Subfascial ligation of perforating veins in recurrent stasis ulceration

Lim, Robert C.; Blaisdell, F. William; Zubrin, Jay; Stallone, Robert J.; Hall, Albert D.

doi:10.1016/0002-9610(70)90044-9

Cited by 20 publications

(5 citation statements)

References 3 publications

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“…3 The morbidity of the open surgical approach with wound slough, however, prompted modification of the incision's location and size, such as ‘the posterior stocking seam incision’, which avoids an incision through the lipodermatosclerotic tissue of the medial calf. 4 Outcomes from numerous observational studies with high ulcer recurrence rates combined with a significant incidence of wound morbidity led to a decreased use of this procedure in the 1980s. 5…”

Section: Background and Evolution Of Methods For Treating Incompetent Perforating Veinsmentioning

confidence: 99%

The role of perforators in chronic venous insufficiency

O’Donnell

2010

Phlebology

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The treatment of incompetent calf perforating veins (ICPVs) has been ascribed an important role in the therapeutic strategy for reducing superficial venous hypertension in patients with advanced chronic venous insufficiency (C4-C6). Since the open approach to ligation of ICPVs was developed by Linton over 70 years ago, there has been an evolution toward less invasive techniques with lower morbidity. This paper will review the evidence for interruption of ICPVs through a series of systematic analyses of (1) subfascial endoscopic perforating surgery (SEPS) and (2) percutaneous thermal ablation techniques (PAPS). The effectiveness and morbidity of each approach will be discussed as well as the strength of evidence supporting that technique. While there are numerous case series that suggest that SEPS is beneficial for ulcer healing and for the prevention of ulcer recurrence, the sole two RCTs that have compared either open division or SEPS for ICPVs have failed to show a statistical advantage for ICPV ablation. The results of these studies are clouded by the inclusion of patients who received concomitant treatment of their great saphenous vein (GSV). The evidence for PAPS is based on a few (n = 5) case series in peer-reviewed journals, which are limited by small patient populations, limited follow-up, and a focus on surrogate outcomes (occlusion of the perforator) rather than clinical or functional outcomes. Moreover, most of these series were carried out in patients with mild disease. Sclerotherapy of ICPVs, by either liquid or foam, shows promise, but requires greater evidence. Our current approach for limbs with C4-C6 disease is to treat the GSV first and limit treatment of ICPVs to those with high volume flow and large-diameter ICPVs. [corrected]

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Section: Background and Evolution Of Methods For Treating Incompetent Perforating Veinsmentioning

confidence: 99%

The role of perforators in chronic venous insufficiency

O’Donnell

2010

Phlebology

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“…3 Several technical modifications were developed to minimize wound morbidity associated with subfascial ligation, which included placement of the incision away from the compromised skin and subcutaneous tissue to over the posterior calf-"the posterior stocking seam approach." 23 Minimally invasive approach. Hauer modified available endoscopic techniques to ligate ICPVs through a remote entry site on the upper medial calf using conventional instruments (mediastinoscope and liga-clips).…”

Section: Discussionmentioning

confidence: 99%

The present status of surgery of the superficial venous system in the management of venous ulcer and the evidence for the role of perforator interruption

O’Donnell

2008

Journal of Vascular Surgery

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Superficial venous hypertension has been cited as the putative etiologic factor in advanced chronic venous insufficiency with venous ulcer (CEAP C 5/6). For over a century, influenced by this belief, surgeons have ablated the superficial venous system as a treatment for venous ulcer. Incompetent perforating veins (ICPVs) have become a particular focus of this therapeutic strategy. This review examines the evidence for the surgical approach. A MEDLINE search of the literature identified only four randomized controlled trials (RCTs) directed at the surgical reduction of superficial venous hypertension. Risk ratios for ulcer healing and prevention of recurrence were calculated to determine benefits for these four RCTs, while mortality and morbidity, where available, was used to determine risk from the procedure. In addition, the quality of the trials (design and outcomes) was assessed. While two trials compared ICPV ligation to compression, the great saphenous vein (GSV) was also treated in many of these limbs, which confounds the results. By contrast, two RCTs, which compared treatment of the GSV alone to compression, demonstrated a significant reduction in the incidence of ulcer recurrence. Case series that employed hemodynamic or surrogate outcomes showed little effect on the addition of ICPV treatment to GSV stripping, while GSV ablation alone was associated with a reduction in the number of ICPVs in several studies. This review suggests a grade 1A recommendation for the treatment of venous ulcer by GSV ablation to reduce ulcer recurrence. The role of ICPV ablation alone or concomitant with GSV treatment awaits results of properly conducted RCTs.

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“…The authors have took keen interest in perforating vein ligation as a means of venous ulcer management, which between 1961 and 1971 resulted in numerous, conscientiously documented clinical trials concerning the effects of such treatment [1]. A few technical modifications of surgical treatment were introduced in order to minimize the percentage of complications connected with subfascial ligation of perforators such as cutaneous incision remote from the ulcer, in the posterior area of the lower leg, the so-called posterior stocking seam approach [23]. Hauer modified available endoscopic techniques in order to ligate incompetent perforating veins by making an incision in the proximal medial area of the lower limb using mediastinoscopy and vascular clips [24].…”

Section: Surgical Treatmentmentioning

confidence: 99%

The place of subfascial endoscopic perforator vein surgery (SEPS) in advanced chronic venous insufficiency treatment.

Pesta¹,

Kurpiewski²,

Kowalczyk³

et al. 2011

Videosurgery and Other Miniinvasive Techniques

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In spite of medical science development and initiation of new technologies in minimally invasive surgery, treatment of advanced chronic venous insufficiency at the 5th and 6th degree of CEAP classification is still a great clinical challenge. In case of no satisfactory results of non-surgical treatment of recurrent venous ulcers, scientists search for alternative therapeutic methods which could be more effective and lasting. Subfascial endoscopic perforator vein surgery (SEPS) as a method of reducing venous pressure in the superficial venous system could provide healing of the recurrent venous ulcer. In this study we present a review of contemporary opinions about the place and significance of subfascial endoscopic perforator vein surgery as a treatment of advanced chronic venous insufficiency.

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Subfascial ligation of perforating veins in recurrent stasis ulceration

Cited by 20 publications

References 3 publications

The role of perforators in chronic venous insufficiency

The role of perforators in chronic venous insufficiency

The present status of surgery of the superficial venous system in the management of venous ulcer and the evidence for the role of perforator interruption

The place of subfascial endoscopic perforator vein surgery (SEPS) in advanced chronic venous insufficiency treatment.

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