Combined treatment with endovenous laser ablation and compression therapy of incompetent perforating veins for treatment of recalcitrant venous ulcers

Objective Patients with healed venous ulcers often experience recurrence of ulceration, despite the use of long-term compression therapy. This study examines the effect of closing incompetent perforating veins (IPVs) on ulcer recurrence rates in patients with progressive lipodermatosclerosis and impending ulceration. Methods Patients with nonhealing venous ulcers of >2 months’ duration underwent duplex ultrasound to assess their lower extremity venous system for incompetence of superficial, perforating, and deep veins. Endovenous laser ablation (EVLA) of perforating veins was performed on patients with CEAP 6 disease with increasing hyperpigmentation, lipodermatosclerosis, and/or progressive malleolar pain. A minimum of 2 months of compressive therapy was attempted before endovenous ablation of IPVs. Demographic data, risk factors, CEAP classification, procedural details, and postoperative status were all recorded. Results Forty ulcers with 46 associated IPVs were treated with EVLA in 36 patients with CEAP 6 recalcitrant venous ulcers. Treated incompetent perforator veins were located in the medial ankle (85.7%), calf (10.7%), and lateral ankle (3.5%). Endovenous laser ablation was successful in 76% (35/46) with the first laser treatment of incompetent perforator veins and 15.2% (7/46) additional ablation procedures were performed. Of the 46 treated IPVs, 42 (91.3%) were occluded on the duplex examination at 12 months. The average energy administrated per perforating vein treated was 162 joule. Two patients reported localized paresthesia, which subsided spontaneously, but no deep venous thrombosis or skin burn was observed. Conclusion Especially in the case of liposclerotic or ulcerated skin in the affected region, PAP of IPVs is highly effective, safe, and appears to be feasible. Patients with active venous ulcers appear to benefit from EVLA of incompetent perforators in order to reduce the risk of ulcer recurrence.

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Superficial vein ablation for the treatment of primary chronic venous ulcers

Phlebology The Journal of Venous Disease ◽

10.1258/phleb.2010.010058 ◽

2011 ◽

Vol 26 (7) ◽

pp. 301-306 ◽

Cited By ~ 9

Author(s):

S Sufian ◽

S Lakhanpal ◽

J Marquez

Keyword(s):

Ulcer Healing ◽

Ulcer Recurrence ◽

Superficial Vein ◽

Recurrence Rates ◽

Perforating Veins ◽

Venous Ulcers ◽

Endovenous Ablation ◽

Ceap Classification ◽

Small Ulcer

Objective This retrospective study was undertaken to review our experience with ablation of superficial veins with significant reflux, using VNUS ClosureFAST RF (radiofrequency) or laser 980 nm, in patients with primary chronic venous ulcers, and also determine its effects in ulcer healing and ulcer recurrence. Method Included were 25 limbs (18 patients with chronic primary venous ulcers (clinical, aetiological, anatomical and pathological elements [CEAP] classification C6), who underwent endovenous ablation with RF for the axial veins or laser for the perforating veins during a two-year period. Results Of the 18 patients, there were eight men and 10 women. The median age of the group was 68 (range 37–89) years. The number of ablations done in each leg with an ulcer varied from one to eight, with a median of three. During a follow-up period of 6–12 months, one patient failed ulcer healing despite sequential ablations of refluxing veins. There was one case that developed recurrence of a small ulcer after six months and was successfully treated with a perforator ablation. Conclusion Endovenous ablation of incompetent superficial veins improves the healing of chronic primary venous ulcers and decreases the recurrence rates.

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Combined treatment with compression therapy and ablation of incompetent superficial and perforating veins reduces ulcer recurrence in patients with CEAP 5 venous disease

Journal of Vascular Surgery ◽

10.1016/j.jvs.2011.08.009 ◽

2012 ◽

Vol 55 (2) ◽

pp. 446-450 ◽

Cited By ~ 28

Author(s):

Michael Harlander-Locke ◽

Peter Lawrence ◽

Juan Carlos Jimenez ◽

David Rigberg ◽

Brian DeRubertis ◽

...

Keyword(s):

Combined Treatment ◽

Compression Therapy ◽

Venous Disease ◽

Ulcer Recurrence ◽

Perforating Veins

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Influence of perforating vein surgery in patients with venous ulceration

Phlebology The Journal of Venous Disease ◽

10.1177/0268355513517685 ◽

2013 ◽

Vol 30 (2) ◽

pp. 127-132 ◽

Cited By ~ 10

Author(s):

WB van Gent ◽

CHA Wittens

Keyword(s):

Ulcer Healing ◽

Controlled Trial ◽

Clinical Importance ◽

Compression Therapy ◽

Venous Ulcer ◽

Ulcer Recurrence ◽

Recurrence Rates ◽

Venous Ulceration ◽

Perforating Veins ◽

Perforating Vein

Objectives The exact role of perforating vein surgery is still unclear. The aim of this study is to analyze the influence of perforating vein surgery in patients with venous ulceration. Methods This study was part of a randomized controlled trial in which conservative and surgical treatment of venous ulceration was compared. It is a secondary analysis of prospectively gathered data. Ninety-seven active leg ulcers were surgically treated with a subfascial endoscopic perforating vein surgery (SEPS) procedure. Concomitant superficial venous incompetence was treated with flush saphenopopliteal ligation and/or saphenofemoral ligation and limited stripping of the great saphenous vein. All patients were also treated with ambulatory compression therapy. Ulcer healing and recurrences are described in detail. To measure the completeness of the SEPS procedure duplex ultrasonography was performed on each patient before and 6 weeks and 12 months after surgery. Also newly formed perforators after surgery were scored and their influence was analyzed. Results Analyses were performed on 94 ulcerated legs with a mean follow-up of 29 months. In all treated legs, only 45% all perforators were treated. In 55% one (29%) or more (26%) perforators were missed. Healing was not significantly influenced by the number of remaining incompetent perforating veins, but recurrence was significantly higher in patients who had incomplete SEPS procedure ( p = 0.007 log-rank). New incompetent perforating veins did not affect ulcer healing or recurrence. The plotted location of new perforators did not show a pattern. Deep vein incompetence and treatment of superficial venous incompetence had no significant influence on healing or recurrence rates in a complete or incomplete SEPS procedure. Conclusion In this series a well-performed SEPS procedure lowers the venous ulcer recurrence rate significantly, indicating the clinical importance of incompetent perforating veins in patients with an active venous ulcer.

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Comparison of combined compression and surgery with high ligation-endovenous laser ablation-foam sclerotherapy with compression alone for active venous leg ulcers

Scientific Reports ◽

10.1038/s41598-019-50617-y ◽

2019 ◽

Vol 9 (1) ◽

Author(s):

Xiaochun Liu ◽

Guofu Zheng ◽

Bo Ye ◽

Weiqing Chen ◽

Hailiang Xie ◽

...

Keyword(s):

Laser Ablation ◽

Ulcer Healing ◽

Healing Time ◽

High Ligation ◽

Ulcer Recurrence ◽

Leg Ulcers ◽

Venous Reflux ◽

Foam Sclerotherapy ◽

Recurrence Rates ◽

Endovenous Laser Ablation

Abstract We aimed to assess the ulcer healing time and recurrence rates after treatment with compression therapy (CT) with or without high ligation-endovenous laser ablation-foam sclerotherapy (HL-EVLA-FS) in people with active venous leg ulcers (VLUs). A retrospective cohort study was conducted with 350 patients with active VLUs treated by compression with or without HL-EVLA-FS in our hospital from 2013 to 2017. The primary outcome was the ulcer healing time; secondary outcomes were the 12-month recurrence rates, the relationship between recurrence and venous reflux, and the complications of the two treatments. In total, 193 patients (200 limbs) underwent compression plus HL-EVLA-FS, and 157 patients (177 limbs) underwent CT alone. The ulcer healing time was shorter in the compression plus HL-EVLA-FS group than in the CT alone group (Hazard Ratio [HR] for ulcer healing, 1.845 [95% CI, 1.474–2.309], P = 0.0001). The 12-month ulcer recurrence rates were significantly reduced in the compression plus HL-EVLA-FS group (HR for ulcer recurrence, 0.418 [95% CI, 0.258–0.677], P = 0.0001). Calf perforator vein reflux (CPVR) and isolated superficial venous reflux (ISVR) were risk factors for ulcer recurrence. The combined operation with CT resulted in faster healing of VLUs, a lower ulcer recurrence rate and lower VCSS values after intervention than CT alone.

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Endovenous laser ablation of incompetent calf perforating veins does not prevent recurrence of venous ulcers in patients with post-thrombotic syndrome

Phlebological Review ◽

10.5114/pr.2015.54036 ◽

2015 ◽

Vol 2 ◽

pp. 54-59

Author(s):

Igor Zolotukhin ◽

Evgeny Seliverstov ◽

Karina Khabazova ◽

Evgeny An ◽

Igor Lebedev

Keyword(s):

Laser Ablation ◽

Endovenous Laser Ablation ◽

Perforating Veins ◽

Post Thrombotic Syndrome ◽

Venous Ulcers

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Surgical Treatment of the Superficial and Perforating Veins

Phlebology The Journal of Venous Disease ◽

10.1177/026835550001500309 ◽

2000 ◽

Vol 15 (3-4) ◽

pp. 131-136 ◽

Cited By ~ 2

Author(s):

P. Gloviczki

Keyword(s):

Surgical Treatment ◽

Chronic Venous Insufficiency ◽

Venous Insufficiency ◽

Varicose Veins ◽

High Ligation ◽

Ulcer Recurrence ◽

Perforating Veins ◽

Post Thrombotic Syndrome ◽

Venous Ulcers ◽

Ulcer Surgery

Objective: To review the techniques and results of surgical treatment of the superficial and perforating veins in patients with chronic venous insufficiency. Methods: The current techniques used at the Mayo Clinic for treatment of simple varicose veins and venous ulcers are presented. Results of subfascial endoscopic perforator vein surgery (SEPS) are discussed and data from large centres are tabulated. Results are compared with those reported following non-operative management. Synthesis: High ligation and invagination stripping of the incompetent segment of the saphenous vein, with stab avulsion of branch varicosities, is the optimal surgical technique to ablate superficial venous incompetence. SEPS is safer than open perforator vein ligation and is the technique of choice to interrupt incompetent perforating veins. A review of 12 series on SEPS, that included 361 limbs, found an ulcer recurrence rate of 10% in those 211 patients who underwent ablation of superficial reflux together with SEPS. One hundred and fifty limbs had SEPS alone, without saphenous stripping: ulcer recurrence in this group at a mean of 23 months was 12%. Results in primary valvular incompetence were significantly better than in post-thrombotic syndrome. Conclusions: Ablation of superficial reflux remains the main surgical treatment of all forms of chronic venous insufficiency. SEPS is safe and effective to interrupt medial calf perforators and results in rapid ulcer healing and low recurrence in patients with primary valvular incompetence. The treatment of post-thrombotic syndrome remains a challenge. Results of the North American Venous Ulcer Surgery (NAVUS) trial, a prospective, randomised, multicentre study, will be required to provide level 1 evidence of the effectiveness of surgical treatment over medical therapy in the treatment of venous ulcers.

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Endothermal ablation for the treatment of clinically significant incompetent lower limb perforating veins: factors influencing the early outcomes

Phlebology The Journal of Venous Disease ◽

10.1177/0268355520955085 ◽

2020 ◽

pp. 026835552095508

Author(s):

Kenneth R Woodburn

Keyword(s):

Radiofrequency Ablation ◽

Laser Ablation ◽

Lower Limb ◽

Closure Rate ◽

Short Treatment ◽

Endovenous Laser Ablation ◽

Perforating Veins ◽

Factors Influencing ◽

Early Closure ◽

Clinically Significant

Background To review the clinical experience and early outcomes of endothermal perforator ablation. Method Retrospective review of an endovenous practice from 2007-2019. Clinically significant incompetent perforators were treated by Endovenous Laser Ablation (EVLA), or segmental radiofrequency ablation (RFA). Result Complete data were available for 110 of the 116 symptomatic incompetent perforating veins treated. Radiofrequency ablation of 20 perforators produced a 55% perforator closure rate, while 90 EVLA perforator ablations resulted in a closure rate of 80%. Closure rates with EVLA varied by location and perforator length. Closure rates for truncal ablation were 95.5% for RFA and 97.2% for EVLA. Conclusion Early closure rates following endothermal ablation of incompetent lower limb perforating veins are lower than those obtained for truncal ablation. EVLA perforator closure appears to be more effective than segmental RFA in most situations but short treatment lengths and location at the ankle are associated with the poorest outcomes.

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