The Management of Chronic Venous Insufficiency With Ulceration: The Role of Minimally Invasive Perforator Interruption

Systematic review and meta-analysis of the management of incompetent perforators in patients with chronic venous insufficiency

OBJECTIVE

Incompetent perforator veins (IPVs) contribute to venous pathology and are surgically treated based on hemodynamic measurement, size, and Clinical, Etiological, Anatomical, and Pathophysiological (CEAP) classification. The objective of this study was to systematically review and synthesize current literature regarding surgical management of IPVs, including open ligation, subfascial endoscopic perforator surgery (SEPS), endovascular laser ablation (EVLA), ultrasound guided sclerotherapy (USGS), and radiofrequency ablation (RFA).

METHODS

English-language literature published prior to November 2021 was reviewed from the PubMed, EMBASE, and MEDLINE databases for primary literature reporting safety and efficacy outcomes in the surgical treatment of incompetent perforating veins. Study quality and risk of bias was assessed using the Cochrane risk-of-bias tool for comparative studies and a modified version of the Newcastle-Ottawa Scale for non-comparative studies. A random effects model was used to pool effect sizes for efficacy outcomes of wound healing and freedom from wound recurrence.

RESULTS

A total of 81 studies were included for qualitative synthesis representing 7010 patients with a mean age of 54.7 years. Overall evidence quality was low to intermediate, with moderate to high risk of bias in comparative studies. There was an 11.3% complication rate across interventions, with no reported incidences of stroke or air embolism. With regards to efficacy, pooled estimates for short-term (up to 1-year) wound healing were 99.9% for USGS (95% CI 0.81 - 1), 72.2% for ligation (95% CI 0.04, 0.94) and 96.0% for SEPS (95% CI 0.79 -0.99). For short-term freedom from wound recurrence, the pooled estimate for SEPS is 91.0% (95% CI 0.3 - 0.99).

CONCLUSION

Current evidence regarding treatment of incompetent perforator veins is limited due to low adherence to reporting standards in observational studies and lack of randomization, blinding, and allocation concealment in comparative studies. Additional comparative studies are needed to guide clinical decision-making regarding invasive treatment options for incompetent perforator veins.

A randomized clinical trial of the effects of saphenous and perforating veins radiofrequency ablation on venous ulcer healing (VUERT trial)

OBJECTIVES

To investigate whether radiofrequency endovenous ablation (RFA) of saphenous and perforating veins increases venous leg ulcer (VLU) healing rates and prevents ulcer recurrence.

METHOD

This prospective, open-label, randomized, controlled, single-center trial recruited 56 patients with VLU divided into: compression alone (CR, N = 29) and RFA plus compression (RF, N = 27). Primary endpoints were ulcer recurrence rate at 12 months; and ulcer healing rates at 6, 12, and 24 weeks. Secondary endpoints were ulcer healing velocity; and Venous Clinical Severity Score (VCSS).

RESULTS

Recurrence was lower in the RF group (p < .001), as well as mean VCSS after treatment (p = .001). There were no significant between-group differences in healing rates. Healing velocity was faster in the RF group (p = 0.049). In the RF group, 2 participants had type 1 endovenous heat-induced thrombosis (EHIT).

CONCLUSIONS

RFA plus compression is an excellent treatment for VLU because of its safety, effectiveness, and impact on ulcer recurrence reduction and clinical outcome.Registration: Clinicaltrials.gov, NCT03293836, clinicaltrials.gov.

Surgical methods and clinical results of subfascial endoscopic perforator surgery in Japan

Objectives

To clarify the surgical methods and the clinical results of subfascial endoscopic perforator surgery in Japan.

Methods

This study included 1287 limbs of 1091 patients who underwent subfascial endoscopic perforator surgery in 14 hospitals. Simultaneous saphenous vein treatment was performed in 1079 limbs (83.8%), and 118 limbs (9.2%) had deep venous lesions. The venous clinical severity score was calculated before and 6 to 12 months after surgery. The ulcer healing rate and ulcer recurrence rate were calculated cumulatively.

Results

Preoperative venous clinical severity score was significantly decreased from 10.0 ± 6.6 to 3.1 ± 3.4 ( P < .0001) postoperatively. The primary ulcer healing rate was 96.2% (332/345 C6 limbs) at an average follow-up of 47.7 months, and the ulcer recurrence rate was 12.0% (49/393 C5, C6 limbs) at the average follow-up of 46.0 months after the ulcer healed.

Conclusion

These results indicate that subfascial endoscopic perforator surgery is an alternative to improve the long-lasting disease severity and/or clinical outcome.

A review of the current management and treatment options for superficial venous insufficiency

The recognition of lower extremity venous disease as a significant cause of morbidity and lower quality of life, afflicting up to 25 % of Western populations, has led to rapid and drastic improvements in treatment options as well as an increasing awareness of the disease. Superficial venous disease, a frequent medical problem encountered in clinical practices, is now a common reason for referral to providers offering a spectrum of interventions. Venous guidelines have been set forth by the American Venous Forum and Society for Vascular Surgery covering simple spider veins to chronic venous ulcerations. (Gloviczki et al. J Vas Surg 53:2S-48S, 2011) This review provides an overview of the modern management of varicose veins and venous insufficiency.

Algorithm-based approach to management of venous leg ulceration

Management of venous ulceration has evolved tremendously during the last 2 decades. There has been considerable progress in our understanding of the pathophysiology, hemodynamics, venous imaging, and therapeutic options for venous ulcers, including endovenous ablation, iliac vein stenting, and vein-valve repair techniques. Details of these procedures are described in this issue of Seminars. With so many permutations and combinations of venous disease, including superficial and deep vein abnormalities, that produce venous ulceration, as well as a plethora of diagnostic and therapeutic tools at our disposal, it is important to have an algorithm for venous ulcer management. Also important is knowledge about risk factors that can influence poor outcomes, despite interventions for venous ulcers. In the end, authors also discuss the gray areas of venous ulcer management, which do not have common consensus and that treatment could be individualized based on patient needs.

Endovenous laser ablation of insufficient perforating veins: Energy is key to success

Objective

To evaluate the feasibility and anatomical success of endovenous laser ablation (EVLA) of incompetent perforating veins (IPV).

Methods

All 135 consecutive patients with IPV treated with ELVA (intention-to-treat) from January 2008 to December 2013 were included. Up to the end of 2011, an 810-nm laserset (14 W) was used, and afterwards, a 1470-nm laserset (6 W) was introduced. Duplex ultrasound was performed at 6 weeks’ follow-up to assess anatomical success.

Results

Overall anatomical success at 6 weeks’ follow-up was 56%. Anatomical success was 63% after treatment with 810 nm and 45% with 1470 nm ( p = 0.035). This difference in the success rate seems associated with the significantly higher amount of energy delivered in the 810 nm cohort (560 J) versus 1470 nm (186 J). Regardless of the type of laser, anatomical success was significantly higher after treatment with more than 400 J (66%) compared with 0–200 J (40%, p = 0.009) and 200–400 J (43%, p = 0.029). Complications were limited to two cases of transient paresthesia.

Conclusions

EVLA of IPVs is safe and feasible. The amount of energy is highly important in achieving anatomical success.

Current state of the treatment of perforating veins

Perforating veins may play a role in the development of chronic venous insufficiency and ulceration. There is renewed interest in minimally invasive treatments vs historic surgical options. Current indications for treatment, technical success, and evidence for clinical efficacy are summarized. Existing recommendations include perforator closure in Clinical, Etiology, Anatomy, and Pathophysiology class 5 or class 6 disease through percutaneous thermal ablation, subfascial endoscopic perforator surgery, open surgery, or sclerotherapy. Closure rates for percutaneous thermal ablation are reported as 60% to 80% initially. More recanalization and de novo perforator formation have been reported than after thermal saphenous closure. Ultrasound-guided foam sclerotherapy has shown promise in perforator closure and wound healing, but with variable success rates. Regardless of method used, successful closure of perforators appears predictive of wound healing with minimal morbidity. However, the power and design of all studies supporting this are far from robust, and more work is needed.

Debate: whether venous perforator surgery reduces recurrences

Superficial venous surgery and perforator vein surgery, specifically, have a long and varied history in the evolution of vascular surgery, especially because venous disease continues to be extremely common. As with other areas of our specialty, perforator vein procedures have progressed from being purely open operations to becoming less invasive procedures. Despite this, there remains much discussion (as well as overt disagreement) about whether perforator vein surgery is actually appropriate and beneficial in the first place. Surgeons have no level I evidence from randomized controlled studies to determine whether perforator vein surgery does or does not reduce the chances of recurrence of superficial venous varicosities, so we must rely on the evidence as it currently is. Perhaps not surprisingly, our two experts have assembled divergent opinions on the role of perforator venous surgery in contemporary practice.

Factors that influence perforator thrombosis and predict healing with perforator sclerotherapy for venous ulceration without axial reflux

OBJECTIVE

Refluxing perforators contribute to venous ulceration. We sought to describe patient characteristics and procedural factors that (1) impact rates of incompetent perforator vein (IPV) thrombosis with ultrasound-guided sclerotherapy (UGS) and (2) impact the healing of venous ulcers (CEAP 6) without axial reflux.

METHODS

A retrospective review of UGS of IPV injections from January 2010 to November 2012 identified 73 treated venous ulcers in 62 patients. Patients had no other superficial or axial reflux and were treated with standard wound care and compression. Ultrasound imaging was used to screen for refluxing perforators near ulcer(s). These were injected with sodium tetradecyl sulfate or polidocanol foam and assessed for thrombosis at 2 weeks. Demographic data, comorbidities, treatment details, and outcomes were analyzed. Univariate and multivariable modeling was performed to determine covariates predicting IPV thrombosis and ulcer healing.

RESULTS

There were 62 patients (55% male; average age, 57.1 years) with active ulcers for an average of 28 months with compression therapy before perforator treatment, and 36% had a history of deep venous thrombosis and 30% had deep venous reflux. At a mean follow-up of 30.2 months, ulcers healed in 32 patients (52%) and did not heal in 30 patients (48%). Ulcers were treated with 189 injections, with an average thrombosis rate of 54%. Of 73 ulcers, 43 ulcers (59%) healed, and 30 (41%) did not heal. The IPV thrombosis rate was 69% in patients whose ulcers healed vs 38% in patients whose ulcers did not heal (P < .001). Multivariate models demonstrated male gender (P = .03) and warfarin use (P = .01) negatively predicted thrombosis of IPVs. A multivariate model for ulcer healing found complete IPV thrombosis was a positive predictor (P = .02), whereas a large initial ulcer area was a negative predictor (P = .08). Increased age was associated with fewer ulcer recurrences (P = .05). Predictors of increased ulcer recurrences were hypertension (P = .04) and increased follow-up time (P = .02). Calf vein thrombosis occurred after 3% (six of 189) of injections.

CONCLUSIONS

Thrombosis of IPVs with UGS increases venous ulcer healing in a difficult patient population. Complete closure of all IPVs in an ulcerated limb was the only predictor of ulcer healing. Men and patients taking warfarin have decreased rates of IPV thrombosis with UGS.