Venous ulceration: active approaches to treatment

Preventing Venous Ulcer Recurrence: The Impact of the Well Leg Clinic

Background:

The aim of this prospective study was to evaluate the effectiveness of a nursing-led clinic within a District Hospital setting in detecting early skin break-down in healed venous ulcers.

Patients and Methods:

A total of 76 patients (45 women, 31 men; age range 24-91 years, mean 74 years) with healed venous ulcers were included in the study between July 1999 and April 2001. Patients were counselled about managemant of ulcers at their initial visit and followed up at 3 and 6 months.

Results:

We received 79 referrals and of those 76 (96%) accepted our invitation. Fifty-six patients did attend the first clinic appointment, 39 (67%) attended their second clinic visit at 3 months and 38 (68%) were followed up by a telephone call at 6 months. During this period 9 recurrent leg ulcers were noted which were referred for further intervention.

Conclusion:

It is important to provide follow-up for patients with healed ulcers in order to minimise the recurrence rate and to re-institute treatment soon, as recurrence can occur early following healing.

Low-intensity laser therapy/combined phototherapy in the management of chronic venous ulceration: a placebo-controlled study

OBJECTIVE

The current placebo-controlled study was undertaken to investigate the efficacy of combined phototherapy and low-intensity laser therapy (LILT) in the management of chronic venous ulceration when used in conjunction with standardized nursing intervention.

MATERIALS AND METHODS

Approval was granted by Research Ethical Committees at the University of Ulster and Altnagelvin Hospitals Health and Social Services Trust. Patients (n = 15; 10 female/5 male; age +/- SD = 69.9 +/- 13.8 years) were recruited from an outpatient "leg ulcer clinic," where they attended once per week for irradiation/sham treatments for 4 weeks. Treatment was withheld for a total of 8 weeks, and patients were reviewed during this time (weeks 8 and 12) for ulcer and pain assessment only. A multisource diode array (660-950 nm) was used for irradiation; parameters were kept constant for the duration of the study (532 mW; 5 kHz; 12 J/cm(2)). Wound and pain assessment were carried out by an independent investigator. Digitizing was used to quantify surface areas from wound tracings.

RESULTS

Although there was no statistically significant difference between Treatment and Placebo groups, an apparent clinical difference in wound healing rate was noted; at postirradiation, a continued reduction in wound size was evident for the treatment group. These effects were believed to be due to an apparent delayed effect. There was no statistically significant difference between groups for pain.

CONCLUSION

These findings provide only limited evidence for the use of this modality as an adjunctive therapy with current nursing intervention. Further group studies are indicated to investigate the apparent delayed effect reported here for various etiologies of ulceration.

Target selection for surgical intervention in severe chronic venous insufficiency: comparison of duplex scanning and phlebography

PURPOSE

The goal of this study was to determine whether duplex scanning (DS) alone, compared with ascending phlebography (AP) and descending phlebography (DP), would have been sufficient to guide treatment of severe chronic venous insufficiency (CVI), CEAP Clinical Classes 5 and 6.

METHODS

Beginning in 1994, patients presenting to the VA Sierra Nevada Vascular Clinic with ulceration due to CVI, CEAP Clinical Classes 5 and 6, were examined with DS, AP, and DP. Phlebography mainly guided surgical interventions. The ability of DS findings to select surgical interventions, with the aims of diversion of reflux from area of trophic skin or reduction of global venous hypertension was compared with phlebography. Of the 33 male patients (age, 29-70 years; average, 55 years) considered for operative interventions between January 1994 and November 1999, 30 were selected for operative treatment.

RESULTS

DS was 100% sensitive and specific for detection of complete occlusion of the superficial femoral vein (10/10) and for saphenous incompetence; sensitivity was 95% (19/20); and specificity was 100%. However, DS failed to reveal subtle changes in recanalized femoral veins because of prior thrombophlebitis, which was uncovered by AP in six of 23 patent femoral veins. There were 16 positive findings on AP of residual thrombophlebitis, of which six were not read on DS. Sensitivity was 63%, specificity was 100%, the positive predictive value was 100%, and the negative predictive value was 53%. Reflux grading with DP agreed with DS in 23 of 33 cases or varied by one grade in five of 33 cases: sensitivity, 82%; specificity, 75%; positive predictive value, 96%; and negative predictive value, 37%. Kistner grade 4 reflux involving the superficial femoral and popliteal veins was noted by DP in five of the 33 cases when DS described reflux as "moderate." Incompetent superficial femoral vein valve stations in the upper third of the vein, which caused primary reflux, were clearly defined by DP in four of 33 cases; valve location was not well defined by DS. Below-knee perforator identification with DS was difficult; this was related to the severity of lipodermatosclerosis and the presence of ulceration. The number of perforators described at operation with subfascial endoscopic perforator surgery (n = 13) averaged 6 +/- 2, whereas AP identified an average of 4 +/- 2 in supramalleolar area. In four men, two previously undiagnosed caval and two iliac obstructions were detected with AP; one was corrected with Palma bypass grafting. Follow-up at 4 to 60 months (average, 40 months) showed four ulcer recurrences among 30 patients who were operated on. Two patients underwent repeat operations on the basis of repeated phlebographic study and are cured at this time, one patient was healed with conservative therapy, and one patient is lost to follow-up.

CONCLUSIONS

DS would have been inadequate for identifying surgical targets in CVI, CEAP Clinical Classes 5 and 6. DS overlooked iliac and caval lesions. Potential valveplasty sites, which were only delineated on DP, resulted in four valveplasties in the upper third of the superficial femoral vein for grade 4 reflux. AP localized mid- to upper-leg perforators, but neither AP nor DP detected perforators in the range of 5 to 10 cm above the calcaneus. The net effect of phlebography was a choice for deep interventions in five (17%) of 30 cases, which would not have been possible with DS alone. The identification of iliocaval occlusion influenced the decision, based on prior experience, not to perform distal procedures in three cases.

Living with chronic venous leg ulcers: a descriptive study of knowledge and functional health status

A descriptive design was used to identify the functional health status and knowledge level of individuals living at home with chronic venous leg ulcers (N = 21). Limitations in physical function and vitality were moderate to severe, impacting on study participants' productive activities and activities of daily living. Severe to moderate pain was experienced by 19% of the participants. In addition, knowledge deficits were apparent regarding the cause and treatment of leg ulcers. Findings of this study suggest the importance of assessing these factors in addition to the wound when caring for individuals in the community with chronic venous leg ulcers.

Explanatory model of chronic venous disease in the rural Midwest--a factor analysis

Advanced practice nurses caring for patients with venous disease may not be aware of the patient's understanding of illness, including the disease process, treatment, or outcomes. The advanced practice nurse uses his or her interpretation of illness to teach patients. Greater congruence between the nurse's and patient's understanding may result in enhanced communication, learning, and adherence. Exploration of the patient's reality may provide insight into a unique view of illness that may or may not be congruent with the biomedical model of disease. The current investigation attempts to identify an explanatory model of illness for chronic venous disease, by using the researcher-developed Diseases of Veins Explanation Survey. Data from a nonprobability sample of 114 primarily white, rural Midwestern, well-educated patients with medically confirmed and patient-acknowledged venous disease was collected at 7 sites. Twelve (10.5%) patients were men and 102 (89.5%) were women. Age range was 18 to 81 years. The factor analysis is presented. Elements of illness according to Kleinman (factors) did not fit within Kleinman's explanatory model of illness categories identified a priori in the instrument.

Warm-Up Active Wound Therapy: a novel approach to the management of chronic venous stasis ulcers

This preliminary study investigates the use of a radiant-heat bandage, Warm-Up Active Wound Therapy, as a new approach to the treatment of patients with chronic venous ulcers. Thirteen patients were randomly assigned to either conventional therapy or Warm-Up Active Wound Therapy for inpatient treatment of chronic venous stasis ulcers. Our results indicated that Warm-Up Active Wound Therapy is more effective than conventional therapy in healing chronic venous ulcers, and patients reported a significant reduction in wound pain. Warm-Up Active Wound Therapy also was found to be a safe treatment modality with no adverse events occurring in any patient.

Experience with open-heeled Unna boot application technique

One of the most common and effective treatments for venous stasis ulcers (VSUs) is the Unna boot dressing (UBD), first described by Unna in the 1890s. No one technique for UBD application has been documented by research to be the most effective for ulcer healing. This article discusses the open-heeled UBD application technique. Twelve patients with 17 VSUs that have been treated with the open-heeled UBD application technique are reviewed. The patients were primarily treated by the first author. Detailed patient education instructions are given. The open-heeled UBD is easier to apply patients are more comfortable and can fit into their normal shoewear condition of the heel can be monitored while the UBD is in place, and specially trained practitioners can apply UBDs with minimal to no compression on patients with concomitant venous arterial insufficiency. Ambulatory patients can also maintain greater ankle mobility during treatment. This may have important implications for activating the muscle pump under compression, which can facilitate blood return and reduce venous hypertension while the patient with venous stasis ulcer is ambulatory. The open-heel method may also allow greater mobility of the ankle that can help prevent "frozen" ankles associated with VSUs.