Assessment of venous insufficiency in patients with chronic venous leg ulcers.Venous hemodynamics before and after surgery

Abstract

Venous insufficiency in the legs is a common disease, which may be complicated by chronic leg ulcers in 1% among the population. Venous ulcer duration is often long compared to other aetiologies and for the patient it involves long periods of pain, discomfort and reduced quality of life. Superficial insufficiency can frequently be observed in leg ulcer patients, which makes them suitable for varicose vein surgery.Colour Doppler ultrasound (CDU) is widely used for diagnosis of venous disease by its possibilities to localize the level of reflux both in the superficial and in the deep vein systems. Hence, less ulcer recurrence can be observed after CDU-guided varicose vein surgery in comparison to conservative treatment.The purposes of the studies were 1) to evaluate CDU in comparison to descending phlebography, the golden standard investigation of venous insufficiency, 2) to investigate common sites of insufficient vein compartments in legs with chronic leg ulcers, 3) to investigate vein surgery outcome and its relation to ulcer healing or ulcer recurrence, and 4) to describe the pathophysiology of postoperative venous ulcer recurrence in terms of venous reflux, ambulatory venous pressure and muscle pump dysfunction and to find predictive risk variables for venous ulcer recurrence.We found a good agreement between CDU and descending phlebography. However, CDU was superior to find distal venous valve insufficiencies in cases of competent proximal ones. In leg ulcer patients with primary venous insufficiency, isolated superficial insufficiency was found in 50% and combinations with deep insufficiency was observed in 35%. In patients with secondary venous insufficiency deep reflux is common (38%), but 49% had mixed superficial and deep insufficiency. Thus, a large part of patients with leg ulcers might benefit of surgery. The ulcer recurrence rate was estimated to be 19% within a 5 year period after a median follow-up time of 2-6 years. In all patients with recurrent leg ulcers, the post-operative CDU investigation showed new insufficient or residual incompetent pathways. Long lasting ulcer disease was a significant preoperative and postoperative risk variable, which should have influence on interventional decisions and follow-up strategies. Another postoperative risk factor was axial reflux and high ambulatory venous pressure (p<0.018). At post-operative follow-up, venous function improved initially, but deteriorated again within a two 2 years period, especially in legs with ulcer recurrence (17%). Muscle pump function (APF%) and venous refilling times (VRT90) were significant risk variables for ulcer recurrence after surgery.In conclusion, Colour Doppler Ultrasound is reliable in diagnosing venous insufficiency and should always be used before surgical interventions. Since superficial venous insufficiency is common in legs with venous ulcers, varicose vein surgery should be considered in those cases. Correctly performed varicose vein interventions improve the muscle pump function and lower thereby the risk of ulcer recurrence. Post-operative follow-up with tests of muscle pump function is recommended in patients at risk of ulcer recurrence.