Limitations of subfascial ligation for refractory chronic venous stasis ulceration

Eighteen subfascial ligations of deep venous perforators were performed on 17 patients with refractory venous stasis ulceration. Thirteen patients also required concomitant or subsequent split thickness skin grafting. Primary indications included: (1) recurrence of ulceration during adequate support therapy with failure to heal using conservative measures (10 cases--55%) and (2) failure to heal with support therapy alone (eight cases 45%). Five limbs had ulcers greater than 30 cm2 and two had giant ulcers (greater than 50 cm2). Most extremities had evidence of venous reflux by photoplethysmography or Doppler ultrasound (10 of 11) or chronic deep venous thrombosis by venography (six of seven). Mean hospital stay was 23 days +/- 17, range six to 68 days. Early complications, including incisional breakdown or partial skin graft loss, were common and occurred in 10 patients. With a mean follow-up interval of 28 months (range nine to 49 months), most limbs (N = 10) were judged cured, including both with giant ulcers, and three significantly improved. By life table analysis, 63% were free from significant ulcer recurrence at 42 months. Four limbs were not significantly improved following surgery. Most patients with refractory venous ulceration will benefit from subfascial ligation of deep venous perforators and skin grafting, although recurrent or persistent ulceration remains problematic for a significant number of patients.