Genese des Ulcus cruris: Analyse der Patienten einer dermatologischen Wundambulanz

32-year-old Traumatic Arteriovenous Fistula Presenting With Leg Ulcer and High-output Heart Failure

Traumatic arteriovenous fistula (AVF) is not a common disorder, and dermatological signs and heart failure caused by AVF are rarely reported. We present the case of a 55-year-old woman who was referred for congestive heart failure symptoms. Echocardiography revealed preserved left ventricular ejection fraction. Due to edema of the right leg with a long-standing leg ulcer and palpable femoral thrill, duplex ultrasonography was performed. It showed an AVF between the right superficial femoral artery (SFA) and the right femoral vein (FV). The patient recalled a 32-year-old gunshot injury that was not medically treated. After the diagnosis of AVF she was referred to a surgeon for an AVF ligation, with subsequent resolution of her symptoms. The differential diagnosis of leg ulcer with leg edema should include the possibility of AVF as a cause.

[Venous ulcus cruris-Surgical treatment]

Venous ulcus cruris is usually a chronic disease and an extreme burden for patients and their families. An analysis based on a random statutory health insurance sample of the AOK Hessen/KV Hessen estimated the number of affected people to be 400,000 in Germany. A venous ulcus cruris is always caused by an underlying chronic venous insufficiency (CVI). A spontaneous healing of this chronic disease without treatment is not to be expected. The conservative treatment includes an adequate compression treatment and exudate management. Surgical treatment is based on three pillars: an open surgical or endovenous approach to resolve the pathological venous reflux, uIcer surgery and in rare cases the various procedures of fascia surgery as well as defect coverage by a combination of negative pressure wound therapy and skin transplantation.

Inflammatory skin diseases and wounds

Inflammatory wounds of the skin can be caused by many different diseases. Of particular importance here are the very heterogeneous groups of vasculitides and vasculopathies. These are usually interdisciplinary relevant diseases that require extensive diagnostics in specialized centres. Clinically, these inflammatory wounds present as very painful ulcers that develop from necrosis and are surrounded by erythematous livid borders. The healing process is often difficult and protracted. Moreover, it considerably impairs the quality of life of the affected patients. In addition to clinical evaluation, histopathological examination of biopsies taken as early as possible is particularly important in diagnosis. Numerous differential diagnoses must be ruled out. Therapeutically, in addition to the often necessary systemic therapies, which include immunosuppressants (immunomodulating drugs and/or rheologics), appropriate topical wound treatment, usually in combination with compression therapy, should always be considered. Whenever possible, the causative factors should be diagnosed early and avoided or treated.

[Modern ulcer surgery : Invasive treatment options using the example of therapy-resistant venous leg ulcers]

The socioeconomic significance of chronic venous leg ulcers is considerable due to the high number of patients, the costs of diagnosis and therapy, the deterioration in quality of life, and the loss of working capacity during the disease. This is further increased by a progressive course and an increased tendency to recurrence. Taking these facts into account, surgical treatment options are of particular importance, especially in otherwise therapy-refractory courses. For this purpose, an extensive spectrum of surgical and new, partly not yet finally evaluated, invasive techniques are now available. Venous surgery and endovenous closure techniques are suitable for eliminating primary or secondary varicosis as a causal therapy for venous leg ulcers. Shave therapy is the method of choice in the presence of dermatolipo(fascio)sclerosis. Current long-term results show good results with cure rates of 70-80%. In individual cases, surgical techniques involving fascia cruris (faciotomy, fasciotomy) can also be used. Recurrence ulcers can often be successfully treated by repeated shave therapy, optionally with simultaneous vacuum-assisted dressing techniques or by a fasciotomy. In addition, local invasive techniques such as autologous fat tissue transplantation or autologous platelet-rich plasma can be used to promote wound healing. Thus, both surgically invasive local therapy and advanced surgery of the causes of chronic venous leg ulcers play a key role in the overall therapy concept.

The Treatment of Low Leg Nonischemic Ulcers With a Traditional Chinese-Pharmaceutical Medium: A Randomized Controlled Multicenter Clinical Study

The aim of this study was to observe the curative effect and mechanism of Shengji Yuhong ointment in the healing of chronic ulcer of lower limbs. 400 patients were equally divided into treatment group and control group. The treatment group was covered with a piece of Shengji Yuhong ointment gauze, while the control group was covered with a piece of Vaseline gauze. Both groups changed dressings every other day for 4 weeks. On the 3rd, 7th, 14th, 21st, and 28th days of treatment, the reduction rate of wound area and the growth of wound granulation were observed and the levels of hydroxyproline and hemoglobin in wound granulation tissue were measured. The total effective rate was 99.00% in the treatment group and 71.00% in the control group. The treatment group was significantly better than the control group ( P < .01). The ulcer area reduction rate of the treatment group was significantly higher than that of the control group ( P < .01). The scores of ulcer depth, granulation color, and coverage area on the 7th, 14th, 21st, and 28th days after treatment in the treatment group were significantly lower than those before treatment ( P < .05). After treatment, the levels of hydroxyproline and hemoglobin in granulation tissue of wounds in both groups were significantly higher than those before treatment ( P < .01), and the levels in the treatment group were significantly higher than those in the control group ( P < .01). Shengji Yuhong ointment can improve the healing rate of chronic ulcer of lower limbs.

A randomized trial of early endovenous ablation in venous ulceration: a critical appraisal: Original Article: Gohel MS, Heatly F, Liu X et al. A randomized trial of early endovenous ablation in venous ulceration. N Engl J Med 2018; 378:2105-114

AIM

Gohel et al. aimed to compare early endovenous ablation vs. deferred endovenous ablation of superficial venous reflux with regard to time to healing of venous leg ulcers, rate of healing at 24 weeks, recurrence rate, ulcer-free time and health-related quality of life.

SETTING AND DESIGN

This multicentre, parallel-group (ratio 1 : 1), randomized controlled trial was conducted in a vascular surgery department setting at 20 participating centres across the U.K.

STUDY EXPOSURE

A total of 450 patients with venous leg ulcers were randomly assigned to receive compression therapy and undergo early endovenous ablation of superficial venous reflux within 2 weeks after randomization (early-intervention group) or to receive compression therapy alone, with consideration of endovenous ablation deferred until after the ulcer was healed or until 6 months after randomization if the ulcer was unhealed (deferred-intervention group).

OUTCOMES

The primary outcome was the time to ulcer healing. Secondary outcomes were the rate of ulcer healing at 24 weeks, the rate of ulcer recurrence, the length of time free from ulcers (ulcer-free time) during the first year after randomization, and patient-reported health-related quality of life.

TRIAL INTERVENTIONS

Endovenous laser or radiofrequency ablation, ultrasound-guided foam sclerotherapy, or nonthermal, nontumescent methods of treatment (such as cyanoacrylate glue or mechanochemical ablation) were performed either alone or in combination. The treating clinical team determined the method and strategy of endovenous treatment.

RESULTS

The time to ulcer healing was shorter in the early-intervention group than in the deferred-intervention group. Furthermore, more patients had healed ulcers with early intervention [hazard ratio for ulcer healing 1·38, 95% confidence interval (CI) 1·13-1·68; P = 0·001]. The median time to ulcer healing was 56 days (95% CI 49-66) in the early-intervention group and 82 days (95% CI 69-92) in the deferred-intervention group. The rate of ulcer healing at 24 weeks was 85·6% in the early-intervention group and 76·3% in the deferred-intervention group. The median ulcer-free time during the first year after trial enrolment was 306 days (interquartile range 240-328) in the early-intervention group and 278 days (interquartile range 175-324) in the deferred-intervention group (P = 0·002). The most common complications were pain and deep vein thrombosis (DVT) (early-intervention group: pain, six of 28; DVT, nine of 28; deferred-intervention group: pain, six of 24; DVT, three of 24).

CONCLUSIONS

Gohel et al. conclude that early endovenous ablation of superficial venous reflux results in faster healing of venous leg ulcers than deferred endovenous ablation. Patients assigned to the early-intervention group also had longer ulcer-free time during the first year after randomization.

Management of Patients With Venous Leg Ulcers: Challenges and Current Best Practice

Introduction It is well documented that the prevalence of venous leg ulcers (VLUs) is increasing, coinciding with an ageing population. Accurate global prevalence of VLUs is difficult to estimate due to the range of methodologies used in studies and accuracy of reporting. (1) Venous ulceration is the most common type of leg ulceration and a significant clinical problem, affecting approximately 1% of the population and 3% of people over 80 years of age (2) in westernised countries. Moreover, the global prevalence of VLUs is predicted to escalate dramatically, as people are living longer, often with multiple comorbidities. Recent figures on the prevalence of VLUs are based on a small number of studies, conducted in Western countries, and the evidence is weak. However, it is estimated that 93% of VLUs will heal in 12 months, and 7% remain unhealed after five years. (3) Furthermore, the recurrence rate within 3 months after wound closure is as high as 70%. (4) (-6) Thus, cost-effective adjunct evidence-based treatment strategies and services are needed to help prevent these ulcers, facilitate healing when they occur and prevent recurrence. The impact of a VLU represents social, personal, financial and psychological costs on the individual and further economic drain on the health-care system. This brings the challenge of providing a standardised leg ulcer service which delivers evidence-based treatment for the patient and their ulcer. It is recognised there are variations in practice and barriers preventing the implementation of best practice. There are patients not receiving appropriate and timely treatment in the initial development of VLUs, effective management of their VLU and preventing recurrence once the VLU has healed. Health-care professionals (HCPs) and organisations must have confidence in the development process of clinical practice guidelines and have ownership of these guidelines to ensure those of the highest quality guide their practice. These systematic judgments can assist in policy development, and decision making, improve communication, reduce errors and improve patient outcomes. There is an abundance of studies and guidelines that are available and regularly updated, however, there is still variation in the quality of the services offered to patients with a VLU. There are also variations in the evidence and some recommendations contradict each other, which can cause confusion and be a barrier to implementation. (7) The difference in health-care organisational structures, management support and the responsibility of VLU management can vary in different countries, often causing confusion and a barrier to seeking treatment. These factors further complicate the guideline implementation process, which is generally known to be a challenge with many diseases. (8).

Moderne Ulkus-Chirurgie – Chirurgische Behandlungsoptionen

Einleitung: Die sozioökonomische Bedeutung des chronischen Ulcus cruris venosum ist bedingt durch die hohe Anzahl der Erkrankten, die Kosten der Diagnostik und Therapien, die Verschlechterung der Lebensqualität und des Verlustes der Arbeitsfähigkeit während der Erkrankung beträchtlich. Diese Problematik wird durch einen oft langjährigen Verlauf sowie eine hohe Rezidivneigung zusätzlich gesteigert.

Diskussion: Unter Berücksichtigung dieser Fakten, kommt den chirurgischen Therapieoptionen insbesondere bei ansonsten therapieresistenten Verläufen eine besondere Bedeutung zu. Heute steht hierfür ein umfangreiches Spektrum an interventionellen Methoden zur Verfügung. Venenchirurgie und endovenöse Verschlusstechniken sind für die Ausschaltung einer primären oder sekundären Varikosis als kausale Therapie des Ulcus cruris venosum geeignet. Die sogenannte Shave-Therapie ist bei dem Vorliegen einer Dermatolipo(faszio)sklerose die Behandlungsmethode der Wahl. Aktuelle Langzeitergebnisse zeigen gute Resultate mit Heilungsraten von 70-80 %. In Einzelfällen kann auch auf Opera-tionstechniken mit Einbeziehung der Fascia cruris zurückgegriffen werden.

Schlussfolgerung: Somit kommt sowohl der chirurgischen Lokaltherapie als auch der erweiterten, teils sehr komplexen chirurgischen Intervention insbesondere des Venensystems zunehmend eine Schlüsselrolle in modernen Gesamttherapiekonzepten der Patienten mit chronischem Ulcus cruris venosum zu.

Versorgungswege von Patienten mit chronischen Wunden in Deutschland

Einleitung: In die Behandlungsabläufe von Patienten mit chronischen Wunden sind zu unterschiedlichen Zeitpunkten verschiedene Berufs- und Facharztgruppen involviert. Zu den Versorgungswegen der Patienten mit einem chronischen Ulcus cruris in Deutschland finden sich in der aktuellen Literatur kaum Untersuchungen.

Patienten und Methoden: Prospektiv sollten die Behandlungswege von 100 Patienten, die aufgrund eines chronischen Ulcus cruris in unserem Wundzentrum vorstellig wurden, erhoben werden. Die Datenerhebung erfolgte anamnestisch mit Hilfe eines neu entwickelten Fragebogens und – falls vorhanden – nach Durchsicht von Unterlagen.

Ergebnisse: Patienten mit chronischem Ulcus cruris stellen sich durchschnittlich nach 17,5 Monaten nach Erstmanifestation in unserem Wundzentrum vor. Patienten mit Rezidiv kommen nach durchschnittlich 10,6 Monaten Behandlungszeitraum signifikant früher als Patienten mit Erstmanifestation (22,6 Mona-ten); Patienten mit entzündlichen Erkrankungen werden nach durchschnittlich 9,1 Mona-ten angebunden. Patienten mit stärkeren Schmerzen kommen nach 16,5 Monaten in unserem Wundzentrum, Patienten mit weniger starken Schmerzen nach 19,4 Monaten. Insgesamt 47 % der Patienten suchen als ersten Arztkontakt ihren Hausarzt, 28 % einen Dermatologen, 10 % einen Chirurgen, 3 % einen Internisten und 2 % einen Gefäßchirurgen auf. Insgesamt 10 % der Patienten stellen sich ohne vorherigen Arztkontakt direkt in unserer Ambulanz vor.

Diskussion: Unsere Daten zeigen, dass Patienten mit chronischem Ulcus cruris erst nach einem Zeitraum von durchschnittlich 1,5 Jahren, meist frustraner Therapie in einem Wundzentrum der Maximalversorgung vorstellig werden. Die wesentlichen Faktoren für eine frühzeitigere Vorstellung sind die entzündliche Genese, individuelle Vorerfahrungen sowie stärkere Schmerzen. Um Chronifizierungen zu vermeiden und die Gefahr therapierefraktärer Verläufe zu vermindern, wäre eine frühzeitigere Vorstellung von Patienten mit stagnierender Wundheilung nach spätestens 8 Wochen bei einem Spezialisten bzw. in einem Wundzentrum wünschenswert.