Cost and effectiveness of laser with phlebectomies compared with foam sclerotherapy in superficial venous insufficiency. Early results of a randomised controlled trial

OBJECTIVES

Quantify endovenous laser ablation (EVLA) with concurrent phlebectomies and ultrasound-guided foam sclerotherapy (UGFS) in cost and effectiveness at 3 weeks and 3 months.

DESIGN

Single-centre, prospective, randomised controlled trial.

PATIENTS

One hundred patients (100 legs), C(2-6), age 21-78, M:F 42:58, with primary varicose veins received either EVLA under local anaesthetic or UGFS.

METHODS

Assessments included duplex, Aberdeen varicose vein questionnaire (AVVQ), venous clinical severity score (VCSS), venous filling index (VFI), visual analogue 7-day pain score and analgesia requirements. Additional treatments with UGFS were performed, if required. Micro-costing, using individually timed treatments, was based on consumables, staff pay and overheads.

RESULTS

Changes in AVVQ, VCSS and VFI values (3 months) did not demonstrate any significant difference between groups. At 3 months, the above-knee GSV occlusion rate (without co-existing reflux) was not significantly different between the groups (74% vs 69%; EVLA vs UGFS; P = .596). Of the 9 haemodynamic failures in each group, 7 EVLA patients and 4 UGFS patients had co-existing cross-sectional above-knee GSV occlusion at some point. However, UGFS significantly outperformed EVLA in cost, treatment duration, pain, analgesia requirements and recovery.

CONCLUSIONS

UGFS is 3.15 times less expensive than EVLA (£230.24 vs £724.72) with comparable effectiveness but 56% (versus 6%) required additional foam (ISRCTN:03080206).

Magnetic resonance venous velocity mapping during intermittent pneumatic compression of the calf and foot

Objective

Assessment and optimization of intermittent pneumatic compression (IPC) devices for prophylaxis of deep vein thrombosis has previously used duplex ultrasound. The aim was to investigate novel magnetic resonance (MR) venous velocity mapping (VM) for IPC research and development.

Methods

Twelve normal subjects were scanned in the supine position using realtime MR VM with sequential foot and calf IPC (120 mmHg) at 1.5 T. Measurements were taken in the popliteal vein at baseline using both cuffs and each cuff individually recording 60 seconds continuously. Temporal resolution was 310 ms per independent image, at 1 ×1 mm spatial resolution.

Results

Peak velocity ( Vp) measurements: baseline, Vp = 2.1 cm/second (range = 1.1–3.5); using both compression cuffs, Vp = 41.5 cm/second (18.0–58.1); calf cuff alone, Vp = 40.6 cm/second (18.1–62.2); foot cuff alone, Vp = 7.9 cm/second (4.2–15.3). Flow volume measurements per compression cycle ( F): baseline, F = 2.3 cm3 (0.5–11.4); both compression cuffs, F = 7.1 cm3 (2.5–24.6); calf cuff only, F = 7.1 cm3 (2.4–24.5); foot cuff only, F = 2.6 cm3 (0.9–10.7). The foot cuff contribution was insignificant when combined with the calf cuff ( P < 0.01). The MR venous VM results were similar to those reported elsewhere using ultrasound.

Conclusion

This novel technique for MR venous VM can measure the realtime variations in venous blood flow during IPC.

Can combined (mechanical and pharmacological) modalities prevent fatal VTE?

AIM

The aim of this paper was to perform a systemic review and meta-analysis of the efficacy of combined modalities (intermittent pneumatic leg compression and pharmacological prophylaxis, treatment group) against single modalities alone (control group) in preventing pulmonary embolism (PE), including fatal PE and deep-vein thrombosis (DVT) in high-risk patients.

METHODS

Databases searched included the Cochrane Central Register of Controlled Trials, the Specialized Register of the Peripheral Vascular Diseases Group, MEDLINE and EMBASE.

RESULTS

Seventeen studies, six of them randomized controlled trials (RCTs), which enrolled a total of 9998 patients in a variety of specialties were identified. Sixteen of the included studies evaluated the role of combined modalities on the incidence of symptomatic PE. These showed a reduction in symptomatic PE from 2.83% (122/4313) in the control group to 0.86% (33/3838) in the treatment group. Odds ratio was 0.34, 95% Confidence interval (CI) 0.23 to 0.50. Fatal PE was reduced from 0.56% (11/1972) in the control group to 0.07% (1/1377) in the treatment group (results were available in 10 studies). Odds ratio was 0.37 (95% CI; 0.09 to 1.48). Fourteen studies investigated the role of combined modalities on the incidence of DVT. These showed a reduction in DVT from 6.18% (200/3238) in the control group to 2.05% (63/3074) in the treatment group. Odds ratio was 0.31, 95% CI 0.23 to 0.43.

CONCLUSION

Combined prophylactic modalities decrease significantly the incidence of PE and DVT, compared to single modalities, but the reduction seen in fatal PE did not reach statistical significance. Further research on the role of combined modalities in reducing DVT and PE is necessary.

Introduction to the biomechanics of carotid plaque pathogenesis and rupture: review of the clinical evidence

The management of patients with asymptomatic carotid disease is currently under debate and new methods are warranted for better risk stratification. The role of the biomechanical properties of the atherosclerotic arterial wall together with the effect of different stress types in plaque destabilisation has only been recently investigated. PubMed and Scopus databases were reviewed. There is preliminary clinical evidence demonstrating that the analysis of the combined effect of the various types of biomechanical stress acting on the carotid plaque may help us to identify the vulnerable plaque. At present, MRI and two-dimensional ultrasound are combined with fluid-structure interaction techniques to produce maps of the stress variation within the carotid wall, with increased cost and complexity. Stress wall analysis can be a useful tool for carotid plaque evaluation; however, further research and a multidisciplinary approach are deemed as necessary for further development in this direction.

The efficacy of a new stimulation technology to increase venous flow and prevent venous stasis

OBJECTIVES

Electrical stimulation of calf muscles has been shown to be effective in prevention of DVT. The aim was to determine: (a) dependence of venous blood velocity and ejected volume on the rates of stimulated calf contractions: (b) clinical factors affecting efficacy in healthy individuals.

METHODS

The maximum intensity stimulus tolerated was applied to calves of 24 volunteers. In popliteal veins, peak systolic velocities (PSV), ejected volume per individual stimulus (stroke volume SV) and ejected total volume flow per minute (TVF) of expelled blood were determined using ultrasound. Stimulation rates from 2 to 120 beats per minute (bpm) were applied.

RESULTS

Mean baseline popliteal PSV was 10 cm/s. For stimulation rates between 2 and 8 bpm, the PSV was 10 times higher and reached 96-105 cm/s. Stroke volume (SV) per individual stimulus decreased in a similar fashion. With increasing rates of stimulation the TVF increased by a factor of 12 times (from 20 ml/min to 240 ml/min).

CONCLUSION

Electrical stimulation is an effective method of activating the calf muscle pump. Enhancements of popliteal blood velocity and volume flow are key factors in the prevention of venous stasis and DVT. Further studies are justified to determine the stimulation rates in those with a compromised venous system.

Debranching of the aorta produces thrombosis of the false lumen in selected cases of chronic type A aortic dissection

Patent false lumen of the descending aorta is related to poor prognosis in patients who undergo surgery for acute type A aortic dissection. We describe a patient with chronic type A aortic dissection and a patent dilated false lumen that was successfully thrombosed following an ilio-renal bypass. In patients with chronic aortic dissection and a single intimal tear on contrast spiral CT, debranching of arteries of the infra-diaphragmatic aorta supplied by the false lumen and reimplantation of these vessels may produce complete thrombosis of the false lumen. This outcome can spare such patients from extensive aortic replacement or endografts.

Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thrombo-embolism in high-risk patients

BACKGROUND

It has been suggested that combined modalities (methods of treatment) are more effective than single modalities in preventing venous thrombo-embolism (defined as deep vein thrombosis and pulmonary embolism, or both) in high-risk patients.

OBJECTIVES

To assess the efficacy of intermittent pneumatic leg compression combined with pharmacological prophylaxis versus single modalities in preventing venous thrombo-embolism in high-risk patients.

SEARCH STRATEGY

The Cochrane Peripheral Vascular Diseases (PVD) Group searched the reference lists of their Specialised Register (last searched 17 July 2007) and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched The Cochrane Library 2008, issue 3) for relevant articles to identify additional trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or controlled clinical trials (CCTs) of combined intermittent pneumatic leg compression and pharmacological interventions used to prevent venous thrombo-embolism in high-risk patients.

DATA COLLECTION AND ANALYSIS

Data extraction was undertaken independently by two review authors using data extraction sheets.

Comparison of three intermittent pneumatic compression systems in patients with varicose veins: a hemodynamic study

AIM

Previous studies have demonstrated the hemodynamic impact of sequential leg compression, compared to uniform compression. The aim of this study was to compare the hemodynamic effectiveness of three compression devices: 1) circumferential sequential gradient compression (CSG); 2) a posterior uniform compression device (PU) and a posterior sequential rapid gradient inflation device (PSR).

METHODS

DESIGN OF THE STUDY

open, controlled trial. Thigh length sleeves were tested in 12 patients with primary bilateral varicose veins.

INTERVENTIONS

the three devices were tested in the semirecumbent position.

MAIN OUTCOME MEASURES

augmented flow velocity and volume flow, including the total and peak volume of blood expelled per hour during compression, were measured using duplex scanning. Refilling time was determined from velocity recordings of the common femoral vein. All values were expressed as median and interquartile range with P values obtained using the Mann-Whitney U-test.

RESULTS

Compared to the median baseline flow, all three devices increased flow during compression by 2.5-3 times (P<0.0001). The cycles per hour for the three devices CSG, PSR and PU were 78 (70-88), 60 and 60, respectively; the duplex effective compression time was 11, 12 and 6 s, respectively; single cycle volume expelled during compression was 105, 85 and 45 mL (P<0.005), respectively; the total volume expelled per hour was 7 800, 5 200 (P<0.028) and 3 300 (P<0.005) mL/hr, respectively; peak velocity increased (P<0.001) from baseline of 12 cm/s to 38 cm/s for the CSG, 33 cm/s for the PU and to 68 cm/s for the PSR.

CONCLUSION

The highest volume expelled per hour during compression was observed with the CSG and the lowest with the PSR. This was due to increased volume per cycle and more compression cycles over time, because of the CSG device's sensing of refill time. Although the peak velocity with the PSR was high, it was associated with reduced expelled volume, because of its short compression period. The PU occupied an intermediate position. The relative effectiveness of the three devices in deep vein thrombosis prevention should be tested in future studies.

Immediate Hemodynamic Effect of the Additional Use of the SCD EXPRESS™ Compression System in Patients with Venous Ulcers Treated with the Four-layer Compression Bandaging System

OBJECTIVES

To test the hypothesis that the SCD EXPRESS intermittent pneumatic compression applied in combination with a four-layer bandage in patients with venous ulcers increases popliteal vein volume flow and velocity.

DESIGN

Twenty limbs of 18 patients with venous leg ulcers were studied, median age 76 years. The Total Volume Flow (TVF) and the Peak Systolic Velocity (PSV) were recorded in the popliteal vein using duplex ultrasonography. Measurements were made (i) without bandage, (ii) with four layer bandage and (iii) following the application of the SCD Compression System on top of a four-layer bandage for at least 15 minutes.

RESULTS

The median VCSS was 17 (range, 12-22) while the median VSDS for reflux was 4.5 (range, 1-7.5). The median TVF was 71 mL/min (inter-quartile range 57-101) without bandage, 112 (IQR 89-148) with four-layer bandage and 291 (IQR 241-392) with the addition of the SCD System (P<.001, Wilcoxon signed ranks test). The median PSV was 8.4 cm/sec (IQR 6.8-14) without bandage, 13 (9.0-19) with four-layer bandage and 27 (21-31) with the addition of the SCD System (P<.001, Wilcoxon signed ranks test). Both TVF and PSV increased slightly with the addition of the four-layer bandage. However, with the addition of the SCD System these parameters increased three fold.

CONCLUSIONS

The SCD EXPRESS Compression System accelerates venous flow in the legs of patients with venous ulcers already treated with a four-layer bandage. The combination of four-layer compression with the SCD System on healing venous ulcers needs to be tested by a clinical effectiveness study.

Texture Analysis of Ultrasonic Images of Symptomatic Carotid Plaques can Identify Those Plaques Associated with Ipsilateral Embolic Brain Infarction

OBJECTIVES

The aim of our study was to determine the association between objective, computerised texture analysis of carotid plaque ultrasonic images and embolic CT-brain infarction in patients presenting with hemispheric neurological symptoms.

DESIGN

Cross-sectional study in patients with 50%-99% (ECST) carotid stenosis.

PATIENTS AND METHODS

Carotid plaque ultrasonic images (n=54, 26 with TIAs and 28 with stroke) obtained during carotid ultrasound were normalised and standardised for resolution and subsequently assessed visually for the presence of discrete echogenic or juxtaluminal echolucent components and overall echogenicity (plaque type). Using computer software, 51 histogram/textural features of the plaque outlines were calculated. Factor analysis was subsequently applied to eliminate redundant variables. Small cortical, large cortical and discrete subcortical infarcts on CT-brain scan were considered as being embolic.

RESULTS

Twenty-five cases (46%) had embolic infarcts. On logistic regression, grey-scale median (GSM), a measure of echolucency, spatial grey level dependence matrices (SGLDM) correlation and SGLDM information measure of correlation-1, measures of homogeneity were significant (p<0.05), but not grey level runlength statistics (RUNL) Run Percentage (RP), stenosis severity, type of symptoms or echolucent juxtaluminal components. Using ROC curves methodology, SGLDM information measure of correlation-1 improved the value of GSM in distinguishing embolic from non-embolic CT-brain infarction.

CONCLUSION

Computerised texture analysis of ultrasonic images of symptomatic carotid plaques can identify those that are associated with brain infarction, improving the results achieved by GSM alone. This methodology could be applied to prospective natural history studies of symptomatic patients not operated on or randomised trials of patients undergoing carotid angioplasty and stenting in order to identify high-risk subgroups for cerebral infarction.

Comparison of two intermittent pneumatic compression systems. A hemodynamic study

AIM

Sequential leg compression has been previously shown to be superior to uniform compression. The aim of our study was to compare the hemodynamic effectiveness of the portable sequential compression device (SCD Express Compression System, Tyco Healthcare Group LP, Mansfield, MA, USA) with a rapid inflation device (VenaFlow, Aircast, Inc, Summit, NJ, USA). The former, by sensing venous refill time, commences compression when the calf veins are refilled.

METHODS

The two devices were tested in 12 normal volunteers in the semirecumbent position using duplex ultrasound. Baseline and augmented flow velocity and volume flow were measured at the level of the common femoral vein, above the saphenofemoral junction. Refilling time was determined from velocity recordings of the common femoral vein. Total and peak volume of blood expelled per hour during compression were calculated using flow data and the individual cycling rate.

RESULTS

Both devices increased venous flow velocity, up to 3.8 times the baseline (all P<0.001). Refill time of the rapid inflation device was shorter in comparison with the sequential compression device (15+/-2.2 vs 25+/-4 s; P<0.001), suggesting incomplete vein evacuation. The sequential compression device, by augmenting flow throughout a significantly longer compression period per cycle (10.9 s vs 6.3 s), expelled significantly more venous blood (121+/-68 vs 81+/-63 mL; P<0.001). Similarly, the total volume of blood expelled per hour with the sequential compression device was 100% higher than the rapid inflation device (9685+/-5426 vs 4853+/-3658 mL; P<0.001). Although peak velocity enhancement was higher with the rapid inflation device, flow augmentation (a product of average blood flow velocity) was comparable (669+/-367 vs 771+/-574 cm/s; P=0.223) with the sequential compression device, mainly because the rapid inflation device failed to maintain flow enhancement beyond the initial flow surge.

CONCLUSIONS

Sequential compression showed hemodynamic superiority compared to a rapid inflation device. This was enhanced further by the sensing of refill time, which resulted in more compression cycles over time. The relative efficacy of the two devices in deep vein thrombosis prevention should be tested in future studies.

Ultrasound-guided foam sclerotherapy combined with sapheno-femoral ligation compared to surgical treatment of varicose veins: early results of a randomised controlled trial

AIM

This study is a prospective randomised controlled trial comparing sapheno-femoral ligation, great saphenous stripping and multiple avulsions with sapheno-femoral ligation and ultrasound guided foam sclerotherapy to the saphenous vein. Primary end points were patient recovery period and quality of life and secondary end points frequency of complications on the two arms of the trial and the cost of the treatment.

MATERIAL AND METHOD

Sixty patients with primary varicose veins due to GSV incompetence and suitable for day case surgery were randomly allocated to undergo ultrasound-guided sclerotherapy with sapheno-femoral ligation under local anaesthesia (n=30) or sapheno-femoral ligation, stripping and multiple avulsions under general anaesthesia (n=30). The study protocol included history, physical examination, assignment of CEAP class and assessment venous clinical severity score (VCSS), completion of the aberdeen vein questionnaire (AVQ) and colour duplex ultrasound.

RESULTS

All treatments were completed as intended. Median time to return to normal activities was significantly reduced in the foam sclerotherapy group (2 days) compared to the surgical group (8 days) (p<0.001, Mann-Whitney). AVQ score was also significantly reduced at 3 months by 46% in the sclerotherapy group, and by 40% in the conventional surgery group (p<0.001, Wilcoxon). The time taken to complete treatment was shorter in the foam sclerotherapy plus SFJ ligation group: 45 vs. 85 min (p<0.001, Mann-Whitney). The overall cost of the procedure in the sclerotherapy group ( 672.97 pounds) was significantly less compared to conventional surgery ( 1120.64 pounds). At 3 weeks, there was no statistical difference in the complication rate between the two groups. At 3 months, median CEAP class dropped from four pre-operatively to one following treatment in both groups and the median VCSS score dropped from five to one in group one and from seven to three in group two (p<0.001, Wilcoxon test). In group one four patients (13%) had a recanalised vein which needed further sessions of foam sclerotherapy, resulting in a short-term closure rate of 87%.

CONCLUSION

Ultrasound guided sclerotherapy combined with sapheno-femoral ligation was less expensive, involved a shorter treatment time and resulted in more rapid recovery compared to sapheno-femoral ligation, saphenous stripping and phlebectomies.

Factors associated with mortality in patients with asymptomatic carotid stenosis: results from the ACSRS Study

AIM

This study determines the factors associated with mortality in patients with asymptomatic carotid stenosis.

METHODS

Patients (n=1,101) with asymptomatic internal carotid artery stenosis greater than 50% in relation to the bulb diameter were followed up for a period of 6 to 84 (median 38) months. Stenosis was graded using duplex scanning and expressed as a percentage of the carotid bulb diameter. Clinical and biochemical risk factors were recorded. The end-points were ipsilateral ischemic stroke, cardiovascular death and all cause mortality.

RESULTS

In a Cox multivariate analysis 6 factors emerged as independent predictors of risk. Age, male gender, cardiac failure, left ventricular hypertrophy on electrocardiogram (ECG) and myocardial ischemia on ECG were associated with increased risk. Antiplatelet therapy was associated with decreased risk. Based on these risk factors a high-risk group consisting of one third of the population with a 40% cumulative cardiovascular death rate and a 66% all cause death rate at 7 years could be identified. The remaining 2/3 consisted of a low-risk group with a 10% cumulative cardiovascular death rate and a 21% all cause death rate at 7 years (P<0.0001 compared to the high risk group). There was not any significant difference in the cumulative ipsilateral stroke rate, which was 12% in the low and 13% in the high cardiovascular risk group (Log Rank P>0.05).

CONCLUSIONS

The methodology and findings from the ACSRS natural history study need to be applied to randomized controlled trials on the value of carotid endarterectomy or stenting in patients with asymptomatic carotid stenosis. They may help refine the indications for intervention in patients with carotid endarterectomy.

Severity of Asymptomatic Carotid Stenosis and Risk of Ipsilateral Hemispheric Ischaemic Events: Results from the ACSRS Study

OBJECTIVES

This study determines the risk of ipsilateral ischaemic neurological events in relation to the degree of asymptomatic carotid stenosis and other risk factors.

METHODS

Patients (n=1115) with asymptomatic internal carotid artery (ICA) stenosis greater than 50% in relation to the bulb diameter were followed up for a period of 6-84 (mean 37.1) months. Stenosis was graded using duplex, and clinical and biochemical risk factors were recorded.

RESULTS

The relationship between ICA stenosis and event rate is linear when stenosis is expressed by the ECST method, but S-shaped if expressed by the NASCET method. In addition to the ECST grade of stenosis (RR 1.6; 95% CI 1.21-2.15), history of contralateral TIAs (RR 3.0; 95% CI 1.90-4.73) and creatinine in excess of 85 micromol/L (RR 2.1; 95% CI 1.23-3.65) were independent risk predictors. The combination of these three risk factors can identify a high-risk group (7.3% annual event rate and 4.3% annual stroke rate) and a low risk group (2.3% annual event rate and 0.7% annual stroke rate).

CONCLUSIONS

Linearity between ECST per cent stenosis and risk makes this method for grading stenosis more amenable to risk prediction without any transformation not only in clinical practice but also when multivariable analysis is to be used. Identification of additional risk factors provides a new approach to risk stratification and should help refine the indications for carotid endarterectomy.

Improvement of the Walking Ability in Intermittent Claudication due to Superficial Femoral Artery Occlusion with Supervised Exercise and Pneumatic Foot and Calf Compression: A Randomised Controlled Trial

OBJECTIVES

To compare the effect of unsupervised exercise, supervised exercise and intermittent pneumatic foot and calf compression (IPC) on the claudication distance, lower limb arterial haemodynamics and quality of life of patients with intermittent claudication.

METHODS

Thirty-four eligible patients with stable intermittent claudication were randomised to IPC (n = 13, 3h/d for 6 months), supervised exercise (n = 12, three hourly sessions/week for 6 months) or unsupervised exercise (n = 9). In each patient, initial claudication distance (ICD), absolute claudication distance (ACD), resting ankle brachial pressure index (ABPI), and resting hyperaemic calf arterial inflow were measured before, 6 weeks, 6 months and 1 year after randomisation. Quality of life was assessed with the short form (SF)-36, walking impairment (WIQ) and intermittent claudication questionnaires (ICQ).

RESULTS

Compared with unsupervised exercise, both IPC and supervised exercise, increased ICD and ACD, up to 2.83 times. IPC increased arterial inflow (p < 0.05 at 6 weeks) and ABPI. Supervised exercise decreased arterial inflow and increased ABPI (p < 0.05 at 6 months). Unsupervised exercise had no effect on arterial inflow or ABPI. IPC improved significantly the ICQ score and the speed score of the WIQ, while supervised exercise improved the WIQ claudication severity score. At 1 year clinical effectiveness of supervised exercise and IPC was largely preserved.

CONCLUSIONS

IPC, by augmenting leg perfusion, achieved improvement in walking distance comparable with supervised exercise. Long-term results in a larger number of patients will provide valuable information on the optimal treatment modality of intermittent claudication.

Antegrade revascularisation for chronic visceral ischaemia

There is no consensus of opinion on the best surgical approach for the management of chronic visceral ischaemia. The antegrade revascularisation has several advantages. It provides an excellent exposure of the supraceliac aorta, the option of originating the bypass from several areas of the distal thoracic and supraceliac aorta that is usually spared of atherosclerosis and the bypass is placed in the direction of normal blood flow (antegrade direction). The supraceliac aorta can be approached through an abdominal or a low thoracoabdominal extraperitoneal route. The results on several series indicate that it is a durable and effective technique.

Measuring the impact of venous leg ulcers on quality of life

OBJECTIVE

To identify health-related quality-of-life (HRQoL) issues in patients with venous leg ulcers, with the aim of generating items for a treatment outcome measure.

METHOD

Thirty-eight patients with venous leg ulcers were interviewed by a psychologist using a semi-structured guide; they also completed a HRQoL questionnaire (modified Skindex). Data from the questionnaire were examined to explore the impact of venous leg ulcers on patients' lives. Interview transcripts were analysed using qualitative methods to identify additional venous leg ulcer-specific HRQoL items.

RESULTS

Skindex scores indicated that older patients had worse HRQoL (p<0.05), as did those with pain and non-healing ulcers. Ulcer duration and size did not correlate with HRQoL. Interviews revealed the following effects of ulceration: pain (80.5%); itching (69.4%); altered appearance (66.7%); loss of sleep (66.6%); functional limitation (58.3%); and disappointment with treatment (50%). Based on the interview transcripts, items were generated and discussed with an expert panel, with a view to including them in a venous leg ulcer-specific HRQoL questionnaire.

CONCLUSION

Disease-specific HRQoL outcome measures should be considered when evaluating treatments for venous leg ulcers.