Venous intervention in chronic venous ulcer treatment and recurrence avoidance^[*]

Summary

In this brief overview I will progress from superficial venous intervention for venous leg ulcers (VLU) to perforator intervention and finally to deep venous intervention. But first there are a number of concepts that must be accepted. We know that 70 % of patients with leg ulcers have a venous component (1), and in at least 40 % of those patients, ulcers will be caused by superficial venous insufficiency alone or in combination with perforator incompetence (2). Such patients will likely benefit from treatment of their superficial venous disease.

One of the most important but often overlooked factors in venous ulcers is calf pump failure. Simka has reported that 45 % of patients with venous ulcers have calf pump failure (3).

Thorough duplex evaluation of the venous leg ulcer patient is paramount for accurate diagnosis, the differentiation between arterial and venous components (purely arterial, venous, or mixed etiology), and the obstructive and/or incompetent nature and location of venous lesions. In obstructive venous lesions the degree of obstruction as well as how proximal the lesion extends must be known. For venous insufficiency the location (deep and/or superficial venous system) and the extent (segmental or axial) will help determine how much the incompetence contributes to the overall ulcer condition, and what lesions can be safely treated.

Zusammenfassung

In diesem kurzen Überblick werde ich von der oberflächlichen Intervention bei venösen Beingeschwüren zu Perforator-Intervention und schließlich zu einer tiefen Venenintervention berichten. Jedoch gibt es zunächst einige Konzepte, die akzeptiert werden müssen. Wir wissen, dass 70 % der Patienten mit Ulcus cruris eine venöse Komponente aufweisen (1) und bei mindestens 40 % dieser Patienten werden Ulzera durch die oberflächliche venöse Insuffizienz verursacht, entweder allein oder in Kombination mit einer Perforator-Inkompetenz (2). Solche Patienten profitieren wahrscheinlich von der Behandlung ihrer oberflächlichen Venenerkrankung. Einer der wichtigsten, aber oft übersehen Faktoren bei venösen Ulzera, ist Pumpenausfall in den unteren Extremitäten. Simka berichtete, dass 45 % der Patienten mit venösen Ulzera Wadenpumpeausfälle hatten.

Eine gründliche Duplex-Auswertung des Ulcus cruris-Patienten ist von größter Bedeutung für eine genaue Diagnose und die Unterscheidung zwischen arteriellen und venösen Komponenten (rein arterielle, venöse oder gemischte Ätiologie) und die obstruktive und/oder insuffiziente Natur und der Ort der venösen Läsionen. Bei obstruktiven venösen Läsionen muss sowohl der Grad der Behinderung als auch die proximale Ausdehnung der Läsion bekannt sein. Bei venöser Insuffizienz kann die Lage (tiefes und/oder oberflächliches Venensystem) und das Ausmaß (segmental oder axial) dazu beitragen, festzustellen, in welchem Maß die Insuffizienz insgesamt zum Zustand des Ulkus beiträgt und welche Läsionen sicher behandelt werden können.

Keywords

Ulcer - vein incompetence - postthrombotic syndrom - venous intervention

Schlüsselwörter Ulkus

Veneninsuffizienz - postthrombotisches Syndrom - venöse Intervention

^* This article is derived from a presentation made at the 4th International Symposium on Venous Interventions: Focus on venous ulcer, 12 December, 2015 – Krakow, Poland

• References

• 1 Baker S, Stacey M, Jopp-McKay A. et al. Epidemiology of chronic venous ulcers. Br J Surg 1991; 78: 864-867.
• 2 Labropoulos N, Giannoukas A, Nicolaides A. et al. New insights into the pathophysiologic condition of venous ulceration with color flow duplex imaging: indications for treatment?. J Vasc Surg 1995; 22: 45-50.
• 3 Simka M. Abstract. Calf muscle pump failure in air-phlethysmography as an independent factor of delayed healing of venous leg ulcers. Phlebology 2005; 20: 154.
• 4 Gohel M, Barwell J, Taylor M. et al. Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomized controlled trial. Br Med J 2007; 335: 83.
• 5 van Gent WB, Fatarinella FS, Lam YL. et al. Conservative versus surgical treatment of venous leg ulcers. 10-year follow up of a randomized, multicenter trial. Phlebology 2015; 30 (1S): 35-41.
• 6 Teo T, Tay K, Lin S. et al. Endovenous laser therapy in the treatment of lower-limb venous ulcers. J Vasc Interv Radiol 2010; 21: 657-662.
• 7 Zamboni P, Cisno C, Marchetti F. et al. Minimally invasive surgical management of primary venous ulcers vs. compression treatment: a randomized clinical trial. Eur J Vasc Endovasc Surg 2003; 25: 313-318.
• 8 Malas M, Qazi U, Lazarus G. et al. Comparative effectiveness of surgical interventions aimed at treating underlying venous pathology in patients with chronic venous ulcer. J Vasc Surg: Venous and Lym Dis 2013; 02 (02) 212-225.
• 9 Mauck K, Asi N, Undavalli C. et al. Systematic review and meta-analysis of surgical interventions versus conservative therapy for venous ulcers. J Vasc Surg 2014; 60: 60S-70S.
• 10 Marston W. Efficacy of endovenous ablation of the saphenous veins for prevention and healing of venous ulcers. J Vasc Surg 2015; 03: 113-116.
• 11 O’Donnell TF, Passman MA, Marston WA. et al. Management of venous leg ulcers: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2014; 60: 3S-59S.
• 12 Mosti G, De Maeseneer M, Cavezzi A. et al. Society for Vascular Surgery and American Venous Forum guidelines on the management of venous leg ulcers: the point of view of the IUP. Int Angiol 2015; 34: 202-218.
• 13 Samuel N, Carradice D, Wallace T, Smith GE. et al. Endovenous thermal ablation for healing venous ulcers and preventing recurrence. Cochrane Database of Systematic Reviews 2013; 10: CD009494.
• 14 Luis S, O’Donnell T, Tangney E. et al. Abstract: Is superficial venous surgery in C6 patients justified from a cost/benefit viewpoint?. J Vasc Surg 2014; 03 (01) 123.
• 15 Ma H, O’Donnell T, Rosen N. et al. Abstract: The real costs of treating venous ulcers in a contemporary vascular practice. J Vasc Surg Dis 2014; 03 (02) 124.
• 16 Simka M. Principles and technique of foam sclerotherapy and its specific use in the treatment of venous leg ulcers. Int J Lower Extremity Wounds 2011; 10 (03) 138-145.
• 17 Darvall K, Bate G, Adam D. et al. Ultrasoundguided foam sclerotherapy for the treatment of chronic venous ulceration: A preliminary study. Eur J Vasc Endovasc Surg 2009; 38: 764-769.
• 18 Howard J. et al. Recanalisation and ulcer recurrence rates following ultrasound-guided foam sclerotherapy. Phlebology. 2015 doi: 10.1177/0268355515598450..
• 19 Kulkarni S, Slim F, Emerson L, at al. Abstract: Effect of foam sclerotherapy on healing and longtem recurrence in chronic venous leg ulcers. Phlebology 2012; 26 (06) 257-270.
• 20 Figueiredo M, de Araujo S, Figueiredo M. Late follow-up of saphenofemoral junction ligation combined with ultrasound-guided foam sclerotherapy in patients with venous ulcers. Ann Vasc Surg 2012; 26: 977-981.
• 21 Poblete H, Elias S. Venous Ulcers: New options in treatment: Minimally invasive vein surgery. J Am Coll Clin Wound Specialists 2009; 01: 12-19.
• 22 Alden P, Lips E, Zimmerman K. et al. Chronic venous ulcer: Minimally invasive treatment of superficial axial and perforator vein reflux speeds healing and reduces recurrence. Ann Vasc Surg 2013; 27: 75-83.
• 23 Kiguchi M, Hager E, Winger D. et al. Factors that influence perforator thrombosis and predict healing. J Vasc Surg 2014; 591: 368-376.
• 24 O’Donnell T. The great venous ulcer debate. American College of Phlebology Annual Congress. Nov 4, 2011
• 25 Raju S, Kirk O, Jones T. Endovenous management of venous leg ulcers. J Vasc Surg 2013; 01: 165-73.
• 26 Neglen P, Hollis K, Olivier J. et al. Stenting of the venous outflow in chronic venous disease: Longterm stent-related outcome, clinical, and hemodynamic result. J Vasc Surg 2007; 46: 979-990.
• 27 American College of Phlebology Guidelines for Femoro-iliocaval Obstruction. www.phlebology.org
• 28 Kistner R. Surgical repair of venous valve. Straub Clin Proc 1968; 24: 41-43.
• 29 Maleti O, Perrin M. Reconstructive surgery for deep vein reflux in the lower limbs: techniques, results and indications. Eur J Vasc Endovasc Surg 2011; 41: 837-848.