Impact of the calf perforators on the venous hemodynamics in primary varicose veins

The hemodynamic significance of the calf perforating veins continues to be the point of controversy. The conception that incompetent perforating veins cause hemodynamic disturbance and are responsible for the formation of leg ulceration has still many adherents prefering perforator surgery, whereas others reject any causal relation between large, incompetent perforators and severe forms of chronic venous insufficiency. In this study well documented facts concerning the impact of the calf perforators on the venous hemodynamics are reviewed. There is a bidirectional flow within calf perforators in healthy subjects enabling a quick equilibration of pressure changes produced during calf muscle contractions and relaxations, so that recordings of the mean pressure display identical values in superficial and deep veins of the lower leg, a feature typical of conjoined vessels. In cases with saphenous reflux, the bidirectional flow within calf perforators has a distinct inward vector directed to the deep veins; this inward component is the more pronounced, the larger the saphenous reflux is. Incompetent calf perforators do not cause ambulatory venous hypertension, exactly the opposite happens: the high hydrostatic pressure found in the quiet standing position drops significantly during ambulation, as soon as the saphenous reflux is interrupted. In primary varicose veins calf perforators can not become the source of reflux because they are situated at the lower pole of the ambulatory pressure gradient, which occurs between thigh and lower leg veins during ambulation. The size of the calf perforators is determined by the amount of saphenous reflux. When the saphenous reflux is abolished (e.g. by high ligation), the enlarged calf perforators diminish.

A systematic review of randomized controlled trials of wound dressings for chronic venous ulcer

OBJECTIVE

To determine whether more "modern" complex wound dressings further improve the healing of venous ulcers over that with simple wound dressings, we conducted a systematic review of randomized controlled trials (RCTs) of wound dressing trials that were published from October 1, 1997, through September 1, 2005.

METHODS

We searched MEDLINE, CINAHL, and the Cochrane Controlled Trials Registry Database to identify RCTs. Criteria for ultimate selection included treatment with compression and an objective outcome describing the proportion of wounds healed. Twenty RCTs were identified that satisfied these criteria and were classified into three wound dressing classes: semiocclusive/occlusive group (n = 8), growth factor group (n = 7), and human skin equivalent group (n = 5).

RESULTS

Assessment of study design quality for the 20 RCTs showed a low percentage (<49%) of RCTs that incorporated at least 3 of 7 indicators of trial quality, but it seemed better in the 5 RCTs that showed significance for ulcer healing; 4 of the studies used at least 6 of the 7 characteristics of adequate study design. Five (25%) of the 20 RCTs had a statistically significantly improved proportion of ulcers healed in the experimental dressing group over control values: zinc oxide paste bandage (79% vs 56%) and Tegasorb (59% vs 15%) in the semiocclusive/occlusive group and perilesional injection of granulocyte-macrophage colony-stimulating factor (57% vs 19%) and porcine collagen derived from small-intestine submucosa (Oasis; 55% vs 34%) in the growth factor group. In the sole significant RCT from the human skin equivalent group, Apligraf (63%) was superior to Tegapore (48%). Four of these five studies also showed an improved time to complete healing by Kaplan-Meier estimate.

CONCLUSIONS

Certain wound dressings can improve both the proportion of ulcers healed and the time to healing over that achieved with adequate compression and a simple wound dressing. The selection of a specific dressing, however, will depend on the dressing characteristics for ease of application, patient comfort, wound drainage absorption, and expense.

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.

Prognostic role of factor XIII gene variants in nonhealing venous leg ulcers

OBJECTIVE

Many factors impair healing of chronic venous ulcer (CVU), and many theories have been proposed to explain their pathogenesis. Coagulation factor XIII (FXIII) influences tissue regeneration and angiogenesis with effects on wound healing. Because FXIII properties depend upon its genetic variants, we investigated whether intragene polymorphisms may have modulating effects on the CVU area.

METHODS

The study included 121 patients with nonhealing CVUs (CEAP clinical class C6) that included 67% with primary chronic venous disease (CVD), 26% with post-thrombotic ulcers, and 7% with mixed ulcer origin. Polymerase chain reaction was used to genotype them for Val34Leu, Pro564Leu, and Tyr204Phe variants in the FXIII-A subunit gene and for His95Arg variant in the FXIII-B subunit gene. The same variants were analyzed in 102 controls, healthy subjects who were case-matched by age and gender.

RESULTS

Genotype distribution for all polymorphisms investigated was not significantly different between cases and controls. Conversely, our CVU cases had a mean ulcer area inversely related with the presence of both Leu34 and Leu564 alleles (ValVal, 12.3 +/- 22.4 cm2 vs LeuLeu, 3.9 +/- 2.6 cm2, P = .002; ProPro, 10.2 +/- 21.2 cm2 vs LeuLeu, 2.9 +/- 1.4 cm2, P = .002). In combined analysis, those cases who were wild-type for both variants (ValVal34/ProPro564) had a further increase in mean ulcer size compared with cases carrying both variants (Leu34/Leu564) (13.3 +/- 27.1 cm2 vs 5.2 +/- 5.6 cm2; P = .034).

CONCLUSIONS

No correlation exists between FXIII genotypes and the prevalence of chronic venous ulcers, thus demonstrating that FXIII polymorphisms have no role in ulcer development. In contrast, FXIII-gene variants, in particular the non-wild-type alleles Leu34 and Leu564, were associated with a smaller venous ulcer surface and might have favorable effects on reparative processes.

The silver-releasing foam dressing, Contreet Foam, promotes faster healing of critically colonised venous leg ulcers: a randomised, controlled trial

The study compared the effect of a sustained silver-release foam dressing (Contreet Foam) with a foam dressing (Allevyn Hydrocellular) without added silver in critically colonised venous leg ulcers with delayed healing. The study was a multicentre, open, randomised, controlled study lasting for 4 weeks. Ulcer area and healing were assessed weekly. Odour, maceration, absorption capacity and leakage were evaluated at dressing changes. All adverse events were recorded. One hundred and twenty-nine patients were included (Contreet Foam: 65, Allevyn Hydrocellular: 64). The two groups were comparable in all respects. After 4 weeks, there was a significantly greater reduction in ulcer area in the Contreet Foam group (45%) than in the Allevyn Hydrocellular group (25%). After 1 and 4 weeks, odour was present in significantly less of the ulcers in the Contreet Foam group (17% and 19%, respectively) compared with the Allevyn Hydrocellular group (47% and 39%, respectively) and at the final visit there were significantly fewer leakages in the Contreet Foam group (19%) compared with the Allevyn Hydrocellular group (49%). Also, less maceration was observed after 1 and 4 weeks in the Contreet Foam group (34% and 37%, respectively) compared with the Allevyn Hydrocellular group (55% and 48%, respectively). The occurrence and cause of adverse events were equally distributed between the study groups. The present study provides evidence of the superior performance of the silver-releasing dressing, Contreet Foam, compared with a traditional moist foam wound healing dressing in the treatment of critically colonised, chronic venous leg ulcers. The results of this randomised, controlled study suggest an important role of sustained silver-releasing dressings in the treatment of critically colonised chronic wounds.

A potential role of interferon-gamma in the pathogenesis of venous leg ulcers

Venous leg ulcer is the most severe expression of chronic venous insufficiency. Venous ulcerations are always associated with venous ambulatory hypertension, but the exact mechanism leading from pathological hemodynamics in venous circulation to the necrotic lesions in the skin still remains undiscovered. It has been shown that tissue injury in venous ulcer patients was induced by leukocytes. However, though infiltrating leukocytes have at their disposal a powerfully cytotoxic arsenal, it has not been discovered which molecular mechanisms may contribute to the skin damage. The search for this hypothetical factor responsible for the development of ulceration should be focused on mechanisms leading to apoptosis of keratinocytes, on pathogenesis of related dermatological pathologies, on other pathologies associated with epithelial lesions, and on mechanisms responsible for the expression of adhesion molecules. A thorough review of the literature, with special regard to cytokines, has revealed that proinflammatory cytokine--interferon-gamma (INFgamma)--could be a pivotal cytokine in the pathogenesis of venous ulceration. This cytokine, however, has not been investigated in venous leg ulcer patients before. INFgamma is a glycoprotein with numerous immunological and antiproliferative activities. The most important message from recent investigations is the fact that INFgamma seems to be the main mediator of keratinocyte apoptosis. INFgamma mediates also leukocyte chemotaxis, and enhances the expression of adhesion molecules involved in the pathophysiology of chronic venous insufficiency. Therapeutic injections of interferons can result in skin necrosis. If it were proven that INFgamma was responsible for the development of venous leg ulcers, this fact would have important clinical consequences. In such a case, anti-INFgamma agent could be used, either in the management of active ulceration, or in the prevention of recurrent ulcer.

Accelerated wound healing: multidisciplinary advances in the care of venous leg ulcers

The etiologies of venous leg ulcers have been well known for millennia, and yet there remains no simple solution to this very common problem. Achieving closure of venous leg ulcers is often a lengthy process that is further complicated by the presence of significant comorbidities. The authors present data on healing venous leg ulcers in a cohort of 231 patients, most of whom had 1 or more complicating factors. Our multidisciplinary and aggressive approach to healing venous leg ulcers is described and has resulted in an average healing time of 29 days, a significantly shorter duration of treatment than the reported average of 6 months.

Venous ulcer fibroblasts respond to basic fibroblast growth factor at the cell cycle protein level

Fibroblasts cultured from venous ulcers demonstrate phenotypic characteristics of cellular senescence including slow growth, altered morphology, upregulation of fibronectin, and increased senescence-associated beta-galactosidase activity. In senescent cells, arrest of cell replication is related to overexpression of p21 and underexpression of phosphorylated tumor-suppressor protein retinoblastoma (ppRb). The regulatory mechanisms for cell proliferation in venous ulcer fibroblasts are unknown. In this study, venous ulcer fibroblasts are examined for cell cycle protein expression and modulation by basic fibroblast growth factor (bFGF). Fibroblasts were isolated from the venous ulcer of the distal lower extremity (fb-D) of patients with chronic venous insufficiency. A control biopsy was obtained from the proximal ipsilateral thigh (fb-P). Paired cultures were plated at 100,000 cells/plate and the cells synchronized. After 24 hr, one culture set was treated with bFGF (20 ng/mL) and the other was kept in culture medium only (untreated). All cultures, treated and untreated, were lysed following 24 hr of incubation, and the lysate was used to perform immunoblot analysis for p21, ppRb, and cyclin D1. Immunoblot samples were standardized to protein content. In all patients analyzed (n = 4), at basal levels (untreated) fb-D demonstrated significant overexpression of p21 versus fb-P (p = 0.016). Treatment with bFGF resulted in significant downregulation of p21 levels for fb-D (p = 0.008) and fb-P (p = 0.037) compared to untreated fibroblasts. ppRb was underexpressed in fb-D versus fb-P (p = 0.069). Treatment with bFGF increased ppRb significantly in fb-D (p = 0.030) and in fb-P (p = 0.027) compared to untreated fibroblasts. No differences were observed in cyclin D1 with respect to basal levels in fb-P versus fb-D or in treated versus untreated groups. Venous ulcer fibroblasts show phenotypic similarity to senescent cells, with overexpression of p21 as well as down regulation of phosphorylated pRb. The aberrations seen in the cell cycle proteins in fb-D are similar to those seen in senescent cells; however, bFGF can modulate important cell cycle regulatory proteins, promoting a proliferative environment in fb-D that is not possible in a senescent cell. The role of bFGF may be useful in the clinical treatment of venous ulcer pathology.

Emerging new drugs for wound repair

Every year, millions of people experience burns, suffer from nonhealing wounds, or have acute wounds that become complicated by infection, dehiscence or problematic scarring. Effective wound treatment requires carefully considered interventions often requiring multiple clinic or hospital visits. The resulting costs of wound care are staggering, and more efficacious and cost-effective therapies are needed to decrease this burden. Unfortunately, the expenses and difficulties encountered in performing clinical trials have led to a relatively slow growth of new treatment options for the wound management. Research efforts attempting to examine wound pathophysiology have been hampered by the lack of an adequate chronic wound healing model, and the complexity of the wound healing cascade has limited attempts at pharmacological modification. As such, currently available wound healing therapies are only partially effective. Therefore, many new therapies are emerging that target various aspects of wound repair and the promise of new therapeutic interventions is on the immediate horizon.

A sociodemographic, clinical study of patients with venous ulcer

BACKGROUND

Venous ulcer is the most serious consequence of chronic venous insufficiency and is responsible for almost 70% of chronic leg ulcers. The main purpose of this research was to describe social, demographic and clinical characteristics of patients with venous ulcers and to identify some professional repercussions of this pathology.

SUBJECTS AND METHODS

We evaluated patients with a clinical picture compatible with venous ulcer. The sociodemographic characteristics of the patients, and the clinical characteristics and professional repercussions of the pathology were studied. We used the ankle-brachial index to identify associated arterial disease. The body mass index (BMI) was used for the classification of the nutritional condition of the patients.

RESULTS

A total of 120 patients were included in the study (90 females and 30 males; 80.8% White; 44.2% > 60 years old). Ninety-one per cent of the patients had been in education for less than 4 years, and 89.7% were on the poverty line. Thirty-five per cent were retired, 2.5% were receiving government help due to disease and 4.2% were unemployed. About 16% of patients were out of work due to the disease, and 49.2% presented some degree of disability in terms of work tasks. The ulcer area was less than 30 cm(2) in 69.1% of patients. The first ulcer episode occurred in 13.4 years on average, and 64.2% of patients had recurrent episodes. Females presented on average 5.65 pregnancies, and 75.4% of patients were overweight.

CONCLUSION

Venous ulcer occurred mainly in the low-income population, who presented with little formal education. Generally, the ulcers were present for a long time and were recurrent, with repercussions for the capabilities of patients to work.

Micronized diosmin (Detralex) for vein-related trophic ulcers: European experience

The paper presents a meta-analysis of 5 large European studies (N - 723) on the micronized diosmin administration to patients with venous trophic ulcers (CEAP class VI). With the use of evidence-based approach, it was shown that micronized diosmin has a statistically significant clinical effect on middle-sized trophic ulcers (5 - 10 cm(2)) that persisted for 6 - 12 months. The study concludes that polyvalent venotonics are an appropriate and valuable addition to complex therapy of complicated chronic venous insufficiency.

Leg ulcers: uncommon presentations

Uncommon presentations like vasculitis or other immunologic causes and malignancy account for about 1% to 2% of patients suffering from leg ulcers. We focus on such uncommon leg ulcers including: cutaneous vasculitis causing cutaneous ulceration, other immunologic or metabolic cutaneous lesions such as pyoderma gangrenosum and necrobiosis lipoidica, and ulcers based on neoplastic etiology. A short description on leg ulcers in the tropics is also included. The described uncommon presentations of leg ulcers are typically difficult to diagnose and treat; it is a specialist's job to take care of patients with these types of ulcers. Multidisciplinary specialized wound healing concepts integrated in the national health care system, as an accepted expert function, is the ideal way to organize the wound healing area. Such a system would result in an earlier diagnosis and more sufficient treatment for patients with uncommon presentations of leg ulcers.

[Venous leg ulcers: no improvement of wound healing with 685-nm low level laser therapy. Randomised, placebo-controlled, double-blind study]

INTRODUCTION

Venous leg ulcers (ulcera crurum venosa) are frequently seen in elderly patients. It has been suggested that low level laser irradiation has a biostimulative and wound healing effect; however, this has not yet been clinically verified by controlled studies.

STUDY DESIGN

The difference in size reduction of leg ulcers with and without low level laser or placebo laser treatment was measured in 44 patients randomised into two treatment groups (685-nm low level laser and placebo laser) or a control group which served to quantify the effect of laser application. All patients received standardized wound care.

OBJECTIVE

The aim of the study was to compare the effectiveness of low level laser irradiation with that of a placebo "light source". The size of the ulcers was planimetrically measured at baseline (day 1), at the end of therapy (day 28) and 2 months later (day 90). The difference in wound size was evaluated.

RESULTS

There were no statistically significant differences in reduction of wound size between the three groups, thus suggesting that low level laser light does not have any stimulatory effect on wound healing in ulcera crurum venosa.

Microcirculation Disturbances in Patients with Venous Ulcer before and after Healing as Assessed by Laser Doppler Flux-Metry

BACKGROUND

We studied whether a characteristic pattern of laser Doppler flux (LDF) could be identified in perimalleolar skin of patients with venous ulcer before and after ulcer healing.

METHODS

Nine subjects with venous ulcer that healed after conservative treatment in 1-6 months and nine healthy persons were included in the study. Microcirculation investigations of laser Doppler flux (LDF) were carried out before and after ulcer healing at rest, upon arterial occlusion, during thermal stimulation and during experimental venous hypertension.

RESULTS

Resting LDF expressed as median and range (in arbitrary perfusion units) was significantly higher in patients with venous ulcer in comparison to healthy subjects: 60.6 (40.2-156.5) vs. 9.2 (6.5-19.5), p=0.008. During thermal stimulation and during postischemic reactive hyperemia, absolute values of LDF were slightly but significantly higher in patients with venous ulcer than in healthy subjects, but indices of hyperemic reactivity were very low in patients (median postischemic LDF increase to 101.8 vs. 450.0% in healthy controls, p=0.008; and thermally induced LDF increase to 125.5 vs. 881.5% in healthy controls, p=0.008. Experimental venous hypertension (cuff pressure 40 and 70 mmHg, respectively) led to an equally pronounced relative reduction of LDF in healthy persons as in patients with venous ulcer before and after ulcer healing, but the absolute values of flow remained about six to seven times higher in patients when compared to healthy subjects. Hyperemic reactivity and venoarteriolar response did not change after ulcer healing.

CONCLUSIONS

Elevated basal LDF and preserved maximal LDF during reactive hyperemia were found in perimalleolar skin of patients with venous ulcers that eventually healed. The relative venoarteriolar response was preserved in spite of elevated absolute values of LDF during experimental venous hypertension. These hemodynamic characteristics remained unchanged after epithelialization of venous ulcers.

Does the use of low-level laser influence wound healing in chronic venous leg ulcers?

OBJECTIVE

Venous leg ulcer treatment often requires months or years of regular wound care by trained staff. It has been suggested that low-level laser irradiation has a biostimulative and wound healing effect, but this has not been clinically verified by controlled studies. This study aimed to compare the effectiveness of low-level laser irradiation with that of a placebo 'light source'.

METHOD

Forty-four patients were assigned to two treatment groups (laser and placebo) or a third group (standardised treatment only) to quantify the effect of the laser therapy. Patients in all three groups received standardised wound care (disinfection, a hydrofibre dressing and compression bandaging). Ulcer size was measured at baseline (day 1), at the end of therapy (day 28) and then two months later (day 90). The relative difference in wound size was evaluated.

RESULTS

The difference in the reduction in wound size was not statistically significant in all three groups. A positive effect of using the non-laser device (placebo effect) was demonstrated in some patients.

CONCLUSION

These study results suggest that low-level laser does not stimulate wound healing in venous leg ulcers. Further controlled studies are needed to clarify the efficacy of low-level laser treatment as a wound-healing stimulant.