Endovenous management of venous leg ulcers
Raju S, Kirk OK, Jones TL.
J Vasc Surg Venous Lymphat Disord. 2013;1:165-173.
Reviewed by: Ramesh K Tripathi and Himanshu Verma Narayana Institute of Vascular Sciences, Bangalore, India
This is an important paper highlighting the various modalities of treatment that come into play in the treatment of venous leg ulceration due to chronic venous insufficiency.
The authors apparently were able to follow-up on 192 limbs that had failed conservative therapy and then underwent endovascular treatment that included 39 endovenous laser ablation (ELVA ) of superficial axial veins, 99 iliac vein stents and 59 using both procedures in combination. The numbers treated are impressive in a short time although they add up to 197, so we have little information on the 5 patients who have been missed out in the analyses.
The criteria defining treatment modality does, however, need some detailed explanations and objective definitions of limb swelling and disability or pain score. Authors have also used diameter of refluxing vein as insufficiency criteria, rather than time of reflux. This is not the standard protocol used by other venous researchers including the reviewer.
Although thrombophilia workup was done in every patient, the reader does not get an idea of its yield and whether it influenced decision making for therapy with one modality or another.
Transfemoral venography was done in 160 limbs, however, there was no clarity regarding wether these were performed with the intention to treat deep venous obstruction once obstructive lesions were uncovered by venography.
Sensitivity of venography alone was only 50% for iliac venous obstruction. Therefore, a combination of venography and intravascular ultrasound imaging (IVUS) were performed in patients considered for a stent procedure and not when EVLA alone was planned.
Preoperative venograms (n=160) showed direct or indirect venographic evidence for an obstructive lesion in 52% (83 of 160). IVUS was performed in 158 limbs with a median area stenosis by IVUS planimetry of ≥70%.
IVUS planimetry measured an area stenosis ≥50% in 135 limbs (85%) and a stenosis <50% in 23 limbs (15%). Trial balloon sizing in 14 of 23 (61%) of the latter limbs unmasked significant stenoses.
Overall, IVUS, trial balloon sizing maneuver, or both revealed stentable stenosis in 94% of limbs with venous leg ulcers when the criteria to stent was ≥50% stenosis, which is unusual for most venous practices around the world.
The diameter stenosis of the deep vein was also in reference to the dilated prestenotic vein that may overestimate the degree of stenosis, another practice that is different from other operators of iliac vein stenting including the reviewer.
IVUS planimetry measured an area stenosis ≥50% stenosis in 135 limbs (85%) and a stenosis <50% in 23 limbs (15%). Balloon sizing in 14 of 23 of the latter limbs unmasked significant stenoses.
149 limbs were diagnosed to have significant stenoses that made up for 149/192 (77.6%) of venous ulcer limbs. Also, 158 limbs were stented, so 9 limbs that were stented had neither significant (≥50% stenosis ) on IVUS nor significant stenosis on balloon sizing.
Table III. shows median stenosis detected by IVUS was 70% in 192 limbs, whereas IVUS was performed in only 158 limbs. This may need further clarification.
Saphenous vein ablation was performed in 30 limbs. 27% of these (n=8) did not have any reflux at all (Table III): the rationale behind laser ablation in limbs without any reflux is unclear.
Despite its weaknesses, this paper highlights 4 major aspects of venous ulcer management.
Firstly, it describes a focused algorithmic approach for venous ulcers especially in relation to clinical and imaging findings, which has been missing from literature so far.
Secondly, non-use of compression stockings following endovascular treatment, though attractive and desirable, contrasts current literature on the adjunctive value of compression therapy to heal C6 ulcers.
Thirdly, simultaneous iliac vein stenting along with endovenous ablation is an interesting concept and has its origin historically when venous surgeons were performing deep venous valve repairs in conjunction with GSV/SSV stripping. Although there is evidence that the individual contribution of each modality of treatment may be masked by that of the other, it will be of great interest to observe in further studies whether these impacts will have additional benefits.
Finally, and perhaps most importantly are the details of pitfalls of IVUS, that Dr Raju humbly submits to after championing it for almost a decade. Ours and other authors have for some time believed that the IVUS diameter of a postthrombotic vein is, at best, only in reference to the trabeculated mass track that the IVUS catheter lies in. It is unrepresentative of other channels wider or narrower than the channel it lies in.
Overall, it is a comprehensive paper that not only provides an algorithmic approach to venous ulcers, imaging options and impressive healing rates of venous ulcers. It also promises patients with the difficult problem of chronic venous insufficiency, an independence from compression therapy.