Division of Vascular Surgery, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC.
Division of Vascular Surgery, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC.
J Vasc Surg Venous Lymphat Disord. 2017 Jul;5(4):525-532. doi: 10.1016/j.jvsv.2017.02.007. Epub 2017 May 12.
The Effect of Surgery and Compression on Healing and Recurrence (ESCHAR) trial previously reported that patients with venous leg ulcers treated with saphenous stripping experienced a significantly reduced incidence of ulcer recurrence compared with patients treated with compression therapy. Most patients with leg ulcers and saphenous insufficiency are currently treated with endovenous thermal ablation (EVTA), but little information is available on the long-term results after EVTA in Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) clinical class 5 (C5) and class 6 (C6) patients.
We retrospectively reviewed all CEAP C5 or C6 patients treated with EVTA to define the incidence of ulcer healing and recurrence. Patients with active ulcers were managed weekly in a comprehensive wound center until healed. After healing, patients were treated with compression stockings and returned at 6-month intervals for follow-up. Time to healing and time to ulcer recurrence were determined by Kaplan-Meier survival analysis. Risk factors were assessed to determine their association with ulcer recurrence.
EVTA of the great saphenous vein (n = 146), small saphenous vein (n = 20), or both (n = 7) was performed on 173 limbs with active (n = 72) or healed (n = 101) ulcers. Deep venous insufficiency was present in 54 cases (31.2%). Concomitant phlebectomy was performed in 59 limbs (34%). Median follow-up time was 25.2 months after EVTA. Venous ulcers healed after EVTA in 57% of cases at 3 months, 74% at 6 months, and 78% at 12 months. Ulcers recurred in 9% of patients at 1 year after EVTA, 20% at 2 years, and 29% at 3 years of follow-up. Ulcers recurred significantly more often in patients with deep venous insufficiency and in patients who did not undergo phlebectomy of associated varicose veins at the time of EVTA.
Ulcers recurred in a minority of CEAP clinical C5 and C6 patients after EVTA of the saphenous veins. Ulcer recurrence was less frequent in patients without concomitant deep venous reflux and in those treated with phlebectomy of varicose veins at the time of EVTA. We suggest consideration of phlebectomy at the time of EVTA for patients with C5 and C6 venous insufficiency, particularly in those with isolated superficial venous insufficiency.
此前，“手术和压迫对愈合和复发的影响（ESCHAR）”试验报告称，与接受压迫治疗的患者相比，接受隐静脉剥离术治疗的静脉性腿部溃疡患者其溃疡复发的发生率显著降低。目前，大多数腿部溃疡伴隐静脉功能不全的患者接受静脉内热消融术（EVTA）治疗，但关于 EVTA 治疗临床分类 5（C5）和 6（C6）患者的长期结果的信息很少。
我们回顾性分析了所有接受 EVTA 治疗的 C5 或 C6 临床分类患者，以确定溃疡愈合和复发的发生率。有活动性溃疡的患者在一个综合伤口中心每周接受一次治疗，直到溃疡愈合。溃疡愈合后，患者使用压缩袜治疗，并每 6 个月进行一次随访。通过 Kaplan-Meier 生存分析确定愈合时间和溃疡复发时间。评估风险因素以确定其与溃疡复发的关系。
对 173 条有活动性（n=72）或已愈合（n=101）溃疡的肢体进行了大隐静脉（n=146）、小隐静脉（n=20）或两者（n=7）的 EVTA。54 例（31.2%）存在深静脉功能不全。59 条肢体（34%）同时进行了静脉切除术。EVTA 后中位随访时间为 25.2 个月。EVTA 后 3 个月时，57%的病例静脉溃疡愈合，6 个月时 74%愈合，12 个月时 78%愈合。EVTA 后 1 年时，9%的患者溃疡复发，2 年时 20%，3 年时 29%。深静脉功能不全和 EVTA 时未行伴发曲张静脉静脉切除术的患者溃疡复发率显著更高。
EVTA 治疗大隐静脉后，少数 CEP 临床 C5 和 C6 患者的溃疡复发。无伴发深静脉反流且 EVTA 时行曲张静脉静脉切除术的患者溃疡复发频率较低。我们建议对于 C5 和 C6 静脉功能不全的患者，特别是对于单纯的浅静脉功能不全患者，考虑在 EVTA 时行静脉切除术。
