Postthrombotic or non-postthrombotic severe venous insufficiency: impact of removal of superficial venous reflux with or without subcutaneous fasciotomy.
BACKGROUND
Severe chronic venous insufficiency is often associated with therapy-resistant or recurrent venous leg ulcers, either as a result of deep vein thrombosis (DVT)- (postthrombotic syndrome [PTS]) or superficial venous insufficiency (SVI). Frequently present dermatoliposclerosis affects the skin as well as the subcutaneous and subfascial structures, which may impact tissue pressures and compromise skin perfusion. This study was undertaken to measure tissue pressures in PTS and SVI limbs and to evaluate the impact of removal of superficial venous reflux with or without concomitant subcutaneous fasciotomy.


METHODS
In eight patients with recurrent, therapy-resistant venous leg ulcers, due to PTS (11 limbs, 12 ulcers) and 14 patients with severe SVI (14 limbs, 14 ulcers), subcutaneous fasciotomy was performed in addition to removal of superficial reflux. They were compared with eight patients with PTS (11 limbs, 11 ulcers) and 10 patients with SVI (13 limbs, 13 ulcers) who did not have fasciotomy in addition to removal of their superficial venous reflux. Intramuscular (i.m.) and subcutaneous (s.c.) tissue pressures and transcutaneous oxygen tension (TcPO(2)) were measured prior to, immediately after, and 3 months following the surgical intervention. Healing of ulcer (spontaneous or by skin grafting) at 3 months was also observed.


RESULTS
There were no statistical differences between the groups regarding gender and age distribution or ulcer age at the time of surgery. All patients had in addition to surgery compression stockings class II (30 mm Hg). The i.m. tissue pressure was higher in patients with PTS compared with SVI patients, while s.c. tissue pressure and TcPO(2) did not differ between the groups. When fasciotomy was performed, i.m. and s.c. tissue pressures decreased and TcPO(2) increased significantly. Without fasciotomy, only s.c. tissue pressure decreased first at 3 months postoperatively. In the SVI-group, i.m tissue pressure was significantly decreased at 3 months in the group without fasciotomy.


CONCLUSIONS
Patients with severe chronic venous insufficiency with therapy-resistant or recurrent ulcer disease due to deep and superficial insufficiency have higher i.m. tissue pressures than patients with only superficial venous reflux, even though both groups have higher i.m. and s.c. tissue pressures compared with normal values. Eradication of all superficial reflux lowers s.c. tissue pressure, while additional fasciotomy lowers both i.m. and s.c. tissue pressures and increases TcPO(2), which seems to promote ulcer healing.
Christenson
Jan T
JT
Division of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland. jan.christenson@hcuge.ch
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002908:Chronic Disease; D005208:Fasciitis / Q000601:surgery*; D005260:Female; D006801:Humans; D008026:Ligation; D008297:Male; D008875:Middle Aged; D009132:Muscles / Q000503:physiopathology; D011186:Postphlebitic Syndrome / Q000150:complications / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D011312:Pressure; D012008:Recurrence; D012039:Regional Blood Flow; D012720:Severity of Illness Index; D012867:Skin / Q000098:blood supply; D040521:Subcutaneous Tissue / Q000503:physiopathology; D016896:Treatment Outcome; D014647:Varicose Ulcer / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D014656:Vascular Surgical Procedures; D014689:Venous Insufficiency / Q000150:complications / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D020246:Venous Thrombosis / Q000150:complications* / Q000503:physiopathology / Q000601:surgery; D014945:Wound Healing