![]() ![]() The impact of ablation of incompetent superficial and perforator veins on ulcer healing rates. ![]() Harlander-Locke M, Lawrence PF, Alktaifi A, et al. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. O’Donnell TF Jr, Passman MA, Marston WA, et al. The American Venous Forum, as well as other national wound healing organizations, should take the lead on this, organizing data repositories to answer difficult questions and continue to provide guidelines.ġ. Lawrence’s work demonstrating the differences in healing rates for various vein ablations 2 should be the model for future work as we strive to determine the value of interventions for clinical, etiology, anatomic, and pathophysiology of C4 and C5 patients, the best strength of compression for C5 patients, and at what arterial insufficiency level should be considered. There is still a great deal of debate among experts as to the best strategies for ulcer healing and recurrence. Healing venous ulcers is difficult tracking their progress and reasons for recurrence is even harder. The Society for Vascular Surgery and American Venous Forum have crafted guidelines to create standardized protocols for venous ulcer care, 1 but even with a blueprint from leaders in the field, we have many patients who continue to suffer. However, despite these advances, we are still frustrated with stubborn venous ulcers that refuse to heal or heal and immediately recur. ![]() Superficial vein care has seen tremendous changes in the past 2 decades with availability, better methods of saphenous ablation/closure, and dramatic improvements in ultrasound resolution, as well as better, safer means of sclerotherapy. 2013 58:166-172.ĭurham, North Consultant to BTG International and Vascular Insights President of the IAC Vein Center Accreditation Board. Endovenous ablation with concomitant phlebectomy is a safe and effective method of treatment for symptomatic patients with axial reflux and large incompetent tributaries. Harlander-Locke M, Jimenez JC, Lawrence PF, Derubertis BG. Femoral vein valve incompetence as a risk factor for junctional recurrence. Gianesini S, Occhionorelli S, Menegatti E, et al. Patterns of reflux and their clinical implications. Hemodynamics of the sapheno-femoral junction. Cappelli M, Molino Lova R, Ermini S, Zamboni P. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus open surgery for great saphenous vein varices. Nesbitt C, Bedenis R, Bhattacharya V, Standsby G. By doing this, it will finally be possible to observe meaningful comparisons among the same “fruits” of our postoperative outcomes: apples with apples and oranges with oranges!ġ. To move forward in our evaluation of treatment options, the first thing we need to do is take a step back and standardize the way we assess and report the treated reflux patterns. The effectiveness of one treatment technique compared to another can be significantly influenced by the hemodynamics of whether a system is protected by a competent femoral or terminal valve rather than overloaded by a still-present incompetent tributary along the leg. Thus, it becomes evident that all studies comparing different treatment techniques but, for example, do not report femoral valve and terminal valve competence have a serious risk of being biased, if also considered in terms of an incompetent tributaries assessment and their eventual staged treatment. 4Ī significant number of patients who present with incompetent tributaries along the leg and a GSV reflux require further tributary treatment after GSV reflux suppression, pointing to the fundamental hemodynamic role of the same incompetent tributaries. 3 An incompetent femoral valve above an incompetent terminal valve increases the risk of postoperative reflux recurrence in the saphenofemoral junction by almost fivefold (odds ratio, 4.8 95% confidence interval, 1.8–12.6 P <. For example, in 45% of great saphenous vein (GSV) trunk reflux detections, the saphenofemoral terminal valve is competent. One of the next big things we need is the ability to set specific guidelines in study protocols, including fundamental data representing a potential bias if it is not reported. 1,2 At the same time, we still have very few studies assessing homogenous reflux patterns, which significantly decreases robustness of the same scientific comparison. In the modern venous literature, many investigations have compared the performance of different therapeutic techniques. We need to keep apples with apples and oranges with oranges! In brainstorming what we need next in superficial care, I focused on what we have not accomplished during the past few years of venous therapy.
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