The treatment of rebellious venous stasis ulcers. Correlation of outcome with extension of deep venous damage

Objective: to assess the relationship between the extent of damage to the d eep venous system and the long-term outcome of surgical treatment of rebell ious stasis ulcers. Design: retrospective analysis of long-term results of surgical treatment i n two consecutive series of patients with a total of 227 legs with superfic ial varicosis alone associated in 25 patients with recurrent stasis ulcers (group A); analysis of a second cohort of consecutive patients with a total of 76 rebellious ulcers in 39 patients without previous deep venous thromb osis (DVT) and in 37 patients with varying degrees of deep venous obstructi on due to DVT (Group B). Setting: Vascular surgical unit, University Hospital Methods: 1. In group A the patients with varicosis of the great or lesser s aphenous vein and varicose branches thereof had normal deep veins and were treated surgically by radical removal of all incompetent veins. They were e xamined clinically 2 and 5 years postoperatively to assess the percentage o f recurrences and the effect of surgery upon the recurrent ulcers. 2. The s econd patient cohort (group B) consisted of 76 patients, 39 of which presen ted with reticular varicosis but no signs of incompetence of the great or l esser saphenous vein or the deep venous system and therefore underwent loca l radical surgery consisting of wide excision of the ulcer with resection e n bloc of all underlying fibrotic tissue, the muscle fascia, interruption o f corresponding perforators and neighbouring varicose clusters. The other 3 7 patients all had postphlebitic obstruction of the deep venous system affe cting 1 to 4 levels and were treated in similar fashion by radical local ex cisision. All patients were examined clinically 2-5 years later with respec t to long-term healing of the rebellious ulcers. The deep venous system was assessed by ascending phlebography. Results: Group A: In all 25 patients with recurrent ulceration and a normal deep venous system treated for superficial varicosis alone the ulcers were solidly healed without exception 2 and 5 years later. In group B of the 39 patients with stasis ulcer and normal deep veins treated by radical local exzision 34 (87%) had solid healing of their ulcer(s) at 2 years whilst in the subgroup of 37 patients with postphlebitic damage of the deep venous sy stem the 2-year closure rate of ulcers was 62% (p < 0.05). This cure-rate c orrelated well with the extent of postphlebitic damage: if only 1 or 2 leve ls were affected the cure-rate was 80% at 2 years, whilst in those patients with postphlebitic damage of 3 or all 4 levels the ulcer closure-rate drop ped to 25% (p = 0.003) Conclusions: The state and extent of damage inflicted upon the deep venous system is decisive in the surgical treatment of rebellious stasis ulcers. T he greater the extent of postphlebitic injury to the deep venous system the poorer the long-term results of surgical treatment. The correlation is lin ear.