The present status of surgery of the superficial venous system in the management of venous ulcer and the evidence for the role of perforator interruption

• Published in: Journal of vascular surgery 2008-10, Vol.48 (4), p.1044-1052
• Main Author: O'Donnell, Thomas F., MD
• Format: Article
• Language: English
• Subjects: Aged; Biological and medical sciences; Dermatology; Female; Humans; Ligation; Male; Medical sciences; Middle Aged; Recurrence; Surgery; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Varicose Ulcer - surgery; Vascular disorders of the skin; Vascular surgery: aorta, extremities, vena cava. Surgery of the lymphatic vessels; Vascular Surgical Procedures - methods
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2008.06.017

Superficial venous hypertension has been cited as the putative etiologic factor in advanced chronic venous insufficiency with venous ulcer (CEAP C 5/6). For over a century, influenced by this belief, surgeons have ablated the superficial venous system as a treatment for venous ulcer. Incompetent perforating veins (ICPVs) have become a particular focus of this therapeutic strategy. This review examines the evidence for the surgical approach. A MEDLINE search of the literature identified only four randomized controlled trials (RCTs) directed at the surgical reduction of superficial venous hypertension. Risk ratios for ulcer healing and prevention of recurrence were calculated to determine benefits for these four RCTs, while mortality and morbidity, where available, was used to determine risk from the procedure. In addition, the quality of the trials (design and outcomes) was assessed. While two trials compared ICPV ligation to compression, the great saphenous vein (GSV) was also treated in many of these limbs, which confounds the results. By contrast, two RCTs, which compared treatment of the GSV alone to compression, demonstrated a significant reduction in the incidence of ulcer recurrence. Case series that employed hemodynamic or surrogate outcomes showed little effect on the addition of ICPV treatment to GSV stripping, while GSV ablation alone was associated with a reduction in the number of ICPVs in several studies. This review suggests a grade 1A recommendation for the treatment of venous ulcer by GSV ablation to reduce ulcer recurrence. The role of ICPV ablation alone or concomitant with GSV treatment awaits results of properly conducted RCTs.