1
|
Türkmen U. Single-center clinical experience of cyanoacrylate embolization method for incompetent perforating veins in treating CEAP-6 patients. J Vasc Surg Venous Lymphat Disord 2024; 12:101939. [PMID: 38960130 DOI: 10.1016/j.jvsv.2024.101939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 06/05/2024] [Accepted: 06/16/2024] [Indexed: 07/05/2024]
Abstract
OBJECTIVE The most severe form of chronic venous insufficiency includes venous leg ulcers in the CEAP-6 stage. The aim of this study is to evaluate the relationship between incompetent perforator veins occluding with cyanoacrylate and closure of perforator veins and healing of venous leg ulcers in patients at the CEAP-6 stage. METHODS A total of 187 patients who underwent cyanoacrylate application to incompetent perforator veins due to venous leg ulcers from 2018 to 2021 were retrospectively reviewed. Twelve months after the procedure, patients were evaluated for perforator vein closure, ulcer diameter, and Venous Clinical Severity Scale. Receiver operating characteristic analysis was used to estimate the probability of postoperative nonocclusion of the perforating vein based on the preoperative ulcers' diameters and the perforating veins' mean diameters. Univariate and multivariate binary logistic regression analyses were conducted to identify the risk factors associated with incomplete closure of the perforating vein. RESULTS At the 12 months, 87.1% of patients experienced incompetent perforator veins closure, leading to complete healing of venous leg ulcers. Preoperative ulcer diameter significantly decreased from 7.20 ± 3.48 cm2 to 0.28 ± 0.77 cm2 after the procedure (P < .001). On average, 3.5 ± 1.01 perforating veins were treated, with a diameter of 4.09 ± 0.41 mm. No postoperative paresthesia or deep vein thrombosis occurred. Preoperative Venous Clinical Severity Scale scores decreased significantly from 17.85 ± 3.06 to 8.03 ± 3.53 postoperatively (P < .001). Patients with nonoccluded perforating veins had larger preoperative ulcer diameters (13.77 ± 1.78 cm2) than those with occluded perforating veins (6.24 ± 2.47 cm2; P < .001). The mean perforating vein diameter was also larger in nonoccluded perforating veins patients (4.45 ± 0.41 mm) than in occluded perforating veins patients (4.04 ± 0.38 mm; P < .001). The sensitivity, specificity, and accuracy of the preoperative ulcer diameter cutoff point of 11.25 cm2 for the possibility of postoperative nonocclusion of perforating veins were 100% each. In contrast, those for the preoperative mean perforating vein diameter cutoff point of 4.15 mm were determined as 66.7%, 79.1%, and 77.5%, respectively. The presence of diabetes mellitus increased the likelihood of incompetent perforator veins, remaining open by 3.4 times (95% confidence interval: 1.11-10.44; P = .032), whereas a 1 mm larger mean perforating vein diameter increased this likelihood by 9.36 times (95% confidence interval: 3.47-25.29; P < .001). CONCLUSIONS This study demonstrates that occlusion of incompetent perforator veins with cyanoacrylate is effective, safe, and associated with low complication rates in CEAP-6 patients. The findings support that cyanoacrylate occlusion of perforator veins may be a valuable option in the treatment of venous leg ulcers.
Collapse
Affiliation(s)
- Ufuk Türkmen
- Department of Cardiovascular Surgery, Hitit University Faculty of Medicine, Corum, Türkiye.
| |
Collapse
|
2
|
Taofan T, Dakota I, Kartamihardja AHA, Afandy JE, Indriani S, Adiarto S. Satisfactory result of great saphenous vein endovenous laser ablation until below the knee on active venous leg ulcer: a case series. F1000Res 2024; 12:383. [PMID: 39246584 PMCID: PMC11377932 DOI: 10.12688/f1000research.131695.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/16/2024] [Indexed: 09/10/2024] Open
Abstract
Background Active venous leg ulcer (VLU) is the most severe manifestation of chronic venous disease which not only affects patients' health, but also decreases the quality of life, and delivers economic burdens. Treatment of superficial venous reflux with early endovenous laser ablation (EVLA) has been associated with reducing ulcer recurrence levels and promoting faster VLU healing. We reported three cases of patients with active VLU undergoing EVLA with different approaches. Case illustration Three patients came with complaint of leg ulcer, diagnosed with C6sEpAsdPr, with venous clinical severity scores (VCSS) of 15, 23, and 22 respectively. Severe great saphenous veins (GSV) reflux was found in all patients by duplex ultrasound examination. The second patient had undergone above-the-knee EVLA. All patients underwent EVLA using 1470-nano meter wavelength laser device and ELVeS radial fiber (Biolitec, Bonn, Germany). The laser energy protocol used was 6 W linear endovenous energy density (LEED) 50 J/cm for proximal until media ATK GSV ablation, 5 W LEED 40 J/cm for media ATK until proximal below-the-knee (BTK) GSV, and 2 W LEED 20 J/cm for proximal until distal BTK GSV. The third patient was also treated with EVLA for small saphenous vein severe reflux. Follow-up until 6 months post-EVLA showed significant healing of the ulcer with 14, 16, and 17 VCSS reduction consecutively without any complication. Conclusion We've reported three cases of patients with active VLU undergoing EVLA until BTK with significant results. The EVLA of GSV until BTK where there is still significant reflux is safe and provides satisfactory results in patients with VLU.
Collapse
Affiliation(s)
- Taofan Taofan
- Department of Cardiology and Vascular Medicine, Faculty of Medicine University of Indonesia / National Cardiovascular Center Harapan Kita / University of Indonesia Academic Hospital, Jakarta, Indonesia
| | - Iwan Dakota
- Department of Cardiology and Vascular Medicine, Faculty of Medicine University of Indonesia / National Cardiovascular Center Harapan Kita / University of Indonesia Academic Hospital, Jakarta, Indonesia
| | - Achmad Hafiedz Azis Kartamihardja
- Departement of Cardiology and Vascular Medicine, Faculty of Medicine Padjadjaran University / Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Jonathan Edbert Afandy
- Assistant of Vascular Division, Department of Cardiology and Vascular Medicine, Faculty of Medicine University of Indonesia / National Cardiovascular Center Harapan Kita / University of Indonesia Academic Hospital, Jakarta, Indonesia
| | - Suci Indriani
- Department of Cardiology and Vascular Medicine, Faculty of Medicine University of Indonesia / National Cardiovascular Center Harapan Kita / University of Indonesia Academic Hospital, Jakarta, Indonesia
| | - Suko Adiarto
- Department of Cardiology and Vascular Medicine, Faculty of Medicine University of Indonesia / National Cardiovascular Center Harapan Kita / University of Indonesia Academic Hospital, Jakarta, Indonesia
| |
Collapse
|
3
|
Rerkasem K, Oo MZ, Papi M, Papanas N. Evolving Strategies in the Management of Venous Leg Ulcers. INT J LOW EXTR WOUND 2024:15347346241283142. [PMID: 39248191 DOI: 10.1177/15347346241283142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Affiliation(s)
- Kittipan Rerkasem
- Environmental-Occupational Health Sciences and Non Communicable Diseases Research Centre, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Myo Zin Oo
- Environmental-Occupational Health Sciences and Non Communicable Diseases Research Centre, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Massimo Papi
- National Institute for Health, Migration and Poverty (NIHMP), ADOI National Study Group Vulnology and Vascular Dermatology, Rome, Italy
| | - Nikolaos Papanas
- Second Department of Internal Medicine, Diabetes Centre-Diabetic Foot Clinic, Democritus University of Thrace, Alexandroupolis, Greece
| |
Collapse
|
4
|
Blomgren L, Jansson L. The influence of socioeconomic factors on intervention and postoperative healing of venous ulcers: a prospective study. J Wound Care 2024; 33:474-479. [PMID: 38967345 DOI: 10.12968/jowc.2022.0143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
OBJECTIVE In previous studies, venous ulcers (VUs) have been found to occur more often in patients with lower socioeconomic status. The aim of this study was to explore if socioeconomic factors influence the delay of referral to a vascular service or the time to healing after superficial venous intervention. METHOD In this prospective study, patients answered a questionnaire about the duration and recurrence of their VU, comorbidities, body mass index (BMI), smoking, alcohol, social and physical activities, ambulatory status, education, marital status, housing, perceived economic status and dependence on home care. Postoperative complications, VU healing and recurrence were noted one year after superficial venous intervention. RESULTS A total of 63 patients were included in this study (30 females and 33 males), with a mean age of 71.2 years (range: 37-92 years). Duration of the present VU in patients was: <3 months in 48%; 3-6 months in 27%; 6-12 months in 11%; and >12 months in 14%. Risk factors for delayed referral were recurrent VU (odds ratio (OR): 4.92; p=0.021); walking impairment (OR: 5.43; p=0.009) and dependence on home care (OR: 4.89: p=0.039) in a univariable analysis. The latter was the only significant finding in a multivariable analysis with socioeconomic risk factor (OR: 4.89; p=0.035). In 85% of patients, their VU healed without recurrence during one year follow-up. Healing took longer if the patients: were of older age (p=0.033); had a normal BMI (independent samples t-test, p=0.028); had a recurrent VU (OR: 5.00; p=0.049); or walking impairment (Fishers exact test, OR: 9.14; p=0.008), but no significant socioeconomic risk factors were found. CONCLUSION In this study, socioeconomic factors were not important risk factors for delayed referral of VU patients to a vascular service or prolonged healing time after superficial venous intervention. DECLARATION OF INTEREST This work was supported by the Scandinavian Research Foundation for Varicose Veins and other Venous Diseases (SFÅV) and by ALF funding from Region Örebro County. The authors have no conflicts of interest to declare.
Collapse
Affiliation(s)
- Lena Blomgren
- Karlskoga Vein Centre, Department of Cardiovascular Surgery, Faculty of Medicine and Health, Örebro University Hospital, Sweden
| | - Linda Jansson
- Karlskoga Vein Centre, Karlskoga Hospital, Region Örebro County, Sweden
| |
Collapse
|
5
|
Pihlaja T, Vanttila LM, Ohtonen P, Pokela M. Factors associated with delayed venous ulcer healing after endovenous intervention for superficial venous insufficiency. J Vasc Surg Venous Lymphat Disord 2022; 10:1238-1244. [PMID: 35961629 DOI: 10.1016/j.jvsv.2022.07.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/05/2022] [Accepted: 07/17/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE This retrospective trial analyzed the effect of predetermined variables on venous ulcer healing after endovenous ablation of insufficient veins. METHODS A total of 259 patients presenting 273 venous leg ulcers (VLUs) at Oulu University Hospital vascular outpatient clinic between January 2010 and December 2020 were included in the study. In addition to compression therapy, all patients received endovenous ablation (endothermal ablation and/or foam sclerotherapy) to promote venous healing. The hazard ratio (HR) for an ulcer to heal was analyzed in univariate analysis of predetermined factors, including age, sex, recurrent venous ulcer, presence of great saphenous vein or small saphenous vein reflux, persistent superficial vein reflux after ablation, recanalization in treated segments, ulcer age, body mass index >35 kg/m2, history of deep vein thrombosis, history of erysipelas, ability to move, smoking, hypertension, atrial fibrillation, coronary artery disease, diabetes mellitus, and cardiac insufficiency. Logistic regression was used in a multivariate analysis to identify independent risk factors for ulcer healing. RESULTS In the univariate analysis, healing was negatively associated with persistent superficial vein reflux after ablation (HR, 0.117; 95% confidence interval [CI], 0.088-0.354), recanalization in treated segments (HR, 0.161; 95% CI, 0.060-0.433), nonambulatory patient (HR, 0.322; 95% CI, 0.130-0.800), history of deep vein thrombosis (HR, 0.518; 95% CI, 0.294-0.910), and presence of small saphenous vein reflux (HR, 0.565; 95% CI, 0.384-0.830). Independent risk factors included persistent superficial vein reflux after ablation (HR, 0.123; 95% CI, 0.0051-0.295). All the patients in the persistent superficial vein reflux group had their VLUs eventually healed after further endovenous treatment. CONCLUSIONS When treating patients with VLUs, persistent superficial vein reflux after ablation was negatively associated with ulcer healing. After additional endovenous ablative treatment, ulcers with persistent reflux eventually healed.
Collapse
Affiliation(s)
- Toni Pihlaja
- Department of Vascular Surgery, Oulu University Hospital, Oulu, Finland; Medical Research Center Oulu, University of Oulu, Oulu, Finland.
| | | | - Pasi Ohtonen
- Division of operative care, Oulu University Hospital, Oulu, Finland; Medical Research Center Oulu, University of Oulu, Oulu, Finland
| | - Matti Pokela
- Department of Vascular Surgery, Oulu University Hospital, Oulu, Finland
| |
Collapse
|
6
|
Whiteley MS. Current Best Practice in the Management of Varicose Veins. Clin Cosmet Investig Dermatol 2022; 15:567-583. [PMID: 35418769 PMCID: PMC8995160 DOI: 10.2147/ccid.s294990] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/27/2022] [Indexed: 12/01/2022]
Abstract
This article outlines the current best practice in the management of varicose veins. “Varicose veins” traditionally means bulging veins, usually seen on the legs, when standing. It is now a general term used to describe these bulging veins, and also underlying incompetent veins that reflux and cause the surface varicose veins. Importantly, “varicose veins” is often used for superficial venous reflux even in the absence of visible bulging veins. These can be simply called “hidden varicose veins”. Varicose veins usually deteriorate, progressing to discomfort, swollen ankles, skin damage, leg ulcers, superficial venous thrombosis and venous bleeds. Patients with varicose veins and symptoms or signs have a significant advantage in having treatment over conservative treatment with compression stockings or venotropic drugs. Small varicose veins or telangiectasia without symptoms or signs can be treated for cosmetic reasons. However, most have underlying venous reflux from saphenous, perforator or local “feeding veins” and so investigation with venous duplex should be mandatory before treatment. Best practice for investigating leg varicose veins is venous duplex ultrasound in the erect position, performed by a specialist trained in ultrasonography optimally not the doctor who performs the treatment. Pelvic vein reflux is best investigated with transvaginal duplex ultrasound (TVS), performed using the Holdstock-Harrison protocol. In men or women unable to have TVS, venography or cross-sectional imaging is needed. Best practice for treating truncal vein incompetence is endovenous thermal ablation. Increasing evidence suggests that significant incompetent perforating veins should be found and treated by thermal ablation using the transluminal occlusion of perforator (TRLOP) approach, and that incompetent pelvic veins refluxing into symptomatic varicose veins in the genital region or leg should be treated by coil embolisation. Bulging varicosities should be treated by phlebectomy at the time of truncal vein ablation. Monitoring and reporting outcomes is essential for doctors and patients; hence, participation in a venous registry should probably be mandatory.
Collapse
|
7
|
Qiu Y, Osadnik CR, Team V, Weller CD. Effects of physical activity as an adjunct treatment on healing outcomes and recurrence of venous leg ulcers: A scoping review. Wound Repair Regen 2022; 30:172-185. [PMID: 35142412 PMCID: PMC9303258 DOI: 10.1111/wrr.12995] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/19/2021] [Accepted: 01/09/2022] [Indexed: 01/05/2023]
Abstract
Healing time is protracted and ulcer recurrence is common in patients with venous leg ulcers. Although compression is the mainstay treatment, many patients do not heal timely. Physical activity may be a clinically effective adjunct treatment to compression to improve healing outcomes. This scoping review provides a broad overview of the effect of physical activity as an adjunct treatment to compression on wound healing and recurrence. We followed the six-step framework developed by Arksey and O'Malley. We searched electronic databases and trial registration websites for relevant studies and ongoing trials. Two authors independently screened and selected articles. Findings were presented in a descriptive statistical narrative summary. We consulted and presented our findings to the wound consumer group to ensure the relevance of our study. Physical activity interventions in 12 out of the 16 eligible studies consisted of only one component, eight studies were resistance exercises, three studies reported ankle and/or foot range of motion exercises, and one study reported aerobic/walking exercises. The remaining four studies involved multicomponent exercise interventions. Resistance exercise combined with ankle and/or foot range of motion exercise minimised ulcer size on day 12 (intervention group: 4.55 ± 1.14 cm2 vs. control group: 7.43 ± 0.56 cm2 ) and improved calf muscle pump performance on day 8 (ejection fraction: 40%-65%; residual volume fraction: 56%-40%). We identified one study that reported ulcer recurrence rate with no clinical difference in the intervention group versus the control group (i.e., 12% in intervention vs. 5% in control). Our review identified that resistance exercise was the most common type of physical activity intervention trialled in the published literature. Resistance exercise combined with ankle and/or foot range of motion exercise appears to be effective adjunct treatments; however, the overall evidence is still relatively weak as most programmes had a short intervention period which limited clinical outcomes.
Collapse
Affiliation(s)
- Yunjing Qiu
- School of Nursing and Midwifery, Monash University, Melbourne, Victoria
| | - Christian R Osadnik
- Department of Physiotherapy, Monash University, Frankston, Victoria, Australia
| | - Victoria Team
- School of Nursing and Midwifery, Monash University, Melbourne, Victoria
| | - Carolina D Weller
- School of Nursing and Midwifery, Monash University, Melbourne, Victoria
| |
Collapse
|
8
|
Weber B, Marquart E, Deinsberger J, Tzaneva S, Böhler K. Comparative analysis of endovenous laser ablation versus ultrasound-guided foam sclerotherapy for the treatment of venous leg ulcers. Dermatol Ther 2022; 35:e15322. [PMID: 35040545 PMCID: PMC9285388 DOI: 10.1111/dth.15322] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/10/2022] [Accepted: 01/16/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Endovenous thermal and non-thermal therapeutic approaches have become standard of care for the treatment of venous insufficiency. However, comparative studies on its use in the population of venous leg ulcer patients are scarce. METHODS The present study aimed at a comparison of the efficacy of endovenous laser ablation (EVLA) and ultrasound-guided foam sclerotherapy (UGFS) for the treatment of venous leg ulcers (VUs). We retrospectively analyzed patient records of 68 patients with active VUs (C6 of the CEAP-classification), who underwent EVLA (n=33) or UGFS (n=35) between January 2001 and January 2021. RESULTS In 68 patients, 97 venous segments (GSV: 43, SSV: 17:, NSV: 37) were treated. Ulcer surface area at initial presentation did not differ significantly between both treatment groups (EVLA: 7.7±10.7 vs. UGFS: 8.5±16.3 cm2 ; p=0.73). No significant difference regarding patient characteristics was found, with the exception of age, as patients receiving UGFS treatment were significantly older (EVLA: 61±17 vs. UGFS: 70±14 years; p=0.018). The rate of ulcer resolution was not significantly different between EVLA and UGFS groups (97.0% vs. 85.7%; p=0.20). Also, the mean time to complete ulcer healing after endovenous intervention was comparable (EVLA: 59±37 vs. UGFS: 63±41 days; p=0.68). However, the relapse rate was significantly higher for UGFS than for EVLA treated patients (31.4% vs. 3.0%; p=0.002). CONCLUSION Rates of ulcer resolution and ulcer healing time after endovenous intervention were comparable between both treatment modalities. However, a significantly higher relapse rate was observed in UGFS treated patients.
Collapse
Affiliation(s)
- Benedikt Weber
- Department of Dermatology, Medical University of Vienna, Austria
| | - Elias Marquart
- Department of Dermatology, Medical University of Vienna, Austria
| | | | | | - Kornelia Böhler
- Department of Dermatology, Medical University of Vienna, Austria
| |
Collapse
|
9
|
Abdelgawad MS, El-Shafei AM, Sharaf El-Din HA, Saad EM, Khafagy TA, Sameer A, Elsaadany NA, Abdelmaksoud MA. Radiofrequency ablation for markedly incompetent perforators versus compression therapy in the management of post-phelebtic venous ulcers: A randomized controlled trial. Vascular 2021; 30:357-364. [PMID: 33884938 DOI: 10.1177/17085381211010022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Venus ulcers developed mainly due to reflux of incompetent venous valves in perforating veins. PATIENTS AND METHODS In this randomized controlled trial, 119 patients recruited over two years, with post-phelebtic venous leg ulcers, were randomly assigned into one of two groups: either to receive radiofrequency ablation of markedly incompetent perforators (Group A, n = 62 patients) or to receive conventional compression therapy (Group B, n = 57 patients). Follow-up duration required for ulcer healing continued for 24 months post randomization. RESULTS Statistically significant shorter time to healing (ulcer complete healing or satisfactory clinical improvement) between both groups (56 patients, 90.3% of cases in Group A versus 44 patients 77.2% of cases in Group B) over the follow-up period of 24 months was attained (p = 0.001). Also, significantly different ulcer recurrence was recorded between both groups, 8 patients (12.9%) in Group A versus 19 patients (33.3%) in Group B (p = 0.004). CONCLUSION In absence of deep venous obstruction, the monopolar radiofrequency ablation for incompetent perforators is a feasible and effective method that surpasses the traditional compression protocol for incompetent perforator-induced venous ulcers in terms of time required for healing even in the presence of unresolved deep venous valvular reflux.
Collapse
Affiliation(s)
- Mohamed Shukri Abdelgawad
- Department of Vascular and Endovascular Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Amr M El-Shafei
- Department of Vascular and Endovascular Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Hesham A Sharaf El-Din
- Department of Vascular and Endovascular Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Ehab M Saad
- Department of Vascular and Endovascular Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Tamer A Khafagy
- Department of Vascular and Endovascular Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Amr Sameer
- Department of General Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Nshaat A Elsaadany
- Department of Vascular and Endovascular Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| | - Mohamed A Abdelmaksoud
- Department of Vascular and Endovascular Surgery, Mansoura University Hospitals, Mansoura University, Mansoura, Egypt
| |
Collapse
|
10
|
McNamara SA, Cahn BA, Sanders M, Lopez AJ. Venous Procedures to Treat Venous Leg Ulcers. CURRENT DERMATOLOGY REPORTS 2020. [DOI: 10.1007/s13671-020-00318-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
11
|
Gohel MS, Heatley F, Liu X, Bradbury A, Bulbulia R, Cullum N, Epstein DM, Nyamekye I, Poskitt KR, Renton S, Warwick J, Davies AH. Early versus deferred endovenous ablation of superficial venous reflux in patients with venous ulceration: the EVRA RCT. Health Technol Assess 2020; 23:1-96. [PMID: 31140402 DOI: 10.3310/hta23240] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Venous ulceration is a common and costly health-care issue worldwide, with poor healing rates greatly affecting patient quality of life. Compression bandaging has been shown to improve healing rates and reduce recurrence, but does not address the underlying cause, which is often superficial venous reflux. Surgical correction of the reflux reduces ulcer recurrence; however, the effect of early endovenous ablation of superficial venous reflux on ulcer healing is unclear. OBJECTIVES To determine the clinical effectiveness and cost-effectiveness of compression therapy with early endovenous ablation of superficial venous reflux compared with compression therapy with deferred endovenous ablation in patients with venous ulceration. DESIGN A pragmatic, two-arm, multicentre, parallel-group, open randomised controlled trial with a health economic evaluation. SETTING Secondary care vascular centres in England. PARTICIPANTS Patients aged ≥ 18 years with a venous leg ulcer of between 6 weeks' and 6 months' duration and an ankle-brachial pressure index of ≥ 0.8 who could tolerate compression and were deemed suitable for endovenous ablation of superficial venous reflux. INTERVENTIONS Participants were randomised 1 : 1 to either early ablation (compression therapy and superficial endovenous ablation within 2 weeks of randomisation) or deferred ablation (compression therapy followed by endovenous ablation once the ulcer had healed). MAIN OUTCOME MEASURES The primary outcome measure was time from randomisation to ulcer healing, confirmed by blinded assessment. Secondary outcomes included 24-week ulcer healing rates, ulcer-free time, clinical success (in addition to quality of life), costs and quality-adjusted life-years (QALYs). All analyses were performed on an intention-to-treat basis. RESULTS A total of 450 participants were recruited (224 to early and 226 to deferred superficial endovenous ablation). Baseline characteristics were similar between the two groups. Time to ulcer healing was shorter in participants randomised to early superficial endovenous ablation than in those randomised to deferred ablation [hazard ratio 1.38, 95% confidence interval (CI) 1.13 to 1.68; p = 0.001]. Median time to ulcer healing was 56 (95% CI 49 to 66) days in the early ablation group and 82 (95% CI 69 to 92) days in the deferred ablation group. The ulcer healing rate at 24 weeks was 85.6% in the early ablation group, compared with 76.3% in the deferred ablation group. Median ulcer-free time was 306 [interquartile range (IQR) 240-328] days in the early ablation group and 278 (IQR 175-324) days in the deferred endovenous ablation group (p = 0.002). The most common complications of superficial endovenous ablation were pain and deep-vein thrombosis. Differences in repeated measures of Aberdeen Varicose Vein Questionnaire scores (p < 0.001), EuroQol-5 Dimensions index values (p = 0.03) and Short Form questionnaire-36 items body pain (p = 0.05) over the follow-up period were observed, in favour of early ablation. The mean difference in total costs between the early ablation and deferred ablation groups was £163 [standard error (SE) £318; p = 0.607]; however, there was a substantial and statistically significant gain in QALY over 1 year [mean difference between groups 0.041 (SE 0.017) QALYs; p = 0.017]. The incremental cost-effectiveness ratio of early ablation at 1 year was £3976 per QALY, with a high probability (89%) of being more cost-effective than deferred ablation at conventional UK decision-making thresholds (currently £20,000 per QALY). Sensitivity analyses using alternative statistical models give qualitatively similar results. LIMITATIONS Only 7% of screened patients were recruited, treatment regimens varied significantly and technical success was assessed only in the early ablation group. CONCLUSIONS Early endovenous ablation of superficial venous reflux, in addition to compression therapy and wound dressings, reduces the time to healing of venous leg ulcers, increases ulcer-free time and is highly likely to be cost-effective. FUTURE WORK Longer-term follow-up is ongoing and will determine if early ablation will affect recurrence rates in the medium and long term. TRIAL REGISTRATION Current Controlled Trials ISRCTN02335796. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 24. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Manjit S Gohel
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - Francine Heatley
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Xinxue Liu
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Andrew Bradbury
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Richard Bulbulia
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK.,Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK.,Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nicky Cullum
- School of Health Sciences, University of Manchester, Manchester, UK
| | - David M Epstein
- Department of Applied Economics, University of Granada, Granada, Spain
| | | | - Keith R Poskitt
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | | | - Jane Warwick
- Imperial Clinical Trials Unit, Imperial College London, London, UK.,Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Alun H Davies
- Department of Surgery and Cancer, Imperial College London, London, UK
| |
Collapse
|
12
|
Reitz KM, Salem K, Mohapatra A, Liang NL, Avgerinos ED, Singh MJ, Hager E. Complete Venous Ulceration Healing after Perforator Ablation Does Not Depend on Treatment Modality. Ann Vasc Surg 2020; 70:109-115. [PMID: 32603845 DOI: 10.1016/j.avsg.2020.06.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 05/06/2020] [Accepted: 06/24/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Venous leg ulceration (VLU) represents the most advanced form of chronic venous insufficiency (CVI). Persistent VLU that fails to respond to noninvasive treatment requires a minimally invasive endovascular treatment, which may include chemical (ultrasound-guided foam sclerotherapy [UGFS]) and thermal ablation (endovenous laser therapy [EVLT] or radiofrequency ablation [RFA]) targeting incompetent veins. Current guidelines suggest ablation of incompetent perforating veins (IPVs) juxtaposed to active or healed VLU; however, the ideal treatment modality is unknown. We hypothesize that similar to incompetent superficial vein treatment options therapies, VLU healing will be equivalent across minimally invasive IPV treatment options. METHODS Using the Vascular Low Frequency Disease Consortium, adults with VLU across 11 medical centers were retrospectively reviewed (2013-2017). We included those who underwent IPV therapies. The primary outcome was complete ulcer healing over time compared with cumulative hazard curves, log-rank testing, and multivariable Cox proportional hazard regression. Secondary outcomes included number of subsequent procedures, which were compared using negative binomial regression. RESULTS Of the 832 adults with VLU, 158 (19%) were exclusively treated conservatively, and 232 (28%) underwent index treatment for IPV and constitute the full and final cohort. The mean age was 60 ± 14 years, 57% were men, and the mean ulcer area was 3.0 cm2 (interquartile range, 1-6 cm2). Ninety-one (39%) were treated with EVLT, 127 (55%) RFA, and 14 (6%) UGFS. Patients treated with RFA were older (RFA 62 ± 14 years; EVLT 59 ± 14 years; UGFS 52 ± 9 years; P = 0.01), more likely to be men (RFA 68%, n = 86; EVLT 41%, n = 37; UGFS 64%, n = 9; P < 0.001), with a higher frequency of anticoagulation (RFA 36%, n = 46; EVLT 18%, n = 16; UGFS 14%, n = 2; P = 0.005). VLU did not significantly differ in size between groups (RFA 6.2 ± 8; EVLT 4.2 ± 5.4; UGFS 6.1 ± 8; P < 0.001). There were no differences in 1-year ulcer healing rates between groups (P = 0.18). The number of subsequent procedures did not differ by treatment modality (P = 0.47). CONCLUSIONS This multi-institutional retrospective study does not demonstrate any association of IPV treatment modality with differing rates of VLU healing or number of subsequent procedures.
Collapse
Affiliation(s)
| | - Karim Salem
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Nathan L Liang
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Michael J Singh
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Eric Hager
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
13
|
Liu X, Zheng G, Ye B, Chen W, Xie H, Zhang T, Lin J. A retrospective cohort study comparing two treatments for active venous leg ulcers. Medicine (Baltimore) 2020; 99:e19317. [PMID: 32080149 PMCID: PMC7034671 DOI: 10.1097/md.0000000000019317] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Endovenous laser ablation (EVLA) and ultrasound-guided foam sclerotherapy (UGFS) have largely replaced traditional surgery for treatment of varicose veins (VVs) with active venous leg ulcers (VLUs), and multiple combined modes have emerged. A retrospective cohort study was performed to compare the effect of traditional surgery (high ligation and stripping followed with compression [compression plus HL-S]) to high ligation-endovenous laser ablation-foam sclerotherapy followed with compression (compression plus HL-EVLA-FS) on the treatment of active VLUs.Data of active VLUs treated in our center from 2008 to 2017 and followed up for 1 year were analyzed. The intervention measures in the first 5 years were compression plus HL-S, and in the following 5 years were compression plus HL-EVLA-FS. The primary outcome was ulcer healing time. The secondary outcomes were the VVs occlusion and clinical success as assessed by a change in venous clinical severity score (VCSS) and complications.The study included 120 patients and 200 patients treated with HL-S and HL-EVLA-FS, respectively, during 2008 to 2017. The average ulcer healing time were 2.3 ± 2.4 and 1.7 ± 1.7 months, respectively. Significant difference was found in the cumulative ulcers healing rate between the two groups (Hazard ratio [HR] and 95% confidence interval [CI] was respectively 1.458 and 1.140-1.865, P = .0002), but no difference was found in the VVs occlusion (HR and 95% CI was respectively 1.005 and 0.774-1.3071, P = .967). Significant difference occurred in 6 months and 12 months post-operatively in the VCSS change and in the procedure data and some complications between the 2 groups.In conclusion, the treatment of HL-EVLA-FS can accelerate the healing of VLUs, improve the VCSS and present superior procedure data. However, no advantage could be found in the VVs occlusion compared with control group.
Collapse
|
14
|
Gould L, Li WW. Defining complete wound closure: Closing the gap in clinical trials and practice. Wound Repair Regen 2019; 27:201-224. [DOI: 10.1111/wrr.12707] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 02/11/2019] [Indexed: 12/26/2022]
Affiliation(s)
- Lisa Gould
- South Shore Hospital Center for Wound Healing Weymouth Massachusetts
| | | |
Collapse
|
15
|
Gohel MS, Heatley F, Davies AH. Endovenous Ablation in Venous Ulceration. N Engl J Med 2018; 379:1482-3. [PMID: 30304658 DOI: 10.1056/nejmc1811147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
16
|
Finlayson KJ, Parker CN, Miller C, Gibb M, Kapp S, Ogrin R, Anderson J, Coleman K, Smith D, Edwards HE. Predicting the likelihood of venous leg ulcer recurrence: The diagnostic accuracy of a newly developed risk assessment tool. Int Wound J 2018; 15:686-694. [PMID: 29536629 PMCID: PMC7949606 DOI: 10.1111/iwj.12911] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 02/02/2018] [Accepted: 02/06/2018] [Indexed: 12/01/2022] Open
Abstract
The aim of this study was to validate a newly developed tool for predicting the risk of recurrence within 12 months of a venous leg ulcer healing. Performance of the tool to predict recurrence within a 12-month period was assessed using Area Under the Receiver Operating Characteristic Curve (AUC) analysis. Multi-site retrospective and prospective longitudinal studies were undertaken to validate a risk assessment tool for the recurrence of venous leg ulcers within 12 months. In the retrospective study (n = 250), 55% of venous leg ulcers recurred within 12 months, and the risk assessment total score had excellent discrimination and goodness of fit with an AUC of 0.83 (95% CI, 0.76-0.90, P < .001). The prospective study (n = 143) observed that 50.4% (n = 63) of venous leg ulcers recurred within 12 months of healing. Participants were classified using the risk assessment tool as being at low risk (28%), moderate risk (59%), and high risk (13%); the proportion of wounds recurring at 12 months was 15%, 61%, and 67% for each group, respectively. Validation results indicated good discrimination and goodness of fit, with an AUC of 0.73 (95% CI, 0.64-0.82, P < .001). Validation of this risk assessment tool for the recurrence of venous leg ulcers provides clinicians with a resource to identify high-risk patients and to guide decisions on adjunctive, tailored interventions to address the specific risk factors to decrease the risk of recurrence.
Collapse
Affiliation(s)
- Kathleen J. Finlayson
- Faculty of HealthQueensland University of TechnologyKelvin GroveQueenslandAustralia
- Institute of Health & Biomedical InnovationQueensland University of TechnologyKelvin GroveQueenslandAustralia
- Wound Management Innovation Cooperative Research CentreQueenslandAustralia
| | - Christina N. Parker
- Faculty of HealthQueensland University of TechnologyKelvin GroveQueenslandAustralia
- Institute of Health & Biomedical InnovationQueensland University of TechnologyKelvin GroveQueenslandAustralia
- Wound Management Innovation Cooperative Research CentreQueenslandAustralia
| | - Charne Miller
- La Trobe UniversityMelbourneVictoriaAustralia
- Alfred Health Clinical SchoolThe Alfred CentrePrahranVictoria 3181Australia
| | - Michelle Gibb
- Wound Management Innovation Cooperative Research CentreQueenslandAustralia
| | - Suzanne Kapp
- School of Health Sciences, Department of NursingThe University of MelbourneCarltonVictoriaAustralia
- Austin HealthHeidelbergVictoriaAustralia
| | | | | | - Kerrie Coleman
- Multidisciplinary Skin Integrity ServiceRoyal Brisbane & Women's HospitalSt. HerstonQueenslandAustralia
| | - Dianne Smith
- Multidisciplinary Skin Integrity ServiceRoyal Brisbane & Women's HospitalSt. HerstonQueenslandAustralia
| | - Helen E. Edwards
- Faculty of HealthQueensland University of TechnologyKelvin GroveQueenslandAustralia
- Institute of Health & Biomedical InnovationQueensland University of TechnologyKelvin GroveQueenslandAustralia
- Wound Management Innovation Cooperative Research CentreQueenslandAustralia
| |
Collapse
|
17
|
Weiß KT, Zeman F, Schreml S. 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. Br J Dermatol 2018; 180:51-55. [PMID: 30238444 DOI: 10.1111/bjd.17237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
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.
Collapse
Affiliation(s)
- K T Weiß
- Department of Dermatology and, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - F Zeman
- Center for Clinical Studies, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - S Schreml
- Department of Dermatology and, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| |
Collapse
|
18
|
Gohel MS, Heatley F, Liu X, Bradbury A, Bulbulia R, Cullum N, Epstein DM, Nyamekye I, Poskitt KR, Renton S, Warwick J, Davies AH. A Randomized Trial of Early Endovenous Ablation in Venous Ulceration. N Engl J Med 2018; 378:2105-2114. [PMID: 29688123 DOI: 10.1056/nejmoa1801214] [Citation(s) in RCA: 194] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Venous disease is the most common cause of leg ulceration. Although compression therapy improves venous ulcer healing, it does not treat the underlying causes of venous hypertension. Treatment of superficial venous reflux has been shown to reduce the rate of ulcer recurrence, but the effect of early endovenous ablation of superficial venous reflux on ulcer healing remains unclear. METHODS In a trial conducted at 20 centers in the United Kingdom, we randomly assigned 450 patients with venous leg ulcers 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). 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. RESULTS Patient and clinical characteristics at baseline were similar in the two treatment groups. The time to ulcer healing was shorter in the early-intervention group than in the deferred-intervention group; more patients had healed ulcers with early intervention (hazard ratio for ulcer healing, 1.38; 95% confidence interval [CI], 1.13 to 1.68; P=0.001). The median time to ulcer healing was 56 days (95% CI, 49 to 66) in the early-intervention group and 82 days (95% CI, 69 to 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 enrollment was 306 days (interquartile range, 240 to 328) in the early-intervention group and 278 days (interquartile range, 175 to 324) in the deferred-intervention group (P=0.002). The most common procedural complications of endovenous ablation were pain and deep-vein thrombosis. CONCLUSIONS Early endovenous ablation of superficial venous reflux resulted in faster healing of venous leg ulcers and more time free from ulcers than deferred endovenous ablation. (Funded by the National Institute for Health Research Health Technology Assessment Program; EVRA Current Controlled Trials number, ISRCTN02335796 .).
Collapse
Affiliation(s)
- Manjit S Gohel
- From Cambridge University Hospitals NHS Foundation Trust, Cambridge (M.S.G.), the Department of Surgery and Cancer (M.S.G., F.H., A.H.D.) and Imperial Clinical Trials Unit (X.L., J.W.), Imperial College London, London, University of Birmingham, Birmingham (A.B.), Gloucestershire Hospitals NHS Foundation Trust, Gloucester (R.B., K.R.P.), the Medical Research Council Population Health Research Unit and the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford (R.B.), University of Manchester, Manchester (N.C.), Worcestershire Acute Hospitals NHS Trust, Worcester (I.N.), North West London Hospitals NHS Trust, Harrow (S.R.), and University of Warwick, Coventry (J.W.) - all in the United Kingdom; and the University of Granada, Granada, Spain (D.M.E.)
| | - Francine Heatley
- From Cambridge University Hospitals NHS Foundation Trust, Cambridge (M.S.G.), the Department of Surgery and Cancer (M.S.G., F.H., A.H.D.) and Imperial Clinical Trials Unit (X.L., J.W.), Imperial College London, London, University of Birmingham, Birmingham (A.B.), Gloucestershire Hospitals NHS Foundation Trust, Gloucester (R.B., K.R.P.), the Medical Research Council Population Health Research Unit and the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford (R.B.), University of Manchester, Manchester (N.C.), Worcestershire Acute Hospitals NHS Trust, Worcester (I.N.), North West London Hospitals NHS Trust, Harrow (S.R.), and University of Warwick, Coventry (J.W.) - all in the United Kingdom; and the University of Granada, Granada, Spain (D.M.E.)
| | - Xinxue Liu
- From Cambridge University Hospitals NHS Foundation Trust, Cambridge (M.S.G.), the Department of Surgery and Cancer (M.S.G., F.H., A.H.D.) and Imperial Clinical Trials Unit (X.L., J.W.), Imperial College London, London, University of Birmingham, Birmingham (A.B.), Gloucestershire Hospitals NHS Foundation Trust, Gloucester (R.B., K.R.P.), the Medical Research Council Population Health Research Unit and the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford (R.B.), University of Manchester, Manchester (N.C.), Worcestershire Acute Hospitals NHS Trust, Worcester (I.N.), North West London Hospitals NHS Trust, Harrow (S.R.), and University of Warwick, Coventry (J.W.) - all in the United Kingdom; and the University of Granada, Granada, Spain (D.M.E.)
| | - Andrew Bradbury
- From Cambridge University Hospitals NHS Foundation Trust, Cambridge (M.S.G.), the Department of Surgery and Cancer (M.S.G., F.H., A.H.D.) and Imperial Clinical Trials Unit (X.L., J.W.), Imperial College London, London, University of Birmingham, Birmingham (A.B.), Gloucestershire Hospitals NHS Foundation Trust, Gloucester (R.B., K.R.P.), the Medical Research Council Population Health Research Unit and the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford (R.B.), University of Manchester, Manchester (N.C.), Worcestershire Acute Hospitals NHS Trust, Worcester (I.N.), North West London Hospitals NHS Trust, Harrow (S.R.), and University of Warwick, Coventry (J.W.) - all in the United Kingdom; and the University of Granada, Granada, Spain (D.M.E.)
| | - Richard Bulbulia
- From Cambridge University Hospitals NHS Foundation Trust, Cambridge (M.S.G.), the Department of Surgery and Cancer (M.S.G., F.H., A.H.D.) and Imperial Clinical Trials Unit (X.L., J.W.), Imperial College London, London, University of Birmingham, Birmingham (A.B.), Gloucestershire Hospitals NHS Foundation Trust, Gloucester (R.B., K.R.P.), the Medical Research Council Population Health Research Unit and the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford (R.B.), University of Manchester, Manchester (N.C.), Worcestershire Acute Hospitals NHS Trust, Worcester (I.N.), North West London Hospitals NHS Trust, Harrow (S.R.), and University of Warwick, Coventry (J.W.) - all in the United Kingdom; and the University of Granada, Granada, Spain (D.M.E.)
| | - Nicky Cullum
- From Cambridge University Hospitals NHS Foundation Trust, Cambridge (M.S.G.), the Department of Surgery and Cancer (M.S.G., F.H., A.H.D.) and Imperial Clinical Trials Unit (X.L., J.W.), Imperial College London, London, University of Birmingham, Birmingham (A.B.), Gloucestershire Hospitals NHS Foundation Trust, Gloucester (R.B., K.R.P.), the Medical Research Council Population Health Research Unit and the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford (R.B.), University of Manchester, Manchester (N.C.), Worcestershire Acute Hospitals NHS Trust, Worcester (I.N.), North West London Hospitals NHS Trust, Harrow (S.R.), and University of Warwick, Coventry (J.W.) - all in the United Kingdom; and the University of Granada, Granada, Spain (D.M.E.)
| | - David M Epstein
- From Cambridge University Hospitals NHS Foundation Trust, Cambridge (M.S.G.), the Department of Surgery and Cancer (M.S.G., F.H., A.H.D.) and Imperial Clinical Trials Unit (X.L., J.W.), Imperial College London, London, University of Birmingham, Birmingham (A.B.), Gloucestershire Hospitals NHS Foundation Trust, Gloucester (R.B., K.R.P.), the Medical Research Council Population Health Research Unit and the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford (R.B.), University of Manchester, Manchester (N.C.), Worcestershire Acute Hospitals NHS Trust, Worcester (I.N.), North West London Hospitals NHS Trust, Harrow (S.R.), and University of Warwick, Coventry (J.W.) - all in the United Kingdom; and the University of Granada, Granada, Spain (D.M.E.)
| | - Isaac Nyamekye
- From Cambridge University Hospitals NHS Foundation Trust, Cambridge (M.S.G.), the Department of Surgery and Cancer (M.S.G., F.H., A.H.D.) and Imperial Clinical Trials Unit (X.L., J.W.), Imperial College London, London, University of Birmingham, Birmingham (A.B.), Gloucestershire Hospitals NHS Foundation Trust, Gloucester (R.B., K.R.P.), the Medical Research Council Population Health Research Unit and the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford (R.B.), University of Manchester, Manchester (N.C.), Worcestershire Acute Hospitals NHS Trust, Worcester (I.N.), North West London Hospitals NHS Trust, Harrow (S.R.), and University of Warwick, Coventry (J.W.) - all in the United Kingdom; and the University of Granada, Granada, Spain (D.M.E.)
| | - Keith R Poskitt
- From Cambridge University Hospitals NHS Foundation Trust, Cambridge (M.S.G.), the Department of Surgery and Cancer (M.S.G., F.H., A.H.D.) and Imperial Clinical Trials Unit (X.L., J.W.), Imperial College London, London, University of Birmingham, Birmingham (A.B.), Gloucestershire Hospitals NHS Foundation Trust, Gloucester (R.B., K.R.P.), the Medical Research Council Population Health Research Unit and the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford (R.B.), University of Manchester, Manchester (N.C.), Worcestershire Acute Hospitals NHS Trust, Worcester (I.N.), North West London Hospitals NHS Trust, Harrow (S.R.), and University of Warwick, Coventry (J.W.) - all in the United Kingdom; and the University of Granada, Granada, Spain (D.M.E.)
| | - Sophie Renton
- From Cambridge University Hospitals NHS Foundation Trust, Cambridge (M.S.G.), the Department of Surgery and Cancer (M.S.G., F.H., A.H.D.) and Imperial Clinical Trials Unit (X.L., J.W.), Imperial College London, London, University of Birmingham, Birmingham (A.B.), Gloucestershire Hospitals NHS Foundation Trust, Gloucester (R.B., K.R.P.), the Medical Research Council Population Health Research Unit and the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford (R.B.), University of Manchester, Manchester (N.C.), Worcestershire Acute Hospitals NHS Trust, Worcester (I.N.), North West London Hospitals NHS Trust, Harrow (S.R.), and University of Warwick, Coventry (J.W.) - all in the United Kingdom; and the University of Granada, Granada, Spain (D.M.E.)
| | - Jane Warwick
- From Cambridge University Hospitals NHS Foundation Trust, Cambridge (M.S.G.), the Department of Surgery and Cancer (M.S.G., F.H., A.H.D.) and Imperial Clinical Trials Unit (X.L., J.W.), Imperial College London, London, University of Birmingham, Birmingham (A.B.), Gloucestershire Hospitals NHS Foundation Trust, Gloucester (R.B., K.R.P.), the Medical Research Council Population Health Research Unit and the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford (R.B.), University of Manchester, Manchester (N.C.), Worcestershire Acute Hospitals NHS Trust, Worcester (I.N.), North West London Hospitals NHS Trust, Harrow (S.R.), and University of Warwick, Coventry (J.W.) - all in the United Kingdom; and the University of Granada, Granada, Spain (D.M.E.)
| | - Alun H Davies
- From Cambridge University Hospitals NHS Foundation Trust, Cambridge (M.S.G.), the Department of Surgery and Cancer (M.S.G., F.H., A.H.D.) and Imperial Clinical Trials Unit (X.L., J.W.), Imperial College London, London, University of Birmingham, Birmingham (A.B.), Gloucestershire Hospitals NHS Foundation Trust, Gloucester (R.B., K.R.P.), the Medical Research Council Population Health Research Unit and the Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford (R.B.), University of Manchester, Manchester (N.C.), Worcestershire Acute Hospitals NHS Trust, Worcester (I.N.), North West London Hospitals NHS Trust, Harrow (S.R.), and University of Warwick, Coventry (J.W.) - all in the United Kingdom; and the University of Granada, Granada, Spain (D.M.E.)
| |
Collapse
|