The role of superficial venous surgery in the management of venous ulcers: a systematic review.
Howard DP., Howard A., Kothari A., Wales L., Guest M., Davies AH.
BACKGROUND: The complicated natural history of venous ulcers requires the continued development and improvement of treatments to ensure the most effective management. Compression therapy or surgical correction of superficial venous incompetence (SVI) are currently the main methods employed for the treatment for venous ulceration (VU). This review compares and summates the healing and recurrence rates for each treatment modality used over the last thirty years. METHODS: Sixty-one articles investigating compression and superficial venous surgical treatments were obtained from a systematic search of electronic databases (Medline, Embase, The Cochrane Library, and Google Scholar) and then an expanded reference list review. Patient demographics, CEAP classification, patterns of venous insufficiency, type of intervention, length of follow up, healing and recurrence rates for venous ulceration was assessed. Inadequate data in seven reports led to their exclusion. Recent randomised controlled trials (RCTs) specifically comparing superficial surgery to compression therapy were reviewed and data from non-randomised and/or 'small' clinical studies prior to 2000 underwent summation analysis. RESULTS: Five RCTs since 2000 demonstrate a similar healing rate of VU with surgery and conservative compression treatments, but a reduction in ulcer recurrence rate with surgery. The effect of deep venous incompetence (DVI) on the ulcer healing is unclear, but sub-group analysis of long-term data from the ESCHAR trial suggests that although surgery results in a less impressive reduction in ulcer recurrence in patients with DVI, these patients appear to still benefit from surgery due to the haemodynamic and clinical benefits that result. The RCTs also highlight that a significant proportion of VU patients are unsuitable for surgical treatment. Summation of data from earlier studies (before 2000), included twenty-one studies employing conservative compression alone resulted in an overall healing rate of 65% (range 34-95%) and ulcer recurrence of 33% (range 0-100%). In thirty-one studies investigating superficial venous surgery, the overall rate of ulcer healing was 81% (range 40-100%) with a post-operative recurrence rate of 15% (range 0-55%). The duration of follow up care in the surgical studies was approximately twice as long as in the conservative studies, which would lend to more reliable recurrence data. CONCLUSIONS: Evidence from the current literature, would suggest that superficial venous surgery is associated with similar rates of ulcer healing to compression alone, but with less recurrence. The effects of post-operative compression and DVI on the efficacy of surgery are still unclear.