Clinical Characteristics of Mixed Arteriovenous Leg Ulcers: A Descriptive Study

Updates in Arterial Ulcers

Arterial ulcers are a clinical symptom of a complex array of underlying comorbid factors, namely peripheral artery disease (PAD). Chronic limb-threatening ischemia is representative of end-stage PAD. Ulcers of other etiologies can carry an arterial component, mandating recognition of risk factors, a comprehensive history and physical examination, and appropriate diagnostic testing in lower extremity ulcers. The primary therapy for arterial ulcers is re-establishment of in-line arterial flow, achieved by endovascular therapy or open revascularization. Medical management is essential to slow disease progression, and topical therapies are crucial to promote rapid ulcer closure and reduce infection risk.

Review of Mixed Arterial Venous Leg Ulcers (MAVLU) Disease in Contemporary Practice

BACKGROUND

Mixed Arterial and Venous Leg Ulcers (MAVLU) are challenging. Clinical evidence specific to MAVLU management is scarce. We evaluated our recent experience with MAVLU patients and reviewed current data regarding MAVLU epidemiology, aetiology, diagnostic assessment and management options.

METHODS

A prospective leg ulcer database was retrospectively interrogated to determine the prevalence and clinical outcome of MAVLU over 2-year period (2021-2022). The literature was reviewed to determine if optimal treatment strategies.

RESULTS

307 patients attended the ulcer clinic over a 2-year period. Most were venous leg ulcers (71%), 24% were arterial and 5% were MAVLU. The highest healing rate was in MAVLU (93%), followed by (74%) and (41%), in arterial and venous leg ulcer groups, respectively.

CONCLUSION

Evidence-based guidelines for MAVLU remain lacking. Well-developed randomised controlled trials are warranted to guide current clinical practice.

2024 Guideline for Management of Wounds in Patients With Lower Extremity Arterial Disease: An Executive Summary

This article is an executive summary of the Wound, Ostomy, and Continence Nurses Society's (WOCN) 2024 Guideline for Management of Wounds in Patients With Lower Extremity Arterial Disease. It is part of the Society's Clinical Practice Guideline Series. This article presents an overview of the systematic process used to update and develop the guideline. It also lists specific recommendations from the guideline for screening and diagnosis, assessment, management, and education of patients with wounds due to lower extremity arterial disease (LEAD). Suggestions for implementing recommendations from the guideline are also summarized. The guideline is a resource for WOC nurse specialists, other nurses, and health care professionals who work with adults who have/or are at risk of wounds due to LEAD. The complete guideline includes the evidence and references supporting the recommendations, and it is available from the WOCN Society's Bookstore (www.wocn.org). Refer to the Supplemental Digital Content Appendix (available at: http://links.lww.com/JWOCN/A123) associated with this article for a complete reference list for the guideline.

Management of Pain in People Living With Chronic Limb Threatening Ischemia: Highlights From a Rapid Umbrella Review

Peripheral artery disease is a complex health condition. It is associated with atherosclerotic occlusive lesions in the arteries limiting normal blood flow, mostly involving the lower extremities, leading to chronic limb-threatening ischemia (CLTI). Chronic unrelenting ischemic leg pain can be debilitating and distressing, contributing to poor health-related quality of life. Comprehensive management of pain associated with CLTI requires multimodal approaches that draw on a range of strategies and specialist treatments delivered by an interdisciplinary team across various health care settings. We recognized a significant gap in evidence-based strategies that are accessible, appropriate, acceptable, effective, and safe for the elderly with CLTI-associated pain. We therefore conducted an umbrella review or overview of multiple existing reviews that employ a rigorous and transparent method to comprehensively identify and synthesize relevant literature including systematic, scoping, and narrative reviews. The purpose of this umbrella review was to aggregate and compare various management options to inform best practices and quality indicators for the management of ischemic pain in older patients with peripheral artery disease.

Leishmania spp. amastigotes surrounding sensory nerve fibers in human painless skin ulcers: Evidence of pathogen-neuron proximity and absence of neuronal apoptosis

In this present study, carried out between November 2020 and July 2023 at Londrina's University Hospital, patients with active lesions of cutaneous leishmaniasis (CL) were analyzed regarding pain perception and anatomopathological aspects of the ulcers. Pain was assessed using a numerical rating scale (NRS) to compare five patients diagnosed with CL with four control patients diagnosed with vascular skin ulcers. Histopathological evaluations were used to investigate the nociceptor neuron-Leishmania interface. Patients with CL ulcers reported less pain compared to patients with vascular ulcers (2.60 ± 2.30 and 7.25 ± 0.95, respectively, p = 0.0072). Histopathology evidenced Leishmania spp. amastigote forms nearby sensory nerve fibers in profound dermis. Schwann cells marker (S100 protein) was detected, and caspase-3 activation was not evidenced in the in the nerve fibers of CL patients' samples, suggesting absence of apoptotic activity in nerve endings. Additionally, samples taken from the active edge of the lesion were negative for bacilli acid-alcohol resistant (BAAR), which excludes concomitant leprosy, in which painless lesions are also observed. Thus, the present data unveil for the first time anatomopathological and microbiological details of painless ulcers in CL patients, which has important clinical implications for a better understanding on the intriguing painless clinical characteristic of CL.

The Chronic Wound-Related Pain Model: Holistic Assessment and Person-Centered Treatment

Chronic wound-related pain is a complex biopsychosocial experience that is experienced spontaneously at rest and exacerbated during activities. Tissue debridement, trauma at dressing change, increased bioburden or infection, exposure of periwound skin to moisture, and related treatment can modulate chronic wound-related pain. Clinicians should consider multimodal and multidisciplinary management approach that take into account the biology, emotions, cognitive thinking, social environment, and other personal determinants of pain. Unresolved pain can have a significant impact on wound healing, patients' adherence to treatment, and individual's quality of life.

CONSTRUCT VALIDITY AND RELIABILITY OF THE LEG ULCER MEASUREMENT TOOL SCALE ADAPTED FOR BRAZIL

ABSTRACT Objective: to validate the Portuguese version of the Leg Ulcer Measurement Tool regarding construct and reliability. Method: this is a methodological research study. Data collection was conducted between January and July 2019. A total of 105 participants were included for construct validation and internal consistency and, of these, 50 were selected for intra-observer stability. For the analysis of construct validity, factor analysis was performed; for internal consistency, Cronbach's alpha coefficient was calculated, and for stability, the intraclass correlation coefficient. Results: A total of 12items were confirmed for the Brazilian reality, meeting all the theoretical requirements of the factor analysis model. As for the internal consistency (reliability) analysis, the Cronbach's alpha coefficient values (α=0.711) showed that the set of items that make up the scale measures the same characteristics and presents internal consistency. In the global stability analysis (ICC=0.823), the Leg Ulcer Measurement Tool test and retest scores presented good agreement, showing that the adapted scale is stable. Conclusion: the Leg Ulcer Measurement Tool scale adapted to the Portuguese language contains 12 items, with scores varying from 0 to 4 and, thus, produces a score from 0 to 48 points. It presents construct validity analyzed by means of factor analysis and reliability in terms of internal consistency and stability.

Persistent venous leg ulcers complicated by linear morphea: a case report

Soft tissue ulceration resulting from chronic venous insufficiency is a common condition that requires standardised long-term therapy, which has been thoroughly established. We report a patient with a five-year history of persistent venous stasis ulcers despite treatment consistent with traditional wound care. Resolution of the ulcers began only upon deviation from conventional therapy. This report considers non-standard treatments in patients with venous ulcers that do not progress.

Cross-cultural adaptation of the Leg Ulcer Measurement Tool for Brazil: nursing methodology research

OBJECTIVES

to translate and cross-culturally adapt the Leg Ulcer Measurement Tool to Brazilian Portuguese.

METHODS

methodological study involving the steps of initial translation, synthesis of translations, back-translation, expert panel and pretest. For analysis by the expert committee, the content validity index was calculated and in the pretest for practicality, the agreement rate was calculated. Satisfactory agreement was considered when > 0.8 and 80%, respectively.

RESULTS

the initial steps of translation were satisfactorily developed and there was little disagreement between the translators. In the expert panel, was obtained significant concordance of 0.97. The pretest was performed with ten nurses and 30 patients. The feasibility of the translated version was evaluated with 100% agreement.

FINAL CONSIDERATIONS

the instrument presented a high level of concordance among the experts during all steps and showed content validity thereby making the adaptation appropriate for the Brazilian context.

Peripheral arterial disease screening and diagnostic practice: A scoping review

Early reliable, valid screening, diagnosis, and treatment improve peripheral arterial disease outcomes, yet screening and diagnostic practices vary across settings and specialties. A scoping literature review described reliability and validity of peripheral ischaemia diagnosis or screening tools. Clinical studies in the PUBMED database January 1, 1970, to August 13, 2018, were reviewed summarising ranges of reliability and validity of peripheral ischaemia diagnostic and screening tools for patients with non-neuropathic lower leg ischaemia. Peripheral ischaemia screening and diagnostic practices varied in parameters measured such as timing, frequency, setting, ordering clinicians, degree of invasiveness, costs, definitions, and cut-off points informing clinical and referral decisions. Traditional ankle/brachial systolic blood pressure index <0.9 was a reliable, valid lower leg ischaemia screening test to trigger specialist referral for detailed diagnosis. For patients with advanced peripheral ischaemia or calcified arteries, toe-brachial index, claudication, or invasive angiographic imaging techniques that can have complications were reliable, valid screening, and diagnostic tools to inform management decisions. Ankle/brachial index testing is sufficiently reliable and valid for use during routine examinations to improve timing and consistency of peripheral ischaemia screening, triggering prompt specialist referral for more reliable, accurate Doppler, or other diagnosis to inform treatment decisions.

Peripheral arterial disease: Scoping review of patient-centred outcomes

Peripheral arterial disease (PAD) impairs patients' quality of life (QOL), walking and ulcer healing, increasing patient pain, costs, and risks of amputation or mortality. A literature appraisal described PAD treatment capacity to improve validated patient-centred outcomes in controlled clinical studies. The PUBMED database was searched from 1 January 1970 to 21 June 2018, for original and derivative controlled clinical trial references addressing MeSH terms for 'ischemia' AND 'leg ulcer'. Non-ischemic ulcer treatment references were excluded. Frequencies of improved (P < .05) outcomes were reported. Eighty-eight studies on 4153 patients were summarized. Walking, pain or QOL improved mainly for interventions administered before PAD became severe. Amputation incidence, pain and ulcer healing were more frequently reported in those with severe PAD. Independent of PAD severity, patients experienced more likely improved walking, QOL, or pain reduction in response to structured walking interventions or those increasing calf muscle activity. Those with more severe PAD were more likely to report amputation reduction, mainly in response to invasive interventions. Those with PAD experienced more consistently improved patient-centred outcomes if they received multidisciplinary PAD management with supervised walking or calf muscle activity, with more likely amputation risk reduced for those with more severe PAD.

Correlation between chronic venous ulcer exudate proteins and clinical profile: A cross-sectional study

Chronic venous ulcers affect the quality of life of patients around the world. The aims of this study were to identify the proteins expressed in chronic venous ulcer exudates, to categorize them according to their roles and to correlate them with the clinical and epidemiological aspects of the disease. The study population consisted of 37 ulcers from 28 patients, and the inflammatory exudates of these thirty-seven ulcers were subjected to tryptic digestion and mass spectrometry analysis. Twenty-three patients were female (62.2%), and five (37.8%) were male. The patients had a mean age of 70 (±10.1) years. Of the patients, 73% adhered to compression and rest, 81.1% reported a history of primary varices, 54.1% reported a history of systemic arterial hypertension, 54.1% reported a history of devitalized tissue in the wound bed and 64.9% reported ulcers with more than ten years of evolution. Seventy-six proteins were identified, and they were grouped according to their primary role in the healing process. Eight correlations between clinical and epidemiological data and protein expression were noteworthy: diabetes mellitus vs. Ig gamma-2 and apolipoprotein-A1 and albumin; congestive heart failure vs. Ig lambda-2; colonization vs. actin; compressive therapy vs. Ig kappa; systemic arterial hypertension vs. alpha-2-macroglobulin and apolipoprotein-A1; area of ulcer vs. apolipoprotein-A1; race vs. heavy chain Ig and Ig γ-1 chain; age and race vs. Ig γ-1 chain. These associations may help to elucidate the prognosis and chronicity of chronic venous ulcers based on secreted proteins.

Translation and validation of the Chinese powerlessness assessment tool

The objectives of this study were to translate the powerlessness assessment tool (PAT) into Chinese, and to evaluate its psychometric performance. The PAT was translated into Chinese and was evaluated in patients with chronic wounds. Mean PAT scores were compared between various wound types to evaluate the scale's power to differentiate wound severity (PUSH score). There were 154 consecutive patients included in this study. All items were included, and the results of item-domain correlation (r ranged from 0.838 to 0.967) and small-group analysis (critical ratio, p < 0.05) were satisfactory. Furthermore, the Chinese PAT also showed good criterion validity when correlated with the Cardiff wound impact schedule (r = 0.726, p < 0.01). Exploratory factor analysis of these items extracted only two domains instead of the hypothesized three domains: self-perception of behavioral control and decision making (9 items) and emotional responses to perceived control (3 items), explained 82.045% of the variance. Sensitivity was demonstrated between patients with different activity of daily living, wound severity (PUSH score) and wound types. The internal consistency of all scales of the Chinese PAT was consistently high (Cronbach's alpha ranged from 0.939 to 0. 965) and split-half reliability was 0.901. In conclusion, the validated Chinese PAT has good psychometric properties, and may be used to objectively evaluate the powerlessness experience of Chinese patients with chronic wounds.

The Role of Complex Treatment in Mixed Leg Ulcers - A Case Report of Vascular, Surgical and Physical Therapy

BACKGROUND:

Leg ulcers are a burden to patients, their families and society. The second most common cause of chronic leg ulcers is the mixed arterio-venous type. An 80-year-old female patient presented to our department due to painful enlarging chronic leg ulcer of mixed arteriovenous origin on her left lower leg. She suffered from peripheral arterial occlusive disease stage I and chronic venous insufficiency Widmer grade IIIa, and a number of comorbidities.

AIM:

The aim of our ulcer treatment was a complete and stable wound closure that was hampered by arterial occlusion, exposed tendon, and renal insiffuciency.

CASE REPORT:

To improve the prognosis for ulcer surgery, we performed percutaneous transluminal angioplasty, transcutaneous CO₂ and deep ulcer shaving. The wound was closed by sandwich transplantation using elastin-collagen dermal template and meshed split skin graft. She had a 100% graft take with rapid reduction of severe wound pain.

CONCLUSION:

Complex approaches are necessary, to gain optimum results in leg ulcer therapy in mixed leg ulcers. Therapeutic nihilism should be abandonend.