Venous ulceration: a cross-over study from nonoperative to operative treatment

This study compared 3 years of nonoperative therapy in a vascular clinic (1991 to 1993) with a proactive approach to diagnosis and operative treatment (1994 to 1995).

In the first period, 11 compliant men 48 to 69 years of age (average, 55 years) were treated without surgery using Unna's boot dressing, compression wound care, and patient education. In the second period, after duplex scans and venographic examinations when appropriate, operative interventions were performed in 10 patients.

In period 1 there were 44 occurrences of ulceration (range, 3 to 8 per individual), with an average time to heal of 13 weeks (range, 7 to 28 weeks per individual). Beginning in January 1994 (period 2), 11 patients who had current active ulceration underwent duplex scans and venographic examinations to detect correctable lesions, including deep, superficial, or perforator incompetence, or deep venous occlusions. Ten became candidates for surgery. One patient was not a candidate for venous surgery because of extensive caval thrombosis. Operations included extrafascial perforator division in nine patients; long saphenous stripping with submalleolar saphenous and perforator interruption in seven; one Palma crossover venous graft; and one superficial femoral valvuloplasty. In period 2 (24 months), there were two recurrent ulcers, one related to failure to use adequate compression and one related to infection of an incision. Nine of 10 patients remained healed at 24 months. Average time to heal was 4 weeks. Clinical severity score as described in the Consensus Statement of the American Venous Forum was reduced from 12 (range, 9 to 17) in period 1 to a mean of 3.5 (range, 2 to 8) in period 2 (p < 0.01 by paired t test).

Improved diagnostic and operative techniques make possible more active approaches to venous ulceration. Nonoperative treatment, even in skilled hands, is associated with prolonged disability and ulcer recurrence. The condition of selected patients in whom nonoperative treatment fails can be improved substantially with operative intervention.