Combined treatment with endovenous laser ablation and compression therapy of incompetent perforating veins for treatment of recalcitrant venous ulcers

Abstract

Objective Patients with healed venous ulcers often experience recurrence of ulceration, despite the use of long-term compression therapy. This study examines the effect of closing incompetent perforating veins (IPVs) on ulcer recurrence rates in patients with progressive lipodermatosclerosis and impending ulceration. Methods Patients with nonhealing venous ulcers of >2 months’ duration underwent duplex ultrasound to assess their lower extremity venous system for incompetence of superficial, perforating, and deep veins. Endovenous laser ablation (EVLA) of perforating veins was performed on patients with CEAP 6 disease with increasing hyperpigmentation, lipodermatosclerosis, and/or progressive malleolar pain. A minimum of 2 months of compressive therapy was attempted before endovenous ablation of IPVs. Demographic data, risk factors, CEAP classification, procedural details, and postoperative status were all recorded. Results Forty ulcers with 46 associated IPVs were treated with EVLA in 36 patients with CEAP 6 recalcitrant venous ulcers. Treated incompetent perforator veins were located in the medial ankle (85.7%), calf (10.7%), and lateral ankle (3.5%). Endovenous laser ablation was successful in 76% (35/46) with the first laser treatment of incompetent perforator veins and 15.2% (7/46) additional ablation procedures were performed. Of the 46 treated IPVs, 42 (91.3%) were occluded on the duplex examination at 12 months. The average energy administrated per perforating vein treated was 162 joule. Two patients reported localized paresthesia, which subsided spontaneously, but no deep venous thrombosis or skin burn was observed. Conclusion Especially in the case of liposclerotic or ulcerated skin in the affected region, PAP of IPVs is highly effective, safe, and appears to be feasible. Patients with active venous ulcers appear to benefit from EVLA of incompetent perforators in order to reduce the risk of ulcer recurrence.

Endothermal ablation for the treatment of clinically significant incompetent lower limb perforating veins: factors influencing the early outcomes

“…Treatment with EVLA appears to have a higher initial success rate than can be achieved with segmental RFA catheters, but remains considerably lower than can be achieved for truncal ablation. Perforator closure rates ranging from 45–96% have been reported using a 1470 nm laser, 10–13 and our 80% overall primary closure rate with EVLA, was achieved without the use of concomitant foam sclerotherapy, employed by Zerwek et al. 12 in cases where EVLA alone did not immediately abolish perforator flow.…”

“…While the energy delivered to the perforating vein, has been linked to successful closure, 10 there is considerable variation in Linear Endovenous Energy Densities (LEED) between series, 11–15 and in this series of 90 perforating veins treated with the 1470nm radial laser there was no clear association between successful perforator closure and LEED. Although the majority of calf and ankle perforators in this series were successfully closed, treatment failures occurred throughout the LEED range, despite exceeding the LEED values reported in other series of successful perforator closure.…”

Factors related to the size of venous leg ulcers

“…[28] In addition, Seren et al used laser and pressure to treat a group of patients with refractory VLUs. [22] The mean diameter of the perforating veins was 4.6 ± 0.3 mm. Prasad et al also reported a group of patients with recurrent CVI with a minimum diameter of 3 mm of PVs in the fascial layer.…”

Treatment of incompetent perforators in recurrent venous insufficiency with adhesive embolization and sclerotherapy

“…Treatment used Time of follow-up Perforator occlusion rate (%) Toonder et al 10 Cyanoacrylate glue (Sapheon) 3 months 76 Bacon et al 32 Radiofrequency ablation 5 years 81 Marsh et al 33 Radiofrequency ablation 1 year 72.3 (recurrent varicose veins) 87 (primary varicose veins) Van den Bos et al 34 Radiofrequency ablation 3 months 64 Hingorani et al 35 Radiofrequency ablation 1 month 88 Hissink et al 36 Laser ablation (810 nm) 3 months 78 Boersma et al 37 Laser ablation (810 nm) 6 weeks 63 Boersma et al 37 Laser ablation (1470 nm) 6 weeks 45 Shi et al 38 Laser ablation 1 year 81.3 Seren et al 8 Combined laser ablation and compression therapy…”

“…[3][4][5] Various treatment modalities have been employed for perforator interruption including open ligation, subfascial endoscopic perforator surgery, sclerotherapy, thermal ablation, coil embolization and Sapheon glue embolization. [5][6][7][8][9][10] Open ligation and subfascial endoscopic perforator surgery are not routinely performed due to invasive nature and high complication rate, thermal ablation techniques are successful but require anaesthesia and may cause inadvertent nerve damage, and coil embolization has been found ineffective. 6,9,10 Sapheon glue embolization has been shown to cause satisfactory perforator occlusion but requires insertion of large vascular sheaths into the perforator and special application devices to deliver Sapheon glue.…”