The axial reflux patterns of primary deep venous disease must be thoroughly diagnosed prior to planning deep vein valve repair. Primary cases often present with a single axial reflux tract that courses from the CFV through the femoral vein of the thigh to the popliteal and into the calf veins. In this case, a single valve repair in the femoral vein has been shown to be all that is needed to restore clinical compensation to the venous return. These cases usually have little or no communication between the distal profunda veins and the popliteal vein and seldom have other collaterals. The lack of collaterals is due to the lack of an obstructive element in the development of primary disease, in contrast to post-thrombotic deep vein disease.
When the deep femoral vein is incompetent in addition to the femoral vein itself, attention needs to be directed to the distal communications between the profunda veins and the popliteal vein, usually via large connecting branches at the adductor canal (profunda-popliteal connecting veins). If there is significant distal reflux by the CFV-deep femoral-popliteal route, a separate valve is needed for this tract. The choice when reflux occurs by both femoral and deep femoral tracts is either to provide one competent valve at the popliteal level, or two valves, one in the femoral and the other in the profunda veins. In post-thrombotic disease the profunda-popliteal branches provide a collateral route of return flow when the femoral vein itself becomes occluded by the thrombotic process, and it persists when there are elements of relative obstruction in the scarred and recanalized femoral vein outflow tract.
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