provide  a longer cusp which  is supposed  to be  more hemodynamic structure. Valve thickening is another problem with the prosthetic valves. Cryopreserved valves are superficial femoral vein containing valve allograft made by Cryo Life, Inc,  Kennesaw, Georgia. They can prevent venous  reflux up  to  125 mmHg  of  retrograde  venous  pressure. They  may  require  valvuloplasty  at  the time  of implantation for optimal performance and competency [50]. The cryopreserved valve allografts have failed in early and midterm clinical trial and are not considered suitable for treating DVT [51]. Graft rejection is a concerning issue regarding graft failure. T-cell immunosuppressive drugs like cyclosporine and azathioprine may prevent graft rejection. Another technique of restoring deep venous valve competence involves intussusception of the vein into itself [52]. The bicuspid valve is made by two sutures placed at 180 degree to hold the inner vein wall in correct position. Short-term patency was good with competency rate of 90–100%. But hemodynamic results are not as fair as in the case of native valves. Modifications like thinning of the adventitia and partly of the media to decrease the thickness of these valves  have  been done  and studied  in  canine  model  [53]. Problem of valve  thrombosis  is  a limiting  factor  in prosthetic valve as compared to native valves. Repopulating a decellularized external vein containing valve allograft with donor smooth muscle cells and endothelial cells has been attempted to make the transplant quite similar to an autogenous vein in sheep experiments [54]. 75% of the valves (nine out of twelve) were patent and competent at 12 weeks. Two were affected by the neointimal growth and one had occluded [54]. Use of Z-type stent configuration with metal exoskeleton and a vein containing the valve lining inside has been used. The Z-configuration allows expansion in the area of valve which is considered essential for proper valve cleansing and long-term function [55].


## 3.3.6. Axillary Vein Autotransplantation

First described in humans by Taheri in 1982 [56], this procedure is done in cases of deep venous reflux with destroyed valves. A 2-3 cm of axillary vein segment containing a competent valve or a reparable one is removed. The femoral vein is accessed, and the segment containing the incompetent valve is removed. Presence of intraluminal synechiae in the femoral vein near the site of anastomosis requires excision to create a sizeable lumen for proper anastomosis  [57]. If the axillary vein valve explant is incompetent (as seen in 40% of the axillary vein explants), a bench repair by transcommissural external valvuloplasty technique is done before anastomosis [37, 38]. With the help of interrupted sutures, the proximal anastomosis of femoral vein with the axillary vein segment is performed. Proximal anastomosis is done earlier than the distal anastomosis as this allows to  check  for  valvular  competence  and  causes  distension  and  lengthening  of  the  axillary  vein  segment,  thus facilitating better distal anastomosis. An external PTFE sleeve is placed over the axillary vein graft and secured in position by adventitial stitches. It prevents future dilatation of the graft segment.


## 3.3.7. Valve Transposition

It is a technique in which the incompetent venous system with destroyed valves is placed distal to the competent valve. Prerequisite for this procedure is that at least a single axial venous valve in the groin area is  competent.  Examples  include  transaction  of incompetent  femoral  vein  and  reimplantation  distal to  the competent  valve  in  the  profunda  femoris  vein  or  distal to  the  competent  great  saphenous  vein. Similarly, the incompetent profunda femoris vein can be transposed distal to the competent femoral vein valve. From the results of using the ipsilateral great saphenous vein transposition, it has been found to be safe and effective with good mid-term results, especially  for pain. For ulcers, the  primary  success  rate  was  55% but  it  increased to  84% with  proper surveillance and treatment of secondary insufficiency of the superficial venous system [58].


## 4. Conclusion

Postthrombotic syndrome is a challenging complication of deep vein thrombosis requiring multimodal approach for appropriate management. Prevention is better than cure holds true in this case. Identification of patients at risk for deep  vein   thrombosis   is   essential.   Prevention   of   DVT   in   these  high   groups   by   using   mechanical  and chemoprophylaxis  agents  is  required  to  decrease the  incidence  and  complications  of  postthrombotic  syndrome. Though many surgical options have been described, they are performed only at selected centres and are not full proof. The first line and easily available management includes use of graduated compress ion stockings, pneumatic compression  devices, oral and  injectable  anticoagulants.  Surgery  or  endovascular therapy, if feasible,  should  be considered  complementary  to  medical  management.  Venous  outflow obstruction  is  treated  earlier than  venous reflux. Superficial venous reflux is managed before treatment of deep venous reflux. Surgical management is a more definitive treatment than the conservative treatment.



---

*Source: 520604-2011-10-31.xml*