Varicose vein recurrence and patient satisfaction 10-14 years following combined superficial and perforator vein surgery: a prospective case study.

OBJECTIVE: To assess real long-term varicose vein recurrence and patient satisfaction following surgical intervention with combined subfascial endoscopic perforator surgery (SEPS) and superficial venous surgery. METHOD: Prospective consecutive case study (C3-C4). Patients were included March 1993 to September 1998 and 83/104 legs of 80/100 patients were re-assessed 2008; 71 legs underwent duplex ultrasound scanning (DUS). RESULTS: The median follow up was 12 years (range 10-14). Twelve patients/legs had undergone additional vein surgery during follow-up. Incompetent lower leg perforators were noted in 18/71 limbs (25%). Following groin surgery 23/51 (45%) showed a duplex detected groin recurrence, neovascularization dominated 18/23. In legs where primary great saphenous vein (GSV) surgery had been performed, groin recurrence was found in 14/37 (38%). Previously unknown deep vein incompetence was detected in 14/71 legs (20%), six had axial reflux. The correlation between DUS-detected recurrence and remaining symptoms and cosmetic result was low. The overall satisfaction was high, 70/82 (85%). Patient satisfaction did not deteriorate over time (p < .557). CONCLUSION: Despite a fair number of DUS-detected recurrences, the overall long-term result, from the patients' point of view was surprisingly favorable. Technically well performed open venous surgery seems to result in a durable long-term outcome.

Changes in the aetiological spectrum of leg ulcers after a broad-scale intervention in a defined geographical population in Sweden.

OBJECTIVE: The study aims to compare the spectrum of leg ulcer aetiology in Skaraborg County in 1988 and 2002, an evaluation of 14 years of targeted leg ulcer intervention. DESIGN: Cross-sectional study within the professional health-care system in Skaraborg County. MATERIALS: In 2002, 621 leg ulcer patients were identified through a cross-sectional population survey. METHODS: Half of the registered patients were randomly selected and offered clinical examination. A total of 198 patients with 246 legs underwent examination and were categorised in detail according to aetiology. Data were compared with the initial study in 1988. RESULTS: Venous incompetence was present in 140 (57%) legs and the dominating cause in 94 (38%) of the leg ulcers, 40 (16%) due to deep venous incompetence. Arterial insufficiency was identified in 90 (37%) legs and the dominating aetiological factor in 41 legs (17%), eight (3%) being critical ischaemic ulcers. The relative risk (RR) of developing a leg ulcer in 2002 vs. 1988 was 0.77. The RR of a venous ulcer was reduced by 46%, arterial by 28%, while there was an increase in diabetic ulcers by 29% and multifactorial by 42%. CONCLUSION: The aetiological spectrum of leg ulcers has changed, most likely due to a new management strategy in the care of leg ulcer patients.

Early results from a randomized trial of saphenous surgery with or without subfascial endoscopic perforator surgery in patients with a venous ulcer.

BACKGROUND: The aim was to clarify the role of incompetent perforators (IPs) in venous leg ulcers. This short-term report focused on safety, patient satisfaction and the fate of IPs after subfascial endoscopic perforator surgery (SEPS), or saphenous surgery alone. METHODS: Patients aged 30-78 years with an open or recently healed venous ulcer, and with an incompetent saphenous vein and IPs, were allocated randomly to saphenous surgery alone, or in combination with SEPS. A control duplex scan was performed 6-9 months after surgery, and clinical follow-up was scheduled after 1 week, 3 and 12 months. A standard questionnaire was completed at each clinical visit. RESULTS: Seventy-five patients were enrolled; 37 had SEPS and 38 had saphenous surgery alone. SEPS prolonged the operation by a median of 15 min (P = 0.003). Duplex imaging revealed significantly more remaining IPs in the no-SEPS group (P < 0.001). Compared with the preoperative scan, significantly more legs were free from IPs in the SEPS group compared with the no-SEPS group (21 of 36 versus 7 of 37 respectively; P < 0.001). There were no other major outcome differences between the groups. CONCLUSION: There was no short-term clinical benefit from adding SEPS to saphenous surgery in patients with varicose ulcers and IPs, although SEPS reduced the number of perforators remaining after 1 year.

True long-term healing and recurrence of venous leg ulcers following SEPS combined with superficial venous surgery: a prospective study.

BACKGROUND: The role of perforator surgery remains unclear in the management of patients with leg ulcers. The aim of this study was to assess long-term healing and recurrence rates of leg ulcers following surgical intervention with combined Subfascial Endoscopic Perforator Surgery (SEPS) and superficial venous surgery. METHOD: Case series with prospective long-term follow-up of 90 consecutive patients operated on with open (CEAP C6) or healed (CEAP C5) venous ulcers in 97 legs. Popliteal vein reflux was present in 21 legs. All 97 legs were treated with SEPS and 87% had additional superficial venous surgery. Patients were follow-up for a median of 77 months (range 60-112 months) with a minimum of 5 years. RESULTS: 87% of all ulcerated legs healed. The three and five year recurrence rates were 8% and 18% respectively among survivors. In a multivariate Cox regression analysis previous vein surgery was the only factor significantly associated with recurrent ulceration (p=.004). CONCLUSION: SEPS combined with superficial venous surgery leads to healing with a low recurrence rate in patients with open and healed venous ulcers. Previous venous surgery was found to be a significant risk factor for ulcer recurrence. This result emphasizes the importance of assiduous technique for varicose vein surgery and suggests a continuing role for perforator surgery in leg ulcer patients.

Leg ulcer recurrence and its risk factors: a duplex ultrasound study before and after vein surgery.

OBJECTIVES: Assessment of risk factors for ulcer recurrence in chronic leg ulcer patients treated by varicose vein surgery. DESIGN: Retrospective follow-up study. MATERIALS: 62 patients, 43 women and 19 men (Median=56.5 years, range 24-77) with the CEAP classifications of C(5)-C(6) and E(P) (primary venous insufficiency). METHODS: Patients underwent colour duplex ultrasound (CDU) investigation before varicose vein surgery. Post-operatively CDU, ambulatory venous pressure (AVP) and an interview were performed. The median clinical follow-up was 5.5 years (range 2-11 years). RESULTS: The estimated 5-year ulcer recurrence rate was 19% in all patients. The risk of ulcer recurrence was significantly lower (p<0.05) in legs without residual varices or recurrence. The five year risk of ulcer recurrence depended on the time interval between ulcer appearance and the surgical intervention (index operation), post-operative venous axial reflux and AVP (mmHg). More than 50% of the patients had a calculated probability of ulcer recurrence of less than 3%, but 13% had a probability of more than 23% based on our analysis. CONCLUSIONS: A long history of venous ulcer is a pre- and post-operative risk factor for recurrent ulceration. Total elimination of incompetent superficial and perforator veins lowers the risk of ulcer recurrence, whereas residual axial reflux increases the risk. Postoperative CDU is effective in identifying patients at risk of ulcer recurrence.

A colour Doppler ultrasound study of venous reflux in patients with chronic leg ulcers.

OBJECTIVES: to evaluate the distribution of superficial and deep venous reflux in patients with chronic leg ulcers. MATERIALS: retrospective study of 186 patients with chronic leg ulcers (212 lower limbs). RESULTS: in 127 legs without arterial disease and a history of deep venous thrombosis (DVT), 62 (49%) had superficial, 45 (35%) had superficial and deep, and 14 (11%) had isolated deep venous reflux. In legs with a previous DVT, isolated deep venous reflux was more common (21/55, 38%) but superficial reflux, often in combination with deep reflux, still predominated (56%). CONCLUSIONS: a large part of the venous insufficiency causing venous leg ulcers is superficial and suitable for varicose vein surgery. In patients with chronic leg ulcers most reflux affects the superficial system and is potentially suitable for surgical correction.

[Varices and venous insufficiency--therapeutic philosophy prior the 2000's]. / Varicer och venös insufficiens--behandlingsfilosofi inför 2000-talet.

Varicose veins represent everything from a cosmetic problem to a risk of venous leg ulcers. Predicting the risk of complications has been difficult, not least due to less than satisfactory diagnostic procedures. Recent investigations have pointed out some important new concepts: Superficial venous incompetence may give rise to an ulcer, and such an ulcer may be prevented by varicose vein surgery. Recanalization and stenting may be useful in treating chronic iliac and caval venous occlusions; however, long-term outcome is yet to be established. Venous diameter can be reduced, thus effecting valve competence. To what extent this result is long-lasting is not known. Neither has the method been attempted on deep veins. Clinical diagnosis is never sufficient in cases of suspected chronic venous incompetence. The minimum requirement is the use of a hand-held Doppler. Frequently, a more detailed ultrasonographic analysis is required, and for a global assessment of venous function, plethysmographic techniques are useful. Primary health care may contribute effectively to the care of venous leg ulcers.

Prospective study of safety, patient satisfaction and leg ulcer healing following saphenous and subfascial endoscopic perforator surgery.

BACKGROUND: Subfascial endoscopic perforator surgery (SEPS) is a minimally invasive alternative to conventional techniques for incompetent calf perforators. Although SEPS has been performed for more than a decade, limited and insufficient data have been published regarding its safety, patient satisfaction and results. METHODS: A prospective follow-up was undertaken of consecutive SEPS operations on 149 legs, performed in 138 patients: 67 legs with ulceration, 34 with skin changes and 48 with varicose veins. Conventional saphenous vein surgery was performed, when indicated, together with the SEPS procedure. Follow-up was performed after 1 week and later by postal questionnaire to assess long-term morbidity, late complications and patient satisfaction. Patients with ulcers were followed continuously. RESULTS: Most operations (n = 107) were performed as day-case surgery. Combined saphenous vein surgery was performed in 89 per cent. No serious complications occurred: wound infection in 7 per cent; severe postoperative pain in 9 per cent; delayed wound healing in 15 per cent. After a median follow-up of 7 (1-31) months, 91 per cent of patients were satisfied. After a median of 32 (14-57) months, ulcer healing had occurred in 30 of 36 patients with open ulceration at the time of operation. CONCLUSION: SEPS is a safe procedure, suitable for day-case surgery. Patients are generally satisfied with the outcome and the results of leg ulcer healing are promising.

Long-term prognosis for patients with chronic leg ulcers: a prospective cohort study.

OBJECTIVES: To assess the long-term prognosis of leg ulcers. DESIGN: A 5 year prospective cohort study. MATERIALS: A random sample of 382 patients with open leg ulcers (foot ulcers included) treated in the community. METHODS: Interim analyses were made at 15 months (arterial ulcers) and at 20 months (varicose ulcers). Long-term healing was assessed at 54 months by a postal questionnaire. Five year survival was assessed by official population registries. RESULTS: At 54 months 212 patients (55%) were still alive, of whom 124 (58%) had healed their ulcers, 80 (38%) had open ulcers and eight (4%) were amputated. The healing was worst for patients with venous ulcers, only 44% had healed their original ulcers without recurrence. The 5 year survival was 52%, significantly lower than for age- and sex-matched controls (68%) (p = 0.0002). Patients with venous ulcers had a survival not significantly different from controls and patients with arterial or other aetiologies had a doubled risk of death. Diabetic patients had a lower survival than non-diabetics (p < 0.05) and controls (p < 0.0001), but the healing prognosis was not significantly different. CONCLUSION: Only patients with non-venous ulcers have a higher mortality than expected. The long-term healing prognosis for leg ulcer patients is poor and worst for patients with venous ulcers.

The prevalence of chronic lower-limb ulceration has been underestimated: results of a validated population questionnaire.

A validated population questionnaire was used to survey 12,000 randomly selected inhabitants, aged 50-89 years, in two defined regions of Sweden. The sample included 7 per cent of the total population in the age interval. Overall response rate was 91 per cent. Open ulcers were reported by 306 subjects and 143 (47 per cent) agreed to be examined. The false-positive response rate was high (43 per cent). The observed point prevalence of open leg ulcers was 0.63 (95 per cent confidence interval 0.54-0.72) per cent of the total population. The overall prevalence of leg ulcer history (open plus healed) in the population was estimated to be around 2 per cent and the ratio of open: previous ulcers was 1:2. This study shows a point prevalence more than double that expected, indicating a high rate of self treatment. Assessments of leg ulcer prevalence through the health care system, without knowledge of the rate of self care, measure only the workload of health care professionals. The problem of leg ulcers has generally been underestimated.

Venous and non-venous leg ulcers: clinical history and appearance in a population study.

In a defined Swedish population of 270,800, all patients with current chronic leg ulcers (827) were identified and a random sample of 382 studied in detail. Ulcers of primarily venous cause comprised 54 per cent of the total, giving a point prevalence of 0.16 per cent (95 per cent confidence interval 0.15-0.18 per cent). Half of all patients experienced their first ulcer episode before the age of 65 years, a greater proportion (61 per cent, P < 0.0001) in the subgroup with venous ulcers. The median duration of ulcer diathesis was significantly longer in patients with venous than in those with non-venous lesions (13.4 versus 2.5 years, P < 0.001). About half the patients with venous and non-venous ulcers had had their current lesion for longer than 1 year. Venous ulcers were more often recurrent than those of non-venous type (72 versus 45 per cent of patients, P < 0.0001). Patients with venous ulcers had a significantly higher body mass index (P < 0.001). The number of dressing changes performed per week was 1100 per 100,000 population. The predictive value of 'classical' clinical indicators of venous ulcer did not exceed 0.76. To increase the accuracy of diagnosis of venous ulcer, clinical examination should be combined with non-invasive 'objective' haemodynamic assessment of the venous circulation.

High prevalence of diabetes in chronic leg ulcer patients: a cross-sectional population study.

In a cross-sectional survey, designed to detect all patients with current chronic leg ulcers, 27% of the patients had diabetes mellitus. The outcome for the 104 examined diabetic patients has been evaluated and compared with the 278 nondiabetic patients. The purpose was to establish the prevalence of leg ulcers among diabetic patients and to assess potential causes. The point prevalence was calculated by extrapolating the leg ulcer frequency to the total diabetic population in the studied area. The point prevalence for active leg ulcers (including foot ulcers) in diabetic patients was 3.5% (95% CI 2.8-4.2). Ulcers above the malleoli were almost as common as foot ulcers. Peripheral vascular disease was present in 67% of all ulcerated legs in patients with diabetes compared to 42% in nondiabetic patients (p < 0.001). In 72% of foot ulcers in diabetic patients arterial impairment was judged to be a contributing aetiological factor and in nondiabetic patients 45% (p < 0.001). Ulcers solely attributed to possible neuropathy were less common (15%). Ulcers with multifactorial causes were common above the malleoli. This survey has given the size of the problem and indicates macroangiopathy to be the dominating factor responsible for slow or nonhealing ulcers in diabetic patients. Objective assessment of arterial circulation is mandatory and signs of arterial impairment require consultation with a vascular surgeon.

Leg ulcer etiology--a cross sectional population study.

Three hundred eighty-two patients with active leg ulcers were clinically examined after random selection out of a population of 827 patients identified within a previous cross-sectional population survey. Bidirectional Doppler ultrasonography was used for objective assessment of arterial and venous circulation. The purpose was to register causative factors and the etiologic spectrum. Venous insufficiency was present in 332 (72%) of 463 legs with active ulceration; deep insufficiency occurred in 176 (38%), and purely superficial insufficiency was present in 156 (34%). Ankle/brachial index was 0.9 or less in 185 (40%) of ulcerated legs. Venous insufficiency was the dominating causative factor in 250 legs (54%), of which 60% was the result of deep venous insufficiency. Arterial insufficiency was judged to be the possible dominating factor in 12%, and 6% showed clearly ischemic ulcers. Mixed ulcers with combined arterial and venous insufficiency were found to be common as were patients with diabetes and arterial impairment. In 10% of the legs a multifactorial origin was present, and in 10% no venous or arterial impairment was detectable. Thus after classification of causes 40% of all ulcerated legs showed potentially surgically curable circulatory disturbances. It is necessary to objectively assess all patients with chronic leg ulcers to be able to detect patients with potentially surgically curable disease.