Evidence for varicose vein surgery in venous leg ulceration

Deep Venous Thrombosis and Ulcers of Lower Limbs: Ultrasound Findings in 156 Patients

Venous ulcers (VUs) of lower limbs affect 1% of Western population. In most cases, ultrasounds show only superficial venous insufficiency (SVI), but a deep venous insufficiency (DVI) may also be present without a history of deep vein thrombosis (DVT). To assess SVI and DVI in DVT-positive and DVT-negative patients with VU, a retrospective cohort of 123 patients entered the study (50 male and 73 female, minimum age 29 years and maximum age 90 years, and mean 70.6 years). In 56 patients (45.5%), ulcer was on the right leg, in 52 (42.3%) on the left leg, and in 15 patients (12.2%), ulcer was bilateral, resulting in a total number of 138 limbs in the study. Sixty-six patients suffered DVT, while in 72 anamnesis was negative. Color duplex ultrasound was performed on both limbs, which revealed insufficiencies of superficial and/or deep veins in 18 limbs which had not been affected by an ulcer or a previous DVT. So the study was on 156 limbs. SVI were substantially overlapping in two groups ( p -value = 0.593), while combined SVI and DVI was 72.5% in DVT positive limbs ( p -value = 0.001). In 70% of cases with a femoral vein insufficiency ( p -value = 0.036) or popliteal vein insufficiency (PVI) ( p -value 0,003), a DVT history was present. Of 18 limbs, although not affected by ulcer or previous DVT, eight were positive for DVI (two femoral veins and six popliteal veins). In the patient with VU, the history of DVT is a strong predictor of DVI insufficiency. In DVT-positive patients with ulcer, the number of "combined superficial and deep insufficiencies" appears to be particularly significant and surgical treatment must take this into account. A previous DVT has a low impact on great and small saphenous insufficiencies in ulcer patients; these were substantially overlapping in DVT-positive and DVT-negative patients. The 18 limbs with DVI and SVI without ulcer and DVT history were unexpected result. We think these patients must have a close follow-up to avoid the onset of a VU.

DEep VEin Lesion OPtimisation (DEVELOP) trial: protocol for a randomised, assessor-blinded feasibility trial of iliac vein intervention for venous leg ulcers

BACKGROUND

Venous leg ulceration is a widespread, debilitating pathology with high recurrence rates. Conservative treatment using graduated compression dressings may be associated with unacceptable ulcer recurrence rates. Early superficial venous ablation encourages ulcer healing and reduces recurrence. However, many of this cohort display concomitant ilio-caval stenosis, which further contributes to lower limb venous hypertension and ulceration. An approach that combines early superficial venous ablation with early treatment of ilio-caval stenotic disease may significantly improve ulcer healing and recurrence rates. We question whether early iliac vein interrogation with intravascular ultrasound (IVUS), stenting of significant occlusive disease plus superficial venous ablation, in patients with active venous leg ulceration, will produce superior ulcer healing to standard therapy.

METHODS

This is a prospective, multi-centre, randomised controlled, feasibility trial recruiting patients with lower limb venous ulceration and saphenous venous incompetence. Patients will be randomised to undergo either truncal ablation and compression therapy or truncal ablation, simultaneous iliac interrogation with intravascular ultrasound and stenting of significant (> 50%) iliac vein lesions plus compression therapy. The primary feasibility outcome will be the rate of eligible patient participation while the primary clinical outcomes will be ulcer healing and procedural safety. Secondary outcomes include time to healing, quality of life and clinical scores, ulcer recurrence rates and rates of post-thrombotic syndrome. Follow-up will be over a 5-year period. This feasibility trial is designed to include 60 patients. Should it be practicable a total of 594 patients would be required to adequately power the trial to definitively address ulcer-healing rates.

DISCUSSION

This trial will be the first randomised trial to examine the role iliac interrogation and intervention in conjunction with standard operative therapy in the management of venous ulceration related to superficial truncal venous incompetence.

ETHICAL COMMITTEE REFERENCE

C.A. 2111 Galway Clinical Research Ethics Committee REGISTRATION: Clinical Trials.gov registration NCT03640689 , Registered on 21 August 2018.

Strategies and challenges in the treatment of chronic venous leg ulcers

Evaluating patients with chronic venous leg ulcers (CVLUs) is essential to find the underlying etiology. The basic tenets in managing CVLUs are to remove the etiological causes, to address systemic and metabolic conditions, to examine the ulcers and artery pulses, and to control wound infection with debridement and eliminating excessive pressure on the wound. The first-line treatments of CVLUs remain wound care, debridement, bed rest with leg elevation, and compression. Evidence to support the efficacy of silver-based dressings in healing CVLUs is unavailable. Hydrogen peroxide is harmful to the growth of granulation tissue in the wound. Surgery options include a high ligation with or without stripping or ablation of the GSVs depending on venous reflux or insufficiency. Yet, not all CVLUs are candidates for surgical treatment because of comorbidities. When standard care of wound for 4 wk failed to heal CVLUs effectively, use of advanced wound care should be considered based on the available evidence. Negative pressure wound therapy facilitates granulation tissue development, thereby helping closure of CVLUs. Autologous split-thickness skin grafting is still the gold standard approach to close huge CVLUs. Hair punch graft appears to have a better result than traditional hairless punch graft for CVLUs. Application of adipose tissue or placenta-derived mesenchymal stem cells is a promising therapy for wound healing. Autologous platelet-rich plasma provides an alternative strategy for surgery for safe and natural healing of the ulcer. The confirmative efficacy of current advanced ulcer therapies needs more robust evidence.

Strategies and challenges in the treatment of chronic venous leg ulcers

Evaluating patients with chronic venous leg ulcers (CVLUs) is essential to find the underlying etiology. The basic tenets in managing CVLUs are to remove the etiological causes, to address systemic and metabolic conditions, to examine the ulcers and artery pulses, and to control wound infection with debridement and eliminating excessive pressure on the wound. The first-line treatments of CVLUs remain wound care, debridement, bed rest with leg elevation, and compression. Evidence to support the efficacy of silver-based dressings in healing CVLUs is unavailable. Hydrogen peroxide is harmful to the growth of granulation tissue in the wound. Surgery options include a high ligation with or without stripping or ablation of the GSVs depending on venous reflux or insufficiency. Yet, not all CVLUs are candidates for surgical treatment because of comorbidities. When standard care of wound for 4 wk failed to heal CVLUs effectively, use of advanced wound care should be considered based on the available evidence. Negative pressure wound therapy facilitates granulation tissue development, thereby helping closure of CVLUs. Autologous split-thickness skin grafting is still the gold standard approach to close huge CVLUs. Hair punch graft appears to have a better result than traditional hairless punch graft for CVLUs. Application of adipose tissue or placenta-derived mesenchymal stem cells is a promising therapy for wound healing. Autologous platelet-rich plasma provides an alternative strategy for surgery for safe and natural healing of the ulcer. The confirmative efficacy of current advanced ulcer therapies needs more robust evidence.

Research on a physical activity tracking system based upon three-axis accelerometer for patients with leg ulcers

Venous leg ulcerations are a common problem, with high prevalence in the middle-aged and elderly population, and more attention on research of their physical activities has been paid, as they have great effects on the blood circulation of the lower limb. With enough, appropriate training, the chronic venous ulcerations in the lower limb can be avoided and alleviated, and venous hypertension can be reduced effectively. The study deals with a physical activity tracking system for the patients based on a three-axis accelerometer. The system uses a three-axis accelerometer, a microcontroller, and a wireless Bluetooth module to form a data acquisition platform to acquire accelerations of the lower limb movement, and sends it to a smart mobile phone via the wireless Bluetooth module. The system takes advantages of the smart mobile phone to guide the chronic venous leg ulcers to do prescribed rehabilitation exercises for the lower limb muscles, perform acceleration data preprocessing, wavelet transform and reconstruction, denoising and feature extraction, obtain the results of the rehabilitation exercises, and then give reasonable evaluation and judgment. It is helpful to treat underlying venous reflux, create such an environment that allows skin to grow across an ulcer, and accelerate ulcer healing process consequently.

Periulcer Foam Sclerotherapy Injection in Chronic Venous Leg Ulcers Using Near-Infrared Laser for Vein Visualization

High recurrence and high costs of treatment are the main problems with venous ulcer management. Therefore, it is of utmost importance to target the exact pathological cause. The role of cutaneous microvalves reflux in the pathogenesis of these ulcers has been confirmed. In this study, 20 chronic venous leg ulcers were prospectively subjected to foam sclerotherapy injection into periulcer veins using direct visualization by AccuVein AV400. Patients having infected ulcers, acute deep vein thrombosis, hypercoagulability, Ankle-Brachial Index <0.9, pregnancy, and/or allergy to the sclerosant were excluded. Endpoints included rates of ulcer size reduction, complete healing, ulcer recurrence, and procedure-related complications. Aethoxysklerol 1% was used in all cases to produce foam employing the double-syringe system. The mean reduction in ulcer surface area, postinjection, was 75% after 8 weeks and 91% after 12 weeks. Nineteen ulcers (95%) healed in a median time of 8 weeks, range 3 to 17 weeks. At 1 year of follow-up, 18 patients (90%) were still ulcer-free, while 1 patient's ulcer (5%) recurred 19 weeks postinjection. No major complications were encountered. Periulcer foam sclerotherapy injection, guided by vein visualization technology, should be one of the main lines of treatment of venous leg ulcers. It offers good results with regard to rapid ulcer healing and low recurrence rate without major risk. Randomized controlled trials are needed to establish these conclusions.

Prevalence of chronic venous pathology in healthcare workers and the role of upright standing

BACKGROUND

Chronic venous disease (CVD) affects around 25% of adult population in developed countries and it often represent a health problem for different kind of workers, in particular for who spend much of the working time in upright standing.

METHODS

The study was carried out on a population of 173 nonmedical workers of a midsize hospital in Italy (91 nurse, 31 support staff workers and 51 employees). The study protocol was taken from a previous study of our group and included a clinical examination and a questionnaire.

RESULTS

From the analysis of data it emerged a particular importance of upright standing as major risk factor for CVD. The prevalence of venous pathology seems to be greater among nurses and auxiliaries than the administrative staff and, as expected, it was significantly higher among female workers than in males.

CONCLUSIONS

The results obtained show that the clinical-diagnostic protocol described can be used by doctors for screening venous pathology at workplaces.

Predicting the likelihood of venous leg ulcer recurrence: The diagnostic accuracy of a newly developed risk assessment tool

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.