Chronic Venous Insufficiency

Introducing knowledge of wearing compression stockings on the skin blood flow by using microHematron device

The aim of this preliminary study was to review the actual state of knowledge concerning the mechanisms underlying compression medical stockings action on the skin blood flow (SBF) in capillaries. SBF was assessed by measuring the thermal conductivity of living-tissues using microHematron ambulatory device. The investigation was performed for different postures using three standard French classes (10-15 mmHg, 15-20 mmHg and 20-36 mmHg) of Medical compression stockings (MCS) on six healthy subjects without chronic venous insufficiency. The experiment was divided into four stages (supine, sitting, standing and walking) and was repeated for each class of compression stockings and without MCS. The results showed a significant improvement of SBF depending on the class of MCS used. Best results were obtained for the Class III, which exerts to the highest level of pressure exerted around the ankle. Due to the low number of subjects, which therefore reduces the statistical relevance of results, a non-significant difference in SBF due to the subject's posture was observed. Nonetheless, a positive action by all the classes of MCS on SBF was measured for the supine position. This is a very important result; with patients with chronic venous insufficiency have often some mobility reduction, MCS may enhance their microcirculation even at rest.

Human skin wounds: a major and snowballing threat to public health and the economy

ABSTRACT In the United States, chronic wounds affect 6.5 million patients. An estimated excess of US$25 billion is spent annually on treatment of chronic wounds and the burden is rapidly growing due to increasing health care costs, an aging population and a sharp rise in the incidence of diabetes and obesity worldwide. The annual wound care products market is projected to reach $15.3 billion by 2010. Chronic wounds are rarely seen in individuals who are otherwise healthy. In fact, chronic wound patients frequently suffer from "highly branded" diseases such as diabetes and obesity. This seems to have overshadowed the significance of wounds per se as a major health problem. For example, NIH's Research Portfolio Online Reporting Tool (RePORT; http://report.nih.gov/), directed at providing access to estimates of funding for various disease conditions does list several rare diseases but does not list wounds. Forty million inpatient surgical procedures were performed in the United States in 2000, followed closely by 31.5 million outpatient surgeries. The need for post-surgical wound care is sharply on the rise. Emergency wound care in an acute setting has major significance not only in a war setting but also in homeland preparedness against natural disasters as well as against terrorism attacks. An additional burden of wound healing is the problem of skin scarring, a $12 billion annual market. The immense economic and social impact of wounds in our society calls for allocation of a higher level of attention and resources to understand biological mechanisms underlying cutaneous wound complications.

Impact of injection drug use on distribution and severity of chronic venous disorders

We examined chronic venous disorders (CVD) in persons who injected illicit drugs. The study design was cross-sectional, comparative stratified by age, gender, ethnicity, as well as by three types of drug use (noninjection; arm or upper body injection only; and legs with or without upper body injection). Subjects completed demographic, health, and substances abuse questionnaires and were evaluated using the clinical component of the Clinical-Etiology-Anatomy-Pathophysiology Classification. Seven hundred and thirteen participants were evaluated. Those who injected in the legs +/- arms had significantly worse CVD. Thirty-nine percent of leg +/- arm injectors vs. 4.2% or noninjectors or arm only injectors had moderate to severe CVD. Persons who injected in the legs +/- arms were 9.14 times more likely to develop venous ulcers than those that injected in the arms and upper body only and 34.64 times more likely as those who never injected. CVD was associated with injecting in the groin, legs and feet as compared with other sites. The pattern of disorders associated with leg injection is consistent with the underlying pathology of chronic venous insufficiency.

Varicose veins show enhanced chemokine expression

OBJECTIVES

Leucocyte infiltration in the wall of varicose veins has been reported previously. This study was designed to investigate the expression of pro-inflammatory cytokines and chemokines in control and in patients with varicose veins and to test the effect of treating varicose vein patients with acetylsalicylic acid (ASA) on cytokine expression prior to removal of varices.

MATERIAL AND METHODS

Sections of vein were removed during operation from both patient groups, and ribonuclease protection assays (RPAs) were performed to assess the expression of chemokines. Group I included non-varicose saphenous veins from healthy patients undergoing amputation for trauma. Varicose veins were obtained from patients with primary varicose undergoing surgical treatment who received no drug (group II) or treatment with 300 mg day(-1) of ASA for 15 days before surgery (group III).

RESULTS

Non-varicose veins constitutively expressed low levels of monocyte-chemoattractant protein (MCP-1) and interleukin (IL)-8 mRNA. Varicose veins had a distinct chemokine expression pattern, since significant up-regulation of MCP-1 and IL-8 and a marked expression of IP-10, RANTES, MIP-1alpha and MIP-1beta mRNA were detected. Removal of the endothelium did not alter this pattern. Varicose veins obtained from patients treated with ASA showed a consistent decrease in chemokine expression, although it did not reach statistical significance.

CONCLUSIONS

Varicose veins showed increased expression of several chemokines compared to control veins. A non-significant reduction of activation was observed following treatment with ASA for 15 days.

Chronic venous insufficiency is associated with elevated level of circulating microparticles

BACKGROUND

Chronic venous insufficiency (CVI) results when the veins in the legs no longer pump blood back to the heart effectively. Microparticles (MPs) are small membrane vesicles released by several circulating and vascular cells upon activation or apoptosis.

OBJECTIVES

The purpose of this study was to assess the subpopulations of circulating endothelial (EMPs) and platelet microparticles (PMPs) in CVI, and to disclose their contribution in mediating dysfunction of human peripheral venules.

PATIENTS AND METHODS

Human peripheral venules were explanted during leg surgery on patients with CVI and on control subjects (C); concurrently, blood samples were collected and circulating MPs isolated. The techniques used were: flow cytometry, fluorescence and electron microscopy, myograph technique and western-blotting technique.

RESULTS

The results showed that compared with controls, patients with CVI had: (i) a marked elevation of circulating EMPs and PMPs; (ii) a structural modification of the venous wall consisting of activation of endothelial and smooth muscle cells, an abundance of intermediary filaments and synthesis of hyperplasic-multilayered basal lamina; (iii) a significantly altered reactivity of the venous wall, closely associated with EMPs and PMPs adherence; (iv) altered contractile response to noradrenaline, acetylcholine, 5-hydroxytryptamine and KCl, and an impeded relaxation in response to sodium nitroprusside; and (iv) a substantially increased protein expression of tissue factor (TF) and of P-Selectin both in the venular vascular wall and on the surface of EMPs and PMPs.

CONCLUSIONS

The findings indicate that CVI is accompanied by an enhanced release of EMPs and PMPs that contribute to altered dysfunctional response of the venous wall.

Venous Insufficiency and Foot Dysmorphism: Effectiveness of Visco-Elastic Rehabilitation Systems on Veno-Muscle System of the Foot and of the Calf

Chronic venous disease is very common and widespread. Chronic Venous Insufficiency (CVI) is a condition characterized by hypertension of the venous system of the lower limbs which manifests itself through a large range of symptoms. The main cause of (CVI) is hypertension of the venous system of lower limbs, which in most cases is due to reflux for the incontinence of the valvar system of veins. Other causes are related to obstruction of the venous outflow, or at a reduced venous emptying due to inefficiency of the system of the veno-muscular pumps of the calf and of the foot. The purpose of this study was to evaluate if the use of a non-invasive rehabilitative model, which is characterized by two different visco-elastic insoles, is effective both to reduce postural imbalances and to improve the efficiency of the veno-muscular pumps of the foot and of the calf using photoplethysmography in reflected light.

Fifty (50) patients suffering from flatfoot and ped cavus, were studied doing a stabilometric and baropodometric test to evaluate the angle of the foot and the podalic angle. Patients were evaluated by examining vascular examination and venous reography in basal condition, using corrective visco-elastic insoles for the correction of dysmorphisms that we were studying.

An improvement of the angle of the Right and Left axis (p<0.05) and the podalic angle (p<0.001), using the right insole both in the flatfoot and cavus foot, was shown by the podobarographic examination. A not important tendency to improvement was also shown by the use of non-specific insole in both pathologies. The vascular examination showed an improvement of 38% in venous emptying capacity of the foot/calf veno-muscular pump in cavus foot with the specific “B” insole (p<0.002). An important improvement of 24%, using the specific “A” insole (p<0.05), was documented in flatfoot.

The photoplethysmography examination documented a significant improvement of the venous emptying capacity of foot-calf veno-muscular system due to the use of specific insoles for the studied dysmorphism, with an improving tendency even with the use of non-specific insoles. The hemodynamic improvement is correlated with the improvement of the analyzed biomechanical parameters: contact time, lenght of the halfstep, podalic angle and angle of the foot. The partial normalization of biomechanical parameters allows a reorganization of relationships of forces between ground and foot, as well as the improvement of the function of the subtalar joint, causing a partial recovery of the complex physiological mechanism of activation of the veno-muscular pumps of the foot and of the calf.

The effect of surface neuromuscular electrical stimulation and compression hosiery applied to the lower limb, on the comfort and blood flow of healthy subjects

Chronic venous insufficiency (CVI) is a severe disease affecting the venous system of the lower limbs. Compression therapy aims to counteract the venous hypertension caused by CVI. However, in spite of significant advances in compression treatments in recent years, CVI and its associated diseases are frequently characterized by slow healing rates and a need for more aggressive therapies such as surgery. Surface neuromuscular electrical stimulation (SNMES) offers potential benefits when used in conjunction with compression therapy by increasing venous return through muscular compression of the calf muscles. In order to assess the long term feasibility of SNMES with compression hosiery as a treatment modality for CVI, it is necessary to evaluate the effects of such a treatment on subject blood flow and comfort levels. This paper presents the results of a study investigating the effects of long term SNMES and compression hosiery applied to the lower limb, in the comfort and blood flow of healthy subjects.

A nonlinear lumped parameters model to analyze the dynamics of venous reflux

The aim of this work is to formulate a lumped parameters model of the venous tree of the lower limbs in order to study the effects and the possible clinical treatments for Chronic Venous Insufficiency (CVI). CVI is a pathology characterized by an important socio-economic impact due to its relevant prevalence, the costs for its diagnosis and treatment being more frequently widespread among the working population. The planning of haemodynamic surgical operations is critical to treat a pathological pattern of venous blood flow; such planning, in turn, depends on the right analysis of the possible consequences of flow modification. To this regard, the blood flow correction allows to solve the most important venous pathologies, in order to guarantee the restoration of normal blood flow by means of proper modifications of the venous tree. The developed model preserves the geometry of the venous network and considers some non linear resistive and capacitive effects. In fact, the study of the variability of some parameters (i.e. vessel radius) is very important to allow a correct diagnosis of vascular diseases. This variability causes a non linear behaviour of resistance and compliance effects. With the aid of the developed model we evaluate the time profile of blood velocity, flow and pressure in the entire venous network, both in physiological and pathological cases. The obtained results are discussed in comparison with available experimental data.

Exercise training improves cutaneous microvascular endothelial function in post-surgical varicose vein patients

This study investigated the effects of exercise training on cutaneous microvascular function in post-surgical varicose vein patients. Sixteen post-surgical (4-5 weeks) varicose vein patients were randomised to a treadmill-walking exercise group or a non-exercise control group. The exercise group trained twice weekly for 8 weeks. Changes in cutaneous microvascular function of the gaiter area were assessed using laser Doppler flowmetry combined with incremental-dose iontophoretic administration of acetylcholine chloride (ACh) and sodium nitroprusside (SNP) in both supine and standing positions. At 8 weeks, peak flux responses to ACh in the supine position were increased in the exercise group (44+/-30 to 62+/-33 PU; P=0.03) with a similar trend in the standing position (37+/-27 to 74+/-31 PU; P=0.08). There were no such changes in the control group (P>0.05). Additionally, peak flux responses to SNP were unchanged in both groups and body positions (P>0.05). The results suggest that moderate-intensity lower-limb exercise training improves microvascular endothelial vasodilator function in post-surgical varicose vein patients.

Risk factors related to the failure of venous leg ulcers to heal with compression treatment

BACKGROUND

Compression therapy is the most widely used treatment for venous leg ulcers and it was used in different forms for more than 400 years. Published healing rates of venous ulcers obtained with compression therapy vary widely from 40-95%. According to numerous studies, it has been suggested that the application of external pressure to the calf muscle raises the interstitial pressure resulting in improved venous return and reduction in the venous hypertension. Several risk factors have been identified to be correlated with the failure of venous leg ulcers to heal with compression therapy (longer ulcer duration; large surface area; fibrinous deposition present on >50% of the wound surface and an Ankle Brachial Pressure Index (ABPI) of <0.85.

METHODS

An open prospective single-center study was performed in order to determine possible risk factors associated with the failure of venous ulcers to heal when treated with multi-layer high compression bandaging system for 52 weeks. In the study, 189 patients (101 women, 88 men; mean age 61 years) with venous leg ulcers (ulcer surface >5 cm(2); duration >3 months) were included. The study excluded patients with arterial disease (ABPI <0.8), heart insufficiency with ejection fraction (EF) <35, pregnancy, cancer disease, rheumatoid arthritis, and diabetes. Based on clinical opinion and available literature, the following were considered as potential risk factors: sex, age, ulceration surface, time since ulcer onset, previous operations, history of deep vein thrombosis, body mass index (BMI), reduction in calf circumference >3 cm during the first 50 days of treatment, walking distance during the day <200 meters, calf:ankle circumference ratio <1.3, fixed ankle joint, history of surgical wound debridement, >50% of wound covered with fibrin, depth of the wound >2 cm.

RESULTS

Within 52 weeks of limb-compression therapy, 24 (12.7%) venous ulcers had failed to heal. A small ulceration surface (<20 cm(2)), the duration of the venous ulcer <12 months, a decrease in calf circumference of more than 3 cm, and emergence of new skin islets on >10% of wound surface during the first 50 days of treatment were favorable prognostic factors for ulcer healing. A large BMI (>33 kg/m(2)), short walking distance during the day (<200 m), a history of wound debridement, and ulcers with deepest presentation (>2 cm) were indicators of slow healing. Calf:ankle circumference ratio <1.3, fixed ankle joint, and reduced ankle range of motion were the only independent parameters associated with non-healing (P < .001).

CONCLUSION

The results obtained in this study suggest that non-healing venous ulcers are related to the impairment of the calf muscle pump.

Impact of lower extremity venous ulcers due to chronic venous insufficiency on quality of life

Lower extremity venous ulcers comprise a complex medical and social issue. The conservative and/or surgical management of venous ulcers is often inadequate. In addition, the psychosocial aspect of the disease is often overlooked and most often undertreated. Common symptoms such as pain, low self-esteem and patient isolation are usually not recognized and therefore not adequately managed.This mini-review summarizes the current data on the management of lower extremity venous ulcers and their impact on the quality of life of these patients.

Reversal of lower limb edema by calf muscle pump stimulation

BACKGROUND

Peripheral edema (PE) is commonly coupled with heart failure, restrictive cardiomyopathy, nephrotic syndrome, renal failure, and hypoproteinemia. Diuretics and/or limb elevation, although commonly prescribed to treat PE, are often insufficient to remove sufficient fluid to prevent complications. We assessed the ability of the calf muscle pump (CMP) stimulation to reverse PE.

METHODS

Fluid volume was evaluated by air plethysmography in the right legs of 54 adult women (mean age 46.7 +/- 1.5 years) following venous status assessment. Change in calf volume was assessed during 30 minutes of quiet sitting, followed by 30 minutes of sitting with CMP stimulation via micromechanical stimulation of the plantar surface.

RESULTS

Leg volume changes demonstrated a bimodal distribution. Leg volume decreased during quiet sitting in 56% of the study group, whereas in 44% of the group, significant lower leg fluid pooling was evident (increase in calf volume of 14.0 +/- 0.3 mL/h). CMP stimulation reversed the fluid pooling in the edematous group (-2.7 +/- 0.1 mL/h) and was able to accelerate fluid removal in the nonedematous group.

CONCLUSIONS

Approximately two fifths of adult women experience substantial pooling when their lower limbs are maintained in a dependent position. Lower-extremity edema exhibited by these women may primarily be due to inadequate calf muscle tone because exogenous stimulation of the CMP was sufficient to halt and reverse fluid pooling. Whether CMP stimulation would provide a means to treat PE in individuals with edema-related health complications, such as congestive heart failure, merits further investigation.

[New results in the research of the biomechanics of the venous system]

The upright posture of man had been a major evolutional challenge. The mechanisms responsible for orthostatic tolerance mostly affect the venous system. In this paper, we discuss new results regarding the biomechanics of the venous system highlighting a rather neglected field, the biomechanical properties of the vein wall. These properties change according to localization of veins, age, gender and body mass. The anti-gravitational adaptation of veins is a complex process involving all three layers of the venous wall. Local myogenic and humoral mechanisms as well as systemic hormonal and nervous influences control the adaptive processes in the veins. Long term adaptation involves structural and functional remodeling of the venous wall. Disorders of the veins mostly cause pathological remodeling. Hemodynamic factors (pressure and flow) together with inflammatory processes may lead to pathological alterations, changing the biomechanical properties of the vein wall, which further contribute to the reservation and progression of venous dysfunction. Appropriate testing of venous function can reveal biomechanical disorders even in clinically asymptomatic patients. Thus, biomechanical investigation of veins not only helps to understand the underlying pathomechanism but it also can contribute to early diagnosis and follow-up of venous disorders. When recognized in time, pathological remodeling can be prevented or treated. In this way, the incidence of venous disorder could be cut back reducing both human suffering and material loss.

Minimally invasive vein therapy and treatment options for endovenous heat-induced thrombus

Radiofrequency ablation and endovenous laser therapy are types of minimally invasive techniques that have been used in the treatment of chronic venous insufficiency. In both procedures, high-intensity heat via thermal energy is produced and delivered via an endovenous catheter placed in the saphenous vein. This results in changes that therapeutically induce closure of the vein by denaturing the vessel wall with subsequent thrombus formation. Patients undergo ultrasound 48 to 72 hours postprocedure to confirm vessel occlusion and assess for possible extension of thrombus into the deep venous system. Thrombus is frequently visualized with the procedure in the tributaries, the venous dilations, and at times the saphenofemoral junction. In any other setting, thrombus at the saphenofemoral junction would warrant anticoagulation. However, the characteristics, composition, and behavior of endovenous heat-induced thrombus are different than de novo thrombosis. This postprocedure endovenous heat-induced thrombus is considered a normal consequence of the procedure and does not require traditional anticoagulation in most cases, depending on the location.

Effect of prolonged treatment with compression stockings to prevent post-thrombotic sequelae: a randomized controlled trial

OBJECTIVE

Compression stockings are widely applied after acute proximal deep vein thrombosis, but their efficacy in preventing the post-thrombotic syndrome remains controversial. This study assessed the effect of prolonged compression therapy after a standard treatment of 6 months after acute deep vein thrombosis.

METHODS

Of 900 patients screened, we randomly allocated 169 patients with a first or recurrent proximal deep vein thrombosis after receiving 6 months of standard treatment to wear compression stockings or not. Primary efficacy analysis was performed on the end point of emerging skin changes (C4-C6 according to the CEAP classification). Secondary analysis was done on symptoms associated with post-thrombotic syndrome. All analyses were done according to the intention-to-treat principle.

RESULTS

The primary end point occurred in 11 patients (13.1%) in the treatment group compared with 17 (20.0%) in the control group (hazard ratio [HR], 0.60; 95% confidence interval [CI], 0.28-1.28; P = .19). Mean follow-up was 3.2 years and 2.9 years, respectively. Five additional patients in the control group required compression therapy owing to post-thrombotic signs and symptoms not included in the primary end point. No venous ulceration was observed in either group. Within subgroup analyses of the primary end point, we observed a large sex-specific difference between women (HR, 0.11; 95% CI, 0.02-0.91) and men (HR, 1.07; 95% CI, 0.42-2.73). Symptom relief was significant in favor of compression treatment during the first year but not thereafter.

CONCLUSION

Prolonged compression therapy after proximal deep vein thrombosis significantly reduces symptoms and may prevent post-thrombotic skin changes. Whether these findings translate to the prevention of advanced disease states with ulcerations remains unclear.

Mitogen-Activated Protein Kinase p38 Pathway in Venous Ulcer Fibroblasts

Objective: Venous ulcer fibroblasts (w-fb) have attenuated growth compared to normal fibroblasts (n-fb). The MAPKp38 pathway mediates stress-responses in various diseases. We hypothesize that p38 pathway is altered in w-fb. Methods: W-fb were isolated from venous ulcers and n-fb from the ipsilateral thigh. Fibroblasts were analyzed for phosphorylated p38 using immunoblot. The relation between p38 and w-fb proliferation was assessed with SB203580 (p38 inhibitor). Fibroblasts were treated with bFGF, TNF-a, and IL-1 and p38 expression analyzed. Results: Phosphorylated p38 expression was increased in w-fb (AU%=233.5±59.7, P=0.039) compared to n-fb (AU%=99.9±14.6). W-fb treated with SB203580 demonstrated increased growth compared to untreated w-fb. W-fb treated with bFGF demonstrated decreased p38. TNF-α and IL-1β significantly increase p38 expression. Conclusions: MAPK p38 is up-regulated in w-fb. Regulation of w-fb proliferation is influenced by p38. Altering the p38 pathway in vivo with growth factors or cytokine inhibition may improve fibroblast proliferation and venous ulcer healing.

Cutaneous changes of nephrogenic systemic fibrosis: predictor of early mortality and association with gadolinium exposure

OBJECTIVE

Nephrogenic systemic fibrosis (NSF) is a rapidly progressive, debilitating condition that causes cutaneous and visceral fibrosis in patients with renal failure. Little is known about its prevalence or etiology. The aim of this study was to establish the prevalence of NSF and associated risk factors

METHODS

Two cohorts of patients were recruited from 6 outpatient hemodialysis centers and examined for cutaneous changes of NSF, which were defined using a scoring system based on hyperpigmentation, hardening, and tethering of skin on the extremities. Demographic data were gathered, mortality was followed up prospectively for 24 months, and gadolinium exposure was ascertained for a subgroup of patients in the second cohort.

RESULTS

Examination reproducibility was 97% in cohort 1. In cohort 2, 25 (13%) of 186 patients demonstrated cutaneous changes of NSF. Twenty-four-month mortality following examination was 48% and 20% in patients with and those without cutaneous changes of NSF, respectively (adjusted hazard ratio 2.9, 95% confidence interval [95% CI] 1.4-5.9). Cutaneous changes of NSF were observed in 16 (30%) of 54 patients with prior exposure to gadopentetate dimeglumine contrast during imaging studies. Exposure to gadolinium-containing contrast was associated with an increased risk of developing cutaneous changes of NSF (odds ratio 14.7, 95% CI 1.9-117.0) compared with nonexposed patients.

CONCLUSION

In patients receiving hemodialysis, NSF is an underrecognized disorder that is associated with increased mortality. Exposure to gadolinium-containing contrast material appears to be a significant risk factor for the development of NSF.

A haemodynamic model of the venous network of the lower limbs

The pathologies of the venous system are characterized by a relevant socioeconomic impact in western countries. To this regard, the blood flow correction allows to solve the most important venous pathologies. In these cases, in order to guarantee the restoration of normal blood flow by means of proper modifications of the venous network, the correct planning of haemodynamics surgical operations is needed; such planning in turn depends on the right analysis of the possible consequences of flow modification. To this end, a mathematical model, that allows to precisely study the physiological and pathological behaviour of the venous network of the lower limbs, has been developed. The final goal is to use this model as an instrument helpful to plan surgical operations and give guidelines for the design and the test of new artificial devices. As for the modelling processing, a lumped parameters model has been derived with a resolution which allows to take into account the anatomic characteristics of the venous system.

The nature of skin pigmentations in chronic venous insufficiency: a preliminary report

BACKGROUND

Chronic Venous Insufficiency (CVI) provokes skin pigmentation commonly seen in the gaiter region of the leg. The exact nature and pathogenesis of this are poorly understood.

OBJECTIVE

To evaluate the presence of melanin and haemosiderin in histological sections of the skin of limbs with primary varicose veins.

METHODS

Histological investigations were performed in 49 biopsies from pigmented and non-pigmented skin of limbs with varicose veins and control limbs.

RESULTS

All samples from pigmented skin showed a higher content of melanin than controls. In contrast, haemosiderin was found in only a few biopsies taken from the more severely pigmented skin in areas of lipodermatosclerosis. Erythrocyte diapedesis was observed only where an intense inflammatory process was also present.

CONCLUSIONS

Our findings suggest that in the initial phases of skin changes due to venous disease, pigmentation is attributable to melanin. Haemosiderin seems to play a role in the evolution of skin changes toward lipodermatosclerosis and ulceration. Erythrocyte diapedesis is likely to occur only during acute phases of the inflammatory process. Further investigations are needed to explain the cause and the exact cellular and molecular mechanisms responsible for hypermelanisation occurring in early phases of skin changes in CVI.

A randomized trial of the Tubulcus multilayer bandaging system in the treatment of extensive venous ulcers

BACKGROUND

Venous ulcers are a major health problem because of their high prevalence and associated high cost of care. Compression therapy is the most widely used treatment for this condition. The vast majority of published articles on compression therapy present the results in the treatment of venous ulcers usually up to 15 to 20 cm(2). However, there are no published data in English medical literature on the efficacy of compression therapy in the treatment of extensive venous ulcers (ulcers >20 cm(2) of more than 6 months' duration) with regard to healing rate, time to healing, and recurrence rate at 12 months after healing.

METHODS

A total of 138 patients with extensive venous ulceration (ulceration surface, 20-210 cm(2); duration, 7 months to 28 years) were randomized into 2 groups: (1) a treatment group (72 patients who were treated by using a multilayer bandaging system with the Tubulcus (a heelless open-toed elastic compression device knitted in tubular form) and elastic bandages and (2) a control group (66 patients treated with a multilayer bandaging system with elastic bandages only). The patients were treated on an ambulatory basis; the primary end point of the study was complete ulcer healing at 500 days. The secondary end point was to assess the ulcer recurrence rate during continuation of below-knee compression of different degrees of compression. In the treatment group, patients were instructed to continue to wear the Tubulcus (35 mm Hg), and patients in the control group were instructed to wear compression stockings with compression of 20 to 25 mm Hg. The exclusion criteria from the study were heart insufficiency with an ejection fraction <35, an ankle-brachial pressure index less than 0.8, and pregnancy.

RESULTS

The cumulative healing rate was 93% in the treatment group and was 51% in the control group (P < .001). The median healing time in the treatment group was 133 days (range, 28 to 464 days), and in the control group it was 211 days (range, 61 to 438 days). The recurrence rate at 12 months in the treatment group was 24% (16/67) and was 53% (18/34) in the control group (P < .05). After additional compression treatment with the same treatment protocol, all 16 recurrent ulcers in the treatment group healed. In the control group, the healing rate of recurrent ulcers was 89% (16/18).

CONCLUSIONS

This study suggests that for extensive venous ulceration, multilayer compression therapy with the Tubulcus provides an extremely high healing rate. Compression of more than 30 mm Hg results in decreased ulcer recurrence. However, recurrence cannot be completely avoided.

Recent insights into the causes of chronic leg ulceration in venous diseases and implications on other types of chronic wounds

Venous ulceration represents the most prevalent form of difficult-to-heal wounds and these problematic wounds require a significant amount of healthcare resources for their treatment. In order to develop effective treatment regimens a clearer understanding of the underlying pathological processes that lead to skin breakdown is required. However, to date, most of these studies have tended to focus on describing the pathology of already-established ulcers. By bringing together relevant aspects of diverse disciplines such as inflammation, cardiovascular, and connective tissue biology, we aim to provide an insight into how circulatory abnormalities that are caused by the underlying disease etiology can induce local tissue inflammation resulting in tissue breakdown. Initially this results in internal tissue damage but if the underlying disease is not treated, the internal tissue damage can worsen and lead to open ulceration. This article discusses the cause-and-effect relationships between chronic venous insufficiency and venous ulceration, focusing particularly on the biological processes that lead from the underlying disease condition to overt ulceration. Available evidence also suggests that formation of pressure, diabetic foot and arterial ulcers, and ulcers as results of blood disorders, is also likely to share some of the same biological processes as venous ulcers.

Treatment of chronic venous insufficiency

Chronic venous insufficiency (CVI) results from venous hypertension secondary to superficial or deep venous valvular reflux. Treatment modalities are aimed at reducing venous valvular reflux, thereby inhibiting the ensuing pathologic inflammatory process. Compression therapy using pumps, bandaging, and/or graded compression stockings is the mainstay of treatment for CVI. Compression therapy has been shown to be effective in reducing venous hypertension retarding the development of inflammation and pathologic skin changes. Pharmacologic agents such as diuretics and topical steroid creams reduce swelling and pain short term but offer no long-term treatment advantage. Herbal supplements may reduce the inflammatory response to venous hypertension, but are not licensed by the US Food and Drug Administration, and vary in their efficacy, quality, and safety. However, several randomized controlled trials using the herbal horse chestnut seed extract containing aescin have shown short-term improvement in signs and symptoms of CVI. Endovascular and surgical techniques aimed at treatment of primary and secondary venous valvular reflux have been shown to improve venous hemodynamics promoting healing of venous ulcers and improving quality of life. The newer endovascular treatments of varicose veins using laser, radiofrequency ablation, and chemical foam sclerotherapy show some promise.

Emergency Management of Chronic Wounds

As America's emergency departments witness an increase in care provided to an aging population, the emergency physician increasingly evaluates and treats manifestations of chronic disease. Nonhealing wounds are often a presenting manifestation of chronic disease. They are a source of pain and disability for this population. Emergency physicians should possess a fundamental knowledge in the management of chronic wounds. This article familiarizes the emergency physician with the epidemiology of chronic wounds, the physiology of tissue repair, the pathophysiology involved in wound healing failure, the common types of chronic wounds, and specific management strategies.

Contention-compression élastique, plaidoyer et proposition pour une utilisation raisonnée

Elastic stockings and compression therapy are often considered as a major tool in the prevention and in the treatment of chronic venous insufficiency and of lymphedema. Nevertheless we must note that this therapeutic option is both underused and misused. We discuss the reasons for this paradox and the expected modes of action and pathophysiological benefits, and finally propose a prescription guide (indications, dosage, practice details) for a rational use of elastic stockings and compression therapy.

Venous thromboembolism: scope of the problem and the nurse's role in risk assessment and prevention

Deep vein thrombosis and pulmonary embolism, comprising different manifestations of the same clinical entity referred to as venous thromboembolism, are a significant cause of morbidity and mortality. Despite pulmonary embolism being considered the most preventable cause of in-hospital death, the use of appropriate thromboprophylaxis remains suboptimal in many patients. Nurses are on the frontline of thrombosis prevention. By playing an essential role in diagnosis and risk assessment, applying timely preventive methods, and providing vital educational and psychologic support for patients with venous thromboembolism, skilled nursing intervention can save lives.

Treatment of patients with venous insufficiency with fresh plant horse chestnut seed extract: a review of 5 clinical studies

Extracts from the seed of the horse chestnut (Aesculus hippocastanum L.) have traditionally been used to treat patients with chronic venous insufficiency and to alleviate its associated symptoms, including lower leg swelling. The efficacy of preparations that contain horse chestnut seed extract (HCSE) is believed to be due largely to an inhibitory effect on the catalytic breakdown of capillary wall proteoglycans. Aesculaforce is a fresh plant HCSE that is available as an oral tincture, as tablets (20 mg or 50 mg), and as topical gel. Four clinical trials in patients with chronic venous insufficiency and 1 study in patients with varicose veins demonstrated the effectiveness of these preparations through the objective measure of reduction in lower leg edema and the subjective alleviation of leg pain, heaviness, and itching. Safe, well tolerated, and acceptable to patients, the fresh plant HCSE preparation Aesculaforce offers a real alternative in the treatment of patients with mild to moderate venous insufficiency.