Factors influencing ulcer healing in patients with combined arterial and venous insufficiency

Purpose: The purpose of this study was to determine the effectiveness of tr eatment of patients with combined arterial and venous insufficiency (CAVI), evaluate variables associated with successful ulcer healing, and better de fine criteria for interventional therapy. Study design: We retrospectively reviewed the records of patients treated a t four institutions from 1995 to 2000 with lower extremity ulcers and CAVI. Arterial disease was defined as an ankle/brachial index less than 0.9, abs ent pedal pulse, and at least one in-line arterial stenosis > 50% by arteri ography. Venous insufficiency was defined as characteristic clinical findin gs and duplex findings of either reflux or thrombus in the deep or superfic ial system. Clinical, demographic, and hemodynamic parameters were statisti cally analyzed with multiple regression analysis and correlated with ulcer healing and limb salvage. Results: Fifty-nine patients with CAVI were treated for nonhealing ulcers t hat had been present from 1 to 39 months (mean, 6.4 months). All patients h ad edema. The mean ankle/brachial index was 0.55 (range, 0-0.86). Treatment included elastic compression and leg elevation in all patients and greater saphenous vein stripping in patients with superficial venous reflux. Fifty -two patients underwent arterial bypass grafting, three underwent an endart erectomy, one underwent superficial femoral artery percutaneous translumina l angioplasty, and three underwent primary below-knee amputation. For purpo ses of analysis, patients were divided into four groups according to the pa ttern of arterial and venous disease and the success of arterial reconstruc tion. Group 1 consisted of 22 patients with a patent arterial graft, superf icial venous incompetence, and normal deep veins. Group 2 consisted of seve n patients with a patent graft, superficial reflux, and deep venous reflux. Group 3 included 22 patients with a patent graft and deep venous thrombosi s (DVT), and group 4 included eight patients with an occluded arterial graf t. Follow-up ranged from 2 to 47 months (mean, 21.6 months). Forty-nine pat ients remained alive, and 10 died of unrelated causes. During follow-up, 48 of the 56 treated arteries remained patent and eight occluded. Thirty-four ulcers (58%) healed, 18 ulcers (31%) did not heal, and 7 patients (12%) re quired below-knee amputation for nonhealed ulcers and uncontrolled infectio n. No patient with graft occlusion was healed, and 12 ulcers persisted desp ite successful arterial reconstruction. Twenty-one (78%) of 27 patients und ergoing greater saphenous vein stripping were healed, but none of these pat ients had DVT. The mean interval from bypass graft to healing was 7.9 month s. Thirty-two (68%) of 46 patients without prior DVT were healed, whereas o nly two (15%) of 13 patients with prior DVT were healed, and this variable, in addition to graft patency, was the only factor statistically significan t in predicting healing (P < .05). Conclusions: Ulcers may develop anywhere on the calf or foot in patients wi th CAVI, and healing requires correction of arterial insufficiency. Patient s with prior DVT are unlikely to heal, even with a patent bypass graft. Ulc er healing is a lengthy process and requires aggressive treatment of edema and infection, and successful arterial reconstruction. Patients with a prio r DVT are unlikely to benefit from aggressive arterial or venous reconstruc tion.