PC182 the Impact of Different Treatment Modalities on Recalcitrant Venous Ulcer Healing

Refractory venous ulcers are a national health issue, despite advances in wound care and compression therapy. We examined the impact of compression, correction of incompetent superficial and perforator veins, and dilatation of iliac stenosis/occlusion. All patients with venous ulcers from eight institutions, treated between January 2013 and January 2016, were retrospectively evaluated for the impact of different treatment modalities. A total of 406 patients with venous ulcers, accompanied by reflux in lower extremity deep veins (30%), superficial veins (92%), perforator veins (80%), and with iliac venous stenosis (4%) were treated, and 105 patients (26%) were managed conservatively with compression, for a mean of 3.8 months until ulcer healing. The remaining 301 patients (74%) underwent wound care for a mean of 9 months prior to surgical treatment. There were 276 patients (68%) who underwent ablation of an incompetent great saphenous vein 6.4 months after ulcer onset, 83 patients (20%) underwent ablation of an incompetent small saphenous vein after 11 months, and 288 patients (71%) underwent ablation of an incompetent perforator vein after 21 months. Patients undergoing perforator ablation had a mean of 1.7 perforator veins closed. Ulcer size at beginning of conservative treatment was smaller in those that healed with compression and wound care alone (7 vs 22 cm2, respectively; P < .05). Patients with concomitant deep venous reflux required more vein ablations (3.1 vs 1.4 veins, respectively; P < .05) to achieve ulcer healing. Time from onset to ulcer healing for patients requiring only superficial vein ablation was 9.1 months but was 13.8 months for patients requiring both superficial and perforator vein ablation (P < .05). Patients with deep vein incompetence took the longest time to heal, with a mean of 21 months. Stenosis >75% in the femoral or popliteal vein was a significant barrier to ulcer healing (P < .05). In patients with prior superficial vein ablation and iliac vein stenosis >50%, ulcer healing was achieved following iliac vein stenting in 76%. Absolute ulcer healing was achieved during the study period in 336 patients (83%). There were 35 ulcer recurrences (10%) during the study; new incompetent perforator veins were identified in 13 patients (37%). Patients with multilevel venous disease involving the deep system are at highest risk for developing venous ulcers that are refractory to compression therapy alone. Venous ulcer healing time and rate is improved with ablation of incompetent superficial and perforator veins. Correction of iliac venous stenosis/occlusion also facilitates ulcer healing.