Complete Venous Ulceration Healing after Perforator Ablation Does Not Depend on Treatment Modality

Abstract

Venous leg ulceration (VLU) represents the most advanced form of chronic venous insufficiency (CVI). Persistent VLU that fails to respond to noninvasive treatment requires a minimally invasive endovascular treatment, which may include chemical (ultrasound-guided foam sclerotherapy [UGFS]) and thermal ablation (endovenous laser therapy [EVLT] or radiofrequency ablation [RFA]) targeting incompetent veins. Current guidelines suggest ablation of incompetent perforating veins (IPVs) juxtaposed to active or healed VLU; however, the ideal treatment modality is unknown. We hypothesize that similar to incompetent superficial vein treatment options therapies, VLU healing will be equivalent across minimally invasive IPV treatment options. Using the Vascular Low Frequency Disease Consortium, adults with VLU across 11 medical centers were retrospectively reviewed (2013-2017). We included those who underwent IPV therapies. The primary outcome was complete ulcer healing over time compared with cumulative hazard curves, log-rank testing, and multivariable Cox proportional hazard regression. Secondary outcomes included number of subsequent procedures, which were compared using negative binomial regression. Of the 832 adults with VLU, 158 (19%) were exclusively treated conservatively, and 232 (28%) underwent index treatment for IPV and constitute the full and final cohort. The mean age was 60±14years, 57% were men, and the mean ulcer area was 3.0cm2 (interquartile range, 1-6 cm2). Ninety-one (39%) were treated with EVLT, 127 (55%) RFA, and 14 (6%) UGFS. Patients treated with RFA were older (RFA 62±14years; EVLT 59±14 years; UGFS 52±9 years; P=0.01), more likely to be men (RFA 68%, n=86; EVLT 41%, n=37; UGFS 64%, n=9; P<0.001), with a higher frequency of anticoagulation (RFA 36%, n=46; EVLT 18%, n=16; UGFS 14%, n=2; P=0.005). VLU did not significantly differ in size between groups (RFA 6.2±8; EVLT 4.2±5.4; UGFS 6.1±8; P<0.001). There were no differences in 1-year ulcer healing rates between groups (P=0.18). The number of subsequent procedures did not differ by treatment modality (P=0.47). This multi-institutional retrospective study does not demonstrate any association of IPV treatment modality with differing rates of VLU healing or number of subsequent procedures.