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Barbati ME, Avgerinos ED, Baccellieri D, Doganci S, Lichtenberg M, Jalaie H. Interventional treatment for post-thrombotic chronic venous obstruction: Progress and challenges. J Vasc Surg Venous Lymphat Disord 2024; 12:101910. [PMID: 38777042 DOI: 10.1016/j.jvsv.2024.101910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 04/28/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024]
Abstract
Chronic venous obstruction, including nonthrombotic iliac vein lesions and post-thrombotic syndrome, presents a significant burden on patients' quality of life and health care systems. Venous recanalization and stenting have emerged as promising minimally invasive approaches, yet challenges in patient selection, procedural techniques, and long-term outcomes persist. This review synthesizes current knowledge on the interventional treatment of post-thrombotic syndrome, focusing on the evolution of endovascular techniques and stenting. Patient selection criteria, procedural details, and the characteristics of dedicated venous stents are discussed. Particular emphasis is given to the role of inflow and other anatomical considerations, along with postoperative management protocols for an optimal long-term outcome.
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Affiliation(s)
- Mohammad E Barbati
- Clinic of Vascular and Endovascular Surgery, RWTH Aachen University Hospital, Aachen, Germany.
| | | | | | - Suat Doganci
- Department of Cardiovascular Surgery, University of Health Sciences, Ankara, Turkey
| | | | - Houman Jalaie
- Clinic of Vascular and Endovascular Surgery, RWTH Aachen University Hospital, Aachen, Germany
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2
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Zheng G, Xie H, Lai M, Qin B, Liu X. Comparison of two ablation procedures combined with high ligation and foam sclerotherapy and compression therapy for patients with venous leg ulcers. Postgrad Med 2024; 136:514-522. [PMID: 38861319 DOI: 10.1080/00325481.2024.2366155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 06/06/2024] [Indexed: 06/13/2024]
Abstract
AIM To compare the ablation techniques' efficacy of endovenous microwave ablation (EMA) combined with high ligation (HL), foam sclerotherapy (FS) and compression therapy (CT) and endovenous laser ablation (EVLA) combined with HL-FS-CT in the treatment of VLUs. METHOD 301 consecutive patients with VLUs from 2013 to 2022 in a 3200-bed hospital were intervened by EMA combined with HL-FS-CT and EVLA combined with HL-FS-CT were retrospectively compared. RESULTS One hundred thirty-four patients underwent EMA+HL-FS-CT and 167 patients underwent EVLA+HL-FS-CT. The primary outcome of the ulcer healing time was 1.45(0.75-1.5) months and 1.86(0.5-2.5) months, respectively, in the two groups (HR for ulcer healing was 1.26, 95% CI [0.96-1.66], p = 0.097). Secondary outcomes included that no significant difference was found in ulcer recurrence and GSV recanalization and complications between the two groups, and the postoperative VCSS and AVVQ were significantly lower than the baseline values in the respective groups (p = 0.0001). CONCLUSION EMA+HL-FS-CT and EVLA+HL-FS-CT are both effective at treating VLUs. Both of the two comprehensive treatments were beneficial to the healing of ulcers, but no evidence showed which one was superior in the ulcer healing time.
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Affiliation(s)
- Guofu Zheng
- Department of General Surgery, Ganzhou People's Hospital, Ganzhou, Jiangxi, People's Republic of China
| | - Hailiang Xie
- Department of General Surgery, Ganzhou People's Hospital, Ganzhou, Jiangxi, People's Republic of China
| | - Minggui Lai
- Department of General Surgery, Ganzhou People's Hospital, Ganzhou, Jiangxi, People's Republic of China
| | - Bao Qin
- Department of General Surgery, Ganzhou People's Hospital, Ganzhou, Jiangxi, People's Republic of China
| | - Xiaochun Liu
- Department of General Surgery, Ganzhou People's Hospital, Ganzhou, Jiangxi, People's Republic of China
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Marston WA. Polidocanol sclerotherapy for venous insufficiency in patients with recalcitrant leg ulcers: More treatment is better. J Vasc Surg Venous Lymphat Disord 2023; 11:1082-1083. [PMID: 37591596 DOI: 10.1016/j.jvsv.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 05/02/2023] [Indexed: 08/19/2023]
Affiliation(s)
- William A Marston
- Division of Vascular Surgery, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
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Metzger PB, Rossi FH, Fernandez MG, de Carvalho SFC, Metzger SL, Izukawa NM, Kambara AM, Thorpe P. Association between the degree of iliac venous outflow obstruction by intravascular ultrasound and lower limb venous reflux. J Vasc Surg Venous Lymphat Disord 2023; 11:1004-1013.e1. [PMID: 37353155 DOI: 10.1016/j.jvsv.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/18/2023] [Accepted: 05/23/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVE The present study aims to evaluate the association between the degree of iliac venous outflow obstruction (IVOO) identified by intravascular ultrasound (IVUS) and venous reflux presentation in the lower limbs on duplex ultrasound (DU). METHODS Patients with bilateral chronic venous insufficiency, CEAP (clinical-etiology-anatomy-pathophysiology) C3 to C6, and a visual analog scale score for pain >5 underwent DU for reflux evaluation of the deep venous system (reflux ≥1 second); superficial system, great saphenous vein, and small saphenous vein (reflux ≥0.5 second); and perforator system (reflux ≥0.35 second). All patients underwent IVUS in the iliac venous territory. The area of the impaired venous segments was categorized as obstruction <50% (category 1), 50% to 79% (category 2), and ≥80% (category 3). The venous clinical severity score and reflux multisegment score (RMS) were assessed. RESULTS A total of 51 patients (n = 102 limbs; age, 50.53 ± 14.5 years; 6 men) were included. The predominant clinical severity CEAP class was C3 in 54 of 102 limbs (52.9%). The mean VCSS was 14.3 ± 6.7. A severe RMS (≥3) was registered in 63.4% of the limbs. Of the 102 limbs, 51 (50%) presented with category 1, 27 (26.5%) with category 2, and 24 (23.5%) with category 3. Previous deep vein thrombosis (DVT) was associated with critical obstruction (odds ratio [OR], 3.65; 95% confidence interval [CI], 1.29-10.38; P = .015). The superficial and perforator venous systems had no association with the degree of IVOO. Deep venous reflux (DVR) had a significant association with significant IVOO (obstruction ≥50%; OR, 6.44; 95% CI, 2.19-18.93; P = .001) and critical IVOO (obstruction ≥80%; OR, 4.57; 95% CI, 1.70-12.27; P = .003) and a significant linear association with the IVOO degree and reflux in the femoral veins (P < .001) and popliteal vein (P = .008). Significant lesions were significantly more likely to develop in the left limb (OR, 5.76; 95% CI, 2.46-13.50; P < .001). After multivariate analysis, DVR remained a predictor for significant and critical obstruction (P < .003 and P < .012, respectively). Left limb and previous DVT remained as predictors for IVOO of ≥50% and ≥80% (P < .001 and P = .043, respectively). CONCLUSIONS We found a significant linear association between the degree of IVOO and reflux in the deep venous system on DU. Limbs with DVR, a severe RMS, loss of respiratory variation on DU, and previous DVT were more likely to be affected by IVOO of ≥50%, especially with left leg involvement.
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Affiliation(s)
- Patrick Bastos Metzger
- Department of Interventional Radiology, Federal University of Bahia, Salvador, Brazil; Department of Vascular Surgery, Hospital Cardiopulmonar - Rede D'Or, Salvador, Brazil.
| | - Fabio Henrique Rossi
- Department of Vascular Surgery, Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil
| | | | | | - Simone Lessa Metzger
- Bahiana School of Medicine and Public Health, Salvador, Brazil; Department of Geriatrics, Hospital Santo Antônio, Obras Sociais Irmã Dulce, Salvador, Brazil
| | - Nilo Mitsuru Izukawa
- Department of Vascular Surgery, Instituto Dante Pazzanese de Cardiologia, São Paulo, Brazil
| | | | - Patricia Thorpe
- Department of Vascular Interventional Radiology, Arizona Heart Institute, Phoenix, AZ
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Learned A, Robinson SA, Nguyen TT. Comprehensive Care of Lower-Extremity Wounds. Surg Clin North Am 2023; 103:745-765. [PMID: 37455035 DOI: 10.1016/j.suc.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
There are 5 common types of chronic nonhealing lower-extremity wounds: arterial, venous, diabetic foot ulcer, pressure, and mixed or atypical. Each chronic wound type has distinct features, and understanding the underlying cause will dictate the wound treatment plan. Here, the authors review the distinguishing wound properties for these 5 common chronic nonhealing lower-extremity wounds and outline a comprehensive treatment plan that addresses wound perfusion, debridement, infection control, moisture balance, and use of complementary advanced wound care products.
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Affiliation(s)
- Allison Learned
- Department of Surgery, Division of Vascular Surgery, University of Massachusetts Chan Medical School, 55 North Lake Avenue, Worcester, MA 01655, USA
| | - Sudie-Ann Robinson
- Department of Surgery, Division of Vascular Surgery, University of Massachusetts Chan Medical School, 55 North Lake Avenue, Worcester, MA 01655, USA
| | - Tammy T Nguyen
- Department of Surgery, Division of Vascular Surgery, University of Massachusetts Chan Medical School, 55 North Lake Avenue, Worcester, MA 01655, USA; University of Massachusetts Diabetes Center of Excellence.
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Livingstone V, Johnson O, Peta S, Mengtsu A, Quintana B, Moyna C, Hunter C, Thulasidasan N, Black SA. Leg Ulcer Pathway Acceleration (LUPA) study. Br J Surg 2023:7146942. [PMID: 37119234 DOI: 10.1093/bjs/znad088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/29/2023] [Accepted: 03/15/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND Leg ulcers are common, costly, and significantly impair quality of life, but their management is variable and associated with considerable delays in healing. The aim of this study was to design an accelerated leg ulcer care pathway in a community and hospital setting to improve patient outcomes. METHODS A new referral pathway was developed using a series of healthcare professional and patient interviews, focus groups, and stakeholder workshops. The referral pathway, investigation and treatment protocols were further informed by clinical guidelines to develop the Leg Ulcer Pathway Acceleration care pathway. The outcomes of a consecutive series of patients enrolled in the Leg Ulcer Pathway Acceleration care pathway were compared with the outcomes of patients from a historical leg ulcer cohort from the same community and hospital setting. RESULTS A total of 110 eligible patients were enrolled and followed prospectively through the Leg Ulcer Pathway Acceleration care pathway. Their outcomes were compared with those of 183 patients with venous leg ulcers identified from existing hospital and community ulcer centres, and acting as the historical control group. The 110 patients in the Leg Ulcer Pathway Acceleration group consisted of 73 (66 per cent) men, had a mean(s.d.) age of 55.7(17.2) years, and had a median initial ulcer duration of 14.5 (i.q.r. 6-30) months. The 183 patients in the historical control group consisted of 119 (65 per cent) men, had a mean(s.d.) age of 56.4(17.2) years, and had a median initial ulcer duration of 13.5 (i.q.r. 6-47) months. Venous disease was treated in 67/110 (61 per cent) and deep venous disease was treated in 33/110 (30 per cent) of patients in the Leg Ulcer Pathway Acceleration cohort. In contrast, only 16/183 (8 per cent) of patients in the control group were treated for superficial venous insufficiency and 4/183 (2 per cent) of patients in the control group were treated for deep venous disease. Ulcer healing rates at 12 months were 80 and 20 per cent in the Leg Ulcer Pathway Acceleration group and the control group respectively (P < 0.001). Adjusted for baseline characteristics, the OR for a healed ulcer at 12 months was 21.21 (95 per cent c.i.. 11.32 to 42.46) (P < 0.001). CONCLUSION The introduction of an accelerated leg ulcer care pathway significantly improves ulcer healing when compared with historical controls.
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Affiliation(s)
| | - Oscar Johnson
- Department of Vascular Surgery, Guy's and St Thomas' Hospital, London, UK
| | - Sujith Peta
- Department of Vascular Surgery, Guy's and St Thomas' Hospital, London, UK
| | - Azeb Mengtsu
- Department of Vascular Surgery, Guy's and St Thomas' Hospital, London, UK
| | - Belen Quintana
- Department of Vascular Surgery, Guy's and St Thomas' Hospital, London, UK
| | - Cory Moyna
- Tissue Viability Service, Guy's and St Thomas' Hospital, London, UK
| | - Caroline Hunter
- Guy's and St Thomas' Hospital, Community Nurse Specialist Team, London, UK
| | | | - Stephen A Black
- Department of Vascular Surgery, Guy's and St Thomas' Hospital, London, UK
- School of Cardiovascular and Metabolic Medicine & Sciences, Kings College University, London, UK
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Saleem T. An Overview of Specific Considerations in Chronic Venous Disease and Iliofemoral Venous Stenting. J Pers Med 2023; 13:jpm13020331. [PMID: 36836565 PMCID: PMC9966343 DOI: 10.3390/jpm13020331] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 02/17/2023] Open
Abstract
Unlike arterial disease, chronic venous disease (CVD) is rarely life-threatening or limb-threatening. However, it can impose substantial morbidity on patients by influencing their lifestyle and quality of life (QoL). The aim of this nonsystematic narrative review is to provide an overview of the most recent information on the management of CVD and specifically, iliofemoral venous stenting in the context of personalized considerations for specific patient populations. The philosophy of treating CVD and phases of endovenous iliac stenting are also described in this review. Additionally, the use of intravascular ultrasound is described as the preferred operative diagnostic procedural tool for iliofemoral venous stent placement.
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Affiliation(s)
- Taimur Saleem
- The RANE Center for Venous and Lymphatic Diseases, Suite 401, 971 Lakeland Drive, Jackson, MS 39216, USA
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8
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Kiernan A, Fahey B, Boland F, Aherne T. A systematic review and meta-analysis of concomitant truncal and perforator surgery. J Vasc Surg Venous Lymphat Disord 2023; 11:648-656.e3. [PMID: 36736858 DOI: 10.1016/j.jvsv.2022.12.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 12/23/2022] [Accepted: 12/27/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Incompetent perforator veins are encountered frequently during ultrasound assessment of the venous system in chronic venous disease. Some studies have shown that concomitant treatment of truncal and perforator incompetence improves ulcer healing, yet a Cochrane review was unable to determine the potential benefits of perforator surgery in venous ulcer management due to poor quality evidence. This study aims to establish the exact role of concomitant treatment in patients with chronic venous disease. METHODS A search of online databases including MEDLINE, Embase, and Cochrane was performed in March 2022. All studies comparing the outcomes of concomitant superficial venous plus perforator surgery with standard therapy were included. Variables assessed included ulcer healing, time to healing, and ulcer recurrence. Disease severity and quality of life, vein occlusion rates, number of incompetent perforator veins on duplex ultrasound post treatment, and reintervention and complication rates were also analyzed. Data were pooled using a random effects model. RESULTS Seven studies (872 limbs) were included for analysis. Included studies were of reasonable methodological quality. Ulcer healing rates were similar in each group (relative risk [RR], 1.07; 95% confidence interval [CI] 0.96-1.19; P = .23). Two studies reported no difference in mean time (days) to ulcer healing between groups (mean difference, -14.60; 95% CI, -34.57 to 5.38; P = .15; I2 = 0%; P = .56). Ulcer recurrence was significantly lower in the concomitant group (3.7% vs 44%) (RR, 0.21; 95% CI, 0.07- 0.65; P = .007; I2 = 43%; P = .17). Overall, there was no difference in disease severity measured at 12-month follow-up, with a weighted mean difference between groups of -0.88 (95% CI, -2.05 to 0.29; P = .14; I2 = 84%; P = .002). Quality of life was reported in only one study. The total number of perforator veins identified at follow-up duplex ultrasound was significantly lower in the concomitant group (22.4% vs 89%) compared with standard therapy (RR, 0.31; 95% CI, 0.19-0.53; P < .0001; I2 = 88%; P = .0002). There was no difference between groups for occlusion rates of treated great saphenous vein or incompetent perforators (RR, 2.22; 95% CI, 0.10-49.74; P = .61). Reported minor (RR, 0.98; 95% CI, 0.63-1.52; P = .92) and thrombotic complications (RR, 2.04; 95% CI, 0.59-6.99; P = .26) were similar between groups. CONCLUSION Concomitant truncal and perforator surgery is comparable to standard therapy in terms of ulcer healing, safety, and efficacy. Meta-analysis suggests that concomitant treatment could significantly reduce ulcer recurrence rates, but included studies were subject to some biases and short follow-up. Concomitant treatment may be considered to prevent recurrence rather than improve ulcer healing.
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Affiliation(s)
- Aoife Kiernan
- Royal College of Surgeons in Ireland, Dublin, Ireland; University of Edinburgh, Edinburgh, Scotland.
| | - Brian Fahey
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fiona Boland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Thomas Aherne
- Royal College of Surgeons in Ireland, Dublin, Ireland
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Chinchalongporn W, Tanmit P, Pruekprasert K, Prapassaro T, Hongku K, Hahtapornsawan S, Puangpunngam N, Chinsakchai K, Wongwanit C, Ruangsetakit C, Sermsathanasawadi N. Prevalence and predictors of combined >50% iliocaval venous obstruction and superficial venous reflux in chronic venous insufficiency patients with healed or active venous leg ulcer. J Vasc Surg Venous Lymphat Disord 2023; 11:502-509. [PMID: 36736699 DOI: 10.1016/j.jvsv.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/02/2022] [Accepted: 11/27/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The aim of the present study was to investigate the prevalence and predictors of combined >50% iliocaval venous obstruction (ICVO) and superficial venous reflux (SVR) in patients with chronic venous insufficiency (CVI) with a healed (C5) or an active (C6) venous leg ulcer (VLU). METHODS We conducted a retrospective review of prospectively collected data from patients with CVI with CEAP (Clinical, Etiology, Anatomy, Pathophysiology) class C5 (healed ulcer) or C6 (active ulcer) with SVR who had been treated at our institution from February 2017 to January 2018. The demographic, clinical, and surgical data and duplex ultrasound and computed tomography venography findings were collected. We used OsiriX MD, version 2.9, software (Pixmeo SARL, Bernex, Switzerland) to measure the vein diameter via multiplanar reconstruction. The prevalence of combined >50% ICVO and SVR was evaluated, and univariate and multivariate analyses were performed to identify the independent predictors of >50% ICVO in patients with CVI and SVR. RESULTS A total of 79 limbs from 67 patients were enrolled. The mean age was 59.82 ± 12.86 years, the mean body mass index was 28.68 ± 6.41 kg/m2, and 41.8% were men. The prevalence of >50% ICVO in the patients with SVR was 31.6%. Univariate analysis showed a history of deep vein thrombosis (DVT) in the affected leg (P = .001), a VLU in the left leg (P = .033), a history of a recurrent VLU (P = .038), and reversed flow in the superficial epigastric vein (P = .004) were significantly associated with >50% ICVO in patients with CVI and SVR. Multivariate analysis revealed a history of DVT in the affected leg (adjusted odds ratio [aOR], 8.31; 95% confidence interval [CI], 2.29-30.19; P = .001), a VLU in the left leg (aOR, 3.95; 95% CI, 1.18-13.19; P = .026), and a history of a recurrent VLU (aOR, 3.08; 95% CI, 1.02-9.32; P = .047) to be independently associated with combined >50% ICVO and SVR in patients with CVI. CONCLUSIONS The prevalence of combined >50% ICVO and SVR in patients with CVI and CEAP C5 or C6 was 31.6%. The independent predictors of combined >50% ICVO and SVR in those with CVI were a history of DVT in the affected leg, a VLU in the left leg, and recurrent VLUs.
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Affiliation(s)
- Wanchai Chinchalongporn
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Parichat Tanmit
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kanin Pruekprasert
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tossapol Prapassaro
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kiattisak Hongku
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Suteekhanit Hahtapornsawan
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nattawut Puangpunngam
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Khamin Chinsakchai
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chumpol Wongwanit
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chanean Ruangsetakit
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nuttawut Sermsathanasawadi
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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Attaran RR, Carr JG. Chronic Venous Disease of the Lower Extremities: A State-of-the Art Review. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100538. [PMID: 39132527 PMCID: PMC11307564 DOI: 10.1016/j.jscai.2022.100538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 09/26/2022] [Accepted: 10/07/2022] [Indexed: 08/13/2024]
Abstract
Chronic venous disease is a common disease, the prevalence of which increases with age, and can cause debilitating symptoms that adversely affect the quality of life. The risk factors include family history, female sex, obesity, pregnancy, parity, and history of deep vein thrombosis. Moreover, it is associated with venous obstruction, reflux, or both, which, in turn, leads to ambulatory venous hypertension. Chronic venous disease is the leading cause of leg ulcers, which place a significant cost burden on the health care system. Compression therapy remains the cornerstone of treatment, particularly for more advanced disease. Superficial saphenous vein reflux can be associated with significant symptoms. Catheter techniques, both thermal and nonthermal, have demonstrated efficacy and safety in successful closure and symptom improvement. Deep vein obstruction can be broadly divided into thrombotic and nonthrombotic and can lead to symptomatic chronic venous disease. Recanalization using balloons and stents has been increasingly used and studied in such patients. It is critical to develop training opportunities and guidelines to improve evidence-based and appropriate care for cardiologists treating chronic venous disease.
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Affiliation(s)
- Robert R. Attaran
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jeffrey G. Carr
- CardiaStream at Tyler Cardiac and Endovascular Center, Tyler, Texas
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11
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Cooke PV, Bai H, Collins LC, Cho LD, Dionne E, Vasan V, Gonzalez C, Kim J, Kang Y, Tadros RO, Ting W. Patients with active venous leg ulcers at the time of iliac vein stenting require more reoperations. J Vasc Surg Venous Lymphat Disord 2022; 10:1304-1309. [PMID: 35779830 DOI: 10.1016/j.jvsv.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 05/11/2022] [Accepted: 05/25/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE An active venous leg ulcer (VLU) caused by lower extremity venous insufficiency is challenging to treat and will often recur after initially healing. In the present study, we compared the symptomatic outcomes and need for reoperation after iliac vein stenting (IVS) in patients with an active VLU (VLU+) and those without an active VLU (VLU-). METHODS A single-institution database of patients with chronic venous outflow obstruction who underwent IVS from August 2011 to June 2021 was analyzed. Symptoms were quantified using the venous clinical severity score. The patients were divided into two cohorts: those with (VLU+) and without (VLU-) VLUs. RESULTS A total of 872 patients (71 VLU+ and 801 VLU-) were identified. Many of the demographics and comorbidities differed between the two cohorts, and these variables were included in the multivariable analysis. On univariate analysis, the VLU+ cohort was more likely to need a major reoperation (odds ratio, 1.94; 95% confidence interval, 1.01-3.52; P = .036). However, on multivariable analysis, the difference was not statistically significant (odds ratio, 1.17; 95% confidence interval, 0.55-2.40; P = .667). Additionally, the VLU+ cohort required a significantly greater mean total of reoperations (1.4 vs 1.0; P = .006) than the VLU- cohort. Comparatively, for patients who underwent at least one reoperation, the difference in the mean total number of reoperations was even greater for the VLU+ cohort (2.6 vs 1.8; P = .001). The results from the Kaplan-Meier log-rank test revealed no differences in the reintervention-free survival time (P = .980). Both cohorts experienced a durable mean reduction in the venous clinical severity score. The ulcer healing rates for the VLU+ cohort at 6, 12, 24, and 36 months were 38%, 47%, 52%, and 59%, respectively. The ulcer recurrence rates for the VLU+ cohort were 4%, 10%, 19%, and 30% at 6, 12, 24, and 36 months, respectively, with a median time to recurrence of 1.2 years. CONCLUSIONS Patients with active VLUs who underwent a first reintervention after initial IVS, on average, required an additional reintervention.
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Affiliation(s)
- Peter V Cooke
- Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Halbert Bai
- Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Logan D Cho
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Elyssa Dionne
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Vikram Vasan
- Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Jinseo Kim
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yeju Kang
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rami O Tadros
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Windsor Ting
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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12
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Avrahami R, Silverberg D, Kolvenbach R, Elias S, Sivak G. Biological autologous excised varicose vein dressing compared to conservative dressing on the ulcer bed during endovenous ablation. Phlebology 2022; 37:386-392. [DOI: 10.1177/02683555221081635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective To compare the use of biological autologous excised varicose vein dressing ( VenoDress) compared to conservative dressing on the ulcer bed during endovenous ablation Methods This retrospective non-blinded study included all consecutive patients with primary or recurrent venous leg ulcers (VLU) with superficial varices treated in one center between September 2019 and October 2020. They all underwent venous ablation, wound debridement, and when needed phlebectomy. On the study group, the excised veins were incised, formed into a sheet, and applied onto the debrided wound bed with the endothelial side facing the wound bed. Adhesion was assessed weekly for 3 weeks. The study group was compared to a control group that underwent similar procedures but with the debrided wound bed treated with low-adherent paraffin dressing. The primary outcome was complete wound healing at 1 and 3 months, and the secondary outcomes were wound-related pain and leg edema. Results Complete wound closure was documented in 17/26 study group patients at 1 month (65%) and in 25/26 (96%) at 3 months. Complete wound closure was documented in 37/82 patients in the control group (45%) and in 67/82 (82%) at 3 months. The 1-month healing rates were significantly in favor of the VenoDress group when adjusted to sex and diabetes: odds ratio = 2.81 (1.05–7.532), p = .04. The preoperative pain level of the study group (as measured by a visual analog scale VAS (0–10) decreased from 4.96 ± 2.71 to 0.73 ± 1.36 at 1 week and that of the control group from 4.8 ± 2 to 1.35 ± 1.38 at 1 week ( p < .001). Conclusion the use of autologous varicose veins as dressing effectively reduced pain in VLU patients compared to conventional techniques. Although its effects on wound closure appear highly promising, further validation is warranted in a randomized comparative study.
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Affiliation(s)
- Ram Avrahami
- T. L. M. Medical Center, Tel-Aviv, Israel
- Department of Vascular Surgery, Rabin Medical Center, Petach Tikva, Israel
| | - Daniel Silverberg
- Department of Vascular Surgery, the Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ralph Kolvenbach
- Department of Vascular Surgery and Endovascular Therapy, SANA Hospital Group, Düsseldorf, Germany
- Academic Teaching Hospital, Heinrich Heine University of Düsseldorf, Düsseldorf, Germany
| | - Steven Elias
- Center for Vein Disease, Englewood Health Network, Englewood, NJ, USA
| | - Galit Sivak
- T. L. M. Medical Center, Tel-Aviv, Israel
- Department of Vascular Surgery, Rabin Medical Center, Petach Tikva, Israel
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13
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Benfor B, Peden EK. A systematic review of management of superficial reflux in the setting of deep venous obstruction. J Vasc Surg Venous Lymphat Disord 2022; 10:945-954.e2. [PMID: 35066218 DOI: 10.1016/j.jvsv.2021.12.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/09/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Due to fear of obliterating collateral outflow path and thus worsening venous hypertension, many physicians believe that deep venous obstruction is a contraindication for treatment of superficial venous reflux. This review will present the available clinical data in this important group of patients. METHODS A literature search was performed on PubMed, Web of Science and Google scholar to identify clinical research studies between 1991 and 2021 evaluating the concomitant management of superficial reflux and deep venous obstruction. Studies were excluded if they reported on less than 5 patients, did not specify interventions to treat superficial reflux or had no follow-up data available. All studies included were observational, and their quality assessed using the Newcastle-Ottawa scale. RESULTS Ten retrospective cohort studies were included, encompassing a total of 2476 limbs in 2428 patients out of which concurrent superficial venous reflux (SVR) and deep venous obstruction (DVO) or a known history of DVT were managed in 944 limbs. Eight of the studies were comparative. The level of deep venous obstruction was supra-inguinal when specified in most cases. The mean age ranged between 42 and 65 years, and 1432 patients (59%) were female and advanced CVD (i.e. CEAP C4-6) was present in 614 limbs (70%) with two studies reporting uniquely on C6 patients. Out of the 944 limbs treated for concomitant SVR and DVO, a combination of saphenous vein ablative procedures and deep venous stenting (DVS) was carried out in 483 limbs (51.2%), saphenous vein ablative procedures alone in 293 limbs (31%) and DVS alone in 168 (17.8%). Out of the five studies comparing different treatment strategies of concurrent SVR and DVO, four reported better outcomes after a combined deep venous stenting and saphenous vein ablation compared to ablation alone. Studies comparing the outcomes of saphenous ablation in patients with reflux alone versus patients with concurrent reflux and DVO did not find any significant difference in clinical improvement and postoperative complication rates. CONCLUSION Current evidence is weak owing to limited number of studies and small sample size but suggests that ablation of superficial venous reflux is safe in patients with concurrent deep venous obstruction. Patients with advanced venous disease and iliac vein obstruction have better results when superficial reflux ablation is combined with treatment of iliac vein obstruction. Additional contemporary studies are needed to confirm the safety and specifically investigate the efficacy of superficial reflux ablation in relieving symptoms in patients with concurrent infrainguinal obstruction.
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Affiliation(s)
- Bright Benfor
- Department of Vascular Surgery, Debakey Heart & Vascular Center, Houston Methodist Hospital, Houston TX, USA
| | - Eric K Peden
- Department of Vascular Surgery, Debakey Heart & Vascular Center, Houston Methodist Hospital, Houston TX, USA.
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14
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Bush RL. Need to get the word out! J Vasc Surg Venous Lymphat Disord 2021; 10:94-95. [PMID: 34920852 DOI: 10.1016/j.jvsv.2021.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 04/19/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Ruth L Bush
- University of Houston College of Medicine, Houston, Tex.
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15
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O'Banion LA, Woo K. Balancing Quality and Quantity in Optimizing Health Care Resource Utilization. JAMA Netw Open 2021; 4:e2138907. [PMID: 34905013 DOI: 10.1001/jamanetworkopen.2021.38907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Leigh Ann O'Banion
- Division of Vascular Surgery, Department of Surgery, University of California San Francisco-Fresno, Fresno
| | - Karen Woo
- Division of Vascular Surgery, Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles
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16
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Saleem T, Powell T, Raju S. Iliofemoral venous stenting in patients with central neuromuscular disorders. J Vasc Surg Venous Lymphat Disord 2021; 10:626-632. [PMID: 34695594 DOI: 10.1016/j.jvsv.2021.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/13/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Leg swelling in patients with various central neuromuscular disorders is a common clinical scenario and can lead to significant morbidity. The aim of the present study was to evaluate a subset of patients with central neuromuscular disorders who had undergone iliofemoral venous stenting at a specialty venous clinic at a tertiary care hospital. METHODS From January 2000 to December 2020, the medical records of all patients with a known central neuromuscular disorder who had undergone iliofemoral venous stenting for chronic iliofemoral venous obstruction were retrospectively analyzed. RESULTS A total of 42 patients (45 limbs) with central neuromuscular disorders had undergone iliofemoral stenting after failure of a trial of conservative therapy. The central neuromuscular disorders included Parkinson disease (n = 20 limbs), multiple sclerosis (n = 15 limbs), and other neuromuscular conditions (n = 10 limbs). The mean age of the sample was 59 ± 14 years. The ratio of post-thrombotic to nonthrombotic iliac vein lesions was 3:1. Most of the patients had had CEAP (clinical, etiologic, anatomic, pathophysiologic) class ≥C4 (64.4%); 25 limbs had a history of venous thromboembolism (56%). A trend was seen toward improvement in all clinical parameters measured (venous clinical severity score, visual analog scale for pain score, and edema grade) after stenting. An ulcer healing rate of ≤90% was noted after stenting. Of the 45 limbs, 24 had required some form of reintervention (53%) after initial stent placement. CONCLUSIONS Venous intervention in the form of endovenous stenting was associated with improvement in the clinical parameters for patients with central neuromuscular disorders. However, these patients should be counseled regarding the relatively higher rate of reinterventions that might be required to correct residual or recurrent symptoms.
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Affiliation(s)
- Taimur Saleem
- The RANE Center for Venous and Lymphatic Diseases, Jackson, Miss.
| | - Thomas Powell
- The RANE Center for Venous and Lymphatic Diseases, Jackson, Miss
| | - Seshadri Raju
- The RANE Center for Venous and Lymphatic Diseases, Jackson, Miss
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17
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Venous Ulcers: Review Article. Indian J Surg 2021. [DOI: 10.1007/s12262-021-03064-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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18
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Bademci MS, Kocaaslan C, Bayraktar FA, Oztekin A, Aydin HB, Aydin E. Efficacy of treatment modalities for venous insufficiency patients with venous ulcers. J Vasc Surg Venous Lymphat Disord 2021; 9:1350. [PMID: 34399942 DOI: 10.1016/j.jvsv.2021.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/04/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Mehmet Senel Bademci
- Department of Cardiovascular Surgery, Medicine Faculty, Istanbul Medeniyet University, Istanbul, Turkey
| | - Cemal Kocaaslan
- Department of Cardiovascular Surgery, Medicine Faculty, Istanbul Medeniyet University, Istanbul, Turkey
| | - Fatih Avni Bayraktar
- Department of Cardiovascular Surgery, Medicine Faculty, Istanbul Medeniyet University, Istanbul, Turkey
| | - Ahmet Oztekin
- Department of Cardiovascular Surgery, Medicine Faculty, Istanbul Medeniyet University, Istanbul, Turkey
| | - Huseyin Bilal Aydin
- Department of Cardiovascular Surgery, Medicine Faculty, Istanbul Medeniyet University, Istanbul, Turkey
| | - Ebuzer Aydin
- Department of Cardiovascular Surgery, Medicine Faculty, Istanbul Medeniyet University, Istanbul, Turkey
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19
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Kolluri R, Lugli M, Villalba L, Varcoe R, Maleti O, Gallardo F, Black S, Forgues F, Lichtenberg M, Hinahara J, Ramakrishnan S, Beckman JA. An estimate of the economic burden of venous leg ulcers associated with deep venous obstruction. Vasc Med 2021; 27:63-72. [PMID: 34392750 PMCID: PMC8808361 DOI: 10.1177/1358863x211028298] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: Venous leg ulcers (VLU) embody the most severe stage of the broad spectrum of
chronic venous disease. Approximately 40% of patients with VLU present with
the underlying deep venous disease (DVD). Although the data are scarce,
these deep venous disease-related VLU (DRV) are thought to have higher
recurrence rates and a substantial economic burden. The objective of this
study was to assess the economic burden of DRV across Australia, France,
Germany, Italy, Spain, the UK, and the USA. Methods: A comprehensive literature review was undertaken to identify publications
documenting the incidence and prevalence of VLU and DRV, medical resource
utilization, and associated costs of DRV. Findings from this literature
review were used to estimate the economic burden of illness, including
direct medical costs over a 12-month interval following initial presentation
of a newly formed DRV. Results: Total annual incidence of new or recurrent DRV in Australia, France, Germany,
Italy, Spain, UK, and the US are estimated at 122,000, 263,000, 345,000,
253,000, 85,000, 230,000, and 643,000 events, respectively, in 2019.
Incidence ranges from 0.73 to 3.12 per 1000 persons per year. The estimated
annual direct medical costs for patients managed conservatively in these
geographies total ~ $10.73 billion (USD) or $5527 per person per year. Conclusion: The availability of published data on the costs of VLU care varies widely
across countries considered in this analysis. Although country-specific VLU
practice patterns vary, there is a uniform pattern of high-cost care.
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Affiliation(s)
- Raghu Kolluri
- Department of Internal Medicine, Riverside Methodist Hospital/OhioHealth, Columbus, OH, USA
| | - Marzia Lugli
- Department of Cardiovascular Surgery, Hesperia Hospital, Modena, Emilia-Romagna, Italy
| | - Laurencia Villalba
- Department of Vascular Surgery, Vascular Care Centre, Wollongong, NSW, Australia
| | - Ramon Varcoe
- Department of Surgery, University of New South Wales, Sydney, NSW, Australia
| | - Oscar Maleti
- Department of Cardiovascular Surgery, Hesperia Hospital, Modena, Emilia-Romagna, Italy
| | - Fernando Gallardo
- Department of Vascular Surgery, Hospital Quironsalud, Marbella, Spain
| | - Stephen Black
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Fannie Forgues
- Centre de Phlébologie Interventionnelle, Région de Toulouse, Clinique Pasteur, Toulouse, France
| | | | | | | | - Joshua A Beckman
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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20
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Avrahami M, Silverberg D, Elias S, Kolvenbach R, Shufutinsky N, Sivak G, Tal M, Avrahami R. Inframalleolar access in endovenous treatment of venous ulcers and C5 disease with nonthermal nontumescent techniques. J Vasc Surg Venous Lymphat Disord 2021; 10:417-422. [PMID: 34352423 DOI: 10.1016/j.jvsv.2021.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 07/10/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE To evaluate the use of inframalleolar access for endovenous ablation when treating advanced venous disease with nonthermal nontumescent (NTNT) techniques. METHODS This single-center retrospective study included 109 patients with advanced venous disease, treated using inframalleolar access between May 2018 and March 2020. NTNT techniques included ClariVein (Merit Medical Systems, South Jordan, Utah) and ScleroSafe (VVT Medical, Kefar Sava, Israel). Outcomes measured were postprocedure pain, leg edema, ulcer healing and recurrence rates, and venous insufficiency recurrence. RESULTS Seventy-seven patients (70%) were treated with ClariVein and 32 (30%) with ScleroSafe. Postprocedure pain score (range, 0-10) after 1 week decreased from a preprocedure median of 5 (interquartile range, 3-6) to 1 ((interqartiel range, 0-2) (P = .0001). Complete wound healing was achieved in 38 patients (43.7%) after 30 days and in 71 patients (81.6%) after 90 days. One patient developed an ulcer recurrence and six developed venous insufficiency recurrence. There was no reported nerve or skin injuries. CONCLUSIONS NTNT ablation techniques using inframalleolar access are effective and safe without risk of nerve damage. Their use facilitates ulcer healing and limits pain in patients with advanced disease.
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Affiliation(s)
- Maya Avrahami
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Silverberg
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Vascular Surgery, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Steve Elias
- Center for Vein Disease, Englewood Health Network, Englewood, NJ
| | - Ralf Kolvenbach
- Department of Vascular Surgery and Endovascular Therapy, SANA Hospital Group, Gerresheim, Germany; Department of Vascular Surgery and Endovascular Therapy, Augusta Hospital, Düsseldorf, Germany
| | - Noa Shufutinsky
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Galit Sivak
- Vascular Surgery Department, Rabin Medical Center, Petah Tikva, Israel; T.L.M Medical Center, Tel-Aviv, Israel
| | - Michael Tal
- T.L.M Medical Center, Tel-Aviv, Israel; Hadassah Medical Center, Jerusalem, Israel
| | - Ram Avrahami
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Vascular Surgery Department, Rabin Medical Center, Petah Tikva, Israel; T.L.M Medical Center, Tel-Aviv, Israel.
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21
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The need for perforator treatment after VenaSeal and ClosureFast endovenous saphenous vein closure in CEAP 6 patients. J Vasc Surg Venous Lymphat Disord 2021; 9:1510-1516. [PMID: 34111593 DOI: 10.1016/j.jvsv.2021.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 04/08/2021] [Indexed: 02/02/2023]
Abstract
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.
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22
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Yang X, Wu X, Peng Z, Yin M, Lu X, Ye K. Outcomes of endovenous laser ablation with additional iliac vein stenting of nonthrombotic lesions in patients presenting with active venous ulcers. J Vasc Surg Venous Lymphat Disord 2021; 9:1517-1525. [PMID: 33957281 DOI: 10.1016/j.jvsv.2021.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We evaluated the clinical outcomes of superficial and perforator ablation and the effects on wound healing by adding iliac vein stenting of nonthrombotic iliac vein lesions (NIVLs) in patients presenting with active venous ulcers. METHODS A retrospective analysis was performed of patients who had presented with venous ulcers and had a diagnosis of NIVLs from January 2017 to December 2019. Patients with a >50% diameter reduction in the iliac vein as determined by computed tomography venography had undergone transfemoral venography for further confirmation. Patients were divided into the endovenous laser ablation (EVLA) group and EVLA with stenting (EVLAS) group. The EVLA group had undergone endovascular laser treatment of superficial venous reflux, and the EVLAS group had undergone EVLA and stenting for NIVLs. The clinical outcomes were compared between the two groups. The primary endpoint was cumulative ulcer healing at 12 months. The secondary endpoints included complications, venous clinical severity score improvements, and pain scores during the follow-up period. Univariable and multivariable regression models were used to determine the refractory ulcer predictors. RESULTS A total of 157 patients were included, 93 in the EVLAS group and 64 in the EVLA group. Of the 93 patients in the EVLAS group and patients in the EVLA group, 30 (32.26%) and 17 (26.56%) had presented with iliac venous occlusion, respectively (P = .48). The mean percentage of stenosis was 78.0% ± 13.6% in EVLAS group and 77.0% ± 14.0% in the EVLA group (P = .36). No significant differences in the general preoperative data were observed between the two groups. Cumulative ulcer healing at 1 year was 86.8% and 65.6% in the EVLAS and EVLA groups, respectively (P = .001). After a mean follow-up of 22 months (median, 24 months), the EVLAS group had a significantly improved venous clinical severity score compared with the EVLA group (EVLAS group, 8.3; EVLA group, 11.7; P = .01). Multivariable analysis of the entire cohort showed that obesity and employment that requires standing were predictive of refractory ulcers and that iliac venous stent placement was a protective factor for ulcer healing. CONCLUSIONS The results of the present study have suggested an association between improvement in the overall success of venous leg ulcer healing when including treatment of NIVLs with stents into a treatment plan that already includes saphenous and perforator vein ablation.
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Affiliation(s)
- Xinrui Yang
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China; Vascular Centre of Shanghai JiaoTong University, Shanghai, China
| | - Xiaoyu Wu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China; Vascular Centre of Shanghai JiaoTong University, Shanghai, China
| | - Zhiyou Peng
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China; Vascular Centre of Shanghai JiaoTong University, Shanghai, China
| | - Minyi Yin
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China; Vascular Centre of Shanghai JiaoTong University, Shanghai, China
| | - Xinwu Lu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China; Vascular Centre of Shanghai JiaoTong University, Shanghai, China
| | - Kaichuang Ye
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai JiaoTong University, School of Medicine, Shanghai, China; Vascular Centre of Shanghai JiaoTong University, Shanghai, China.
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Raffetto JD, Ligi D, Maniscalco R, Khalil RA, Mannello F. Why Venous Leg Ulcers Have Difficulty Healing: Overview on Pathophysiology, Clinical Consequences, and Treatment. J Clin Med 2020; 10:jcm10010029. [PMID: 33374372 PMCID: PMC7795034 DOI: 10.3390/jcm10010029] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/14/2020] [Accepted: 12/21/2020] [Indexed: 12/13/2022] Open
Abstract
Venous leg ulcers (VLUs) are one of the most common ulcers of the lower extremity. VLU affects many individuals worldwide, could pose a significant socioeconomic burden to the healthcare system, and has major psychological and physical impacts on the affected individual. VLU often occurs in association with post-thrombotic syndrome, advanced chronic venous disease, varicose veins, and venous hypertension. Several demographic, genetic, and environmental factors could trigger chronic venous disease with venous dilation, incompetent valves, venous reflux, and venous hypertension. Endothelial cell injury and changes in the glycocalyx, venous shear-stress, and adhesion molecules could be initiating events in VLU. Increased endothelial cell permeability and leukocyte infiltration, and increases in inflammatory cytokines, matrix metalloproteinases (MMPs), reactive oxygen and nitrogen species, iron deposition, and tissue metabolites also contribute to the pathogenesis of VLU. Treatment of VLU includes compression therapy and endovenous ablation to occlude the axial reflux. Other interventional approaches such as subfascial endoscopic perforator surgery and iliac venous stent have shown mixed results. With good wound care and compression therapy, VLU usually heals within 6 months. VLU healing involves orchestrated processes including hemostasis, inflammation, proliferation, and remodeling and the contribution of different cells including leukocytes, platelets, fibroblasts, vascular smooth muscle cells, endothelial cells, and keratinocytes as well as the release of various biomolecules including transforming growth factor-β, cytokines, chemokines, MMPs, tissue inhibitors of MMPs (TIMPs), elastase, urokinase plasminogen activator, fibrin, collagen, and albumin. Alterations in any of these physiological wound closure processes could delay VLU healing. Also, these histological and soluble biomarkers can be used for VLU diagnosis and assessment of its progression, responsiveness to healing, and prognosis. If not treated adequately, VLU could progress to non-healed or granulating VLU, causing physical immobility, reduced quality of life, cellulitis, severe infections, osteomyelitis, and neoplastic transformation. Recalcitrant VLU shows prolonged healing time with advanced age, obesity, nutritional deficiencies, colder temperature, preexisting venous disease, deep venous thrombosis, and larger wound area. VLU also has a high, 50-70% recurrence rate, likely due to noncompliance with compression therapy, failure of surgical procedures, incorrect ulcer diagnosis, progression of venous disease, and poorly understood pathophysiology. Understanding the molecular pathways underlying VLU has led to new lines of therapy with significant promise including biologics such as bilayer living skin construct, fibroblast derivatives, and extracellular matrices and non-biologic products such as poly-N-acetyl glucosamine, human placental membranes amnion/chorion allografts, ACT1 peptide inhibitor of connexin 43, sulodexide, growth factors, silver dressings, MMP inhibitors, and modulators of reactive oxygen and nitrogen species, the immune response and tissue metabolites. Preventive measures including compression therapy and venotonics could also reduce the risk of progression to chronic venous insufficiency and VLU in susceptible individuals.
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Affiliation(s)
- Joseph D. Raffetto
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
- Correspondence: (J.D.R.); (F.M.)
| | - Daniela Ligi
- Department of Biomolecular Sciences, Section of Biochemistry and Biotechnology, Unit of Clinical Biochemistry, University Carlo Bo of Urbino, 61029 Urbino, Italy; (D.L.); (R.M.)
| | - Rosanna Maniscalco
- Department of Biomolecular Sciences, Section of Biochemistry and Biotechnology, Unit of Clinical Biochemistry, University Carlo Bo of Urbino, 61029 Urbino, Italy; (D.L.); (R.M.)
| | - Raouf A. Khalil
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
| | - Ferdinando Mannello
- Department of Biomolecular Sciences, Section of Biochemistry and Biotechnology, Unit of Clinical Biochemistry, University Carlo Bo of Urbino, 61029 Urbino, Italy; (D.L.); (R.M.)
- Correspondence: (J.D.R.); (F.M.)
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Ren SY, Liu YS, Zhu GJ, Liu M, Shi SH, Ren XD, Hao YG, Gao RD. Strategies and challenges in the treatment of chronic venous leg ulcers. World J Clin Cases 2020. [PMID: 33269244 DOI: 10.12998/wjcc.v8.i21.5070.pmid:] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Evaluating patients with chronic venous leg ulcers (CVLUs) is essential to find the underlying etiology. The basic tenets in managing CVLUs are to remove the etiological causes, to address systemic and metabolic conditions, to examine the ulcers and artery pulses, and to control wound infection with debridement and eliminating excessive pressure on the wound. The first-line treatments of CVLUs remain wound care, debridement, bed rest with leg elevation, and compression. Evidence to support the efficacy of silver-based dressings in healing CVLUs is unavailable. Hydrogen peroxide is harmful to the growth of granulation tissue in the wound. Surgery options include a high ligation with or without stripping or ablation of the GSVs depending on venous reflux or insufficiency. Yet, not all CVLUs are candidates for surgical treatment because of comorbidities. When standard care of wound for 4 wk failed to heal CVLUs effectively, use of advanced wound care should be considered based on the available evidence. Negative pressure wound therapy facilitates granulation tissue development, thereby helping closure of CVLUs. Autologous split-thickness skin grafting is still the gold standard approach to close huge CVLUs. Hair punch graft appears to have a better result than traditional hairless punch graft for CVLUs. Application of adipose tissue or placenta-derived mesenchymal stem cells is a promising therapy for wound healing. Autologous platelet-rich plasma provides an alternative strategy for surgery for safe and natural healing of the ulcer. The confirmative efficacy of current advanced ulcer therapies needs more robust evidence.
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Affiliation(s)
- Shi-Yan Ren
- Department of General Surgery and Vascular Surgery, Aviation General Hospital, China Medical University, Beijing 100012, China.
| | - Yong-Sheng Liu
- Department of Dermatology, Aviation General Hospital, Beijing 100012, China
| | - Guo-Jian Zhu
- Department of General Surgery, Taian Communications Hospital, Taian 271000, Shandong Province, China
| | - Meng Liu
- Department of Surgery, Tianjin Hexi Hospital, Tianjin 300202, Tianjin, China
| | - Shao-Hui Shi
- Department of Orthopaedic Surgery, Aviation General Hospital, China Medical University, Beijing 100012, China
| | - Xiao-Dong Ren
- Department of Surgery, Wanquanqu Zhongyi Hospital, Zhangjiakou 076250, Hebei Province, China
| | - Ya-Guang Hao
- Department of Medical Administrative, Aviation General Hospital, China Medical University, Beijing 100012, China
| | - Rong-Ding Gao
- Department of General Surgery, Aviation General Hospital, China Medical University, Beijing 100012, China
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Ren SY, Liu YS, Zhu GJ, Liu M, Shi SH, Ren XD, Hao YG, Gao RD. Strategies and challenges in the treatment of chronic venous leg ulcers. World J Clin Cases 2020; 8:5070-5085. [PMID: 33269244 PMCID: PMC7674718 DOI: 10.12998/wjcc.v8.i21.5070] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 08/06/2020] [Accepted: 09/28/2020] [Indexed: 02/05/2023] Open
Abstract
Evaluating patients with chronic venous leg ulcers (CVLUs) is essential to find the underlying etiology. The basic tenets in managing CVLUs are to remove the etiological causes, to address systemic and metabolic conditions, to examine the ulcers and artery pulses, and to control wound infection with debridement and eliminating excessive pressure on the wound. The first-line treatments of CVLUs remain wound care, debridement, bed rest with leg elevation, and compression. Evidence to support the efficacy of silver-based dressings in healing CVLUs is unavailable. Hydrogen peroxide is harmful to the growth of granulation tissue in the wound. Surgery options include a high ligation with or without stripping or ablation of the GSVs depending on venous reflux or insufficiency. Yet, not all CVLUs are candidates for surgical treatment because of comorbidities. When standard care of wound for 4 wk failed to heal CVLUs effectively, use of advanced wound care should be considered based on the available evidence. Negative pressure wound therapy facilitates granulation tissue development, thereby helping closure of CVLUs. Autologous split-thickness skin grafting is still the gold standard approach to close huge CVLUs. Hair punch graft appears to have a better result than traditional hairless punch graft for CVLUs. Application of adipose tissue or placenta-derived mesenchymal stem cells is a promising therapy for wound healing. Autologous platelet-rich plasma provides an alternative strategy for surgery for safe and natural healing of the ulcer. The confirmative efficacy of current advanced ulcer therapies needs more robust evidence.
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Affiliation(s)
- Shi-Yan Ren
- Department of General Surgery and Vascular Surgery, Aviation General Hospital, China Medical University, Beijing 100012, China
| | - Yong-Sheng Liu
- Department of Dermatology, Aviation General Hospital, Beijing 100012, China
| | - Guo-Jian Zhu
- Department of General Surgery, Taian Communications Hospital, Taian 271000, Shandong Province, China
| | - Meng Liu
- Department of Surgery, Tianjin Hexi Hospital, Tianjin 300202, Tianjin, China
| | - Shao-Hui Shi
- Department of Orthopaedic Surgery, Aviation General Hospital, China Medical University, Beijing 100012, China
| | - Xiao-Dong Ren
- Department of Surgery, Wanquanqu Zhongyi Hospital, Zhangjiakou 076250, Hebei Province, China
| | - Ya-Guang Hao
- Department of Medical Administrative, Aviation General Hospital, China Medical University, Beijing 100012, China
| | - Rong-Ding Gao
- Department of General Surgery, Aviation General Hospital, China Medical University, Beijing 100012, China
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Köksoy C, Bahçecioğlu İB, Çetinkaya ÖA, Akkoca M. Iliocaval outflow obstruction in patients with venous ulcers in a small comparison study between patients with primary varicose veins and chronic deep vein disease. J Vasc Surg Venous Lymphat Disord 2020; 9:703-711. [PMID: 32827736 DOI: 10.1016/j.jvsv.2020.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 08/12/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Iliocaval outflow obstruction was investigated in patients with venous ulcers caused by primary superficial disease and chronic deep vein disease METHODS: After clinical assessment, patients with healed or active venous leg ulcers underwent lower extremity duplex ultrasound examination to identify the presence of venous disease in the superficial, deep and perforating systems. Bilateral contrast venography and intravascular ultrasound examination were then performed to determine the presence and degree of iliocaval obstructive lesions. RESULTS This retrospective study included a total of 59 patients with 71 legs presenting active or healed ulcer. There were 16 limbs (22.5%) with superficial venous reflux associated with normal infrainguinal deep veins (group I) and 55 limbs (77.5%) with infrainguinal post-thrombotic deep venous disease (group II). Using venography and intravascular ultrasound examination, the incidence of >50% of venous obstruction in the iliocaval system in groups I and II were 75% and 83.6%, respectively. All obstructive lesions in group I were nonthrombotic. However, group II included thrombotic, nonthrombotic and combinations of the two types of obstructions. Group II had more ulcers (1.73 ± 1.3 vs 1.17 ± 0.5; P = .03), larger ulcers (>6 cm in 34.1% vs 8.3%), longer duration of ulcers (71.3 ± 110.5 months vs 37.9 ± 40.4 months; P = .03), smaller diameter of refluxing superficial veins (7.7 ± 2.6 mm vs 15.1 ± 6.6 mm; P = .001), and higher incidence of occluded iliocaval systems (18 [32.7%] vs 0; P = .003) than group I. After the exclusion of bilateral cases and thrombotic obstructions, the incidence of >50% nonthrombotic obstruction in ipsilateral and contralateral sides was 76.5% and 24.4%, respectively (P = .003). CONCLUSIONS The results of this study revealed that the majority of patients with venous ulcers with either infrainguinal primary superficial or post-thrombotic deep venous disease had an element of iliocaval venous obstruction.
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Affiliation(s)
- Cüneyt Köksoy
- Division of Vascular Surgery, Ankara University Medical School, Ankara, Turkey.
| | | | - Ömer Arda Çetinkaya
- Division of Vascular Surgery, Ankara University Medical School, Ankara, Turkey
| | - Muzaffer Akkoca
- Department of General Surgery, University of Health Sciences, Dışkapı Yıldırım Beyazıt Research and Training Hospital, Ankara, Turkey
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Fan W, Yang X, Yang B, Fu C, Huang R, Xv F, Liu G. The safety and efficacy of Sclerosing foam on treating venous leg ulcers: Protocol for systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e21608. [PMID: 32769918 PMCID: PMC7593037 DOI: 10.1097/md.0000000000021608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 07/08/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Venous leg ulcers (VLUs) are common throughout the world, which seriously affects the patient's work and life. Relevant researches suggested that sclerosing foam (SF) has potential benefits for VLUs. However, there is no consistent conclusion. The purpose of our study is to assess whether SF is effective and safe for VLUs. METHODS Relevant clinical randomized controlled trials will be obtained from a search of 8 databases (with no language restrictions) from their inception to May 2020: PubMed, the Cochrane Library, EMBASE, Web of Science, China National Knowledge Infrastructure Database, Wanfang Database, China Science and Technology Journal Database, and Chinese Biological Medicine. Data will be analyzed using RevMan 5.3 after literature screening and data extraction according to predefined inclusion and exclusion criteria. Cochrane Collaboration Risk of bias Tool will be applied in evaluating the quality of enrolled articles. The primary outcome is Closure of venous leg ulcers, ulcer healing rate, adverse events related to SF. The secondary outcomes include ulcer healing time, ulcer recurrence rate, pain. Risk ratio will be used for categorical data; mean differences will be used for measurement data. Where possible and appropriate, meta-analysis will be performed for each outcome. RESULTS To clarify whether Sclerosing foam can be safe and efficient on treating venous leg ulcers. CONCLUSION Our review will provide useful information to judge whether Sclerosing Foam is an effective and safe intervention for patients with venous leg ulcers.
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Affiliation(s)
- Weijing Fan
- Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine
- Shanghai University of Traditional Chinese Medicine, Shanghai
| | - Xiao Yang
- Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine
| | - Baozhong Yang
- Dongfang Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Changgeng Fu
- Dongfang Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Renyan Huang
- Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine
- Shanghai University of Traditional Chinese Medicine, Shanghai
| | - Feng Xv
- Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine
- Shanghai University of Traditional Chinese Medicine, Shanghai
| | - Guobin Liu
- Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine
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Wang S, He Y, Xin S, Zhang J. Iliac vein stenting is a safe and effective treatment for iliac vein compression syndrome: A systematic review of Chinese data. Phlebology 2020; 35:752-770. [PMID: 32715909 DOI: 10.1177/0268355520940910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES This study was a systematic review of available data from China, and our aim was to evaluate the safety and efficacy of stenting in iliac vein compression syndrome. METHODS We searched the PubMed, National Knowledge Infrastructure, Chongqing Weipu Information Company, and Cochrane Central Register for Controlled Trials databases, and key references. RESULTS Twelve studies were included (nine retrospective analyses, two retrospective case series studies, and one prospective cohort study) involving 2292 patients and 1897 stented limbs. The overall primary patency rates ranged from 81.8% to 100%. Studies showed significant improvements in patients' symptoms, and ulcer healing rates ranged from 71.4% to 100% in stented limbs. The incidence of severe complications ranged from 0 to 16.8%. CONCLUSIONS For Chinese patients with iliac vein compression syndrome, stenting provided significant efficacy regarding favorable patency rates, symptom relief, and complications. However, the quality of evidence to support the use of iliac vein stenting to treat iliac vein compression syndrome is currently weak, especially for Chinese patients.
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Affiliation(s)
- Shiyue Wang
- Department of Vascular & Thyroid Surgery, the First Hospital of China Medical University, Shenyang, China
| | - Yuchen He
- Department of Vascular & Thyroid Surgery, the First Hospital of China Medical University, Shenyang, China
| | - Shijie Xin
- Department of Vascular & Thyroid Surgery, the First Hospital of China Medical University, Shenyang, China
| | - Jian Zhang
- Department of Vascular & Thyroid Surgery, the First Hospital of China Medical University, Shenyang, China
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Reitz KM, Salem K, Mohapatra A, Liang NL, Avgerinos ED, Singh MJ, Hager E. Complete Venous Ulceration Healing after Perforator Ablation Does Not Depend on Treatment Modality. Ann Vasc Surg 2020; 70:109-115. [PMID: 32603845 DOI: 10.1016/j.avsg.2020.06.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/06/2020] [Accepted: 06/24/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Venous leg ulceration (VLU) represents the most advanced form of chronic venous insufficiency (CVI). Persistent VLU that fails to respond to noninvasive treatment requires a minimally invasive endovascular treatment, which may include chemical (ultrasound-guided foam sclerotherapy [UGFS]) and thermal ablation (endovenous laser therapy [EVLT] or radiofrequency ablation [RFA]) targeting incompetent veins. Current guidelines suggest ablation of incompetent perforating veins (IPVs) juxtaposed to active or healed VLU; however, the ideal treatment modality is unknown. We hypothesize that similar to incompetent superficial vein treatment options therapies, VLU healing will be equivalent across minimally invasive IPV treatment options. METHODS Using the Vascular Low Frequency Disease Consortium, adults with VLU across 11 medical centers were retrospectively reviewed (2013-2017). We included those who underwent IPV therapies. The primary outcome was complete ulcer healing over time compared with cumulative hazard curves, log-rank testing, and multivariable Cox proportional hazard regression. Secondary outcomes included number of subsequent procedures, which were compared using negative binomial regression. RESULTS Of the 832 adults with VLU, 158 (19%) were exclusively treated conservatively, and 232 (28%) underwent index treatment for IPV and constitute the full and final cohort. The mean age was 60 ± 14 years, 57% were men, and the mean ulcer area was 3.0 cm2 (interquartile range, 1-6 cm2). Ninety-one (39%) were treated with EVLT, 127 (55%) RFA, and 14 (6%) UGFS. Patients treated with RFA were older (RFA 62 ± 14 years; EVLT 59 ± 14 years; UGFS 52 ± 9 years; P = 0.01), more likely to be men (RFA 68%, n = 86; EVLT 41%, n = 37; UGFS 64%, n = 9; P < 0.001), with a higher frequency of anticoagulation (RFA 36%, n = 46; EVLT 18%, n = 16; UGFS 14%, n = 2; P = 0.005). VLU did not significantly differ in size between groups (RFA 6.2 ± 8; EVLT 4.2 ± 5.4; UGFS 6.1 ± 8; P < 0.001). There were no differences in 1-year ulcer healing rates between groups (P = 0.18). The number of subsequent procedures did not differ by treatment modality (P = 0.47). CONCLUSIONS This multi-institutional retrospective study does not demonstrate any association of IPV treatment modality with differing rates of VLU healing or number of subsequent procedures.
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Affiliation(s)
| | - Karim Salem
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Nathan L Liang
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Michael J Singh
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Eric Hager
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
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