The prevention of venous ulcers

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In a session concentrating on the prevention of venous ulcers, at the recent ESVS meeting, delegates were honoured to have a distinguished panel before them, including Dr Anthony Comerota (University of Michigan, USA), Dr Alun Davies (Imperial College, London, UK) and Dr Michel Perrin (Lyon, France).

Comerota began the session by stating that for the treatment of acute ilio-femoral venous thrombosis, there are two treatment options; venous thrombectomy or anti-coagulation. According to Comerota, the randomised trial which compared venous thrombectomy vs. anti-coagulation demonstrated that patients who received thrombectomy showed improved patency, lower venous pressures, less leg swelling and fewer post-thrombotic symptoms, compared with anti-coagulation.

He said that patients who presented with acute ilio-femoral venous thrombosis should have immediate anti-coagulation (with leg elevation and long leg compression) and sent for a CT scan with contrast (of the chest, abdomen and pelvis). The patient’s physical activity should then be assessed. If the patient is not physically active a treatment regime of anti-coagulation and compression should be prescribed. If the patient is physically active a strategy of thrombus removal should be initiated.

According to Comerota, one reason that anti-coagulation is often ineffective with large clots associated with iliofemoral venous disease is because anti-coagulation lacks chemical thrombolytic activity. As a result, an anti-coagulation regime (especially for extensive DVT) means thrombolysis occurs slowly, is often incomplete and the results vary.

As long as there are no contra-indications to thrombolysis, catheter-directed thrombolysis and/or pharmaco-mechanical thrombolysis should be administered and then a correction of the underlying venous lesions should occur.

If there is a contra-indication, thrombolysis contemporary venous thrombectomy or segmental pharmaco-mechanical thrombolysis (Trellis catheter should be administered, followed by long-term anti-coagulation should be considered. In conclusion, Comerota said that the management strategy of iliofemoral venous disease for an ambulatory patient necessitates that the thrombus should be removed and unobstructed venous drainage should be provided, thus allowing the patient to benefit.

Following Comerota, Alun Davies questioned whether all patients with a venous ulcer have a duplex scan or should we wait till the ulcer has healed, as this would result in a high number of patients requiring screening. As a consequence, he asked whether perforator ablation had a role.

He commented that the abolition of superficial reflux decreases the rate of ulcer recurrence, although not the rate at which the ulcer heals. He concluded that the evaluation of other techniques of ablation in these groups is required.

Finally, Michel Perrin presented an evaluation of venous reconstructive procedures commenting that the primary aims should be ulcer healing, the prevention of ulcer recurrence (C5) and the prevention of ulcer in the patient (C2-4). He added that there is no evidence that deep venous reconstructive surgery (DVRS) improves ulcer healing compared to compression, citing the work of McMullen MJA (2001), who stated that 83% of venous ulcers healed with appropriate conservative treatment compression within four months. Therefore, DVRS should be evaluated according to the etiology and physiopathology.

In discussing the prevention of ulcer recurrence, Perrin said that there are no randomised control trials comparing conservative treatment and/or superficial venous surgery and/or perforator ligation to DVRS. In addition, most of the patients treated by deep venous surgery had been previously treated by conservative or/and superficial venous surgery or/and perforator ligation and had a recurrence of their ulcer. The results provided by DVRS (mainly valvuplasty) have been estimated by large series (11 in total) and between 63-83% of patients remain ulcer free beyond five years follow-up. Moreover, when superficial and perforator insufficiency are associated they must be treated in combination as a first or second step. The current guidelines, commented Perrin, are evidenced based and may recommend valuloplasty after failure of conservative treatment or superficial and perforator venous surgery (recommendation grade 2b).

Next, he discussed primary deep venous obstruction, which according to Raju and Neglen (JVS 2006) can be related to primary compression is frequent and can only be identified by intravascular ultrasound scanning. In a series of 39 limbs (isolated primary obstruction=10, associated with reflux=29) were treated by ballooning and stenting without any reflux correction. At 2.5 years follow-up, ulcer healing without recurrence were 76% (obstruction) and 67% (obstruction and reflux), respectively.

Perrin then commented on what might the future treatment strategies; Neovalve (Maleti) and Xenografts (Pavcnik) delivered by endovascular access. In 27 procedures (25 patients), with 27 months of follow-up the results showed an ulcer-healing rate of 85% with no recurrence and valve competency of 88%. In an additional 64 patient study (Perrin, Cardiovasc Surg 2000) treated by valve transfer of valvuoplasty only one patient presented with an ulcer, after five years (no data available for obstruction).

In conclusion, Perrin said that there was no data for ulcer healing. As regards to ulcer recurrence prevention he said that in primary etiology valvuoplasty gives satisfactory results. Ballooning and stenting is the first procedure for both primary and secondary etiology but indications remain controversial as evaluation of the obstruction severity is less standardised than reflux one. In secondary etiology, valve transfer efficacy remains debatable. New procedures such as valve reconstruction are promising but, he added, longer follow-up is needed.

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