Varicose leg ulcer 20 years after saphenectomy

Dr. Maurizio RonconiClinica Chirurgica

Spedali Civili di Brescia

Case report

female, 74 year old

ulcer of lateral surface of right distal leg

present for about 5 years

18/5/2010

Patient history

GSV stripping 1985

Type 2 Diabetes Mellitus

peripheral obstructive artery disease

Plastic reconstruttive free flaps for leg

ulcer in 2008, 2009, 2010

Clinical examination

Leg disconfort BMI 31,2

Right lateral leg ovalar ulcer, 3 cm in lenght,

surrounded by 8 x 5 distrophic cutaneus area

Visible varicosities along all the leg

Ankle-brachial pressure index (ABPI): 0.4

Dupplex findings

bilateral major superficial venous reflux

junctional reconnection of the sapheno-femoral

confluence and its related tributaries

distal incopetent perforator vessels

venous filling index > 2 mL/sec

Bacteriological swab

Staph Aureus

Enterobacter cloacae

Late recurrent saphenofemoral junction refluxafter ligation and stripping of the greater saphenous

veinReinhard Fischer, MD,a Nikolaus Linde, MD,a Claudio Duff, MD,a Christina Jeanneret, MD,b James G.

Chandler, MD,c and Philline Seeber, MD,d St Gallen, Basle, and Wattwil, Switzerland; and Boulder, Colo

CONCLUSIONSCurrent opinion holds that there are fewer recurrences after correct saphenofemoral ligation than after incom- plete or ill-defined ligation. Many phlebologists have even ventured that there should be no saphenofemoral recur- rences after a correct ligation, but this study, with its 31- to 39-year follow-up, shows that the recurrence incidence after a well-documented and sonographically confirmed correct ligation may rise to 60% when patients are observed over the long term with color-coded duplex scanning. More than one third of the duplex scanning–detectable saphenofemoral recurrences will require additional treat- ment, and almost all of these will be B2 single-lumen vari- cose direct reconnections to the common femoral vein at the site of the former saphenofemoral ligation

J Vasc Surg 2001;34:236-40J Vasc Surg 2001;34:236-40

Leg’s ulcer natural history

Healing ratesHealing rates

68 – 83%68 – 83%

Multilayer elastic compression bandagingLeg elevationMedications

Antibiotic therapyStockings

very slowly healingvery slowly healing

elevated recurrence rateelevated recurrence rate

venous refluxvenous reflux

Visible varicosities only in about 40% of patients with superficial venous reflux

Duplex ultrasonography studies in legs with chronic ulceration show

reflux:51-53% in superficial system alone32-44% in both systems5-15% in deep system alone

Leg’s ulcer and venous reflux

Recurrence rates after healing

Study F-up Reflux Compression alone

Barweel JREurop J Vasc Endovasc Surg 2000

non random

1 year superficial 28%

ZamboniEurop J Vasc Endovasc Surg 2003

random 3 years superficial 38%

14%

9%

Compression + relux surgery

242

compression + surgery

258 compression alone

500 randomised500 randomised

1418 patients assessed

Healed legs not recurred

66%

85%

82%

76%Ulcer healing

Therapeutic option

A. surgeryB. EndoVenous Laser Ablation (EVLA)C. RFD. Foam sclerotherapyE. CompressionF. Other

Li AKC: A technique for re-exploration of the SFJ for recurrent varicose veins.Br J Surg 1975;62:745- 6

da Agus G.B.Chirurgia delle VariciEdra Ed., Milano 2006

dissezione da laterale (CFA) a mediale (CFV)fino a neocrosse (NC)

Surgery

EVLA

116 consecutive patients

Microfoam F-up

Healing 83%6 monthsRecurrence rate 8%

“… This minimally invasive procedure may become the treatment of choice

for venous ulcers in the future.”

Foam

27 patientsCEAP C6Reflux:

•SVR: 20 patients•SVR + DVR: 7 patients

Median Foam: 8 ml

70%

93%Ulcer healing

Venous occlusion

Median F-up Compression + foam

sclerotherapy

Healing 12 months 93%Recurrence rate 12 months 7%

“…eradication of superficial venous reflux (SVR) improves chronic venous ulcer outcome

when compared to compression alone…”

“…UGFS appears to be at least as effective as surgery as a means of dealing with SVR…”

Conclusions

We did sointravenous injection of foam, prepared in according to Tessari’s method, connecting two syringes through a three-way valve, one containing air and the other Polidocanol 3%, with a 4:1 gas/liquide ratio

1. 5 mL in the neo-safena trunk, at the middle of the tigh2. 3 mL 5 cm above a distal perforating vein near the ulcer

superficial phlebitis along the treated vein

Minor complication

Management of the complication

A.phlebectomyB. low molecular weight heparin C.occlusion bendageD.antimicrobial therapyE. non steroidal anti inflammatoryF. other

We did so

• needle thrombectomy with local anesthesia

• Evacuation of endovaricose organized hematoma

• stocking

Follow-up6/7/2010

Thank you for your kindly

attention