By: Mark H. Meissner, MD
Visit VeinGlobal at http://www.veinglobal.com/ for more presentations and videos on this topic, or for more information on venous disease news, education and research.
2. Mark H. Meissner, MD
Professor of Surgery
University of Washington School of Medicine
Seattle, WA
Outcomes of Venous
Interventions in C5-6 Disease
3. Chronic Venous Insufficiency
๏ฌ 5% prevalence (US) of CEAP class 4 - 6
๏ฌ 6 - 7 million people with skin changes
๏ฌ 400,000 - 500,000 people with ulcers
๏ฌ 90% require medical treatment
๏ฌ Direct medical costs of $600 - $2000
๏ฌ > $10,000 if not healed within 12 weeks
๏ฌ Treatment options
๏ฌ Medical
Compression
Pharmacologic adjuncts
Wound care adjuncts
๏ฌ Surgical
Superficial venous surgery
Perforator interruption
Valvular reconstruction
Iliac stenting
C5
C6
5. ๏ฌ Observational study of 119 patients
๏ฌ 34% bed rest followed by ECS
๏ฌ 66% ambulatory treatment with ECS
๏ฌ Complete Healing
๏ฌ Compliant 97%
๏ฌ Noncompliant 55%
๏ฌ Recurrence (5 yr life table)
๏ฌ Compliant - 29%
๏ฌ Noncompliant - 100%
Compression for Venous Leg Ulcers
Mayberry, Surgery 1991
7. Surgery for C5-6 Disease
The ESCHAR Trial - Barwell JR, Lancet 2004
๏ฌ Prospective randomized trial
๏ฌ High ligation, stripping, phlebectomy
๏ฌ Multilayer compression bandaging
๏ฌ 500 patients with CEAP 5 and 6 disease
๏ฌ Endpoints
๏ฌ 24 week ulcer healing (NS)
Compression - 65%
Surgery + Compression - 65%
๏ฌ 12 month ulcer recurrence (p < .0001)
Compression - 28%
Surgery + Compression - 12%
Ulcer healing
Freedom from recurrence
8. IPV Interruption & Ulcer Recurrence
OโDonnell TO, J Vasc Surg 2008
๏ฌ Systematic review of RCTs for venous ulceration (C6)
๏ฌ Compression vs perforator surgery (2 trials)
๏ฌ Compression vs superficial surgery (2 trials)
Author N
Trial
Intervention
Zamboni 47
Superficial
Surgery
ESCHAR 428
Superficial
Surgery
Van Gent 196
Perforator
Surgery
Stacey 41
Perforator
Surgery
Risk Ratio (95% CI)
0.50.20.10.050.02 1 2 5 10 20 50
Favors Surgery Favors Compression
9. The Problem of Perforator โIncompetenceโ
๏ฌ Perforator reflux often resolves with correction of superficial
reflux
๏ฌ Perforator incompetence unlikely to be the primary cause of
recurrent / residual varicosities
๏ฌ Perforator interruption does not reduce recurrent ulceration
๏ฌ Current studies have often taken non-specific approach
๏ฌ Ability to distinguish important perforators is limited
๏ฌ Unknown role for identification and interruption of critical
perforators in future
Available Evidence Suggestsโฆ
Butโฆ
10. Defining Important Perforators
Gloviczki et al, J Vasc Surg 2011
๏ฌ > 3.5 mm diameter
๏ฌ Outward flow > 0.5 sec
๏ฌ Localized in the area of a healed or
active ulcer
Think โPathologicโ
NOT
โIncompetentโ
Perforators