Venous Registry Ulcer Project and Prevalence of Surgically Correctable Reflux Disease

Introduction, Objectives, and/or Purpose: Clinical presentations of venous disease resulting from venous insufficiency may reflect abnormalities in the superficial and/or deep venous systems. CVD encompasses overlapping common presentations, including progressive leg discomfort, fullness, edema, with end stage physical findings of VLU. CVD is common with varicose veins in ~ 40% of the population. VLU affects 1−2% of the population, with the prevalence increasing to up to 4% in those over 65 years of age (Davies 2019). Both conditions are expensive, together responsible for up to 2% of the annual healthcare budget expenditure of Western societies (Rabe 2010). The ESCHAR and EVRA trials demonstrated that surgical correction of superficial venous reflux with compression reduced ulcer recurrence, resulted in faster healing times (EVRA), and are cost effective.(Epstein study from EVRA Investigators 2019). Large scale data regarding patients with chronic VLUs presenting to venous centers with treatable superficial venous insufficiency has not been previously reported. Our study was designed to evaluate what percentage of leg ulcer patients presenting to dedicated vein centers possess surgically correctable superficial venous insufficiency

Methods: The AVLS PRO Venous Registry began collecting data in 2014 and is one of two registries focused on chronic venous disorders. Of providers entering data, greater than 60% are diplomats of the ABVLM. The database was queried first for presence of ulcer by CEAP C6 status. This was further correlated by crossing the number of ulcers for the same limb in rVCSS. From here, the demographics, index duplex details, and rVCSS features for duration of ulcer and compression use were analyzed. Once presence of ulcer had been validated by CEAP and rVCSS, the population was further distinguished into groups based upon sonography reported hemodynamic pathology, e.g., Normal, Reflux, Obstruction, or Reflux & Obstruction. The query was directed toward all patients entering participating centers from January 2018 thru January 2022.

Results: More than 270,000 unique patient records were reviewed, resulting in 1878 unique subjects (0.69%) presenting with a leg wound, 1,048 (55.8%) males and 830 (44.2%) females. Group A represents patients with isolated superficial pathology (68.6%), Group B represents patients with mixed superficial and deep pathology (12.7%), Group C represents patients with post thrombotic syndrome and isolated deep vein pathology (14.8%), group N were patients with leg wounds and no venous pathology (14.8%). rVCSS values in Groups A & B were significantly higher than Group N. In Group A, the dominant patterns involved the GSV above the knee (54.8%), the SSV (30.7%) and the Anterior Accessory GSV (14.4%). We evaluated each pattern for multiple noncontiguous axial segments of reflux and found single axial, double axial, and triple axial frequencies of 62.0%, 31.5%, and 6.5% respectfully. The limbs in this group would be eligible for 1.45 ablation procedures per limb. In Group B, venous insufficiency was found in the GSV above the knee (61.7%), the SSV (26.2%), and the Anterior Accessory GSV (12.1%). Evaluating frequencies of noncontiguous axial segments of reflux, we found single axial, double axial, and triple axial frequencies of 56.2%, 35.3%, and 8.4% respectively. This group would be eligible for 1.52 ablations per limb. When considering Groups A, B and C, duplex analysis found that 97% of subjects in this study have surgically correctable disease.

Conclusion(s): The AVLS PRO database demonstrated 85% of leg ulcers in this study were venous and 97% of these patients had surgically correctable superficial reflux disease. Vein centers serve in a pivotal position to both accurately identify and efficiently treat VLU patients, potentially accelerating wound closure rates and decreasing recidivism rates. For vein centers not providing wound cares, further collaborative efforts are indicated to maximize patient care. Additionally, further study of the impact on medical economics for the cost of care within the registry is indicated.