Fig. 13.1
Flow chart for the management of primary CVI
Treatment Outcome: Current Literature
In contrast to a C2 lesion where all interventions have shown to produce considerable improvement in the VCSS and QoL, the outcome in patients with C4, C5, and C6 classes is more disappointing. The literature on this subject is voluminous. A brief cross-sectional analysis is provided below.
The ulcer recurrence rate in patients undergoing saphenous surgery with postoperative compression therapy (CT) was 12 % at the end of 1 year. When CT alone was employed, the rate was 28 % [12].
Only few reports on endovenous thermal ablations, in patients with C6 class, are available. In a study of 25 patients with C6 lesion, recurrence of ulcer was observed in only one patient after 6–12 months follow-up, after RF or laser ablation [25].
The North American SEPS registry reports an ulcer recurrence rate of 28 % at the end of 2 years. The rate was 35 % in the SEPS alone group and 25 % in the group who had SEPS along with superficial vein ablation [27, 28].
The recurrence of ulcers after deep vein valve reconstruction depends on the technique of repair, site of repair, and whether single or multiple sites were repaired. It is difficult to provide a standard figure, but the recurrence rate varies from 12 to 50 % at the end of 5 years.
The cumulative patency rate of 100 % was reported following iliac vein stenting for May-Thurner syndrome after 72 months [20].
Post-interventional Care
There is sufficient data to show that continued use of CT minimizes ulcer recurrence after interventions in a C3 to C6 class patient [12]. This is in contrast to a C2 class, where CT is provided for only 1 week postoperative. For patients with combined superficial and deep axial reflux, elimination of superficial reflux with continued use of CT is suggested to minimize ulcer recurrence [29].
Occasionally local secondary procedures may be needed in some patients. The procedures used include ablation of recurrent veins, SEPS, skin grafting, and vacuum-assisted closure (VAC), etc. USFS is an extremely useful strategy in the management of recurrence as a day-case procedure. A neglected area is attention to correction of morbid obesity. This strategy can sometimes work wonders [30].
Strategies for Prevention of Venous Ulcers
Treatment of an established venous ulcer is a prolonged and expensive affair. The focus should be on prevention of venous ulcers rather than on the lengthy and costly treatment of established ulcers. The Pacific Vascular Symposium 2009 was convened with the goal to reduce the incidence of venous ulcers by 50 % globally in 10 years [31]. One of the important considerations was to formulate the guidelines for a “standardized chronic venous scan” to bring in uniformity in the assessment of CVD [29]. Three approaches were suggested for reducing the incidence of venous ulcers – identify risk factors for progression of class, prevent/minimize recurrence of established venous ulcer, and focus on certain nonmedical initiatives.
Risk Factors for Class Progression and Preventive Measures
This is a difficult but important consideration. The incidence of progression to CVI from C3 to C6 was 2 % per year [19]. Risk factors identified for such class progression include residual axial deep vein reflux especially popliteal reflux, residual/recurrent superficial vein reflux, and persistent venous hypertension [19, 32]. Feeling of swelling in the limb, corona phlebectatica, mechanical dysfunction of the calf muscle pump, and diminished ankle joint movement are also important. It has been identified that presence of hemochromatosis C282Y gene mutation in patients with primary CVD increases the risk of development of ulceration [33].
Early interventions in high-risk group to prevent ulceration would be a logical step. CT, pharmacotherapy, and endovenous/open surgical procedures have all been tried with this end in view. Studies have not confirmed the effectiveness of any of these measures [19]. Open/endovenous interventions to correct superficial reflux are practiced extensively in C2 and C3 clinical classes. It is reported that 100 patients with varicose veins need to be operated to prevent one ulcer; the number comes down to 10 when limbs with C4 class alone are considered [19].
Prevent/Minimize Recurrence of Established Venous Ulcer
Compression, correction, and surveillance are the three strategies to prevent recurrence of venous ulcers [29]. Compression is the primary treatment of venous ulcer of any etiology. Continuation of CT is recommended as long as the risk for recurrence exists [29]. Correction of reflux and obstruction is significant in preventing recurrence since these procedures eliminate the basic cause for venous hypertension. Surveillance is by constant evaluation to assess the progression of the disease and adopting prompt treatment strategies to prevent tissue damage [29].
Nonmedical Initiatives to Decrease Venous Ulcer Prevalence
These measures are aimed at improving the awareness of the problem by patients and health care personnel [34]. Funding for research in venous ulcer treatment and prevention and establishing a strong central organization to streamline the various activities are effective supportive measures.
Summary
The treatment of a patient with CVI and leg ulceration would need the coordination and cooperation of several disciplines. It is important that the clinician is aware of the proper guidelines in the total care of these patients.
Treatment of a patient with established venous ulcer is a long affair. Ulcer care and CT are the mainstays of management. MPFF has shown promising results in symptomatic improvement and ulcer healing. An emerging strategy is guided exercise program for optimizing calf muscle pump function and improving ankle joint mobility.
Several interventions, surgical and nonsurgical, are available. Proper selection of the optimum procedure and meticulous execution of the same would go a long way in improving the final outcome. The most rational approach would be to prevent venous ulceration in high-risk patients.
