Chronic venous insufficiency of the lower extremity. Pathogenesis and surgical treatment

Surgical treatment of venous ulcers: role of subfascial endoscopic perforator vein ligation

Existing data in the literature lack answers to several questions about the optimal treatment of patients with advanced CVI, especially venous ulcers. There is no level I evidence to support the superiority of surgical over medical treatment and the extent of surgical intervention. Specifically, knowledge about the efficacy and applicability of SEPS is incomplete, and prospective, randomized studies are needed. In the light of present-day knowledge, all patients should undergo a trial of medical management before resorting to surgery. Patients who benefit from surgical treatment and the addition of SEPS, if indicated, are patients with ulcers resulting from PVI of the superficial and perforating veins, with or without DVI. Based on available data, these patients can be assured an 80% to 90% chance of long-term freedom from ulcer recurrence. Despite subjective symptomatic and objective clinical score improvement, the role of surgery and SEPS is controversial in patients with PT because only 50% of patients can be predicted to have long-term freedom from ulcer recurrence. Patients with ulcer recurrence after SEPS should undergo duplex scanning to exclude recurrent or persistent perforators. If these are found to be incompetent, repeat SEPS is warranted. If there is no perforator incompetence, patients should be considered for deep venous reconstruction.

Endoscopic perforating vein surgery

Perforator incompetence, caused by primary valvular incompetence or by previous deep venous thrombosis, contributes to ambulatory venous hypertension and the development of chronic venous disease. Although the exact role and contribution of perforators to the development of ulcers are still debated, poor results of nonoperative management to prevent ulcer recurrence justify surgical attempts at perforator ligation, in addition to ablation of superficial reflux. The endoscopic technique of perforator interruption has significantly fewer wound complications than the open technique and is the preferred method for ablation of medial perforating veins. Interruption of incompetent perforators with ablation of the superficial reflux, if present, effectively and durably decreases symptoms of CVI and rapidly heals ulcers. Ulcer recurrence following correction of perforator and superficial reflux in patients with post-thrombotic syndrome is much higher than in patients with primary valvular incompetence. A prospective randomized trial is needed to define the long-term benefits of interrupting incompetent perforators in all patients with advanced chronic venous disease and which patients with post-thrombotic syndrome should undergo perforator interruption.

Early benefits of subfascial endoscopic perforator surgery (SEPS) in healing venous ulcers

Efficacy of subfascial endoscopic perforator vein surgery (SEPS) in assisting the healing of venous ulcers was determined. During the period June 1995 to May 1996, 19 limbs in 17 patients were treated by SEPS. Thirteen limbs had open ulcers (class 6), five limbs had healed ulcers (class 5), and one limb had severe lipodermatosclerosis (class 4). There were nine male and eight female patients (average age 58, range 33-86). One male had bilateral open ulcers and one female had one open and one healed ulcer. Open ulcers had been present for an average duration of 4.4 years (range 1-14 years). The average ulcer size was 2.8 x 2.2 cm (range 1 x 1 cm to 12 x 6 cm). All operations were conducted on an outpatient basis. At surgery an attempt was made to correct all superficial venous pathophysiology. In addition to SEPS, 12 limbs (63%) had greater saphenous vein (GSV) stripping and 15 patients (79%) had stab avulsion of painful varicose veins. The average number of perforators ligated during SEPS was 3.68 (range 2-8). All active ulcers healed within 90 days. The mean time to healing was 30.5 days (range 6-90 days). Minor postoperative complications (one groin hematoma, three wound infections) occurred in four limbs (21%). There have been no ulcer recurrences during follow-up (mean 8.6 months, range 3-16 months). Outpatient SEPS is an important adjunct in the treatment of chronic venous insufficiency. Experience in this group of 19 limbs strongly suggests that SEPS appears to accelerate the healing of venous ulcers compared to historical controls.

Subfascial endoscopic perforator vein surgery: a preliminary report

Although the open Linton subfascial perforator vein interruption operation succeeded, for the most part, in preventing recurrent venous ulceration, it was associated with morbidity and prolonged hospitalization. We have attempted to obtain the beneficial effects of perforator interruption by the less invasive procedure of subfascial endoscopic perforator vein surgery using laparoscopic instrumentation and limited or no hospitalization. A total of 31 consecutive operations were performed in 30 patients. Sixteen women and 14 men were entered into the study, and all of them had severe chronic venous insufficiency with either open or healed ulcers. Operations were carried out without gas insufflation, in 17 without a hemostatic tourniquet, and in 13 entirely on an outpatient basis. The 18 hospitalizations produced a total of 49 days of inpatient care (mean 2.72 days). One to six perforating veins were encountered in these operations, and veins identified as perforators were electrocoagulated or clipped and sectioned. Sixteen limbs had severe chronic venous insufficiency or healed ulcers, and 15 had open ulcers. In 13 limbs, ulcers were intermittently present for 1 to 5 years. Seven of these healed within 4 weeks of operation and four others within 8 weeks. Two healed more than 8 weeks after surgery. In two limbs with ulcers that were present for 1 to 6 months, healing took place within 4 weeks of the operation in both. Complications included atelectasis in one patient, cellulitis requiring antibiotic therapy in three, wound hematomas not requiring intervention in two, and wound seroma not requiring therapy in one. This preliminary experience suggests that perforator vein interruption can be accomplished using existing instrumentation and a variety of technical modifications to achieve the objectives of the Linton operation without the attendant morbidity. Videoscopic instrumentation obtains benefits of subfascial perforator vein interruption without morbidity of the open operations. This preliminary study suggests that the operative procedure is attended by minimum morbidity without the need for rehospitalization. Long-term observation will be required to assess the procedure definitively, but the short-term objectives can be safely accomplished with minimum use of inpatient facilities.

Foot volumetry and duplex ultrasonography after saphenous and subfascial perforating vein ligation for recurrent venous ulceration

Forty-three patients undergoing superficial and perforating vein ligation for recurrent venous ulceration underwent preoperative and postoperative foot volumetry and postoperative duplex ultrasonography. Patients were followed for a median of 66 (range 18-144) months. Of nine patients who developed recurrent ulceration, six had femoral vein incompetence and all had popliteal vein incompetence demonstrated by duplex ultrasonography. Of the 34 patients who remained ulcer-free, five had femoral vein incompetence and a single patient had popliteal vein incompetence on duplex scanning, giving positive predictive values for recurrent ulceration of 55 per cent (femoral vein incompetence) and 90 per cent (popliteal vein incompetence). Patients with saphenofemoral incompetence on late follow-up were also more likely to suffer recurrence. Preoperative foot volumetry with tourniquet occlusion of superficial veins showed that the median expulsion fraction of patients who developed recurrent ulcer during follow-up was 0.8 (range 0.6-2.3) per cent compared with 1.5 (range 0.4-2.9) per cent for those who remained ulcer-free (P = 0.025); the median half-refilling time of patients with recurrent ulcer was 1.5 (range 0.5-5.5) s compared with 5.0 (range 0.5-23.0) s for those without recurrence (P < 0.01). Postoperative foot volumetry showed similar differences. Deep venous incompetence, particularly of the popliteal segment, as demonstrated by duplex ultrasonography and foot volumetry, is a useful predictor of recurrent ulceration after subfascial perforator and superficial venous ligation.