Place de la chirurgie dans le traitement de l’ulcère veineux de jambe

Abstract

Venous ulcer is the most frequent lower leg ulcer and is considered as the most severe complication of the chronic venous disease. Its prevalence has been estimated between 0.2 and 0.3 %. Chronicity and recurrence of venous ulcer are responsible of its major impact on Health expenses. In terms of etiology primary venous insufficiency is identified in half of the patients presenting a venous ulcer and at less two thirds out the 3 venous systems (superficial, deep and perforator) are pathologic. Microcirculation abnormalities and their tissue consequences are presently better understood and identified. Clinical examination is the key for deciding what investigations may be undertaken and allows to establish a prognosis both in terms of healing and recurrence. Surgical procedures can be classified in 2 groups, those that are devoted to ulcer healing and those that aim to prevent recurrence. Superficial venous surgery provides excellent results in absence of deep venous insufficiency. The exact benefice of combined perforator surgery is still debated. Deep venous reconstructive surgery gives better results for preventing ulcer recurrence in primary etiology than in secondary. In ulcer with combined arterial and venous insufficiency when reconstructive arterial is successful in association with superficial venous surgery results are good in primary venous insufficiency. Results are less satisfactory in postthrombotic insufficiency. In terms of indications, surgery is exceptionally justified for healing venous ulcer. Conversely venous surgery is strongly recommended in absence of deep venous insufficiency for preventing ulcer recurrence in primary varicose veins. Perforator surgery indication remains unclear, but a relative consensus has been established for treating large incompetent calf perforators. Indications of deep venous reconstructive surgery are controversial. It looks to be considered after failure of the conservative treatment. In ulcer with combined arterial and venous insufficiency reconstructive arterial surgery when potentially feasible is mandatory both for healing and preventing ulcer recurrence.