Prevention and treatment of venous ulcers in primary chronic venous insufficiency

An overview of systematic reviews of clinical studies of platelet-rich plasma for venous ulcers

To evaluate the clinical evidence of platelet-rich plasma (PRP) in the treatment of venous ulcers (VUs). Electronic searches were conducted through the Cochrane Library, Web of Science, Embase and PubMed. AMSTAR-2 was used to assess the methodological quality. The quality of evidence was assessed using the GRADE system. According to AMSTAR-2, the methodological quality of the included reviews was generally inadequate owing to the limitations of entries 2, 4 and 7. Due to bias risk and imprecision, the evidence quality of the outcome measures was inadequate. In conclusion, PRP may have a therapeutic effect on VUs. However, this conclusion must be treated with caution due to methodological flaws of the included systematic reviews and meta-analyses.

Chronic Venous Insufficiency With Emphasis on the Geriatric Population

The underpinning of Chronic Venous Insufficiency (CVI) is valvular dysfunction, which manifests on a spectrum depending on the severity of insufficiency and duration of the disease. The mainstay of treatment relies on compression therapy of a proper type and intensity. In older adults, special consideration must be taken during the patient encounter to account for age-related factors. This review discusses the clinical presentation, diagnosis, and mimicking of CVI, focusing mainly on older adults. The epidemiology, risk factors, disease burden, and grave complications -- such as thrombosis and ulceration, are reviewed. The physiological impacts of CVI are described, providing the background for treatment strategies, including non-invasive, medical, and surgical therapies. The findings show advanced age to be an important risk factor contributing to CVI and that other age-related factors add to the risk of severe complications. Clinical assessments combined with objective measurements that assess localized skin water using tissue dielectric constant values or whole limb assessments may aid in the differential diagnosis. Furthermore, understanding the mechanism of action of compression therapy, the mainstay of CVI treatment, and its physiological impacts, allows for its informed use in geriatric patients with increased risks of potential compression-related side effects.

A Contemporary Comparison of Cyanoacrylate, Radiofrequency, and Endovenous Laser Ablation on Healing of Active Venous Ulceration

BACKGROUND

The goal of this study is to compare the healing rates of active lower extremity venous ulcers for patients receiving one of 3 ablation methods, compare their complications, and identify factors affecting successful healing and prevention of recurrence.

METHODS

For this study, data were collected retrospectively on 146 patients at a single institution, tertiary referral center, with an active venous ulcer who underwent ablation therapy via cyanoacrylate (VenaSeal), radiofrequency (RFA), or endovenous laser ablation (EVLA) from 2010 to 2020.

RESULTS

The study showed a nonsignificant difference in days to ulcer healing postintervention between ablative techniques, with 80.8 days for cyanoacrylate ablation (n = 15), 70.07 for RFA (n = 44), and 67.04 days for EVLA (n = 79). A similar, nonsignificant trend was observed for ulcer recurrence, with a rate of 35.7% (5/14) for cyanoacrylate ablation, 26.7% (20/75) for EVLA, and 23.1% (9/39) for RFA. The same nonsignificant trend occurred with deep venous thrombosis following the procedure in 6.3% (1/16) of cyanoacrylate ablation, 4.8% (4/84) of EVLA, and 2.2% (1/46) of RFA cases. The rate of endovenous glue induced thrombosis was also higher (6.3%) for cyanoacrylate than endovenous heat induced thrombosis in EVLA (3.6%) and RFA (2.2%). Cox proportional hazard was significant for compliance with compression therapy (hazard ratio [HR] 2.12, confidence interval [CI] 95% = 1.10-4.20, P = 0.031) and a lack of working with a wound clinic (HR 0.50, CI 95% = 0.33-0.75, P = 0.001) were associated with the decreased time to healing of ulcer but was not influenced by the presence of other comorbidities of smoking or diabetes mellitus.

CONCLUSIONS

This study indicates a trend toward cyanoacrylate ablation having longer healing times and more complications compared to other ablation methods when used in patients with active venous ulcers. Compliance with compression treatment is predictive of venous ulcer healing and working with a wound clinic had significantly longer healing times.

Safety and efficacy of acellular human amniotic fluid and membrane in the treatment of non-healing wounds in a patient with chronic venous insufficiency

Chronic, non-healing venous ulcers of the lower extremity are often limb-threatening conditions. Their management is characterized by a prolonged and frequently frustrating clinical course that represents an economic burden to both the patient and healthcare system. During the last two decades, thermal ablation of underlying incompetent venous systems has been extensively utilized to treat chronic venous insufficiency. Despite successful correction of venous hypertension, a substantial subgroup of patients remain affected by non-healing venous ulcers, thus posing a significant clinical challenge. In this case report, we detail quantitative and qualitative wound treatment course in a patient refractory to standard interventions, by treatment with a combination of cell-free amniotic fluid and dehydrated amniotic membrane following successful thermal ablation of refluxing veins.

Advanced Chronic Venous Insufficiency

Introduction:

Intervention for advanced chronic venous insufficiency is considered an appropriate standard of care. However, outcomes vary among patients who present in advanced clinical stages of disease. The main objectives of this study were to determine whether racial disparity exists at initial presentation and response to intervention.

Methods:

A retrospective database was created to include all radiofrequency ablation procedures performed by a single surgeon from January 14, 2009, through May 25, 2011. Demographics, clinical traits, race, procedure, and outcomes were analyzed. Stepwise model selection reduced candidate baseline factors to a final parsimonious model, which was analyzed using analysis of variance.

Results:

The database consisted of 300 patients with a predominant female (n = 215, 85%) base and 85 (15%) males, with a mean age distribution of 53 years. The mean body mass index was 30.2. Racial distribution revealed Asian (n = 9, 3.3%), Pacific Islander (n = 1, 0.4%), African American (n = 37, 13.6%), and Caucasian (CAU, n = 225, 82.7%). African Americans presented with more advanced clinical stages than the CAU group—C2: African American 21.6%, CAU 36.7%; C4: African American 35%, CAU 24.3%; and C6: African American 35.1%, CAU 7.5%. African Americans demonstrated a higher preoperative venous clinical severity score (VCSS) than their CAU counterparts. Postprocedural decrease in VCSS score was lower in African Americans than their CAU counterparts.

Conclusion:

African American patients present with more advanced venous insufficiency than CAUs. Postprocedural analysis reveals not only slower ulcer healing times but also higher ulcer recurrence rates.

Study on the efficacy of surgery of the superficial venous system and of compression therapy at early stages of chronic venous disease for the prevention of chronic venous ulceration

The mainstay of treatment of chronic venous ulceration (CVU), as also suggested by current treatment guidelines for chronic venous disease (CVD), is represented by surgery and compression therapy for which there is strong evidence of their role in clinically relevant improvement in wound healing and also in the reduction of CVU recurrence, but no information is available as to whether or not these treatments provide effective protection from the onset of CVU. In our study, we have followed, for a median time of 13 years, a total of 3947 patients with CVD at classes C2-C3 of CEAP classification, treated with our treatment protocol (surgery and compression therapy) in order to track the natural history of these patients with regards to CVU development. We identified four groups of patients: 2354 patients (59·64%) (Group A) fully adherent to protocols; 848 patients (21·48%) (Group B) fully adherent to surgery and non-compliant to compression therapy; 432 patients (10·95%) (Group C) fully adherent to compression therapy and non-compliant to surgery; and 313 patients (7·93%) (Group D) non-compliant to either treatments. Regardless of compliance to treatments, the ulcer development rates were very similar between groups (range: 3·23-4.79%), with no statistical significance (P = 0·1522). Currents treatments used in the early stages of CVD appear to have no effects to progression to CVU. Additional longitudinal studies are required to confirm these findings.

Knowledge, Attitude, and Practice in the Management of Mixed Arteriovenous Leg Ulcers

Leg ulceration is a chronic health condition that constitutes a significant disease burden. In this cross-sectional descriptive study, a sample of wound care clinicians were asked to respond to a web-based survey. Based on a review of literature and recommended best practices in the management of mixed arteriovenous (AV) ulcers, a questionnaire was developed to examine the knowledge, attitude, and practice pattern in the management of AV ulcers. A total of 436 clinicians participated in the survey. A number of assessment techniques were perceived to be relevant for the assessment of AV ulcers; medical history and the appearance of ulcers were the most commonly used methods in clinical practice. While over 80% of the participants conceded that compression should be used to promote wound healing, half of them would consider using compression for AV ulcers if ankle brachial index was less than 0.8. Half of the participants considered an ankle brachial index of 0.8 or higher as the optimal cutoff value for safe compression. The majority of respondents disagreed with the perception that caring for people with AV ulcers was unrewarding. However, challenges to promote treatment adherence, address psychosocial concerns, and optimize symptom management are common.

Impact of daily cooling treatment on skin inflammation in patients with chronic venous disease

People with chronic venous disease are at high risk for developing venous leg ulcers. Inflammation is posited as a pathological factor for this chronic condition as evidenced by persistently elevated skin temperature. As part of a larger trial to test the effects of a cooling regimen on leg ulcer prevention, the objective of this preliminary study was to evaluate the first 30 days of intense daily cooling. Compared to a placebo control cuff, a gel cuff applied to the most severely affected lower leg skin for 30 min daily showed no statistically significant differences between temperatures taken in the home at baseline compared to those measured at the 1 month follow up visit. There were also no differences in temperatures noted between the two groups, although the temperatures in the treatment group were lower 30 min after treatment, an indication of adherence. There was no discernable decrease or increase in temperature at a given time point during the 30 day treatment period compared to the control group. It may be better to have patients monitor skin temperature on a daily basis and then apply the cuff as necessary, rather than requiring daily cooling based on baseline measurement. This "prn" approach may provide a sufficient cooling milieu to prevent escalation of inflammation and thwart ulcer occurrence or recurrence. Clinical trials registration #NCT01509599.

Autologous platelet-rich plasma in treatment of chronic venous leg ulcers: A prospective case series

Study

We report our results on a case series of 19 patients receiving platelet-rich plasma application in treatment of patients with chronic unhealing venous leg ulcers.

Material and methods

There were 16 males and three females with a mean age of 38.55 ± 16.46 years. Planimetric size measurements were performed and pain was tested throughout the treatment period. Follow-up was made in seven-day periods. Patients received 5 ml of platelet-rich plasma for each 5 cm2 of the wound surface with half of the amount being injected 1–2 mm deep into the wound and the wound surface was covered with the remaining half.

Results

Complete wound healing occurred in 18 of 19 patients (94.7%) within a mean of 4.82 ± 2.16 week. There were significant reductions in wound area among all consecutive measurements except for first week. A significant reduction in wound volume was apparent even in first week and sustained among consecutive measurements.

Conclusion

Platelet-rich plasma seems effective in terms of promoting healing of venous leg ulcers. Improvement in wound depth was slightly more prominent than that in wound area, indicating a potential role of platelet-rich plasma especially in deep venous ulcers.

Compression in mixed ulcers: venous side

Introduction:

arterial involvement may coexist in about 15–30 of venous ulcers. In this case compression therapy maybe applied, only by expert caregivers, with a reduced pressure which must not overcome the arterial pressure at ankle and foot level. It remains to assess if such a reduced pressure may be effective also on the impaired venous hemodynamics. Aim of this paper is to present an overview of the data we have, showing the effects on venous hemodynamics of a reduced compression pressure.

Material and methods:

in different groups of patients affected by deep and superficial venous incompetence, venous reflux and ejection fraction (EF) from the lower leg were measured in baseline conditions, without any compression, and after application of different elastic and inelastic compression devices exerting different pressure ranges from 20 to 60 mm Hg. The compression pressure was always recorded simultaneously with venous reflux of EF assessment.

Results:

strong pressures show the greatest effect in reducing/abolishing venous reflux and increasing EF but also a reduced pressure in the range of 20 to 40 mm Hg is effective in improving venous hemodynamics provided inelastic materials are used.

Conclusions:

inelastic but not elastic materials exert a standing pressure which is significantly higher than in supine position even starting from a reduced supine pressure of 40 mm Hg which does not impair the arterial inflow. This strong pressure is able to reduce and even abolish the venous reflux and improve the EF up to restoring its normal range. A reduced or modified compression pressure is able to significantly improve the venous hemodynamics without affecting the arterial inflow in patients with mixed ulcers, provided inelastic materials are used.

Review and update on new horizon in the management of venous ulcers

Chronic venous ulcers (CVUs) contribute to functional deficits and are a source of significant morbidity among the affected population. In addition, they directly impact the quality of life of patients and are a significant economic burden on the health care system. In this review, we critically evaluate the current strategies for treating CVUs that have emerged within the last decade and outlined a suggested algorithm for treating patients with this difficult condition.

The European burden of primary varicose veins

BACKGROUND

The treatment of varicose veins has been demonstrated to improve quality of life, alleviate symptoms of depression and treat the complications of venous disease. This study aims to show the studies which contain information regarding the prevalence and distribution of venous disease. Then using the population and prevalence data for venous disease, and considering the cost of treating varicose veins, this study aims to analyse the treatment of varicose veins and assess whether there is a disparity between European countries.

METHODS

Relevant papers regarding the prevalence or incidence of venous disease were identified through searches of PubMed (1966 to October 2010). The search terms 'prevalence OR incidence' AND 'varicose veins or venous disease' were used. Population data, prevalence data and the number of varicose vein procedures performed in each country was obtained for 2010.

RESULTS

Four studies were included. From calculated values comparing the predicted and actual number of patients requiring treatment for venous disease, the UK, Finland and Sweden are potentially not treating all patients with C2 disease. In contrast to this, all other European countries represented are treating more patients, suggesting that they may be treating additional patients. There was up to a four-fold difference in the numbers of procedures per million population that were performed for varicose veins in different European countries.

CONCLUSION

There is a marked disparity across Europe between the predicted number of patients with varicose veins requiring treatment and the actual care given. The factors influencing this need more detailed investigation.

Value of magnetic resonance venography and computed tomographic venography in lower extremity chronic venous disease

For the treatment of chronic venous disease (CVD) of the lower extremity, identification of the underlying venous pathologies is essential. Traditionally, the pathologies to detect with imaging have been centred on insufficiency and reflux of the superficial, perforator and deep veins of the leg. More recently, stenosis and obstruction of the deep veins of the pelvis and abdomen (i.e. inferior vena cava, common and external iliac veins) have been identified as significant underlying pathologies in CVD. Accurate detection of stenotic and/or occlusive venous disease expands the treatment options for patients with CVD. In most cases, imaging of venous disease is performed with duplex ultrasound. In this article we discuss the existing evidence and potential value of computed tomographic venography and magnetic resonance venography to contribute in accurately identifying chronic venous disease, in particular chronic venous obstruction.

Low molecular weight heparin improves healing of chronic venous ulcers especially in the elderly

Venous ulcers are common, especially in the elderly, accounting for more than 50% of all lower extremity ulcers with important socioeconomic problems. Improving extracellular matrix functioning, by heparin administration, seems to be a way to support wound healing. A total of 284 patients with venous ulcers were recruited in a 4-year period. All patients were subjected to the most appropriate treatment after considering their preference (compression therapy followed or not by vein surgery). Patients were randomised into two groups of 142 persons in each (group A and group B as cases and controls, respectively). Patients of group A, in addition to the basic treatment as described earlier, received administration of nadroparin 2850 IU/0.3 ml through subcutaneous injection once a day for 12 months, whereas group B patients received basic treatment alone. Healing was assessed by means of direct ulcer tracing with computerised planimetry. Group A showed a healing rate of 83·80% at 12 months, whereas that of group B was 60·56%. Results by age group surprisingly showed that the group of older patients took the most advantage from long-term treatment with low molecular weight heparin; this group also had lowest recurrence rate.

[Efficacy of Chinese herbal medicine Mailuo Shutong Granule and Hirudoid cream for chronic venous disorder-induced pigmentation in lower extremities: a prospective, randomized controlled trial]

BACKGROUND

Chronic venous disorder (CVD) of the lower extremities generally induces dermatologic complications in lower extremity skin, such as hyperpigmentation. If not treated effectively, the lesions may develop into severe outcomes, including dermal ulcer or necrosis.

OBJECTIVE

To evaluate the clinical efficacy of Mailuo Shutong Granule, a compound traditional Chinese herbal medicine, and Hirudoid cream (heparinoid), in treatment of patients with dermal hyperpigmentation of skin caused by CVD.

DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS

A total of 108 CVD outpatients with pigmentation from Department of Vascular Surgery, Shanghai Changhai Hospital were randomly divided into Mailuo Shutong group, Hirudoid group and combined therapy group, with 36 patients in each group. Patients in the Mailuo Shutong group and the Hirudoid group were treated with Mailuo Shutong Granule or Hirudoid cream, respectively, while those in the combined therapy group were treated with Mailuo Shutong Granule plus Hirudoid cream. They were all treated for 28 d.

MAIN OUTCOME MEASURES

Before and after the 28-day treatment, area and average gray value of pigmentation lesions were measured and evaluated.

RESULTS

Thirty-three cases in the Mailuo Shutong group, 34 cases in the Hirudoid group and 31 cases in the combined therapy group were included for analysis. After treatment, area of pigmentation decreased and average gray value of pigmentation declined in all the 3 groups (P<0.05). The reductions of area and average gray value in the combined therapy group were more significant than those in the Mailuo Shutong group and Hirudoid group (P<0.05). There were no differences in improvement of pigmentation between the Mailuo Shutong group and Hirudoid group (P>0.05).

CONCLUSION

These data suggest that both Mailuo Shutong Granule and Hirudoid cream can improve CVD-induced hyperpigmentation, and combined treatment of the two drugs results in better clinical efficacy.

What is the Medical Rationale for the Treatment of Varicose Veins?

Varicose veins occur in up to one-third of Western populations and are associated with clinical manifestations ranging from asymptomatic, isolated varicose veins (C2 disease) to venous ulceration. While the development of less invasive treatment options, such as endovenous ablation and sclerotherapy, have been well accepted by patients they have led to increased utilization of scarce healthcare resources. While few would argue with the treatment of acute complications such as superficial venous thrombosis and variceal haemorrhage, the role of interventional treatment in the management of lifestyle limiting symptoms and the prevention of disease progression may be debatable. Good-quality evidence does suggest that surgical management of varicose veins is associated with improved quality of life at costs below the thresholds of many Western healthcare systems. However, the progression of isolated C2 disease to advanced chronic venous insufficiency occurs infrequently and the role of treatment to prevent such progression remains undefined at present.