Seshadri Raju1, Orla K Kirk2, Tamekia L Jones3. 1. The Rane Center, Jackson, Miss. Electronic address: rajumd@earthlink.net. 2. The Rane Center, Jackson, Miss. 3. Department of Biostatistics, University of Florida, Gainesville, Fla.
Abstract
BACKGROUND: Compression is the current "standard" in the treatment of venous leg ulcers, and corrective surgery is ancillary. The emergence of safe and effective minimally invasive corrective techniques prompts a reappraisal of this paradigm. METHODS: Among 192 consecutive limbs with venous leg ulcers, 189 were treated by (1) endovenous laser ablation (n = 30), (2) iliac vein stent placement (n = 89), or (3) both (n = 69). Residual deep reflux was not treated. No specialized wound care was used, and 38% of patients did not use stockings. Outcome measures were time to heal the ulcer and cumulative long-term healing. RESULTS: Sixty percent of the limbs were post-thrombotic. The median reflux segment score was 3 (range, 0-7). Thirty-seven percent had deep axial reflux. Median intravascular ultrasound-detected stenosis was 70% (range, 0%-100%) in stented patients. Sensitivity of venography to iliac vein obstruction was 52%. Postprocedural mortality was 0%, and 2% had deep venous thrombosis (<30 days). By 14 weeks, 81% of the small ulcers approximately ≤1 inch in diameter had healed. Larger ulcers were slower in healing (P < .001). Post-thrombotic etiology, presence of uncorrected deep reflux, demographic factors, or stocking use had no bearing on healing time. Long-term cumulative healing at 5 years overall was 75%. Healing was better in nonthrombotic limbs compared with post-thrombotic limbs (87% vs 66% at 5 years; P < .02) but was similar among the various demographic subsets, procedures, and whether or not patients used compression. Quality-of-life measures improved significantly. Cumulative long-term healing was unaffected by residual axial reflux and was unrelated to hemodynamic severity (air plethysmography, ambulatory venous pressure). However, long-term ulcer healing was inferior in limbs with reflux segment score of ≥3 (P < .03). Post-thrombotic limbs with a reflux score of ≥3 had the lowest cumulative healing among cohorts, but even in this category, 60% of limbs had durable healing with very few recurrences. CONCLUSIONS: Most venous leg ulcers in this consecutive series achieved long-term healing with the described minimally invasive algorithm. Uncorrected residual reflux was not an impediment to ulcer healing. Ulcers sized ≤1 inch required no specialized or prolonged wound care. Compression was not necessary to achieve or maintain healing after interventional correction.
BACKGROUND: Compression is the current "standard" in the treatment of venous leg ulcers, and corrective surgery is ancillary. The emergence of safe and effective minimally invasive corrective techniques prompts a reappraisal of this paradigm. METHODS: Among 192 consecutive limbs with venous leg ulcers, 189 were treated by (1) endovenous laser ablation (n = 30), (2) iliac vein stent placement (n = 89), or (3) both (n = 69). Residual deep reflux was not treated. No specialized wound care was used, and 38% of patients did not use stockings. Outcome measures were time to heal the ulcer and cumulative long-term healing. RESULTS: Sixty percent of the limbs were post-thrombotic. The median reflux segment score was 3 (range, 0-7). Thirty-seven percent had deep axial reflux. Median intravascular ultrasound-detected stenosis was 70% (range, 0%-100%) in stented patients. Sensitivity of venography to iliac vein obstruction was 52%. Postprocedural mortality was 0%, and 2% had deep venous thrombosis (<30 days). By 14 weeks, 81% of the small ulcers approximately ≤1 inch in diameter had healed. Larger ulcers were slower in healing (P < .001). Post-thrombotic etiology, presence of uncorrected deep reflux, demographic factors, or stocking use had no bearing on healing time. Long-term cumulative healing at 5 years overall was 75%. Healing was better in nonthrombotic limbs compared with post-thrombotic limbs (87% vs 66% at 5 years; P < .02) but was similar among the various demographic subsets, procedures, and whether or not patients used compression. Quality-of-life measures improved significantly. Cumulative long-term healing was unaffected by residual axial reflux and was unrelated to hemodynamic severity (air plethysmography, ambulatory venous pressure). However, long-term ulcer healing was inferior in limbs with reflux segment score of ≥3 (P < .03). Post-thrombotic limbs with a reflux score of ≥3 had the lowest cumulative healing among cohorts, but even in this category, 60% of limbs had durable healing with very few recurrences. CONCLUSIONS: Most venous leg ulcers in this consecutive series achieved long-term healing with the described minimally invasive algorithm. Uncorrected residual reflux was not an impediment to ulcer healing. Ulcers sized ≤1 inch required no specialized or prolonged wound care. Compression was not necessary to achieve or maintain healing after interventional correction.