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149
12
Superfi cial Surgery and
Perforator Interruption
in the Treatment of
Venous Leg Ulcers
William Marston
INTRODUCTION
The primary goals when treating patients with leg ulcers associated with
chronic venous insuffi ciency (CVI) are to heal the ulcers as rapidly as pos-
sible, control the patients’ other symptoms manifesting from their venous
disease, and minimize the potential for ulcer recurrence after healing.
Because venous leg ulcers (VLUs) are a result of chronic venous hyperten-
sion, it is generally believed that interventions capable of reducing the
severity of venous hypertension should impact positively on these goals of
treatment.
In this chapter, data concerning the effi cacy of superfi cial and perforator
surgery on healing leg ulcers and preventing recurrence will be reviewed.
The diagnostic evaluation and indications for intervention in these patients
will be discussed. The options for surgical management of various ana-
tomic types of venous insuffi ciency will be reviewed and contrasted with
nonsurgical techniques.
PRESENTATION OF PATIENTS WITH CVI
A commonly held perception is that VLUs are always the result of deep
venous refl ux, and this is not amenable to surgical or interventional recon-
struction. For this reason, the majority of patients treated with VLUs are
never referred to a venous specialist for consideration of a corrective pro-
cedure. Several authors have defi ned the anatomy of refl ux in patients with
Venous Ulcers
Copyright © 2007 by Academic Press, Inc.
All rights of reproduction in any form reserved.
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150 Superfi cial Surgery and Perforator Interruption in the Treatment
CEAP clinical classes 5 and 6 CVI, and isolated saphenous or saphenous
and perforator refl ux is not uncommon, occurring in 20% to 35% of
patients in various series. Also, as outlined by Drs. Neglen, Raju, and
Kistner in other chapters, many patients with deep venous insuffi ciency
causing ulceration may be improved with surgical or endovenous proce-
dures, reducing symptoms and the incidence of recurrent ulcers.
For these reasons, all patients with VLUs who are candidates for cor-
rective procedures should be studied with diagnostic studies to determine
the anatomy and physiology of their individual case. Referral to a venous
specialist familiar with surgical and nonsurgical options will allow the
optimal method of correction to be selected.
DIAGNOSTIC TESTING FOR PATIENTS WITH
VENOUS LEG ULCERS
The interventional treatment of a patient with venous leg ulcers
requires the use of noninvasive studies to determine the anatomic and
hemodynamic characteristics of the patient’s venous system. The anatomic
sites of venous dysfunction and the hemodynamic importance of this
dysfunction are required to allow treatment plans to be formulated and
optimal results to be achieved. Selecting surgical therapy without a knowl-
edge of which vein segments are abnormal is essentially blind surgery
and cannot result in optimal results. The optimal time to perform these
noninvasive studies would be after the limb edema and wound exudate
are controlled. This will allow better visualization of the veins and
better patient compliance with the maneuvers required for standing venous
refl ux examination and plethysmography. Morbidly obese patients and
those with limited ability to stand without assistance are poor candidates
for accurate testing and usually are poor candidates for venous interven-
tion as well.
DUPLEX ULTRASOUND
Imaging techniques using ultrasound combined with Doppler interroga-
tion of the venous system have been validated as sensitive methods of
diagnosis of deep venous thrombosis. Important information for patients
with VLUs that would be detected with this technique includes the pres-
ence or absence of venous obstruction or other changes typical of previous
DVT. This information will help to determine whether the patient’s venous
hypertension is due to obstruction, refl ux, or both (pathophysiology). The
presence of outfl ow obstruction in the iliac veins and/or IVC can often be
detected looking at fl ow patterns, phasicity, and respiratory variation in
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Superfi cial Surgery and Perforator Interruption in the Treatment 151
the common femoral vein. In addition to an examination of the deep and
superfi cial systems, the perforator veins are carefully examined for evi-
dence of incompetence.
Second, venous refl ux in the deep and superfi cial venous systems is
evaluated with the patient in the standing position using duplex ultrasound
and either manual compression or a rapid infl ation/defl ation system to
elicit refl ux. In studies of normal volunteers and patients with CVI, a
normal valve closure time of <0.5 has been defi ned. Systematic interroga-
tion of the common femoral, superfi cial femoral, popliteal, greater saphe-
nous, and lesser saphenous veins is conducted, allowing an anatomic map
of venous refl ux in the limb to be constructed.
Using this information, the clinician can determine the etiology,
anatomy, and pathophysiology of CVI for the patient. Although duplex
evaluation provides detailed information on the anatomy of venous disease,
it cannot defi ne the importance of anatomic abnormalities in the venous
function of the limb. Clearly, one patient with gross refl ux in the saphenous
vein will have no resultant symptoms, while another patient may have an
active ulcer from saphenous refl ux alone. The clinical assessment of the
severity of CVI is often subjective, so testing that allows objective measure-
ment of the hemodynamic performance of the lower extremity venous
system would greatly assist with patient assessment and treatment
decisions.
PHOTOPLETHYSMOGRAPHY
Plethysmography is defi ned as the determination of changes in volume,
and various techniques of plethysmography have been evaluated in the
noninvasive examination of the venous system. Photoplethysmography
(PPG) utilizes a transducer that emits infrared light from a light emitting
diode into the dermis. The backscattered light is measured by an
adjacent photodetector and displayed as a line tracing. The amount of
backscattered light varies with the capillary red blood cell volume in the
dermis. Through use of this technology and provocative limb maneuvers,
an assessment of the venous system is obtained. The primary measure
obtained, the refi ll or recovery time (VRT), represents the time required
for the PPG tracing to return to 90% of baseline after cessation of calf
contraction. PPG does not produce a quantitative measure, but the refi ll
time has been found to correlate closely with ambulatory venous pressure
(AVP) measurements.
Limbs affected with CVI typically have a much shorter VRT than
normal limbs. As such, PPG can provide a relatively simple measure of
whether or not venous insuffi ciency is present. However, the technique can
vary depending on the site of photosensor placement and the small sample
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152 Superfi cial Surgery and Perforator Interruption in the Treatment
area obtained. PPG measurements have not been proven to be a strong
discriminator of the severity of CVI. Nicolaides and Miles reported that
normal limbs were well identifi ed by a PPG refi ll time of greater than 18
seconds with their protocol. Abnormal limbs with CVI consistently had a
refi ll time of <18 seconds. However, in the abnormal group, PPG refi ll time
could not differentiate between degrees of CVI, with similar PPG refi ll
times obtained in patients with AVP measurements ranging from 45 to
100 mmHg. Therefore, PPG is a poor test for assessing the results of venous
corrective surgical procedures.
In summary, PPG is a reasonable measure of the presence or absence
of CVI that is best used when no further information concerning the
venous hemodynamic situation is desired. It would be useful to help diag-
nose whether the etiology of a chronic leg ulcer was related to venous
disease. However, if information concerning the severity of CVI or an
evaluation of the improvement after venous surgery is required, a quantita-
tive test will be more useful.
AIR PLETHYSMOGRAPHY
Air plethysmography (APG) utilizes a technique to improve on the
shortcomings of PPG and other types of plethysmography that have limited
sampling areas. It employs a low-pressure air-fi lled cuff measuring 30 to
40 cm in length that is applied to the lower leg, allowing quantitative evalu-
ation of volume changes of the entire lower leg from knee to ankle. Briefl y,
the patient lies supine initially with the leg elevated and supported at
the heel, allowing the cuff to be applied to the lower leg. The cuff is
infl ated to a pressure of 6 mmHg to provide snug apposition to the limb
without compressing the superfi cial veins. A baseline volume in the supine
position is obtained with the patient resting. The patient then moves to a
standing position supported by a walker to remove weight from the tested
limb. The volume tracing gradually increases until a plateau is reached.
The patient then performs one calf contraction/tiptoe maneuver followed
by rest. A subsequent series of 10 tiptoe maneuvers completes the test
procedure.
Figure 12-1 illustrates the data calculated from the tracings obtained.
The venous volume (VV) is the difference in limb volumes obtained in the
resting and standing positions. The venous fi lling index (VFI) is calculated
by measuring 90% of the VV and dividing this volume by the time the
limb requires to refi ll to 90% of the VV after moving to the standing posi-
tion. Expressed in cc per second, VFI measures the average fi lling rate of
the dependent leg and is slow in normal limbs. The volume of blood ejected
with one tiptoe movement divided by the VV gives the ejection fraction
(EF), and the limb volume remaining after 10 tiptoe movements divided
by the VV gives the residual volume fraction (RVF).
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Superfi cial Surgery and Perforator Interruption in the Treatment 153
In 1988, Christopoulos et al. described the use of APG for evaluation
of normal limbs and those affected with CVI. A VFI <2 ml /second was
associated with clinically normal limbs, and increasing levels of VFI were
associated with more severe symptoms (Table 12-1).
1
The VFI is believed
to provide a reasonable approximation of the global function of the lower
extremity venous system in resisting refl ux in the standing position.
The EF and RVF are measures of the effi cacy of the calf muscle to pump
blood out of the leg. The RVF was found to correlate closely with AVP
throughout the range of AVP measurements, with lower RVF values rep-
resenting better calf pump function (normal RVF defi ned as <35%).
FIGURE 12-1 Diagrammatic representation of hemodynamic values obtained from air
plethysmography. VV = venous volume, VFI = venous fi lling index, EF = ejection fraction,
RVF = residual volume fraction. Reprinted with permission from Christopoulos et al. Air-
plethysmography and the effect of elastic compression on venous hemodynamics of the leg.
J Vasc Surg. 1987;5:148–159.
TABLE 12-1 Prevalence of the Sequelae of Venous Disease in Relation to VFI in 134
Limbs with Venous Disease Studied with Air Plethysmography
VFI, ml/sec Swelling (%) Skin Changes (%) Ulceration (%)
<3
0 0 0
3–5 12 19 0
5–10 46 61 46
>10
76 76 58
From Christopoulos et al.
1
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154 Superfi cial Surgery and Perforator Interruption in the Treatment
Further work with APG measurements has demonstrated that the post-
operative VFI can predict the long-term symptomatic outcome for patients
after venous surgical procedures. Ninety-four percent of patients in whom
the VFI corrected to <2 ml/second after surgery were asymptomatic at a
mean follow-up time of 44 months (Figure 12-2).
2
The VFI was also found
to be predictive of the incidence of ulcer recurrence. Limbs with a VFI
<4 m l/sec ond had signi fi cantly fewer episodes of ulcer recurrence (22% at
3 years) compared to those with a VFI >4 ml/second (47% at 3 years).
3
In summary, APG, by sampling a large portion of the calf area, provides
a better measure than PPG of the global venous function of the limb.
It provides a quantitative analysis that appears to be useful in the
follow-up of patients with VLUs, particularly those undergoing venous
intervention.
INDICATIONS FOR INTERVENTION
Intuitively, most vascular specialists believe that patients with true
VLUs will experience an improved long-term course if their underlying
venous hypertension can be corrected. However, there is little evidence
that venous intervention can be recommended to accelerate healing of the
ulcer. Patients with active ulcers can expect ulcer healing in 10–12 weeks
on average using various high-compression bandaging systems.
4
Unfortu-
nately, patients with larger ulcers and those of long duration heal more
0
1
2
3
4
5
6
CEAP Mean
Clinical
Symptom
Score
VFI <2 VFI 2-4 VFI >4
Postoperative VFI (ml/sec)
FIGURE 12-2 Comparison of mean clinical symptom score in patients who had normal
postoperative VFI with mean CSS in those whose values did not normalize (abnormal
>2 m l/se c). P < 0.01 between groups. VFI = venous fi lling index.
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Superfi cial Surgery and Perforator Interruption in the Treatment 155
slowly in most cases. It is not clear whether intervention with correction of
CVI will accelerate healing in these cases, but it is reasonable to perform
corrective procedures if possible prior to ulcer healing. The incidence of
ulcer recurrence after healing has been reported as 50% or greater at 5
years, and is somewhat dependent on compliance with the use of compres-
sion stockings. Most patients who develop one episode of ulcer recurrence
will experience multiple episodes.
For patients with active or healed VLUs, Barwell et al. performed a
randomized study, termed the ESCHAR study, comparing the effi cacy of
saphenous stripping plus compression compared to compression alone for
healing and prevention of venous leg ulcers.
5
In this study, 500 patients
with isolated superfi cial refl ux (60%) or combined superfi cial and deep
venous disease (40%) were enrolled. Demographic factors were similar in
the two groups. Ulcer healing was no different, with 65% healed in each
group by life table analysis at 24 weeks after randomization (Figure 12-3).
In the group with healed ulcers, mean follow-up time was 14 months.
Signifi cantly fewer patients in the surgery group experienced recurrent
ulceration (15%) compared to the compression alone group (34%) (Figure
12-4). Adverse events were infrequent (<5% in each group), primarily
composed of compression bandage injuries in the conservative group and
wound infection (n = 5) in the surgical group.
FIGURE 12-3 Kaplan-Meier analysis of ulcer healing for legs treated with compression
alone compared to saphenous surgery and compression.
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156 Superfi cial Surgery and Perforator Interruption in the Treatment
Based on the results of this trial, it is reasonable to recommend venous
intervention to reduce the incidence of ulcer recurrence whenever superfi -
cial venous refl ux is a prominent component of the abnormal venous func-
tion. This will comprise 30% to 50% of cases seen at most VLU centers.
But intervention cannot be recommended for most patients in order to
accelerate wound healing.
Anatomically, any combination of superfi cial, perforator, and/or deep
venous disease may result in severe CVI. Marston et al. reported that 29%
of limbs with CVI and leg ulceration displayed superfi cial or superfi cial
and perforator disease on standing refl ux examination (Table 12-2).
4
Small
saphenous refl ux may also be suffi cient to cause leg ulceration with no
other abnormalities, typically resulting in ulceration near the lateral
malleolus. The contribution of incompetent perforators to global venous
insuffi ciency remains controversial and will be discussed in detail later in
this chapter, but it is clear that some leg ulcers are associated with large
incompetent perforators that should be ligated.
A signifi cant percentage of patients with VLUs are found to have abnor-
mal venous function in multiple systems. Over 27% displayed both deep
and superfi cial refl ux in a study of 138 limbs with leg ulceration (Table 12-
2).
4
It is not always clear whether these patients will experience a n improve-
ment in the severity of symptoms if their superfi cial or superfi cial and
FIGURE 12-4 Kaplan-Meier analysis of ulcer recurrence for legs treated with compres-
sion alone compared to saphenous surgery and compression.
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Superfi cial Surgery and Perforator Interruption in the Treatment 157
perforator abnormalities are corrected. This issue will be discussed in
detail later in this chapter.
Hemodynamic evaluation using APG is very useful in the management
of patients with multisystem venous insuffi ciency. Patients with deep and
superfi cial refl ux may be initially treated with superfi cial stripping or abla-
tion, and the APG can be repeated to determine the degree of improve-
ment without addressing the deep venous refl ux. As noted previously,
postoperative normalization of the VFI is associated with fewer episodes
of ulcer recurrence and fewer symptoms at late follow-up. Therefore, a
patient who has improvement in the VFI with correction of only one ana-
tomic component of his/her venous refl ux can be followed conservatively,
while a patient with a persistent hemodynamic abnormality with a poor
VFI can be considered for further intervention.
CONVENTIONAL SURGICAL PROCEDURES
FOR CORRECTION OF CVI IN PATIENTS
WITH VLU
SUPERFICIAL VENOUS REFLUX:
GREAT SAPHENOUS VEIN
Traditional surgical techniques for removal of the great saphenous vein
have typically employed ligation of the vein at the saphenofemoral junction
and removal of the vein between the groin and knee or groin and ankle
using a stripping technique. The goal of high ligation is to identify and
divide all venous branches communicating with the saphenofemoral junc-
tion (SFJ) to minimize the potential for recurrent refl ux pathways resulting
in recurrent symptoms. Bergan and others have consistently advocated
wide exposure of venous tributaries to their branch points during high
ligation. Unfortunately, it appears that many patients developing recurrent
venous insuffi ciency do so because of neovascular generation of new venous
communications re-establishing the saphenofemoral junction, or dilation
TABLE 12-2 Anatomic Distribution of Venous Refl ux
in 138 Limbs with CEAP Clinical Class 6 CVI
Anatomic Site Incidence
Deep alone 43.5%
Deep and superfi cial 21.0%
Deep, perforator, and superfi cial 6.5%
Superfi cial alone 18.1%
Superfi cial and perforator 10.9%
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