Conservative versus surgical treatment of venous leg ulcers: A prospective, randomized, multicenter trial
Article Outline
Background
The prevalence of venous leg ulcers is as high as 1% to 1.5%, and the total costs of this disease are 1% of the total annual health care budget in Western European countries. Treatment modalities are conservative or surgical. Subfascial endoscopic perforating vein surgery (SEPS) combined with superficial vein ligation is performed in many centers to address vein incompetence in patients with chronic venous leg ulcers. Several reports describe good healing and low recurrence rates, although a randomized trial to compare surgical treatment including SEPS and treatment of the superficial venous system to conservative modalities has never been performed. Therefore, a prospective, randomized, multicenter trial was conducted to study whether ambulatory compression therapy with venous surgery is a better treatment than just ambulatory compression therapy in venous leg ulcer patients.
Methods
Patients with an active (open) venous leg ulcer (CEAP C6) qualified for the study. The study consisted of two treatment groups. All patients were treated by standardized ambulatory compression therapy, and half of the patients received SEPS. Concomitant superficial venous incompetence was also treated in the second group. For allocation to both treatment groups, each patient was assigned by a computer program at the randomization center. The primary goal of the study was to compare the ulcer-free period during follow-up in both study groups. Secondary end points were ulcer healing and recurrence rates.
Results
From April 1997 until January 2001, 200 ulcerated legs (170 patients) were included in the study in 12 centers in The Netherlands. A total of 97 ulcers were allocated to the surgical group and 103 to the conservative group. Patient characteristics were similar in the two treatment groups at baseline, with the exception of a higher proportion in the conservative group of diabetes mellitus. Healing rates were 83% in the surgical group and 73% in the conservative group (not significant; median time to healing, 27 months). Recurrence rates were the same in both treatment groups (22% surgical vs 23% conservative). During follow-up of a mean of 29 months (median, 27 months) in the surgical group and 26 months (median, 24 months) in the conservative group, we found that in the surgical group, the ulcer-free rate was 72%, whereas in the conservative group this rate was 53% (P = .11; Mann-Whitney test). Patients with recurrent ulceration or medially located ulcers in the surgical group had a longer ulcer-free period than those treated in the conservative group (P = .02 for both). A first-time ulcer and one of the centers also had a positive effect on the ulcer-free period during follow-up (P < .001 and P = .02), independent of the treatment group. Deep vein incompetence did not affect the ulcer-free period.
Conclusions
In conclusion, we suggest that patients with medial and/or recurrent ulceration should receive surgery combined with ambulatory compression therapy. A dedicated center should provide care for those patients.
The prevalence of venous leg ulcers is as high as 1% to 1.5%.1, 2 The total costs of the treatment of venous leg ulcers are 1% of the total annual health care budget in Western European countries.3 Treatment modalities are conservative or surgical. Conservative treatment includes bed rest, leg elevation, local treatment, and compression therapy. Surgical treatment consists of superficial and perforating vein ablation and deep vein reconstruction. Subfascial endoscopic perforating vein surgery (SEPS) combined with superficial vein ligation is performed in many centers to address vein incompetence in patients with chronic venous leg ulcers. Several reports describe good healing and low recurrence rates, although a randomized trial to compare conservative and surgical treatment modalities, including SEPS and, if necessary, treatment of the superficial venous system, has never been performed.4 Therefore, a prospective, randomized, multicenter trial was conducted to study whether ambulatory compression therapy with venous surgery is a better treatment than just ambulatory compression therapy in venous ulcer patients.
Patients and methods
Patients
Between April 1997 and January 2001, patients with an active (open) venous leg ulcer (CEAP C6) were randomized in this study in 12 centers in The Netherlands. Both medial and lateral venous ulcers were included. Exclusion criteria were arterial pathology (ankle-brachial index <0.8), total or partial occlusion of the deep venous system, former subfascial ligation of perforating veins, severe neurologic or muscular pathology, and immobility.
Patients with bilateral leg ulcers were included in the study. The trial was approved by the ethics committees of all 12 participating centers. All patients provided written informed consent, and the study adhered to the Declaration of Helsinki.
Methods
All patients were analyzed by medical history, physical examination, duplex ultrasonography, and digital photographs. Both primary and secondary causes of leg ulcers were included.
Both deep axial and segmental reflux were considered to be deep vein incompetence (DVI) in this series. Reflux was defined as retrograde flow more than 0.5 seconds after calf compression or Vasalva maneuver. We did not discriminate primary from secondary chronic venous disease.
Patients were stratified before randomization for three factors: first-time ulcer or recurrent ulceration; presence or absence of DVI; and center. Treatment consisted of two treatment groups. For allocation to the treatment groups, each patient was assigned by a computer program at an independent randomization center. The randomization took place within stratification groups. In case patients had two ulcerated legs in the study, the legs were randomized separately.
All patients were treated by standardized ambulatory compression therapy, and half of the patients got SEPS, combined, when indicated, with surgery of the superficial venous system. Concomitant superficial venous incompetence was treated in the second group by flush saphenopopliteal ligation and/or saphenofemoral ligation and limited stripping of the long saphenous vein from the groin to just below the knee level. In most cases, the procedure can be performed in an outpatient setting.
Ambulatory compression therapy was started directly after randomization. Surgical treatment was performed within five working days. SEPS was performed with an Olympus scope (Olympus, Hamburg, Germany), as described elsewhere.10 A one-port technique and carbon dioxide were used in all cases. All perforating veins were interrupted by the use of hemoclips (Ligaclip; Ethicon Endosurgery Amersfoort, The Netherlands) in a bloodless area. The intermuscular septum was opened to reach perforators near the tibial crest in the lower part of the leg.
Patients were mobilized on the first postoperative day and treated by dual-layer short-stretch ambulatory compression therapy (Comprilan; Beiersdorf Medical, Almere, The Netherlands) until the ulcer had healed. Therapeutic elastic stockings (class II or III, depending on concomitant incompetence of the deep vein system) were prescribed after healing in all cases. Ulcer healing and recurrence were described separately and in detail. Digital photographs were taken at each visit. After randomization, patients were seen on an outpatient basis after 1, 2, 3, 6, and 12 weeks and then every 3 months. In cases of recurrence, patients were seen immediately. Duplex ultrasonography was repeated 3 and 12 months after randomization.
Study end points
During follow-up, every ulcer was scored as active (open) or healed. The primary goal of the study was to compare the ulcer-free period during follow-up in both study groups. The ulcer-free period was defined as the total percentage of days during follow-up a patient had no ulceration. Healing and recurrence rates were assessed as secondary end points.
To evaluate the pattern of ulcer-free time, the follow-up period from 0 to 36 months was divided into intervals of 3 months each. As long as a patient was under observation, it was determined for each interval for how many days the patient’s leg was ulcer free. The outcome was expressed as a percentage of days, and the outcome was considered valid and was analyzed only if the number of observation days within the period was sufficiently large (arbitrarily chosen as ≥45 days, ie, half of the period). For example, if a patient were under observation at the fifth interval for 60 days and if, during this interval, his leg were ulcer free for 20 days, the analyzed percentage for this interval would be 100 × 20/60 = 33%. Each patient provided in this way a number of subsequent interval percentages, and the means of these repeated measurements are graphically displayed (Fig 2, Fig 3, Fig 4, Fig 5, Fig 6).
Fig 2.
Ulcer-free period per patient per 3 months in patients with an ulcer present before randomization for shorter or longer than 4 months (P < .001; analysis of variance).
Fig 3.
The ulcer-free period per patient per 3 months in the surgical and conservative groups (analysis of variance, P = .14) Numbers along the horizontal axis represent legs still in follow-up at the particular time points for the two groups.
Fig 4.
Ulcer-free period per patient per 3 months in first-time and recurrent ulceration patients (P < .001; analysis of variance). Error bars represent standard errors of the mean.
Fig 5.
Ulcer-free period per patient per 3 months in patients treated in one of the centers (SFG; P = .02; analysis of variance).
Fig 6.
Ulcer-free period per patient per 3 months in patients with a first-time ulcer and/or a medial ulcer in the surgical and conservative groups (P = .045; analysis of variance).
Statistical analysis
The study power was set at 90% (β = .10 and α = .01), which indicated that with expected healing and recurrence rates of 70% and 35% in the conservative group and 85% and 10% in the surgical group, inclusion of 100 ulcerated legs in each limb of the study was necessary. The analysis was performed by intention to treat. Overall analysis of the ulcer-free period was performed with the Mann-Whitney test. To assess differences in both groups during follow-up, repeated analyses were performed with analysis of variance (ANOVA; SAS PROC MIXED; SAS Institute, Cary, NC).
Role of the funding source
The study was sponsored by Ziekenfondsraad/Ontwikkelingsgeneeskunde (Dutch government; project OG98-045). The sponsor of the study had no role in data collection, data analysis, data interpretation, writing the report, or the decision to submit the paper for publication.
Results
From April 1997 until January 2001, 200 ulcerated legs (170 patients) were included in the study in 12 centers in The Netherlands. A total of 97 ulcers were allocated to the surgical group and 103 to the conservative group. Four patients were lost to follow-up directly after randomization (three in the surgical and one in the conservative group), without known cause, all in the same center. A total of 94 legs in the surgical and 102 legs in the conservative group were analyzed (Fig 1). Patient characteristics were similar in the two treatment groups at baseline, with the exception of a higher proportion of diabetes mellitus in the conservative group (Table I).
Fig 1.
Trial profile. SEPS, Subfascial endoscopic perforating vein surgery.
Table I. Patient characteristics
| Variable | Surgical (n = 94) | Conservative (n = 102) | P value (χ2) |
|---|---|---|---|
| Sex (male:female) | 2:3 | 2:3 | NS |
| Age, y (mean ± SD) | 64 ± 15 | 68 ± 14 | NS |
| Open ulcer, d (median) | 120 | 120 | NS |
| First-time ulcer | 31 (33%) | 36(35%) | NS |
| Deep vein incompetence | 49(52%) | 57(56%) | NS |
| Diabetes mellitus | 6(7%) | 17(17%) | .05 |
| Deep vein thrombosis in medical history | 29(31%) | 31(30%) | NS |
| Localization: medial | 70(74%) | 62(61%) | NS |
| Ulcer size, mm2, median (range) | 225(4-7800) | 260(1-27,000) | NS |
In the surgical group, 91 of 94 patients underwent a SEPS procedure. Three patients were not operated on at all. One patient experienced a myocardial infarction before surgery, one developed deep vein occlusion, and one died before surgery. Concomitant superficial incompetence was treated in 51 cases (54%). Of the 40 patients (43%) who were treated only by a SEPS procedure, 29 had had superficial vein surgery in the past. Only 11 patients (12%) had isolated perforator vein incompetence. The mean number of treated perforators was 3.7 (range, 0-8).
During follow-up, with a mean of 29 months (median, 27 months) in the surgical group and 26 months (median, 24 months) in the conservative group, 23 patients died (this concerned 8 legs in the surgical group and 17 in the conservative group; 2 patients had both legs in the trial). None of the deaths was related to the ulcer or the allocated treatment.
Age, sex, ulcer size, diabetes, deep vein thrombosis, and localization of the ulcer had no influence on the ulcer-free period in this series (Table II). In contrast, the number of days the ulcer existed before randomization showed a positive effect on this primary end point. Patients with ulcers existing 4 months or less before randomization had a longer ulcer-free rate during follow-up (P < .001; ANOVA; Fig 2). However, when we compared the surgical with the conservative group for the primary end point (ulcer-free days during follow-up), we found that in the surgical group, the median ulcer-free period was 72% (range, 0%-99%), and in the conservative group this was 53% (range, 0%-99%; P = .11; Mann-Whitney test). Similarly, when individual patient follow-up was assessed, no significant difference was found between the two groups (P = .14; ANOVA; Fig 3).
Table II. Median values of follow-up without ulcer for the entire patient population according to various baseline characteristics
| Variable | n | % | P value (Mann-Whitney) | P value (ANOVA) |
|---|---|---|---|---|
| Male/female | 77/119 | 62/69 | NS | NS |
| Age (y) | .06⁎ | NS | ||
| <55 | 52 | 85 | ||
| 55-75 | 81 | 56 | ||
| >75 | 63 | 60 | ||
| <4/>4 mo† | 93/82 | 85/39 | <.001 | <.001 |
| First-time/recurrent ulcer | 67/129 | 86/48 | <.001 | <.001 |
| Deep vein incompetence (−/+) | 90/106 | 75/53 | .08 | NS |
| Diabetes (−/+)‡ | 170/23 | 68/56 | NS | NS |
| Deep vein thrombosis (−/+)‡ | 133/60 | 71/50 | NS | NS |
| Medial/lateral ulcer | 132/64 | 69/54 | NS | NS |
| SFG (center) (+/−) | 131/65 | 74/42 | .001 | .02 |
⁎ P value from the Kruskal-Wallis test. |
† The duration of ulceration before randomization was known for 175 legs. |
‡ The existence of diabetes and deep vein thrombosis was known in 193 legs. |
As previously noted, during randomization we stratified for first-time ulcer vs recurrent ulceration, presence or absence of DVI, and center. Of these strata, a first-time ulcer and one of the centers had a positive effect on the ulcer-free period during follow-up for both study groups (P < .001 [Fig 4] and P = .02 [Fig 5]). DVI did not affect this primary end point. Patients with recurrent ulceration treated in the surgical group also had a higher ulcer-free rate during follow-up (62% vs 33% in the conservative group; P = .02; ANOVA). Also, medially located ulcers had this same advantage in the surgical group (78% vs 43% in the conservative group; P = .02; ANOVA). Patients older than 75 years had a higher ulcer-free rate in the surgical group (70% vs 24% in the conservative group; P = .004; ANOVA), but analysis showed that this was related to recurrent ulceration (Table III). Considered on a per-patient basis, patients with recurrent ulceration and/or medially located ulcers in the surgical group also had a higher ulcer-free rate during follow-up than those treated in the conservative group (P = .045; ANOVA; Fig 6).
Table III. Median values of follow-up without ulcer for the surgical and conservative groups, according to various baseline characteristics
| Variable | n | Surgical | Conservative | P value (Mann-Whitney) | P value (ANOVA) |
|---|---|---|---|---|---|
| Total | 196 | 72% | 53% | .11 | .14 |
| Male | 77 | 74 | 47 | NS | NS |
| Female | 119 | 70 | 55 | NS | NS |
| <55 y | 52 | 86 | 85 | NS | NS |
| 55-75 y | 81 | 53 | 68 | NS | NS |
| >75 y | 63 | 70 | 24 | .008 | .004 |
| <4 mo | 63 | 88 | 76 | NS | NS |
| >4 mo | 82 | 55 | 11 | .09 | .09 |
| First-time ulcer | 67 | 86 | 86 | NS | NS |
| Recurrent ulcer | 129 | 62 | 33 | .05 | .02 |
| DVI+ | 106 | 64 | 43 | NS | NS |
| DVI− | 90 | 84 | 72 | NS | NS |
| Diabetes+ | 23 | 85 | 46 | NS | NS |
| Diabetes− | 170 | 70 | 53 | NS | NS |
| DVT+ | 60 | 69 | 38 | NS | .01 |
| DVT− | 133 | 74 | 69 | NS | NS |
| Medial ulcers | 132 | 78 | 43 | .02 | .02 |
| Lateral ulcers | 64 | 49 | 71 | NS | NS |
| SFG center | 131 | 76 | 72 | NS | NS |
| Other centers | 65 | 53 | 4 | NS | NS |
Ulcer healing rates were 83% and 73% in the surgical and conservative groups, respectively (not significant; Fig 7). The median and mean time to ulcer healing were 11 and 4.2 months in the surgical group and 15 and 5.7 months in the conservative group (not significant). Healing rates in both groups were significantly influenced by first-time ulcers (P < .001), ulcers of more than 4 months’ duration (P < .001), ulcer size (P < .001), DVI (P = .03), deep vein thrombosis in the medical history (P = .03), and center (P = .002; Table IV). Medial and recurrent ulcers also had significantly higher healing rates in the surgical group (P = .04 and P = .01) compared with the conservative group (Table V). Finally, when we compared the surgical and conservative treatment groups, no statistical difference was found in recurrence rates (22% vs 23%; Fig 8), and the only parameter that influenced recurrence rates was a first-time ulcer. First-time ulcers had significantly lower recurrence rates than recurrent ulcers (P = .01; Table VI).
Fig 7.
Cumulative healing rates according to randomized treatment groups (P = .24). Tickmarks note the ends of follow-up of patients.
Table IV. Healing rates for the entire patient population according to various baseline characteristics
| Variable | n | Healing rate (%) | P value (log-rank) |
|---|---|---|---|
| Surgical/conservative | 94/102 | 83/73 | NS |
| Male/female | 77/119 | 74/80 | NS |
| Age (y) | |||
| <55 | 52 | 79 | |
| 55-75 | 81 | 78 | |
| >75 | 63 | 76 | |
| <4/>4 mo | 93/82 | 91/65 | <.001 |
| First-time/recurrent ulcer | 67/129 | 84/74 | <.001 |
| DVI (−/+) | 90/106 | 78/77 | .03 |
| DM (−/+) | 170/23 | 78/74 | NS |
| DVT (−/+) | 133/60 | 79/73 | .03 |
| Location: medial/lateral | 132/64 | 80/73 | NS |
| Superficial vein surgery (−/+) | 40/51 | 80/78 | NS |
| Ulcer size (<250/>250 mm2) | 78/74 | 87/68 | <.001 |
| Center: SFG (+/−) | 131/65 | 82/68 | .002 |
Table V. Healing rates for the surgical and conservative groups, according to various baseline characteristics
| Variable | n | Surgical (%) | Conservative (%) | P value (log-rank) |
|---|---|---|---|---|
| Male | 77 | 78 | 70 | NS |
| Female | 119 | 86 | 74 | NS |
| Age (y) | ||||
| <55 | 52 | 84 | 71 | NS |
| 55-75 | 81 | 75 | 80 | NS |
| >75 | 63 | 93 | 64 | NS |
| <4 mo | 93 | 92 | 91 | NS |
| >4 mo | 82 | 77 | 53 | NS |
| First-time ulcer | 67 | 87 | 80 | NS |
| Recurrence | 129 | 81 | 69 | NS |
| DVI+ | 106 | 82 | 74 | NS |
| DVI− | 90 | 84 | 71 | NS |
| DM+ | 23 | 83 | 71 | NS |
| DM− | 170 | 83 | 73 | NS |
| DVT+ | 60 | 86 | 61 | NS |
| DVT− | 133 | 81 | 77 | NS |
| Medial | 132 | 87 | 72 | .04 |
| Lateral | 64 | 70 | 74 | NS |
| Ulcer size <250 mm2 | 78 | 88 | 86 | NS |
| Ulcer size >250 mm2 | 74 | 78 | 57 | .01 |
| Center: SFG | 131 | 86 | 79 | NS |
| Center: other | 65 | 77 | 60 | NS |
Fig 8.
Cumulative recurrence rates according to randomized treatment groups (not significant). Tickmarks note the ends of follow-up of patients.
Table VI. Recurrence rates for the entire patient population according to various baseline characteristics
| Variable | n | Recurrence (%) | P value (log-rank) |
|---|---|---|---|
| Surgical/conservative | 77/72 | 22/24 | NS |
| Male/female | 56/93 | 25/22 | NS |
| Age (y) | |||
| <55 | 40 | 18 | |
| 55-75 | 62 | 26 | |
| >75 | 47 | 23 | |
| <4/>4 mo | 83/52 | 19/27 | NS |
| First-time ulcer/recurrence | 56/93 | 13/29 | .01 |
| DVI (−/+) | 69/80 | 20/25 | NS |
| DM (−/+) | 129/17 | 24/12 | NS |
| DVT (−/+) | 103/43 | 21/28 | NS |
| Medial/lateral | 102/47 | 19/15 | NS |
| Superficial vein surgery (−/+) | 40/51 | 22/20 | NS |
| Ulcer size (<250/>250 mm2) | 68/50 | 18/24 | NS |
| Center: SFG (+/−) | 108/44 | 24/18 | NS |
Discussion
Treatment modalities for patients with chronic venous disease may be conservative or surgical. Conservative treatment is reported to provide good healing rates in mixed patient groups (C2-C6), but recurrence rates can be high (55%-100%) and are dependent on patient compliance.5 Since the introduction of SEPS by Hauer6 in 1985, several reports have claimed good healing and reduced recurrence rates in patients treated with this method. However, publications involving SEPS describe mixed patient groups and comparison to different treatments,4, 7, 8, 9 and just one prospective, randomized trial has been performed. Pierik et al10 compared the Linton procedure with SEPS. Despite the small patient number in that study, SEPS was recommended because of the high complication rate after the Linton procedure and the comparable healing and recurrence rates between the two treatments. Thus, currently, circumstantial evidence suggests that surgical treatment of incompetent superficial and perforating veins improves healing rates and decreases recurrences when compared with nonsurgical treatment in venous ulcer patients.
To our knowledge, this article describes the first multicenter, prospective, randomized trial investigating SEPS in combination with treatment of the incompetent superficial venous system in patients with venous ulcers. In addition to common end points involving ulcer treatment, such as healing and recurrence rates, we describe another primary end point for this study. We postulate that the ulcer-free period during follow-up gives us more insight into the actual course of the disease, because recurrence is dependent on healing. Additionally, healing and recurrence rates do not show the amount of time that an ulcer is active. Therefore, we used healing and recurrence rates as secondary end points in this study.
In this prospective study, we found similar high ulcer-free rates in the surgical and conservative groups (72% vs 53%, respectively; P = .14; ANOVA). However, in subgroup analysis, we found that medial ulcers benefited significantly (P = .02) from surgery, whereas lateral ulcers did not. de Rijcke et al11 reported poor results with SEPS procedures performed on the lateral aspect of the lower leg in a small series. The authors claimed that these poor results of lateral procedures may be explained by alignment of perforating veins along the intermuscular septa, which requires full septa dissection on the lateral side if lateral crural perforating veins are to be treated effectively.12 In our series, full septum dissections were performed on the medial aspects of the lower leg, but not on the lateral sides, and this may have influenced the outcome on all end points. Regardless, medial and lateral leg ulcers were equally distributed in the two study groups. Patients with recurrent ulceration also had a longer ulcer-free period during follow-up in the surgical group. Thus, 168 (86%) of 196 patients in our series had either a medial or recurrent ulcer, and we conclude that in most cases, SEPS surgery can be beneficial for patients with chronic venous leg ulcers. In contrast, surgery of the superficial system did not influence the ulcer-free period (73% vs 61%; P = .09). This can be explained by the fact that after surgery, all patients in the surgical group had a treated or competent superficial system.
During randomization, we stratified for center, recurrent ulceration, and DVI. In analysis of the entire patient population, we found that in one of the centers patients had a longer ulcer-free period when compared with the other centers. This center is known to be a dedicated center for the treatment of venous diseases and contributed more than half of the patients in the study. Dedicated, multidisciplinary ulcer care centers have previously been reported to be associated with good healing rates.13, 14 Patients with a first-time ulcer also had a longer ulcer-free period during follow-up when compared with patients with recurrent ulceration. A possible explanation is that recurrent ulceration may be seen as an advanced stage of chronic venous disease when compared with first-time ulceration, and, thus, the natural history of a first-time ulcer may be better than that of recurrent ulceration. Finally, DVI did not influence the primary end point in this series.
Demographics of the randomized population showed a higher proportion of patients with diabetes mellitus in the conservative group (17% vs 7%; P = .05). However, analysis of the effect of diabetes mellitus on all end points demonstrated no significant influence, possibly because of the small number of patients in this series.
Healing rates (83% in the surgical and 73% in the conservative group; not significant) were comparable to rates previously reported in the literature. However, recurrence rates in the surgical group were much higher than anticipated (22%). A possible cause for the high recurrence rates is the quality of the SEPS procedure. The number of persistent or new incompetent perforating veins after a SEPS procedure and the recurrence of incompetence of the superficial system could influence healing and recurrence rates. Further analysis to evaluate the effect of the quality of the procedures has to be performed.
To conclude, we suggest that patients with medial and/or recurrent ulceration could benefit from surgery combined with ambulatory compression therapy. Additionally, a dedicated center should provide the care for such patients.
Author contributions
Irwin Toonder, RVT, performed duplex imaging; Cora Hazelzet provided secretarial support. Participating centers included Sint Franciscus Gasthuis, Rotterdam; Erasmus Medisch Centrum, lokatie Dijkzigt, Rotterdam; Reinier de Graaf Groep, lokatie Reinier de Graaf Gasthuis, Delft; VU Medisch Centrum, Amsterdam; Meander Medisch Centrum, Amersfoort; Stichting Het van Weel Bethesda Ziekenhuis, Dirksland; Havenziekenhuis, Rotterdam; Ikazia Ziekenhuis, Rotterdam; Medisch Centrum Rijnmond Zuid, lokatie St Clara Ziekenhuis, Rotterdam; Vlietland Ziekenhuis, lokatie Schiedam, Schiedam; Vlietland Ziekenhuis, lokatie Vlaardingen, Vlaardingen; and Albert Schweitzer Ziekenhuis, lokatie Dordwijk, Dordrecht.
References
- . Chronic ulceration of the leg (extent of the problem and provision of care) . Br Med J . 1985;290:1855–1856
- Influences of a specialized leg ulcer service on management and outcome . Br J Surg . 2000;87:1048–1056
- . Leg ulcers (economic aspects) . Phlebology . 2000;15:110–114
- Systematic review of outcomes after surgical management of venous disease incorporating subfascial endoscopic perforator surgery . J Vasc Surg . 2004;39:583–589
- . Fifteen-year results of ambulatory compression therapy for chronic venous ulcers . Surgery . 1991;109:575–581
- . Endoscopic subfascial discussion of perforating veins—preliminary report . [in German] Vasa . 1985;14:59–61
- . Mid-term results of endoscopic perforator vein interruption for chronic venous insufficiency (lessons learned from the North American subfascial endoscopic perforator surgery registry) . J Vasc Surg . 1999;29:489–502
- . Is the nihilistic approach to surgical reduction of superficial and perforator vein incompetence for venous ulcer justified? . J Vasc Surg . 2002;36:1167–1174
- . Subfascial endoscopic perforator vein surgery combined with saphenous vein ablation (results and critical analysis) . J Vasc Surg . 2003;38:67–71
- . Endoscopic versus open subfascial division of incompetent perforating veins in the treatment of venous leg ulceration (a randomized trial) . J Vasc Surg . 1997;26:1049–1054
- . Subfascial endoscopic perforating vein surgery as treatment for lateral perforating vein incompetence and venous ulceration . J Vasc Surg . 2003;38:799–803
- . Surgical anatomy for subfascial endoscopic perforating vein surgery of laterally located perforating veins . J Vasc Surg . 2003;38:1349–1352
- . A new concept of a multidisciplinary wound healing center and a national expert function of wound healing . Arch Surg . 2001;136:765–772
- Community clinics for leg ulcers and impact on healing . BMJ . 1992;305:1389–1392
Competition of interest: none.
PII: S0741-5214(06)00817-2
doi:10.1016/j.jvs.2006.04.053
© 2006 The Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
