SLR - May 2012 - Ryan Payne
Reference: The Impact of Ablation of Incompetent Superficial and Perforator Veins on Ulcer Healing Rates J Vasc Surg. 2012;55:458–464
Scientific Literature Review
Reviewed by: Ryan Payne, DPM
Residency Program: Yale/VACT
Podiatric Relevance:
This study evaluates a modality for the treatment of lower extremity venous ulcerations non-responsive to standard conservative treatments.
Methods:
Patients with venous stasis ulcerations at the UCLA wound center were treated weekly with topical antibiotics, topical wound healing agents, three to four layer compression therapy and debridement (as needed) for a minimum of five weeks. All patients were also assessed by venous Doppler to evaluate reflux of the lower leg venous system. The wounds were photographed and measured with the assistance of a computer software program. Wounds that did not decrease in size in the ascribed five-week interval were treated with venous ablation. The vein to be ablated was determined by Doppler results. Veins would be ablated one at a time to determine the effect specific veins had on the ulcer. Sequential ablations beginning with the superficial veins (great saphenous then small saphenous) were performed if needed. Some patients had primary ablation of the perforating veins if indicated. Once the first vein was ablated, four weeks of treatment with three to four layer compression was completed. If the ulcer was not healing at that time an additional ablation was performed. Wound healing rates were determined by weekly measurements being plotted graphically over time. Concomitant procedures included microphlebectomy of tributary veins that went directly into the ulcer, wound debridement and biopsy. The primary objective was to evaluate the rate of healing using the computer measurements of wound area vs. time elapsed. Secondary objectives were complete healing rates and recurrence.
Results:
Of the 433 patients who presented to the wound clinic 72 (17 percent) showed no healing after five consecutive weeks of conservative therapy. There were 110 ulcers in 88 limbs found on the medial leg at or below the level of the calf in the non-healing group. Mean duration of the ulcers was 71 ± six months and the mean area was 23 ± 6 cm². Sixty-three had ABI>0.9 and nine had ABI >0.8. DVT, superficial thrombophlebitis, DM, and vasculitis were not statistically significant with regards to failure to heal.
Seventy four out of 140 ablations were of superficial veins, while 66 were on perforators. Twenty-two patients received multiple ablations. Success rate of ablation in the superficial veins was 100 percent and 81.8 percent in the perforators.
With a mean follow-up of 12 ± 1.25 months, 76.3 percent of the ulcers healed. This was accomplished in a mean duration of 142 ± 14 days. With respect to the healing rate, there was a statistically significant difference at the p<0.05 level for all specific vein ablations and also when evaluated as an aggregate (both healed and non-healed). The fastest healing rate was with respect to great saphenous ablation alone, approximately six cm²/month in both the healed and non-healed ulcer groups. Of the 12 patients whose ulcers did not completely heal, six were lost to follow-up and the other six had healing rates that were equal to the group that did heal. The difference was that the non-healing group started with larger ulcers (46 cm² to 19 cm²). There was a 7.1 percent recurrence rate.
Conclusions:
Although the study demonstrated that most (83 percent) of venous ulcers healed with compression therapy and local wound care, there is a sub-group that showed no progress. These patients represent challenging cases and to have a modality available for consideration in their treatment is encouraging. The study could have been strengthened with a control group with whom to compare healing rates. The methodology of measuring healing rates seemed very reasonable. Although specifying single vein ablation and proceeding in sequence gives important data about healing, an interesting addition or follow-up study would be to compare rates when all veins with evidence of reflux are ablated simultaneously. This treatment warrants consideration for patients whose wounds are stagnant or digressing despite a course of appropriate treatment.