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Is the nihilistic approach to surgical reduction of superficial and perforator vein incompetence for venous ulcer justified?
J Vasc Surg. 2002 Dec; 36(6):1167-74.JV

Abstract

OBJECTIVE

Twenty-five years ago, the senior author showed a 55% postoperative ulcer recurrence rate after open perforator ligation. Those data contributed to a nihilistic attitude toward incompetent perforating veins. Conversely, since the introduction of subfascial endoscopic perforator surgery (SEPS), we have undertaken ablation of superficial and perforator reflux as initial treatment in patients with ulcers (C6) or healed ulcers (C5). This report outlines our long-term results.

METHODS

Between December 1994 and November 1999, SEPS was performed on 51 limbs in 45 patients with C5/C6 disease. Sixteen limbs underwent SEPS alone, and 35 had additional surgery on the greater saphenous vein (GSV), the lesser saphenous vein, or the tributary varicies. Data were collected according to the reporting standards in venous disease. Preoperative duplex scan of deep, superficial, and perforating veins was performed. Data were analyzed with Kaplan-Meier method, Mantel-Cox log-rank test, or t test.

RESULTS

Of the 51 limbs that underwent SEPS, the GSV was stripped in 28. Twenty-nine were C6, and 22 were C5. Etiology was primary (Ep) in 25 limbs and secondary (Es) in 26 limbs. All limbs had duplex scan evidence of perforator incompetence (Ap), and deep insufficiency (A(D)) was seen in 39 cases (76%). Reflux predominated (P(R)). The clinical follow-up period was 0 to 82 months (median, 38 months). Venous disability scores improved from 9.8 before surgery to 4.2 at last follow-up (P <.05). Kaplan-Meier analysis showed 74% healing at 6 months. The presence of an ulcer more than 2 cm in diameter, secondary etiology, and SEPS without concomitant GSV stripping were associated (P <.05) with delayed healing. Among patients in whom ulcers healed or who were seen with healed ulcers, the 5-year ulcer recurrence rate was 13%. Lesser saphenous vein reflux was the only factor that correlated with increased ulcer recurrence. Deep system reflux as measured with duplex scan valve closure times did not correlate with the rate of ulcer healing or recurrence.

CONCLUSION

Nihilism has no place in the management of venous disease in the 21st century. An aggressive approach to superficial and perforating vein reflux in this cohort of patients with C5 and C6 disease resulted in rapid ulcer healing and low 5-year recurrence rates. Prior saphenous vein stripping, large ulcers, and secondary etiology were associated with delayed healing. A less aggressive posture toward lesser saphenous vein reflux contributed to a higher recurrence rate in this subgroup of patients. These risk factors are useful in counseling patients as to their expected postoperative course; however, no combination of factors should a priori preclude surgical intervention in this group of patients.

Authors+Show Affiliations

Division of Vascular Surgery, New England Medical Center, Box 1035, Boston, MA 02111, USA. Miafrati@lifespan.orgNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article

Language

eng

PubMed ID

12469048

Citation

Iafrati, Mark D., et al. "Is the Nihilistic Approach to Surgical Reduction of Superficial and Perforator Vein Incompetence for Venous Ulcer Justified?" Journal of Vascular Surgery, vol. 36, no. 6, 2002, pp. 1167-74.
Iafrati MD, Pare GJ, O'Donnell TF, et al. Is the nihilistic approach to surgical reduction of superficial and perforator vein incompetence for venous ulcer justified? J Vasc Surg. 2002;36(6):1167-74.
Iafrati, M. D., Pare, G. J., O'Donnell, T. F., & Estes, J. (2002). Is the nihilistic approach to surgical reduction of superficial and perforator vein incompetence for venous ulcer justified? Journal of Vascular Surgery, 36(6), 1167-74.
Iafrati MD, et al. Is the Nihilistic Approach to Surgical Reduction of Superficial and Perforator Vein Incompetence for Venous Ulcer Justified. J Vasc Surg. 2002;36(6):1167-74. PubMed PMID: 12469048.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Is the nihilistic approach to surgical reduction of superficial and perforator vein incompetence for venous ulcer justified? AU - Iafrati,Mark D, AU - Pare,Gary J, AU - O'Donnell,Thomas F, AU - Estes,James, PY - 2002/12/7/pubmed PY - 2003/1/8/medline PY - 2002/12/7/entrez SP - 1167 EP - 74 JF - Journal of vascular surgery JO - J Vasc Surg VL - 36 IS - 6 N2 - OBJECTIVE: Twenty-five years ago, the senior author showed a 55% postoperative ulcer recurrence rate after open perforator ligation. Those data contributed to a nihilistic attitude toward incompetent perforating veins. Conversely, since the introduction of subfascial endoscopic perforator surgery (SEPS), we have undertaken ablation of superficial and perforator reflux as initial treatment in patients with ulcers (C6) or healed ulcers (C5). This report outlines our long-term results. METHODS: Between December 1994 and November 1999, SEPS was performed on 51 limbs in 45 patients with C5/C6 disease. Sixteen limbs underwent SEPS alone, and 35 had additional surgery on the greater saphenous vein (GSV), the lesser saphenous vein, or the tributary varicies. Data were collected according to the reporting standards in venous disease. Preoperative duplex scan of deep, superficial, and perforating veins was performed. Data were analyzed with Kaplan-Meier method, Mantel-Cox log-rank test, or t test. RESULTS: Of the 51 limbs that underwent SEPS, the GSV was stripped in 28. Twenty-nine were C6, and 22 were C5. Etiology was primary (Ep) in 25 limbs and secondary (Es) in 26 limbs. All limbs had duplex scan evidence of perforator incompetence (Ap), and deep insufficiency (A(D)) was seen in 39 cases (76%). Reflux predominated (P(R)). The clinical follow-up period was 0 to 82 months (median, 38 months). Venous disability scores improved from 9.8 before surgery to 4.2 at last follow-up (P <.05). Kaplan-Meier analysis showed 74% healing at 6 months. The presence of an ulcer more than 2 cm in diameter, secondary etiology, and SEPS without concomitant GSV stripping were associated (P <.05) with delayed healing. Among patients in whom ulcers healed or who were seen with healed ulcers, the 5-year ulcer recurrence rate was 13%. Lesser saphenous vein reflux was the only factor that correlated with increased ulcer recurrence. Deep system reflux as measured with duplex scan valve closure times did not correlate with the rate of ulcer healing or recurrence. CONCLUSION: Nihilism has no place in the management of venous disease in the 21st century. An aggressive approach to superficial and perforating vein reflux in this cohort of patients with C5 and C6 disease resulted in rapid ulcer healing and low 5-year recurrence rates. Prior saphenous vein stripping, large ulcers, and secondary etiology were associated with delayed healing. A less aggressive posture toward lesser saphenous vein reflux contributed to a higher recurrence rate in this subgroup of patients. These risk factors are useful in counseling patients as to their expected postoperative course; however, no combination of factors should a priori preclude surgical intervention in this group of patients. SN - 0741-5214 UR - https://www.unboundmedicine.com/medline/citation/12469048/Is_the_nihilistic_approach_to_surgical_reduction_of_superficial_and_perforator_vein_incompetence_for_venous_ulcer_justified L2 - https://linkinghub.elsevier.com/retrieve/pii/S0741521402003129 DB - PRIME DP - Unbound Medicine ER -