A 48-year-old male was admitted to our hospital with severe CVI of the lower extremity. Fifteen years ago, he developed edema and experienced a feeling of heaviness in both lower limbs, but the right side was worse. He sought medical attention without success (oral drug and unknown treatments). Skin itching and lower pigmentation in both limbs gradually appeared. Three years ago at a local hospital, he was diagnosed with DVT in right lower limb deep veins, including the right external iliac vein and common iliac vein, due to aggravated edema of the right lower extremity and a right foot fracture on the second day after a trauma had occurred. He was implanted with an inferior vena cava filter and the filter was removed in time. Apart from trauma, which is a risk factor for clotting, his doctor at that time did not screen for other clotting factors. After this, he was regularly anticoagulated with warfarin for 1 year, however, lower limb edema had not been alleviated, and right lower limb swelling and heaviness became more serious; moderate pain in the right calf occurred after standing for more than 15 min, which seriously affected his life and work. A systems review revealed a hypertension and hyperlipidemia history. There was no tobacco, alcohol, drug abuse, or recent trauma history, while the family history of arterial and venous thromboembolism was unremarkable. There was no recent history of fever, headaches, visual disturbance, shortness of breath, abdominal pain, nausea, or vomiting.

Physical examination medical records showed no varicose veins in the cross pubic, anterior, and lateral abdominal wall, only superficial varicose veins scattered across both calves. Right lower limb skin color was a mild red color and moderate hemosiderin pigment deposition was observed over the footwear area. Additionally, no evidence of ulceration and healed ulceration was identified. Both lower limbs showed concave edema, which were relatively serious on the right side. The lower leg circumference was 15 cm below the knee, 32.5 cm on the left, and 35 cm on the right. Dorsalis pedis and posterior tibial arteries of the lower limb were palpable. The patient weighed 72 kg. He had normal strength and range of motion in all four limbs. The Villalta scale [5] was 15 points and the Revised-Venous Clinical Severity Score (r-VCSS) [6] was 11 points. Color flow duplex ultrasonography revealed marked full patency of right iliac vein blood flow, right lower extremity venous reflux, with a venous refill time of 5 s and no evidence of obstructed venous outflow. Duplex examinations revealed marked incompetence of the common femoral, superficial femoral, popliteal, and greater saphenous veins. Descending phlebography confirmed incompetence of the superficial femoral vein, with blood flowing back to the lower part of the right calf. Ascending phlebography showed superficial varicosities over the bilateral calves, with no incompetent perforating veins. Based on venous hemodynamic [7], ascending phlebography [8], and descending phlebography evaluations [9], the patient was classified as C4b, EsiAdPro, and Grade IV (Kinster classification; femoral vein reflux below the knee joint level and proximal leg) regurgitation of right femoral vein valve [9], as previously described.

(A) The anterior valve of the SFV had almost disappeared, the posterior valve was rigid and thickened. (B) The AV was anastomosed with the FV end to side and the SFV ligated. (C) The transplanted AV valve segment was covered with the patch. (D) The arrow shows the lengthy posterior valve of the first pair of valves of the SFV during surgery. The anterior valve had almost disappeared and could not be shown in images. (E) The long arrow refers to the ligated SFV. The short arrow refers to the healthy valve area of the shunt AV, which completely blocked proximal blood flow (strip test). (F) The arrow shows the sleeve wrapping (SW) for the AV valve. Abbrevation CFV, Common femoral vein; SFV, Superficial femoral vein; GSV, Great saphaneous vein; AV, Axillary vein; SW, Sleeve wrapping

The surgical procedure (described later) was carried out under general anesthesia. After full heparinization, a ‘strip test’ showed that the right femoral vein had severe regurgitation issues. The veins around the proximal end of the superficial femoral vein were blocked. Longitudinal incision of the superficial femoral vein at the first pair of valves, with care taken to protect the internal valve, showed that the anterior valve had almost disappeared and the posterior valve was rigid and thickened. Considering that this flap could not be normally repaired, we performed axillary vein valve transplantation. An anterograde incision was made at the projection of the body surface of the mid and distal axillary vein, with valves marked by ultrasound before surgery. We identified a transplantable axillary valved vein of 5 mm in diameter. A strip test showed that the function of the axillary vein valve, prepared for transplantation, was normal. In order to match the transplant site, we trimmed the axillary vein segment with valves for transplantation, which was approximately 4 cm long.

The axillary vein was smoothly removed and anastomosed with the femoral vein end to side at the appropriate position of the proximal and distal part of the first pair of diseased valves of the superficial femoral vein. After proximal anastomosis, we opened the proximal block to confirm that the tube wall at the valve graft filled without reflux. We ligated the superficial femoral vein segment corresponding to the bridging vessel. We used an 8 × 75 mm Maquet patch to sleeve-wrap the transplanted axillary vein valve segment [8]. A strip test was repeated after valvuloplasty to confirm no reflux. Indwelling drainage in inguinal and axillary incisions were then sutured and the operation was completed (Fig. 1).

Heparinization was provided for 3 consecutive days after surgery, maintaining Activated Partial Thromboplastin Time = 1.5–2.5 at all times. Then, the patient received adequate anticoagulation therapy (rivaroxaban for the first three weeks: 15 mg, bid; After 3 weeks–3 months: 20 mg, Qd for 3 months). Edema, heaviness, and pain in the right lower limb were significantly relieved after surgery. The patient continued to maintain pressure treatment from medical elastic stockings. The patient was rechecked at 1 and 3 months after surgery and showed no obvious regurgitation of the right femoral graft vein valve. Valve function and d-dimer values were normal and no new thrombosis was identified. The patient returned to normal life and work. At 3 months post-surgery, right lower leg pigmentation became lighter, tension was reduced in varicose veins in the lower leg, and the right ankle was slightly edematous (Fig. 2). Heavy feelings, pain, and other lower limb symptoms disappeared, and edema was well controlled by elastic stockings. The Villalta scale reduced to 5 points and the r-VCSS was reduced to 5 points. Ultrasound (Fig. 2) showed no thrombosis near the original ligated superficial femoral vein, the valve in the transplanted bypass vessel opened and closed well, and no reflux was observed when the valsalva maneuver was performed. The patient was very satisfied. When he revisited at 3 months after surgery, we advised him to discontinue anticoagulation and continue with long-term elastic compression stockings. It has been 1 year since the surgery, and the patient has been wearing elastic compression stockings. Lower limb swelling symptoms have all disappeared. A follow-up ultrasound (local hospital) showed that the bridging blood vessel was unobstructed and its valve showed no reflux. We obtained the patients consent for this publication.

Ultrasound at 3 months after surgery (A) The long solid arrow shows the SFV, and the long arrow shows the AV. The short solid arrow shows the ring, and the cross mark shows the ligation point of the SFV. (B) The diverted axillary vein is unobstructed; the arrow shows the healthy axillary vein valve. (C) During the valsalva maneuver, no blood reflux was recorded in the diverted vein valve. (D and E) The patients lower limbs before and at 3 months after surgery, which showed slight edema in the right calf, but the leg circumference at 15 cm below the knee was 1 cm less than that before surgery