Division of Vascular Surgery, Department of Surgery, University of California Los Angeles, Los Angeles Calif.
Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pa.
J Vasc Surg Venous Lymphat Disord. 2020 Jul;8(4):601-609. doi: 10.1016/j.jvsv.2019.09.016. Epub 2020 Feb 21.
To evaluate the impact of three treatment modalities, superficial truncal vein ablation, perforator vein ablation, and deep venous stenting on venous leg ulcer (VLU) healing, as well as their cumulative effect on ulcer healing, in an attempt to establish the best algorithm for the treatment of chronic and recalcitrant VLUs.
Multicenter retrospective cohort study using a standardized database to evaluate patients with chronic venous ulcers treated between January 2013 and December 2017.
Eight-hundred thirty-two consecutive patients with VLU were identified at 11 centers in the United States. All patients were initially managed with wound care and compression for at least 2 months. Compression and wound care management alone, used in 187 patients, led to ulcer healing in 75% of patients by 36 months. Ulcer recurrence in patients managed without surgery at 6, 12, and 24 months was 3%, 5% and 15%, respectively. Five hundred twenty-eight patients underwent ablation of incompetent superficial veins, and 344 of those also underwent incompetent perforator ablation. Patients who underwent truncal vein ablation alone had an ulcer healing rate of 51% at 36 months. Patients who received both superficial and perforator ablation were significantly younger, and had a 17% improvement in healing at 36 months (68% vs 51%, respectively), but there was no impact of combined superficial and perforator ablations on ulcer recurrence rates. One hundred thirty-four patients had stenosis of one of more lower extremity deep veins and 95 (71%) underwent endovenous stenting. Ulcer healing and recurrence rates for those who underwent stent placement alone was 77% and 27%, respectively, at 36 months. Patients who underwent deep venous stenting and ablation of both incompetent truncal and perforator veins had an ulcer healing rate of 87% at 36 months and ulcer recurrence of 26% at 24 months.
This study demonstrates that correction of superficial truncal vein reflux, as well as deep vein stenosis, both contribute to healing of VLU. Patients who fail to heal their VLU after superficial and perforator ablation should have the iliocaval system imaged to identify hemodynamically significant stenoses or occlusions amenable to stenting, which facilitates venous ulcer healing even in patients with large ulcers.
评估三种治疗方式（浅静脉消融术、穿通静脉消融术和深静脉支架置入术）对静脉性腿部溃疡（VLU）愈合的影响，以及它们对溃疡愈合的累积效应，试图建立治疗慢性和复发性 VLU 的最佳方案。
采用多中心回顾性队列研究，使用标准化数据库评估 2013 年 1 月至 2017 年 12 月在美国 11 个中心接受治疗的慢性静脉性溃疡患者。
在美国 11 个中心共确定了 832 例 VLU 连续患者。所有患者均首先接受至少 2 个月的伤口护理和压迫治疗。在未接受手术的 187 例患者中，单纯采用压迫和伤口护理管理，36 个月时 75%的患者溃疡愈合。未接受手术的患者在 6、12 和 24 个月时溃疡复发率分别为 3%、5%和 15%。528 例患者接受了功能不全浅静脉消融术，其中 344 例患者还接受了功能不全穿通静脉消融术。单纯进行主干静脉消融的患者 36 个月时的溃疡愈合率为 51%。同时接受浅静脉和穿通静脉消融的患者年龄较小，36 个月时愈合率提高了 17%（分别为 68%和 51%），但联合浅静脉和穿通静脉消融对溃疡复发率没有影响。134 例患者有一条或多条下肢深静脉狭窄，95 例（71%）接受了静脉内支架置入术。单独进行支架置入的患者在 36 个月时的溃疡愈合率和复发率分别为 77%和 27%。同时进行深静脉支架置入和功能不全主干和穿通静脉消融的患者在 36 个月时的溃疡愈合率为 87%，24 个月时的溃疡复发率为 26%。
本研究表明，纠正浅静脉主干反流和深静脉狭窄均有助于 VLU 的愈合。在浅静脉和穿通静脉消融后未能治愈 VLU 的患者，应进行髂静脉系统成像以确定是否存在可进行支架置入的有血流动力学意义的狭窄或闭塞，即使在有大溃疡的患者中，也可促进静脉性溃疡愈合。
