Great Debates in Vascular Medicine

Pro: Iliac vein lesions/obstruction should

always be treated PRIOR to lower

extremity superficial vein ablation for

patients with venous leg ulcers

Mitchell Silver DO FACC FSVM RPVI

Director, Center for Critical Limb Care

Ohio Health Heart and Vascular

Columbus, Ohio

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The Real World

Fix the Ulcer vs Fix the Patient…..

64 year old male

Venous stasis ulcer for 2 years

Venous claudication

Recurrent stasis cellulitis

Chronic leg pain/ache with standing

Recurrent swelling

Very low score on quality of life

questionnaire

>> CTA CHRONIC LEFT COMMON ILIAC VEIN OCCLUSION

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Superficial Vein Ablation

May Heal the Ulcer ???

BUT WHAT ABOUT THE PATIENT ???

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This is Simple Physiology…..

The Effect of Outflow Obstruction on Blood Flow

20% Reduction in Area 50% Reduction in Area

49% Reduction in Flow

87% Reduction in Flow

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J VASC SURG 1993;17:414-9.

“The presence of venous

outflow obstruction is a major

contributor to venous ulceration”

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Simple Physiology

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The Facts from the Evidence – Venous Ulcers

Etiology, Anatomy, Pathophysiology

Venous outflow obstructions are found in combination with

reflux in 55% of symptomatic patients.

This combination leads to the higher levels of venous

ambulatory pressure and more severe symptoms then when

either condition is present alone.

The authors recommend that when significant obstruction is

localized above the inguinal ligament, the obstruction

should be treated before any concomitant reflux.

McDaniel HB, Marston WA, Farber MA, et al. Recurrence of chronic venous ulcers on the

basis of clinical, etiologic, anatomic, and pathophysiologic criteria and air

plethysmography. J Vasc Surg. 2002;35:723-728.

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JOURNAL OF VASCULAR SURGERY

Volume 35, Number 1, 2003

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“THE MESSAGE”

Significant iliofemoral venous obstruction should be

treated, whether associated with reflux or not, in

patients with venous stasis ulceration.

When obstruction is shown with reflux, the obstruction

should be treated first.

JOURNAL OF VASCULAR SURGERY

Volume 35, Number 1, 2003

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The CONCLUSION

Iliocaval intervention alone may be sufficient

to treat patients with combined significant

reflux of both CFV and GSV.

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Let’s Be Logical…..

58 year old male with venous stasis ulcer

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INTRAVASCULAR

ULTRASOUND (IVUS)

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Let’s Be Logical…..

SUPERFICIAL

VEIN

ABLATION

WILL NOT

FIX

THE

PATIENT

VENOUS

CLAUDICATION

RECURRENT

SWELLING

SECONDARY

LYMPHEDEMA

RECURRENT

STASIS

CELLULITIS

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What About Ulcer Recurrence ?

The EVRA Trial

6,555 patients screened

6,105 patients excluded

93% of patients excluded (are results real world ?)

Ulcer recurrence was 11.4% with early intervention and

16.5% with deferred intervention before the end of one year

post randomization.

The ESCHAR Trial

Ulcer recurrence was 9% at 1 year, 20% at 2 years, and 29%

at 3 years in the intervention group.

Ulcers recurred significantly more in patients with deep

venous reflux.

ESCHAR Trial Journal Vasc Surg Venous Lymph Disorders2017 Jul;5(4):525-532.

EVRA. N Engl J Med 2018; 378:2105-2114

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Maybe patients with

ulcer recurrence

had this !!!

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THEY PROBABLY DID…

Incidence of and risk factors for iliocaval venous

obstruction in patients with active or healed venous

leg ulcers.

37% of imaging studies demonstrated obstruction of at

least 50%, and 23% had obstruction of >80%.

Risk factors that were found to be independently

associated with a significantly higher incidence of >80%

obstruction included female gender (P = .023), a medical

history of DVT (P = .035), and reflux in the deep venous

system (P = .035)

YOU DON’T KNOW UNLESS YOU LOOK !!!

Marston W. J Vasc Surg 2011 May;53(5):1303-8.

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REBUTTAL

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The Evidence

McDaniel HB, Marston WA, Farber MA, et al. Recurrence of chronic venous ulcers on the

basis of clinical, etiologic, anatomic, and pathophysiologic criteria and air plethysmography.

J Vasc Surg. 2002;35:723-728.

Johnson BF, Manzo RA, Bergelin RO, Strandness DE Jr. The site of residual abnormalities in

the leg veins in long-term follow-up after deep vein thrombosis and their relationship to

the development of the post-thrombotic syndrome. Int Angiol. 1996;15:14-19.

Johnson BF, Manzo RA, Bergelin RO, Strandness DE Jr. Relationship between changes in the

deep venous system and the development of the postthrombotic syndrome after an acute

episode of lower limb deep vein thrombosis: a one- to six-year follow-up. J Vasc Surg.

1995;21:307-312

Alimi YS, DiMauro P, Fabre D, Juhan C. Iliac vein reconstructions to treat acute and

chronic venous occlusive disease. J Vasc Surg. 1997;25:673-681.

O’Sullivan GJ, Semba CP, Bittner CA, et al. Endovascular management of iliac vein

compression (May-Thurner) syndrome. J Vasc Interv Radiol. 2000;11:823-836.

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There is increasing support for the beneficial effect of superficial

vein ablation on the healing rate and recurrence of venous leg

ulcers.

The ulcer recurrence rate is, however, markedly increased by the

presence of deep reflux even after superficial reflux ablation.

A cumulative recurrence rate at 4 to 5 years is reported to be

67% to 100%, and 6% to 28% in limbs with and without deep

involvement, respectively.

Thus, deep venous insufficiency appears to be a major

determinant for ulcer recurrence.

The Facts from the Evidence