Surgical management of refractory stasis ulceration

Transcription

1 Surgical management of refractory stasis ulceration venous Dolores F. Cikrit, M.D., W. Kirt Nichols, M.D., and Donald Silver, M.D., Columbia, 340. The postphlebitic syndrome with its resultant venous stasis ulceration is a common disorder that affects an estimated 0.5% of the population? At least 85% of patients with the postphlebitic syndrome do well with simple medical management, which includes the use of support hose and avoidance of positions of venous stasis. Some of the postphlebitic patients have severe venous hypertension and secondary venous stasis ulceration, a debilitating disorder with a staggering socioeconomic impact. O'Donnell et al., 2 in a study of 21 patients with iliofemoral thrombosis (18 of them had stasis ulcers), estimated that the average patient with venous insufficiency incurs approximately $40,000 in medical expenses. Most venous stasis ulcers respond to the avoidance of positions of limb dependency, good hygiene and skin care, Unna's paste boots, and control of associated infection. After the ulcer has healed, graduated compression hose are worn to decrease the incidence of recurrence. A few patients with venous stasis ulceration have multiple recurrences and become candidates for surgical intervention to decrease their ambulatory venous hypertension and heal their ulcers. In 1938 Linton ~ emphasized the importance of interrupting the perforating and communicating veins, with their incompetent valves, between the deep and superficial system in the treatment of venous ulceration. His initial technique involved three incisions--anterolateral, posterolateral, and medial--for the complete ligation of the perforators.3 In 1953 he began using only a medial incision since most perforators could be reached through this incision. 4 Cockett and Jones 5 in 1953 described an extrafascial ligation method of management of venous stasis ulceration. They reported no recurrences al- From the Department of Surgery, University of Missouri-- Columbia Health Sciences Center. Presented at the combined breakfast program of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery, North American Chapter, Toronto, Ontario, Canada, June 9, Reprint requests: Donald Silver, M.D., Professor and Chairman, M580, Department of Surgery, University of Missouri-- Columbia, One Hospital Drive, Columbia, MO though their follow-up was "short. "5 Since those early reports, mukiple authors have reported experiences with subfascial ligation of perforators. Silver et al. 6 previously reported a 90% "cure rate" for patients with refractory postphlebitic ulcers who were treated with a modified Linton procedure. This article is a continued review of this procedure and presents a 15-year experience with the surgical management of patients with refractory venous ulceration. MATERIAL AND METHODS From 1971 to 1986, 27 patients had 32 modified Linton procedures for refractory Venous stasis ulcers. Five patients had bilateral procedures. Causes of the postphlebitic syndrome included trauma without fracture in seven patients, trauma with fracture in five, surgery or hospitalization related in five, postpartum in two, primary varicosities in two, and an unknown origin in six. The 11 women and 16 men ranged in age from 20 to 75 years and had a mean age of 51 years at the time of surgery. The patients had venous insufficiency before surgery for 3 to 57 years (mean 17 years). Ulceration first occurred at a mean age of 39 years (range 19 to 56 years). Ulcers had been present for a mean duration of 13 years (range 1 to 44 years) before surgery. All patients had been managed with avoidance of positions of venous stasis, elastic wraps, Unna's paste boots, support hose, and graduated compression stockings. Prior surgical procedures included vein stripping in nine limbs, split-thickness skin grafts for 15 patients, with two or more grafts placed in 11 of these 15 patients because of recurrent ulceration, and one saphenous vein crossover bypass graft. Phlebograms from 22 patients revealed postphlebitic changes with incompetent valves in the deep system and incompetent perforators. All patients had adequate arterial flow for wound (ulcer) healing. Because of the multiple recurrences of the ulcers, each patient was offered a modified Linton procedure to reduce the venous hypertension in the area of ulceration. Surgical technique. The operative technique is similar to that reported in 1971 and will only be 473

2 474 Symposium: Venous Ulcer journal of VASCULAR SURGERY Fig. 1. Subfascial dissection continues anteriorly to edge of tibia and posteriorly until the lesser saphenous vein is included in the dissection. Table I. Results of modified Linton procedure No. of limbs Completely healed 21 Recurrence of ulceration 5 Result of morbid obesity (2) Poor compliance with support hose (3) Ulceration on nonoperated side 1 Lost to follow-up 5 NOTE: Follow-up 6 months to 10 years. briefly described. 6 The medial approach is used most often. With the patient in a slight Trcndelcnburg position, a longitudinal incision is placed medially and extends from the subgeniculate area near the condyles downward to encompass the ulcer, which is excised. If an ulcer is not present, the incision extends through the healed ulcer bed. The incision extends through the skin, subcutaneous tissue, and the crural fascia. The dissection continues in the subcrural plane anteriorly to the edge of the tibia and posteriorly until the lesser saphenous vein is included in the dissection. All perforating veins are identified, ligated, and divided (Fig. 1). A second plane of dissection is developed in thesubcutaneous tissue and extends anteriorly and posteriorly to the previous dissection margins. The fascia and attached subcutaneous tissue are excised (Fig. 2). The excision of the fascia and subcutaneous tissue facilitates the removal of the greater and lesser saphenous veins from the ankle to the knee and also the communicating veins. Ligation and stripping of the proximal saphenous vein is included if it is patent and its valves are incompetent. Hemostasis is obtained, silicone rubber drains are placed beneath each flap, and the skin edges are approximated. The drains are connected to continuous suction. If an ulcerated area has been excised, placement of split-thickness skin grafts is usually deferred a few days to permit the obtainment of an optimal "bed" for the graft. The leg is dressed and wrapped with Ace elastic bandages and maintained in an elevated position. ::~ RESULTS At the time of surgery, 18 limbs had medial malleolar ulcers, five had bimalleolar ulcers, four had lateral ulcers, three had posterior ulcers, and two patients were free of ulcer. Twenty limbs had medial procedures, six limbs had lateral procedures, three limbs had simultaneous medial and lateral procedures, and three limbs had medial and lateral dissections through a midposterior incision. Split-thickness skin grafts were placed on six limbs the day of surgery whereas in 22 limbs, the skin grafts were placed 4 to 7 days later. Primary closure of the incision was possible in four patients. After the skin graft healed, the patient was allowed to be up with compressive wraps. All patients were fitted for graduated compression stockings and were encouraged to wear them at all times after their wounds had healed. All patients were instructed in ways to avoid positions of venous stasis.

3 Volume 7 Number 3 March 1988 Symposium: Venous Ulcer 475 Fig. 2. Second plane of dissection is developed in the subcutaneous tissue and extends anteriorly and posteriorly to the previous dissection margins. The fascia and attached subcutaneous tissue are excised. Twenty-five limbs were healed by 1 month after operation. Seven limbs were not completely healed at 1 month but did heal subsequently. Follow-up ranged from 6 months to 10 years (mean 4 years). During the most recent clinic visits, 21 limbs were completely healed, one limb had an ulceration on the nonoperated side, and five had recurrent ulcers. Two recurrent ulcers were thought to be a result of morbid obesity, making it difficult to get a properly fitting elastic stocking whereas the remaining ulcerations were believed to be a result of poor compliance with support hose and elevation (Table I). Five patients were lost to follow-up. Twenty-two percent of the limbs (6 of 27) had ulceration present at their most recent clinic visit. Complications included three limbs with partial necrosis of the skin flap, requiring excision and splitthickness skin grafts. Flap necrosis can result from excessive manipulation and trauma to the skin flaps at the time of surgery. Skin graft survival was less than optimal in 15 limbs and required additional grafting to complete coverage. Other postoperative complications included cellulitis in three patients, deep venous thrombosis in two, a wound hematoma in one, and urinary tract infection in one (Table II). DISCUSSION Venous ulcers occur as a result of venous flow disturbances and valvular incompetence. If a perforating vein valve becomes incompetent, each contraction of the calf muscle will pump blood through Table II. Complications of modified Linton procedures No. of limbs Partial failure of STSG 15 Partial necrosis of skin flap 3 Cellulitis 3 Deep venous thrombosis 2 Wound hematoma 1 Urinary tract infection 1 STSG = split-thickness skin graft. the perforator into the venous end of subcutaneous capillaries. This venous hypertension and increased flow results in the development of varicose veins and may reduce capillary and arterial flow sufficiently to cause venous ulceration. Linton 4 indicated that these ulcerations resulted "from too much blood under too great a pressure." Most venous stasis ulcers can be treated nonoperatively with the avoidance of positions of limb dependency, good hygiene and skin care, antibiotics when an infectious component exists, and Uuna's paste boot. After the ulcers are healed, graduated compression hose are worn to decrease the incidence of recurrence. Less than 10% of the venous stasis ulcers are refractory to medical management and become candidates for surgical intervention to reduce venous hypertension. Reduction of venous hypertension can be achieved by valve grafts, venous transpositions, valve reconstructions, and saphenous vein crossover grafts. 7'8 Venous hypertension can also be

4 476 Symposium: Venous Ulcer Journal of VASCULAR SURGERY Table III, Summary of wound complications Wound Authors Year No. of patients No. of limbs complications (%) Recurrence (%) Length of follow-up Wilkinson & Maclaren mo-9 yr 80% > 5 yr Johnson et al)s yr (mean 8.5 yr) Negus & Friedgood mo-6 yr 76% > 3 yr Hyde & HulW Mean 10 yr DePalma mo-12 yr Blumenberg & Gelfand TM mo-6 yr Bowen mo-15 yr 48% > 3 yr Thurston & Williams mo (mean 3.2 yr) Field & Boxe yr (mean 6 yr) Silver et al % > 5 yr Totals reduced by interrupting incompetent perforators and removing superficial veins with incompetent valves. Linton a in 1953 proposed a subfascial technique for the ligation of perforating veins to promote the healing of venous stasis ulcers. His technique had four goals, which included removal of the greater and lesser saphenous veins, subfascial ligation of perforating veins, ligation of the superficial femoral vein, and resection of the fascia of the lower leg to promote lymphatic drainage. 3 Since then certain aspects of the procedure have been found to be not beneficial and may actually be detrimental, such as the ligation of the superficial femoral vein. The technique has been modified to include removal of the greater and lesser saphenous veins below the knee, wide resection of the ulcer bed plus resection of subcutaneous tissue and fascia, and subfascial ligation of perforating -veins. Subsequently, others have advocated a subfascial ligation but have chosen different skin incisions to decrease the wound complications that accompany the Linton procedure. In 1955, Felder et al.9 proposed a posterior subfascial approach for the ligation of communicating veins in the leg. This approach was also demonstrated by Rob in DePahna n'12 proposed another modification of the Linton procedure in 1974, performing subfascial ligation through a series of parallel bipedicle flaps with multiple transverse incisions in skin creases along the medial aspect of the leg. All modifications accomplish the same resultsusubfascial ligation of the perforating veins. Others, such as Cockctt and Jones, 5 accomplish the ligatiou of the perforating veins in an extrafascial dissection. We believe that it is more difficult to accomplish the ligation of all perforators extrafascially. Recurrence rates of ulcer after subfascial ligation range from a low of 2% as reported by Wilkinson and Maclaren 13 in 1986 and Field and Boxe114 in 1971, to a high of 43% reported by Johnson etal. is in A review of the 10 most current reports of subfascial ligation of perforators revealed a recurrence rate of 15% in 767 limbs. Complications included deep vein thrombosis, pulmonary embolism, flap necrosis, wound infections, and a wound complication rate of 17% in the 767 limbs (Table III)6,12-20 The recurrence rate with subfascial ligation of perforators is comparable to that obtained with venous bypass grafting or valve transposition. Saphenous vein crossover grafts and saphenopopliteal vein bypass grafts are associated with good results in 70% to 75% of the patients and with ulcer recurrence in 25% to 30%. 7 Kistner 21 developed a technique in 1975 for the repair of incompetent valves by resuspending the valve cusps; this has been called valve reconstruction or valvuloplasty. His valve reconstruction is associated with good results in 90% of the patients, although he performs a subfascial division of perforators 3 days to 1 week before valve repair. 21 Hume in a discussion of Kistner's excellent results thought that "the inclusion of ligation of perforator veins may have accounted for the good results. "= Others s have reported good results in 85% of valvuloplasties and 74% of vein segment transfers. O'Donnell et al. 23 combined axillary vein transplant

5 Volume 7 Number 3 March 1988 Symposium: Venous Ulcer 477 to the popliteal vein with subfascial ligation in 10 patients. All ulcers healed in these patients, although long-term follow-up is not given? 3 Vein bypass grafting and valve transposition may not have long-term durability. Johnson et al.24 evaluated patients with femoral valve transposition and demonstrated that no patient attained normal venous pressure postoperatively. Venous refilling time returned to preoperative abnormal levels in 12 to 18 months. They thought that "femoral valve reconstruction performed alone for venous stasis is not sufficient. In post-thrombotic venous ulcer, incompetent calf perforators remain a central problem. "2s Ligation of perforator veins reduces ambulatory venous hypertension by preventing the abnormally reversed flow in the perforators. With the incompetent perforators ligated, blood is prevented from ' ~owing from the deep system to the superficial system. This abnormal flow of blood from the deep to the superficial system is the cause of ambulatory venous hypertension. The ligation of incompetent perforators is readily accomplished by the modified Linton procedure. The medial incision allows easy exposure for ligation of all perforators except the rare anterolateral ones. The approach also allows easy excision of the venous ulcer and the greater and lesser saphenous vein below the knee. The results of the modified Linton study (1971) revealed an ulcer recurrence rate of ]0%. The results of our more recent 15-year experience reveals a recurrence rate of 22%. Although these current results are not so good as those obtained earlier, the 22% recurrence rate is similar to the recurrence rate obtained with venous bypass grafting or valve transposition. These recurrence rates are found in patients in whom all types of medical management have failed and thus represent the most severe venous insufficiency. Some of the same factors that contributed to the failure of medical management, such as jobs that require upright positions, poor hygiene, poor compliance with support hose and obesity, wiu persist in these patients even after surgical treatment. We strongly agree with Linton who said, "A careful follow-up regimen is necessary for the best results in these patients since one is dealing with a chronic disease, which by operation alone is only partially relieved and not completely cured. "26 No type of surgical or medical management is truly curative of venous insufficiency, only palliative; the number of recurrences can be decreased but never eliminated. However, the reasonable long-term results indicate that patients with recurrent venous stasis ulcers do benefit from the modified Linton procedure. SUMMARY A 15-year experience with 27 patients, 20 to 75 years of age, with refractory venous stasis ulcers is presented. All patients had been managed with support hose, elevation, elastic wraps, Unna's paste boots, and graduated compression stockings. Because of multiple recurrences of their ulcers, the patients were offered surgical treatment to reduce the venous hypertension in the areas of ulceration. The 27 patients had 32 modified Linton procedures. Five had bilateral procedures. At the time of operation, 18 limbs had medial malleolar ulcers, five had bimalleolar ulcers, four had lateral ulcers, three had posterior ulcers, and two patients were free of ulcer. Medial incisions were used in 20 limbs, lateral incisions in six, medial and lateral incisions in three, and midposterior incisions in three. Split-thickness skin grafts were placed on six limbs the day of surgery and on 22 limbs 4 to 7 days later. Postoperative complications included deep venous thrombosis in two, partial flap necrosis in three, and cellulitis of the lower leg in three patients. Follow-up has ranged from 6 months to 10 years. During the most recent clinic visits, 21 limbs were completely healed, whereas six limbs had a recurrence of the ulcer. Five patients have been lost to follow-up. The good long-term results in 78% of the cases indicate that patients with recurrent venous stasis ulcers may receive lasting benefit from modified Linton procedures. REFERENCES 1. Immehnan EJ, Jeffery PC. The postphlebitic syndrome: pathophysiology, prevention and management. Clin Chest Med 1984;5: O'Donnell TF, Browse NL, Bumand KG, et al. This socioeconomic effects of iliofemoral venous thrombosis. J Surg Res 1977;22: Linton RR. The communicating veins of the lower leg and the operative technic for their ligation. Ann Surg 1938; 107: Linton RR. The post-thrombotic ulceration of the lower extremity: its etiology and surgical treatment. Ann Surg 1953;138: Cockett FB, Jones DE. The ankle blow-out syndrome: a new approach to the varicose ulcer problem. Lancet 1953;1: Silver D, Gleysteen JJ, Rhodes GR, Georgiade NG, Anlyan WG. Surgical treatment of the refractory postphlebitic ulcer. Arch Surg 1971;103: Husni EA. Surgical management. In: Bang NU, Glover JL, Holder RW, Triplett DA, eds. Thrombosis and atherosclerosis. Chicago: Year Book Medical Publishers, 1982: Bergan JJ, Yao JST, Flirm WR, McCarthy WJ. Surgical treat-

6 Symposium: Venous Ulcer Journal of VASCULAR SURGERY ment of venous obstruction and insufficiency. J VASC SURG 1986;3: Felder DA, Murphy TO, Ring DM. A posterior subfascial approach to the communicating veins of the leg. Surg Gynecol Obstet 1955;100: Healey RJ, Healey EH, Wong R, Schaberg FJ. Surgical management of the chronic venous ulcer: the Rob procedure. Am l Surg 1979;137: DePalma RG. Surgical therapy of venous stasis. Surgery 1974;76: DePalma RG. Surgical therapy of venous stasis: results of a modified Linton operation. Am J Surg 1979;137: Wilkinson GE, Maclaren IF. Long-term reviewofprocedures for venous perforator insufficiency. Surg Gynecol Obstet 1986;163: Field P, Boxel PV. The role of the Linton flap procedure in the management of the stasis dermatitis and ulceration in the lower limb. Surgery 1971;70: Johnson WC, O'Hara ET, Corey C, Widrich WC, Nabseth DC. Venous stasis ulceration: effectiveness of subfascial ligation. Arch Surg 1985;120: Negus D, Friedgood A. The effective management of venous ulceration. Br J Surg 1983;70: Hyde GL, Hull DA. Long-term results of subfascial vein ligation for venous stasis disease. Surg Gynecol Obstet 1981;153: Blumenberg RM, Gelfand ML. The posterior stocking seam approach to radical subfascial clipping of perforating veins. Am J Surg 1978;136: Bowen FH. Subfascial figation (Linton operation) of the perforating leg veins to treat post-thrombophlebitic syndrome. Am Surg 1975;41: ThurstOn OG, Williams HT. Chronic venous insufficiency of the lower extremity. Arch Surg 1973;106: Kismer RL. Surgical repair of the incompetent femoral vein valve. Arch Surg 1975; 110: Kismer RL. Surgical repair of the incompetent femoral vein val-~e. Arch Surg 1975;110: O'Donnell TF, Mackey WC, Shepard AD, Callow AD. Clinical, hemodynamic, and anatomic follow-up of direct venous reconstruction. Arch Surg 1987;122: Johnson ND, Queral LA, Flinn WR, Yao JST, Bergan JJ. Late objective assessment of venous valve surgery. Arch Surg 1981;116: Johnson ND, Queral LA, Flinn WR, Yao JST, Bergan JJ. Late objective assessment of venous valve surgery. Arch Surg 1981;116: Linton RR. The post-thrombotic ulceration of the lower extremity: its etiology and surgical treatment. Ann Surg 1953;138:430. A prospective, randomized versus hydroactive dressing venous stasis ulcers trial of Unna's boots in the treatment of Michael J. Kikta, M.D., James J. Schuler, M.D., Joseph P. Meyer, M.D., Joseph R. Durham, M.D., Jens Eldrup-Jorgensen, M.D., Thomas H. Schwarcz, M.D., and D. Preston Flanigan, M.D., Chicago, Ill. It is estimated that 500,000 adult Americans have or have had postphlebitic leg ulcers.~ Although only 10% of them will require hospitalization, outpatient management of the remainder is a significant problem. The standard treatment for venous stasis ulcers, Unna's boot (UB), has been used since Un- From the Department of Surgery, Division of Vascular Surgery, University of Illinois College of Medicine at Chicago. Presented at the combined breakfast program of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery, North American Chapter, Toronto, Ontario, Canada, June 9, Reprint requests: D. Preston Flanigan, M.D., Chief, Division of Vascular Surgery (m/c 957), University of Illinois at Chicago, 1740 West Taylor St., Suite 2200, Chicago, IL na's boot is a moist paste bandage impregnated with zinc oxide, calamine lotion, and glycerine, wrapped snugly about the entire leg in direct contact with the ulcer, worn continuously, and changed weekly. This dressing provides topical wound therapy as well as compression. Disadvantages of UB therapy include dermatitis, difficulty in bathing, and pain while wearhag and changing the boot, all leading to poor patient compliance. A new dressing material has been developed for care of skin ulcers. DuoDERM (Convatec-Squibb, Princeton, N.J.) hydroacfive dressing (HD) is an occlusive, virtually oxygen-impermeable, wafer-like sheet of hydrophilic particles encased in an inert hydrophobic polymer matrix placed on an adhesive 478