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Oo MZ, Siribumrungwong B, Orrapin S, Sermsathanasawadi N, Papanas N, Rerkasem K. Comprehensive Management of Venous Leg Ulcers: Evidence-Based Strategies and Treatment Options. INT J LOW EXTR WOUND 2025; 24:257-259. [PMID: 40232282 DOI: 10.1177/15347346251333202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2025]
Affiliation(s)
- Myo Zin Oo
- Environmental-Occupational Health Sciences and Non Communicable Diseases Research Centre, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Boonying Siribumrungwong
- Vascular Surgery Division, Department of Surgery, Faculty of Medicine, Thammasat University, Thammasat University Hospital, Pathum Thani, Thailand
| | - Saritphat Orrapin
- Vascular Surgery Division, Department of Surgery, Faculty of Medicine, Thammasat University, Thammasat University Hospital, Pathum Thani, Thailand
| | - Nuttawut Sermsathanasawadi
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nikolaos Papanas
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Kittipan Rerkasem
- Environmental-Occupational Health Sciences and Non Communicable Diseases Research Centre, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
- Clinical Surgical Research Center, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Gloviczki ML, Kakkos SK, Urbanek T, Chuback J, Nicolaides A. "The Role of Venoactive Compounds in the Treatment of Chronic Venous Disease". J Vasc Surg Venous Lymphat Disord 2025:102258. [PMID: 40348378 DOI: 10.1016/j.jvsv.2025.102258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2025] [Revised: 04/29/2025] [Accepted: 05/01/2025] [Indexed: 05/14/2025]
Abstract
INTRODUCTION Chronic venous disease (CVD) is a major global health issue, affecting millions of people and contributing to significant morbidity and economic strain. The condition's pathophysiology is complex, involving both mechanical and biochemical processes that lead to venous reflux, obstruction, and chronic inflammation. OBJECTIVE This review will focus on the role of venoactive compounds (VACs), also known as venoactive drugs in Europe and other parts of the world, in managing CVD. The aim is to review the scientific evidence and to define the role of VACs within the comprehensive treatment algorithm for CVD, alongside established and well adopted interventional therapies and non-interventional therapies such as compression. METHODS The review of the scientific evidence was done on VACs mechanism of action and efficacy in alleviating CVD symptoms, reducing swelling or venous edema and improving healing of venous leg ulcers. Whenever available, systematic reviews, meta-analyses and randomized controlled trials were used. The quality of evidence assessment followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology with A = high, B = moderate, and C = low to very low quality. RESULTS Venoactive drugs or compounds share similar effects, such as sealing the endothelial barrier, enhancing lymphatic drainage, reducing edema, improving venous tone, inhibiting leukocyte adhesion to vein walls/valves and inflammatory mediator release, lowering blood viscosity, and promoting red blood cell flexibility. Scientific evidence on the VACs effectiveness on CVD symptoms (pain, cramps, heaviness) and swelling or edema have shown some variability. Micronized purified flavonoid fraction (MPFF) and ruscus extract combined with hesperidin methyl chalcone and ascorbic acid had the highest, mostly level A, quality of evidence. In venous leg ulcers MPFF, sulodexide and pentoxifylline were the most effective adjunctive treatment, with evidence level A. CONCLUSIONS The existing scientific evidence provides a strong rationale for incorporating VACs into a comprehensive treatment plan for CVD, alongside established interventional therapies and non-interventional approaches like compression, to optimize patient outcomes and improve quality of life.
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Affiliation(s)
- Monika Lecomte Gloviczki
- Research Fellow Emeritus, Department of Internal Medicine and Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota; Vascular Science & Art, LLC, Scottsdale, Arizona, US.
| | - Stavros K Kakkos
- Professor and Chair, Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Tomasz Urbanek
- Department of General Surgery, Vascular Surgery, Angiology and Phlebology, Medical University of Silesia, Katowice, Poland
| | | | - Andrew Nicolaides
- Vascular Screening and Diagnostic Centre, Nicosia, Emeritus Professor of Vascular Surgery, Imperial College, London, UKHonorary Professor Vascular Surgery, University of Nicosia Medical School, Nicosia, Cyprus
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Buso G, Santini P, Ghirardini F, Cannavacciuolo F, Visonà A, Zalunardo B, Pola R, Martini R. The role of Bromelain and Liposomal Vitamin C in the treatment of chronic venous disease. VASA 2025; 54:164-176. [PMID: 39967325 DOI: 10.1024/0301-1526/a001184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2025]
Abstract
Chronic venous disease (CVD) is a prevalent condition leading to significant morbidity and affecting quality of life. Among conservative treatment strategies, venoactive drugs are often recommended by major guidelines for the management of CVD. Bromelain and vitamin C are now emerging as promising options in the management of several chronic diseases owing to their anti-inflammatory, immunoregulatory, and antioxidant properties, though evidence remains scarce in this setting. This systematic review of the literature, endorsed by the Italian Society of Angiology and Vascular Medicine (Societa Italiana di Angiologia e Patologia Vascolare, SIAPAV), aims to evaluate the efficacy and safety of these compounds in the treatment of CVD. A comprehensive search yielded nine studies, two on bromelain and seven on vitamin C. No studies have evaluated the effects of bromelain and vitamin C alone or in combination, whereas both molecules were administered in combination with other nutritional supplements. Overall, CVD-related symptoms and edema seem to improve with dietary supplement containing these two compounds, with no major safety issues reported. Bromelain and vitamin C may thus represent attractive options in the management of patients with symptomatic CVD and/or presence of venous edema, provided optimal conservative treatment is in place. Dedicated clinical studies are needed to clarify the efficacy and safety of a combination of these molecules in CVD management.
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Affiliation(s)
- Giacomo Buso
- Department of Clinical and Experimental Sciences, Division of Internal Medicine, ASST Spedali Civili Brescia, University of Brescia, Italy
- University of Lausanne, Switzerland
| | - Paolo Santini
- UOSD Percorso Trombosi, Dipartimento di Scienze dell'Invecchiamento, Ortopediche e Reumatologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | | | | | - Adriana Visonà
- ORAS Ospedale Riabilitativo di Alta Specializzazione di Motta di Livenza, Treviso, Italy
| | | | - Roberto Pola
- UOSD Percorso Trombosi, Dipartimento di Scienze dell'Invecchiamento, Ortopediche e Reumatologiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Romeo Martini
- Angiologia AULSS 1 Dolomiti, San Martino Hospital, Belluno, Italy
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Gloviczki ML, Stoughton J, Puggioni A, Gloviczki P, Raffetto JD. Utility of venoactive compounds in post-thrombotic syndrome: A systematic review. J Vasc Surg Venous Lymphat Disord 2025; 13:102228. [PMID: 40101859 PMCID: PMC12018987 DOI: 10.1016/j.jvsv.2025.102228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2024] [Revised: 01/31/2025] [Accepted: 03/09/2025] [Indexed: 03/20/2025]
Abstract
BACKGROUND Post-thrombotic syndrome (PTS) has been highly prevalent; over 50% of the patients develop PTS after lower extremity acute deep vein thrombosis. Venoactive compounds (VACs) have been recommended for decades for patients with chronic venous insufficiency, including PTS. The objective of our study was to perform a systematic review to determine the quality of evidence on the utility of VACs for both prevention and treatment of PTS. METHODS A systematic review was conducted to search the literature between January 1, 1980, and July 14, 2023, for venoactive drugs or medications, deep vein thrombosis, and PTS using PubMed, MEDLINE, life science journals, and the Cochrane Library. Only randomized controlled trials (RCTs) published in English were included in this review. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the revised Cochrane risk-of-bias tool for RCTs were used. RESULTS Ninety-four references were identified; 11 RCTs fulfilled the inclusion criteria. VACs administered were diosmin, hidrosmin/rutosides, micronized purified flavonoid fraction (MPFF), and sulodexide. The studies included a highly variable proportion of patients with PTS (8.6%-100%). Some older studies omitted details of the methodology. Two studies suggested benefit of diosmin and MPFF as adjunctive treatment to rivaroxaban in the prevention of PTS and showed low or unclear risk of bias. Evaluation of RCTs for the treatment of post-thrombotic chronic venous insufficiency found low or unclear risk of bias in 81.6% to 85.7%. All studies suggested that VACs were beneficial for PTS treatment; they improved venous symptoms, decreased edema, and helped heal venous ulcers. CONCLUSIONS This systematic review found that VACs had at least moderate quality of evidence in improving venous symptoms, decreasing edema, and accelerating venous ulcer healing. Two pilot RCTs of higher quality suggested the usefulness of diosmin and MPFF as adjunctive treatment to rivaroxaban therapy to reduce the incidence of PTS and improve deep vein recanalization. Because most RCTs were published over two decades ago, and several lacked the required precision in reporting, new high-quality, low-bias RCTs are needed to assess the role of specific VACs for both prevention and treatment of PTS.
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Affiliation(s)
| | | | | | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN; Semmelweis University, Budapest, Hungary
| | - Joseph D Raffetto
- VA Boston Healthcare System, Brigham and Women's Hospital, Boston, MA
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Branisteanu DE, Munteanu AE, Dolofan BM, Popescu EG, Vittos O. Adherence to Pharmacological Treatment in Chronic Venous Disease: Results of a Real-World, Prospective, Observational Cohort Study. Life (Basel) 2025; 15:377. [PMID: 40141722 PMCID: PMC11943550 DOI: 10.3390/life15030377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2024] [Revised: 01/25/2025] [Accepted: 01/27/2025] [Indexed: 03/28/2025] Open
Abstract
Chronic venous disease (CVeD) affects millions of patients globally, being a multifactorial progressive condition that significantly impacts the quality of life of individuals. Micronized Purified Flavonoid Fraction (MPFF) is the most utilized and studied venoactive drug because of its safety and effectiveness. This study is a real-world, prospective, observational, multicenter cohort study including patients diagnosed with CVeD who were receiving one tablet of MPFF 1000 mg/day for at least one month and who visited medical facilities in Romania in June-July 2022. We aimed to assess their adherence to pharmacological treatment. The intensity of CVeD symptoms was assessed with the Visual Analog Scale (VAS), while adherence to conservative treatment was evaluated using the Morisky Medication Adherence Scale (MMAS-8) at study inclusion (Visit 1 (V1)) and 8 weeks later, at the study's end (Visit 3 (V3)). This study recruited 1267 patients diagnosed with CVeD, and the statistical analysis set included 1200 patients, the majority of whom were female (71.5%), ≥51 years old (81.8%), and overweight (41.2%) or obese (33.8%), with a mean Body Mass Index (BMI) value (±SD) of 28.9 ± 5.1 kg/m2, classified using the Clinical, Etiological, Anatomical, and Pathophysiological (CEAP) clinical categories as CEAP C3 (38.7%) and C2 (22.6%) at baseline. Mean MMAS-8 scores increased from 6.2 ± 1.9 (V1) to 6.7 ± 1.7 (V3) (p < 0.001). Despite improvement in treatment adherence throughout this study, novel strategies are needed to improve medication adherence and overall health outcomes in CVeD.
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Affiliation(s)
- Daciana Elena Branisteanu
- Faculty of Medicine, General, Dermatology Discipline, University of Medicine and Pharmacy “Gr. T. Popa”, 700115 Iasi, Romania
| | - Alice Elena Munteanu
- Central Military Emergency University Hospital “Dr. Carol Davila”, 010825 Bucharest, Romania
| | | | | | - Oana Vittos
- Clinical Research Department, Medone Research, 18, Alexandr Sergheevici Puskin Street, District 1, 011996 Bucharest, Romania
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Kim SM, Joh JH, Jung IM, Kim MJ, Lee SS, Hwang HP, Kang JM, Jung HJ, Yang SS, Min SK, Yoo YS, Gwon JG, Park HS, Lee T. Vitis Vinifera Seed Extract Versus Micronized Purified Flavonoid Fraction for Patients with Chronic Venous Disease: A Randomized Noninferiority Trial. Ann Vasc Surg 2024; 109:177-186. [PMID: 39009117 DOI: 10.1016/j.avsg.2024.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 06/17/2024] [Accepted: 06/17/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Venoactive drugs (VADs) based on Vitis vinifera extract are widely used in Korea. However, studies on the clinical effects and head-to-head comparisons with other groups of VADs are limited. This trial aimed to evaluate whether Vitis vinifera seed extract was noninferior to the micronized purified flavonoid fraction (MPFF) in relieving venous symptoms and improving quality of life in patients with chronic venous disease. METHODS In this double-blind prospective randomized trial, patients from 13 hospitals, who were diagnosed with venous incompetence by duplex ultrasound and classified as clinical class 1, 2, or 3 in the Clinical, Etiological, Anatomical, and Pathophysiological classifications were enrolled. The primary outcome was the change in the Chronic Venous Disease Quality of Life Questionnaire (CIVIQ-20) score at 8 weeks from baseline. Secondary outcomes included changes in the Aberdeen Varicose Vein Questionnaire, visual analog scale, and Venous Clinical Severity Score at 4 and 8 weeks from baseline. Moreover, the change in leg circumferences was measured at 8 weeks and compared to baseline. RESULTS In total, 303 patients were enrolled and randomly assigned to receive either Vitis vinifera seed extract (n = 154) or MPFF (n = 149). The CIVIQ-20 scores at 8 weeks were significantly reduced compared to those at baseline in both groups. No significant intergroup difference in the change of CIVIQ-20 at 8 weeks from baseline was observed (-8.31 ± 14.63 vs. -10.35 ± 14.38, P = 0.29, 95% confidence interval -1.65 to 5.72). The lower limit of the 95% confidence interval was within the predefined noninferiority margin of 6.9. Furthermore, the Aberdeen Varicose Vein Questionnaire, visual analog scale, and Venous Clinical Severity Score scores significantly decreased at 4 and 8 weeks after randomization compared with baseline in both groups. No significant differences were observed in the reduction of each score between groups. The calf circumference measured at 8 weeks was significantly reduced compared to that at baseline in patients receiving Vitis vinifera seed extract. CONCLUSIONS Vitis vinifera seed extract was noninferior to MPFF in relieving venous symptoms and improving the quality of life in patients with chronic venous disease.
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Affiliation(s)
- Suh Min Kim
- Department of Surgery, Chung-Ang University College of Medicine, Chung-Ang University Hospital, Seoul, Korea
| | - Jin Hyun Joh
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - In Mok Jung
- Division of Vascular and Transplantation Surgery, Department of Surgery, SMG-SNU Seoul Boramae Medical Center, Seoul, Korea
| | - Mi Jin Kim
- Department of Surgery, Jeonbuk National University Medical School and Hospital, Jeonju, Korea
| | - Sang Su Lee
- Research Institute for Convergence of Biomedical Science and Technology, Division of Vascular and Endovascular Surgery, Department of Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Pusan, Korea
| | - Hong Pil Hwang
- Department of Surgery, Jeonbuk National University Medical School and Hospital, Jeonju, Korea
| | - Jin Mo Kang
- Division of Vascular Surgery, Department of Surgery, Gachon University of Medicine and Science, Incheon, Korea
| | - Hyuk Jae Jung
- Endovascular and Vascular and Transplantation Division, Department of Surgery, Pusan National University School of Medicine, Pusan, Korea
| | - Shin-Seok Yang
- Division of Vascular Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Kee Min
- Division of Vascular Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Young Sun Yoo
- Department of Surgery, Chosun University Hospital, Chosun University College of Medicine, Gwangju, Korea
| | - Jun Gyo Gwon
- Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea
| | - Hyung Sub Park
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Taeseung Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.
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Niyangoda D, Muayad M, Tesfaye W, Bushell M, Ahmad D, Samarawickrema I, Sinclair J, Kebriti S, Maida V, Thomas J. Cannabinoids in Integumentary Wound Care: A Systematic Review of Emerging Preclinical and Clinical Evidence. Pharmaceutics 2024; 16:1081. [PMID: 39204426 PMCID: PMC11359183 DOI: 10.3390/pharmaceutics16081081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 08/06/2024] [Accepted: 08/12/2024] [Indexed: 09/04/2024] Open
Abstract
This systematic review critically evaluates preclinical and clinical data on the antibacterial and wound healing properties of cannabinoids in integument wounds. Comprehensive searches were conducted across multiple databases, including CINAHL, Cochrane library, Medline, Embase, PubMed, Web of Science, and LILACS, encompassing records up to May 22, 2024. Eighteen studies met the inclusion criteria. Eleven were animal studies, predominantly utilizing murine models (n = 10) and one equine model, involving 437 animals. The seven human studies ranged from case reports to randomized controlled trials, encompassing 92 participants aged six months to ninety years, with sample sizes varying from 1 to 69 patients. The studies examined the effects of various cannabinoid formulations, including combinations with other plant extracts, crude extracts, and purified and synthetic cannabis-based medications administered topically, intraperitoneally, orally, or sublingually. Four animal and three human studies reported complete wound closure. Hemp fruit oil extract, cannabidiol (CBD), and GP1a resulted in complete wound closure in twenty-three (range: 5-84) days with a healing rate of 66-86% within ten days in animal studies. One human study documented a wound healing rate of 3.3 cm2 over 30 days, while three studies on chronic, non-healing wounds reported an average healing time of 54 (21-150) days for 17 patients by oral oils with tetrahydrocannabinol (THC) and CBD and topical gels with THC, CBD, and terpenes. CBD and tetrahydrocannabidiol demonstrated significant potential in reducing bacterial loads in murine models. However, further high-quality research is imperative to fully elucidate the therapeutic potential of cannabinoids in the treatment of bacterial skin infections and wounds. Additionally, it is crucial to delineate the impact of medicinal cannabis on the various phases of wound healing. This study was registered in PROSPERO (CRD42021255413).
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Affiliation(s)
- Dhakshila Niyangoda
- Faculty of Health, University of Canberra, Canberra, ACT 2617, Australia; (D.N.); (M.M.); (M.B.)
- Department of Pharmacy, Faculty of Allied Health Sciences, University of Peradeniya, Peradeniya 20400, Sri Lanka
| | - Mohammed Muayad
- Faculty of Health, University of Canberra, Canberra, ACT 2617, Australia; (D.N.); (M.M.); (M.B.)
| | - Wubshet Tesfaye
- School of Pharmacy, Faculty of Health and Behavioural Sciences, University of Queensland, Queensland, QLD 4072, Australia;
| | - Mary Bushell
- Faculty of Health, University of Canberra, Canberra, ACT 2617, Australia; (D.N.); (M.M.); (M.B.)
| | - Danish Ahmad
- School of Medicine and Psychology, Australian National University, Canberra, ACT 2601, Australia;
| | | | - Justin Sinclair
- Australian Natural Therapeutics Group, Byron Bay, NSW 2481, Australia;
- NICM Health Research Institute, Western Sydney University, Westmead, NSW 2145, Australia
| | - Shida Kebriti
- Eczanes Pharmaceuticals, Rydalmere, NSW 2116, Australia;
| | - Vincent Maida
- Temerity Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada;
- Hospice Vaughan, Woodbridge, ON L4H 3G7, Canada
| | - Jackson Thomas
- Faculty of Health, University of Canberra, Canberra, ACT 2617, Australia; (D.N.); (M.M.); (M.B.)
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Gloviczki P, Lawrence PF, Wasan SM, Meissner MH, Almeida J, Brown KR, Bush RL, Di Iorio M, Fish J, Fukaya E, Gloviczki ML, Hingorani A, Jayaraj A, Kolluri R, Murad MH, Obi AT, Ozsvath KJ, Singh MJ, Vayuvegula S, Welch HJ. The 2023 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part II: Endorsed by the Society of Interventional Radiology and the Society for Vascular Medicine. J Vasc Surg Venous Lymphat Disord 2024; 12:101670. [PMID: 37652254 PMCID: PMC11523430 DOI: 10.1016/j.jvsv.2023.08.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 08/20/2023] [Indexed: 09/02/2023]
Abstract
The Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society recently published Part I of the 2022 clinical practice guidelines on varicose veins. Recommendations were based on the latest scientific evidence researched following an independent systematic review and meta-analysis of five critical issues affecting the management of patients with lower extremity varicose veins, using the patients, interventions, comparators, and outcome system to answer critical questions. Part I discussed the role of duplex ultrasound scanning in the evaluation of varicose veins and treatment of superficial truncal reflux. Part II focuses on evidence supporting the prevention and management of varicose vein patients with compression, on treatment with drugs and nutritional supplements, on evaluation and treatment of varicose tributaries, on superficial venous aneurysms, and on the management of complications of varicose veins and their treatment. All guidelines were based on systematic reviews, and they were graded according to the level of evidence and the strength of recommendations, using the GRADE method. All ungraded Consensus Statements were supported by an extensive literature review and the unanimous agreement of an expert, multidisciplinary panel. Ungraded Good Practice Statements are recommendations that are supported only by indirect evidence. The topic, however, is usually noncontroversial and agreed upon by most stakeholders. The Implementation Remarks contain technical information that supports the implementation of specific recommendations. This comprehensive document includes a list of all recommendations (Parts I-II), ungraded consensus statements, implementation remarks, and best practice statements to aid practitioners with appropriate, up-to-date management of patients with lower extremity varicose veins.
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Affiliation(s)
- Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN.
| | - Peter F Lawrence
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Los Angeles, CA
| | - Suman M Wasan
- Department of Medicine, University of North Carolina, Chapel Hill, Rex Vascular Specialists, UNC Health, Raleigh, NC
| | - Mark H Meissner
- Division of Vascular Surgery, University of Washington, Seattle, WA
| | - Jose Almeida
- Division of Vascular and Endovascular Surgery, University of Miami Miller School of Medicine, Miami, FL
| | | | - Ruth L Bush
- John Sealy School of Medicine, University of Texas Medical Branch, Galveston, TX
| | | | - John Fish
- Department of Medicine, Jobst Vascular Institute, University of Toledo, Toledo, OH
| | - Eri Fukaya
- Division of Vascular Surgery, Stanford University, Stanford, CA
| | - Monika L Gloviczki
- Department of Internal Medicine and Gonda Vascular Center, Rochester, MN
| | | | - Arjun Jayaraj
- RANE Center for Venous and Lymphatic Diseases, Jackson, MS
| | - Raghu Kolluri
- Heart and Vascular Service, OhioHealth Riverside Methodist Hospital, Columbus, OH
| | - M Hassan Murad
- Evidence Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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Stanek A, Mosti G, Nematillaevich TS, Valesky EM, Planinšek Ručigaj T, Boucelma M, Marakomichelakis G, Liew A, Fazeli B, Catalano M, Patel M. No More Venous Ulcers-What More Can We Do? J Clin Med 2023; 12:6153. [PMID: 37834797 PMCID: PMC10573394 DOI: 10.3390/jcm12196153] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/12/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023] Open
Abstract
Venous leg ulcers (VLUs) are the most severe complication caused by the progression of chronic venous insufficiency. They account for approximately 70-90% of all chronic leg ulcers (CLUs). A total of 1% of the Western population will suffer at some time in their lives from a VLU. Furthermore, most CLUs are VLUs, defined as chronic leg wounds that show no tendency to heal after three months of appropriate treatment or are still not fully healed at 12 months. The essential feature of VLUs is their recurrence. VLUs also significantly impact quality of life and could cause social isolation and depression. They also have a significant avoidable economic burden. It is estimated that the treatment of venous ulceration accounts for around 3% of the total expenditure on healthcare. A VLU-free world is a highly desirable aim but could be challenging to achieve with the current knowledge of the pathophysiology and diagnostic and therapeutical protocols. To decrease the incidence of VLUs, the long-term goal must be to identify high-risk patients at an early stage of chronic venous disease and initiate appropriate preventive measures. This review discusses the epidemiology, socioeconomic burden, pathophysiology, diagnosis, modes of conservative and invasive treatment, and prevention of VLUs.
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Affiliation(s)
- Agata Stanek
- Department of Internal Medicine, Angiology and Physical Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Batorego 15 Street, 41-902 Bytom, Poland
- Vascular Independent Research and Education, European Foundation, 20157 Milan, Italy; (G.M.); (A.L.); (B.F.); (M.C.); (M.P.)
- VAS-International Consortium—International No More Venous Ulcers Strategic Network, 20157 Milan, Italy; (G.M.); (T.S.N.); (E.M.V.); (T.P.R.); (M.B.)
| | - Giovanni Mosti
- VAS-International Consortium—International No More Venous Ulcers Strategic Network, 20157 Milan, Italy; (G.M.); (T.S.N.); (E.M.V.); (T.P.R.); (M.B.)
- Angiology Department, MD Barbantini Clinic, Via del Calcio 2, 55100 Lucca, Italy
| | - Temirov Surat Nematillaevich
- VAS-International Consortium—International No More Venous Ulcers Strategic Network, 20157 Milan, Italy; (G.M.); (T.S.N.); (E.M.V.); (T.P.R.); (M.B.)
- Department of Specialized Surgery, Central Hospital of Ministry of Internal Affairs, Chimboy St. 2 A, Almazar District, Tashkent 100095, Uzbekistan
| | - Eva Maria Valesky
- VAS-International Consortium—International No More Venous Ulcers Strategic Network, 20157 Milan, Italy; (G.M.); (T.S.N.); (E.M.V.); (T.P.R.); (M.B.)
- Department of Dermatology, Venereology and Allergology, University Hospital, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60596 Frankfurt am Main, Germany
| | - Tanja Planinšek Ručigaj
- VAS-International Consortium—International No More Venous Ulcers Strategic Network, 20157 Milan, Italy; (G.M.); (T.S.N.); (E.M.V.); (T.P.R.); (M.B.)
- Dermatovenereological Clinic, University Medical Centre Ljubljana, Gradiskova 10 Street, 1000 Ljubljana, Slovenia
| | - Malika Boucelma
- VAS-International Consortium—International No More Venous Ulcers Strategic Network, 20157 Milan, Italy; (G.M.); (T.S.N.); (E.M.V.); (T.P.R.); (M.B.)
- Department of Internal Medicine, University of Algiers, Bachir Mentouri Hospital, Algiers 16208, Algeria
| | - George Marakomichelakis
- Vascular Independent Research and Education, European Foundation, 20157 Milan, Italy; (G.M.); (A.L.); (B.F.); (M.C.); (M.P.)
- VAS-International Consortium—International No More Venous Ulcers Strategic Network, 20157 Milan, Italy; (G.M.); (T.S.N.); (E.M.V.); (T.P.R.); (M.B.)
- 4th Department of Internal Medicine, General Hospital of Evangelismos, 16676 Athens, Greece
| | - Aaron Liew
- Vascular Independent Research and Education, European Foundation, 20157 Milan, Italy; (G.M.); (A.L.); (B.F.); (M.C.); (M.P.)
- VAS-International Consortium—International No More Venous Ulcers Strategic Network, 20157 Milan, Italy; (G.M.); (T.S.N.); (E.M.V.); (T.P.R.); (M.B.)
- Department of Medicine, Portiuncula University Hospital, University of Galway, H91 TK33 Galway, Ireland
| | - Bahar Fazeli
- Vascular Independent Research and Education, European Foundation, 20157 Milan, Italy; (G.M.); (A.L.); (B.F.); (M.C.); (M.P.)
- Support Association of Patients of Buerger’s Disease, Buerger’s Disease NGO, Mashhad 9183785195, Iran
| | - Mariella Catalano
- Vascular Independent Research and Education, European Foundation, 20157 Milan, Italy; (G.M.); (A.L.); (B.F.); (M.C.); (M.P.)
- VAS-International Consortium—International No More Venous Ulcers Strategic Network, 20157 Milan, Italy; (G.M.); (T.S.N.); (E.M.V.); (T.P.R.); (M.B.)
- Department of Biomedical, Clinical Sciences L Sacco Hospital, Inter-University Research Center on Vascular Disease, University of Milan, 20157 Milan, Italy
| | - Malay Patel
- Vascular Independent Research and Education, European Foundation, 20157 Milan, Italy; (G.M.); (A.L.); (B.F.); (M.C.); (M.P.)
- VAS-International Consortium—International No More Venous Ulcers Strategic Network, 20157 Milan, Italy; (G.M.); (T.S.N.); (E.M.V.); (T.P.R.); (M.B.)
- Department of Vascular Surgery, Apollo CVHF, Heart Institute, Ahmedabad 380059, India
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Learned A, Robinson SA, Nguyen TT. Comprehensive Care of Lower-Extremity Wounds. Surg Clin North Am 2023; 103:745-765. [PMID: 37455035 DOI: 10.1016/j.suc.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
There are 5 common types of chronic nonhealing lower-extremity wounds: arterial, venous, diabetic foot ulcer, pressure, and mixed or atypical. Each chronic wound type has distinct features, and understanding the underlying cause will dictate the wound treatment plan. Here, the authors review the distinguishing wound properties for these 5 common chronic nonhealing lower-extremity wounds and outline a comprehensive treatment plan that addresses wound perfusion, debridement, infection control, moisture balance, and use of complementary advanced wound care products.
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Affiliation(s)
- Allison Learned
- Department of Surgery, Division of Vascular Surgery, University of Massachusetts Chan Medical School, 55 North Lake Avenue, Worcester, MA 01655, USA
| | - Sudie-Ann Robinson
- Department of Surgery, Division of Vascular Surgery, University of Massachusetts Chan Medical School, 55 North Lake Avenue, Worcester, MA 01655, USA
| | - Tammy T Nguyen
- Department of Surgery, Division of Vascular Surgery, University of Massachusetts Chan Medical School, 55 North Lake Avenue, Worcester, MA 01655, USA; University of Massachusetts Diabetes Center of Excellence.
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Lurie F, Branisteanu DE. Improving Chronic Venous Disease Management with Micronised Purified Flavonoid Fraction: New Evidence from Clinical Trials to Real Life. Clin Drug Investig 2023; 43:9-13. [PMID: 37171748 DOI: 10.1007/s40261-023-01261-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2023] [Indexed: 05/13/2023]
Abstract
Chronic venous disease (CVD) develops in the microvessels, and is perpetuated by a vicious cycle of inflammation and endothelial activation, structural and functional changes to vessels and valves, and progressive venous hypertension. Data from animal models indicate that micronised purified flavonoid fraction (MPFF) has beneficial effects on a range of pathophysiological processes that contribute to CVD, including inflammation, micro-vessel permeability, valve and vessel wall remodelling, and reflux in microvalves. These effects explain its beneficial effects on the signs and symptoms of CVD, which have been seen across the spectrum of Clinical, Etiological, Anatomical and Pathophysiological (CEAP) categories of CVD severity. This includes patients with symptoms but no detectable anatomical or pathophysiological anomalies (C0s or C1) and patients with varicose veins (C2). In addition to symptomatic improvement, MPFF has been shown to reduce oedema in patients with C3 CVD, resolve skin symptoms in patients with C4 CVD, and accelerate the healing of venous ulcers in patients with C6 CVD. MPFF is highly recommended in international guidelines of CVD management and is the only veno-active drug to receive guideline endorsement for an improvement in patient quality of life.
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Affiliation(s)
- Fedor Lurie
- Jobst Vascular Institute, 2109 Hughes Drive, Toledo, OH, 43606, USA.
- Division of Vascular Surgery, University of Michigan, Ann Arbor, MI, USA.
| | - Daciana E Branisteanu
- Department of Dermatology, Universtatea de Medicina si Farmacie 'Grigore T. Popa', Iasi, Romania
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Zulkefli N, Che Zahari CNM, Sayuti NH, Kamarudin AA, Saad N, Hamezah HS, Bunawan H, Baharum SN, Mediani A, Ahmed QU, Ismail AFH, Sarian MN. Flavonoids as Potential Wound-Healing Molecules: Emphasis on Pathways Perspective. Int J Mol Sci 2023; 24:ijms24054607. [PMID: 36902038 PMCID: PMC10003005 DOI: 10.3390/ijms24054607] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/21/2023] [Accepted: 01/25/2023] [Indexed: 03/02/2023] Open
Abstract
Wounds are considered to be a serious problem that affects the healthcare sector in many countries, primarily due to diabetes and obesity. Wounds become worse because of unhealthy lifestyles and habits. Wound healing is a complicated physiological process that is essential for restoring the epithelial barrier after an injury. Numerous studies have reported that flavonoids possess wound-healing properties due to their well-acclaimed anti-inflammatory, angiogenesis, re-epithelialization, and antioxidant effects. They have been shown to be able to act on the wound-healing process via expression of biomarkers respective to the pathways that mainly include Wnt/β-catenin, Hippo, Transforming Growth Factor-beta (TGF-β), Hedgehog, c-Jun N-Terminal Kinase (JNK), NF-E2-related factor 2/antioxidant responsive element (Nrf2/ARE), Nuclear Factor Kappa B (NF-κB), MAPK/ERK, Ras/Raf/MEK/ERK, phosphatidylinositol 3-kinase (PI3K)/Akt, Nitric oxide (NO) pathways, etc. Hence, we have compiled existing evidence on the manipulation of flavonoids towards achieving skin wound healing, together with current limitations and future perspectives in support of these polyphenolic compounds as safe wound-healing agents, in this review.
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Affiliation(s)
- Nabilah Zulkefli
- Institute of Systems Biology (INBIOSIS), Universiti Kebangsaan Malaysia, Bangi 43600, Selangor, Malaysia
| | | | - Nor Hafiza Sayuti
- Institute of Systems Biology (INBIOSIS), Universiti Kebangsaan Malaysia, Bangi 43600, Selangor, Malaysia
| | - Ammar Akram Kamarudin
- UKM Molecular Biology Institute (UMBI), UKM Medical Center, Kuala Lumpur 56000, Selangor, Malaysia
| | - Norazalina Saad
- Laboratory of Cancer Research UPM-MAKNA (CANRES), Institute of Bioscience, Universiti Putra Malaysia, Serdang 43400, Selangor, Malaysia
| | - Hamizah Shahirah Hamezah
- Institute of Systems Biology (INBIOSIS), Universiti Kebangsaan Malaysia, Bangi 43600, Selangor, Malaysia
| | - Hamidun Bunawan
- Institute of Systems Biology (INBIOSIS), Universiti Kebangsaan Malaysia, Bangi 43600, Selangor, Malaysia
| | - Syarul Nataqain Baharum
- Institute of Systems Biology (INBIOSIS), Universiti Kebangsaan Malaysia, Bangi 43600, Selangor, Malaysia
| | - Ahmed Mediani
- Institute of Systems Biology (INBIOSIS), Universiti Kebangsaan Malaysia, Bangi 43600, Selangor, Malaysia
| | - Qamar Uddin Ahmed
- Drug Discovery and Synthetic Chemistry Research Group, Department of Pharmaceutical Chemistry, Kulliyyah of Pharmacy, International Islamic University Malaysia, Kuantan 25200, Pahang, Malaysia
| | - Ahmad Fahmi Harun Ismail
- Kulliyyah of Allied Health Sciences, International Islamic University Malaysia, Kuantan 25200, Pahang, Malaysia
- Correspondence: (A.F.H.I.); (M.N.S.)
| | - Murni Nazira Sarian
- Institute of Systems Biology (INBIOSIS), Universiti Kebangsaan Malaysia, Bangi 43600, Selangor, Malaysia
- Correspondence: (A.F.H.I.); (M.N.S.)
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Mansilha A, Caldevilla H, Puskás A, Lucien A, Roby L, Kirienko A. MPFF 1000 mg chewable once daily vs. MPFF 500 mg twice daily in chronic venous disease: the double-blind, randomized, non-inferiority CHEWY trial. INT ANGIOL 2022; 41:464-475. [PMID: 36598370 DOI: 10.23736/s0392-9590.22.04987-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The efficacy and tolerability of the new micronized purified flavonoid fraction (MPFF) 1000 mg once-daily chewable formulation in comparison with the established MPFF 500 mg conventional tablet at the same daily dose are unknown. METHODS CHEWY was an international, multicenter, double-blind, double-dummy, randomized, parallel group, non-inferiority phase III study conducted in adult patients with symptomatic chronic venous disease (CVD). Patients were randomly allocated to MPFF 1000 mg chewable or MPFF 2x500 mg daily treatment. The primary efficacy endpoint for clinical non-inferiority (non-inferiority margin predefined at 1 cm) was lower limb discomfort (LLD) assessed by a 10 cm electronic visual analog scale (eVAS) at 8 weeks. Secondary endpoints included leg pain (LP), leg heaviness (LH), and quality of life (QoL) measured by the eCIVIQ-14 questionnaire. Overall acceptability was assessed at each visit by patient and investigator. RESULTS Three hundred and nine patients were randomized to MPFF 1000 mg chewable and 302 to MPFF 2x500 mg. After 8 weeks, LLD decreased from baseline by -3.6±2.4 cm and -3.6±2.5 cm in the MPFF chewable and 2x500 mg groups, respectively. Non-inferiority of the once-daily chewable formulation compared with twice daily tablets on improving LLD was demonstrated (adjusted between-group difference [Standard Error]) (E [SE]) = 0.00 (0.18) cm, 95%CI -0.35; 0.35, non-inferiority P value <0.0001. Decreases of similar magnitude were observed at 8 weeks for LP and LH in both treatment arms: -3.4±2.3 cm and -3.5±2.5 cm, respectively for LP, and -3.5±2.5 cm and -3.5±2.6 cm, respectively for LH. QoL (global score) improved by -21.0±17.2 and -22.5±20.1 in the MPFF 1000 mg chewable group and 2x500 mg groups, respectively (E [SE]=1.03 [1.20], 95%CI [-1.32; 3.38]), with similar improvements in the QoL subscore components in both groups. Treatment acceptability was high for both patients and physicians and tolerability similar to the tablet formulation. CONCLUSIONS MPFF 1000 mg chewable was non-inferior to MPFF 2x500 mg tablets with respect to its effect on LLD. Both formulations were associated with improvements of similar magnitude in lower limb symptoms and QoL. The chewable formulation was observed to be well tolerated and well accepted. Once-daily MPFF chewable tablet offers patients with CVD a good alternative treatment regimen.
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Affiliation(s)
| | - Hector Caldevilla
- Argentine College of Venous & Lymphatic Surgery, Buenos Aires, Argentina
| | - Attila Puskás
- Angio-Center-Vascular Medicine, Targu Mures, Romania
| | - Arnaud Lucien
- Servier Institute of International Research, Suresnes, France -
| | - Lucas Roby
- Servier Institute of International Research, Suresnes, France
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Mansilha A, Gianesini S, Ulloa JH, Lobastov K, Wang J, Freitag A, Schaible KR, Martin M, Yaltirik P, Nicolaides AN. Pharmacological treatment for chronic venous disease: an umbrella review of systematic reviews. INT ANGIOL 2022; 41:249-257. [PMID: 35373942 DOI: 10.23736/s0392-9590.22.04877-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Chronic venous disease is a persistent venous drainage alteration caused by valvular incompetence and/or outflow obstruction. Disease management includes a variety of treatments, whose evidence and clinical performance in the mid-long term are variable. The objective of this umbrella review was to summarize efficacy data for pharmacological treatments including venoactive drugs from previously published reviews that included a meta-analytic component. EVIDENCE ACQUISITION Systematic database searches were conducted via Ovid SP on 13 August 2019, covering MEDLINE, Embase, and the Cochrane Database of Systematic Reviews. Reviews that included a meta-analytic component of four or more clinical trials or observational studies reporting on the efficacy of systemic or topical pharmacological treatments for adults with chronic venous disease published since 2010 were eligible for inclusion. EVIDENCE SYNTHESIS Eleven publications were included in this umbrella review. Change in ankle circumference was the most commonly reported outcome. Overall, several systemic treatments had significant effects compared with placebo on multiple efficacy outcomes, including measures of edema and pain. Out of them, Micronized Purified Flavonoid Fraction had the most comprehensive evidence of effectiveness on main symptoms and signs and on improving quality of life throughout chronic venous disease stages. CONCLUSIONS Systemic pharmacotherapies represent a valuable therapeutic option in CVD management. As a result of this umbrella review, several gaps were identified with respect to research topics that warrant further investigation, particularly in the category of topical medications.
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Affiliation(s)
| | - Sergio Gianesini
- Vascular Diseases Center, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, MD, USA
| | - Jorge H Ulloa
- Division of Vascular Surgery, Department of Surgery, University of the Andes, Bogota, Colombia
| | - Kirill Lobastov
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - Jinsong Wang
- Affiliated Hospital Sun Yat-Sen University, Guangzhou, China
| | | | | | | | - Pelin Yaltirik
- Internal Medicine and Neuropsychiatry, Global Medical and Patient Affairs (GMPA), Servier, Suresnes, France
| | - Andrew N Nicolaides
- Medical School, Department of Surgery, University of Nicosia, Nicosia, Cyprus
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Abstract
Background: Varicose veins are a common chronic venous disorder that leads to a significantly reduced quality of life and high healthcare resource burden. There is a large amount of research-based data and opinions regarding varicose veins. There are also some common myths and misconceptions about the treatment options.Current Concepts: Management options include compression therapy, open venous surgery, and endovenous therapy. An appropriate treatment option must be selected on a case-by-case basis based on the symptoms, severity, and duplex ultrasonography findings. Venous intervention should be considered if the condition is symptomatic and often, there is no need for urgent surgery or endovenous therapy because the symptoms usually progress slowly and severe cardiac problems are rare. According to previous studies, there is no difference between the endovenous therapy modalities and the traditional surgical method (i.e., high ligation and stripping) in terms of recurrence rates. Therefore, case-specific factors, such as anatomy and economic factors, should be considered. When compression therapy is considered, graduated compression stocking with suitable pressure should be prescribed. Venoactive drugs can be suggested in addition to compression therapy for symptomatic varicose veins or venous ulcers.Discussion and Conclusion:. Correct information regarding treatment for varicose veins based on the best available evidence must be provided to patients. The treatment options for varicose veins should be selected on a case-by-case basis considering the patient`s symptoms, anatomy and economic factors.
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16
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Probst S, Saini C, Rosset C, Skinner MB. Superabsorbent charcoal dressing versus silver foam dressing in wound area reduction: a randomised controlled trial. J Wound Care 2022; 31:140-146. [PMID: 35148626 DOI: 10.12968/jowc.2022.31.2.140] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
AIM This study aimed to compare the effect of a novel sterile polyacrylate wound pad with activated carbon cloth treatment with a standard non-adhesive hydrocellular foam dressing with silver in reducing wound area. METHOD A multicentre randomised controlled open-label wound-dressing trial was conducted in two wound care outpatient clinics in western Switzerland from November 2018 to March 2020. RESULTS A total of 77 successive patients were randomised to receive either a sterile polyacrylate wound pad with activated carbon cloth treatment (n=38) or the standard non-adhesive hydrocellular foam dressing with silver (n=39). Reduction in wound area was the primary outcome, whereas the application period of the dressing, odour, maceration and pain were the secondary outcomes. Wound area was measured at baseline and during each wound dressing change until the dressings were no longer indicated. Wound area reduced faster in the intervention group than in the control group (0.45cm2 per day vs. 0.2cm2 per day), although the application period was longer in the intervention group compared with the control group (9.5 days vs. 8.1 days). Maceration reduction was more pronounced in the intervention group (-2.07cm2) than in the control group (-0.71cm2). Odour, pain and infection were similar in both groups. CONCLUSION Sterile polyacrylate wound pad dressings with activated carbon cloth reduced the wound area, as well as the maceration area, faster than the non-adhesive hydrocellular foam dressing with silver.
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Affiliation(s)
- Sebastian Probst
- HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva School of Health Sciences, Geneva, Switzerland.,Care Directorate, University Hospital, Geneva, Switzerland.,Faculty of Medicine Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Camille Saini
- HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva School of Health Sciences, Geneva, Switzerland
| | | | - Monika Buehrer Skinner
- University of Zurich, Epidemiology, Biostatistics and Prevention Institute, Zurich, Switzerland
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De Maeseneer MG, Kakkos SK, Aherne T, Baekgaard N, Black S, Blomgren L, Giannoukas A, Gohel M, de Graaf R, Hamel-Desnos C, Jawien A, Jaworucka-Kaczorowska A, Lattimer CR, Mosti G, Noppeney T, van Rijn MJ, Stansby G, Esvs Guidelines Committee, Kolh P, Bastos Goncalves F, Chakfé N, Coscas R, de Borst GJ, Dias NV, Hinchliffe RJ, Koncar IB, Lindholt JS, Trimarchi S, Tulamo R, Twine CP, Vermassen F, Wanhainen A, Document Reviewers, Björck M, Labropoulos N, Lurie F, Mansilha A, Nyamekye IK, Ramirez Ortega M, Ulloa JH, Urbanek T, van Rij AM, Vuylsteke ME. Editor's Choice - European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs. Eur J Vasc Endovasc Surg 2022; 63:184-267. [PMID: 35027279 DOI: 10.1016/j.ejvs.2021.12.024] [Citation(s) in RCA: 337] [Impact Index Per Article: 112.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 11/12/2021] [Indexed: 01/12/2023]
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18
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Kamaev A, Bulatov V, Vakhratyan P, Volkov A, Volkov A, Gavrilov E, Golovina V, Efremova O, Ivanov O, Ilyukhin E, Katorkin S, Konchugova T, Kravtsov P, Maksimov S, Mzhavanadze N, Pikhanova Z, Pryadko S, Smirnov A, Sushkov S, Chabbarov R, Shimanko A, Yakushkin S, Apkhanova T, Derkachev S, Zolotukhin I, Kalinin R, Kirienko A, Kulchitskaya D, Pelevin A, Petrikov A, Rachin A, Seliverstov E, Stoyko Y, Suchkov I. Varicose Veins. FLEBOLOGIIA 2022; 16:41. [DOI: 10.17116/flebo20221601141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2024]
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19
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Yun S. Venoactive Drugs, Summary of the Clinical Trials and Guidelines. Phlebology 2021. [DOI: 10.37923/phle.2021.19.2.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sangchul Yun
- Department of Surgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
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Ortega MA, Fraile-Martínez O, García-Montero C, Álvarez-Mon MA, Chaowen C, Ruiz-Grande F, Pekarek L, Monserrat J, Asúnsolo A, García-Honduvilla N, Álvarez-Mon M, Bujan J. Understanding Chronic Venous Disease: A Critical Overview of Its Pathophysiology and Medical Management. J Clin Med 2021; 10:3239. [PMID: 34362022 PMCID: PMC8348673 DOI: 10.3390/jcm10153239] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 01/19/2023] Open
Abstract
Chronic venous disease (CVD) is a multifactorial condition affecting an important percentage of the global population. It ranges from mild clinical signs, such as telangiectasias or reticular veins, to severe manifestations, such as venous ulcerations. However, varicose veins (VVs) are the most common manifestation of CVD. The explicit mechanisms of the disease are not well-understood. It seems that genetics and a plethora of environmental agents play an important role in the development and progression of CVD. The exposure to these factors leads to altered hemodynamics of the venous system, described as ambulatory venous hypertension, therefore promoting microcirculatory changes, inflammatory responses, hypoxia, venous wall remodeling, and epigenetic variations, even with important systemic implications. Thus, a proper clinical management of patients with CVD is essential to prevent potential harms of the disease, which also entails a significant loss of the quality of life in these individuals. Hence, the aim of the present review is to collect the current knowledge of CVD, including its epidemiology, etiology, and risk factors, but emphasizing the pathophysiology and medical care of these patients, including clinical manifestations, diagnosis, and treatments. Furthermore, future directions will also be covered in this work in order to provide potential fields to explore in the context of CVD.
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Affiliation(s)
- Miguel A. Ortega
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (O.F.-M.); (C.G.-M.); (C.C.); (L.P.); (J.M.); (N.G.-H.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
- Cancer Registry and Pathology Department, Hospital Universitario Principe de Asturias, 28806 Alcalá de Henares, Spain
| | - Oscar Fraile-Martínez
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (O.F.-M.); (C.G.-M.); (C.C.); (L.P.); (J.M.); (N.G.-H.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
| | - Cielo García-Montero
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (O.F.-M.); (C.G.-M.); (C.C.); (L.P.); (J.M.); (N.G.-H.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
| | - Miguel A. Álvarez-Mon
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (O.F.-M.); (C.G.-M.); (C.C.); (L.P.); (J.M.); (N.G.-H.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
| | - Chen Chaowen
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (O.F.-M.); (C.G.-M.); (C.C.); (L.P.); (J.M.); (N.G.-H.); (M.Á.-M.); (J.B.)
| | - Fernando Ruiz-Grande
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain;
- Department of Vascular Surgery, Príncipe de Asturias Hospital, 28801 Alcalá de Henares, Spain
| | - Leonel Pekarek
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (O.F.-M.); (C.G.-M.); (C.C.); (L.P.); (J.M.); (N.G.-H.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
| | - Jorge Monserrat
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (O.F.-M.); (C.G.-M.); (C.C.); (L.P.); (J.M.); (N.G.-H.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
| | - Angel Asúnsolo
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain;
- Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, The City University of New York, New York, NY 10027, USA
| | - Natalio García-Honduvilla
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (O.F.-M.); (C.G.-M.); (C.C.); (L.P.); (J.M.); (N.G.-H.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
| | - Melchor Álvarez-Mon
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (O.F.-M.); (C.G.-M.); (C.C.); (L.P.); (J.M.); (N.G.-H.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
- Immune System Diseases—Rheumatology and Internal Medicine Service, University Hospital Príncipe de Asturias, (CIBEREHD), 28806 Alcalá de Henares, Spain
| | - Julia Bujan
- Department of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, 28801 Alcalá de Henares, Spain; (M.A.O.); (O.F.-M.); (C.G.-M.); (C.C.); (L.P.); (J.M.); (N.G.-H.); (M.Á.-M.); (J.B.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain;
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Review of the Current Evidence for Topical Treatment for Venous Leg Ulcers. J Vasc Surg Venous Lymphat Disord 2021; 10:241-247.e15. [PMID: 34171531 DOI: 10.1016/j.jvsv.2021.06.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/06/2021] [Indexed: 01/30/2023]
Abstract
OBJECTIVE The development of a venous leg ulcer (VLU) represents the most severe clinical manifestation of a chronic venous disease. Despite major progress, there is a limited understanding of VLU pathogenesis and wound healing biology. Treatment of VLUs remains a serious challenge for physicians of different specialties. This communication focuses on describing the rationale and scientific basis for topical wound care in the management of VLUs. METHODS A literature review was performed to summarize methods with proven efficacy in VLU management. A systematic literature search was also performed to identify new evidence from the randomized controlled trials published within 2014-2021. The scientific challenges, clinical practice concerns, economic obstacles, and possible directions for further research have been discussed. RESULTS Hundreds of topical products have been advertised for the treatment of VLUs. Published data on topical treatment of venous ulcers is insufficient, scattered, weak, and has significant methodological flaws. Forty-three randomized controlled trials on topical treatment of VLUs have been published within 2014-2021. Clinical practice guidelines need to be updated. Major gaps in knowledge have been identified, and suggestions for future research directions have been provided. CONCLUSIONS The American Venous Forum Research Committee would like to bring attention to topical wound care for VLUs as a critical gap in knowledge, and encourage scientists, practitioners, and industry to collaborate to fill this gap.
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Maida V, Shi RB, Fazzari FGT, Zomparelli L. Topical cannabis-based medicines - A novel adjuvant treatment for venous leg ulcers: An open-label trial. Exp Dermatol 2021; 30:1258-1267. [PMID: 34013652 DOI: 10.1111/exd.14395] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/06/2021] [Accepted: 05/07/2021] [Indexed: 12/25/2022]
Abstract
Venous leg ulcers are highly prevalent lower limb integumentary wounds that remain challenging to heal despite the use of evidence-based compression therapies. A multitude of adjuvant treatments has been studied but none have demonstrated enough efficacy to gain adoption into treatment guidelines. Global attention on Cannabis-Based Therapies is increasing and has been driven by quantum scientific advancements in the understanding of the endocannabinoid signalling system. Topical Cannabis-Based Medicines represent a novel treatment paradigm for venous leg ulcers in terms of promoting wound closure. Fourteen complex patients with sixteen recalcitrant leg ulcers were treated with Topical Cannabis-Based Medicines in conjunction with compression bandaging, every second day, to both wound bed and peri-wound tissues. The cohort had a mean age of 75.8 years and was medically complex as reflected by a mean M3 multimorbidity index score of 2.94 and a mean Palliative Performance Scale score of 67.1%. Complete wound closure, defined as being fully epithelialized, was achieved among 11 patients (79%) and 13 wounds (81%) within a median of 34 days. All three remaining patients demonstrated progressive healing trends but were lost to follow-up. The treatments were well tolerated, and no significant adverse reactions were experienced. The rapid wound closure of previously non-healing venous leg ulcers among elderly and highly complex patients suggests that Topical Cannabis-Based Medicines may become effective adjuvants in conjunction with compression therapy. This may also indicate that they may have an even broader role within integumentary and wound management. Therefore, this treatment paradigm warrants being subjected to controlled trials.
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Affiliation(s)
- Vincent Maida
- Division of Palliative Care, University of Toronto, Toronto, ON, Canada.,Division of Supportive & Palliative Care, William Osler Health System, Toronto, ON, Canada
| | - Runjie Bill Shi
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Li KX, Diendéré G, Galanaud J, Mahjoub N, Kahn SR. Micronized purified flavonoid fraction for the treatment of chronic venous insufficiency, with a focus on postthrombotic syndrome: A narrative review. Res Pract Thromb Haemost 2021; 5:e12527. [PMID: 34027293 PMCID: PMC8128666 DOI: 10.1002/rth2.12527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 03/14/2021] [Accepted: 04/06/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Postthrombotic syndrome (PTS) is a form of secondary chronic venous insufficiency (CVI) that occurs after deep vein thrombosis (DVT). Effective treatments for PTS are lacking. Micronized purified flavonoid fraction (MPFF) is a venoactive drug used in the treatment of CVI. OBJECTIVE To determine whether MPFF is a good candidate to explore as a therapeutic agent for PTS. METHODS We performed a narrative review in which we identified 14 systematic reviews, 33 randomized controlled trials, and 19 observational studies that discussed the use of MPFF in CVI, as well as studies that reported on the mechanistic action of MPFF in relation to the pathophysiology of PTS. RESULTS MPFF targets a number of pathophysiologic components of PTS. Based on animal models and human studies investigating objective vascular and lymphatic measures, MPFF promotes venous recanalization after DVT, decreases venous remodeling and reflux, inhibits inflammatory processes, improves venous tone and stasis, improves lymphatic circulation, improves capillary hyperpermeability, and decreases tissue hypoxia. Furthermore, MPFF shows promise in improving clinical manifestations, quality of life, and objective venous parameters of CVI. Studies suggest good patient acceptability and tolerability with the use of MPFF in CVI. CONCLUSION MPFF is a good candidate to explore as a potential therapy for PTS. Confirmatory high-quality studies are still needed to reinforce the evidence supporting the use of MPFF in CVI. Double-blind randomized controlled trials with clinical endpoints are needed to assess the clinical efficacy of MPFF in the treatment of PTS.
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Affiliation(s)
- Ke Xuan Li
- Faculty of MedicineMcGill UniversityMontrealQCCanada
| | - Gisele Diendéré
- Centre of Excellence in Thrombosis and Anticoagulation Care (CETAC)Center for Clinical Epidemiology of the Lady Davis Institute for Medical ResearchMontrealQCCanada
| | - Jean‐Philippe Galanaud
- Department of MedicineSunnybrook Health Sciences Centre and University of TorontoTorontoONCanada
| | - Nada Mahjoub
- Centre of Excellence in Thrombosis and Anticoagulation Care (CETAC)Center for Clinical Epidemiology of the Lady Davis Institute for Medical ResearchMontrealQCCanada
| | - Susan R. Kahn
- Centre of Excellence in Thrombosis and Anticoagulation Care (CETAC)Center for Clinical Epidemiology of the Lady Davis Institute for Medical ResearchMontrealQCCanada
- Department of MedicineSir Mortimer B Davis Jewish General HospitalMontrealQCCanada
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Maida V, Shi RB, Fazzari FGT, Zomparelli L. Topical cannabis-based medicines - A novel paradigm and treatment for non-uremic calciphylaxis leg ulcers: An open label trial. Int Wound J 2020; 17:1508-1516. [PMID: 32875692 PMCID: PMC7540661 DOI: 10.1111/iwj.13484] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/30/2020] [Accepted: 07/31/2020] [Indexed: 11/30/2022] Open
Abstract
Non-Uremic Calciphylaxis (NUC) is a rare condition that often manifests as intractable and painful integumentary wounds, afflicting patients with a high burden of co-morbidity. The Endocannabinoid System (ECS) is a ubiquitous signalling system that is theorised to be dysregulated within wound beds and associated peri-wound tissues. Preclinical research has shown that the dominant chemical classes derived from the cannabis plant, cannabinoids, terpenes, and flavonoids, interact with the integumentary ECS to promote wound closure and analgesia. This is a prospective open label cohort study involving two elderly Caucasian females with recalcitrant NUC leg ulcers of greater than 6 months duration. Topical Cannabis-Based Medicines (TCBM) composed of cannabinoids, terpenes, and flavonoids were applied daily to both the wound bed and peri-wound tissues until complete wound closure was achieved. Wounds were photographed regularly, and the digital images were subjected to planimetric analysis to objectively quantify the degree of granulation and epithelization. Analgesic utilisation, as a surrogate/proxy for pain scores, was also tracked. The cohort had a mean M3 multimorbidity index score of 3.31. Complete wound closure was achieved in a mean of 76.3 days. Additionally, no analgesics were required after a mean of 63 days. The treatments were well tolerated with no adverse reactions. The positive results demonstrated in very challenging wounds such as NUC, among highly complex patients, suggest that TCBM may have an even broader role within integumentary and wound management. This treatment paradigm warrants being trialled in other wound types and classes, and ultimately should be subjected to randomised controlled trials.
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Affiliation(s)
- Vincent Maida
- Division of Palliative CareUniversity of TorontoTorontoOntarioCanada
- Division of Supportive & Palliative CareWilliam Osler Health SystemTorontoOntarioCanada
| | - Runjie B. Shi
- Division of Palliative CareUniversity of TorontoTorontoOntarioCanada
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25
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Guarnera G. What is the role of pharmacological therapy in venous ulcers management? Minerva Cardiol Angiol 2020; 69:127-129. [PMID: 32524811 DOI: 10.23736/s2724-5683.20.05300-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Probst S, Saini C, Skinner MB. Comparison of sterile polyacrylate wound dressing with activated carbon cloth and a standard non-adhesive hydrocellular foam dressing with silver: a randomised controlled trial protocol. J Wound Care 2020; 28:722-728. [PMID: 31721666 DOI: 10.12968/jowc.2019.28.11.722] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Hard-to-heal wounds such as leg (LU) or diabetic foot ulcers (DFU) are slow healing, have a high recurrence rate and are associated with infection, smell and exudate. Current therapeutic approaches are multifaceted and focus on improving wound healing and preventing recurrences. Advanced wound dressings, especially super absorbent dressings are an important aspect of wound care, as hard-to-heal wounds tend to produce excessive amounts of exudate, which may contribute to maceration and excoriation, thus delaying wound healing. Additionally, excessive wound exudate is associated with malodour. Therefore, an important aspect of care is the management of exudate and odour. The use of effective advanced wound dressings is a promising strategy to achieve adequate absorption of wound exudate and malodour promoting wound healing. The aim of the current study is to determine whether there is a difference in wound size reduction between wounds dressed with either a sterile polyacrylate wound dressing with activated carbon cloth or a hydrocellular foam dressing with silver. METHOD A randomised controlled trial with 248 participants in one wound care outpatient clinic is proposed. Randomisation will be concealed. The outcome assessor will be blinded to the group allocation of participants. CONCLUSION This research project compares two wound dressings in an everyday care setting. Since the cost of hard-to-heal wounds to individuals, the economy and society is high, an evaluation of which wound dressing leads to a faster reduction of wound size and subsequent wound healing is an important issue/question for the individuals affected, their families, society and the health-care system.
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Affiliation(s)
- Sebastian Probst
- HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva School of Health Sciences, Geneva
| | - Camille Saini
- HES-SO University of Applied Sciences and Arts Western Switzerland, Geneva School of Health Sciences, Geneva
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Lyons OT, Saha P, Smith A. Redox dysregulation in the pathogenesis of chronic venous ulceration. Free Radic Biol Med 2020; 149:23-29. [PMID: 31560951 DOI: 10.1016/j.freeradbiomed.2019.09.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/04/2019] [Accepted: 09/20/2019] [Indexed: 12/23/2022]
Abstract
In chronic venous ulcers (CVUs), which account for up to 75% of leg ulcers, the inflammatory stage of wound healing fails to down-regulate, preventing progression to proliferation, remodeling and eventual epithelialisation. The roles of reactive oxygen species (ROS) in the oxidative burst and pathogen killing are well known, but ROS also have important functions in extra-cellular and intra-cellular signalling. Iron deposition, resulting from venous reflux, primes macrophages towards a persistent inflammatory response, with ongoing stimulation by bacteria potentially playing a role. Generation of excessive ROS by activated inflammatory cells causes tissue destruction and disintegration of the dermis, and then at later stages, a failure to heal. Here, we review the evidence for ROS in CVU formation and in normal and delayed healing. We also discuss how ROS modulation might be used to influence the healing of these complex wounds, which cause long-term morbidity and are associated with a significant financial burden to healthcare systems.
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Affiliation(s)
- Oliver Ta Lyons
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine and Sciences, BHF Centre of Research Excellence, King's College London, St Thomas' Hospital, United Kingdom; Basildon and Thurrock University Hospitals NHS Foundation Trust, United Kingdom
| | - Prakash Saha
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine and Sciences, BHF Centre of Research Excellence, King's College London, St Thomas' Hospital, United Kingdom
| | - Alberto Smith
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine and Sciences, BHF Centre of Research Excellence, King's College London, St Thomas' Hospital, United Kingdom.
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Nicolaides AN. The Benefits of Micronized Purified Flavonoid Fraction (MPFF) Throughout the Progression of Chronic Venous Disease. Adv Ther 2020; 37:1-5. [PMID: 31970659 PMCID: PMC7004432 DOI: 10.1007/s12325-019-01218-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Indexed: 12/24/2022]
Abstract
At the 2019 European Venous Forum in Zurich Switzerland, a symposium entitled "State of the art: benefits of MPFF throughout CVD progression" was held to discuss the developing treatment strategies for patients at all stages of chronic venous disease (CVD). At the early stages of CVD, management should be focused on preventing disease progression through lifestyle changes and conservative treatment; treatment can also include venoactive drugs (VAD) such as micronized purified flavonoid fraction (MPFF; Daflon®), which is the most well-known and most widely prescribed VAD in Europe. As the disease progresses, patients who require interventional procedures (e.g., endovenous procedure or sclerotherapy) can also benefit from MPFF treatment in the recovery period after the procedure, as MPFF has been shown to reduce periprocedural pain and bleeding (hematoma), and to improve CVD symptoms during this period. Management of CVD in patients with venous leg ulcers (VLU) is the most challenging; in these patients, recommended adjunct therapies to be combined with standard compression therapy include VAD (MPFF) and non-VAD drugs (pentoxifylline and sulodexide) which have been shown to speed VLU healing in comparison with compression therapy alone.
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Affiliation(s)
- Andrew N Nicolaides
- Department of Surgery, University of Nicosia Medical School, Nicosia, Cyprus.
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29
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The Most Severe Stage of Chronic Venous Disease: An Update on the Management of Patients with Venous Leg Ulcers. Adv Ther 2020; 37:19-24. [PMID: 31970660 PMCID: PMC7004438 DOI: 10.1007/s12325-020-01219-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Indexed: 12/14/2022]
Abstract
Venous leg ulcers (VLUs) are the most severe manifestation of chronic venous disease (CVD). Due to their chronic nature, high recurrence rate and slow healing time, VLUs account for 80% of all leg ulcers seen in patients with CVD. VLUs impose a heavy burden on patients that reduces their quality of life; VLUs also represent a major socioeconomic impact due to the cost and duration of care. The primary medical approach to treating VLUs is local compression therapy in combination with venoactive drug (VAD) pharmacotherapy to promote the reduction of the inflammatory reaction initiated by venous hypertension. Micronized purified flavonoid fraction (MPFF; Daflon®) is the most widely prescribed VAD. MPFF counteracts the pathophysiologic mechanisms of CVD and ulceration and has proven to be an effective adjunct to compression therapy in patients with large and chronic VLUs. Two other non-VAD drugs, pentoxifylline and sulodexide, have also been shown to improve VLU healing and are also recommended in addition to compression therapy. However, MPFF is the only VAD with the highest strength of recommendations in the 2018 guidelines for the healing of VLUs.
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30
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Yarmolinsky L, Budovsky A, Yarmolinsky L, Khalfin B, Glukhman V, Ben-Shabat S. Effect of Bioactive Phytochemicals from Phlomis viscosa Poiret on Wound Healing. PLANTS (BASEL, SWITZERLAND) 2019; 8:E609. [PMID: 31888128 PMCID: PMC6963389 DOI: 10.3390/plants8120609] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/06/2019] [Accepted: 12/06/2019] [Indexed: 11/30/2022]
Abstract
Phlomis viscosa Poiret is an evergreen shrub growing in Israel, Turkey, Lebanon, and Syria with acknowledged pro-wound healing (WH) properties. In this study, we evaluated the pro-WH potential of selected compounds found in this plant. Among the pro-WH compounds (identified by us) was a combination of three chemicals-diosmin, 1-octen-3-ol, and himachala-2,4-diene which enhanced WH significantly both in in vitro and in vivo models. The determined phytochemicals combination could be used for the treatment of chronic wounds. The effect of the extracts, diosmin, 1-octen-3-ol on the secretion of pro-inflammatory cytokines, IL-6 (A) and IL-8 (B) by human dermal fibroblasts was significant (p < 0.001). In addition, the beneficial effect of extracts of P. viscosa and its phytochemicals on WH was evidenced by inhibiting the growth of several WH delaying microorganisms.
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Affiliation(s)
| | - Arie Budovsky
- Barzilai University Medical Center, Ashkelon 7830604, Israel;
| | | | - Boris Khalfin
- Eastern R&D Center, Kiryat Arba 9010000, Israel; (L.Y.); (B.K.)
- Department of Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel
| | | | - Shimon Ben-Shabat
- Department of Biochemistry and Pharmacology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel
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31
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Stoĭko IM, Iashkin MN, Tiurin VP, Gudymovich VG. [Efficacy and safety of micronized purified flavonoid fraction (MPFF) in treatment of venous diseases in geriatric patients]. ANGIOLOGIIA I SOSUDISTAIA KHIRURGIIA = ANGIOLOGY AND VASCULAR SURGERY 2019; 25:88-91. [PMID: 30994613 DOI: 10.33529/angio2019112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Analysed herein is the experience with micronized purified flavonoid fraction (MPFF) in treatment of geriatric patients with decompensated forms of chronic venous diseases. A total of 218 geriatric patients were examined and treated. Of these, 132 patients had trophic disorders (C4-C6 class), including 40 patients found to have venous trophic ulcers (VTU). Therapeutic policy consisted in wound cleansing, application of topical antiseptics, hydroalginate dressing, stimulation of regenerative processes by therapy with MPFF at a dose of 1,000 mg daily. The microcirculatory blood flow was examined by means of laser Doppler flowmetry. By the end of a 4-week course of comprehensive treatment, 31 of 40 patients were found to have elevated microcirculation index to 16.9±2.1 perfusion units, suggesting improved perfusion of the lower-limb skin. Venous trophic ulcers completely epithelialized in 9 patients and decreased by half of their initial area in 22 patients. Repeat assessment of cardiac activity showed a decreased functional class of chronic heart failure in 9 of 17 patients with healed VTU. Assessing safety of phlebotrophic therapy revealed neither adverse reactions nor decompensation of accompanying diseases during the whole follow-up period.
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Affiliation(s)
- Iu M Stoĭko
- National Medical and Surgical Centre named after N.I. Pirogov under the RF Ministry of Public Health, Moscow, Russia
| | - M N Iashkin
- National Medical and Surgical Centre named after N.I. Pirogov under the RF Ministry of Public Health, Moscow, Russia
| | - V P Tiurin
- National Medical and Surgical Centre named after N.I. Pirogov under the RF Ministry of Public Health, Moscow, Russia
| | - V G Gudymovich
- National Medical and Surgical Centre named after N.I. Pirogov under the RF Ministry of Public Health, Moscow, Russia
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32
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Menezes PDP, Gomes CVC, de Carvalho YMBG, Santos NGL, Andrade VM, Oliveira AMS, de Lima CM, Araújo AADS. Evaluation of the Use of Compressive Stockings Impregnated With Hesperetin-Based Nanocapsules in the Healing of Venous Ulcers: A Case Report. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2019; 12:1179547619858977. [PMID: 31360076 PMCID: PMC6640063 DOI: 10.1177/1179547619858977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 05/24/2019] [Indexed: 11/24/2022]
Abstract
Venous ulcers are a more severe complication of chronic venous insufficiency, significantly compromising patient quality of life (QoL). Compressive stockings are still the gold standard treatment method with alternative therapies currently being evaluated. In this perspective, we investigate the influence of compressive stockings impregnated with hesperetin-based nanocapsules in the healing process of venous ulcers. Compressive stockings impregnated with hesperetin-based nanocapsules were applied to a consenting patient for 6 months following all relevant ethical principles for patient studies. The patient was evaluated at baseline (T0), 3 months (T3), and 6 months (T6), using photographic register (healing) probes to measure skin melanin, erythema and hydration parameters, and venous diameters, followed by questionnaires regarding QoL and pain perception. Healing was observed at the 3-month time point and with 91.6% and 93.1% of retraction area in larger ulcers of the right leg and lateral portion of the left leg, respectively. The deepest ulcer in a medial portion of the left leg healed 47.3%. A reduction of all measured skin parameters was observed, indicating a possible hesperetin effect. The scores of QoL and pain were, respectively, in the ranges of 91.6 to 31.2 and 7 to 0. Reduction in venous diameters also indicates healing function. These preliminary findings suggest that compressive stockings impregnated with hesperetin nanocapsules enhance venous ulcer healing. Further clinical trial controlled by placebo, involving a greater number of patients, is required to confirm the findings of this case report.
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33
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Molnar C, Opincariu D, Benedek T, Toma M, Nicolescu C. Association between varicose veins anatomical pattern and procedural complications following endovascular laser photothermolysis for chronic venous insufficiency. ACTA ACUST UNITED AC 2019; 52:e8330. [PMID: 30970086 PMCID: PMC6459463 DOI: 10.1590/1414-431x20198330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 01/25/2019] [Indexed: 11/22/2022]
Abstract
We sought to assess clinical characteristics and pattern of collateral network involvement associated with development of truncal (systematized) versus diffuse/non-truncal (non-systematized) varicose veins (VVs) in patients undergoing endovascular laser photothermolysis for chronic venous insufficiency (CVI). Secondly, we aimed to assess whether the type of VVs influenced the procedural complications of endovascular laser therapy. A total of 508 patients with hydrostatic VVs of the lower limbs who underwent endovenous laser treatment were included, out of which 84.1% (n=427) had truncal VVs (group 1) and 15.9% (n=81) had diffuse (non-systematized) VVs (group 2). Patients with truncal varices were significantly older (47.50±12.80 vs 43.15±11.75 years, P=0.004) and those with associated connective tissue disorders were more prone to present diffuse VVs (P=0.004). Patients in group 1 presented a significantly higher number of Cockett 1 (P=0.0017), Cockett 2 (P=0.0137), Sherman (P<0.0001), and Hunter (P=0.0011) perforator veins compared to group 2, who presented a higher incidence of Kosinski perforators (P<0.0001). There were no significant differences regarding postoperative complications: thrombophlebitis (P=0.773), local inflammation (P=0.471), pain (P=0.243), paresthesia (P=1.000), or burning sensation (P=0.632). Patients with more advanced CEAP (clinical, etiologic, anatomic, pathophysiologic) classes were older (P<0.0001), more were males (39.05 vs 27.77%, P=0.0084), more were prone to present ulcers (P<0.0001) and local hyperthermia (P=0.019), and presented for endovenous phlebectomy after a longer time from symptom onset. In patients with CVI, systematized VVs were associated with a more severe clinical status and a distinct anatomical pattern of perforators network compared to non-systematized VVs, which is more common in advanced stages.
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Affiliation(s)
- C Molnar
- 1st Surgery Clinic, University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania.,TopMed Medical Center, Tîrgu Mureş, Romania
| | - D Opincariu
- Clinic of Cardiology, University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania
| | - T Benedek
- Clinic of Cardiology, University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania.,Center of Advanced Research in Multimodality Cardiovascular Imaging, CardioMed Medical Center, Tîrgu Mureş, Romania
| | - M Toma
- Faculty of Medicine, University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania
| | - C Nicolescu
- TopMed Medical Center, Tîrgu Mureş, Romania.,Department of Anatomy, University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania
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Youn YJ, Lee J. Chronic venous insufficiency and varicose veins of the lower extremities. Korean J Intern Med 2019; 34:269-283. [PMID: 30360023 PMCID: PMC6406103 DOI: 10.3904/kjim.2018.230] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 09/08/2018] [Indexed: 12/15/2022] Open
Abstract
Chronic venous insufficiency (CVI) of the lower extremities manifests itself in various clinical spectrums, ranging from asymptomatic but cosmetic problems to severe symptoms, such as venous ulcer. CVI is a relatively common medical problem but is often overlooked by healthcare providers because of an underappreciation of the magnitude and impact of the problem, as well as incomplete recognition of the various presenting manifestations of primary and secondary venous disorders. The prevalence of CVI in South Korea is expected to increase, given the possible underdiagnoses of CVI, the increase in obesity and an aging population. This article reviews the pathophysiology of CVI of the lower extremities and highlights the role of duplex ultrasound in its diagnosis and radiofrequency ablation, and iliac vein stenting in its management.
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Affiliation(s)
- Young Jin Youn
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Division of Interventional Cardiology, Calhoun Cardiology Center, UConn Health, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Juyong Lee
- Division of Interventional Cardiology, Calhoun Cardiology Center, UConn Health, University of Connecticut School of Medicine, Farmington, CT, USA
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35
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Rabe E, Carpentier P, Maggioli A. Understanding lower leg volume measurements used in clinical studies focused on venous leg edema. INT ANGIOL 2018; 37:437-443. [DOI: 10.23736/s0392-9590.18.04057-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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36
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ten Cate‐Hoek AJ. Prevention and treatment of the post-thrombotic syndrome. Res Pract Thromb Haemost 2018; 2:209-219. [PMID: 30046723 PMCID: PMC6055553 DOI: 10.1002/rth2.12085] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 01/14/2018] [Indexed: 11/12/2022] Open
Abstract
Post thrombotic syndrome (PTS) is a common chronic complication of deep vein thrombosis of the leg (DVT). Treatment options are limited therefore emphasis is placed on its prevention. Several risk factors have been recognized, but were so far not used for risk stratification or translation into prediction models. Early interventions did not yet result in more successful preventive treatment strategies; for the acute phase of DVT there is equipoise on the value of elastic compression, as well as on catheter directed thrombolysis. There are no drugs specifically targeted at PTS prevention. The use of anticoagulant medication such as direct oral anticoagulants (DOACs) might decrease PTS incidence, but this needs to be corroborated. Both research into more effective treatment options as well as future PTS management may benefit from a uniform diagnostic strategy and the use of prediction rules to better allocate treatment and thereby increase treatment efficacy.
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Affiliation(s)
- Arina J. ten Cate‐Hoek
- Heart+ and Vascular Center, Internal MedicineCardiovascular Research InstituteMaastricht University Medical CenterMaastrichtthe Netherlands
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Jindal R, Dekiwadia DB, Krishna PR, Khanna AK, Patel MD, Padaria S, Varghese R. Evidence-Based Clinical Practice Points for the Management of Venous Ulcers. Indian J Surg 2018; 80:171-182. [PMID: 29915484 DOI: 10.1007/s12262-018-1726-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 01/15/2018] [Indexed: 10/18/2022] Open
Abstract
Venous ulcer is an extremely common aetiology of lower extremity ulceration, which affects approximately 1% population in most of the countries, and the incidence rate increases with age and female gender. Proper assessment and diagnosis of both the patient and ulcer are inevitable in order to differentiate venous ulcers from other lower extremity ulceration and to frame an adequate and individualised management plan. Venous ulcers generally persist for weeks to many years and are typically recurrent in nature. This consensus aims to present an evidence-based management approach for the patients with venous ulcers. Various management options for venous ulcers include compression therapy, minimally invasive procedures like sclerotherapy and ablation techniques, surgical procedures, debridement and medical management with micronised purified flavonoid fraction (MPFF). Compression therapy is the mainstay treatment for venous ulcer. However, in failure cases, surgery can be preferred. Medical management with MPFF as an adjuvant therapy to standard treatment has been reported to be effective and safe in patients with venous ulcer. In addition to standard therapy, diet and lifestyle modification including progressive resistance exercise, patient education, leg elevation, weight reduction, maintaining a healthy cardiac status and strong psychosocial support reduces the risk of recurrence and improves the quality of life in patients with venous ulcer.
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Affiliation(s)
| | | | | | - Ajay K Khanna
- 4Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | | | - Shoaib Padaria
- Jaslok Hospital, Breach Candy Hospital, Sir H.N. Hospital, Saifee Hospital, Mumbai, India
| | - Roy Varghese
- 7Daya Hospital, Jubilee Mission Medical College, Trichur, Kerala India
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YASIM A. Venöz Ülser Tedavisinde Venoaktif İlaçlar. KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNIVERSITESI TIP FAKÜLTESI DERGISI 2017. [DOI: 10.17517/ksutfd.351614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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McDaniel JC, Szalacha L, Sales M, Roy S, Chafee S, Parinandi N. EPA + DHA supplementation reduces PMN activation in microenvironment of chronic venous leg ulcers: A randomized, double-blind, controlled study. Wound Repair Regen 2017; 25:680-690. [DOI: 10.1111/wrr.12558] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 07/03/2017] [Indexed: 12/12/2022]
Affiliation(s)
| | - Laura Szalacha
- College of Nursing, University of Arizona; Tucson Arizona
| | - Michelle Sales
- College of Nursing, The Ohio State University; Columbus Ohio
| | - Sashwati Roy
- College of Medicine; The Ohio State University; Columbus Ohio
- Davis Heart and Lung Research Institute; The Ohio State University; Columbus Ohio
| | - Scott Chafee
- College of Medicine; The Ohio State University; Columbus Ohio
- Davis Heart and Lung Research Institute; The Ohio State University; Columbus Ohio
| | - Narasimham Parinandi
- College of Medicine; The Ohio State University; Columbus Ohio
- Davis Heart and Lung Research Institute; The Ohio State University; Columbus Ohio
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Bush R, Comerota A, Meissner M, Raffetto JD, Hahn SR, Freeman K. Recommendations for the medical management of chronic venous disease: The role of Micronized Purified Flavanoid Fraction (MPFF). Phlebology 2017; 32:3-19. [PMID: 28211296 DOI: 10.1177/0268355517692221] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Scope A systematic review of the clinical literature concerning medical management of chronic venous disease with the venoactive therapy Micronized Purified Flavonoid Fraction was conducted in addition to an investigation of the hemodynamics and mechanism of chronic venous disease. Methods The systematic review of the literature focused on the use of Micronized Purified Flavonoid Fraction (diosmin) which has recently become available in the US, in the management of chronic venous disease. The primary goal was to assess the level of evidence of the role of Micronized Purified Flavonoid Fraction in the healing of ulcers, and secondarily on the improvement of the symptoms of chronic venous disease such as edema. An initial search of Medline, Cochrane Database for Systematic Reviews and Google Scholar databases was conducted. The references of articles obtained in the primary search, including a Cochrane review of phlebotonics for venous insufficiency, were reviewed for additional studies. Studies were included if patients had a diagnosis of chronic venous disease documented with Doppler and Impedance Plethysmography. Studies excluded were those that had patients with arterial insufficiency (Ankle Brachial Index < .6), comorbidity of diabetes, obesity, rheumatological diseases, or if other causes of edema were present (congestive heart failure, renal, hepatic or lymphatic cause), or if the patient population had recent surgery or deep vein thrombosis, or had been using diuretics (in studies of edema). Other elements of the study design were to note specifically the type of compression therapy used in conjunction with Micronized Purified Flavonoid Fraction. Results The literature review yielded 250 abstracts, 65 of which met criteria for further review and 10 papers were selected for consideration in the systematic review. Conclusion In summary, the general level of evidence supports the recommendation that the use of medical therapy with Micronized Purified Flavonoid Fraction has beneficial outcomes without serious adverse events. In the United States, diosmiplex is the only available prescription formulation of Micronized Purified Flavonoid Fraction. It is derived from the rinds of oranges and is categorized as a medical food and not as a drug; and may be a particularly attractive therapy for many chronic venous disease patients because of its favorable safety profile. The Working Group for chronic venous disease concurs with previous guidance by the International European Society for Vascular Surgery in 2015 which recommended the use of Micronized Purified Flavonoid Fraction for the healing of venous ulcers, alone and adjunctive to compression therapy, and for the reduction in symptoms of chronic venous disease such as edema.
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Abstract
The postthrombotic syndrome (PTS) is a frequent cause of long-term disability in patients with lower extremity deep vein thrombosis. A broad variety of interventions have been applied to patients with established PTS, including lifestyle, medical, compressive, endovascular, and open surgical therapies. However, the volume of evidence to support many individual elements of care is sparse, and important questions remain that must be answered to enable judicious individualization of PTS care. The purpose of this article is to describe what is known about PTS care elements and to identify important evidence gaps that merit future studies.
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Affiliation(s)
- Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, Missouri
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Abstract
Patients suffering from any class of the Clinical, Etiological, Anatomical, Pathophysiological (CEAP) classification of chronic venous disease (CVD) may be symptomatic (C0s-C6s). Leg heaviness, discomfort, itching, cramps, pain, paresthesia, and edema (C3) are the most frequent manifestations of CVD and a major reason for medical consultation. Daflon 500 mg (micronized purified flavonoid fraction [MPFF]) is an effective treatment for symptoms and edema in CVD as demonstrated in several randomized controlled studies. A 2-month, double-blind study in 40 patients established the superiority of Daflon 500 mg over placebo with regard to symptoms and objective signs. This was confirmed in another double-blind, placebo-controlled trial (2 months’ treatment, 160 patients), and in the Reflux assEssment and quaLity of lIfe improvEment with micronized Flavonoids (RELIEF) study. The latter included 5,052 patients in 23 countries, using a visual analog scale for evaluating pain, leg heaviness, cramps, and a sensation of swelling. All symptoms showed significant and progressive improvement. The quality-of-life results (scores on the ChronIc Venous Insufficiency quality of life Questionnaire [CIVIQ]) paralleled those of symptoms. The decrease in the ankle and calf circumferences was significantly greater (p<0.001) in the group of patients treated with Daflon 500 mg in two studies, and correlated well with the improvement in the sensation of swelling (p<0.001). This was confirmed with more sophisticated measurement techniques as in the RELIEF study or in a trial assessing edema with an optoelectronic volumeter in 20 patients. A further double-blind, randomized, controlled study established a statistically significant difference in favor of Daflon 500 mg in comparison with diosmin, both on symptoms and edema. The therapeutic efficacy of Daflon 500 mg on CVD symptoms and edema has been demonstrated in double-blind, randomized, controlled studies. Further studies using a new approach may define the most precise and validated methodology for application in future research in phlebology.
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Nguyen T, Bergan J, Min R, Morrison N, Zimmet S. Curriculum of the American College of Phlebology. Phlebology 2016. [DOI: 10.1258/026835506779613534] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- T Nguyen
- Dermatology, Mohs Micrographic & Dermatologic surgery, Procedural Dermatology, University of Texas-MD Anderson Cancer Center, Houston, TX, USA
| | - J Bergan
- Department of Surgery, UCSD School of Medicine, San Diego, CA, USA
| | - R Min
- Department of Radiology, Cornell University School of Medicine, New York, NY, USA
| | - N Morrison
- Morrison Vein Institute, Scottsdale AZ, USA
| | - S Zimmet
- Zimmet Vein and Dermatology, Austin, TX, USA
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Evidence-based (S3) guidelines for diagnostics and treatment of venous leg ulcers. J Eur Acad Dermatol Venereol 2016; 30:1843-1875. [PMID: 27558268 DOI: 10.1111/jdv.13848] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 06/17/2016] [Indexed: 11/29/2022]
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45
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Chapter 6 - Oral medication. J Eur Acad Dermatol Venereol 2016. [PMID: 27557626 DOI: 10.1111/jdv.7_13848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Toledo RR, Santos MERDC, Schnaider TB. Effect of Pycnogenol on the Healing of Venous Ulcers. Ann Vasc Surg 2016; 38:212-219. [PMID: 27521821 DOI: 10.1016/j.avsg.2016.04.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 03/30/2016] [Accepted: 04/12/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Venous ulcers are common complications of chronic venous insufficiency that result in severe physical and mental suffering to patients. The oral administration of diosmin/hesperidin has been used as adjuvant therapy in the treatment of chronic venous insufficiency. The purpose of this study was to evaluate and compare the effect of pycnogenol and diosmin/hesperidin on the healing of venous ulcers. METHODS This longitudinal, prospective, randomized clinical trial was conducted with 30 adult patients with venous ulcers from a vascular surgery outpatient clinic of a university hospital. The patients were randomly allocated to 2 groups: Group 1 (n = 15) was treated with pycnogenol (50 mg orally, 3 times daily) and Group 2 (n = 15) was treated with diosmin/hesperidin (450/50 mg orally, twice daily). They were assessed every 15 days for 90 days. During follow-up visits, photo-documentation was obtained and the ulcer area and circumference of the affected limb were measured. Friedman's test and Mann-Whitney test were used to compare ulcer areas and circumference of affected limbs between and within groups at different time points. The level of significance was set at 5% (P < 0.05) for all tests. RESULTS Both the pycnogenol and diosmin/hesperidin treatments had a similar effect on the healing of venous ulcers and led to a significant decrease in the circumference of affected limbs (P < 0.0001). CONCLUSION The results suggest that pycnogenol has an adjuvant effect on the healing of venous ulcers, similar to diosmin/hesperidin.
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Affiliation(s)
- Renato Riera Toledo
- Professional Master's Program in Applied Health Sciences, Department of Surgery, Universidade do Vale do Sapucaí, Pouso Alegre, Brazil.
| | | | - Taylor Brandão Schnaider
- Professional Master's Program in Applied Health Sciences, Department of Surgery, Universidade do Vale do Sapucaí, Pouso Alegre, Brazil
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Raffetto JD, Eberhardt RT, Dean SM, Ligi D, Mannello F. Pharmacologic treatment to improve venous leg ulcer healing. J Vasc Surg Venous Lymphat Disord 2016; 4:371-4. [DOI: 10.1016/j.jvsv.2015.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 10/11/2015] [Indexed: 10/22/2022]
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48
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Varatharajan L, Thapar A, Lane T, Munster AB, Davies AH. Pharmacological adjuncts for chronic venous ulcer healing: a systematic review. Phlebology 2016; 31:356-65. [PMID: 26036247 DOI: 10.1177/0268355515587194] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The aim of this study was to systematically review the current evidence and determine whether there is a clinical benefit for using pharmacological agents as adjunctive treatment for chronic venous ulcers. METHOD A systematic review of the MEDLINE and EMBASE (from 1 January 1947 through 15 August 2013) and Cochrane databases (from inception through 15 August 2013) was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria were all randomised controlled trials investigating pharmacological adjuncts for the treatment of venous ulcers with a minimum sample size of 20 patients for each treatment arm. RESULTS Ten relevant articles were identified; one pilot randomised controlled trial and four Cochrane reviews were included. Pentoxifylline, aspirin, sulodexide, mesoglycan, flavonoids, thromboxane A2 antagonist (ifetroban), zinc, prostaglandin and prostacyclin analogues were the drugs reviewed. Pentoxifylline was found to be more effective than placebo in terms of complete ulcer healing or in causing a significant improvement (greater than 60% reduction in ulcer size) (RR 1.70, 95% CI 1.30 to 2.24). Aspirin and flavonoids show potential to be effective adjuncts but methodological shortcomings and issues with bias limit the validity of results from trials involving each of these drugs, respectively. There was no significant difference between placebo and Ifetroban and likewise pooled results from trials investigating sulodexide and zinc showed no benefit in comparison to placebo. CONCLUSION Many systemic pharmacological agents have been investigated as adjuncts to venous ulcer healing; however, pentoxifylline (400 mg, three times a day) is currently the only drug that has promising evidence to support its use. Other compounds are in early stage research.
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Affiliation(s)
| | - Ankur Thapar
- Academic Section of Vascular Surgery, Imperial College London, UK
| | - Tristan Lane
- Academic Section of Vascular Surgery, Imperial College London, UK
| | - Alex B Munster
- Academic Section of Vascular Surgery, Imperial College London, UK
| | - Alun Huw Davies
- Academic Section of Vascular Surgery, Imperial College London, UK
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Serra R, Grande R, Butrico L, Buffone G, Caliò FG, Squillace A, Rizzo BA, Massara M, Spinelli F, Ferrarese AG, de Caridi G, Gallelli L, de Franciscis S. Effects of a new nutraceutical substance on clinical and molecular parameters in patients with chronic venous ulceration. Int Wound J 2016; 13:88-96. [PMID: 24612734 PMCID: PMC7949894 DOI: 10.1111/iwj.12240] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 01/27/2014] [Indexed: 01/08/2023] Open
Abstract
Pathophysiological events involved in the onset of chronic venous ulceration (CVU) are inflammation, activation of polymorphonucleates (PMNs) and secretion of proteases such as matrix metalloproteinases (MMPs), which degrade extracellular matrix (ECM) that is a support for vascular and tissutal wall. MMPs, neutrophil gelatinase-associated lipocalin (NGAL) and inflammatory cytokines are overexpressed in CVUs and they could play a central role in pathophysiological mechanisms of skin lesion and delayed wound healing. Bioflavonoids, such as diosmin and other compounds, appear to have several provessel function activities including anti-inflammatory, antioxidant and phlebotonic effects and are widely used in the treatment of chronic venous disease (CVD)-related problems. In this article, we evaluated the effects of Axaven(®) , a new nutraceutical on both clinical and molecular parameters in patients with CVUs. During the study period, 83 patients with CVUs of both sexes were enrolled and divided into two groups: group A (treated group): 25 females and 19 males (median age is 67·7 years) received standard treatment (compression therapy and surgical correction of superficial venous incompetence) + Axaven(®) once a day for 8 months as adjunctive treatment. Group B (control group): 24 females and 15 males (median age is 65·2 years) were treated only with basic treatment according to their clinical conditions. In our study, the administration of Axaven(®) in patients with CVUs was able to decrease inflammatory cytokines, MMPs and NGAL, inducing an improvement of both symptoms with an increase of the speed of wound healing.
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Affiliation(s)
- Raffaele Serra
- Interuniversity Center of Phlebolymphology, International Research and Educational Program in Clinical and Experimental Biotechnology, University Magna Graecia of Catanzaro, Catanzaro, Italy
- Department of Surgical and Medical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Raffaele Grande
- Department of Surgical and Medical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Lucia Butrico
- Department of Surgical and Medical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Gianluca Buffone
- Department of Surgical and Medical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | | | - Aida Squillace
- Department of Health Science, University of Catanzaro, Catanzaro, Italy
| | - Barbara A Rizzo
- Department of Health Science, University of Catanzaro, Catanzaro, Italy
| | - Mafalda Massara
- Cardiovascular and Thoracic Department, "Policlinico G. Martino" Hospital, University of Messina, Messina, Italy
| | - Francesco Spinelli
- Cardiovascular and Thoracic Department, "Policlinico G. Martino" Hospital, University of Messina, Messina, Italy
| | - Alessia G Ferrarese
- Section of General Surgery, Teaching Hospital "San Luigi Gonzaga", School of Medicine, University of Turin, Turin, Italy
| | - Giovanni de Caridi
- Cardiovascular and Thoracic Department, "Policlinico G. Martino" Hospital, University of Messina, Messina, Italy
| | - Luca Gallelli
- Department of Health Science, University of Catanzaro, Catanzaro, Italy
| | - Stefano de Franciscis
- Interuniversity Center of Phlebolymphology, International Research and Educational Program in Clinical and Experimental Biotechnology, University Magna Graecia of Catanzaro, Catanzaro, Italy
- Department of Surgical and Medical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
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Sista AK, Vedantham S, Kaufman JA, Madoff DC. Endovascular Interventions for Acute and Chronic Lower Extremity Deep Venous Disease: State of the Art. Radiology 2015; 276:31-53. [PMID: 26101920 DOI: 10.1148/radiol.2015132603] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The societal and individual burden caused by acute and chronic lower extremity venous disease is considerable. In the past several decades, minimally invasive endovascular interventions have been developed to reduce thrombus burden in the setting of acute deep venous thrombosis to prevent both short- and long-term morbidity and to recanalize chronically occluded or stenosed postthrombotic or nonthrombotic veins in symptomatic patients. This state-of-the-art review provides an overview of the techniques and challenges, rationale, patient selection criteria, complications, postinterventional care, and outcomes data for endovascular intervention in the setting of acute and chronic lower extremity deep venous disease. Online supplemental material is available for this article.
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Affiliation(s)
- Akhilesh K Sista
- From the Department of Radiology, Weill Cornell Medical College, 525 E 68th St, P-518, New York, NY 10065 (A.K.S., D.C.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (S.V.); and Dotter Interventional Institute, Oregon Health and Science Center, Portland, Ore (J.A.K.)
| | - Suresh Vedantham
- From the Department of Radiology, Weill Cornell Medical College, 525 E 68th St, P-518, New York, NY 10065 (A.K.S., D.C.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (S.V.); and Dotter Interventional Institute, Oregon Health and Science Center, Portland, Ore (J.A.K.)
| | - John A Kaufman
- From the Department of Radiology, Weill Cornell Medical College, 525 E 68th St, P-518, New York, NY 10065 (A.K.S., D.C.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (S.V.); and Dotter Interventional Institute, Oregon Health and Science Center, Portland, Ore (J.A.K.)
| | - David C Madoff
- From the Department of Radiology, Weill Cornell Medical College, 525 E 68th St, P-518, New York, NY 10065 (A.K.S., D.C.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (S.V.); and Dotter Interventional Institute, Oregon Health and Science Center, Portland, Ore (J.A.K.)
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