Comparative effectiveness of surgical interventions aimed at treating underlying venous pathology in patients with chronic venous ulcer

Comparison of high saphenous ligation and stripping, radiofrequency ablation, and subfascial endoscopic perforator surgery for the treatment of active venous ulcers: Retrospective cohort with five-year follow-up

OBJECTIVE

To compare the use of high saphenous ligation and stripping, radiofrequency ablation, and subfascial endoscopic perforator surgery for the treatment of active venous ulcers.

METHODS

One hundred ninety-five (n = 195) subjects who were treated for venous leg ulcers were enrolled between 2009 and 2014. Three groups were formed (Group A: high saphenous ligation and total stripping, Group B: radiofrequency ablation of the great saphenous vein + perforators, and Group C: radiofrequency ablation of the great saphenous vein + subfascial endoscopic perforator surgery) (n = 65 for each group). The venous clinical severity score for baseline, 1st, 6th, and 12th months, great saphenous vein occlusion at the 1st, 6th, and 12th months, and ulcer rates for the 1st, 2nd, 3rd, 4th, and 5th years were recorded.

RESULTS

For venous clinical severity score, only the first month decrease was significant for the subfascial endoscopic perforator surgery group (p = 0.001). Great saphenous vein occlusion was higher at the 6th and 12th months for the high saphenous ligation and stripping and subfascial endoscopic perforator surgery groups than for the radiofrequency ablation group (p = 0.036 and p = 0.037). The rate of ulcers for the subfascial endoscopic perforator surgery group was lower at the second, third, fourth, and fifth years (p = 0.011). No significant difference was found between groups for the five-year recovery rates (p > 0.05).

CONCLUSION

Subfascial endoscopic perforator surgery technique in conjunction with radiofrequency ablation of axial vein was superior to both high saphenous ligation and stripping and radiofrequency ablation of axial and perforators for ulcer healing.

Wireless, skin-interfaced sensors for compression therapy

Therapeutic compression garments (TCGs) are key tools for the management of a wide range of vascular lower extremity conditions. Proper use of TCGs involves application of a minimum and consistent pressure across the lower extremities for extended periods of time. Slight changes in the characteristics of the fabric and the mechanical properties of the tissues lead to requirements for frequent measurements and corresponding adjustments of the applied pressure. Existing sensors are not sufficiently small, thin, or flexible for practical use in this context, and they also demand cumbersome, hard-wired interfaces for data acquisition. Here, we introduce a flexible, wireless monitoring system for tracking both temperature and pressure at the interface between the skin and the TCGs. Detailed studies of the materials and engineering aspects of these devices, together with clinical pilot trials on a range of patients with different pathologies, establish the technical foundations and measurement capabilities.

Management of venous ulcers according to their anatomical relationship with varicose veins

Background

Adequately excising varicose and incompetent perforating veins is necessary for reducing their recurrence rate of venous ulcer.

Method

In total, 66 venous ulcers (C6) in 1083 legs with primary varicose veins were managed through endoscopic-assisted surgery. In an endoscopic operative view, the nonvaricose, varicose, and incompetent perforating veins were clearly visualized and precisely dissected. The varicose and incompetent perforating veins were divided and completely excised.

Result

The varicose veins were traced to the base or periphery of the 55 ulcers. Moreover, 89.4% of the ulcers healed within 14 weeks. Kaplan–Meier analysis revealed a five-year recurrence rate of 0.0%, and the satisfaction mean score was 4.6.

Conclusion

Endoscopic-assisted surgery can be used to radically excise varicose veins complicated with venous ulcers; the surgery yields low recurrence and high satisfaction rates.

Clinical interventions for venous leg ulcers: Proposals to improve the quality of clinical leg ulcer research

The present status of clinical leg ulcer healing research was reviewed by 25 experts over 2 days on September 28 and 29, 2015. Multiple clinical effectiveness reviews were presented suggesting that published clinical wound healing research often does not meet present (2015) evidence based standards. Specific areas requiring remediation were highlighted and approaches to overcoming existing challenges were proposed. Participants using anonymous voting technology developed an action plan to resolve perceived deficiencies. Statements were accepted if 75% of participants agreed. Older patients with a high frequency of comorbid conditions posed particular difficulties in designing clinical research protocols and better diagnostic categorization is necessary A standardized model template for collecting information about diagnosis and evaluation of the effect of interventions on healing of all types of leg ulcers was considered a high priority. Such a model template could be modified depending on the specific etiology of the leg ulcers. Generally agreed on quantifiable standards to establish degree of morbidity was considered a high priority. There was universal agreement that sources of funding and conflicts of interest needed to be disclosed in presentations and all publications. All clinical research studies should be registered with appropriate authorities. There was substantial enthusiasm for a clinical research network with quality standards for membership and an advisory research core available to investigators. Such a network should be funded and actively managed to insure long-term viability. The governance of such an entity needs to be established by the wound care community. The present trend to integrate patients into the clinical research process was endorsed and there was enthusiasm to develop patient advocacy for wound healing research.

Surgical management for venous leg ulcers: The role of hope, investment and agency

A recent systematic review suggests that minimally invasive venous surgery for the treatment of leg ulcers may have a greater impact on quality of life than traditional approaches. A total of 11 participants who had previously undergone surgical management for leg ulcers took part in semi-structured interviews regarding their experiences. Using thematic analysis, three themes were identified: 'Living in Flux', 'Perceptions of Chronicity' and 'Expectations'. Surgical treatment may not only improve patients' quality of life due to treatment of the condition but also by opening up a sense of hope, investment and agency not associated with traditional treatment approaches.

Venous intervention in chronic venous ulcer treatment and recurrence avoidance

In this brief overview I will progress from superficial venous intervention for venous leg ulcers (VLU) to perforator intervention and finally to deep venous intervention. But first there are a number of concepts that must be accepted. We know that 70 % of patients with leg ulcers have a venous component (1), and in at least 40 % of those patients, ulcers will be caused by superficial venous insufficiency alone or in combination with perforator incompetence (2). Such patients will likely benefit from treatment of their superficial venous disease.

One of the most important but often overlooked factors in venous ulcers is calf pump failure. Simka has reported that 45 % of patients with venous ulcers have calf pump failure (3).

Thorough duplex evaluation of the venous leg ulcer patient is paramount for accurate diagnosis, the differentiation between arterial and venous components (purely arterial, venous, or mixed etiology), and the obstructive and/or incompetent nature and location of venous lesions. In obstructive venous lesions the degree of obstruction as well as how proximal the lesion extends must be known. For venous insufficiency the location (deep and/or superficial venous system) and the extent (segmental or axial) will help determine how much the incompetence contributes to the overall ulcer condition, and what lesions can be safely treated.

Medical and surgical treatment of chronic venous ulcers

Venous ulcer of the lower extremity is a common vascular condition and is associated with decreased quality of life, reduced mobility, and social isolation. Treatment of chronic venous ulcer (CVU) includes compression therapy, debridement of the ulcer when necessary, and wound care. Collagen and antimicrobial dressings can improve the proportion of ulcers healed compared with compression alone. Acellular skin equivalents are not superior to compression, but cellular human skin equivalents can promote more rapid healing, particularly in patients with longstanding ulcers. Current vascular surgical practice is to eliminate documented reflux or obstruction in patients with CVU that have failed a 3-month period of compression dressing, debridement, and local wound care. We found that surgical treatment of the superficial venous system can decrease the time to healing of CVUs compared with compression therapy alone, but does not increase the proportion of ulcers healed.

The comparative impact of conservative treatment versus superficial venous surgery, for the treatment of venous leg ulcers: A systematic review of the impact on patients’ quality of life

Objectives

Leg ulcers are known to have a profound effect on patients’ quality of life; however, the influence of different treatment approaches is unclear. This review aims to evaluate the comparative impact of conservative treatments and superficial venous surgery, for venous leg ulcers, on patients’ Quality of Life.

Data sources

Three electronic databases (PsycInfo, Medline and CINAHL), and reference lists of relevant articles, were searched. A total of 209 articles were initially identified, and 16 articles were included in the review.

Results

The results lend cautious support to the suggestion that all treatments have a positive effect on quality of life, regardless of type, whilst wound status also appears to be an important factor.

Conclusions

Some evidence suggests that surgical treatment methods may lead to greater improvements in patients’ quality of life than compression bandaging alone; however, future research may focus on the psychological mechanisms underlying such changes.