Commentary on “The Effect of Deep Venous Stenting on Healing of Lower Limb Venous Ulcers”

Abstract

It is now well accepted that placement of venous stents is the “method of choice” for treatment of pelvic venous outflow obstruction. George et al.1George R. Verma H. Ram B.L. Tripathi R.K. The effect of deep venous stenting on healing of lower limb venous ulcers.Eur J Vasc Endovasc Surg. 2014; x (xx–xx)Google Scholar performed computed tomography (CT) venography in patients with persistent venous leg ulcers after failed conservative treatment and superficial venous interventions. The authors proceeded with transfemoral/ascending phlebography when CT-venography findings suggested obstruction. Obstruction was found in 38 patients (44 limbs) and stents were placed. The actual number of patients tested to find these patients is not given. The endpoint was healing of the ulcer. The cumulative freedom from ulcer after stenting was at 2 years approximately 60%. This was achieved despite the presence of perforator insufficiency, deep reflux, and significant saphenous incompetence in 90%, 26%, and 10%, respectively, of patients with pre-intervention duplex scanning. Patients with healed ulcers continued to stay healed at a cumulative rate of approximately 83% at 2 years. This findings are line with the results of others as referred to in the study and point to the importance of iliofemoral venous outflow obstruction in the pathophysiology of venous ulcer formation. The prevalence of outflow obstruction in patients with recalcitrant venous ulcers is still unknown. It may be hard to decide since non-thrombotic iliac vein lesions are ubiquitous and we still don't know at what degree a venous stenosis is hemodynamically significant. I agree with the authors that it certainly appears to be worthwhile to search for an iliofemoral outflow obstruction in patients with leg ulcers, which are difficult to heal or recur with other treatment. The authors don't inform us what they considered a significant obstruction. In absence of lack of hemodynamic information, most would consider to treat an obstruction with a minimal diameter stenosis of >50% based on acceptable clinical outcome in patients stented with this criterion. Although very helpful in diagnosis and accurate placing of stents, intravascular ultrasound is unfortunately often too expensive to use. The authors used a so-called “trial angioplasty” or “diagnostic ballooning” when no obvious obstruction was seen. However, there is no information in the study what degree of “waisting” resulted in an intervention. The method has not been validated. I would caution those that use this technique. Large diameter balloons (especially if high pressure balloons are used) placed in the angle at the iliac confluence or at the internal iliac venous inflow may produce a false waist with the unfolding of the balloon. An accurate hemodynamic test for outflow obstruction, preferably non-invasive, needs to be developed to establish a defined indication for stenting. Until then awareness of the importance of obstruction, clinical signs and symptoms, and morphological criteria will have to do. A reduction of the ulcer size is not in itself an accepted endpoint, but could be used within a Venous Clinical Severity Score. A proper CEAP classification of the study patients was not given. It is difficult to analyze the reasons for lack of healing and recurrence of ulcers in this small amount of material. None was found. The presence of axial deep reflux, development of “new” reflux, occlusion of the stent system, recurrence of deep vein thrombosis, incompliance with concomitant compression therapy, etc., have certainly been pointed out in larger studies by others. The Effect of Deep Venous Stenting on Healing of Lower Limb Venous UlcersEuropean Journal of Vascular and Endovascular SurgeryVol. 48Issue 3PreviewTo report the outcomes of endovascular interventions on deep veins in patients with venous ulcers (C6). Full-Text PDF Open ArchiveRe. “The Effect of Deep Venous Stenting on Healing of Lower Limb Venous Ulcers”European Journal of Vascular and Endovascular SurgeryVol. 48Issue 6PreviewWe read with interest Peter Neglen's commentary on our paper.1,2 Full-Text PDF Open Archive