Foot volumetry can predict recurrent ulceration after subfascial ligation of perforators and saphenous ligation

Risk Factors for Healing and Recurrence of Chronic Venous Leg Ulcers

Objective:

To identify independent risk factors for delayed healing and increased recurrence of chronic venous leg ulcers.

Design:

Prospective study.

Setting:

Community-based leg ulcer service.

Patients:

Six hundred and thirty-three limbs in 587 consecutive patients with an ankle-brachial pressure index (ABPI) ≥0.85.

Method:

Potential risk factors were initially assessed in a one-stop clinic incorporating clinical evaluation, ABPI and venous duplex imaging. Limbs were treated within a defined protocol. Twenty-four-week healing and 3-year ulcer recurrence rates were determined.

Results:

Of 12 potential risk factors age ( p< 0.001), ulcer chronicity ( p< 0.001) and popliteal vein reflux ( p< 0.005) were independent risks for delayed healing. Of 13 potential risk factors rheumatoid arthritis ( p<0.005) and healing time ( p < 0.05) were independent risks for ulcer recurrence. Isolated superficial venous reflux treated by saphenous vein surgery predicted reduced ulcer recurrence ( p< 0.005).

Conclusion:

Targeting in primary care of ulcer patients with specific characteristics might encourage earlier referral and appropriate resource management. Leg ulcer patients with superficial venous reflux might benefit from surgical correction.

The role of superficial venous surgery in the management of venous ulcers: a systematic review

BACKGROUND

The complicated natural history of venous ulcers requires the continued development and improvement of treatments to ensure the most effective management. Compression therapy or surgical correction of superficial venous incompetence (SVI) are currently the main methods employed for the treatment for venous ulceration (VU). This review compares and summates the healing and recurrence rates for each treatment modality used over the last thirty years.

METHODS

Sixty-one articles investigating compression and superficial venous surgical treatments were obtained from a systematic search of electronic databases (Medline, Embase, The Cochrane Library, and Google Scholar) and then an expanded reference list review. Patient demographics, CEAP classification, patterns of venous insufficiency, type of intervention, length of follow up, healing and recurrence rates for venous ulceration was assessed. Inadequate data in seven reports led to their exclusion. Recent randomised controlled trials (RCTs) specifically comparing superficial surgery to compression therapy were reviewed and data from non-randomised and/or 'small' clinical studies prior to 2000 underwent summation analysis.

RESULTS

Five RCTs since 2000 demonstrate a similar healing rate of VU with surgery and conservative compression treatments, but a reduction in ulcer recurrence rate with surgery. The effect of deep venous incompetence (DVI) on the ulcer healing is unclear, but sub-group analysis of long-term data from the ESCHAR trial suggests that although surgery results in a less impressive reduction in ulcer recurrence in patients with DVI, these patients appear to still benefit from surgery due to the haemodynamic and clinical benefits that result. The RCTs also highlight that a significant proportion of VU patients are unsuitable for surgical treatment. Summation of data from earlier studies (before 2000), included twenty-one studies employing conservative compression alone resulted in an overall healing rate of 65% (range 34-95%) and ulcer recurrence of 33% (range 0-100%). In thirty-one studies investigating superficial venous surgery, the overall rate of ulcer healing was 81% (range 40-100%) with a post-operative recurrence rate of 15% (range 0-55%). The duration of follow up care in the surgical studies was approximately twice as long as in the conservative studies, which would lend to more reliable recurrence data.

CONCLUSIONS

Evidence from the current literature, would suggest that superficial venous surgery is associated with similar rates of ulcer healing to compression alone, but with less recurrence. The effects of post-operative compression and DVI on the efficacy of surgery are still unclear.

Risk Factors for Delayed Healing and Recurrence of Chronic Venous Leg Ulcers—An Analysis of 1324 Legs

OBJECTIVE

Despite similar disease patterns and treatment, there is great variation in clinical outcome between venous ulcer patients. The aim of this study was to identify independent risk factors for venous ulcer healing and recurrence.

METHODS

Consecutive patients assessed by a specialist nurse-led leg ulcer service between January 1998 and July 2003 with an ABPI>0.85 were included in this study. Independent risk factors for healing and recurrence were identified from routinely assessed variables using a Cox regression proportional hazards model.

RESULTS

A total of 1324 legs in 1186 patients were studied. The 24-week healing rate was 76% and 1 year recurrence rate was 17% (Kaplan-Meier life table analysis). Patient age (p <0.001, HR per year 0.989, 95% CI 0.984-0.995) and ulcer chronicity (p =0.019, HR per month 0.996, 95% CI 0.993-0.999) were independent risk factors for delayed ulcer healing. Ulcer healing time (p <0.001, HR per week 1.016, 95% CI 1.007-1.026) and superficial venous reflux not treated with surgery (p =0.015, HR 2.218, 95% CI 1.166-4.218) were independent risk factors for ulcer recurrence.

CONCLUSIONS

Elderly patients with longstanding ulcers should be targeted for further research and may benefit from adjunctive treatments to improve clinical outcomes. Patients not treated with superficial venous surgery were at increased risk of leg ulcer recurrence.

Surgical options for the treatment of venous ulcers

Venous ulcers are a difficult problem for both patient and physician. Healing of venous ulcers with compression therapy and elevation, although usually successful, often takes months. Some venous ulcers do not heal with conservative therapy, or if they do, can often recur. Proper evaluation of the lower extremity venous system, usually with noninvasive imaging, is essential in planning any surgical intervention. In the appropriate patient, a number of surgical options are available to achieve ulcer healing and/or to prevent recurrence. These options include ablation of superficial reflux, perforator interruption, deep venous reconstruction, and endovenous procedures.

Most incompetent calf perforating veins are found in association with superficial venous reflux

PURPOSE

The indications for surgical perforator interruption remain undefined. Previous work has demonstrated an association between clinical status and the number of incompetent perforating veins (IPVs). Other studies have demonstrated that correction of IPV physiology results from abolition of saphenous system reflux. The purpose of this study was to identify which, if any, patterns of venous reflux and obstruction are particularly associated with IPV.

PATIENTS AND METHODS

Two hundred thirty patients and subjects (103 men, 127 women, 308 limbs) with varying grades of venous disease were examined both clinically and with duplex ultrasound scan. The odds ratios (ORs) for the presence of IPVs were calculated for different anatomical distributions of main-stem venous reflux and obstruction. The base group are those with no main-stem venous disease.

RESULTS

There were no significant associations between the proportions of limbs demonstrating IPVs and patient age or sex. The ORs for the presence of IPVs in association with other venous disease are as follows (age/sex adjusted): long saphenous vein reflux, OR = 1.86, range = 1.32-2.63; short saphenous vein reflux, OR = 1.36, range = 1.02-1.82; deep system venous reflux, OR = 1.61, range = 1.2-2.15; superficial system reflux, OR = 3.17, range = 1.87-5.4; and deep system obstruction, OR = 1.09, range = 0.51-2.33. The ORs for combinations of venous disorders were calculated. Combinations of disease produced higher odds for the presence of IPVs than those above, the highest being long saphenous vein, short saphenous vein, and deep reflux combined, OR = 6.85 (95% CI, 2.97-15.83; P =.0001).

CONCLUSIONS

Although the presence of IPVs is associated with venous ulceration, the highest ORs for the presence of IPVs were found in patients with superficial disease alone or in combination with deep reflux. Many of these may be corrected by saphenous surgery alone.

Surgical correction of isolated superficial venous reflux reduces long-term recurrence rate in chronic venous leg ulcers

OBJECTIVES

surgical correction of isolated superficial venous reflux in ulcerated legs may reduce short term recurrence rates but the longer term benefits are unknown.

DESIGN

prospective non-randomised cohort study.

METHODS

consecutive patients with chronic leg ulcers were prospectively assessed at a one-stop clinic over a 4-year period from July 1995 to July 1999. All patients with ankle brachial pressure indices (ABPI)50.85 were initially treated with weekly four-layer bandaging. Venous duplex studies in all ulcerated legs assessed venous reflux pattern with surgery being offered to all those with isolated superficial reflux, of whom 56% accepted. Patients were advised to wear class two elastic compression stockings after healing.

RESULTS

766 legs in 669 patients were assessed. Six hundred and thirty-three legs had an ABPI50.85, 236 (39%) demonstrating isolated superficial venous reflux. Surgery was performed on 131 of these legs. Twelve and 24 week healing rates were 50% and 72% for operated legs and 62% and 74% for non-operated legs (p=0.67; Kaplan-Meier life table analysis). Recurrence rates at 1, 2 and 3 years were 14%, 20% and 26% for operated legs and 28%, 30% and 44% for non-operated legs (p=0.03; Kaplan-Meier life table analysis).

CONCLUSION

surgical correction of superficial venous reflux in legs with chronic leg ulceration may reduce ulcer recurrence rate at 1, 2 and 3 years.

The relationship between the number, competence, and diameter of medial calf perforating veins and the clinical status in healthy subjects and patients with lower-limb venous disease

PURPOSE

The role of medial calf perforating veins in the pathogenesis of the skin changes of chronic venous insufficiency (CVI) remains controversial. This study examined the relationship between abnormal medial calf perforating vein structure and function and the clinical severity of CVI.

METHODS

Duplex ultrasound was used as a means of determining the number, flow characteristics, and diameter of medial calf perforating veins, and the presence of deep and superficial main stem reflux or occlusion in 50 limbs with no clinical or duplex evidence of venous disease (clinical, etiological, anatomical, and pathological grade [CEAP] 0), 95 limbs with varicose veins only (CEAP 2/3), 58 limbs affected by lipodermatosclerosis but not ulcer (CEAP 4), and 108 limbs affected by healed or open venous ulcer (CEAP 5/6).

RESULTS

The proportion of limbs in which any perforating veins and incompetent perforating veins (IPVs) were demonstrated increased significantly with deteriorating clinical status (CEAP 0, 88% and 6%; CEAP 2/3, 95% and 52%; CEAP 4, 98% and 83%; and CEAP 5/6, 98% and 90%, respectively). The total number of perforators, the total number of IPVs, and the median diameters of perforators increased with deteriorating grade (CEAP 0 median diameter, 2 mm [interquartile range, 1 to 3 mm]; CEAP 2/3 median diameter, 3 mm [interquartile range, 2 to 4 mm]; CEAP 4 median diameter, 4 mm [interquartile range, 3 to 5 mm]; and CEAP 5/6 median diameter, 4 mm [interquartile range, 3 to 5 mm]).

CONCLUSION

The deteriorating CEAP grade of CVI is associated with an increase in the number and diameter of medial calf perforating veins, particularly those permitting bidirectional flow.

Saphenous surgery does not correct perforator incompetence in the presence of deep venous reflux

PURPOSE

To determine which patients require subfascial endoscopic perforator surgery (SEPS) in addition to saphenous surgery to correct pathologic outward flow within incompetent medial calf perforating veins (IPVs).

METHODS

Sixty-two limbs of 47 patients undergoing sapheno-femoral ligation, stripping of the long saphenous vein in the thigh, and multiple phlebectomies (n = 51), sapheno-popliteal ligation and multiple phlebectomies (n = 10), or both (n = 1) were examined with color flow duplex ultrasound scan immediately before and a median of 14 weeks (range, 6 to 26 weeks) after the operations. Indications for surgery were varicose veins (n = 47, Clinical, Etiologic, Anatomic, Pathophysiologic grades C2&3), skin changes (n = 5, C4), and ulceration (n = 10, C5).

RESULTS

Surgery resulted in a significant reduction in the total number of limbs in which IPVs were imaged (40/62 or 65% preoperatively vs 23/62 or 37% postoperatively, P <.01, chi2 test), a significant reduction in the proportion of perforators imaged that were incompetent (68/130 or 52% preoperatively vs 34/120 or 28% postoperatively, P <.01, chi2 test), and a reduction in median IPV diameter (4 mm, with a range of 1 to 11 mm preoperatively, vs 3, with a range of 1 to 8 mm postoperatively, P <.01, Mann-Whitney U test). IPVs remained in 8 of 41 (20%) limbs in which main stem reflux was abolished, compared with 15 of 21 (72%) limbs in which superficial or deep reflux remained (P <.01, chi2 test).

CONCLUSION

Eradication of main stem saphenous reflux corrects IPV reflux in most cases in which reflux is confined to the superficial system. However, in patients with superficial reflux that persists postoperatively, or when there is coexistent deep venous reflux, saphenous surgery alone fails to correct IPVs reflux. In these circumstances, the only way of reliably correcting pathologic outward flow in medial calf perforating veins is to perform SEPS.

A clinical and haemodynamic investigation into the role of calf perforating vein surgery in patients with venous ulceration and deep venous incompetence

OBJECTIVE

To determine the clinical efficacy and local haemodynamic effects of perforating vein surgery in ulcerated limbs with combined deep and perforating vein incompetence.

DESIGN

Prospective, interventional study.

MATERIALS AND METHODS

Seven ulcerated limbs with combined primary deep and perforating vein incompetence were studied. Clinical efficacy was determined by ultimate ulcer healing and reduction in ulcer area, local haemodynamics were assessed at three sites with photoplethysmographic 90% venous refilling times (PPG RT90); both assessments were performed pre- and 1-month postoperatively.

RESULTS

None of the ulcers healed following perforating vein surgery, the median (range) ulcer areas pre- and postoperatively were 31 (7-685) cm2 and 35.5 (7-796) cm2 (Wilcoxon p = 0.07). Preoperative PPG RT90 demonstrated a global abnormality of venous function at all sites examined that persisted after perforating vein surgery.

CONCLUSION

In the presence of deep venous incompetence perforating vein surgery had no influence on venous function or ulcer healing. We conclude that perforating vein surgery is not indicated for the treatment of venous ulceration in limbs with primary deep venous incompetence.

Endoscopic versus open subfascial division of incompetent perforating veins in the treatment of venous leg ulceration: a randomized trial

PURPOSE

Subfascial division of incompetent perforating veins plays an important role in the surgical treatment of patients with venous ulceration of the lower leg. To minimize the high incidence of postoperative wound complications after open exploration, endoscopic approaches have recently been developed. We carried out a prospective, randomized comparison of open and endoscopic treatment of these patients that was aimed at ulcer healing and postoperative wound complications.

METHODS

Patients with current venous ulceration on the medial side of the lower leg were randomly allocated to open exploration by the modified Linton approach or endoscopic exploration by use of a mediastinoscope.

RESULTS

Thirty-nine patients were randomized, 19 to open exploration and 20 to endoscopic exploration. The incidence of wound infections after open exploration was 53%, compared with 0% in the endoscopic group (p < 0.001). Patients in the open group needed longer hospital stays (mean, 7 days; range, 3 to 39 days) than patients in the endoscopic group (mean, 4 days; range, 2 to 6 days; p = 0.001). Four months after operation, the ulcers of 17 patients (90%) in the open group and 17 patients (85%) in the endoscopic group had healed. During a mean follow-up of 21 months (range, 16 to 29 months), no recurrences were noticed in either group.

CONCLUSIONS

Endoscopic division of incompetent perforating veins is equally as effective as open surgical exploration for the treatment of venous ulceration of the lower leg but leads to significantly fewer wound healing complications. Endoscopic division is therefore the preferred method.

Subfascial endoscopic perforator surgery is associated with significantly less morbidity and shorter hospital stay than open operation (Linton's procedure)

BACKGROUND

Subfascial endoscopic perforator surgery (SEPS) is the minimally invasive alternative to the open (Linton's) procedure. This new technique may allow perforating vein interruption with fewer complications and a shorter postoperative hospital stay.

METHODS

This study was a case note review of 67 procedures: 30 SEPS and 37 Linton's.

RESULTS

There were no significant differences between the two groups in age, sex and indication for surgery. SEPS was associated with a significantly reduced postoperative stay in hospital (median 2 (range 1-49) days) compared with the Linton's procedure (median 9 (range 3-36) days) (P < 0.01). Nine patients who had Linton's procedure suffered a calf wound complication compared with none who had SEPS. The presence of an open ulcer at the time of surgery did not prolong the duration of stay in either group, nor did it increase the incidence of calf wound complications.

CONCLUSION

In patients undergoing calf perforator interruption for chronic venous insufficiency, SEPS is associated with significantly less morbidity and a shorter hospital stay than Linton's procedure. SEPS can be performed safely at the same time as skin grafting and in the presence of an open ulcer without any increase in wound complications.

Efficacy of subfascial endoscopy in eradicating perforating veins of the lower leg and its relation with venous ulcer healing

PURPOSE

The purpose of this study was to investigate the efficacy of subfascial endoscopy by use of a mediastinoscope in the identification and ligation of incompetent perforating veins in patients with venous ulceration of the lower leg.

METHODS

All patients who underwent subfascial endoscopy for venous ulceration between Jan. 1, 1994, and Mar. 1, 1995, at the Sint Franciscus Gasthuis in Rotterdam underwent duplex ultrasound scans of the lower leg before and 6 weeks after operation. The number and localization of the perforating veins on the mediodorsal side were compared with the findings during subfascial endoscopy.

RESULTS

In 20 patients, preoperative duplex examination showed 46 incompetent and six competent perforating veins. During operation the site of 43 incompetent and all competent perforating veins was confirmed. Five additional perforating veins were found at operation (false-negatives). Postoperative duplex ultrasound scans showed six incompetent perforating veins (four persisting and two recurring perforating veins) in four patients, of which the ulcers did not heal in three. The ulcers of the other 17 patients healed.

CONCLUSIONS

Subfascial endoscopy is an efficient technique in identifying incompetent perforating veins in patients with chronic ulceration of the lower leg. The persistence of incompetent perforating veins is related to failure of ulcer healing.

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.

Comparison of venous reflux in the affected and non-affected leg in patients with unilateral venous ulceration

In 54 patients with unilateral leg ulceration of purely venous aetiology the only difference in venous reflux between affected and non-affected legs was with respect to the popliteal and crural veins. Deep and superficial venous reflux is common in legs without the skin changes typical of chronic venous insufficiency. The significance of venous reflux in an ulcerated leg cannot therefore be determined without reference to the contralateral, clinically normal, limb. Surgery should be directed at correcting reflux present in the ulcerated limb but not in the unaffected limb. In a minority of patients this entails superficial venous surgery alone, but in the majority such an approach would, ideally, entail correction of deep venous incompetence.

Venous function and clinical outcome following deep vein thrombosis

The severity of post-thrombotic symptoms in 111 limbs (107 patients) with previous phlebographically proven deep vein thrombosis (DVT) was correlated with superficial and deep venous function as determined by foot volumetry (n = 90) and duplex ultrasonography (n = 62). The median delay between DVT and assessment was 8 (range 1-34) years. Symptoms were mild (group 1) in 31 limbs (28 per cent), moderate (group 2) in 41 (37 per cent) and severe (group 3) in 39 (35 per cent). There was no significant relationship between the site of DVT, or the time since DVT, and the severity of symptoms. Without tourniquet occlusion of superficial veins, limbs in group 3 had a significantly shorter half-refilling time than those in groups 1 and 2 (P = 0.01). Although a similar trend was observed after tourniquet occlusion of superficial veins, this was not statistically significant. There was no significant difference in the expelled volumes between the three clinical groups. On duplex scanning, deep and superficial venous reflux was detected in just over half of the limbs in each group. Eight patients had entirely normal scans and none of them had severe symptoms (P = 0.04). This study identifies a strong association between severe postphlebitic syndrome and venous reflux, such that it may be considered that venous reflux is necessary for the development of severe post-thrombotic symptoms. However, many patients with severe reflux have only mild symptoms and additional factors must therefore contribute to the development of severe postphlebitic syndrome.