DynaMed Resident Focus 3: Superficial Venous Surgery plus Compression Therapy May Decrease Recurrence Rates Compared to Compression Therapy Alone in Patients with Chronic Venous Ulcers and Superficial Venous Reflux

Superficial Venous Surgery plus Compression Therapy May Decrease Recurrence Rates Compared to Compression Therapy Alone in Patients with Chronic Venous Ulcers and Superficial Venous Reflux

Reference: BMJ. 2007 July 14; 335(7610): 83, (level 2 [mid-level] evidence)

Venous ulcers, the most common type of leg ulcers, are caused by venous hypertension or insufficiency due to either venous valve incompetence or lack of venous pumping from inadequate muscle functioning. Compression therapy is the mainstay of treatment of lower extremity venous ulcers. Leg elevation, supervised exercise, and oral or topical medications are other methods of treatment but may not be enough to prevent recurrence of ulcers in chronic disease. Surgical procedures have been performed to attempt to prevent recurrence. A randomized trial was conducted to determine whether recurrence of leg ulcers may be better prevented by compression alone or in combination with surgical correction.

Five hundred patients with open or recently healed leg ulcers and superficial venous reflux were randomized between 1999 and 2002 to compression therapy alone or compression therapy plus surgery. The compression therapy comprised of multilayered compression bandaging with 40 mm Hg of pressure at the ankle and 17-20 mm Hg at the upper calf for patients with open ulcers, and class 2 elastic stockings for patients with healed ulcers. Patients in the surgical therapy group were offered superficial venous surgery; type of surgery was guided by findings on ultrasound. Fifty-four (11%) patients withdrew from the trial or failed to follow-up. Ulcer healing rates and ulcer recurrence were the primary outcomes, and ulcer-free time was the secondary outcome.

There were no significant differences between groups in regards to age, sex, and ulcer characteristics. For 341 patients that had open ulcers at the beginning of the study, ulcer healing rates at three years were 89% for the compression group compared to 93% for the compression plus surgery group (not significant). Of the 442 patients that had healed ulcers, ulcer recurrence at four years occurred in 56% for the compression group and 31% for the compression plus surgery group (P<0.001). Ulcer free time over three years was greater in the compression plus surgery group compared with the compression group (P=0.007).

Based on this study it appears that surgical correction of superficial venous reflux, when added to compression bandaging, may not improve ulcer healing, but may reduce the recurrence of venous ulcers and increase ulcer free time over a four year period (level 2 [mid-level] evidence). Early referral for surgical evaluation should be considered.

Reference: Gohel MS, Barwell JR, Taylor M, et al. Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomized controlled trial. BMJ. 2007 Jul 14;335(7610):83

For more information, see Venous ulcer in DynaMed.