The influence of superficial venous surgery and compression on incompetent calf perforators in chronic venous leg ulceration

Chronic Venous Insufficiency With Emphasis on the Geriatric Population

The underpinning of Chronic Venous Insufficiency (CVI) is valvular dysfunction, which manifests on a spectrum depending on the severity of insufficiency and duration of the disease. The mainstay of treatment relies on compression therapy of a proper type and intensity. In older adults, special consideration must be taken during the patient encounter to account for age-related factors. This review discusses the clinical presentation, diagnosis, and mimicking of CVI, focusing mainly on older adults. The epidemiology, risk factors, disease burden, and grave complications -- such as thrombosis and ulceration, are reviewed. The physiological impacts of CVI are described, providing the background for treatment strategies, including non-invasive, medical, and surgical therapies. The findings show advanced age to be an important risk factor contributing to CVI and that other age-related factors add to the risk of severe complications. Clinical assessments combined with objective measurements that assess localized skin water using tissue dielectric constant values or whole limb assessments may aid in the differential diagnosis. Furthermore, understanding the mechanism of action of compression therapy, the mainstay of CVI treatment, and its physiological impacts, allows for its informed use in geriatric patients with increased risks of potential compression-related side effects.

Patterns of flow drainage from varicose veins originating in the incompetent great saphenous vein

Background

Chronic venous insufficiency affects the lives of many people and therefore constitutes a public health problem. Knowledge of the drainage patterns of reflux from varicose veins secondary to incompetent saphenous veins is essential to define the best therapeutic management.

Objectives

To determine the reflux drainage patterns from varicose veins originating in incompetent GSV, the prevalence of perforating veins (PV), and their relationships with symptoms.

Methods

55 ultrasound reports were analyzed to determine the drainage patterns of reflux from the GSV, location and diameter of PV drainage, and staging of symptoms.

Results

In 64% of the sample, reflux from varicose veins drained to PVs, in 4% reflux drained to the GSV itself, in another 4% drainage was to the small saphenous vein, and in 29% drainage was to varicose trunk veins in which no direct communication with the deep system could be identified. No associations were observed between symptoms and reflux drainage patterns or PV diameters.

Conclusions

For this sample, PVs were responsible for draining flow from varicose veins in 64% of cases. Neither PV diameters nor GSV reflux patterns were associated with severity of symptoms.

The fate of calf perforator veins after saphenous vein laser ablation

PURPOSE

We aimed to assess hemodynamic changes in calf perforator veins (PVs) after endovenous laser ablation (EVLA) of saphenous veins.

METHODS

The series comprised 60 limbs of 41 patients (27 female, 14 male; median age, 43 years [range, 22-78 years]) who underwent EVLA for varicose veins. All patients were prospectively evaluated by means of color Doppler ultrasonography before and after the procedure.

RESULTS

EVLA did not change the rate of incompetent PVs (preoperatively, 154/483 [32%] vs. postoperatively, 167/501 [33%]; P = 0.173), but significantly increased the total number of all PVs (n=483 vs. n=501, P = 0.036). Following EVLA, 28% of the limbs had thrombosis of PVs, 34% had new US-detectable PVs, 42% showed new competency, and 52% showed new incompetency. New competent PVs were found more commonly in the medial leg (ablation site) than the lateral leg (nonablation site) (28.3% vs. 11.7%, P = 0.016), while new incompetent PVs were found more commonly in nonablation site than ablation site (31.7% vs. 18.3%, P = 0.086). Additionally, new competent PVs in the posterior leg were found more often in patients who had small saphenous vein ablation than patients who did not (30% vs. 0%, P = 0.002).

CONCLUSION

EVLA induces numerous changes in calf PVs. These changes seem to result from flow offloading in ablation site and onloading in nonablation site in the early postablation period.

Competent and incompetent calf perforators in primary varicose veins: a resistant myth

The pathophysiology of calf perforators is presented. Bidirectional flow within calf perforators with a prevailing inward, into deep veins oriented component arises during calf pump activity in varicose vein patients, as evidenced by venous pressure measurements, plethysmographic findings, duplex ultrasonography, and electromagnetic flow measurements. Reflux within calf perforators is an inward, not outward, flow; the opinion that the outward flow within calf perforators is a reflux is at odds with the reality. During calf muscle contraction, the pressure in the posterior tibial vein is higher than in the great saphenous vein; it induces the harmless outward flow within calf perforators, which runs further via great saphenous vein in the physiological direction toward the heart. Deep and superficial veins of the lower leg form conjoined vessels, as documented by nearly equal pressure curves registered simultaneously in the posterior tibial and great saphenous veins both in varicose vein patients and in healthy people. Calf perforators do not entail ambulatory venous hypertension or any other hemodynamic disorder, even if enlarged and incompetent; their ligation is needless. The diameter of calf perforators is influenced by the intensity of saphenous reflux; it enlarges with increasing intensity of saphenous reflux and diminishes after the abolition of reflux.

Debate: whether venous perforator surgery reduces recurrences

Superficial venous surgery and perforator vein surgery, specifically, have a long and varied history in the evolution of vascular surgery, especially because venous disease continues to be extremely common. As with other areas of our specialty, perforator vein procedures have progressed from being purely open operations to becoming less invasive procedures. Despite this, there remains much discussion (as well as overt disagreement) about whether perforator vein surgery is actually appropriate and beneficial in the first place. Surgeons have no level I evidence from randomized controlled studies to determine whether perforator vein surgery does or does not reduce the chances of recurrence of superficial venous varicosities, so we must rely on the evidence as it currently is. Perhaps not surprisingly, our two experts have assembled divergent opinions on the role of perforator venous surgery in contemporary practice.

Chronic Venous Insufficiency

Varicose veins are a common manifestation of chronic venous disease and affect approximately 25% of adults in the western hemisphere. The historical standard treatment has been surgery, with high ligation and stripping, combined with phlebectomies. In the past decade, alternative treatments such as endovenous ablation of the great saphenous vein (GSV) with laser, radiofrequency ablation, and ultrasonography-guided foam sclerotherapy have gained popularity. Performed as office-based procedures using tumescent local anesthesia, the new minimally invasive techniques have been shown in numerous studies to obliterate the GSV, eliminate reflux, and improve symptoms safely and effectively.

Calf pump activity influencing venous hemodynamics in the lower extremity

Calf muscle pump is the motive force enhancing return of venous blood from the lower extremity to the heart. It causes displacement of venous blood in both vertical and horizontal directions, generates ambulatory pressure gradient between thigh and lower leg veins, and bidirectional streaming within calf perforators. Ambulatory pressure gradient triggers venous reflux in incompetent veins, which induces ambulatory venous hypertension in the lower leg and foot. Bidirectional flow in calf perforators enables quick pressure equalization between deep and superficial veins of the lower leg; the outward (into the superficial veins) oriented component of the bidirectional flow taking place during calf muscle contraction is no pathological reflux but a physiological centripetal flow streaming via great saphenous vein into the femoral vein. Calf perforators are communicating channels between both systems making them conjoined vessels; they are not involved in the generation of pathological hemodynamic situations, nor do they cause ambulatory venous hypertension. The real cause why recurrences develop has not as yet been cleared. Pressure gradient arising during calf pump activity between the femoral vein and the saphenous remnant after abolition of saphenous reflux triggers biophysical and biochemical events, which might induce recurrence. Thus, abolition of saphenous reflux removes the hemodynamic disturbance, but at the same time it generates precondition for reflux recurrence and for the comeback of the previous pathological situation; this chain of events has been called hemodynamic paradox.

[Subcutaneous paratibial fasciotomy in the treatment of chronic venous ulcer]

BACKGROUND/AIM

Chronic venous ulcer (CVU), a disease of high incidence, is one of the most serious chronic venous insufficiency complications. It has been estimated that there are 1%-2% of adults with CVU deriving a high social significance. The aim of this study was to, using the clinical experience, determine the influence of subcutaneous paratibial fasciotomy (SPF) on the course and the treatment outcome of CVU.

METHODS

From February 2006 to September 2009 SPF was applied in a group of 43 patients treated for CVU along with other standard methods of treatment, and its influence on the course of ulcus cruris was followed up regarding the control group of another 43 patients treated with standard methods with no paratibial fasciotomy.

RESULTS

In the group of patients treated with SPF there was a significantly better clinical course of ulcus cruris closing as compared with the group of patients in which this method was not applied. In the group with paratibial fasaciotomy there was no Thiersch skin transplant rejection recorded nor ulcus recurrence within a 6-month after-surgery period, while in the control group there was Thiersch skeen transplant rejection in 11 patients, and ulcus recurrence in 9 patients within the same period.

CONCLUSION

SPF is a useful method with a favorable influence on better clinical course of ulcus cruris closing, reducing recurrence rate and improving local microcirculation in the affected region. Operation act itself is safe, requires no specific equipment nor special training of the team of surgeons, thus being applicable to the majority of patients with ulcus cruris indicated for surgery.

Early results from a randomized trial of saphenous surgery with or without subfascial endoscopic perforator surgery in patients with a venous ulcer

Background

The aim was to clarify the role of incompetent perforators (IPs) in venous leg ulcers. This short-term report focused on safety, patient satisfaction and the fate of IPs after subfascial endoscopic perforator surgery (SEPS), or saphenous surgery alone.

Methods

Patients aged 30–78 years with an open or recently healed venous ulcer, and with an incompetent saphenous vein and IPs, were allocated randomly to saphenous surgery alone, or in combination with SEPS. A control duplex scan was performed 6–9 months after surgery, and clinical follow-up was scheduled after 1 week, 3 and 12 months. A standard questionnaire was completed at each clinical visit.

Results

Seventy-five patients were enrolled; 37 had SEPS and 38 had saphenous surgery alone. SEPS prolonged the operation by a median of 15 min (P = 0·003). Duplex imaging revealed significantly more remaining IPs in the no-SEPS group (P < 0·001). Compared with the preoperative scan, significantly more legs were free from IPs in the SEPS group compared with the no-SEPS group (21 of 36 versus 7 of 37 respectively; P < 0·001). There were no other major outcome differences between the groups.

Conclusion

There was no short-term clinical benefit from adding SEPS to saphenous surgery in patients with varicose ulcers and IPs, although SEPS reduced the number of perforators remaining after 1 year.

Impact of lower extremity venous ulcers due to chronic venous insufficiency on quality of life

Lower extremity venous ulcers comprise a complex medical and social issue. The conservative and/or surgical management of venous ulcers is often inadequate. In addition, the psychosocial aspect of the disease is often overlooked and most often undertreated. Common symptoms such as pain, low self-esteem and patient isolation are usually not recognized and therefore not adequately managed.This mini-review summarizes the current data on the management of lower extremity venous ulcers and their impact on the quality of life of these patients.

True Long-term Healing and Recurrence of Venous Leg Ulcers Following SEPS Combined with Superficial Venous Surgery: A Prospective Study

BACKGROUND

The role of perforator surgery remains unclear in the management of patients with leg ulcers. The aim of this study was to assess long-term healing and recurrence rates of leg ulcers following surgical intervention with combined Subfascial Endoscopic Perforator Surgery (SEPS) and superficial venous surgery.

METHOD

Case series with prospective long-term follow-up of 90 consecutive patients operated on with open (CEAP C6) or healed (CEAP C5) venous ulcers in 97 legs. Popliteal vein reflux was present in 21 legs. All 97 legs were treated with SEPS and 87% had additional superficial venous surgery. Patients were follow-up for a median of 77 months (range 60-112 months) with a minimum of 5 years.

RESULTS

87% of all ulcerated legs healed. The three and five year recurrence rates were 8% and 18% respectively among survivors. In a multivariate Cox regression analysis previous vein surgery was the only factor significantly associated with recurrent ulceration (p=.004).

CONCLUSION

SEPS combined with superficial venous surgery leads to healing with a low recurrence rate in patients with open and healed venous ulcers. Previous venous surgery was found to be a significant risk factor for ulcer recurrence. This result emphasizes the importance of assiduous technique for varicose vein surgery and suggests a continuing role for perforator surgery in leg ulcer patients.

Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomised controlled trial

OBJECTIVE

To determine whether recurrence of leg ulcers may be prevented by surgical correction of superficial venous reflux in addition to compression.

DESIGN

Randomised controlled trial.

SETTING

Specialist nurse led leg ulcer clinics in three UK vascular centres.

PARTICIPANTS

500 patients (500 legs) with open or recently healed leg ulcers and superficial venous reflux.

INTERVENTIONS

Compression alone or compression plus saphenous surgery.

MAIN OUTCOME MEASURES

Primary outcomes were ulcer healing and ulcer recurrence. The secondary outcome was ulcer free time.

RESULTS

Ulcer healing rates at three years were 89% for the compression group and 93% for the compression plus surgery group (P=0.73, log rank test). Rates of ulcer recurrence at four years were 56% for the compression group and 31% for the compression plus surgery group (P<0.01). For patients with isolated superficial reflux, recurrence rates at four years were 51% for the compression group and 27% for the compress plus surgery group (P<0.01). For patients who had superficial with segmental deep reflux, recurrence rates at three years were 52% for the compression group and 24% for the compression plus surgery group (P=0.04). For patients with superficial and total deep reflux, recurrence rates at three years were 46% for the compression group and 32% for the compression plus surgery group (P=0.33). Patients in the compression plus surgery group experienced a greater proportion of ulcer free time after three years compared with patients in the compression group (78% v 71%; P=0.007, Mann-Whitney U test).

CONCLUSION

Surgical correction of superficial venous reflux in addition to compression bandaging does not improve ulcer healing but reduces the recurrence of ulcers at four years and results in a greater proportion of ulcer free time.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN07549334 [controlled-trials.com].

Leg Ulcer Recurrence and its Risk Factors: A Duplex Ultrasound Study before and after Vein Surgery

OBJECTIVES

Assessment of risk factors for ulcer recurrence in chronic leg ulcer patients treated by varicose vein surgery.

DESIGN

Retrospective follow-up study.

MATERIALS

62 patients, 43 women and 19 men (Median=56.5 years, range 24-77) with the CEAP classifications of C(5)-C(6) and E(P) (primary venous insufficiency).

METHODS

Patients underwent colour duplex ultrasound (CDU) investigation before varicose vein surgery. Post-operatively CDU, ambulatory venous pressure (AVP) and an interview were performed. The median clinical follow-up was 5.5 years (range 2-11 years).

RESULTS

The estimated 5-year ulcer recurrence rate was 19% in all patients. The risk of ulcer recurrence was significantly lower (p<0.05) in legs without residual varices or recurrence. The five year risk of ulcer recurrence depended on the time interval between ulcer appearance and the surgical intervention (index operation), post-operative venous axial reflux and AVP (mmHg). More than 50% of the patients had a calculated probability of ulcer recurrence of less than 3%, but 13% had a probability of more than 23% based on our analysis.

CONCLUSIONS

A long history of venous ulcer is a pre- and post-operative risk factor for recurrent ulceration. Total elimination of incompetent superficial and perforator veins lowers the risk of ulcer recurrence, whereas residual axial reflux increases the risk. Postoperative CDU is effective in identifying patients at risk of ulcer recurrence.

Mid-term recurrence rate of incompetent perforating veins after combined superficial vein surgery and subfascial endoscopic perforating vein surgery

BACKGROUND

This study investigated the mid-term (mean, 3.7 years) clinical results and the results of duplex Doppler sonographic examinations of subfascial endoscopic perforating vein surgery (SEPS) in patients with mild to severe chronic venous insufficiency (clinical class 2-6) and assessed the factors associated with the recurrence of insufficient perforating veins (IPVs).

METHODS

Eighty patients with mild to severe chronic venous insufficiency undergoing SEPS were evaluated, and duplex findings, as well as clinical severity and disability scores before and after the operation, were compared. Patients with prior deep vein thrombosis (<6 months) or prior SEPS were excluded from this study.

RESULTS

There were 27 men and 53 women with a median age of 59.8 years (range, 34.3-80.0 years). The distribution of clinical classes (CEAP) was as follows: class 2, 13.1% (12 limbs); class 3, 22.8% (21 limbs); class 4, 19.6% (18 limbs); class 5, 21.7% (20 limbs); and class 6, 22.8% (21 limbs). The etiology of venous insufficiency was primary valvular incompetence in 83 limbs (90.2%) and secondary disease in 9 limbs (9.8%). Concomitant superficial vein surgery was performed in 89 limbs (95.7%). Twenty (95%) leg ulcers healed spontaneously within 12 weeks after operation, whereas one patient required additional split-thickness skin grafting. Eighteen patients had previous surgery of the great and/or short saphenous vein before SEPS. During a mean follow-up of 3.7 years, recurrence of 22 IPVs was observed in 20 (21.7%) of 92 limbs, and recurrent leg ulcers were observed in 2 (9.5%) of 21 limbs. We performed univariate and multivariate analyses to predict factors influencing the recurrence of IPVs (recurrent superficial varicosis, secondary disease, active or healed leg ulcer [C5/6], compression treatment, and previous operation). On multivariate analysis, previous surgery (P = .014) was identified as the only significant factor for the recurrence of IPVs.

CONCLUSIONS

SEPS is a safe and highly effective treatment for IPVs. Within a median follow-up period of 3.7 years, only 2 of 21 venous ulcers recurred, both in patients with secondary disease. Nevertheless, we observed recurrence of IPVs in 21.7% of the operated limbs. On multivariate analysis, patients who had undergone previous surgery were found to have a significantly higher rate of recurrence.

Preventing venous ulcer recurrence: a review

This review article examines the available evidence on both the primary and secondary prevention of venous ulceration, exploring both the individual, social and financial implications of system failures that allow patients to remain at increased risk of recurrent ulceration. The role of both venous disease assessment and corrective superficial venous surgery are discussed in the light of recently published randomised controlled studies on the role of superficial venous surgery as both an adjunct to ulcer healing and ulcer prevention.

Subfascial Endoscopic Perforator Vein Surgery

Chronic venous insufficiency is a tremendous health care problem in western societies. Venous disease can affect any combination of the superficial, deep, and perforator venous systems of the lower extremities. Generally the superficial venous deficits are addressed through sclerotherapy, enovenous ablation, stab phlebectomy, and or stripping. Patients with advanced clinical sequelae (lipodermatosclerosis or ulceration) of CVI should also be evaluated for the presence of incompetent perforating veins. Open surgical approached to the calf perforating veins (ie. Linton procedure) were complicated by significant wound complications and have largely been replaced by the less invasive Subfascial Endoscopic Perforator Surgery (SEPS). The use of SEPS in patients with ulceration has been shown to be safe and to reduce the time that patients will have ulcers during follow-up. This chapter will review the pathophysiology, diagnosis, and treatment of incompetent perforating veins of the legs with particular attention to surgical issues.

Venous leg ulcer: a meta-analysis of adjunctive therapy with micronized purified flavonoid fraction

OBJECTIVE

To assess the effect of oral treatment with micronized purified flavonoid fraction (MPFF) on leg ulcer healing.

DESIGN

Meta-analysis of randomised prospective studies using MPFF in addition to conventional treatment.

MATERIALS AND METHODS

Five prospective, randomised, controlled studies in which 723 patients with venous ulcers were treated between 1996 and 2001 were identified. Conventional treatment (compression and local care) in addition to MPFF was compared to conventional treatment plus placebo in two studies (N = 309), or with conventional treatment alone in three studies (N = 414). The primary end point was complete ulcer healing at 6 months.

RESULTS

At 6 months, the chance of healing ulcer was 32% better in patients treated with adjunctive MPFF than in those managed by conventional therapy alone (RRR: 32%; CI, 3-70%). This difference was present from month 2 (RRR: 44%; CI, 7-94%), and was associated with a shorter time to healing (16 versus 21 weeks; P = 0.0034). The main benefit of MPFF was present in the subgroup of ulcers between 5 and 10 cm2 in area (RRR: 40%; CI, 6-87%), and those present for 6-12 months duration (RRR: 44%; CI, 6-97%).

CONCLUSION

These results confirm that venous ulcer healing is accelerated by MPFF treatment. MPFF might be a useful adjunct to conventional therapy in large and long standing ulcers.

Changes in superficial and perforating vein reflux after varicose vein surgery

OBJECTIVES

This prospective duplex study was conducted to study the effect of current surgical treatment for primary varicose veins on the development of venous insufficiency < or = 2 years after varicose vein surgery.

METHODS

The patients were part of a randomized controlled study where surgery for primary varicose veins was planned from a clinical examination alone or with the addition of preoperative duplex scanning. Postoperative duplex scanning was done at 2 months and 2 years.

RESULTS

Operations were done on 293 patients (343 legs), 74% of whom were women. The mean age was 47 years. In 126 legs, duplex scanning was done preoperatively, at 2 months and 2 years, and at 2 months and 2 years in 251 legs. Preoperative perforating vein incompetence (PVI) was present in 64 of 126 legs. Perforator ligation was not done on 42 of these; at 2 months, 23 of these legs (55%) had no PVI, and at 2 years, 25 legs (60%) had no PVI. Sixty-one legs had no PVI preoperatively, 5 (8%) had PVI at 2 months, and 11 (18%) had PVI at 2 years. In the group of 251 legs, reversal of PVI between 2 months and 2 years was found in 28 (41%) of 68 and was more common than new PVI, which occurred in 41 (22%) of 183 (P = .003). After 2 years, the number of legs without venous incompetence in which perforator surgery was not performed was 11 (26%) of 42 legs with preoperative PVI and 18 (30%) of 61 legs without preoperative PVI, (P = .713). After 2 years, new vessel formation was more common in the surgically obliterated saphenopopliteal junction (SPJ), 4 (40%) of 10, than in the saphenofemoral junction (SFJ), 17 (11%) of 151(P = .027), and new incompetence in a previously normal junction was more common in the SFJ, 11 (18%) of 63, than in the SPJ, 3 (1%) of 226 (P < .001). Reflux in the great saphenous vein (GSV) below the knee was abolished after stripping above the knee in 17 (34%) of 50 legs at 2 months and in 22 legs (44%) after 2 years.

CONCLUSIONS

Varicose vein surgery induces changes in the remaining venous segments of the legs that continue for several months. In most patients, perforators and the GSV below the knee can be ignored at the primary surgery. A substantial number of recurrences in the SFJ and SPJ are unavoidable with present surgical knowledge because they stem from new vessel formation and progression of disease.