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Varicose leg ulcer 20 years after 
saphenectomy 
Dr. Maurizio Ronconi 
Clinica 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 reco...
Clinical examination 
 Leg disconfort 
 BMI 31,2 
 Ankle-brachial pressure index (ABPI): 0.4 
 Right lateral leg ovala...
Dupplex findings 
 bilateral major superficial venous reflux 
 junctional reconnection of the sapheno-femoral 
confluenc...
Bacteriological swab
Staph Aureus 
Enterobacter cloacae
Late recurrent saphenofemoral junction reflux 
after ligation and stripping of the greater saphenous vein 
Reinhard Fische...
Leg’s ulcer natural history 
Healing rates 
68 – 83% 
Multilayer elastic compression bandaging 
Leg elevation 
Medications...
Leg’s ulcer and venous reflux 
Visible varicosities only in about 40% of patients with 
superficial venous reflux 
Duplex ...
Recurrence rates after healing 
Study F-up Reflux Compression 
alone 
Barweel JR 
Europ J Vasc 
Endovasc Surg 2000 
non 
r...
242 
1418 patients assessed 
500 randomised 
compression + surgery 
258 
compression alone
Healed legs not recurred 
85% 
66% 
82% 
76% 
Ulcer healing
Therapeutic option 
A. surgery 
B. EndoVenous Laser Ablation (EVLA) 
C. RF 
D. Foam sclerotherapy 
E. Compression 
F. Othe...
dissezione 
da laterale (CFA) a mediale (CFV) 
fino a neocrosse (NC) 
Li AKC: A technique for re-exploration of the SFJ fo...
EVLA
116 consecutive patients 
Microfoam F-up 
Healing 83% 
Recurrence rate 8% 6 months 
“… This minimally invasive procedure m...
 27 patients 
 CEAP C6 
 Reflux: 
• SVR: 20 patients 
• SVR + DVR: 7 patients 
 Median Foam: 8 ml
Ulcer healing 
93% 
70% 
Venous occlusion 
Median F-up Compression + 
foam sclerotherapy 
Healing 12 months 93% 
Recurrenc...
Conclusions 
“…eradication of superficial venous reflux (SVR) 
improves chronic venous ulcer outcome when 
compared to com...
We did so 
intravenous injection of foam, prepared in according to Tessari’s 
method, connecting two syringes through a th...
Minor complication 
superficial phlebitis along the treated vein
Management of the complication 
A. phlebectomy 
B. low molecular weight heparin 
C.occlusion bendage 
D.antimicrobial ther...
We did so 
• needle thrombectomy with local anesthesia 
• Evacuation of endovaricose organized 
hematoma 
• stocking
Follow-up 
6/7/2010
Thank you for 
your kindly 
attention
“Varicose leg ulcer 20 years after saphenectomy” – Mediterranean Italian-Greek-Turkish Interctive Workshop – Venezia, 9 oc...
“Varicose leg ulcer 20 years after saphenectomy” – Mediterranean Italian-Greek-Turkish Interctive Workshop – Venezia, 9 oc...
“Varicose leg ulcer 20 years after saphenectomy” – Mediterranean Italian-Greek-Turkish Interctive Workshop – Venezia, 9 oc...
“Varicose leg ulcer 20 years after saphenectomy” – Mediterranean Italian-Greek-Turkish Interctive Workshop – Venezia, 9 oc...
“Varicose leg ulcer 20 years after saphenectomy” – Mediterranean Italian-Greek-Turkish Interctive Workshop – Venezia, 9 oc...
“Varicose leg ulcer 20 years after saphenectomy” – Mediterranean Italian-Greek-Turkish Interctive Workshop – Venezia, 9 oc...
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“Varicose leg ulcer 20 years after saphenectomy” – Mediterranean Italian-Greek-Turkish Interctive Workshop – Venezia, 9 october 2010

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Mediterranean Italian-Greek-Turkish Interctive Workshop – Venezia, 9 ottobre 2010

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“Varicose leg ulcer 20 years after saphenectomy” – Mediterranean Italian-Greek-Turkish Interctive Workshop – Venezia, 9 october 2010

  1. 1. Varicose leg ulcer 20 years after saphenectomy Dr. Maurizio Ronconi Clinica Chirurgica Spedali Civili di Brescia
  2. 2. Case report  female, 74 year old  ulcer of lateral surface of right distal leg  present for about 5 years
  3. 3. 18/5/2010
  4. 4. Patient history  GSV stripping 1985  Type 2 Diabetes Mellitus  peripheral obstructive artery disease  Plastic reconstruttive free flaps for leg ulcer in 2008, 2009, 2010
  5. 5. Clinical examination  Leg disconfort  BMI 31,2  Ankle-brachial pressure index (ABPI): 0.4  Right lateral leg ovalar ulcer, 3 cm in lenght, surrounded by 8 x 5 distrophic cutaneus area  Visible varicosities along all the leg
  6. 6. 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
  7. 7. Bacteriological swab
  8. 8. Staph Aureus Enterobacter cloacae
  9. 9. Late recurrent saphenofemoral junction reflux after ligation and stripping of the greater saphenous vein Reinhard 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 CONCLUSIONS Current 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;34:236-40
  10. 10. Leg’s ulcer natural history Healing rates 68 – 83% Multilayer elastic compression bandaging Leg elevation Medications Antibiotic therapy Stockings very slowly healing elevated recurrence rate venous reflux
  11. 11. Leg’s ulcer and venous 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 alone 32-44% in both systems 5-15% in deep system alone
  12. 12. Recurrence rates after healing Study F-up Reflux Compression alone Barweel JR Europ J Vasc Endovasc Surg 2000 non random 1 year superficial 28% Zamboni Europ J Vasc Endovasc Surg 2003 random 3 years superficial 38% Compression + relux surgery 14% 9%
  13. 13. 242 1418 patients assessed 500 randomised compression + surgery 258 compression alone
  14. 14. Healed legs not recurred 85% 66% 82% 76% Ulcer healing
  15. 15. Therapeutic option A. surgery B. EndoVenous Laser Ablation (EVLA) C. RF D. Foam sclerotherapy E. Compression F. Other
  16. 16. dissezione da laterale (CFA) a mediale (CFV) fino a neocrosse (NC) Li AKC: A technique for re-exploration of the SFJ for recurrent varicose veins. da Agus G.B. Chirurgia delle Varici Edra Ed., Milano 2006 Br J Surg 1975;62:745- 6 Surgery
  17. 17. EVLA
  18. 18. 116 consecutive patients Microfoam F-up Healing 83% Recurrence rate 8% 6 months “… This minimally invasive procedure may become the treatment of choice for venous ulcers in the future.” Foam
  19. 19.  27 patients  CEAP C6  Reflux: • SVR: 20 patients • SVR + DVR: 7 patients  Median Foam: 8 ml
  20. 20. Ulcer healing 93% 70% Venous occlusion Median F-up Compression + foam sclerotherapy Healing 12 months 93% Recurrence rate 12 months 7%
  21. 21. Conclusions “…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…”
  22. 22. We did so intravenous 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 tigh 2. 3 mL 5 cm above a distal perforating vein near the ulcer
  23. 23. Minor complication superficial phlebitis along the treated vein
  24. 24. Management of the complication A. phlebectomy B. low molecular weight heparin C.occlusion bendage D.antimicrobial therapy E. non steroidal anti inflammatory F. other
  25. 25. We did so • needle thrombectomy with local anesthesia • Evacuation of endovaricose organized hematoma • stocking
  26. 26. Follow-up 6/7/2010
  27. 27. Thank you for your kindly attention

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