Conservative versus surgical treatment of venous leg ulcers: 10-year follow up of a randomized, multicenter trial.

INTRODUCTION: Leg ulcers have a large socio-economic impact. Treatment modalities are either conservative or surgical. Conservative treatment involves local treatment and compression therapy. Surgical treatment of venous ulcers is based on correcting venous hypertension, by treating incompetent superficial, deep, and perforating veins. A prospective randomized multicenter trial comparing surgical treatment (combined superficial and perforating vein surgery) with ambulatory compression therapy was conducted during 1998 and 2001. This paper presents the results of a 10-year follow-up period of this trial. MATERIALS AND METHODS: All patients enrolled in the original prospective trial were approached and invited for additional examination and duplex ultrasound evaluation. Secondary, disease specific and generic quality-of-life (QoL) was assessed. Current ulcer state and recurrence during the follow-up period was assessed. RESULTS: After a mean of 97 months follow up, 80 (41%) out of 196 legs could be inspected. The incidence of "ulcer-free", the main outcome, was significantly (p = 0.007) higher in the surgical group (58.9%), compared to the conservative group (39.6%). Observed ulcer recurrence was 48.9% for the surgical group and 94.3% for the conservative group. The number of incompetent perforating veins appears to be a significant (p < 0.001) risk factor for not being ulcer-free. Disease specific QoL showed no significant difference between the surgical and conservative groups. CONCLUSIONS: The addition of surgical treatment in patients with venous ulceration leads to a significantly higher chance of being ulcer-free, than just ambulatory compression therapy. This effect persists after 10 years of follow up. The number of incompetent perforating veins has a significant effect on the ulcer-state and recurrence.

Endoscopic versus open subfascial division of incompetent perforating veins in the treatment of venous leg ulceration: long-term follow-up.

PURPOSE: Subfascial division of incompetent perforating veins seems to be a successful treatment for patients with venous leg ulceration (CEAP 6). For postoperative wound complications, endoscopic techniques are more common than open subfascial division of incompetent perforating veins (Linton procedure). We investigated the long-term results of ulcer healing and recurrence rates and compared them with preoperative and postoperative duplex findings. METHODS: Patients with venous ulceration on the medial side of the lower leg were randomly allocated to endoscopic exploration or open exploration by means of the modified Linton approach. Ulcer healing and recurrence rates were documented. RESULTS: Thirty-nine patients were randomly allocated to exploration, 19 patients to open subfascial division of incompetent perforating veins (Linton group), and 20 patients to subfascial endoscopic division of incompetent perforating veins (SEPS group). During the follow-up period, four patients in the SEPS group died, all of causes other than the venous leg ulcer. Because of a squamous cell carcinoma that had developed in the venous ulcer, one patient in the SEPS group underwent a below-knee amputation. In a mean follow-up period of 50.6 months, the venous ulceration of all 18 patients in the Linton group who were available for follow-up initially healed. The recurrence rate in this group was 22% (4 patients). In the SEPS group, the mean follow-up period for 19 patients was 46.1 months, with the ulceration healing in 17 patients and a recurrence rate of 12% (2 patients). The presence of deep venous incompetence (DVI) did not influence the recurrence rates (P =.044, Fisher exact test), but it significantly influenced the development of new incompetent perforating veins (3 of 10 without DVI; 7 of 10 with DVI; P =.011, binomial test). CONCLUSION: The long-term follow-up results of the endoscopic division of perforating veins are comparable with those of the open division of perforating veins (modified Linton procedure).

Complications in subfascial endoscopic perforating vein surgery: a report of two cases.

Subfascial endoscopic perforating vein surgery is a safe method for the division of incompetent perforating veins. Nevertheless, we report two cases with unfortunate complications: the posterior tibial artery and tibial nerve were damaged during the procedures. In one patient this resulted in a reintervention, but in both patients it resulted in permanent discomfort. We then present a guideline that may prevent damage to these critical structures.