A One-Year Audit of Varicose Vein Surgery at a Vascular Surgical Unit with a Long-Term Duplex and Quality of Life Follow-Up

Objective: With the introduction of endovenous treatments, open varicose veins surgery was discarded due to a claimed high risk of neovascularisation. A one-year audit was set up to look at results from performing mainly open surgery. Methods: All varicose vein interventions were registered and prospectively followed with colour Duplex assessments after 4-6 weeks, 1 and >5 years. In addition, Aberdeen Varicose Vein Questionnaire (AVVQ) was used in addition to Varicose Vein Severity Score (VCSS) to assess patients’ quality of life (QoL) and the disease severity. Results: During the year, 236 patients/252 legs were operated and 28% were re-do procedures. Median age was 55 years (16-87) and 70% were females. Duplex at 4-6 weeks showed a primary success rate of 91%. Neovascularisation was noted in 8% one year after primary surgery. The long-term assessment was done after a median of 69 months (39-75) and 67% of all legs were examined. After primary surgery 16% showed neovascularisation compared with and 27% after re-do procedures. VCSS improved significantly from 6 (range 1-22) to 2 at the long-term follow-up (p<0.001). The AVVQ score improved from 20 (range 3-55) down to 10 (p<0.001). Conclusion: The risk for neovascularisation seems to have been overestimated and good long-term results can be achieved following modern open surgery. The major problem is to avoid varicose vein recurrence since results from re-do procedures seem less favourable long term.

Patient related factors affecting in-hospital costs of a TURP procedure

Introduction: Treatment costs of lower urinary tract symptoms secondary to benign prostatic enlargement (BPE) are a substantial economic burden that will continue to increase in the future as a result of the ageing male population and increasing health awareness. The true costs for surgical interventions against BPE have been difficult to quantify as treatment costs strongly depend on the performance setting and may also vary among different healthcare systems, regions and institutions. The purpose of this study was to disclose the in-hospital costs and main expense items associated with a transurethral resection of the prostate (TURP).Methods: A cohort of men subjected to TURP due to BPE was analysed during a 3-year period (2017-2019). All in-hospital expenses were registered using an electronic spreadsheet. Patient background and perioperative variables were registered using retrospective chart reviews.Results: A total of 122 men were available for final analysis. Of these, 70 men were operated on due to bothersome LUTS and 52 men due to urinary retention. The mean and median (inter quartile range) cost per patient was €4025 and €3702 (2961 - 4390), respectively. The main drivers of total cost were length of stay, the surgical procedure and anaesthesia related costs. Factors associated with increasing total cost per patient were increasing age, prostate volume, presence of urinary retention, occurrence of complications, increasing catheter time and length of stay.Conclusion: The main factor that influences total cost for an elective TURP procedure is the occurrence of postoperative complications. Our findings firmly underscore the indispensability to employ every possible means to avoid and prevent complications of any kind.

Transurethral resection of the prostate: fate of the non-responders

BACKGROUND

Transurethral resection of the prostate (TURP) has been the standard method of surgical management of benign prostatic enlargement for decades. Some patients experience significant voiding dysfunction and discomfort postoperatively, without any apparent clinical complications from the procedure. Furthermore, a significant proportion of men still require postoperative catheterisation. This study analysed patients defined as non-responders after TURP with the principal aim to reveal their fate.

METHODS

A prospectively recruited cohort of 355 men, who underwent TURP during 2010-2012, was investigated. Non-responders were identified as still requiring catheterisation postoperatively and/or exhibiting all of the following voiding outcomes based on the de Wildt criteria: IPSS > 7, bother score > 2, Q_max < 15 mL/s and PVR > 100 mL. The non-responders were followed for a maximum period of three years using retrospective chart reviews.

RESULTS

Thirty-five men were defined as non-responders. Of these, 26 men were operated on due to urinary retention and nine men due to bothersome symptoms. The non-responders were followed for a mean time of 72 months. Seven men underwent a redo-TURP and two men a bladder neck incision. Eleven of the 35 men were finally judged as having satisfactory voiding parameters. Sixteen men used CISC. Eleven men reduced the frequency of CISC to a minimum. Seven men had to use an indwelling catheter indefinitely.

CONCLUSION

Men with preoperative urinary retention constituted the vast majority of non-responders. The use of postoperative urodynamic studies was remarkably low. Almost one in three non-responders finally had a satisfactory outcome with or without re-intervention.

The morbidity associated with a TURP procedure in routine clinical practice, as graded by the modified Clavien-Dindo system

Background: Transurethral resection of the prostate (TURP) is considered the reference surgical method of treating benign prostatic enlargement (BPE) causing obstruction. The procedure still carries a significant risk of perioperative morbidity according to previous reports. The aim of the present study was to disclose complications after TURP undertaken in routine clinical practice at a non-academic center.Methods: All patients with BPE submitted to TURP from January 2010 to December 2012 were evaluated for complications occurring during hospital stay, after discharge up to the end of the third post-operative month and finally for any late endourological re-interventions undertaken up to five years after TURP. All complications were graded according to the Clavien-Dindo system.Results: In total, 354 men underwent a TURP during the study period. In total, 47% had pre-operative urinary retention. Significant co-morbidity was seen in 17% of men (ASA III-IV). Spinal anaesthesia was applied to 312 men (88%). During hospital stay, major complications, graded as Clavien-Dindo ≥ III, was seen in only eight men (2.3%). Minor complications occurred in 91 men (26%). Between hospital discharge and follow-up visit major complications were noted in 12 men (3.4%). Minor complications occurred in 79 men (22%). The only factor that was associated with an increased risk of a major complication was general anaesthesia. Late complications, requiring an endourological re-intervention, occurred in 30 men (9.7%).Conclusion: TUR-P in routine clinical practice was associated with a low incidence of severe complications. TUR syndrome was very rare. Within five years a small proportion of men require the transurethral intervention to be redone.

Nationwide Study of the Treatment of Mycotic Abdominal Aortic Aneurysms Comparing Open and Endovascular Repair

Background:

No reliable comparative data exist between open repair (OR) and endovascular aneurysm repair (EVAR) for mycotic abdominal aortic aneurysms (MAAAs). This nationwide study assessed outcomes after OR and EVAR for MAAA in a population-based cohort.

Methods:

All patients treated for MAAAs in Sweden between 1994 and 2014 were identified in the Swedish vascular registry. The primary aim was to assess survival after MAAA with OR and EVAR. Secondary aims were analyses of the rate of recurrent infections and reoperations, and time trends in surgical treatment. Survival was analyzed using Kaplan-Meier and log-rank tests. A propensity score–weighted correction for risk factor differences in the 2 groups was performed, including the operation year to account for differences in treatment and outcomes over time.

Results:

We identified 132 patients (0.6% of all operated abdominal aortic aneurysms in Sweden). Mean age was 70 years (standard deviation, 9.2), and 50 presented with rupture. Survival at 3 months was 86% (95% confidence interval, 80%–92%), at 1 year 79% (72%–86%), and at 5 years 59% (50%–68%). The preferred operative technique shifted from OR to EVAR after 2001 (proportion EVAR 1994–2000 0%, 2001–2007 58%, 2008–2014 60%). Open repair was performed in 62 patients (47%): aortic resection and extra-anatomic bypass (n=7), in situ reconstruction (n=50), and patch plasty (n=3); 2 patients died intraoperatively. EVAR was performed in 70 patients (53%): standard EVAR (n=55), fenestrated/branched EVAR (n=8), and visceral deviation with stent grafting (n=7); no deaths occurred intraoperatively. Survival at 3 months was lower for OR than for EVAR (74% versus 96%, P <0.001), with a similar trend present at 1 year (73% versus 84%, P =0.054). A propensity score–weighted risk-adjusted analysis confirmed the early better survival associated with EVAR. During median follow-up of 36 and 41 months for OR and EVAR, respectively, there was no difference in long-term survival (5 years 60% versus 58%, P =0.771), infection-related complications (18% versus 24%, P =0.439), or reoperation (21% versus 24%, P =0.650).

Conclusion:

This study demonstrates a paradigm shift in treatment of MAAA in Sweden, with EVAR being the preferred treatment modality. EVAR was associated with improved short-term survival in comparison with OR, without higher associated incidence of serious infection-related complications or reoperations.

Prevalence and Aetiology of Leg Ulcers in a Defined Population of Industrial Workers

Objective:

To assess leg ulcer prevalence and aetiology in people below retirement age.

Design:

A validated cross-sectional questionnaire survey. Respondents with a history of leg ulcers were examined.

Setting:

A defined population of industrial workers.

Subjects:

All 2785 employees, aged 30–65 years, at the Volvo motor engine factories in Skövde were included. Men predominated (81%) and the median age was 44 years in both men and women. A questionnaire was used to select people with a history of ulceration. A leg ulcer was defined as ‘any wound below the knee (foot ulcers included) that did not heal within a 6-week period after onset of ulceration’.

Main outcome measures:

Point prevalence of open leg ulcers, overall prevalence of leg ulcer history and aetiological classification.

Results:

The overall response rate was 87%, and 131 out of 153 subjects with a ‘history of leg ulcers’ were examined (86%). In 98% of positive responders the answers were validated. The overall false-positive response rate was 64%. Fifty-four had a true history of ulcers, of whom 16 had open ulcers. Of the latter, 12 were self-caring (75%). Overall venous causation dominated (41%). The ratio of open to healed ulcers was 1:2. The point prevalence for open ulcers was 0.6% and the overall prevalence of ulcer history was 1.6%, if excluding pure traumatic ulcers. The point prevalence was tenfold higher in people aged below 50 years and seven times higher in the age decade 50–59 years if compared with previous estimates based on patients known to health-care professionals.

Conclusion:

Leg ulcer prevalence has been underestimated in people of working age because they are often self-caring. Since many ulcers have curable causes it is necessary to inform the public of the importance of seeking professional help early.

Venous hemodynamic changes in lower limb venous disease: the UIP consensus according to scientific evidence

There are excellent guidelines for clinicians to manage venous diseases but few reviews to assess their hemodynamic background. Hemodynamic concepts that evolved in the past have largely remained unchallenged in recent decades, perhaps due to their often complicated nature and in part due to emergence of new diagnostic techniques. Duplex ultrasound scanning and other imaging techniques which evolved in the latter part of the 20th century have dominated investigation. They have greatly improved our understanding of the anatomical patterns of venous reflux and obstruction. However, they do not provide the physiological basis for understanding the hemodynamics of flow, pressure, compliance and resistance. Hemodynamic investigations appear to provide a better correlation with post-treatment clinical outcome and quality of life than ultrasound findings. There is a far better prospect for understanding the complete picture of the patient's disability and response to management by combining ultrasound with hemodynamic studies. Accordingly, at the instigation of Dr Angelo Scuderi, the Union Internationale de Phlebologie (UIP) executive board commissioned a large number of experts to assess all aspects of management for venous disease by evidence-based principles. These included experts from various member societies including the European Venous Forum (EVF), American Venous Forum (AVF), American College of Phlebology (ACP) and Cardiovascular Disease Educational and Research Trust (CDERT). Their aim was to confirm or dispel long-held hemodynamic principles and to provide a comprehensive review of venous hemodynamic concepts underlying the pathophysiology of lower limb venous disorders, their usefulness for investigating patients and the relevant hemodynamic changes associated with various forms of treatment. Chapter 1 is devoted to basic hemodynamic concepts and normal venous physiology. Chapter 2 presents the mechanism and magnitude of hemodynamic changes in acute deep vein thrombosis indicating their pathophysiological and clinical significance. Chapter 3 describes the hemodynamic changes that occur in different classes of chronic venous disease and their relation to the anatomic extent of disease in the macrocirculation and microcirculation. The next four chapters (Chapters 4-7) describe the hemodynamic changes resulting from treatmen by compression using different materials, intermittent compression devices, pharmacological agents and finally surgical or endovenous ablation. Chapter 8 discusses the unique hemodynamic features associated with alternative treatment techniques used by the CHIVA and ASVAL. Chapter 9 describes the hemodynamic effects following treatment to relieve pelvic reflux and obstruction. Finally, Chapter 10 demonstrates that contrary to general belief there is a moderate to good correlation between certain hemodynamic measurements and clinical severity of chronic venous disease. The authors believe that this document will be a timely asset to both clinicians and researchers alike. It is directed towards surgeons and physicians who are anxious to incorporate the conclusions of research into their daily practice. It is also directed to postgraduate trainees, vascular technologists and bioengineers, particularly to help them understand the hemodynamic background to pathophysiology, investigations and treatment of patients with venous disorders. Hopefully it will be a platform for those who would like to embark on new research in the field of venous disease.

Reconsidering the endovenous revolution

Not as cost-effective as you might think

A Repeat Validated Population Questionnaire of a Defined Swedish Population Verifies Reduction in Leg Ulcer Prevalence Over Time

This study was performed to measure if the introduced interventions in leg ulcer care in a selected Swedish county yield a detectable reduction in leg ulcer prevalence in the population. A validated postal questionnaire sent to 10,000 (9,868) randomly selected 30-89 year olds in the Skaraborg county (255,042 inhabitants). All positive responders were telephone interviewed and verified ulcer patients were clinically examined including assessment of arterial/venous circulation with hand-held Doppler and, where indicated, duplex ultrasound scanning. All results were compared with numbers from 1990 (initial study). The response rate was 82% (8,070/9,868), 200 active ulcers and 290 previous ulcers. The calculated prevalence was 0.75% for 30-89 years and 1.05% for 50-89 years (2.1% in 1990). The leg ulcer prevalence was reduced by 32% (0.52% compared to 0.77% in 1990), and the relative risk was reduced by 50% (95%, CI 0.36-0.69). The study shows a true reduction in leg ulcer prevalence detectable in the population supporting a successful care of leg ulcer patients.

Early results from a randomized trial of saphenous surgery with or without subfascial endoscopic perforator surgery in patients with a venous ulcer

Background

The aim was to clarify the role of incompetent perforators (IPs) in venous leg ulcers. This short-term report focused on safety, patient satisfaction and the fate of IPs after subfascial endoscopic perforator surgery (SEPS), or saphenous surgery alone.

Methods

Patients aged 30–78 years with an open or recently healed venous ulcer, and with an incompetent saphenous vein and IPs, were allocated randomly to saphenous surgery alone, or in combination with SEPS. A control duplex scan was performed 6–9 months after surgery, and clinical follow-up was scheduled after 1 week, 3 and 12 months. A standard questionnaire was completed at each clinical visit.

Results

Seventy-five patients were enrolled; 37 had SEPS and 38 had saphenous surgery alone. SEPS prolonged the operation by a median of 15 min (P = 0·003). Duplex imaging revealed significantly more remaining IPs in the no-SEPS group (P &lt; 0·001). Compared with the preoperative scan, significantly more legs were free from IPs in the SEPS group compared with the no-SEPS group (21 of 36 versus 7 of 37 respectively; P &lt; 0·001). There were no other major outcome differences between the groups.

Conclusion

There was no short-term clinical benefit from adding SEPS to saphenous surgery in patients with varicose ulcers and IPs, although SEPS reduced the number of perforators remaining after 1 year.

Leg ulcer point prevalence can be decreased by broad-scale intervention: a follow-up cross-sectional study of a defined geographical population

In 1988 a cross-sectional epidemiological study was performed in Skaraborg County, Sweden, establishing leg ulcer point prevalence. Based on the results of that study a complete change in the care of leg ulcer patients was brought into practice. The objective of this postal cross-sectional follow-up study was to evaluate the success of the new management strategy. Responding healthcare providers were asked to report all patients with an open wound below the knee that did not heal within a 6-week period after onset of ulceration. Validity of results was ensured by examining 203 randomly selected patients. Based on clinical examination, an assessment of the underlying causes of ulceration was made. The study setting was inpatient and outpatient care in hospitals, primary care and community care within Skaraborg, with a population of 254,111. The response rate was 100% from district nurses, hospital wards and outpatient clinics. Reports were collected from healthcare providers, mainly nurses, in all 15 communities. A total of 621 individual patients with active leg ulcers were identified. Age-adjusted sex ratio of ulcer patients was 1:1.1 (M:F). The median age was 79 years. A total of 507 patients (82%) were older than 64 years. District and community nurses provided care for the majority (88.5%) of patients. The study verified a point prevalence of 2.4/1000 population in 2002 compared with 3.1/1000 in 1988, a 23% decrease in leg ulcer prevalence. Venous insufficiency was still the dominating causative factor, although the number of patients with venous leg ulcers was reduced by 46%. Arterial ulcers had decreased by 23%, while patients with ulcers of diabetic and multifactorial causes were increased. In conclusion, it is likely that this reduction in point prevalence reflects the introduction of the change in management strategy undertaken in the area.

True Long-term Healing and Recurrence of Venous Leg Ulcers Following SEPS Combined with Superficial Venous Surgery: A Prospective Study

BACKGROUND

The role of perforator surgery remains unclear in the management of patients with leg ulcers. The aim of this study was to assess long-term healing and recurrence rates of leg ulcers following surgical intervention with combined Subfascial Endoscopic Perforator Surgery (SEPS) and superficial venous surgery.

METHOD

Case series with prospective long-term follow-up of 90 consecutive patients operated on with open (CEAP C6) or healed (CEAP C5) venous ulcers in 97 legs. Popliteal vein reflux was present in 21 legs. All 97 legs were treated with SEPS and 87% had additional superficial venous surgery. Patients were follow-up for a median of 77 months (range 60-112 months) with a minimum of 5 years.

RESULTS

87% of all ulcerated legs healed. The three and five year recurrence rates were 8% and 18% respectively among survivors. In a multivariate Cox regression analysis previous vein surgery was the only factor significantly associated with recurrent ulceration (p=.004).

CONCLUSION

SEPS combined with superficial venous surgery leads to healing with a low recurrence rate in patients with open and healed venous ulcers. Previous venous surgery was found to be a significant risk factor for ulcer recurrence. This result emphasizes the importance of assiduous technique for varicose vein surgery and suggests a continuing role for perforator surgery in leg ulcer patients.

Leg Ulcer Recurrence and its Risk Factors: A Duplex Ultrasound Study before and after Vein Surgery

OBJECTIVES

Assessment of risk factors for ulcer recurrence in chronic leg ulcer patients treated by varicose vein surgery.

DESIGN

Retrospective follow-up study.

MATERIALS

62 patients, 43 women and 19 men (Median=56.5 years, range 24-77) with the CEAP classifications of C(5)-C(6) and E(P) (primary venous insufficiency).

METHODS

Patients underwent colour duplex ultrasound (CDU) investigation before varicose vein surgery. Post-operatively CDU, ambulatory venous pressure (AVP) and an interview were performed. The median clinical follow-up was 5.5 years (range 2-11 years).

RESULTS

The estimated 5-year ulcer recurrence rate was 19% in all patients. The risk of ulcer recurrence was significantly lower (p<0.05) in legs without residual varices or recurrence. The five year risk of ulcer recurrence depended on the time interval between ulcer appearance and the surgical intervention (index operation), post-operative venous axial reflux and AVP (mmHg). More than 50% of the patients had a calculated probability of ulcer recurrence of less than 3%, but 13% had a probability of more than 23% based on our analysis.

CONCLUSIONS

A long history of venous ulcer is a pre- and post-operative risk factor for recurrent ulceration. Total elimination of incompetent superficial and perforator veins lowers the risk of ulcer recurrence, whereas residual axial reflux increases the risk. Postoperative CDU is effective in identifying patients at risk of ulcer recurrence.

A Colour Doppler Ultrasound Study of Venous Reflux in Patients with Chronic Leg Ulcers

OBJECTIVES

to evaluate the distribution of superficial and deep venous reflux in patients with chronic leg ulcers.

MATERIALS

retrospective study of 186 patients with chronic leg ulcers (212 lower limbs).

RESULTS

in 127 legs without arterial disease and a history of deep venous thrombosis (DVT), 62 (49%) had superficial, 45 (35%) had superficial and deep, and 14 (11%) had isolated deep venous reflux. In legs with a previous DVT, isolated deep venous reflux was more common (21/55, 38%) but superficial reflux, often in combination with deep reflux, still predominated (56%).

CONCLUSIONS

a large part of the venous insufficiency causing venous leg ulcers is superficial and suitable for varicose vein surgery. In patients with chronic leg ulcers most reflux affects the superficial system and is potentially suitable for surgical correction.

[Varices and venous insufficiency--therapeutic philosophy prior the 2000's]

Varicose veins represent everything from a cosmetic problem to a risk of venous leg ulcers. Predicting the risk of complications has been difficult, not least due to less than satisfactory diagnostic procedures. Recent investigations have pointed out some important new concepts: Superficial venous incompetence may give rise to an ulcer, and such an ulcer may be prevented by varicose vein surgery. Recanalization and stenting may be useful in treating chronic iliac and caval venous occlusions; however, long-term outcome is yet to be established. Venous diameter can be reduced, thus effecting valve competence. To what extent this result is long-lasting is not known. Neither has the method been attempted on deep veins. Clinical diagnosis is never sufficient in cases of suspected chronic venous incompetence. The minimum requirement is the use of a hand-held Doppler. Frequently, a more detailed ultrasonographic analysis is required, and for a global assessment of venous function, plethysmographic techniques are useful. Primary health care may contribute effectively to the care of venous leg ulcers.

Prospective study of safety, patient satisfaction and leg ulcer healing following saphenous and subfascial endoscopic perforator surgery

BACKGROUND

Subfascial endoscopic perforator surgery (SEPS) is a minimally invasive alternative to conventional techniques for incompetent calf perforators. Although SEPS has been performed for more than a decade, limited and insufficient data have been published regarding its safety, patient satisfaction and results.

METHODS

A prospective follow-up was undertaken of consecutive SEPS operations on 149 legs, performed in 138 patients: 67 legs with ulceration, 34 with skin changes and 48 with varicose veins. Conventional saphenous vein surgery was performed, when indicated, together with the SEPS procedure. Follow-up was performed after 1 week and later by postal questionnaire to assess long-term morbidity, late complications and patient satisfaction. Patients with ulcers were followed continuously.

RESULTS

Most operations (n = 107) were performed as day-case surgery. Combined saphenous vein surgery was performed in 89 per cent. No serious complications occurred: wound infection in 7 per cent; severe postoperative pain in 9 per cent; delayed wound healing in 15 per cent. After a median follow-up of 7 (1-31) months, 91 per cent of patients were satisfied. After a median of 32 (14-57) months, ulcer healing had occurred in 30 of 36 patients with open ulceration at the time of operation.

CONCLUSION

SEPS is a safe procedure, suitable for day-case surgery. Patients are generally satisfied with the outcome and the results of leg ulcer healing are promising.

Long-term prognosis for patients with chronic leg ulcers: a prospective cohort study

OBJECTIVES

To assess the long-term prognosis of leg ulcers.

DESIGN

A 5 year prospective cohort study.

MATERIALS

A random sample of 382 patients with open leg ulcers (foot ulcers included) treated in the community.

METHODS

Interim analyses were made at 15 months (arterial ulcers) and at 20 months (varicose ulcers). Long-term healing was assessed at 54 months by a postal questionnaire. Five year survival was assessed by official population registries.

RESULTS

At 54 months 212 patients (55%) were still alive, of whom 124 (58%) had healed their ulcers, 80 (38%) had open ulcers and eight (4%) were amputated. The healing was worst for patients with venous ulcers, only 44% had healed their original ulcers without recurrence. The 5 year survival was 52%, significantly lower than for age- and sex-matched controls (68%) (p = 0.0002). Patients with venous ulcers had a survival not significantly different from controls and patients with arterial or other aetiologies had a doubled risk of death. Diabetic patients had a lower survival than non-diabetics (p < 0.05) and controls (p < 0.0001), but the healing prognosis was not significantly different.

CONCLUSION

Only patients with non-venous ulcers have a higher mortality than expected. The long-term healing prognosis for leg ulcer patients is poor and worst for patients with venous ulcers.

The prevalence of chronic lower-limb ulceration has been underestimated: results of a validated population questionnaire

A validated population questionnaire was used to survey 12,000 randomly selected inhabitants, aged 50-89 years, in two defined regions of Sweden. The sample included 7 per cent of the total population in the age interval. Overall response rate was 91 per cent. Open ulcers were reported by 306 subjects and 143 (47 per cent) agreed to be examined. The false-positive response rate was high (43 per cent). The observed point prevalence of open leg ulcers was 0.63 (95 per cent confidence interval 0.54-0.72) per cent of the total population. The overall prevalence of leg ulcer history (open plus healed) in the population was estimated to be around 2 per cent and the ratio of open: previous ulcers was 1:2. This study shows a point prevalence more than double that expected, indicating a high rate of self treatment. Assessments of leg ulcer prevalence through the health care system, without knowledge of the rate of self care, measure only the workload of health care professionals. The problem of leg ulcers has generally been underestimated.

Venous and non-venous leg ulcers: clinical history and appearance in a population study

In a defined Swedish population of 270,800, all patients with current chronic leg ulcers (827) were identified and a random sample of 382 studied in detail. Ulcers of primarily venous cause comprised 54 per cent of the total, giving a point prevalence of 0.16 per cent (95 per cent confidence interval 0.15-0.18 per cent). Half of all patients experienced their first ulcer episode before the age of 65 years, a greater proportion (61 per cent, P < 0.0001) in the subgroup with venous ulcers. The median duration of ulcer diathesis was significantly longer in patients with venous than in those with non-venous lesions (13.4 versus 2.5 years, P < 0.001). About half the patients with venous and non-venous ulcers had had their current lesion for longer than 1 year. Venous ulcers were more often recurrent than those of non-venous type (72 versus 45 per cent of patients, P < 0.0001). Patients with venous ulcers had a significantly higher body mass index (P < 0.001). The number of dressing changes performed per week was 1100 per 100,000 population. The predictive value of 'classical' clinical indicators of venous ulcer did not exceed 0.76. To increase the accuracy of diagnosis of venous ulcer, clinical examination should be combined with non-invasive 'objective' haemodynamic assessment of the venous circulation.

High prevalence of diabetes in chronic leg ulcer patients: a cross-sectional population study

In a cross-sectional survey, designed to detect all patients with current chronic leg ulcers, 27% of the patients had diabetes mellitus. The outcome for the 104 examined diabetic patients has been evaluated and compared with the 278 nondiabetic patients. The purpose was to establish the prevalence of leg ulcers among diabetic patients and to assess potential causes. The point prevalence was calculated by extrapolating the leg ulcer frequency to the total diabetic population in the studied area. The point prevalence for active leg ulcers (including foot ulcers) in diabetic patients was 3.5% (95% CI 2.8-4.2). Ulcers above the malleoli were almost as common as foot ulcers. Peripheral vascular disease was present in 67% of all ulcerated legs in patients with diabetes compared to 42% in nondiabetic patients (p < 0.001). In 72% of foot ulcers in diabetic patients arterial impairment was judged to be a contributing aetiological factor and in nondiabetic patients 45% (p < 0.001). Ulcers solely attributed to possible neuropathy were less common (15%). Ulcers with multifactorial causes were common above the malleoli. This survey has given the size of the problem and indicates macroangiopathy to be the dominating factor responsible for slow or nonhealing ulcers in diabetic patients. Objective assessment of arterial circulation is mandatory and signs of arterial impairment require consultation with a vascular surgeon.

Leg ulcer etiology--a cross sectional population study

Three hundred eighty-two patients with active leg ulcers were clinically examined after random selection out of a population of 827 patients identified within a previous cross-sectional population survey. Bidirectional Doppler ultrasonography was used for objective assessment of arterial and venous circulation. The purpose was to register causative factors and the etiologic spectrum. Venous insufficiency was present in 332 (72%) of 463 legs with active ulceration; deep insufficiency occurred in 176 (38%), and purely superficial insufficiency was present in 156 (34%). Ankle/brachial index was 0.9 or less in 185 (40%) of ulcerated legs. Venous insufficiency was the dominating causative factor in 250 legs (54%), of which 60% was the result of deep venous insufficiency. Arterial insufficiency was judged to be the possible dominating factor in 12%, and 6% showed clearly ischemic ulcers. Mixed ulcers with combined arterial and venous insufficiency were found to be common as were patients with diabetes and arterial impairment. In 10% of the legs a multifactorial origin was present, and in 10% no venous or arterial impairment was detectable. Thus after classification of causes 40% of all ulcerated legs showed potentially surgically curable circulatory disturbances. It is necessary to objectively assess all patients with chronic leg ulcers to be able to detect patients with potentially surgically curable disease.

Chronic leg ulcers: an underestimated problem in primary health care among elderly patients

STUDY OBJECTIVE

The aim was to establish leg ulcer point prevalence, basal patient characteristics, and level of caretaking.

DESIGN

The study was a postal cross sectional survey. The validity was ensured by examining a randomly selected sample of reported patients. Responding health care officials were asked to report all patients with an open wound below knee (including foot ulcer) which did not heal or was supposed to heal within a six week period after onset of ulceration. Response rate was 92%.

SETTING

Inpatient and outpatient care in hospitals, community health care, and private nursing homes within Skaraborg county, with a population of 270,800.

PARTICIPANTS

827 individual patients were found with active leg ulcers, 526 women and 301 men.

MEASUREMENTS AND MAIN RESULTS

Age adjusted sex ratio of ulcer patients was 1:1.4 (M:F). The median age was 78 years for women and 76 for men; 700 patients (85%) were older than 64 years. The point prevalence for active leg ulcers was 3.0/1000 total population. District nurses provided care for 680 patients (82%), 106 (13%) were in hospital care, and 41 (5%) were managed by outpatient departments.

CONCLUSIONS

There has been an underestimation of the leg ulcer problem among elderly patients, especially men. With an expected increasing number of elderly people it is important that this problem is recognised and measures taken to improve the primary care of these patients.