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Moreno O, Kumar K, Lurie F, Passman MA, Jacobowitz G, Aziz F, Henke P, Wakefield T, Obi A. A mapping review of Pacific Vascular Symposium 6 initiatives. J Vasc Surg Venous Lymphat Disord 2024; 12:101723. [PMID: 38135216 DOI: 10.1016/j.jvsv.2023.101723] [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: 07/06/2023] [Revised: 11/08/2023] [Accepted: 11/11/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE The 2010 Pacific Vascular Symposium 6 (PVS6) brought venous disease content experts together with a goal of addressing critical issues collated together in the next decade with concrete plans to achieve these goals. This mapping review aims to provide a broader representation of how progress in critical issues of chronic venous disease has been made by extrapolating scientific publications related to the PVS6 initiatives. METHODS We performed a mapping review identifying original or systematic review/meta-analysis articles related to PVS 6 initiatives (aims) that addressed one of the following key objectives: scales to measure chronic venous disease, effectiveness of interventional deep venous thrombus removal, development of a deep venous valve, and biomarkers related to venous disease. Searches were undertaken in PubMed, Ovid Medline, Cochrane Library, Embase (Elsevier), CINAHL (EBSCO), and Scopus. We extracted descriptive information about the studies and predefined variables for each specific aim, showing what and where research exists on the aims included. RESULTS A total of 2138 articles were screened from 3379 retrieved articles from six electronic databases. We mapped 186 included articles, finding that the total number of publications significantly increased after the 2010 PVS6 meeting. Aim results were visually summarized. The largest body of data addressed catheter-based thrombus removal strategies for acute iliofemoral deep venous thrombosis. Primary research on artificial venous valves and venous biomarkers remained limited. No new post-thrombotic syndrome (PTS) score has been developed. CONCLUSIONS This mapping review identified and characterized the available evidence and gaps in our knowledge of chronic venous disease that exist visually, which may guide where more significant investments for the future should be targeted.
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Affiliation(s)
- Oscar Moreno
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Kiran Kumar
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Fedor Lurie
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI; Jobst Vascular Institute of ProMedica, Toledo, OH
| | - Marc A Passman
- UAB Vein Program and Clinic, Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL
| | - Glen Jacobowitz
- Section of Vascular Surgery, Department of Surgery, New York University, New York, NY
| | - Faisal Aziz
- Division of Vascular Surgery, Department of Surgery, The Pennsylvania State University, Hershey, PA
| | - Peter Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Thomas Wakefield
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Andrea Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI.
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Wang SH, Shyu VBH, Chiu WK, Huang RW, Lai BR, Tsai CH. An Overview of Clinical Examinations in the Evaluation and Assessment of Arterial and Venous Insufficiency Wounds. Diagnostics (Basel) 2023; 13:2494. [PMID: 37568858 PMCID: PMC10417660 DOI: 10.3390/diagnostics13152494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/11/2023] [Accepted: 07/17/2023] [Indexed: 08/13/2023] Open
Abstract
Arterial and venous insufficiency are two major causes of chronic wounds with different etiology, pathophysiology, and clinical manifestations. With recent advancements in clinical examination, clinicians are able to obtain an accurate diagnosis of the underlying disease, which plays an important role in the treatment planning and management of patients. Arterial ulcers are mainly caused by peripheral artery diseases (PADs), which are traditionally examined by physical examination and non-invasive arterial Doppler studies. However, advanced imaging modalities, such as computed tomography angiography (CTA) and indocyanine green (ICG) angiography, have become important studies as part of a comprehensive diagnostic process. On the other hand, chronic wounds caused by venous insufficiency are mainly evaluated by duplex ultrasonography and venography. Several scoring systems, including Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification, the Venous Clinical Severity Score (VCSS), the Venous Disability Score, and the Venous Segmental Disease Score (VSDS) are useful in defining disease progression. In this review, we provide a comprehensive overlook of the most widely used and available clinical examinations for arterial and venous insufficiency wounds.
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Affiliation(s)
- Szu-Han Wang
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Keelung Branch, Keelung 204, Taiwan; (S.-H.W.); (V.B.-H.S.); (B.-R.L.)
- Graduate Institute of Biomedical Informatics, Taipei Medical University, Taipei 110, Taiwan
| | - Victor Bong-Hang Shyu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Keelung Branch, Keelung 204, Taiwan; (S.-H.W.); (V.B.-H.S.); (B.-R.L.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan;
| | - Wen-Kuan Chiu
- Division of Plastic Surgery, Department of Surgery, Wan Fang Hospital, Taipei Medical University, Taipei 116, Taiwan;
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
| | - Ren-Wen Huang
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan;
- Division of Trauma Plastic Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Bo-Ru Lai
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Keelung Branch, Keelung 204, Taiwan; (S.-H.W.); (V.B.-H.S.); (B.-R.L.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan;
| | - Chia-Hsuan Tsai
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Keelung Branch, Keelung 204, Taiwan; (S.-H.W.); (V.B.-H.S.); (B.-R.L.)
- College of Medicine, Chang Gung University, Taoyuan 333, Taiwan;
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Erdinc I. Efficiency of endovenous laser and glue ablation methods in comparison with conventional surgery for the treatment of venous ulcers. Phlebology 2022; 37:670-677. [DOI: 10.1177/02683555221125384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction In this study, we aimed to investigate the efficiency of endovenous laser and glue ablation techniques and compared the results with conventional surgical stripping. Patients and Methods Between January 2005 and January 2020, among 3133 consecutive patients with superficial venous reflux disease receiving treatment at our institution, there were 112 consecutive patients with active venous ulcers. Patients were divided into 3 groups as receiving conventional open surgical treatment (Group 1, n: 70), endovenous glue ablation (Group 2, n: 20), and endovenous laser ablation (Group 3, n: 22). Comorbidity factors, duration and size of the ulcers, deep, perforating, and small saphenous vein disease detected with detailed Doppler ultrasonography, and duration for healing and recurrence were investigated. Results The age, gender, comorbidities, smoking, history of previous treatment, diameter of the small saphenous vein, number of refluxing perforating veins, size of the ulcer, and ulcer recurrence ratio were not significantly different between groups. There were 7 patients with bilateral disease and in total 119 legs were intervened. Mean durations for complete ulcer healing were significantly lower in Group 1 (53.28 ± 22.1 days) than Group 2 (73.7 ± 39.6 days); however, it did not differ significantly between Group 1 and Group 3 (62.59 ± 19.65 days), and Group 2 and Group 3 ( p: 0.26). Ulcers recurred in 23 patients (33%) in stripping group at a mean follow up of 14.42 ± 4.6 months, in 7 patients (35%) in glue ablation group at a mean follow up of 11.97 ± 2.94 months, and in 5 patients (23%) in laser ablation group at a mean follow up of 12.66 ± 3.48 months ( p > 0.05 for all). Increased body mass index, co-existence of chronic venous insufficiency, active cigarette smoking, non-compliance with physician advises and exercise and compression stockings, and depth of the ulcers were correlated with recurrence. Conclusion The rationelle beyond treatment of the venous ulcers and prevention of recurrence relies on relief of the venous hypertension by interventional methods and/or compression therapy. None of the methods is superior over the others. Healing in short term without further recurrence may be achieved with successful intervention as well as good patient compliance.
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Affiliation(s)
- Ibrahim Erdinc
- Cardiovascular Surgery Clinic, Bozyaka Education and Research Hospital, Izmir, Turkey
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Zhou Y, Guan Y, Xue M, Zheng X, Chen X. Clinical Outcomes of Stenting Extending Below the Inguinal Ligament for Treatment of Chronic Iliofemoral Venous Obstruction. Ann Vasc Surg 2021; 75:259-266. [PMID: 33823261 DOI: 10.1016/j.avsg.2021.01.115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 12/27/2020] [Accepted: 01/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients with chronic iliofemoral venous obstructive lesions that often require stenting extending below the inguinal ligament. However, the issue of stents crossing the inguinal ligament is currently controversial. Some guidelines suggest that it should be avoided, and some guidelines suggest that in order to ensure adequate flow, the inguinal ligament can be crossed if necessary. The aim of this study was to evaluate the technical aspects and examine patency rates of stent placement across the inguinal ligament for managing iliofemoral venous obstruction. METHODS A retrospective analysis of 127 patients with chronic iliofemoral venous obstruction were treated with interventional surgery in a single institution from January 2012 to January 2018 was conducted. All patients underwent balloon dilatation and placement of at least 2 stents extending below inguinal ligament. Inflow condition, technical success, operation duration, stent patency rates, anticoagulant selection and duration, and complications were recorded after the interventions. RESULTS The technical success rate was 100%. No major perioperative complications occurred. The mean number of stents was 2.14 ± 0.37. Follow up periods ranged from 12 to 60 months (28.79 ± 10.90 months). Overall cumulative primary, assisted primary, and secondary stent patency rates were 81.9%, 90.5%, and 92.9% at 12 months and 70.4%, 80.9%, and 86.0% at 24 months, and 64.2%, 72.3%, and 74.3% at 36months, respectively. Cumulative patency rates at 12 months, 24 months and 36 months were significantly greater in the patients with "good" inflow as compared to "fair" inflow. The symptoms of all patients improved. None of the stents were compressed, fractured or migrated. CONCLUSIONS Stenting across the inguinal ligament for treatment of the patients with chronic iliofemoral venous obstruction was a feasible and safe treatment with good patency and clinical results in short and midterm follow up, and stents with good inflow have better patency.
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Affiliation(s)
- Yadong Zhou
- Department of Vascular Surgery, Fujian Medical University Union Hospital, Fuzhou City, Fujian Province, China
| | - Yunbiao Guan
- Department of Vascular Surgery, Fujian Medical University Union Hospital, Fuzhou City, Fujian Province, China.
| | - Ming Xue
- Department of Vascular Surgery, Fujian Medical University Union Hospital, Fuzhou City, Fujian Province, China
| | - Xuexun Zheng
- Department of Vascular Surgery, Fujian Medical University Union Hospital, Fuzhou City, Fujian Province, China
| | - Xingsheng Chen
- Department of Vascular Surgery, Fujian Medical University Union Hospital, Fuzhou City, Fujian Province, China
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Radiofrequency ablation and ultrasound-guided foam sclerotherapy in the treatment of venous insufficiency ulcers in the lower limbs. Descriptive study. ANGIOLOGIA 2021. [DOI: 10.20960/angiologia.00339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Raffetto JD, Ligi D, Maniscalco R, Khalil RA, Mannello F. Why Venous Leg Ulcers Have Difficulty Healing: Overview on Pathophysiology, Clinical Consequences, and Treatment. J Clin Med 2020; 10:jcm10010029. [PMID: 33374372 PMCID: PMC7795034 DOI: 10.3390/jcm10010029] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/14/2020] [Accepted: 12/21/2020] [Indexed: 12/13/2022] Open
Abstract
Venous leg ulcers (VLUs) are one of the most common ulcers of the lower extremity. VLU affects many individuals worldwide, could pose a significant socioeconomic burden to the healthcare system, and has major psychological and physical impacts on the affected individual. VLU often occurs in association with post-thrombotic syndrome, advanced chronic venous disease, varicose veins, and venous hypertension. Several demographic, genetic, and environmental factors could trigger chronic venous disease with venous dilation, incompetent valves, venous reflux, and venous hypertension. Endothelial cell injury and changes in the glycocalyx, venous shear-stress, and adhesion molecules could be initiating events in VLU. Increased endothelial cell permeability and leukocyte infiltration, and increases in inflammatory cytokines, matrix metalloproteinases (MMPs), reactive oxygen and nitrogen species, iron deposition, and tissue metabolites also contribute to the pathogenesis of VLU. Treatment of VLU includes compression therapy and endovenous ablation to occlude the axial reflux. Other interventional approaches such as subfascial endoscopic perforator surgery and iliac venous stent have shown mixed results. With good wound care and compression therapy, VLU usually heals within 6 months. VLU healing involves orchestrated processes including hemostasis, inflammation, proliferation, and remodeling and the contribution of different cells including leukocytes, platelets, fibroblasts, vascular smooth muscle cells, endothelial cells, and keratinocytes as well as the release of various biomolecules including transforming growth factor-β, cytokines, chemokines, MMPs, tissue inhibitors of MMPs (TIMPs), elastase, urokinase plasminogen activator, fibrin, collagen, and albumin. Alterations in any of these physiological wound closure processes could delay VLU healing. Also, these histological and soluble biomarkers can be used for VLU diagnosis and assessment of its progression, responsiveness to healing, and prognosis. If not treated adequately, VLU could progress to non-healed or granulating VLU, causing physical immobility, reduced quality of life, cellulitis, severe infections, osteomyelitis, and neoplastic transformation. Recalcitrant VLU shows prolonged healing time with advanced age, obesity, nutritional deficiencies, colder temperature, preexisting venous disease, deep venous thrombosis, and larger wound area. VLU also has a high, 50-70% recurrence rate, likely due to noncompliance with compression therapy, failure of surgical procedures, incorrect ulcer diagnosis, progression of venous disease, and poorly understood pathophysiology. Understanding the molecular pathways underlying VLU has led to new lines of therapy with significant promise including biologics such as bilayer living skin construct, fibroblast derivatives, and extracellular matrices and non-biologic products such as poly-N-acetyl glucosamine, human placental membranes amnion/chorion allografts, ACT1 peptide inhibitor of connexin 43, sulodexide, growth factors, silver dressings, MMP inhibitors, and modulators of reactive oxygen and nitrogen species, the immune response and tissue metabolites. Preventive measures including compression therapy and venotonics could also reduce the risk of progression to chronic venous insufficiency and VLU in susceptible individuals.
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Affiliation(s)
- Joseph D. Raffetto
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
- Correspondence: (J.D.R.); (F.M.)
| | - Daniela Ligi
- Department of Biomolecular Sciences, Section of Biochemistry and Biotechnology, Unit of Clinical Biochemistry, University Carlo Bo of Urbino, 61029 Urbino, Italy; (D.L.); (R.M.)
| | - Rosanna Maniscalco
- Department of Biomolecular Sciences, Section of Biochemistry and Biotechnology, Unit of Clinical Biochemistry, University Carlo Bo of Urbino, 61029 Urbino, Italy; (D.L.); (R.M.)
| | - Raouf A. Khalil
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
| | - Ferdinando Mannello
- Department of Biomolecular Sciences, Section of Biochemistry and Biotechnology, Unit of Clinical Biochemistry, University Carlo Bo of Urbino, 61029 Urbino, Italy; (D.L.); (R.M.)
- Correspondence: (J.D.R.); (F.M.)
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Nguyen H, Agu E, Tulu B, Strong D, Mombini H, Pedersen P, Lindsay C, Dunn R, Loretz L. Machine learning models for synthesizing actionable care decisions on lower extremity wounds. SMART HEALTH (AMSTERDAM, NETHERLANDS) 2020; 18. [PMID: 33299924 DOI: 10.1016/j.smhl.2020.100139] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Lower extremity chronic wounds affect 4.5 million Americans annually. Due to inadequate access to wound experts in underserved areas, many patients receive non-uniform, non-standard wound care, resulting in increased costs and lower quality of life. We explored machine learning classifiers to generate actionable wound care decisions about four chronic wound types (diabetic foot, pressure, venous, and arterial ulcers). These decisions (target classes) were: (1) Continue current treatment, (2) Request non-urgent change in treatment from a wound specialist, (3) Refer patient to a wound specialist. We compare classification methods (single classifiers, bagged & boosted ensembles, and a deep learning network) to investigate (1) whether visual wound features are sufficient for generating a decision and (2) whether adding unstructured text from wound experts increases classifier accuracy. Using 205 wound images, the Gradient Boosted Machine (XGBoost) outperformed other methods when using both visual and textual wound features, achieving 81% accuracy. Using only visual features decreased the accuracy to 76%, achieved by a Support Vector Machine classifier. We conclude that machine learning classifiers can generate accurate wound care decisions on lower extremity chronic wounds, an important step toward objective, standardized wound care. Higher decision-making accuracy was achieved by leveraging clinical comments from wound experts.
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Affiliation(s)
- Holly Nguyen
- Worcester Polytechnic Institute, 100 Institute Road, Worcester and 01609, United States
| | - Emmanuel Agu
- Worcester Polytechnic Institute, 100 Institute Road, Worcester and 01609, United States
| | - Bengisu Tulu
- Worcester Polytechnic Institute, 100 Institute Road, Worcester and 01609, United States
| | - Diane Strong
- Worcester Polytechnic Institute, 100 Institute Road, Worcester and 01609, United States
| | - Haadi Mombini
- Worcester Polytechnic Institute, 100 Institute Road, Worcester and 01609, United States
| | - Peder Pedersen
- Worcester Polytechnic Institute, 100 Institute Road, Worcester and 01609, United States
| | - Clifford Lindsay
- University of Massachusetts Medical School/UMass Memorial Health Car, 55 N Lake Ave, Worcester and 01655, United States
| | - Raymond Dunn
- University of Massachusetts Medical School/UMass Memorial Health Car, 55 N Lake Ave, Worcester and 01655, United States
| | - Lorraine Loretz
- University of Massachusetts Medical School/UMass Memorial Health Car, 55 N Lake Ave, Worcester and 01655, United States
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Aline de Oliveira Kaizer U, Aparecida Rocha Domingues E. Construção e validação de um folheto educativo para tratamento de úlcera venosa. ESTIMA 2019. [DOI: 10.30886/estima.v17.677_pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective: To build and validate an educational leaflet for treatment of patients with ulcer of venous etiology. Methods: Methodological study, developed in two stages: construction of the educational leaflet by literature review and content validation of the material by judges specializing in the subject. Results: The instrument obtained a Content Validity Index (CVI) above 0.80; only one item was modified after the judges’ suggestion. Conclusion: The educational leaflet was presented to be understandable and comprehensive for the content.
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Aline de Oliveira Kaizer U, Aparecida Rocha Domingues E. Construction and validation of an educational leaflet for treatment of venous ulcer. ESTIMA 2019. [DOI: 10.30886/estima.v17.677_in] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective: To build and validate an educational leaflet for treatment of patients with ulcer of venous etiology. Methods: Methodological study, developed in two stages: construction of the educational leaflet by literature review and content validation of the material by judges specializing in the subject. Results: The instrument obtained a Content Validity Index (CVI) above 0.80; only one item was modified after the judges’ suggestion. Conclusion: The educational leaflet was presented to be understandable and comprehensive for the content.
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Biological Mechanisms of Chronic Wound and Diabetic Foot Healing: The Role of Collagen. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2019. [DOI: 10.2478/sjecr-2018-0077] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Abstract
The treatment of chronic wounds is a continuously developing research focus. The problems of excessive mechanical forces, infection, inflammation, reduced production of growth factors, and lack of collagen will affect the results of treatment. The purpose of this study was to analysse the elements that lead to long-term non-healing of chronic wounds and trophic ulcers, including diabetic foot syndrome, by determining the optimal treatment algorithm. The paper presents an analysis of the world literature on the etiopathogenesis and principles of chronic wound treatment in diabetic foot syndrome. The epidemiology of chronic wounds of different genesis is presented. The issues of physiological and metabolic disorders in chronic ulcers affecting the process of wound healing are discussed. Particular attention is paid to collagen, which is a protein that forms the basis of connective tissue; collagen ensures the strength and elasticity of the skin, which confirms the importance of its role not only in aesthetics but also in the process of wound healing. Different types of collagen and their roles in the mechanisms of chronic wound healing in diabetic foot syndrome are described. The results of clinical studies evaluating the effectiveness of medical products and preparations, consisting of collagen with preserved (native collagen) and fractionated structures, in treating chronic wounds of diabetic foot syndrome are analysed. It has been shown that the use of native collagen preparations is a promising treatment for chronic ulcers and wounds, including diabetic foot syndrome, which makes it possible to increase the effectiveness of treatment and reduce the economic costs of managing these patients.
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Bitner J, Sachdev U, Hager ES, Dillavou ED. Standardized care protocol and modifications to electronic medical records to facilitate venous ulcer healing. J Vasc Surg Venous Lymphat Disord 2019; 7:570-576. [PMID: 30777673 DOI: 10.1016/j.jvsv.2018.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 11/12/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Venous ulcers are painful, recurrent, and difficult to heal. Electronic medical records (EMRs) are often not optimized to track wounds. Specialized wound care programs may not interface with office-based records, creating a need to standardize the process of venous ulcer measurement and dressing documentation within existing systems. This work describes the creation of an EMR protocol to track venous ulcer size, to standardize dressings, to address related health issues, and to improve education of the patient. We hypothesized that the institution of an EMR protocol to track clinical features of venous ulcer patients, including wound size and health status, would facilitate wound healing. METHODS We performed a retrospective review of a prospective database from September 2014 to May 2017. Modifications to the EMR included the formation of a venous ulcer patient list, a dressing tracker, calculation of total ulcer area, graphing of ulcer size over time, and images of the wound area. Patient education materials were created through the EMR and loaded into an automatic end-visit printout that emphasized smoking cessation, weight loss, and consultation with specialty services as necessary. Quarterly meetings with the supervising physician were established to review each patient's wound progress and to target areas of improvement. RESULTS During the study period, 204 patients with chronic C5 and C6 disease were observed. Before the start of the project, the healing rate was 53.3%. Wound healing rates improved from 59.5% (quarter 1) to 77.94% (quarter 8). In the quarter before the project started, there were no patients who had quit or cut down on smoking or smokeless tobacco, no patients who were referred for weight loss consultation, and nine who were already patients of bariatric surgery. During the study period, 29% of patients quit smoking, 19% decreased smoking, and 20% cut down smokeless tobacco use. There were 54 patients who underwent advanced arterial evaluation; 175 patients underwent sclerotherapy and 137 patients had endovenous thermal ablation to treat axial reflux in the affected limb. The EMR modification project took 13 months to craft and to implement, with approximately 8 hours of meeting time from the surgical team. CONCLUSIONS A comprehensive care model for venous ulcer patients through EMR modification improved overall patient care, increased communication between providers, and facilitated ulcer healing. EMR modification can be introduced with an acceptable time investment on the part of both the provider and the institutional information technology team.
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Affiliation(s)
- Julie Bitner
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ulka Sachdev
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Eric S Hager
- Department of Surgery, Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ellen D Dillavou
- Department of Surgery, Division of Vascular Surgery, Duke University Health System, Durham, NC.
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Zollino I, Campioni D, Sibilla MG, Tessari M, Malagoni AM, Zamboni P. A phase II randomized clinical trial for the treatment of recalcitrant chronic leg ulcers using centrifuged adipose tissue containing progenitor cells. Cytotherapy 2018; 21:200-211. [PMID: 30583949 DOI: 10.1016/j.jcyt.2018.10.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 10/17/2018] [Accepted: 10/24/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND AIMS Preclinical and observational reports indicate that adipose tissue (AT) is a safe and promising tool to treat non-healing venous leg ulcers (VLUs). METHODS From an initial cohort of 38 patients, 16 patients affected by non-healing VLUs were randomly allocated to the experimental arm (5 men and 3 women) and control arm (5 men and 3 women). In the experimental arm, wounds were treated by debridement, centrifuged adipose tissue (CAT), advanced dressings and compression. No experimental treatment (CAT) was administered to the control arm. We investigated the functional and the immunophenotypical features of the harvested CAT-derived stem cells. The primary outcome measures were healing time and safety of the cell treatment. Secondary outcomes were pain evaluated by numeric rating scale (NRS), complete wound healing at 24 weeks by Margolis Index and wound-healing process expressed in square centimeters per week. The various immunophenotypic and functional characteristics of CAT-derived stem cells were then correlated with the clinical outcomes. RESULTS No major adverse events were recorded. The healing time was significantly faster by applying CAT, 17.5 ± 7.0 weeks versus 24.5 ± 4.9 weeks recorded in the control arm (P < 0.036). NRS dropped after the first week to 2.7 ± 2.0 in the experimental arm versus 6.6 ± 3.0 in the control group (P < 0.01). The rate of healing at the 24th week was not significantly different between arms. Interestingly, we found a strong reverse correlation between the percent of CD34+/CD45- non-hematopoietic cells, respectively, with the healing time (r = -0.894, P < 0.041) and NRS (r = -0.934, P < 0.020). CONCLUSIONS CAT is safe and may accelerate healing time in VLUs as well as reduce wound pain. The percentage of CD34+/CD45- cells in stromal vascular fraction (SVF) seems to be a predictive biomarker of successful CAT treatment in these patients.
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Affiliation(s)
- Ilaria Zollino
- Department of Morphology, Surgery and Experimental Medicine, Section of Translational of Medicine and Surgery, University of Ferrara, Ferrara, Italy.
| | - Diana Campioni
- Center of Hemostasis & Thrombosis, Department of Biomedical and Surgical Science, Section of Medical Biochemistry, Molecular Biology & Genetics, University of Ferrara, Ferrara, Italy
| | - Maria Grazia Sibilla
- Sant'Anna University Hospital, Unit of Translational Surgery and Vascular Diseases Center, Ferrara, Italy
| | - Mirko Tessari
- Department of Morphology, Surgery and Experimental Medicine, Section of Translational of Medicine and Surgery, University of Ferrara, Ferrara, Italy; Sant'Anna University Hospital, Unit of Translational Surgery and Vascular Diseases Center, Ferrara, Italy
| | - Anna Maria Malagoni
- Sant'Anna University Hospital, Unit of Translational Surgery and Vascular Diseases Center, Ferrara, Italy
| | - Paolo Zamboni
- Department of Morphology, Surgery and Experimental Medicine, Section of Translational of Medicine and Surgery, University of Ferrara, Ferrara, Italy; Sant'Anna University Hospital, Unit of Translational Surgery and Vascular Diseases Center, Ferrara, Italy
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13
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Domingues EAR, Kaizer UAO, Lima MHM. Effectiveness of the strategies of an orientation programme for the lifestyle and wound-healing process in patients with venous ulcer: A randomised controlled trial. Int Wound J 2018; 15:798-806. [PMID: 29808613 PMCID: PMC7949876 DOI: 10.1111/iwj.12930] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 03/19/2018] [Indexed: 11/30/2022] Open
Abstract
This study aimed to evaluate the effect of strategies of a lifestyle orientation programme on patients with venous ulcer in elastic compression therapy. This was a single-blind, 2-arm, randomised clinical controlled trial. The primary outcome included the reduction of the wound surface area. The secondary outcomes included the perception of pain, questionnaire of ulcer status, and quality of life. Seventy-one patients with ulcers of venous aetiology were randomised into 2 arms: control group (CG) and intervention group (IG), with a 12-week follow up. The CG was provided with the routine guidelines of the health services. Meanwhile, the IG was provided with lifestyle guidelines regarding the physiopathology of a venous ulcer, importance of compression therapy, physical exercises and rest in 4 face-to-face and 2 telephone interviews. The IG had significant improvement on the wound healing on 30, 60, and 90 days of follow up when compared with the CG (P = .0197; P = .0472; P = .0116). There were no statistical differences between groups; both had improvement in the quality of life and pain perception. Our results demonstrated that elastic compression therapy along with guidelines on lifestyle is effective adjunctive treatment to promote wound healing in patients with leg ulcers.
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Sabolinski ML, Gibbons G. Comparative effectiveness of a bilayered living cellular construct and an acellular fetal bovine collagen dressing in the treatment of venous leg ulcers. J Comp Eff Res 2018; 7:797-805. [PMID: 29809059 DOI: 10.2217/cer-2018-0031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Aim: To compare the effectiveness of bilayered living cellular construct (BLCC) and an acellular fetal bovine collagen dressing (FBCD) for the treatment of venous leg ulcers. Methods: Data from WoundExpert® (Net Health, PA, USA) was used to analyze 1021 refractory venous leg ulcers treated at 177 facilities. Results: Kaplan-Meier analyses showed that BLCC (893 wounds) was superior to FBCD (128 wounds), p = 0.01 for: wound closure by weeks 12 (31 vs 25%), 24 (55 vs 43%) and 36 (68 vs 53%); reduction in time to wound closure of 37%, (19 vs 30 weeks); and improvement in the probability of healing by 45%. Conclusion: BLC versus FBCD showed significant differences in both time to and frequency of healing suggesting that BLCC may provide significant cost savings compared with FBCD.
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Affiliation(s)
- Michael L Sabolinski
- Managing Member Wound Care, Sabolinski LLC, 55 Jefferson Road, Franklin, MA 02038, USA
| | - Gary Gibbons
- Center for Wound Healing, South Shore Hospital, Suite 100, 90 Libbey Parkway, South Weymouth, MA 02189, USA
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Zollino I, Zuolo M, Gianesini S, Pedriali M, Sibilla MG, Tessari M, Carinci F, Occhionorelli S, Zamboni P. Autologous adipose-derived stem cells: Basic science, technique, and rationale for application in ulcer and wound healing. Phlebology 2016; 32:160-171. [PMID: 27056621 DOI: 10.1177/0268355516641546] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objectives The present review represents a translational boundary between basic research and surgery, particularly focusing on the promising application of adipose-derived stem cells harvested intra-operatively during debridement of venous leg ulcers. Methods We reviewed 830 out of 5578 articles on MEDLINE starting from 1997 and sorted by the relevance option. Results The technique currently used for adipose-derived stem cells intra-operative harvesting is presented, including a safety evaluation on a cohort of 5089 revised patients who underwent plastic surgery and maxillo-facial surgical procedures. Complications were reported in 169 cases (3.3%). One hundred and forty-one (2.77%) patients were classified as having minor complications, specifically: nodularity/induration 93 (1.83%), dysesthesia 14 (0.26%), hematoma 12 (0.23%), superficial infection 11 (0.21%), pain 7 (0.13%), poor cosmesis 3 (0.06%), and abnormal breast secretion 1 (0.02%), while 28 patients (0.55%) were classified as having major complications, specifically: deep infection 22 (0.43%), sepsis 3 (0.06%), abdominal hematoma 2 (0.04%), and pneumothorax 1 (0.02%). Application of cell therapy in venous leg ulcer is currently used only for patients not responding to the standard treatment. The review shows the lack of randomized clinical trials for application of adipose-derived stem cells among treatments for venous leg ulcer. Finally, adipose-derived stem cells implantation at the wound site promotes a new tissue formation rich in vascular structures and remodeling collagen. Conclusion Adipose-derived stem cells strategy represents a great opportunity for the treatment of chronic wounds, due to the simplicity of the technique and the application of cell treatment in the operating room immediately following debridement. However, clinical studies and data from randomized trials are currently lacking.
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Affiliation(s)
- Ilaria Zollino
- 1 Department of Morphology, Surgery and Experimental Medicine, Section of Translational of Medicine and Surgery, University of Ferrara, Italy
| | - Michele Zuolo
- 2 Unit of Translational Surgery and Vascular Diseases Center, Sant'Anna University Hospital, Ferrara, Italy
| | - Sergio Gianesini
- 1 Department of Morphology, Surgery and Experimental Medicine, Section of Translational of Medicine and Surgery, University of Ferrara, Italy.,2 Unit of Translational Surgery and Vascular Diseases Center, Sant'Anna University Hospital, Ferrara, Italy
| | - Massimo Pedriali
- 3 Department of Experimental and Diagnostic Medicine, Sant'Anna University Hospital, Ferrara, Italy
| | - Maria Grazia Sibilla
- 2 Unit of Translational Surgery and Vascular Diseases Center, Sant'Anna University Hospital, Ferrara, Italy
| | - Mirko Tessari
- 1 Department of Morphology, Surgery and Experimental Medicine, Section of Translational of Medicine and Surgery, University of Ferrara, Italy.,2 Unit of Translational Surgery and Vascular Diseases Center, Sant'Anna University Hospital, Ferrara, Italy
| | - Francesco Carinci
- 1 Department of Morphology, Surgery and Experimental Medicine, Section of Translational of Medicine and Surgery, University of Ferrara, Italy
| | - Savino Occhionorelli
- 1 Department of Morphology, Surgery and Experimental Medicine, Section of Translational of Medicine and Surgery, University of Ferrara, Italy.,2 Unit of Translational Surgery and Vascular Diseases Center, Sant'Anna University Hospital, Ferrara, Italy
| | - Paolo Zamboni
- 1 Department of Morphology, Surgery and Experimental Medicine, Section of Translational of Medicine and Surgery, University of Ferrara, Italy.,2 Unit of Translational Surgery and Vascular Diseases Center, Sant'Anna University Hospital, Ferrara, Italy
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Iliac Vein Interrogation Augments Venous Ulcer Healing in Patients Who Have Failed Standard Compression Therapy along with Pathological Venous Closure. Ann Vasc Surg 2016; 34:144-51. [DOI: 10.1016/j.avsg.2015.11.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Revised: 09/18/2015] [Accepted: 11/30/2015] [Indexed: 12/12/2022]
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17
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González de la Torre H, Quintana-Lorenzo ML, Perdomo-Pérez E, Verdú J. Correlation between health-related quality of life and venous leg ulcer's severity and characteristics: a cross-sectional study. Int Wound J 2016; 14:360-368. [PMID: 27112627 DOI: 10.1111/iwj.12610] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 04/05/2016] [Accepted: 04/06/2016] [Indexed: 10/21/2022] Open
Abstract
This study aims to determine health-related quality of life (HRQoL) in patients suffering with venous ulceration and to correlate wound's severity status with HRQoL loss as well as identify the aspects of HRQoL most negatively affected by the presence of venous ulcers. In this observational, cross-sectional, descriptive, analytical multi-centre study, data was compiled over a period of 3·5 months. Thrity-four patients with venous ulceration were recruited. The RESVECH 2·0 scale was used to monitor wounds. The MAID scale was used to measure wound's severity. The Charing Cross Venous Ulcer Questionnaire (CCVUQe) (Spanish version) was used to evaluate quality of life. The mean CCVUQe score was 60·58 ± 16·04. The HRQoL dimension most affected was 'Emotional state' (mean score = 77. 67 ± 17·34). The average RESVECH 2.0 score for the wounds was 13·15 ± 5·07. A statistically significant association between total CCVUQ-e score and total RESVECH 2.0 score was detected [Pearson correlation coefficient r = 0·546 (P ≤ 0·001)]. Venous ulcers affect patients' HRQoL, particularly their emotional status. There is a relationship between the severity of the wound and loss of HRQoL. The presence of non-viable tissue, poor exudate control and infection all determine loss of HRQoL. New studies are needed to confirm these findings.
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Affiliation(s)
- Héctor González de la Torre
- Complejo Hospitalario Materno-Infantil Insular de Gran Canaria, Servicio Canario de Salud, Las Palmas de Gran Canaria, Spain
| | - María L Quintana-Lorenzo
- Complejo Hospitalario Materno-Infantil Insular de Gran Canaria, Servicio Canario de Salud, Las Palmas de Gran Canaria, Spain
| | - Estrella Perdomo-Pérez
- Gerencia de Atención Primaria de Gran Canaria, Servicio Canario de Salud, Las Palmas de Gran Canaria, Spain
| | - José Verdú
- Department of Community Nursing, Preventive Medicine, Public Health and History of Science, Faculty of Health Sciences, University of Alicante, Alicante, Spain
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Morton LM, Phillips TJ. Wound healing and treating wounds. J Am Acad Dermatol 2016; 74:589-605; quiz 605-6. [DOI: 10.1016/j.jaad.2015.08.068] [Citation(s) in RCA: 178] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 08/03/2015] [Accepted: 08/14/2015] [Indexed: 11/26/2022]
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19
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Greenhalgh DG. Management of the Skin and Soft Tissue in the Geriatric Surgical Patient. Surg Clin North Am 2015; 95:103-14. [DOI: 10.1016/j.suc.2014.09.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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20
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Validity of International Classification of Diseases, Ninth Revision, Clinical Modification codes for estimating the prevalence of venous ulcer. J Vasc Surg Venous Lymphat Disord 2014; 2:362-7. [DOI: 10.1016/j.jvsv.2014.03.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 03/11/2014] [Indexed: 10/25/2022]
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21
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Mannello F, Ligi D, Canale M, Raffetto JD. Omics profiles in chronic venous ulcer wound fluid: innovative applications for translational medicine. Expert Rev Mol Diagn 2014; 14:737-62. [DOI: 10.1586/14737159.2014.927312] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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22
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Marston WA, Sabolinski ML, Parsons NB, Kirsner RS. Comparative effectiveness of a bilayered living cellular construct and a porcine collagen wound dressing in the treatment of venous leg ulcers. Wound Repair Regen 2014; 22:334-40. [PMID: 24628712 PMCID: PMC4257085 DOI: 10.1111/wrr.12156] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 12/21/2013] [Indexed: 12/21/2022]
Abstract
Using data from a national wound-specific electronic medical record (WoundExpert, Net Health, Pittsburgh, PA), we compared the effectiveness of a bilayered living cellular construct (BLCC) and an acellular porcine small intestine submucosa collagen dressing (SIS) for the treatment of venous leg ulcer. Data from 1,489 patients with 1,801 refractory venous leg ulcers (as defined by failure to have >40% reduction in size in the 4 weeks prior to treatment) with surface areas between 1 and 150 cm(2) in size, treated between July 2009 and July 2012 at 158 wound care facilities across the US were analyzed. Patient baseline demographics and wound characteristics were comparable between groups. Kaplan-Meier-derived estimates of wound closure for BLCC (1,451 wounds) was significantly greater (p = 0.01, log-rank test) by weeks 12 (31% vs. 26%), 24 (50% vs. 41%), and 36 (61% vs. 46%), respectively, compared with SIS (350 wounds). BLCC treatment reduced the median time to wound closure by 44%, achieving healing 19 weeks sooner (24 vs. 43 weeks, p = 0.01, log-rank test). Treatment with BLCC increased the probability of healing by 29% compared with porcine SIS dressing (hazard ratio = 1.29 [95% confidence interval 1.06, 1.56], p = 0.01).
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Affiliation(s)
- William A Marston
- Department of Surgery, Division of Vascular Surgery, University of North Carolina Medical School, Chapel Hill, North Carolina
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Carpentier PH, Blaise S, Satger B, Genty C, Rolland C, Roques C, Bosson JL. A multicenter randomized controlled trial evaluating balneotherapy in patients with advanced chronic venous insufficiency. J Vasc Surg 2014; 59:447-454.e1. [DOI: 10.1016/j.jvs.2013.08.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 07/31/2013] [Accepted: 08/07/2013] [Indexed: 10/26/2022]
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Baritaud S, Desmoulière A, Durand-Fontanier S, Martin C, Pesteil F, Sparsa A. Les principales plaies susceptibles d’être traitées par le miel. ACTUALITES PHARMACEUTIQUES 2013. [DOI: 10.1016/j.actpha.2013.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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An Evaluation of the Association for the Advancement of Wound Care Venous Ulcer Guideline and Recommendations for Further Research. Adv Skin Wound Care 2013; 26:553-61. [DOI: 10.1097/01.asw.0000434057.81199.6c] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
The postthrombotic syndrome (PTS) is a frequent cause of chronic pain, swelling, ulceration, and disability in patients with lower extremity deep vein thrombosis (DVT). As interventional radiologists are consulted on more patients with chronic DVT and PTS, their management strategies must be informed by a balanced understanding of the different facets of chronic DVT care and the available treatment options. This article provides an overview of the important elements of a multifaceted approach to the management of patients with PTS that includes pharmacological, physiological, and endovascular aspects of care.
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Affiliation(s)
- Lina Nayak
- Department of Radiology, Stanford University Medical Center, Stanford, California
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27
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La insuficiencia venosa crónica en el Sistema Nacional de Salud. Diagnóstico, indicaciones quirúrgicas y priorización de listas de espera. Documento de la Sociedad Española de Angiología y Cirugía Vascular (SEACV) y del Capítulo de Flebología y Linfología de la SEACV. ANGIOLOGIA 2013. [DOI: 10.1016/j.angio.2012.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Morton LM, Phillips TJ. Wound Healing Update. ACTA ACUST UNITED AC 2012; 31:33-7. [DOI: 10.1016/j.sder.2011.11.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Revised: 11/10/2011] [Accepted: 11/14/2011] [Indexed: 10/28/2022]
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29
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Harlander-Locke M, Lawrence PF, Alktaifi A, Jimenez JC, Rigberg D, DeRubertis B. The impact of ablation of incompetent superficial and perforator veins on ulcer healing rates. J Vasc Surg 2012; 55:458-64. [DOI: 10.1016/j.jvs.2011.08.054] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2011] [Revised: 08/26/2011] [Accepted: 08/28/2011] [Indexed: 11/16/2022]
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30
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Harlander-Locke M, Lawrence P, Jimenez JC, Rigberg D, DeRubertis B, Gelabert H. Combined treatment with compression therapy and ablation of incompetent superficial and perforating veins reduces ulcer recurrence in patients with CEAP 5 venous disease. J Vasc Surg 2011; 55:446-50. [PMID: 22104338 DOI: 10.1016/j.jvs.2011.08.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 08/02/2011] [Accepted: 08/09/2011] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Patients with healed venous ulcers often experience recurrence of ulceration, despite the use of long-term compression therapy. This study examines the effect of closing incompetent superficial and/or perforating veins on ulcer recurrence rates in patients with CEAP 5 who have progressive lipodermatosclerosis and impending ulceration. METHODS Endovenous ablation was performed on patients with CEAP 5 disease and incompetent superficial and/or perforator veins and increasing lipodermatosclerosis and/or progressive malleolar pain. A minimum of 3 months of compressive therapy was attempted before endovenous ablation of incompetent veins. Demographic data, risk factors, CEAP classification, procedural details, and postoperative status were all recorded. Patients underwent duplex ultrasound scans before ablation to assess for deep, superficial, and perforator venous incompetence as well as postoperatively to confirm successful ablation. RESULTS Twenty-eight endovenous ablation procedures (superficial = 19; perforator = 9) were performed on 20 patients (limbs = 21). The mean patient age was 73 years old (range, 45-93 years) and the mean body mass index was 29.5 (18.9-58.4). Ninety-five percent of patients previously wore compression stockings (20-30 mm Hg = 9; 30-40 mm Hg = 10; none = 1) for a mean time of 23.3 months (range, 3-52 months) since the prior ulcer healed. Indications for venous ablation were increasing malleolar pain (55%) and/or lipodermatosclerosis (70%). Technical success rates for the ablation procedures were 100% for superficial veins and 89% for perforators (96.4% overall). All patients underwent closure of at least one incompetent vein. Postoperatively, 95% of patients were compliant with wearing compression stockings (20-30 mm Hg = 8; 30-40 mm Hg = 11; none = 1). Ulcer recurrence rates were 0% at 6 months and 4.8% at 12 and 18 months. These data compare with prior studies showing an ulcer recurrence rate up to 67% at 12 months with compression alone. CONCLUSION Patients with CEAP 5 healed venous ulcers that undergo endovenous ablation of incompetent superficial and perforating veins and maintain compression have reduced ulcer recurrence rates compared with historical controls that are treated with compression alone.
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