LAUSR

We read with interest the paper by Pagano et al. regarding a peculiar technique to prevent saphenofemoral junction (SFJ) recurrence in patients with common femoral valve incompetence, saphenous insufficiency, and varicose veins. Through a selective ligation of great saphenous vein and inferior SFJ tributaries, blood reflux deriving from an incompetent deep system during venous diastole is driven into SFJ but washed out by superior tributaries during venous systole. The authors advocated that superior tributaries act as “escape points” during muscle contraction and venous return or during relaxation after a valsalva maneuver. Conversely, in case of superior tributaries failure (e.g., thrombosis or aplasia), venous stasis into the SFJ serves as a trigger factor for neoangiogenesis and junctional recurrence. With their assumption and investigation, authors have brought to light once again the role of the femoral valve in lower limb venous disease. Although femoral valves have been recognized as to have a paramount role in the development and worsening of lower limb venous disorders, their investigation and description remain marginal and trivial. As described, femoral valve absence or incompetence— detected in more than 20%—lead to an increase in blood column pressure (according to the Stevino’s law), on both the femoral valve below the SFJ and the terminal valve of the SFJ. The latter, if stressed by refluxing blood flow from abdominal veins through common femoral vein, may become incompetent, as the preterminal one. Furthermore, this not-so-rare condition was established as a risk factor for SFJ recurrence after surgery. Unfortunately, the role of the femoral valve after endovenous procedures is not yet investigated. Although during ablative techniques the principles of inferior selective crossectomy is maintained in an analogous way, sparing the superior epigastric vein, no data are published on the fate of patients with femoral valve incompetence after endovenous procedure. According to principles seen so far, the stump pressure on SFJ after endovenous ablation may be an important risk factor for saphenous vein recanalization. Preliminary reports are appearing in the literature. In conclusion, it is extremely important to detect and analyze femoral valves, in particular the one above SFJ, because it could be discriminating for the treatment choice. We would like to thank the authors of this paper to have once again highlighted this topic in an original way.