Venous leg ulcers affect approximately half a million people in the UK At any one time about 1/4 of these will be open.

New research just about to be published in the New England Journal of Medicine has shown that treating patients with venous leg ulcers with endovenous “keyhole” surgery results in faster healing than compression bandaging(1).

Venous leg ulcers heal faster with endovenous surgery than compression - New research published in the NEJM - Randomised controlled trial

Venous leg ulcers heal faster with endovenous surgery than compression – New research published in the NEJM – Randomised controlled trial

In the UK, most venous leg ulcers are “treated” by nurses putting compression bandaging around the lower leg. This has been the mainstay of treatment for over a century. Although dressings can heal an ulcer temporarily, the ulcers tend to come back again. This is not surprising as the underlying cause, the venous reflux in the majority of cases, has not been treated by simple bandaging.

What is amazing is it has been known since 1984 that varicose veins or “hidden varicose veins” can be a cause of venous ulceration(2). Since 1999 it has been shown that treatment of the superficial varicose veins can cure venous ulcers(3). My own research has shown that we have shown that we can cure 85% of patients with venous leg ulcers in the long term, 52% of them not ever requiring a compression stocking again(4).

Evidence-based medicine to treat venous leg ulcers:

We live in an age of evidence-based medicine. Most people in medicine agree that we should follow what the best evidence shows. In medicine, the highest form of evidence is what is called a “randomised controlled trial”.

In 2004, a randomised controlled trial called the ESCHAR study reported its results. It showed that patients with venous leg ulcers randomised to either varicose vein surgery or compression treatment showed no difference in how quickly the ulcers healed. However, the patients who had the varicose vein surgery had a significantly lower chance of getting ulcers back again one year later(5).

This really isn’t very surprising. Most people would think that when you cure the underlying problem, not only with the condition heal but it would be less likely to come again in the future. Despite this, patients in the UK continued to have compression bandaging and patients were still not referred for venous surgery.

Analysis of the randomised controlled study also showed a flaw in the reasoning. The start of treatment in the ESCHAR study was taken as when the randomisation was performed. Therefore, patients who were randomised to compression had compression started immediately. However, those who were randomised to surgery had to wait for their operation to be scheduled. Hence the advantage in increasing healing rate with surgery was lost in the design of the trial.

This latest study has corrected that problem (1). In this new randomised controlled trial, patients with venous leg ulcers were randomised to endovenous “keyhole” surgery or compression treatment. When this was studied properly, it was clear that venous leg ulcers healed quicker following endovenous surgery than with compression.

The NICE guidelines state that patients who have had a venous leg ulcer for two weeks or more should be referred to a vascular service for a venous duplex ultrasound scan, for consideration of endovenous surgery (6). Endovenous surgery to cure the venous reflux underlying a venous leg ulcer costs approximately the same as one year of dressing a leg ulcer with compression dressings.

Therefore, as treating venous leg ulcers surgically:

  • results in faster healing of venous leg ulcers
  • reduces the risks of the leg ulcer coming back again
  • is less expensive than compression after one year of compression
  • is recommended in the NICE clinical guidelines

then the only question that remains is why are UK patients with venous leg ulcers still having compression treatment and are not being referred for consideration for endovenous surgery?

Article by Professor Mark Whiteley – Founder of the Leg Ulcer Charity

References:

1 – Gohel MS, Heatley F, Liu X, Bradbury A, Bulbulia R, Cullum N, Epstein DM, Nyamekye I, Poskitt KR, Renton S, Warwick J, Davies AH; EVRA Trial Investigators. A Randomized Trial of Early Endovenous Ablation in Venous Ulceration. N Engl J Med. 2018 Apr 24. doi: 10.1056/NEJMoa1801214. [Epub ahead of print] – See link: https://www.ncbi.nlm.nih.gov/pubmed/29688123

2 – Sethia KK, Darke SG. Long saphenous incompetence as a cause of venous ulceration. Br J Surg. 1984 Oct;71(10):754-5. See: https://www.ncbi.nlm.nih.gov/pubmed/6487973

3 – Bello M, Scriven M, Hartshorne T, Bell PR, Naylor AR, London NJ. Role of superficial venous surgery in the treatment of venous ulceration. Br J Surg. 1999 Jun;86(6):755-9. See ; https://www.ncbi.nlm.nih.gov/pubmed/10383574

4 – Thomas CA, Holdstock JM, Harrison CC, Price BA, Whiteley MS. Healing rates following venous surgery for chronic venous leg ulcers in an independent specialist vein unit. Phlebology. 2013 Apr;28(3):132-9. – See link: https://www.ncbi.nlm.nih.gov/pubmed/22833505

5 – Barwell JR, Davies CE, Deacon J, Harvey K, Minor J, Sassano A, Taylor M, Usher J, Wakely C, Earnshaw JJ, Heather BP, Mitchell DC, Whyman MR, Poskitt KR. Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomised controlled trial. Lancet. 2004 Jun 5;363(9424):1854-9. See link: https://www.ncbi.nlm.nih.gov/pubmed/15183623

6 – https://www.nice.org.uk/guidance/cg168/chapter/1-Recommendations