Quality of Life in Patients with Venous Leg Ulcers Treated by Means of Local Hyperbaric Oxygen Therapy or Local Ozone Therapy-A Single Center Study

Background and Objectives: Venous leg ulcers pose a significant medical problem worldwide. The complexity of the problem determines the need for further interdisciplinary activities that will improve the quality of life for treated patients. This study compared the quality of life of patients with venous leg ulcers who received local hyperbaric oxygen therapy or local ozone therapy procedures as part of comprehensive treatment. Materials and Methods: The study included 129 patients (62 men and 57 women) with venous leg ulcers. Group I underwent local hyperbaric oxygen therapy (HBOT), and Group II underwent local ozone therapy (OZONE). In both groups, the patients' quality of life was assessed before the start of the treatment cycle, as well as 10 weeks and 6 months after the completion of the treatment, by means of the EQ-5D-5L questionnaire and the Polish shortened version of the SF-36 scale. Results: After completing the respective therapeutic cycle, both groups showed statistically significant (p < 0.001) improvement in quality of life, according to the EQ-5D-5L questionnaire and the SF-36 scale. Differences were noted between the 1st examination (before treatment) and the 2nd examination (10 weeks after treatment), as well as the 3rd examination (6 months after treatment). In the EQ-5D-5L assessment of anxiety and depression, self-care, and activities of daily living 6 months after the end of treatment, better results were found in the group of patients treated with local hyperbaric oxygen therapy (p < 0.001). In this group, 6 months after the end of the treatment, a statistically significantly higher result on the EQ-VAS scale was also obtained (73.09 ± 19.8 points vs. 68.03 ± 17.37 points, p = 0.043). However, in the SF-36 assessment performed 6 months after the end of treatment, better results-a statistically significantly lower value of the quality of life index-were recorded in the group of patients treated with local ozone therapy (103.13 ± 15.76 points vs. 109.89 ± 15.42 points, p < 0.015). Conclusions: Hyperbaric oxygen therapy and local ozone therapy procedures have a beneficial effect on improving the quality of life of patients with venous leg ulcers.

Effect of hyperbaric oxygen therapy on the patients with venous leg ulcer: A systematic review and meta-analysis

This systematic review and meta-analysis aim to explore the adjuvant effect of hyperbaric oxygen therapy (HBOT) in patients with venous leg ulcer (VLU) undergoing surgeries and non-surgeries. Literatures were searched from Web of Science, Cochrane Library, Embase, Pubmed, Wan fang, China National Knowledge Infrastructure (CNKI), and VIP from inception to November 15, 2022. The risk ratio (RR) and weighted mean difference (WMD) were used as effect size for categorical variables and continuous variables, respectively, with 95% confidence interval (95%CI). The heterogeneity was assessed using Q-test and quantified as I2. Sensitivity analysis was performed for all outcomes. A total of 11 studies were finally included in this study, with a total of 617 patients (313 in the HBOT group and 304 in the control group). Results showed that HBOT in combination with surgeries was associated with shorter ulcer healing time (WMD: -13.76, 95%CI: -20.42 to -7.10), lower VAS score (WMD: -0.95, 95% CI: -1.83 to -0.07), and smaller ulcer area (WMD: -2.64, 95%CI: -3.86 to -1.42). HBOT in combination with non-surgeries was associated with higher ulcer PAR (WMD: 20.82, 95%CI: 5.86 to 35.79), but no statistical significance was found in the improvement of ulcer area (WMD: 0.79, 95% CI: -1.54 to 3.12). Our results indicating that HBOT had a good adjuvant effect in surgeries to treat VLU, and its effect in non-surgeries needed further studies.

Percutaneous mechanical thrombectomy to remove post-thrombotic obstructions and manage post-thrombotic syndrome-associated venous leg ulceration

BACKGROUND

Up to one half of patients with a diagnosis of deep vein thrombosis will develop post-thrombotic syndrome (PTS). Patients with PTS can develop venous leg ulcers (VLUs) due to post-thrombotic obstructions (PTOs) that contribute to prolonged ambulatory venous hypertension. The current treatments for PTS, which include chronic thrombus, synechiae, trabeculations, and inflow lesions, do not target PTOs, and such obstructions can affect stenting success. The aim of the present study was to determine whether removal of chronic PTOs using percutaneous mechanical thrombectomy would promote VLU resolution and positive outcomes.

METHODS

In this retrospective analysis, the characteristics and outcomes for patients with VLUs secondary to chronic PTO who were treated using the ClotTriever System (Inari Medical) between August 2021 and May 2022 were assessed. Technical success was considered the ability to cross a lesion and introduce the thrombectomy device. Clinical success was defined as a decrease of ≥1 in the severity category for the ulcer diameter using the revised venous clinical severity score (score 0, no VLU; score 1, mild VLU [size <2 cm]; score 2, moderate VLU [size 2-6 cm]; score 3, severe VLU [size >6 cm]) at the latest follow-up visit.

RESULTS

A total of 11 patients with 15 VLUs on 14 limbs were identified. Their mean age was 59.7 ± 11.8 years, and four patients (36.4%) were women. The median VLU duration was 11.0 months (interquartile range [IQR], 6.0-17.0 months), and 2 patients had VLUs secondary to a deep vein thrombosis event >40 years previously. All treatments were performed in a single session, with technical success achieved in 100% of the 14 limbs. A median of five passes (IQR, four to six passes) with the ClotTriever catheter were performed per limb. Chronic PTOs were successfully extirpated, and intraprocedural intravascular ultrasound showed effective disruption of venous synechiae and trabeculations. Stents were placed in 10 limbs (71.4%). The time to VLU resolution or the latest follow-up was 12.8 ± 10.5 weeks, and clinical success was achieved for all 15 VLUs (100%), with the revised venous clinical severity score for the ulcer diameter improving from a median of 2 (IQR, 2-2) at baseline to a median score of 0 (IQR, 0-0) at last follow-up. The VLU area had decreased by 96.6% ± 8.7%. Of the 15 VLUs, 12 (80.0%) had resolved completely, and 3 had demonstrated near-complete healing.

CONCLUSIONS

All patients showed complete or near-complete VLU healing within a few months after mechanical thrombectomy. Mechanical extirpation and interruption of chronic PTOs allowed for luminal gain and restoration of cephalad inflow. With additional investigation, mechanical thrombectomy with the study device could prove a vital component to the treatment of VLUs secondary to PTOs.

Examining risk factors and preventive treatments for first venous leg ulceration: A cohort study

BACKGROUND

Large studies that examine risk factors for first occurrence of venous leg ulcerations are needed to guide management.

OBJECTIVE

To investigate factors associated with development of first occurrence of venous leg ulcerations.

METHODS

A retrospective cohort study using a validated national commercial claims database of patients with venous insufficiency. Subjects were followed to determine whether they developed first occurrence of venous leg ulcerations, and risk and protective factors were analyzed.

RESULTS

Adjusted hazard ratio (AHR) for comorbidities demonstrated an increased risk in men (AHR 1.838; 95% confidence interval [CI] 1.798-1.880), older age (45-54 years: AHR 1.316, 95% CI 1.276-1.358; 55-64 years, AHR 1.596, 95% CI 1.546-1.648), history of nonvenous leg ulceration (AHR 3.923; 95% CI 3.699-4.161), anticoagulant use (AHR 1.199; 95% CI 1.152-1.249), antihypertensive use (AHR 1.067; 95% CI 1.040-1.093), and preexisting venous insufficiency including chronic venous insufficiency (AHR 1.244; 95% CI 1.193-1.298), edema (AHR 1.224; 95% CI 1.193-1.256), and chronic venous hypertension (AHR 1.671; 95% CI 1.440-1.939). Possible protective factors were having venous surgery (AHR 0.454; 95% CI 0.442-0.467), using compression stockings (AHR 0.728; 95% CI 0.705-0.753), using prescribed statin medications (AHR 0.721; 95% CI 0.700-0.743), and using pain medications (AHR 0.779; 95% CI 0.757-0.777).

LIMITATIONS

Risk of misclassification, given the use of International Classification of Diseases, Ninth Revision codes. Possible confounding factors such as body mass index could not be adequately controlled with these codes.

CONCLUSION

The new evidence presented supports a paradigm shift toward venous leg ulceration prevention.

Assessment of the use of Unna boot in the treatment of chronic venous leg ulcers in adults: systematic review protocol

INTRODUCTION

Chronic venous insufficiency (CVI) is an anomaly of the normal functioning of the venous system caused by valvular incompetence with or without the obstruction of venous flow. This condition can affect either or both of the superficial and the deep venous systems. Venous dysfunction can even result in congenital or acquired disorders, and its complications include venous leg ulcers (VLUs). The objective of this systematic review is to determine the effectiveness of Unna boot in the treatment of wound healing of VLU by assessing the quality of the available evidence.

METHODS AND ANALYSIS

A literature search in PubMed, CINAHL, Scopus, Web of Science, Cochrane Library, BVS/BIREME, Embase, ProQuest, BDTD, Thesis and Dissertation Catalog, Sao Paulo Research Foundation/Thesis and dissertation, OPEN THESIS, A service of the US National Institute of Health, Center for Reviews and Dissemination-University of New York and SciElo published in the last 10 years, the period from January 1999 to March 2019. The review will include primary studies (original), and Controlled Trials or Observational studies (cross-sectional, case-control or longitudinal studies) with VLU. The exclusion will include leg ulceration due to different causes, such as pressure, arterial, diabetic or mixed-aetiology leg ulcers. Data synthesis will be performed using a narrative summary and quantitative analysis.

ETHICS AND DISSEMINATION

This systematic review does not require approval by the ethics committee, as individual patient data will not be collected. Dissemination of findings will be through publications in peer-reviewed journals and/or via conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42019127947.

Prothrombotic clot properties can predict venous ulcers in patients following deep vein thrombosis: a cohort study

Venous ulcers are the most severe manifestation of post-thrombotic syndrome (PTS). We have previously demonstrated that formation of compact fibrin clots resistant to lysis is observed in patients following deep-vein thrombosis (DVT) who developed PTS. The current study investigated whether unfavourable fibrin clot properties can predict post-thrombotic venous ulcers. In a cohort study on 186 consecutive patients following DVT, we determined plasma fibrin clot characteristics, including clot permeability and lysability, inflammatory markers, thrombin generation, fibrinolysis proteins at 3 months since the index event. Occurrence of PTS and venous ulcers was recorded during follow-up (median, 53; range 24 to 76 months). Fifty-seven DVT patients (30.6%) developed PTS, including 12 subjects (6.45%) with a venous ulcer (4 individuals with recurrent ulcers). Patients who developed ulcers compared with the remainder had at enrolment 13.0% lower clot permeability (Ks), 17.4% longer clot lysis time (CLT), 13.1% longer lag phase of clot formation, and 5.0% higher maximum absorbance, with no difference in fibrinogen, C-reactive protein, and thrombin generation. The baseline prothrombotic fibrin clot phenotype (Ks ≤ 6.5 × 10-9 cm2 and CLT > 100 min) was associated with a higher risk of ulcers [hazard ratio (HR), 5.37; 95% confidence interval (CI), 1.3-21.5]. A multivariate model adjusted for age, sex, and fibrinogen showed that independent predictors of the ulcer occurrence were body mass index (HR 1.53; 95% CI 1.30-1.86), CLT (HR 1.43; 95% CI 1.04-2.05), and α2-antiplasmin (HR 0.95; 95% CI 0.90-0.99). This study suggests that formation of denser fibrin clots with impaired fibrinolysis predisposes to post-thrombotic venous ulcers.

Protocol for a longitudinal cohort study: determination of risk factors for the development of first venous leg ulcer in people with chronic venous insufficiency, the VEINS (venous insufficiency in South Florida) cohort

INTRODUCTION

Chronic venous insufficiency (CVI) affects up to one-third of the adult population yet venous leg ulcers (VLU), a significant complication of CVI, only affect 1%-2% of adults in the USA. Why some develop VLU and others do not is unclear. VLU have a significant impact on quality of life and are extremely costly and difficult to treat. Moreover, VLU prevalence is increasing, doubling in the last 20 years. In order to characterise the differences between people with CVI and those who ultimately develop VLU, we aim to set up the unique venous insufficiency in South Florida cohort.

METHODS AND ANALYSIS

Subjects will be recruited from the University of Miami Hospital and Clinic's vascular laboratory database, which began in July 2011. Any adult age 18-95 who has had venous reflux detected on duplex ultrasound of the lower extremities is included. Approximately 2500 patients are already in the database that meet these criteria, with an estimated 2500 additional potential subjects to be recruited from the vascular laboratory database over the next 5 years. Subjects with a history of VLU prior to the duplex study date will be excluded. Data will be collected via review of the Doppler study report, patient phone interview and review of the electronic medical record. Subjects will be contacted for follow-up every 3 months for at least 5 years until the study endpoint, development of first VLU (fVLU), is reached. In order to estimate the time from reflux documentation to fVLU, Kaplan-Meier survival curves will be constructed. Cox proportional hazard regression models will be constructed to investigate possible risk factors.

ETHICS AND DISSEMINATION

This study is approved by the University of Miami's Institutional Review Board. We hope to present the results of this study to the scientific community at conferences and in peer-reviewed journals.

Can early detection prevent venous leg ulceration?

Venous leg ulceration is the most common form of leg ulceration, affecting 1.5% of the UK adult population. This was reviewed within the latest best practice statement (2016) which set out to create clear guidance on the assessment, management and preventing the reoccurrence of venous leg ulceration. With a growing elderly population at risk of venous insufficiency, early identification of those at risk is vital in the fight to reduce the number of people suffering with chronic venous ulceration. This article looks at the need for early assessment and commencement of appropriate treatment in order to reduce the occurrence of venous ulceration and improve clinical processes across the UK.

Surgical Scarring after Arterial Bypass, an Etiology of Venous Hypertension

Venous ulcers can be a chronic debilitating condition with a high rate of recurrence. Herein, we describe a case of a patient who successfully underwent an arterial bypass for rest pain but returned with lower extremity swelling and venous ulcers. Venography demonstrated a focal common femoral vein stenosis due to scarring from the surgical exposure. This was treated with endovenous stenting and resulted in resolution of the swelling and ulceration.

Utilization of a Viable Human Amnion Membrane Allograft in Elderly Patients With Chronic Lower Extremity Wounds of Various Etiologies

ntroduction. Chronic nonhealing wounds are a growing health care problem in the United States, afflicting more than 6.5 million patients annually. In particular, diseases that compromise skin integrity and impair normal wound healing processes, such as diabetes and peripheral vascular diseases, are becoming more common in the aging population and leading to ever-increasing incidence of these chronic nonhealing wounds.

OBJECTIVE

The aim of this study is to evaluate a viable human amnion membrane allograft (vHAMA) for the treatment of chronic nonhealing wounds in elderly patients (aged > 65 years) with multiple comorbidities.

MATERIALS AND METHODS

Four patients (age range, 69-85 years) with 5 chronic wounds of varying etiologies and sizes (2 traumatic wounds, 2 diabetic foot ulcers, and 1 venous leg ulcer) that persisted for at least 4 weeks and failed previous treatment with standard of care were included in this study. Comorbidities included diabetes mellitus, obesity, polymyalgia rheumatica, lymphedema, peripheral vascular disease, steroid use, and neuropathy. All patients received vHAMA once weekly or as deemed appropriate.

RESULTS

All patients reached complete wound closure with no complications or adverse events. Mean time to closure was 4.8 weeks (range, 2-8 weeks) with an average of 4.2 grafts (range, 1-8). There was no wound recurrence.

CONCLUSIONS

Successful closure of wounds indicates the use of vHAMA may be beneficial for treatment of chronic wounds in elderly patients with comorbidities.

Chronic Venous Insufficiency and the Therapeutic Effects of Daflon 500 mg

Chronic venous insufficiency is linked to venous hypertension and forces of shear stress on the endothelium. Venous hypertension depends upon two forces: the weight of a column of blood from the right atrium transmitted through the valveless vena cava and iliac veins to the femoral vein, and pressure generated by contracting skeletal muscles of the leg transmitted through failed perforating veins. When valve failure occurs in superficial axial veins and perforating veins, the venous pressure in the veins and venules of the skin and subcutaneous tissue is raised. The skin changes in chronic venous insufficiency are directly related to the severity of the venous hypertension. Also, pathologic changes in the valves are linked to venous hypertension and leukocyte infiltration and activation. It is hypothesized that acute venous pressure elevations cause a shift in the venous hemodynamics with changes in wall shear stress. This initiates the inflammatory cascade. Daflon 500 mg ameliorates the effects of chronic inflammation. In randomized trials, 60 days of therapy with Daflon at a dosage of 500 mg 2 tablets daily was effective, in addition to elastic compression, in accelerating venous ulcer healing. Because venous insufficiency is linked to venous hypertension and an inflammatory reaction, it appears that Daflon 500 mg 2 tablets daily shows a great potential for accomplishing blockade of the inflammatory cascade.

Improvement of Microcirculation and Healing of Venous Hypertension and Ulcers With Crystacide ®: Evaluation With a Microcirculatory Model, Including Free Radicals, Laser Doppler Flux, and PO2/PCO2 Measurements

In 32 patients with chronic venous insufficiency and venous hypertension associated with ulcerations, the effects of the local application of a hydrogen peroxide cream (Crystacide) applied onto the skin was evaluated using a complex, proportional, microcirculatory model to assess and quantify venous microangiopathy after local treatment. A comparative group treated without Crystacide was included. Laser Doppler flowmetry was used to assess skin perfusion (flux and venoarteriolar response) in association with transcutaneous PO2 and PCO2 measurements. Local plasma free radicals were evaluated in the area surrounding the venous ulcer using the D-Roms test. Crystacide was applied around and on the ulcer for 10 days. Crystacide was more effective than the control treatments. PO2 was increased (improved, P < .05), and plasma free radicals, PCO2, and laser Doppler flowmetry were decreased (improving toward normal values, P < .05). Also, the ulcerated area was significantly smaller at 10 days in the Crystacide group in comparison with controls (P < .05). In the proportional microcirculatory model, all parameters indicated an important level of improvement significantly larger than in controls. In conclusion, in chronic venous insufficiency and venous ulcerations, local treatment with Crystacide (10 days) improves the microcirculation and decreases skin free radicals, thus improving healing.

Reflux from Thigh to Calf, the Major Pathology in Chronic Venous Ulcer Disease: Surgery Indicated in the Majority of Patients

The aim of this study was to define the underlying anatomical and pathophysiological conditions in limbs with venous ulcers in order to get information for the most appropriate treatment selection. Ninety-eight limbs (83 patients, 59 men), with active chronic venous ulcers, were analyzed retrospectively and classified according to the CEAP (clinical, etiological, anatomical, and pathophysiological) classification. Duplex-ultrasound was performed in all patients, while air-plethysmography and venography were performed selectively on potential candidates for deep venous reconstruction. Sixty-six ulcers were primary in origin and 32 were secondary. Reflux was present in all limbs except 1. Isolated reflux in 1 system (superficial = 3, deep = 4, perforator = 3) was seen in 10 legs (10%), while incompetence in all 3 systems was seen in 51 legs (52%). Superficial reflux with or without involvement of other systems was seen in 84 legs (86%), 72 legs (73%) had deep reflux with or without involvement of other systems, and incompetent perforator veins were identified in 79 limbs (81%). Axial reflux (continuous reverse flow from the groin region to below knee) was found in 77 limbs (79%). The femoral vein was the single most common deep venous segment in which either reflux or obstruction was found. Axial distribution of disease was found in the majority of cases and no patient had isolated deep venous incompetence below knee. Primary disease was the predominant etiologic cause and reflux was the main pathophysiological finding. Practically all patients were found to have 1 or more sites of reflux or obstruction that could benefit from operative treatment.

Patterns of Venous Reflux and Obstruction in Patients With Skin Damage Due to Chronic Venous Disease

Identified were characteristics of individuals with skin damage related to chronic venous disease. Patients with chronic venous disease (n = 164) were evaluated with duplex ultrasound imaging and were placed in classes 4, 5, and 6 according to the CEAP classification. Their findings were compared with 100 class 2 controls. The prevalence of deep venous thrombosis was higher in the study group (23.7%) versus controls (5.1%; P < .0001), as was the prevalence of deep, perforator, and combined patterns of disease ( P < .0001, P < .0007, and P < .0001). The mean duration of disease in controls 2 was shorter compared with the study group ( P = .0019). The prevalence of reflux and obstruction within the study group was higher than in controls ( P = .0021). Skin changes accurately reflect severity of chronic venous disease. Superficial and perforator vein reflux is the major cause of disease.

Congenital absence of infrarenal inferior vena cava and deep veins of the lower limbs: a case report

BACKGROUND

Congenital anomalies of the venous system are known but congenital absence of infrarenal inferior vena cava with absent deep venous system of the lower limbs is extremely rare.

CASE PRESENTATION

We report the case of an 11-year-old Indian girl who presented with large venous collaterals on her anterior abdominal wall and recurrent non-healing venous ulcers on her left leg with complete absence of infrarenal inferior vena cava and absent deep veins of her lower limbs.

CONCLUSIONS

Congenital absence of infrarenal inferior vena cava may occur with absence of the deep venous system of the lower limbs. We have reported this case because of its extreme rarity and to enhance awareness of this entity that has no treatment currently.

VENOUS ULCER--A NEW THERAPEUTIC APPROACH

Trophic leg ulcer is a major health problem affecting approximately 1-2% of the population, the incidence being higher in the elderly (70-80 years). It is a multifactorial condition, but the most common cause is chronic venous insufficiency. This can be attributed to reflux in the saphenous system and calf perforator vein incompetence. These were first described by Linton, the first intervention designed to correct perforator vein incompetence bearing his name. Today Linton's operation has been abandoned due to the large unaesthetic incision and great postoperative pain. Also, ulcer healing time is long (2 months) and recurrence rate is high. Currently a series of minimally invasive procedures are used to close these perforator veins, such as ultrasound-guided sclerotherapy. The advantages of these techniques are less discomfort to the patients, low rate of complications, short hospital stay.

Case 3: chronic venous leg ulcer

A non-healing, sloughy venous leg ulcer quickly responded to topical treatment including octenilin Wound Gel and octenilin Wound Irrigation Solution. Full healing occurred within 6 weeks.

[Current aspects of endothelial protection in treatment of patients with chronic venous insufficiency at the stage of trophic disorders]

The authors analysed the results of comprehensive examination and treatment of a total of 40 patients presenting with lower limb chronic venous insufficiency at the stage of trophic disorders (class C6), including 28 (70%) patients with varicose disease of lower extremities and 12 (30%) patients with post-thrombotic disease. Studying the microcirculatory blood flow by means of laser Doppler flowmetry showed a statistically significant (p<0.05) baseline decrease in the index of microcirculation in patients (12.2±2.4 perf. units for varicose disease and 10.8±1.8 perf. units for post-thrombotic disease) as compared with the control group of apparently healthy volunteers (20.4±1.5 perf. units). All stages of treatment included the program of stimulation of reparative processes and normalization of microcirculation by means of sulodexide. Conservative measures were independent therapeutic procedures in 31 patients. Of these, trophic ulcers completely epithelialized in 9 patients and decreased by half of its initial surface in 22 patients. The study of the microcirculatory blood flow in dynamics suggested improvement of microcirculation during treatment. Hence, comprehensive therapy using sulodexide in patients with venous trophic ulcers is accompanied by an endothelium-protecting effect and leads to improvement of the indices of microcirculation of the skin of the crus.

Treatment of Chronic Venous Ulcers Using New Four Layers Compressive Bandage Dressing

INTRODUCTION

Lower-extremity ulcers represent the largest group of ulcers presenting to an outpatient department. It is a cumbersome, difficult to treat disease, which causes high morbidity and huge cost for the patient and healthcare system. Current standard treatment includes compression therapy.  However, majority of patients need long term treatment with minimal efficacy. Aim of our study is to evaluate efficacy of four layers compressive bandages for the management of chronic venous ulcers.

METHODS

In Group A, we have prospectively included 20 patients with chronic venous ulcers on lower limbs for four layers hosiery bandage using Velfour bandage. Other 15 patients, Group B, were treated with conventional wound dressing. Velfour and crepe bandage were done once weekly for three weeks.

RESULTS

DVT was cause of chronic venous ulcer in 70% patient in group A and in 73.3% in Group B. Majority of patients were having left sided chronic venous ulcers. The mean duration of the ulcers was 15.6 vs 10.86 months (group A vs. group B). At the end of 3rd week, in 55% wounds in Group A were healed except few big and deep wounds remained. Most of these wounds also became smaller with minimal discharge. Size of wounds significantly decreased in Group A vs. Group B patients (0.7±0.81 cm vs. 1.73±0.77 cm, p<0.00031). However, cost of treatment in group A remained higher than group B.

CONCLUSIONS

Our study has shown that four layer compressive bandage using Velfour is an easy, effective, and reproducible method of treatment for the chronic venous ulcer.

CHIVA method for the treatment of chronic venous insufficiency

BACKGROUND

Many surgical approaches are available to treat varicose veins secondary to chronic venous insufficiency. One of the least invasive techniques is the ambulatory conservative hemodynamic correction of venous insufficiency method (cure conservatrice et hémodynamique de l'insuffisance veineuse en ambulatoire (CHIVA)), an approach based on venous hemodynamics with deliberate preservation of the superficial venous system. This is an update of the review first published in 2013.

OBJECTIVES

To compare the efficacy and safety of the CHIVA method with alternative therapeutic techniques to treat varicose veins.

SEARCH METHODS

The Trials Search Co-ordinator of the Cochrane Peripheral Vascular Diseases Group searched the Specialised Register (April 2015), the Cochrane Register of Studies (2015, Issue 3) and clinical trials databases. The review authors searched PubMed (April 2015). There was no language restriction. We contacted study authors to obtain more information when necessary.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared the CHIVA method versus any other treatments. Two review authors independently selected and evaluated the studies. One review author extracted data and performed the quantitative analysis.

DATA COLLECTION AND ANALYSIS

Two independent review authors extracted data from the selected papers. We calculated the risk ratio (RR), mean difference (MD), the number of people needed to treat for an additional beneficial outcome (NNTB), and the number of people needed to treat for an additional harmful outcome (NNTH), with 95% confidence intervals (CI) using Review Manager 5.

MAIN RESULTS

No new studies were identified for this update. We included four RCTs with 796 participants (70.5% women). Three RCTs compared the CHIVA method with vein stripping, and one RCT compared the CHIVA method with compression dressings in people with venous ulcers. We judged the quality of the evidence of the included studies as low to moderate due to imprecision caused by the low number of events and because the studies were open. The overall risk of bias across studies was high because neither participants nor outcome assessors were blinded to the interventions. The primary endpoint, clinical recurrence, pooled between studies over a follow-up of 3 to 10 years, showed more favorable results for the CHIVA method than for vein stripping (721 people; RR 0.63; 95% CI 0.51 to 0.78; I(2) = 0%, NNTB 6; 95% CI 4 to 10) or compression dressings (47 people; RR 0.23; 95% CI 0.06 to 0.96; NNTB 3; 95% CI 2 to 17). Only one study reported data on quality of life (presented graphically) and these results significantly favored the CHIVA method.The vein stripping group had a higher risk of side effects than the CHIVA group; specifically, the RR for bruising was 0.63 (95% CI 0.53 to 0.76; NNTH 4; 95% CI 3 to 6) and the RR for nerve damage was 0.05 (95% CI 0.01 to 0.38; I(2) = 0%; NNTH 12; 95% CI 9 to 20). There were no statistically significant differences between groups regarding the incidence of limb infection and superficial vein thrombosis.

AUTHORS' CONCLUSIONS

The CHIVA method reduces recurrence of varicose veins and produces fewer side effects than vein stripping. However, we based these conclusions on a small number of trials with a high risk of bias as the effects of surgery could not be concealed and the results were imprecise due to low number of events. New RCTs are needed to confirm these results and to compare CHIVA with approaches other than open surgery.

Pharmacological treatment and prevention of chronic venous ulcers: a review

Chronic venous insufficiency and chronic venous ulcers represent an important medical problem, because of the high incidence and prevalence in the general population, and need to be considered as a lifelong degenerative condition, with socioeconomic consequences. Ulceration is a severe complication of the post-thrombotic syndrome, often precipitated by minor trauma. The rate of post-thrombotic syndrome varies between 20% and 100% of patients with deep vein thrombosis, mostly occurring within two years of an initial thrombotic event. This syndrome is difficult to treat, causes significant disability and reduces the quality of life. To date, there are no effective therapies of chronic venous ulcers and no definite strategies for identifying patients at risk for the development of ulceration. The role of adequate compression with elastic stockings is well recognized. Several systemic drugs have been tested for a possible effect on chronic venous ulcer healing, but none has been widely accepted as standard therapy in this setting. It has been suggested that extended oral anticoagulation should be investigated as a possible preventative measure. Waiting for the results in this field, an adequate management of anticoagulation in terms of anticoagulant intensity and duration should be recommended for the prevention of recurrent deep vein thrombosis, post-thrombotic syndrome and chronic venous ulcers.

A cross-sectional pilot study to examine food sufficiency and assess nutrition among low-income patients with injection-related venous ulcers

Adequate nutrition has long been considered a critical component for wound healing, but literature regarding the relationship between nutrition and venous ulcer (VU) healing is limited. A person's nutrition is affected by the availability of food as well as his/her overall health. Food sufficiency and nutrition are important concerns in the care of persons of low income with injection-related VUs, which tend to be large and slow to heal. A cross-sectional pilot study was conducted to explore the relationship between food sufficiency/security and nutrition with regard to demographic, wound, quality-of-life, physical activity, falls, and fall risk variables. Nutrition was examined using 2 well-developed instruments that measure food sufficiency/security and assess nutrition--the United States Department of Agriculture's Adult Food Sufficiency Questionnaire (FSQ) and the Nestle Mini Nutritional Assessment (MNA). All participants (N = 31, 54% men, mean age 56.1 ± 3.6 years, all African American) were recruited from an outpatient clinic. All had injection-related VUs from a history of injecting illicit substances. In terms of food sufficiency/security, most participants (26, 84%) reported having enough food in the house, but 10 (32%) worried about running out of food. From 16% to 22.6% of participants expressed concern with food sufficiency/security in terms of cutting meal size, eating less, hunger, and weight loss. Food sufficiency/security was high for 19 (61.3%), but 12 (39%) had marginal or lower food sufficiency/security. MNA scores showed 16 participants (52%) were at risk of malnutrition or malnourished. Low food sufficiency/security was significantly (P <0.05) associated with less motivation for activity (r = -0.40) and less walking (r = -0.36). Better nutrition assessment scores were significantly associated (P <0.01) with fewer comorbidities (r = -0.57) and falls (r = -0.46) and with higher quality of life (r = 0.50), motivation for physical activity (r = 0.59), and balance confidence (r = 0.60). Both food security and nutrition assessment are important to assess in low-income persons with injection-related VUs. A number of significant relationships of the FSQ and MNA to other variables was found but needs further investigation with a larger sample.

Chronic venous disease cases at the Iaşi dermatology clinic

Chronic venous disease (CVD) is defined as a disturbance of blood return to the deep venous system, superficial venous system, and communicating (perforating) veins. Once present, CVD persists throughout life, so like heart failure it is nowadays considered "a condition for life". Severe CVD of the lower limbs is one of the most common medical problems, affecting up to 25% of the general adult population of industrialized countries.

AIM

to determine the incidence of CVD among the cases admitted to the Dermatology Clinic of the' "Sf. Spiridon" Emergency Clinical Hospital Iasi, CVD incidence by sex, age, area of residence and the main pathogens incriminated in super infection of ulcerative lesions.

MATERIAL AND METHODS

We did a retrospective study of patients admitted to the Dermatology Clinic of the Iasi "Sf. Spiridon" Emergency Hospital over a five years period.

RESULTS

Of the total number of patients admitted to our clinic (9375), 57% were diagnosed with CVD and 26.61% of them were with CEAP 6 class chronic venous insufficiency. There was an approximately equal sex distribution and most patients (44%) were older than 65 years.

CONCLUSIONS

We did a large epidemiological study of venous disease, based on revised CEAP classification, showing again that it is not only a very important medical problem, with various clinical manifestation and multidisciplinary approach, but also an important issue for health insurance system.

Management of venous leg ulcers in general practice - a practical guideline

BACKGROUND

Chronic venous leg ulcers are the most common wounds seen in general practice. Their management can be both challenging and time-consuming.

OBJECTIVE

To produce a short practical guideline incorporating the TIME concept and A2BC2D approach to help general practitioners and their practice nurses in delivering evidence-based initial care to patients with chronic venous leg ulcers.

CONCLUSION

Most chronic venous leg ulcers can be managed effectively in the general practice setting by following the simple, evidence-based approach described in this article. Figure 1 provides a flow chart to aid in this process. Figure 2 illustrates the principles of management in general practice.

DISCUSSION

Effective management of chronic ulcers involves the assessment of both the ulcer and the patient. The essential requirements of management are to debride the ulcer with appropriate precautions, choose dressings that maintain adequate moisture balance, apply graduated compression bandage after evaluation of the arterial circulation and address the patient's concerns, such as pain and offensive wound discharge.

[Nutrition and chronic wound healing. A clinical case of a patient with a hard to heal venous leg ulcers]

The cronicity of a wound can be produced by the alteration of several factors. One of the agents that can produce a delay in the wound healing process is malnutrition. According with the evidence, nutrition is an important factor in chronic wound prevention and treatment. The prevalence of low extremity wounds increases in population aged 65 or more. As we became older, malnutrition risk is more relevant due to physiological changes related to ageing. We describe a clinical case of a torpid venous leg ulcer in an elder patient centering on nutrition assessment and management.

Venous ulcer: risk factors and the Nursing Outcomes Classification

OBJECTIVE

To explore the relationship between the risk factors for the development of venous ulcers and the indicators of tissue integrity from the Nursing Outcomes Classification.

METHODOLOGY

A cross-sectional study conducted in 2013 in a university hospital in Natal/RN (Brazil). Fifty individuals selected by consecutive sampling participated in an interview and physical examination.

RESULTS

The most important risk factors were: 44% presented with arterial hypertension, 26% allergy, 20% diabetes mellitus, 4% participated in some physical activity, 6% were smokers and 14% drank alcohol. There was a statistically significant association between diabetes mellitus and the texture of the lesion (p=0.015) and tissue perfusion (p=0.026); allergy and texture (p=0.034); physical activity and hydration (p = 0.034); smoking and thickness (p = 0.018); and alcoholism and exudate of the ulcer (p=0.045).

CONCLUSION

. The relationship between risk factors and the nursing outcome indicators generated information relevant to the development of guidelines for the monitoring and treatment of venous ulcer information.

The effect of revascularization procedures on healing of mixed arterial and venous leg ulcers

AIM

The optimal management of venous leg ulcers in patients with concomitant peripheral artery disease (PAD) remains unclear. The aim of the present study was to evaluate the effectiveness of revascularization procedures in healing of the ulcers of mixed etiology.

METHODS

During a 6-year period a total of 20 patients with evidence of chronic venous insufficiency, impaired arterial perfusion (ABI<0.75) and active leg ulcer were treated. Patients with moderate PAD (0.5<ABI<0.75) were treated conservatively with modified compression and were considered for revascularization if the ulcer did not heal, while those with severe PAD (ABI<0.5) underwent revascularization.

RESULTS

Eleven out of seventeen (64.7%) limbs with moderate arterial disease showed a significant healing progress after modified compression and healed at an average time of 24.7±3.1 weeks, while the other 6 limbs (35.3%) failed to improve underwent revascularization and healed at an average time of 16±2.6 weeks. Three limbs with severe arterial disease underwent revascularization and healed at an average time of 17.6±2.5 weeks. Overall the nine arterial interventions had a 100% technical success rate, while ABI improved from 0.54±0.07 to 0.94±0.04 after the intervention. The 30-day mortality was null. Healing time in patients treated with revascularization was significantly lower compared to those treated conservatively (16.6±2.6 weeks vs. 24.7±3.2 weeks, P<0.001). During the follow-up period (48.7±14.3 months), there were 9 ulcer recurrences, 6 in the group of conservative treatment and 3 in the group of revascularization. No significant difference in recurrences between the two groups (log rank=0.772, P=0.38) was demonstrated.

CONCLUSION

A protocol-driven therapeutic strategy that includes a revascularization procedure as a therapeutic option in patients with ulcers of mixed etiology may be beneficial. Based on the current data, it is essential the therapeutic strategy to be individualized by including an overall risk assessment accounting for comorbidities of the patient and the risk of the procedure.

CHIVA method for the treatment of chronic venous insufficiency

BACKGROUND

Many surgical approaches are available to treat varicose veins secondary to chronic venous insufficiency. One of the least invasive techniques is the ambulatory conservative hemodynamic correction of venous insufficiency method (cure conservatrice et hémodynamique de l'insuffisance veineuse en ambulatoire (CHIVA)), an approach based on venous hemodynamics with deliberate preservation of the superficial venous system.

OBJECTIVES

To compare the efficacy and safety of the CHIVA method with alternative therapeutic techniques to treat varicose veins.

SEARCH METHODS

The Trials Search Co-ordinator of the Cochrane Peripheral Vascular Diseases Group searched the Specialised Register (November 2012), CENTRAL (2012, Issue 10) and clinical trials databases. The review authors searched PubMed and EMBASE (December 2012). There was no language restriction. We contacted study authors to obtain more information when necessary.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared the CHIVA method versus any other treatments. Two review authors independently selected and evaluated the studies. One review author extracted data and performed the quantitative analysis.

DATA COLLECTION AND ANALYSIS

Two independent review authors extracted data from the selected papers. We calculated the risk ratio (RR), mean difference (MD), the number of people needed to treat for an additional beneficial outcome (NNTB), and the number of people needed to treat for an additional harmful outcome (NNTH), with 95% confidence intervals (CI) using Review Manager 5.

MAIN RESULTS

We included four RCTs with 796 participants (70.5% women) from the 434 publications identified by the search strategy. Three RCTs compared the CHIVA method with vein stripping, and one RCT compared the CHIVA method with compression dressings in people with venous ulcers. We judged the methodological quality of the included studies as low to moderate. The overall risk of bias across studies was high because neither participants nor outcome assessors were blinded to the interventions. The primary endpoint, clinical recurrence, pooled between studies over a follow-up of 3 to 10 years, showed more favorable results for the CHIVA method than for vein stripping (721 people; RR 0.63; 95% CI 0.51 to 0.78; I(2) = 0%, NNTB 6; 95% CI 4 to 10) or compression dressings (47 people; RR 0.23; 95% CI 0.06 to 0.96; NNTB 3; 95% CI 2 to 17). Only one study reported data on quality of life and these results presented graphically significantly favored the CHIVA method.The vein stripping group had a higher risk of side effects than the CHIVA group; specifically, the RR for bruising was 0.63 (95% CI 0.53 to 0.76; NNTH 4; 95% CI 3 to 6) and the RR for nerve damage was 0.05 (95% CI 0.01 to 0.38; I(2) = 0%; NNTH 12; 95% CI 9 to 20). There were no statistically significant differences between groups regarding the incidence of limb infection and superficial vein thrombosis.

AUTHORS' CONCLUSIONS

The CHIVA method reduces recurrence of varicose veins and produces fewer side effects than vein stripping. However, we based these conclusions on a small number of trials with a high risk of bias as the effects of surgery could not be concealed. New RCTs are needed to confirm these results and to compare CHIVA with approaches other than open surgery.

A cross-sectional, comparative study of pain and activity in persons with and without injection-related venous ulcers

Persons with leg ulcers, including venous ulcers, often report pain. A cross-sectional, comparative study was conducted among 61 patients receiving care in an urban clinic (31 with and 30 without a venous ulcer, mean age 54 years [range 40 to 65 years], 93% African American) to examine pain and its relation to activity and walking in persons with injectionrelated venous ulcers. The questionnaire included items about pain and its treatment, as well as activity and walking (ie, Brief Pain Inventory [BPI] Short Form, Self-Treatment of Pain, Pain and Narcotic Use, Difficulty with Activities, and Walking Scale questionnaires). Among those with a venous ulcer (VU+), worst pain significantly related to total interference (r = 0.65, P <0.0001) and total difficulty (r = 0.42, P = 0.02) BPI scores. The common pain sites for those VU+ involved the legs (24, 36.4%), wound sites (13, 19.7%), back (eight, 12.1%), general body (five, 7.6%), shoulder and knee (four, 6.1% each), and other (eight, 12.1%). Persons VU+ were more likely than those without a venous ulcer (VU-) to have received a prescription for narcotics in the past year (96% versus 41%, X(2) = 21.3, P <0.0001). Persons VU+ versus VU- were significantly (X(2) = 8.89, P = 0.003) more likely to resort to street drug use and relapse to addiction if pain was not adequately treated. They were also twice as likely to have decreased walking over the past 5 years (67% versus 33%, X(2) = 5.93, P <0.02). Among those VU+, venous ulcers added to chronic pain and decreased walking. These findings highlight the negative effects of injection-related venous ulcers on pain, activity, and walking, as well as the propensity of this groupto resort to illicit drug use for pain control. Persons VU+ should have pain assessed and treated.

[Climatic impact on venous ulcers of the leg]

Venous leg ulcers have a multifactorial origin. The environmental temperature appears to distinctly modulate the initiation and the subsequent evolution of the leg ulcer. The chronobiology of both episodes is quite distinct. A cold climate favors the initiation while a warmer climate tends to aggravate the ulcer. The seasonal fluctuations of the ulcer process are likely correlated with vasomotor phenomena taking place in the skin following variation in ambient temperature.

[Potential causes and optimal treatment strategy of recurrent venous ulceration in lower limb]

OBJECTIVE

To explore the potential causes and the optimal treatments of recurrent venous ulceration of lower limbs after initial operation.

METHODS

Data of patients admitted between January 2000 and June 2010 for recurrent ulceration in lower limbs after previous operation were retrospectively analyzed. Altogether 81 limbs in 73 patients were recruited. There were 55 male patients (60 limbs) and 18 female patients (21 limbs). The average age was 52.6 years (ranging from 31 to 73 years). All the patients had received at least one surgery procedures before recurrence. The average time between ulceration recurrence and the last operation was 10.6 months (ranging from 5 to 37 months). Average diameter of ulcers was 3.7 cm (ranging from 1.3 to 6.5 cm). Color duplex sonography before re-treatment revealed incompetent calf perforators in 57 limbs (70.4%), primary deep vein insufficiency in 38 limbs (46.9%), post-DVT syndrome in 16 limbs (19.8%), reflux of accessory saphenous veins in 11 limbs (13.6%) and residual/re-opened great saphenous vein in 8 limbs (9.9%). Managements including stripping of great saphenous vein, ligation around the ulcer, percutanous ligation of varicose veins, valvoplasty, and adjuvant compressive therapy were adopted according to different venous abnormality.

RESULTS

All the patients were followed. All the ulcers healed and hemodynamic indexes were greatly improved 6 months after re-operation. Only 3 limbs (3.7%) suffered again from recurrence 1 year after re-operation.

CONCLUSIONS

Incompetent perforators in calf, primary or secondary deep vein insufficiency and incorrectly treated saphenous veins are main causes for recurrent venous ulceration in our series. Management of residual vein abnormalities can still achieve satisfying clinical outcome.

[Method of local treatment of trophic ulcers of venous etiology]

The study is based on the results of local treatment of trophic ulcers of 150 patients with chronic venous insufficiency of the lower extremities. Local treatment is laser treatment and diagnostic unit with a wavelength λ=0,65 mkm and output power of 30 mW in pulsed mode for 10 minutes 1 times per day for 7-10 days. As an objective criterion for determining the speed and intensity of the healing of trophic ulcers and non-contact fixing their area of applied computer thermography. True healing of ulcers was achieved in all patients during the period from 14 to 28 days.