Cost-effectiveness analysis of a randomized clinical trial of early versus deferred endovenous ablation of superficial venous reflux in patients with venous ulceration

BACKGROUND

Treatment of superficial venous reflux in addition to compression therapy accelerates venous leg ulcer healing and reduces ulcer recurrence. The aim of this study was to evaluate the costs and cost-effectiveness of early versus delayed endovenous treatment of patients with venous leg ulcers.

METHODS

This was a within-trial cost-utility analysis with a 1-year time horizon using data from the EVRA (Early Venous Reflux Ablation) trial. The study compared early versus deferred endovenous ablation for superficial venous truncal reflux in patients with a venous leg ulcer. The outcome measure was the cost per quality-adjusted life-year (QALY) over 1 year. Sensitivity analyses were conducted with alternative methods of handling missing data, alternative preference weights for health-related quality of life, and per protocol.

RESULTS

After early intervention, the mean(s.e.m.) cost was higher (difference in cost per patient £163(318) (€184(358))) and early intervention was associated with more QALYs at 1 year (mean(s.e.m.) difference 0·041(0·017)). The incremental cost-effectiveness ratio (ICER) was £3976 (€4482) per QALY. There was an 89 per cent probability that early venous intervention is cost-effective at a threshold of £20 000 (€22 546)/QALY. Sensitivity analyses produced similar results, confirming that early treatment of superficial reflux is highly likely to be cost-effective.

CONCLUSION

Early treatment of superficial reflux is highly likely to be cost-effective in patients with venous leg ulcers over 1 year. Registration number: ISRCTN02335796 (http://www.isrctn.com).

Ankle Motility is a Risk Factor for Healing of Chronic Venous Leg Ulcers

Objective:

To investigate the effect of ankle motility on chronic venous leg ulcer healing, and to relate this to calf pump function and muscle bulk.

Methods:

This was a prospective cohort study undertaken in a leg ulcer clinic. Ankle motility, calf-ankle circumference ratio and calf pump power (derived from digital photoplethysmography) were assessed as to their effect on ulcer healing rate. Thirty consecutive patients undergoing multi-layer compression bandaging for open chronic venous ulcers were included.

Results:

Ankle motility was an independent risk factor for ulcer healing ( p = 0.001, hazard ratio 1.08, 95% CI 1.03–1.13). Ankle motility correlated with calf-ankle circumference ratio ( r = 0.48, p<0.01). No relationship was found between photoplethysmography-derived calf pump power, ankle motility or ulcer healing rate.

Conclusions

Ulcers in legs with poor ankle motility are slower to heal and this may be related to reduced calf muscle bulk. Ankle exercises or physiotherapy could be considered in such patients.

Improving the Diagnosis of Chronic Leg Ulcers: A One-Stop Vascular Assessment Clinic in a Community Service

Objective:

To evaluate the influence of a specialized vascular-led community leg ulcer service on assessment and diagnosis of leg ulcers.

Design:

Before-and-after study with prospective and retrospective data collection.

Setting:

East Gloucestershire, England, UK.

Subjects:

Patients treated for chronic leg ulcers before and within a specialized service incorporating a one-stop assessment including ankle–brachial pressure index (ABPI) and colour venous duplex.

Main outcome measures:

The means of assessment and the identified aetiology of leg ulcers in community patients.

Results:

Before clinics, only 40 (26%) limbs had a diagnosis recorded. After clinics, 83 (21%) limbs had arterial disease, including 64 (16%) with mixed arterial/venous disease. Venous duplex identified 279 (70%) limbs with venous disease of which 121 (43%) had superficial venous disease alone.

Conclusion:

A one-stop assessment clinic with ABPI and colour venous duplex ultrasound within a specialized community service improves diagnosis of leg ulcers. This is essential before appropriate and safe management by specialist nurses in the community.

Preoperative Digital Photoplethysmography Predicts Improvement in Venous Function after Superficial Venous Surgery for Chronically Ulcerated Limbs

Objective:

To evaluate digital photoplethysmography (d-PPG) in predicting the influence of superficial surgery on venous function in chronically ulcerated limbs.

Design:

Prospective case-study.

Setting:

Vascular Laboratory of a District General Hospital.

Patients:

Patients with ulcerated limbs referred to a specialized community leg ulcer service were assessed with colour venous duplex ultrasound and ankle–brachial pressure index and offered surgery in cases of superficial venous reflux alone.

Interventions:

Superficial venous surgery. Four-layer compression bandaging.

Main outcome measures:

D-PPG derived venous refill time (VRT) and pump power (PP) were measured preoperatively with and without a tourniquet, and again after surgery.

Results:

Thirty ulcerated limbs in 27 patients were assessed. VRT increased from a median (interquartile range) of 10 s (7–17) preoperatively to 26 s (19–29)* with an above-knee tourniquet, 26 s (18–32)* with a below-knee tourniquet and 19 s (15–25)* after superficial venous surgery (* p < 0.01). PP increased from 2.3% (1.3–3.1) preoperatively to 3.0% (2.0–4.2)* with an above-knee tourniquet, 2.9% (2.1–4.3)** with a below-knee tourniquet and 4.4% (2.3–7.2)* after surgery (* p < 0.01, ** p < 0.05). The increase in VRT with an above-knee tourniquet preoperatively correlated with an increase in VRT after surgery ( r = 0.40, p < 0.05).

Conclusion:

Superficial venous surgery improves venous function measured by d-PPG in chronically ulcerated limbs. Preoperative assessment with d-PPG and an above-knee tourniquet predicts functional improvement after surgery.

Risk Factors for Healing and Recurrence of Chronic Venous Leg Ulcers

Objective:

To identify independent risk factors for delayed healing and increased recurrence of chronic venous leg ulcers.

Design:

Prospective study.

Setting:

Community-based leg ulcer service.

Patients:

Six hundred and thirty-three limbs in 587 consecutive patients with an ankle-brachial pressure index (ABPI) ≥0.85.

Method:

Potential risk factors were initially assessed in a one-stop clinic incorporating clinical evaluation, ABPI and venous duplex imaging. Limbs were treated within a defined protocol. Twenty-four-week healing and 3-year ulcer recurrence rates were determined.

Results:

Of 12 potential risk factors age ( p< 0.001), ulcer chronicity ( p< 0.001) and popliteal vein reflux ( p< 0.005) were independent risks for delayed healing. Of 13 potential risk factors rheumatoid arthritis ( p<0.005) and healing time ( p < 0.05) were independent risks for ulcer recurrence. Isolated superficial venous reflux treated by saphenous vein surgery predicted reduced ulcer recurrence ( p< 0.005).

Conclusion:

Targeting in primary care of ulcer patients with specific characteristics might encourage earlier referral and appropriate resource management. Leg ulcer patients with superficial venous reflux might benefit from surgical correction.

Incidental non-inguinals hernias in totally extra-peritoneal hernia repair

INTRODUCTION

Totally extra-peritoneal (TEP) inguinal hernia repair allows identification and repair of incidental non-inguinal groin hernias. We assessed the prevalence of incidental hernias during TEP inguinal hernia repair and identified the risk factors for incidental hernias.

MATERIALS AND METHODS

Consecutive patients undergoing TEP repair from May 2005 to November 2012 were the study cohort. Inspection for ipsilateral femoral, obturator and rarer varieties of hernia was undertaken during TEP repair. Patient characteristics and operative findings were recorded on a prospectively collected database.

RESULTS

A total of 1,532 TEP repairs were undertaken in 1,196 patients. Ninety-three patients were excluded due to incomplete data, leaving 1,103 patients and 1,404 hernias for analyses (1,380 male; 802 unilateral and 301 bilateral repairs; median age, 59 years). Among the 37 incidental hernias identified (2.6% of cases), the most common type of incidental hernia was femoral (n=32, 2.3%) followed by obturator (n=2, 0.1%). Increasing age was associated with an increased risk of incidental hernia, with a significant linear trend (p<0.01). The risk for patients >60 years of age was 4.0% vs 1.4% for those aged <60 years (p<0.01). Incidental hernias were found in 29.2% of females vs 2.2% of males, (p<0.0001). Risk of incidental hernia in those with a recurrent inguinal hernia was 3.0% vs 2.6% for primary repair (p=0.79).

CONCLUSIONS

Incidental hernias during TEP inguinal hernia repair were found in 2.6% of cases and, though infrequent, could cause complications if left untreated. The risk of incidental hernia increased with age and was significantly higher in patients aged >60 years and in females.

Maggots as a wound debridement agent for chronic venous leg ulcers under graduated compression bandages: A randomised controlled trial

Objectives

Slough in chronic venous leg ulcers may be associated with delayed healing. The purpose of this study was to assess larval debridement in chronic venous leg ulcers and to assess subsequent effect on healing.

Methods

All patients with chronic leg ulcers presenting to the leg ulcer service were evaluated for the study. Exclusion criteria were: ankle brachial pressure indices <0.85 or >1.25, no venous reflux on duplex and <20% of ulcer surface covered with slough. Participants were randomly allocated to either 4-layer compression bandaging alone or 4-layer compression bandaging + larvae. Surface areas of ulcer and slough were assessed on day 4; 4-layer compression bandaging was then continued and ulcer size was measured every 2 weeks for up to 12 weeks.

Results

A total of 601 patients with chronic leg ulcers were screened between November 2008 and July 2012. Of these, 20 were randomised to 4-layer compression bandaging and 20 to 4-layer compression bandaging + larvae. Median (range) ulcer size was 10.8 (3–21.3) cm2 and 8.1 (4.3–13.5) cm2 in the 4-layer compression bandaging and 4-layer compression bandaging + larvae groups, respectively (Mann–Whitney U test, P = 0.184). On day 4, median reduction in slough area was 3.7 cm2 in the 4-layer compression bandaging group ( P < 0.05) and 4.2 cm2 ( P < 0.001) in the 4-layer compression bandaging + larvae group. Median percentage area reduction of slough was 50% in the 4-layer compression bandaging group and 84% in the 4-layer compression bandaging + larvae group (Mann–Whitney U test, P < 0.05). The 12-week healing rate was 73% and 68% in the 4-layer compression bandaging and 4-layer compression bandaging + larvae groups, respectively (Kaplan–Meier analysis, P = 0.664).

Conclusions

Larval debridement therapy improves wound debridement in chronic venous leg ulcers treated with multilayer compression bandages. However, no subsequent improvement in ulcer healing was demonstrated.

Effect of foam sclerotherapy on healing and long-term recurrence in chronic venous leg ulcers

INTRODUCTION

The ESCHAR trial showed that superficial venous surgery and compression in chronic venous ulceration achieved a 24-week healing rate of 65% and 12-month recurrence rate of 12%. Foam sclerotherapy treatment is an alternative to surgery. The aim of this study is to assess the effect of foam sclerotherapy on ulcer healing and recurrence in chronic venous leg ulcers.

METHODS

Chronic venous leg ulcers (CEAP [clinical, aetiological, anatomical and pathological elements] 5 and CEAP 6) with superficial venous reflux were treated between March 2006 and June 2011 with ultrasound-guided foam sclerotherapy and compression.Venous duplex was performed on all legs before and after treatment. Twenty-four-week ulcer healing and one- and four-year ulcer recurrence rates were calculated using Kaplan–Meier survival analysis.

RESULTS

Two hundred legs (186 patients) with chronic venous ulcers (CEAP 5: n ¼ 163 and CEAP 6: n ¼ 37) were treated with foam sclerotherapy. Complete occlusion was achieved in 185/200 (92.5%) limbs, short segment occlusion in 14/200 (7%) limbs and one leg segment failed to occlude. One patient suffered an asymptomatic non-occlusive deep vein thrombosis (DVT) diagnosed on duplex scan at one week and one presented with an occlusive DVT three weeks following a normal scan at one week. One patient developed an asymptomatic occlusive DVT at two weeks following a non-occlusive DVT diagnosed on initial one-week scan. Eighteen patients were lost to follow-up (3 moved away and 15 died of unrelated causes). The 24-week healing rate was 71.1% and one- and four-year recurrence rates were 4.7% and 28.1%, respectively.

CONCLUSION

Foam sclerotherapy is effective in abolition of superficial venous reflux and may contribute to similar ulcer healing and long-term recurrence rates to superficial venous surgery. Foam sclerotherapy is an attractive alternative to surgery in this group of patients.

The need for a National Service Framework for leg ulcers

Leg ulcers are common and costly to treat, and the quality of care provided to patients with this condition varies widely across the UK. The introduction of specialized community-based leg ulcer clinics in Gloucestershire has been associated with increased ulcer healing rates and decreased rates of ulcer recurrence, but this model of care has not been widely replicated. One way of ending this 'postcode lottery' is to produce a National Service Framework for leg ulcers, with the aim of delivering high-quality evidence-based care via such clinics under the supervision of local consultant vascular surgeons. Existing National Service Frameworks cover a range of common conditions that are, like leg ulceration, associated with significant morbidity, disability and resource use. These documents aim to raise quality and decrease regional variations in health care across the National Health Service, and leg ulceration fulfils all the necessary criteria for inclusion in a National Service Framework. Centrally defined standards of care for patients with leg ulceration, and the reorganization and restructuring of local services to allow the accurate assessment and treatment of such patients are required. Without a National Service Framework to drive up the quality of care across the country, the treatment of patients with leg ulcers will remain suboptimal for the majority of those who suffer from this common and debilitating condition.

Pre-operative inspiratory muscle training preserves postoperative inspiratory muscle strength following major abdominal surgery - a randomised pilot study

INTRODUCTION

The aim of this pilot study was to assess the effect of pre-operative inspiratory muscle training (IMT) on respiratory variables in patients undergoing major abdominal surgery.

PATIENTS AND METHODS

Respiratory muscle strength (maximum inspiratory [MIP] and expiratory [MEP] mouth pressure) and pulmonary functions were measured at least 2 weeks before surgery in 80 patients awaiting major abdominal surgery. Patients were then allocated randomly to one of four groups (Group A, control; Group B, deep breathing exercises; Group C, incentive spirometry; Group D, specific IMT). Patients in groups B, C and D were asked to train twice daily, each session lasting 15 min, for at least 2 weeks up to the day before surgery. Outcome measurements were made immediately pre-operatively and postoperatively.

RESULTS

In groups A, B and C, MIP did not increase from baseline to pre-operative assessments. In group D, MIP increased from 51.5 cmH(2)O (median) pre-training to 68.5 cmH(2)O (median) post-training pre-operatively (P < 0.01). Postoperatively, groups A, B and C showed a fall in MIP from baseline (P < 0.01, P < 0.01) and P = 0.06, respectively). No such significant reduction in postoperative MIP was seen in group D (P = 0.36).

CONCLUSIONS

Pre-operative specific IMT improves MIP pre-operatively and preserves it postoperatively. Further studies are required to establish if this is associated with reduced pulmonary complications.

Randomized clinical trial of mesh versus sutured wound closure after open abdominal aortic aneurysm surgery

Background

Incisional herniation is a common complication of abdominal aortic aneurysm (AAA) repair. This study investigated whether prophylactic mesh placement could reduce the rate of postoperative incisional hernia after open repair of AAA.

Methods

This randomized clinical trial was undertaken in three hospitals. Patients undergoing elective open AAA repair were randomized to routine abdominal mass closure after AAA repair or to prophylactic placement of polypropylene mesh in the preperitoneal plane.

Results

Eighty-five patients with a mean age of 73 (range 59–89) years were recruited, 77 (91 per cent) of whom were men. There were five perioperative deaths (6 per cent), two in the control group and three in the mesh group (P = 0·663), none related to the mesh. Sixteen patients in the control group and five in the mesh group developed a postoperative incisional hernia (hazard ratio 4·10, 95 per cent confidence interval 1·72 to 9·82; P = 0·002). Hernias developed between 170 and 585 days after surgery in the control group, and between 336 and 1122 days in the mesh group. Four patients in the control group and one in the mesh group underwent incisional hernia repair (P = 0·375). No mesh became infected, but one was subsequently removed owing to seroma formation during laparotomy for small bowel obstruction.

Conclusion

Mesh placement significantly reduced the rate of postoperative incisional hernia after open AAA repair without increasing the rate of complications. Registration number: ISRCTN28485581 (http://www.controlled-trials.com).

The importance of early carotid endarterectomy in symptomatic patients

INTRODUCTION

Early carotid endarterectomy (CEA) in symptomatic patients may prevent repeat cerebral events. This study investigates the relationship between waiting time for CEA and the incidence of repeat cerebral events prior to surgery in symptomatic patients.

PATIENTS AND METHODS

A prospective database of consecutive patients undergoing CEA between January 2002 and December 2006 was reviewed. Repeat event rates prior to surgery were calculated using Kaplan-Meier analysis and predictive factors identified using Cox regression analysis.

RESULTS

A total of 118 patients underwent CEA for non-disabling stroke, TIA and amaurosis fugax. Repeat cerebral events occurred in 34 of 118 (29%) patients at a median 51 days (range, 2-360 days) after the first event. The estimated risk of repeat events was 2% at 7 days and 9% at 1 month after first event (Kaplan-Meier survival analysis). Age (HR 1.059; 95% CI 1.014-1.106; P = 0.009] was identified as a predictor of repeat events. Patients underwent surgery at median 97 days (range, 7-621 days) after the first event. Eleven of 60 (18%) patients waiting < or = 97 days for surgery and 23 of 58 (40%) patients waiting > 97 days had repeat events. (P = 0.011, chi-squared test).

CONCLUSIONS

Delays in surgery should be reduced in order to minimise repeat cerebral events in patients with symptomatic carotid stenosis, particularly in the elderly population.

Significance of limb trauma as an initiating factor in chronic leg ulceration

OBJECTIVES

To assess differences in clinical outcomes between patients with traumatic and spontaneous leg ulcers.

METHODS

Consecutive leg ulcer follow-up patients seen between April 2004 and October 2005 in a specialist leg ulcer clinic were asked about the mechanism of the original ulceration. Twenty-four-week healing and 12-month recurrence rates were calculated using Kaplan-Meier analysis and outcomes were compared between groups with traumatic and spontaneous ulcers.

RESULTS

Of the 300 patients assessed, 38 were excluded (incomplete data). In the remaining 262 patients, cause of ulceration was traumatic in 116/262 (44%) and spontaneous in 146/262 (56%). Age, ankle brachial pressure index <0.85 and venous reflux were equally distributed between groups with traumatic and spontaneous ulcers (P = 0.470, 0.793, 0.965 respectively, Chi-square test). Twenty-four-week healing rates were 81% for traumatic and 67% for spontaneous ulcers (P = 0.015, Log-Rank test). Twelve-month recurrence rates were 32% for traumatic and 33% for spontaneous ulcers (P = 0.970, Log-rank test). Patients with traumatic ulcers suffered a total of 53 ulcer recurrences (median 0, range 0-4) compared with 89 in patients with spontaneous ulcers (median 0, range 0-8) (P < 0.001, Mann-Whitney U test).

CONCLUSION

Approximately half of all leg ulcer patients recall a traumatic event. When managed in leg ulcer clinic, traumatic ulcers heal faster and recur less frequently than spontaneous ulcers.

Management of mixed arterial and venous leg ulcers

BACKGROUND

The aim was to assess healing in patients with mixed arterial and venous leg ulcers after protocol-driven treatment in a specialist leg ulcer clinic.

METHODS

The study included consecutive patients referred with leg ulceration and venous reflux over 6 years. Legs without arterial disease (ankle : brachial pressure index (ABPI) above 0.85) were treated with multilayer compression bandaging and patients with severe disease (ABPI 0.5 or less) were considered for immediate revascularization. Those with moderate arterial compromise (ABPI above 0.5 up to 0.85) were initially managed with supervised modified compression and considered for revascularization if their ulcer did not heal. Healing rates were determined using life-table analysis.

RESULTS

Of 2011 ulcerated legs, 1416 (70.4 per cent) had venous reflux. Of these 1416, 193 (13.6 per cent) had moderate and 31 (2.2 per cent) had severe arterial disease. Healing rates by 36 weeks were 87, 68 and 53 per cent for legs with insignificant, moderate and severe arterial disease respectively (P < 0.001). Seventeen legs with moderate and 15 with severe arterial disease were revascularized. Of these, ulcers healed in four legs with moderate and seven with severe disease within 36 weeks of revascularization (P = 0.270). Combined 30-day mortality for revascularization was 6.5 per cent.

CONCLUSION

A protocol including supervised modified compression and selective revascularization achieved good healing rates for mixed arterial and venous leg ulceration.

Residual Venous Reflux after Superficial Venous Surgery Does Not Predict Ulcer Recurrence

OBJECTIVE

The aim of this study was to investigate the importance of venous reflux in ulcer recurrence following saphenous surgery.

METHODS

Ulcerated legs (CEAP 5 and 6) with saphenous reflux were treated with superficial venous surgery plus compression as part of a clinical trial. Patients unfit for general anaesthesia (GA) underwent limited surgery under local anaesthesia (LA). Reflux in superficial and deep segments and venous refill times (VRTs) were assessed before surgery and 3-12 months post-operatively using duplex and digital photoplethysmography respectively.

RESULTS

Of 185 patients treated with surgery, 15 failed to heal and 26 did not have a follow-up duplex. Within 3 years, 25 of the remaining 144 patients (17%) developed ulcer recurrence. Using a Cox regression model, the presence of residual venous reflux and change in reflux pattern were not found to be risk factors for ulcer recurrence (p=ns). LA was used in 4/25 patients who recurred compared to 28/119 who did not (p=0.60; Chi-square test). For legs with recurrence, median VRT before surgery was 10.5s (range 5-29) compared to 11s (range 6-36) after surgery (p=0.097, Wilcoxon Signed Rank test). However, in legs without recurrence, median VRT increased from 10s (range 3-48) to 15s (range 4-48) after surgery (p<0.001).

CONCLUSION

Residual reflux following saphenous surgery is not the most important predictor of venous ulcer recurrence. Poor venous function as demonstrated by VRT may be a better predictor of recurrence in these patients.

The Predictive Value of Haemodynamic Assessment in Chronic Venous Leg Ulceration

OBJECTIVES

The aim of this study was to assess the value of PPG in predicting healing and recurrence in patients with chronic venous ulceration.

METHODS

500 patients with open or recently healed venous ulceration were treated with either multilayer compression or compression plus superficial venous surgery and followed up in specialist clinics as part of a clinical study. At initial assessment, VRT was measured using PPG with and without a below-knee tourniquet inflated to 80 mmHg to occlude superficial veins. Legs were stratified into groups with VRT <11s, 11-20s and >20s and comparison of healing and recurrence rates between these groups was performed.

RESULTS

VRT measurements were not achieved in 117 patients, primarily due to ankle stiffness. Of the remaining 383 patients, VRT without tourniquet did not correlate with ulcer healing (p=0.26, 0.40) or recurrence (p=0.20, 0.79, Log rank test) for legs treated with compression or compression plus surgery respectively. However, VRT readings taken with a below-knee tourniquet were predictive of ulcer healing (p<0.01) and recurrence (p=0.05, Log-rank test). The correlation was greatest for healing in legs treated with compression alone, where 24 week healing rates were 62%, 73% and 92% for legs with VRTs with tourniquet <11s, 11-20s and >20s respectively (p<0.01, Log rank test). For legs treated with surgery, 1 year recurrence rates were 24%, 10% and 3% for groups with VRTs with tourniquet <11s, 11-20s and >20s respectively (p=0.03, Log rank test).

CONCLUSIONS

Digital PPG assessment may predict ulcer healing and recurrence, but only by using a below-knee tourniquet. This information could aid the selection of patients with venous ulceration most likely to benefit from superficial venous surgery.

The Ulcerated Leg Severity Assessment score for prediction of venous leg ulcer healing

BACKGROUND

The aim of the study was to create a reliable scoring system for the prediction of venous ulcer healing in patients treated with compression.

METHODS

A prospective baseline study to identify risk factors for venous ulcer healing was undertaken between March 1999 and August 2001. All patients were treated with multilayer compression. A number of variables were related to 24-week healing rates. A Cox regression model was used to identify risk factors that predicted ulcer healing, from which a scoring system was developed and validated prospectively between February 2004 and March 2005.

RESULTS

In the baseline study of 229 patients, patient age, ulcer chronicity and venous refill time (VRT) of 20 s or less were identified as risk factors. Using these factors and hazard ratios from the Cox regression analysis, the following formula was devised: Ulcerated Leg Severity Assessment (ULSA) score=age+chronicity-50 (when VRT is greater than 20 s). Patients with an ULSA score of 50 or less had higher 24-week ulcer healing rates than those with higher scores in both the baseline study (P<0.001, log rank test) and the validation study performed in 86 patients (P=0.007, log rank test).

CONCLUSION

The ULSA score may help to identify patients with venous ulcers unlikely to respond to conventional treatment who could be offered alternative therapy.

The influence of superficial venous surgery and compression on incompetent calf perforators in chronic venous leg ulceration

OBJECTIVES

Previous studies have suggested that perforating vein incompetence is reduced by surgery to superficial veins. This study analysed the effect in a randomised clinical trial.

DESIGN

Retrospective analysis of duplex data.

METHODS

Patients in this study were part of the ESCHAR randomised controlled trial. All patients had chronic venous leg ulceration with superficial venous reflux. Patients were treated with compression bandaging alone or compression plus superficial venous surgery. Legs were assessed using colour venous duplex prior to treatment and at 3 and 12 months.

RESULTS

Of 500 patients recruited to the ESCHAR trial, 261 were included in this study. One hundred and forty six of 261 legs were treated with compression alone and 115/261 underwent compression and superficial venous surgery. In the compression group, more legs had incompetent perforators at 12 months (77/131) compared to baseline (61/146, p =0.010, Wilcoxon Signed Ranks test for paired data in 131 legs). Following surgery, significantly fewer legs had incompetent calf perforators (59/115 vs 44/104 at 12 months, p =0.001, Wilcoxon Signed Ranks test for paired data in 104 legs). In addition, significantly fewer legs in the compression and surgery group developed new perforator incompetence in comparison to the group treated with compression alone (12/104 vs 36/131, p =0.003, Chi-Squared test).

CONCLUSION

Surgical correction of superficial reflux may abolish incompetence in some calf perforators and offer protection against developing new perforator incompetence.

Randomized clinical trial of compression plus surgery versus compression alone in chronic venous ulceration (ESCHAR study)--haemodynamic and anatomical changes

BACKGROUND

The aim of this study was to evaluate the anatomical and haemodynamic effects of superficial venous surgery and compression on legs with chronic venous ulceration.

METHODS

Legs with open or recently healed ulceration and saphenous reflux were treated with multilayer compression bandaging or superficial venous surgery plus compression as part of a clinical trial. Venous duplex imaging was performed before treatment and at 1 year. Legs were stratified before surgery as having no deep reflux, segmental deep reflux or total deep reflux. Venous refill times (VRTs) were calculated before treatment and at 1 year using photoplethysmography, with and without a narrow below-knee cuff inflated to 80 mmHg.

RESULTS

Of 214 legs investigated, 112 were treated with compression and 102 with compression plus surgery. Saphenous surgery abolished deep reflux in ten of 22 legs with segmental deep reflux and three of 17 with total deep reflux. Overall median (range) VRT increased from 10 (3-48) to 15 (4-48) s 1 year after surgery (P < 0.001). Preoperative change in VRT on application of a below-knee tourniquet correlated with actual change in VRT following surgery.

CONCLUSION

Superficial venous surgery resulted in a significant haemodynamic benefit for legs with venous ulceration despite co-existent deep reflux; residual saphenous reflux was common.

How to approach major surgery where patients refuse blood transfusion (including Jehovah's Witnesses)

Jehovah's Witnesses do not permit the use of allogeneic blood products. An increasing number of patients are refusing blood transfusion for non-religious reasons. In addition, blood stores are decreasing, and costs are increasing. Transfusion avoidance strategies are, therefore, desirable. Bloodless surgery refers to the co-ordinated peri-operative care of patients aiming to avoid blood transfusion, and improve patient outcomes. These principles are likely to gain popularity, and become standard practice for all patients. This review offers a practical approach to the surgical management of Jehovah's Witnesses, and an introduction to the principles of bloodless surgery that can be applied to the management of all patients.

Risk Factors for Delayed Healing and Recurrence of Chronic Venous Leg Ulcers—An Analysis of 1324 Legs

OBJECTIVE

Despite similar disease patterns and treatment, there is great variation in clinical outcome between venous ulcer patients. The aim of this study was to identify independent risk factors for venous ulcer healing and recurrence.

METHODS

Consecutive patients assessed by a specialist nurse-led leg ulcer service between January 1998 and July 2003 with an ABPI>0.85 were included in this study. Independent risk factors for healing and recurrence were identified from routinely assessed variables using a Cox regression proportional hazards model.

RESULTS

A total of 1324 legs in 1186 patients were studied. The 24-week healing rate was 76% and 1 year recurrence rate was 17% (Kaplan-Meier life table analysis). Patient age (p <0.001, HR per year 0.989, 95% CI 0.984-0.995) and ulcer chronicity (p =0.019, HR per month 0.996, 95% CI 0.993-0.999) were independent risk factors for delayed ulcer healing. Ulcer healing time (p <0.001, HR per week 1.016, 95% CI 1.007-1.026) and superficial venous reflux not treated with surgery (p =0.015, HR 2.218, 95% CI 1.166-4.218) were independent risk factors for ulcer recurrence.

CONCLUSIONS

Elderly patients with longstanding ulcers should be targeted for further research and may benefit from adjunctive treatments to improve clinical outcomes. Patients not treated with superficial venous surgery were at increased risk of leg ulcer recurrence.

Late Survival after Elective Repair of Aortic Aneurysms Detected by Screening

BACKGROUND

The aim of this study was to examine whether there was any survival advantage in men following elective repair of an abdominal aortic aneurysm (AAA) detected by ultrasound screening compared to those with an AAA detected incidentally.

METHODS

A total of 424 men underwent elective AAA repair between 1990 and 1998; 181 were detected in an aneurysm screening programme and 243 were diagnosed incidentally. Follow-up survival data were collected until 2003 (minimum 5 years) and survival curves were compared using regression analysis.

RESULTS

The postoperative 30-day mortality rate was significantly lower in men whose aneurysms were detected by screening (4.4%), compared with those detected incidentally (9.0%). Similarly, 5-year survival (78% vs. 65%) and 10-year survival rates (63% vs. 40%) were better after repair of a screen-detected AAA (p<0.0003 at all time intervals, by log rank testing). Multivariate analysis showed that this was largely due to the older age of men who had repair of an incidental AAA (71.2 vs. 67.1 years).

CONCLUSION

Men who had elective repair of an AAA detected by screening had a better late survival rate than men whose aneurysm was discovered incidentally because they were younger at the time of surgery.

Screening for abdominal aortic aneurysms in men

Gloucestershire's screening project shows the potential benefits of a national programme and how it could be run

Recommendations for screening intervals for small aortic aneurysms

BACKGROUND

The aim was to determine the optimum rescreening interval for small abdominal aortic aneurysms (AAAs).

METHODS

Data from 12 years of population screening of 65-year-old men were analysed and 1121 small AAAs (less than 4.0 cm in initial diameter) were divided into groups: group 1 (2.6-2.9 cm; n = 625), group 2 (3.0-3.4 cm; n = 330) and group 3 (3.5-3.9 cm; n = 166). Expansion rate and the cumulative proportions to expand to over 5.5 cm, or require surgery, or rupture were calculated.

RESULTS

Expansion rate was related to initial aortic diameter: 0.09 cm per year in group 1, 0.16 cm per year in group 2 and 0.32 cm per year in group 3 (P < 0.001). Aneurysms in 2.4 per cent of patients in group 1 exceeded a diameter of 5.5 cm or required surgery within 5 years; there were no ruptures. In group 2, no aorta exceeded 5.5 cm but at 3 years 2.1 per cent had reached 5.5 cm and 2.9 per cent had required surgery. The rupture rate at 3 years was zero. In group 3, the aneurysm diameter exceeded 5.5 cm in 1.2 per cent of patients, but no patient required surgery or experienced rupture within 1 year; at 2 years 10.5 per cent of aneurysms had exceeded 5.5 cm in diameter or required surgery and 1.4 per cent had ruptured.

CONCLUSION

The appropriate rescreening interval can be determined by initial aortic diameter in screened 65-year-old men. AAAs of initial diameter 2.6-2.9 cm should be rescanned at 5 years, those of 3.0-3.4 cm at 3 years and those of 3.5-3.9 cm at 1 year.

Surgery reduces long-term recurrence rate in chronic venous leg ulcers

Background

Surgical correction of isolated superficial venous reflux in ulcerated legs reduces short-term recurrence rates but little is known about long-term recurrence. This study aimed to assess the influence of venous reflux pattern and appropriate surgical correction on ulcer healing and long-term recurrence.

Methods

Patients with chronic leg ulcers were assessed prospectively at a one-stop clinic over 4 years to July 1999. Patients with an ankle: brachial pressure index (ABPI) greater than 0·85, including those with diabetes mellitus and rheumatoid arthritis, were treated with weekly four-layer bandaging in community leg ulcer clinics. Venous duplex studies in all ulcerated legs assessed venous reflux pattern and patients with isolated superficial reflux were offered surgery. Patients were advised to wear class 2 elastic compression stockings after healing and were reviewed at 1, 3, 6 and 9 months, and at 1, 2 and 3 years. Ipsilateral ulceration following healing was designated as recurrence.

Results

Some 766 ulcerated legs in 689 patients were assessed; 633 legs had an ABPI greater than 0·85. Venous duplex assessment revealed 8 per cent of these legs to have pure deep, 38 per cent pure superficial and 43 per cent a mixed reflux pattern. Ten per cent of legs had no demonstrable reflux. Some 131 of 241 limbs with pure superficial reflux underwent surgery. Healing rates at 12 and 24 weeks for all legs with an ABPI greater than 0·85 were 48 and 68 per cent respectively. Neither venous pattern nor surgery affected ulcer healing rates. Overall 1-, 2- and 3-year recurrence rates for venous ulcers were 25, 31 and 38 per cent respectively. The influence of venous reflux pattern and surgery on ulcer recurrence is summarized in Table.

Conclusion

Ulcer healing rates are not influenced by venous reflux pattern or surgery. Surgical correction of superficial venous reflux in the presence of chronic leg ulceration reduces long-term ulcer recurrence rates.

Risk factors for delayed healing and long-term recurrence in chronic venous leg ulcers

Background

This study aimed to identify risk factors for delayed healing and increased recurrence of chronic venous leg ulcers.

Methods

Some 669 patients with chronic leg ulcers were assessed at a one-stop clinic over the 4 years to July 1999. Possible risk factors and venous reflux patterns, assessed with colour duplex, were recorded prospectively for each patient. Some 633 legs with an ankle: brachial pressure index greater than 0·85 were treated with weekly four-layer bandaging until healed, followed by class 2 compression stockings and regular follow-up. Patients with isolated superficial venous reflux were offered surgery.

Results

Cox regression analyses of possible risk factors are summarized in the Table below.

Conclusion

Age, ulcer chronicity and reflux in the popliteal vein are independent risk factors for delayed ulcer healing. Delayed ulcer healing and rheumatoid arthritis are independent risk factors for ulcer recurrence. Legs with surgically corrected superficial venous reflux are relatively protected from ulcer recurrence.

Mortality rate of elective abdominal aortic aneurysm repair is lower in screened men

Background

It is expected that the main benefit of abdominal aortic aneurysm (AAA) screening will be derived from differences in the mortality rate between elective and ruptured AAA repair. There may also be differences in elective AAA mortality rate between screened and non-screened patients, and the aim of this study was to compare mortality rates for these two groups using standard statistical analysis, Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM) and P-POSSUM scoring.

Methods

Patients undergoing elective AAA repair were either from a current screening programme to detect men over 65 years with AAA (screened) or were referred from other sources (non-screened). All patients were scored using the POSSUM scoring system. Mortality data were studied. Agreement between observed and expected deaths for POSSUM and P-POSSUM for screened and non-screened patients was determined.

Results

Some 276 elective AAA repairs were performed with an overall mortality rate of 6·9 per cent (see Table below). The mortality rate of 2·7 per cent for 111 screened patients was significantly less than that of 9·7 per cent for 165 non-screened patients (Pearson χ2 = 5·06, P = 0·02). Actual versus predicted death ratio for all elective patients was 0·93 for POSSUM and 2·38 for P-POSSUM.

Conclusion

Screened patients have a lower mortality rate than non-screened patients for AAA repair. POSSUM scoring provides the best prediction of death in this elective AAA group.

Audit of attendance rates for an infra-inguinal graft surveillance programme--how complete is your graft surveillance?

Much has been written on the subject of graft surveillance following infra-inguinal bypass graft surgery, but surprisingly little information exists on actual attendance rates for such programmes. The aim of this study was to calculate the attendance rate for graft surveillance at the vascular unit in Cheltenham. All patients who entered the graft surveillance programme following an infra-inguinal graft procedure over a 5-year period were included in the study. Partial and complete surveillance attendance rates were calculated for each year in the study period. Both rates were seen to rise over the 5-year period, from 31% to 78% and 0 to 38%, respectively. These attendance rates were much lower than were expected. Vascular units relying on such graft surveillance programmes should evaluate their own 'surveillance rates'.

A single normal ultrasonographic scan at age 65 years rules out significant aneurysm disease for life in men

BACKGROUND

Screening for abdominal aortic aneurysm (AAA) has been carried out in Gloucestershire since 1990. All men in the county are offered aortic ultrasonography in their 65th year. Men with an aortic diameter of less than 26 mm are considered 'normal' and no follow-up is arranged. The aim of this study was to ascertain if men with 'normal' aortic diameters at age 65 years ever develop a clinically significant aneurysm.

METHODS

A cohort study was performed on 223 65-year-old men who had an aorta of less than 26 mm in diameter in 1988. These men had repeat ultrasonography in 1993 and 2000. The causes of death in men who died during this interval were investigated.

RESULTS

Eight men were lost to follow-up. As far as it was possible to ascertain, none of the 86 men who died over the 12-year interval did so from ruptured AAA. There was no clinically significant increase in mean aortic diameter in the remaining 129 men who had three serial ultrasonographic scans over the 12-year interval.

CONCLUSION

A single, 'normal' ultrasound scan at age 65 years effectively rules out the risk of clinically significant aneurysm disease for life in men.

A Modern Leg Ulcer Service

Aim:

To define the components and organization of a modern leg ulcer service that is acceptable to patients cost effective and produces high quality outcomes.

Method:

Analysis of data from published literature as well as experience from the organisation of a leg ulcer service in Gloucestershire.

Synthesis:

Assessment of leg ulcers requires the services of a vascular laboratory to assess the venous and arteria systems. Effective systems of compression must be employed. Staff and patients must be educated to understand the principals behind their use. For some patients pinch-grafting may be appropriate. Where arterial disease is present in the lower limb, reconstructive surgery should be used for the lower limb vessels The organisation of such a service must ensure good liaison between General Practitioners, community nurses and hospital specialists. Many patients may be managed in community leg ulcer clinics. In some cases, the advice of specialists such as rheumatologists and dermatologists may be required.

Conclusions:

A national framework for leg ulceir management is needed within which resources are made available in a way that satisfy local needs. Such a framework must be based on management protocols derived from evidence-based practices that have been developed through the experiences of modern leg ulcer services.

Surgical correction of isolated superficial venous reflux reduces long-term recurrence rate in chronic venous leg ulcers

OBJECTIVES

surgical correction of isolated superficial venous reflux in ulcerated legs may reduce short term recurrence rates but the longer term benefits are unknown.

DESIGN

prospective non-randomised cohort study.

METHODS

consecutive patients with chronic leg ulcers were prospectively assessed at a one-stop clinic over a 4-year period from July 1995 to July 1999. All patients with ankle brachial pressure indices (ABPI)50.85 were initially treated with weekly four-layer bandaging. Venous duplex studies in all ulcerated legs assessed venous reflux pattern with surgery being offered to all those with isolated superficial reflux, of whom 56% accepted. Patients were advised to wear class two elastic compression stockings after healing.

RESULTS

766 legs in 669 patients were assessed. Six hundred and thirty-three legs had an ABPI50.85, 236 (39%) demonstrating isolated superficial venous reflux. Surgery was performed on 131 of these legs. Twelve and 24 week healing rates were 50% and 72% for operated legs and 62% and 74% for non-operated legs (p=0.67; Kaplan-Meier life table analysis). Recurrence rates at 1, 2 and 3 years were 14%, 20% and 26% for operated legs and 28%, 30% and 44% for non-operated legs (p=0.03; Kaplan-Meier life table analysis).

CONCLUSION

surgical correction of superficial venous reflux in legs with chronic leg ulceration may reduce ulcer recurrence rate at 1, 2 and 3 years.

A comparison of the mortality rate after elective repair of aortic aneurysms detected either by screening or incidentally

OBJECTIVE

to compare predicted and actual mortality rates, using POSSUM scoring, after elective repair of abdominal aortic aneurysms (AAAs) detected from the Gloucestershire Aneurysm Screening Programme and those discovered incidentally.

METHODS

a sample of 276 men undergoing elective AAA repair in Gloucestershire between 1991 and 1998 was studied. AAAs were either detected from the screening programme or were discovered incidentally and referred from other sources. Mortality data relating to these patients have been recorded prospectively. POSSUM scoring was performed retrospectively from patients>> notes in both groups and related to outcome (30 day and in-hospital mortality). POSSUM and P-POSSUM methodology were used to compare observed and predicted mortality rates.

RESULTS

in the 276 men who had elective AAA repair, the overall mortality rate was 7%. Mortality was lower in screen-detected AAAs (3/111, 3%) than AAAs discovered incidentally (16/175, 9%) (p=0.05). Preoperative physiology scores were significantly lower in men with a screen-detected AAA (median 19, range 13-29 versus 21, 12-41, p<0.001). POSSUM operative scores were similar between the groups. Actual versus predicted death ratios in the sample group were more accurate using POSSUM (ratio 0.93) than P-POSSUM (2.38) analysis.

CONCLUSIONS

men with a screen-detected AAA had a lower mortality rate after elective repair than in those detected incidentally; lower preoperative physiology scores suggested they were fitter (as well as younger). In this study POSSUM analysis more accurately predicted outcome than P-POSSUM.

Influence of a specialized leg ulcer service on management and outcome

BACKGROUND

The organization of leg ulcer care is poorly defined in the community. This study assessed the overall influence of a specialized community service on management and outcome of chronic leg ulcers, irrespective of aetiology.

METHODS

Assessment and outcome of ulcers were compared in patient samples (n = 200) from East and West Gloucestershire, before and after the introduction of specialized clinics into East Gloucestershire. In clinics, vascular disease was routinely assessed by duplex scanning and determination of the ankle : brachial pressure index.

RESULTS

There was no coordinated community structure for the care of patients with leg ulcers before the service was introduced, and 74 and 67 per cent of limbs in East and West Gloucestershire respectively had aetiology undiagnosed. After introduction of the clinics, the 12-week healing rate increased from 12 to 22 per cent in East Gloucestershire (P = 0. 05) and to 47 per cent in the specialized East Gloucestershire clinics (P < 0.001). The 12-month recurrence rate decreased from 50 to 41 per cent in East Gloucestershire and to 17 per cent in the East clinics (P < 0.001). The West Gloucestershire control showed no significant changes.

CONCLUSION

A specialized leg ulcer service with defined protocols provides an improved management structure for treating patients with leg ulcers in the community. Accurate diagnosis of chronic leg ulcers and improved outcome may be achieved within this specialized service.

Population screening reduces mortality rate from aortic aneurysm in men

BACKGROUND

Rupture of an unsuspected abdominal aortic aneurysm is a major cause of death in men over the age of 65 years. A significant reduction in deaths is likely to result only from higher rates of detection and increased numbers of elective aneurysm repairs. Screening of men reaching the age of 65 years has been taking place in the county of Gloucestershire, UK since 1990 and the aim of this study was to investigate any change in the mortality rate from aortic aneurysm in the screened portion of the population.

METHODS

Total number of deaths from all aortic aneurysm-related causes in the county's population was calculated from hospital and post-mortem records, together with computerized death certificate records, for the years 1994-1998. The overall number of aneurysm-related deaths in men aged 65-73 years, who have been progressively influenced by the screening programme, was compared with that for men of all other ages.

RESULTS

The total number of aneurysm-related deaths in men aged 65-73 years decreased progressively year by year between 1994 and 1998; this reduction is highly statistically significant (P < 0. 001). No such change was observed in the unscreened part of the population.

CONCLUSION

Screening for asymptomatic abdominal aortic aneurysm results in a significant reduction in numbers of deaths from all aneurysm-related causes in the screened portion of the male population.

The diagnosis and management of mixed arterial/venous leg ulcers in community-based clinics

OBJECTIVES

To assess a management protocol for mixed arterial/venous leg ulcers in a community service.

DESIGN

Two-year prospective study of outcome with intention of assessing limbs with mixed arterial/venous ulcers when managed by a new protocol.

METHOD

Limbs were assessed for venous reflux by duplex and arterial insufficiency by ankle-brachial pressure index (ABPI) and defined into three categories: ABPI > 0.85, 0.5 > ABPI < or = 0.85 (moderate), ABPI < or = 0.5 (severe). Four-layer compression was applied to limbs with normal arteries. Modified compression was applied to limbs with venous and moderate arterial disease with treatment failure triggering arterial imaging and revascularisation. Limbs with venous and severe arterial disease were investigated for revascularisation.

RESULTS

Of 267 consecutive limbs, 221 had pure chronic venous ulcers and 46 had mixed arterial/venous ulcers with 33 having moderate and 13 having severe arterial disease. Thirty-six week healing rates for chronic venous, moderate arterial/venous and severe arterial/venous ulcers were 70%, 64% and 23%, respectively.

CONCLUSION

Limbs with mixed moderate arterial/venous ulcers achieved rates comparable with venous ulcers with this protocol although nurse-led surveillance was required. Limbs with mixed severe arterial/venous ulcers healed slowly despite an aggressive approach to correct arterial disease.

Influence of a specialised leg ulcer service and venous surgery on the outcome of venous leg ulcers

OBJECTIVES

To assess the influence of a vascular-led community service on the outcome of chronic leg ulcers.

DESIGN

Before and after study.

METHOD

Healing and recurrence were compared between ulcerated limbs (n = 149) from a random sample of 200 patients treated in the community and consecutive limbs (n = 200) from 180 patients treated in specialised clinics. In these clinics, vascular disease was routinely identified with venous duplex and ankle-brachial pressure index. Surgery was offered if superficial vein reflux alone was detected. Compression bandaging was applied to limbs with ABPI > 0.85. Healed limbs were treated with compression hosiery.

RESULTS

After the clinics were introduced, the 12 and 24-week healing rates increased from 12 and 29 per cent to 53 and 68 per cent respectively (p < 0.01), and the 6 and 12 month recurrence rates decreased from 43 and 54 per cent to 21 and 23 per cent respectively (p < 0.01). Superficial venous surgery reduced recurrence at 1 year to 9 per cent.

CONCLUSION

Outcome of leg ulcers is improved in a vascular-led community service. Routine surgical correction, in cases of reflux limited to the superficial system, may further reduce the chance of recurrence.

Quality of life after transthoracic endoscopic sympathectomy for upper limb hyperhidrosis

OBJECTIVE

To assess the outcome after transthoracic endoscopic sympathectomy (TES) for upper limb hyperhidrosis.

DESIGN

Prospective cohort study.

SETTING

District general hospital.

SUBJECTS

Consecutive patients undergoing TES for upper limb hyperhidrosis over a fifteen month period.

INTERVENTIONS

One-stage bilateral TES.

MAIN OUTCOME MEASURES

Change in quality of life as shown by the Short Form-36 health assessment questionnaire.

RESULTS

Sixteen patients (11 women and 5 men, median age 26 years) underwent operation without complications. At median follow-up of 6.2 months, symptomatic improvement was found in 26 of 32 limbs treated (82%). Truncal compensatory hyperhidrosis was reported by 13 patients but was severe in only three. There were significant improvements in social function (p = 0.01) and mental health (p = 0.025) as assessed by the SF-36.

CONCLUSION

Despite a high incidence of compensatory hyperhidrosis, TES improved both the symptoms and overall quality of life in patients with upper limb hyperhidrosis.

Psychological morbidity associated with abdominal aortic aneurysm screening

OBJECTIVES

To identify whether abdominal aortic aneurysm screening causes anxiety in those screened and whether the diagnosis of an aneurysm produces sustained anxiety in subjects in comparison with those in whom no abnormality is detected.

DESIGN

Prospective case controlled study.

MATERIALS AND METHODS

The 28-item General Health Questionnaire (GHQ) was used to assess psychological morbidity in 161 men attending for routine aneurysm screening in the Gloucestershire Aneurysm Screening Programme. One hundred men had a normal aorta and 61 were identified as having aneurysms. The GHQ was administered just before screening and 1 month later. An anxiety linear analogue scale was also used.

RESULTS

There was no difference in anxiety levels between those men with normal aortas and those with aneurysms either before or after screening. There was a statistically significant reduction in both these groups 1 month after screening.

CONCLUSION

This study shows that although the invitation to aneurysm screening may cause some mild anxiety, this is not prolonged even when an asymptomatic aneurysm is diagnosed.