Chronic venous ulcer: minimally invasive treatment of superficial axial and perforator vein reflux speeds healing and reduces recurrence.
BACKGROUND
Chronic venous ulcer (CVU) is common and is responsible for significant health care expenditures worldwide. Compression is the mainstay of treatment, but long-term compliance with this therapy is often inconsistent, particularly in the elderly and infirm. Surgical ablation of axial and perforator reflux has been used as an adjunct to compression to reduce recurrence rates and assist healing. These surgical techniques are being replaced by minimally invasive procedures, such as thermal ablation and foam sclerotherapy, in the treatment of uncomplicated venous disease. The role for these techniques in the treatment of CVU is just beginning to be defined.


METHODS
Eighty-six patients with CVU with 95 active ulcers (Clinical, Etiology, Anatomy, Physiology-CEAP clinical class 6) presenting to a multispecialty wound clinic were retrospectively reviewed and analyzed by leg. All patients underwent duplex scanning for venous insufficiency. Ulcer dimensions at each visit were recorded and used to calculate healing rates. Presence or absence of ulcer recurrence at 1-year follow-up was recorded. Ulcers treated with compression alone ("compression group") were compared with those treated with compression and minimally invasive interventions, such as thermal ablation of superficial axial reflux and ultrasound-guided foam sclerotherapy (UGFS) of incompetent perforating veins and varicosities ("intervention group").


RESULTS
The average age in the intervention and compression groups was 67 and 71 years, respectively (P = not significant [NS]). Body mass index was 32.4 ± 9.5 and 33.6 ± 11.8 kg/m(2), in the compression and intervention groups, respectively (P = not significant [NS]). Ulcers were recurrent in 42% of the intervention group and 26% of the compression group (P = NS). In the intervention group, 33% had radiofrequency ablation of axial reflux, 31% had UGFS of perforators, and 29% had both treatments. The only complication of intervention was a single case of cellulitis requiring hospitalization. Compared with the compression group, the ulcers in the intervention group healed faster (9.7% vs. 4.2% per week; P = 0.001) and showed fewer recurrences at 1-year follow-up (27.1% vs. 48.9 %; P < 0.015). Multivariate analysis showed use of intervention was the strongest determinant of healing with a coefficient of variation of 7.432, SE 2.406, P = 0.003. Analysis of just the intervention group before and after intervention using matched pairs showed acceleration of healing after intervention from ranging from a median of 1.2% (interquartile range [IQR], 14.3) to 9.7% (IQR, 11.3) per week (P ≤ 0.001).


CONCLUSIONS
Minimally invasive ablation of superficial axial and perforator vein reflux in patients with active CVU is safe and leads to faster healing and decreased ulcer recurrence when combined with compression alone in the treatment of CVU.
Division of Vascular Surgery, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA. peter.alden@allina.com
Peter B
PB
Alden
Erin M
EM
Lips
Kate P
KP
Zimmerman
Ross F
RF
Garberich
Adnan Z
AZ
Rizvi
Alexander S
AS
Tretinyak
Jason Q
JQ
Alexander
Kathryn M
KM
Dorr
Mark
M
Hutchinson
Sarah L
SL
Isakson
D055011:Ablation Techniques / Q000009:adverse effects; D000368:Aged; D000369:Aged, 80 and over; D016009:Chi-Square Distribution; D002908:Chronic Disease; D058128:Compression Bandages / Q000009:adverse effects; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D012008:Recurrence; D012189:Retrospective Studies; D015911:Sclerotherapy / Q000009:adverse effects; D013997:Time Factors; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex; D018084:Ultrasonography, Interventional; D014647:Varicose Ulcer / Q000175:diagnosis / Q000628:therapy*; D014945:Wound Healing