Recurrence of chronic venous ulcers on the basis of clinical, etiologic, anatomic, and pathophysiologic criteria and air plethysmography

Abstract

Introduction: Leg ulcers associated with chronic venous insufficiency (CVI) frequently recur after healing. The risk of recurrence has not been well defined for patients in different anatomic and hemodynamic groups. We reviewed the risk of ulcer recurrence on the basis of clinical, etiologic, anatomic, and pathophysiologic criteria and hemodynamic characteristics of the affected limb as assessed with air plethysmography (APG). Methods: Ninety-nine limbs with class 6 CVI were assessed clinically and with standing duplex ultrasound scanning and APG for the definition of clinical, etiologic, anatomic, and pathophysiologic criteria. Leg ulcers were treated with high-pressure compression protocols. Surgical correction of venous abnormalities was offered to patients with appropriate conditions. After ulcer healing, the limbs were placed in compressive garments and followed at 6-month intervals for ulcer recurrence. Results: The mean patient age was 54.3 years, and 46% of the patients were female. Corrective venous surgery was performed in 37 limbs. The mean follow-up time for all 99 limbs was 28 months. The ulcer recurrence rate with life table was 37% ± 6% at 3 years and 48% ± 10% at 5 years. The patients who underwent venous surgery had a significantly lower recurrence rate (27% ± 9% at 48 months) than did those patients who had not undergone surgery (67% ± 8% at 48 months; P =.005). The patients with deep venous insufficiency (DVI; n = 51) had significantly higher recurrence rates (66% ± 8% at 48 months) than did the patients without DVI (n = 48; 29% ± 9% at 48 months; P =.006). This difference was significant even after accounting for the effects of surgery (P =.03).The hazard ratio of ulcer recurrence increases by 14% for every unit increase in the venous filling index (VFI; P =.001). This remains significant even after accounting for the effects of surgery (P =.001). The combination of DVI and a VFI of more than 4 mL/s yields a risk of ulcer recurrence of 43% ± 9% at 1 year and 60% ± 10% at 2 years. Conclusion: Leg ulcers associated with CVI have a high rate of recurrence. Ulcer recurrence is significantly increased in patients with DVI and in patients who do not have venous abnormalities corrected surgically. The VFI obtained from APG is useful in the prediction of increased risk for recurrence, particularly in association with anatomic data. (J Vasc Surg 2002;35:723-8.)