The present status of surgery of the superficial venous system in the management of venous ulcer and the evidence for the role of perforator interruption

The need for perforator treatment after VenaSeal and ClosureFast endovenous saphenous vein closure in CEAP 6 patients

OBJECTIVE

The authors have previously demonstrated that VenaSeal (Medtronic, Inc, Minneapolis, Minn) adhesive, compared with radiofrequency ablation (RFA, ClosureFast; Medtronic, Inc), in treatment of refluxing saphenous veins in CEAP 6 limbs, results in shorter healing times of venous ulcers. The authors hypothesize that the longer treated length possible with VenaSeal's nonthermal modality may affect the number of critical refluxing perforators contributing to the nonhealing wound. This follow-up study compares the need for follow-up treatment of perforator veins after saphenous vein treatment with either radiofrequency ablation (ClosureFast RFA) or adhesive closure (VenaSeal).

METHODS

A multi-institutional retrospective review of CEAP 6 patients who had closure of their saphenous veins from 2015 to 2020 was conducted. Patients who underwent follow-up treatment of perforator veins were grouped according to their method of initial management of their saphenous veins. The primary end point was incidence of a perforator procedure after ClosureFast or VenaSeal ablation. Secondary end points included sclerotherapy to facilitate wound healing. Bivariate analysis used the χ² test, Fisher exact test, t-test, and Wilcoxon rank sum test. A P value of <.05 defined statistical significance.

RESULTS

There were 119 CEAP 6 patients with saphenous closure: 51 limbs treated with VenaSeal and 68 with RFA. Median follow-up was 105 days (interquartile range: 44, 208). All limbs achieved wound healing during the study period. Mean time to wound healing post index procedure was shorter for VenaSeal than RFA (72 vs 293.8 days, P > .0009), as was median time (43 vs 104 days, P = .001). More limbs treated with RFA had previous known deep vein thrombosis (29% vs 10%, P = .009), deep venous insufficiency (82% vs 51%, P = .0003), and perforator reflux (57% vs 29%, P = .002). Limbs with identified follow-up perforator reflux treated with RFA had a higher prevalence of initially treated saphenous veins with RFA compared with those treated with VenaSeal (49% vs 27%, P = .003). There was no difference between the methods of vein closure and use of concurrent sclerotherapy.

CONCLUSIONS

ClosureFast and VenaSeal are both effective and safe modalities of saphenous ablation, but VenaSeal treatment was associated with less perforator RFA intervention.

One-year outcomes of radiofrequency ablation of incompetent perforator veins using the radiofrequency stylet device: Cohort study from East Asia

OBJECTIVES

The present study was designed to assess outcomes of patients undergone radiofrequency ablation (RFA) for their incompetent perforator veins (IPVs) with ClosureFast stylets.

METHODS

Data of 165 IPVs in 138 limbs of 117 consecutive patients between July 2017 to Nov. 2019 were retrospectively reviewed. Primary endpoints (technical success rate, complications) and secondary endpoints (VCSS) were analyzed.

RESULTS

The immediate technical success rate was 100%. There were no major complications. The rate of ecchymosis and induration was 5.8%. 129/165 IPVs in 79.5% (93/117) patients had achieved sonographic evaluation at 1 year followed-up, in which 3 perforators were recanalized. VCSS scores at pre-operation and 1-year follow-up were 5.77 ± 1.88 and 2.70 ± 1.39, respectively (t= 29.644, P= .000).

CONCLUSIONS

In conclusion, RFA is safe and effective for the treatment of IPVs. At the 1-year follow-up, the RFA of IPVs showed a low recanalization rate and had a satisfactory improvement on VCSS.

Endovenous Laser Ablation Combined with Stripping Technique for Large Saphenous Varicose Veins: The Selection of Operation Technique

Objective: Saphenous varicose veins can be accomplished by various operative techniques that result in stripping, ablation, or ligation of the venous reflux section. Great saphenous vein (GSV) stripping is one of the standard operations for varicose veins to eliminate reflux of the sapheno-femoral junction. The goal of any treatment regimen is to eliminate the junctional varicose reflux to control congestive dysfunction. Endovenous laser ablation (EVLA) is safe and effective with less postoperative pain, bleeding, and peripheral nerve damage than open surgery. In this study, a patient with severe progression of primary saphenous varicose veins is presented. We report the outcome of combined surgical strategy and perioperative treatment for extremely swollen varicose veins of the lower limbs to improve leg symptoms and congestion and/or promote skin ulcer healing.

Materials and Methods: The subjects included 42 patients (51 limbs) who underwent EVLA with stripping. The patients comprised 24 males and 18 females, who presented a maximum GSV diameter >15 mm. The Clinical-Etiological-Anatomic-Pathophysiologic classification identified 9, 20, 9, 2, 6, and 5 limbs with C2, C3, C4a, C4b, C5, and C6, respectively, among the 42 patients.

Results: EVLA was used to treat GSV with a mean length of 16.1±2.8 cm. The mean of the maximum GSV diameter was 16.8±3.2 mm (14.6–21.8 mm). The preoperative visual analog scale (VAS) score was 82.1±12.1. After operation, the VAS gradually deteriorated to 31.3±17.9 (p<0.0001), 2.8±3.6 (p<0.0001), and 1.2±1.8 (p<0.0001) in 7 days, 1 month, and 3 months, respectively.

Conclusion: We obtained a satisfactory outcome from our combined strategy and perioperative treatment for extremely swollen saphenous varicose veins. This approach may show the possibility that lower saphenous varicose veins can induce cosmetic and minimally invasive ameliorated intervention to avoid late-phase incompetent perforating veins.

Varicose Veins and Lower Extremity Venous Insufficiency

Lower extremity venous insufficiency and varicose veins are common conditions, affecting up to 25% of women. Herein, we review the pathophysiology of lower extremity venous insufficiency and varicose veins, the epidemiology of varicose veins, clinical diagnosis, and ultrasonographic diagnosis. We also discuss treatment rationale, algorithms, and techniques, with a focus on endovenous great saphenous vein ablation.

Die chronische venöse Insuffizienz - Eine Zusammenfassung der Pathophysiologie, Diagnostik und Therapie

Die chronische Venenerkrankung ist eine weit verbreitete Krankheit, die in späteren Stadien mit einer Vielzahl an Symptomen, aber auch Komplikationen wie dem Ulcus cruris, einhergeht. Dies wiederum hat weitreichende Auswirkungen auf die Lebensqualität der Patienten wie auch auf das Gesundheitssystem. Für die Diagnostik der chronischen Venenerkrankungen steht eine Auswahl an Verfahren zur Verfügung, wobei sich die farbkodierte Duplexsonographie als Goldstandard etabliert hat. Im Bereich der Therapie kam es in den letzten Jahrzehnten zu großen Fortschritten, sodass heute auch Alternativen zum klassischen Stripping durch die endoluminalen Verfahren zur Verfügung stehen. Die Wahl der Therapieoption ist jedoch weiterhin stark abhängig von mehreren Faktoren, unter anderem von den anatomischen Gegebenheiten und dem Krankheitsstadium. Im folgenden Artikel werden die Anatomie und Pathophysiologie, sowie die aktuellen Standards der Diagnostik und Therapie zusammengefasst.

Chronic venous insufficiency - a review of pathophysiology, diagnosis, and treatment

Chronic venous disease is a common disorder associated with a variety of symptoms in later disease stages but also with complications such as venous leg ulcer. This, in turn, has substantial socioeconomic effects and significantly impacts patients' quality of life. While there are a number of diagnostic procedures available, color-flow duplex ultrasound has become the gold standard. As regards therapeutic options, major advances have been made in recent decades. Today, there are alternatives to saphenofemoral ligation and stripping of the great saphenous vein, including endovenous thermal ablation techniques. However, treatment selection continues to depend on many factors such as individual anatomical circumstances and disease stage. The following article provides an overview of the anatomy and pathophysiology as well as current diagnostic and therapeutic standards.

Study on the efficacy of surgery of the superficial venous system and of compression therapy at early stages of chronic venous disease for the prevention of chronic venous ulceration

The mainstay of treatment of chronic venous ulceration (CVU), as also suggested by current treatment guidelines for chronic venous disease (CVD), is represented by surgery and compression therapy for which there is strong evidence of their role in clinically relevant improvement in wound healing and also in the reduction of CVU recurrence, but no information is available as to whether or not these treatments provide effective protection from the onset of CVU. In our study, we have followed, for a median time of 13 years, a total of 3947 patients with CVD at classes C2-C3 of CEAP classification, treated with our treatment protocol (surgery and compression therapy) in order to track the natural history of these patients with regards to CVU development. We identified four groups of patients: 2354 patients (59·64%) (Group A) fully adherent to protocols; 848 patients (21·48%) (Group B) fully adherent to surgery and non-compliant to compression therapy; 432 patients (10·95%) (Group C) fully adherent to compression therapy and non-compliant to surgery; and 313 patients (7·93%) (Group D) non-compliant to either treatments. Regardless of compliance to treatments, the ulcer development rates were very similar between groups (range: 3·23-4.79%), with no statistical significance (P = 0·1522). Currents treatments used in the early stages of CVD appear to have no effects to progression to CVU. Additional longitudinal studies are required to confirm these findings.

A review of a new Dutch guideline for management of recurrent varicose veins

In 2013, the new Dutch guideline for "Venous Pathology" was published. The guideline was a revision and update from the guideline "Diagnostics and Treatment of Varicose Veins" from 2009 and the guideline "Venous Ulcer" from 2005. A guideline for "Deep Venous Pathology" and one for "Compression Therapy" was added to the overall guideline "Venous Pathology." The chapter about treatment of recurrent varicose veins after initial intervention was recently updated in 2015 and is reviewed here. The Dutch term "recidief varices" or the French "récidive de varices" should be used analogous to the English term "recurrent varicose veins." The DCOP Guideline Development Group Neovarices concluded that "recidief" in Dutch actually suggests recurrence after apparent successful treatment and ignores the natural progression of venous disease in its own right. So the group opted to use the term "neovarices." In the Dutch guideline, neovarices is meant to be an all embracing term for recurrent varicose veins caused by technical or tactical failure, evolvement from residual refluxing veins or natural progression of varicose vein disease at different locations of the treated leg after intervention. This report reviews the most important issues in the treatment of varicose vein recurrence, and discusses conclusions and recommendations of the Dutch Neovarices Guideline Committee.

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.

Influence of perforating vein surgery in patients with venous ulceration

Objectives

The exact role of perforating vein surgery is still unclear. The aim of this study is to analyze the influence of perforating vein surgery in patients with venous ulceration.

Methods

This study was part of a randomized controlled trial in which conservative and surgical treatment of venous ulceration was compared. It is a secondary analysis of prospectively gathered data. Ninety-seven active leg ulcers were surgically treated with a subfascial endoscopic perforating vein surgery (SEPS) procedure. Concomitant superficial venous incompetence was treated with flush saphenopopliteal ligation and/or saphenofemoral ligation and limited stripping of the great saphenous vein. All patients were also treated with ambulatory compression therapy. Ulcer healing and recurrences are described in detail. To measure the completeness of the SEPS procedure duplex ultrasonography was performed on each patient before and 6 weeks and 12 months after surgery. Also newly formed perforators after surgery were scored and their influence was analyzed.

Results

Analyses were performed on 94 ulcerated legs with a mean follow-up of 29 months. In all treated legs, only 45% all perforators were treated. In 55% one (29%) or more (26%) perforators were missed. Healing was not significantly influenced by the number of remaining incompetent perforating veins, but recurrence was significantly higher in patients who had incomplete SEPS procedure ( p = 0.007 log-rank). New incompetent perforating veins did not affect ulcer healing or recurrence. The plotted location of new perforators did not show a pattern. Deep vein incompetence and treatment of superficial venous incompetence had no significant influence on healing or recurrence rates in a complete or incomplete SEPS procedure.

Conclusion

In this series a well-performed SEPS procedure lowers the venous ulcer recurrence rate significantly, indicating the clinical importance of incompetent perforating veins in patients with an active venous ulcer.

Comparative effectiveness of surgical interventions aimed at treating underlying venous pathology in patients with chronic venous ulcer

OBJECTIVE

Chronic venous ulcers (CVUs) remain the leading causes for nonhealing wounds in the lower extremities. Although multilayer compression dressing remains the treatment gold standard, there are various surgical procedures aimed at healing CVUs with little or no evidence on the efficacy of these treatment methods. We conducted a systematic review of the effects of various surgical treatments for CVUs, in terms of ulcer healing rates, complete time to heal, recurrence rates, mortality, pain, and quality of life.

METHODS

We searched MEDLINE, EMBASE, the Cochrane Central Register for Controlled Trials, and the Cumulative Index for Nursing and Allied Health Literature databases from January 1980 through July 2012. We included studies that compared a surgical procedure with multilayer compression therapy or another surgical procedure among patients with CVUs. We also included studies without a comparison group if they were of sufficient quality. Two independent reviewers screened titles, abstracts, and articles for eligibility. Two reviewers extracted data on study design, applicability, results, and quality.

RESULTS

We identified 10,676 citations, of which 22 studies (23 publications) were included. Eight studies (six randomized controlled trials, two cohorts) compared a surgical procedure with compression. Fourteen studies evaluated different surgical interventions. Adding superficial vein ligation and stripping to compression did not improve wound-healing rate. However, the recurrence rate was 50% reduced when surgery corrected the underlying superficial venous pathology (moderate to high strength of evidence [SOE]). Adding subfascial endoscopic perforator surgery with superficial vein surgery to compression does not improve the healing rate of venous ulcers or reduce the recurrence rate except for medial and large ulcers (high SOE). The SOE was insufficient to support a conclusion about the effects of sclerotherapy when added to compression in healing CVUs. There was insufficient evidence on the surgical treatment of CVUs secondary to deep venous reflux and venous obstruction. We are unable to draw conclusions about the effects of surgical procedures on mortality, pain, and quality of life.

CONCLUSIONS

Our ability to draw conclusions on most surgical techniques is limited due to poorly designed and executed studies, with no uniformity of treatment methods, follow-up or reporting, and lack of randomization. We found some evidence to suggest superficial vein ligation and stripping may reduce the risk of wound recurrence, but these surgical techniques are infrequently performed. The newer minimally invasive techniques lack evidence. Randomized controlled trials for the endovenous procedures used today for treating CVUs are needed.

Venous disease in women: epidemiology, manifestations, and treatment

Until the past decade, venous disease was commonly underdiagnosed and undertreated due to lack of interest on the part of providers and to reluctance to undergo procedures on the part of patients. Modern venous interventions, improved diagnostic modalities, and increased awareness through education, training, and screening programs have all raised enthusiasm for venous disease in recent years. This has been crucial to gain control over a disease that affects a significant proportion of the population, with women being affected more than men. This article will discuss epidemiologic studies that highlight some of the gender-related issues and review the risk factors for venous disease. We will also discuss the physiologic venous changes that occur with pregnancy and highlight functional venous disease in women. Finally, we will review the indications for and treatment of superficial venous disease.

Treatment of primary varicose veins has changed with the introduction of new techniques

New technologies have produced a revolution in primary varicose vein treatments. Duplex ultrasound is now used for preoperative diagnosis, postoperative surveillance, and during many procedures. Ultrasound has also altered our understanding of the pathophysiology of chronic venous disease. Laser and radiofrequency saphenous ablations are common. Classic techniques, such as sclerotherapy, high ligation, stripping, and phlebectomy, have been improved. Magnetic resonance venography, computed tomographic venography, and intravascular ultrasound have improved diagnostic capabilities. New strategies like ambulatory selective varices ablation under local anesthesia (ASVAL) and conservative hemodynamic treatment for chronic venous insufficiency (CHIVA) raise important questions about how to manage these patients.

The place of subfascial endoscopic perforator vein surgery (SEPS) in advanced chronic venous insufficiency treatment

In spite of medical science development and initiation of new technologies in minimally invasive surgery, treatment of advanced chronic venous insufficiency at the 5(th) and 6(th) degree of CEAP classification is still a great clinical challenge. In case of no satisfactory results of non-surgical treatment of recurrent venous ulcers, scientists search for alternative therapeutic methods which could be more effective and lasting. Subfascial endoscopic perforator vein surgery (SEPS) as a method of reducing venous pressure in the superficial venous system could provide healing of the recurrent venous ulcer. In this study we present a review of contemporary opinions about the place and significance of subfascial endoscopic perforator vein surgery as a treatment of advanced chronic venous insufficiency.

The need for an Intersociety Consensus Guideline for venous ulcer

BACKGROUND

The management of venous leg ulcers (VLU) consumes considerable resources in healthcare systems and accounts for up to 1% of healthcare budgets in some industrialized countries. Best practice clinical guidelines incorporate evidence-based diagnostic and therapeutic recommendations in a cost-effective manner and have been associated with improved quality and less costly outcomes for many diseases. The objective of this study was to determine whether there are common elements in guidelines for VLU and their evidentiary strength.

METHODS

A systematic analysis of guidelines for VLU that were identified through http://clinicaltrials.gov, a government-sponsored Web site, and other Web sites. The proportion of guidelines proposing a recommendation as well as the strength of the guidelines were analyzed.

RESULTS

Fourteen guidelines were identified, of which 13 were evidence-based, with the majority using the grading of recommendations, assessment, development, and evaluation method. Five were sponsored by a government agency and nine by a medical or nursing society, while nine had been developed or updated within the last 5 years. Ankle/brachial index and venous duplex were recommended in 100% and 64%, respectively, of the guidelines. All recommended wound dressings and high compression, with both at the strongly recommended level of 75% and 77%, respectively. Debridement was suggested in 86%, but only one-third at the strong level. For adjunctive measures, 80% advocated pentoxifylline and approximately 50% physical therapy for improving ankle joint mobility. The majority emphasized the preventive value of compression stockings and surgical reduction of superficial venous hypertension, with a strong recommendation in 58% in the former and 73% in the latter.

CONCLUSIONS

While there are numerous evidence-based guidelines for VLU, there is consensus on strong recommendations for dressings and compression only among the various guidelines. A number of the guideline elements need further study and refinement. To improve patient care and reduce wasted resources, it is imperative for specialty societies to collaborate and develop this consensus document.

Subcutaneous fasciotomy and eradication of superficial venous reflux for chronic and recurrent venous ulcers: mid-term results

Objective

Increased intramuscular and subcutaneous tissue pressures are often found in patients with severe chronic venous insufficiency venous ulcer disease. Additional subcutaneous para-tibial fasciotomy promotes early ulcer healing. This study evaluates the mid-term effect of eradication of superficial reflux with additional fasciotomy in patients with increased tissue pressures.

Method

Between January 2006 and June 2009, 58 patients underwent fasciotomy. Tissue pressures (intramuscular and subcutaneous) were measured. Sixty-nine limbs with 91 venous ulcers were treated. Mean duration of the venous ulcer was 3.4 years. Underlying disease was post-thrombotic syndrome (PT) in 19 patients (33%, 24 limbs, 27 ulcers) and non-post-thrombotic (non-PT) severe chronic venous insufficiency in 39 (67%, 45 limbs, 64 ulcers). All patients were C6 at the time of surgery. Preoperative tissue pressures were 23.5 ± 6.1 mmHg (intramuscularly) and 9.8 ± 3.2 mmHg (subcutaneously).

Results

Ninety ulcers (99%) healed postoperatively (42 with and 48 without skin grafting). Tissue pressures significantly decreased following surgery and remained low at three months postoperatively. Ten ulcers in six patients recurred six to 20 months postoperatively (11%), resulting in 86.4 actuarial freedom from venous ulcer recurrence at three years following surgery. Four patients (1 non-PT and 3 PT) had re-fasciotomy; all healed initially but two ulcers (2 patients, PT) recurred at 11 and 12 months. Those patients underwent re-fasciotomy, one healed and one recurred six months later.

Conclusion

Eradication of superficial reflux with additional subcutaneous fasciotomy for chronic and recurrent venous ulcer improves ulcer healing or success of skin grafting. Mid-term results are excellent particularly in patients with non-PT disease. Recurrence is more frequently seen in patients with PT syndrome. In patients with ulcer recurrence and high tissue pressures, re-fasciotomy can be helpful to promote healing, particularly in patients with primary venous disease.

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 &lt; 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 &lt; 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.

The role of perforators in chronic venous insufficiency

Thesis

Venous ulcers (VU) consume considerable resources in healthcare systems, up to 1% of healthcare budgets in industrialized countries. Best practice guidelines (GLs) incorporate evidence-based diagnostic and therapeutic recommendations in a cost-effective manner and have been associated with improved and less costly outcomes for many diseases.

Objectives

To determine whether there are common elements in GLs for VU and their evidentiary strength.

Methods

A systematic analysis of GLs for VU that were identified through clinicaltrials.gov, a government-sponsored website, and from experts outside the USA.

Results

Ten of 12 GLs on VU (7 North America and 5 Europe) were evidence-based, with the majority using the GRADE method. Only two had been developed or updated within the last three years. Venous duplex and ankle ABIs were recommended in all. Debridement was suggested in two, while simple non-adherent wound dressings were favoured in nine, and hydrocolloid in two. Only one GL discussed a range of dressing options, dependent on the condition of the VU. High pressure multi-layer compression bandages were favoured in 10. Only two focused on the importance of improving ankle joint mobility.

Conclusions

While there are numerous evidence-based GLs for VU, the majority may lag recent developments in the field. There is consensus on the elements for dressings and compression among the various GLs, which should facilitate the development of a common consensus GL, similar to that for DVT/PE. To improve patient care and reduce wasted resources, it is imperative for specialty societies to develop this consensus document.

The Impact of Valvular Oxidative Stress on the Development of Venous Stasis Ulcer Valvular Oxidative Stress and Venous Ulcers

Background: It is widely believed that venous ulcers result from venous insufficiency related to venous valve damages. To further investigate the pathogenesis of venous ulcers, we compared the influence of oxidative stress in venous valvular tissue on stasis ulcer formation in patients with venous ulcers secondary to superficial venous reflux disease. Methods: Thirty-nine consecutive patients with superficial venous reflux who underwent saphenectomy were included in the study. Patients were divided into 2 groups: with healed venous ulcers (group 1, n = 15) and without ulcers (group 2, n = 24). All patients were preoperatively evaluated with duplex ultrasound scanning and their blood samples were obtained to examine leukocyte count, interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and C-reactive protein (CRP) levels. All patients underwent standard above-knee saphenectomy. Extracted saphenous vein segments were from the saphenofemoral junction, the first valve along. The biochemical analysis of the valve tissues included matrix metalloproteinase (MMP)-9, MMP-2, IL-6, TNF-α, superoxide dismutase (SOD), malondialdehyde (MDA), and nitric oxide (NO) studies. Results: There was no significant difference between patients in terms of age, gender, hospital stay, and preoperative blood levels of leukocyte, IL-6, TNF-α, and CRP (P > .05). Biochemical examination of valve tissue showed that the levels of MMP-9, MMP-2, IL-6, TNF-α, SOD, MDA, and NO in patients with healing venous ulcer were higher than those of the second group. Conclusion: A higher oxidative stress in the valvular tissue may contribute to venous stasis ulcer formation.