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Venous Insufficiency Ulcers [keywords]
- Endovenous laser ablation of the great and short saphenous veins with a 1320-nm neodymium:yttrium-aluminum-garnet laser: Retrospective case series of 1171 procedures. [JOURNAL ARTICLE]
- J Am Acad Dermatol 2013 Dec 3.
Venous insufficiency is a common medical condition affecting up to 50.5% of women and 30.1% of men. Endovenous laser ablation is a minimally invasive procedure that safely and effectively treats reflux involving the great and short saphenous veins.We sought to present safety and efficacy data of 1171 endovenous laser ablations using the Scripps Clinic endovenous laser therapy (EVLT) protocol.We conducted an institutional review board-approved, retrospective chart analysis of 1171 endovenous laser ablations performed from March 2007 until February 2011 treated at Scripps Clinic with the 1320-nm neodymium:yttrium-aluminum-garnet laser with 1-month, 6-month, 1-year, and 2-year follow-up data.Our current overall experience is greater than 2000 EVLT procedures. The mean follow-up for this case series of 1171 EVLT procedures (1066 great saphenous veins and 105 short saphenous veins) is 11.4 months with an overall closure success rate of 99.9% for patients not lost to follow-up. There has been no incidence of deep vein thrombosis, permanent nerve damage, or pulmonary embolism related to laser ablation.Retrospective chart analysis, investigator bias, patients lost to follow-up, and lack of quality-of-life assessment are limitations.EVLT using a 1320-nm neodymium:yttrium-aluminum-garnet laser appears to be a viable option for venous insufficiency and venous ulceration unresponsive to conservative treatment.
- Clinical analysis of leg ulcers and gangrene in rheumatoid arthritis. [JOURNAL ARTICLE]
- J Dermatol 2013 Dec 4.
Leg ulcers are often complicated in patients with rheumatoid arthritis (RA), however, the etiology is multifactorial. We examined the cases of leg ulceration or gangrene in seven RA patients who were hospitalized over the past 3 years. One patient was diagnosed as having pyoderma gangrenosum. Although vasculitis was suspected in three patients, no histological evidence was obtained from the skin specimens. In these patients, angiography revealed the stenosis or occlusion of digital arteries. In the remaining three patients, leg ulcers were considered to be due to venous insufficiency. Treatment should be chosen depending on the causes of leg ulcers.
- [Symptomatology and diagnosis of inferior vena cava dysplasias.] [JOURNAL ARTICLE]
- Angiol Sosud Khir 2013; 19(3):84-92.
The authors analysed the results of examination and dynamic follow up (from 2003 to 2011) of twenty-one 15-to-55-year-old male patients presenting with hypoplasia or aplasia of the inferior vena cava. The diagnosis was verified by means of SCT- or MRT-phlebography. The disease was newly diagnosed at the age of 15-55 years (mean 25.9±2.6). The pathology manifested itself as a clinical course of thrombosis of deep veins of lower limbs in 16 (76.2%) patients and by oedema thereof in 5 (23.8%) subjects. Of the 16 patients with symptomatology of deep vein thrombosis, 13 patients had proximal (iliofemoral) thrombosis and 3 patients had distal thrombosis. In the overwhelming majority of the patients, the pathological process was localized on the right. All the patients after 1.5-12 months developed signs of impaired patency of the IVC. 1.5-2.5 years later, the course of chronic venous insufficiency was complicated by the development of trophic ulcers of the crus in eight (38.1%) patients. Congenital abnormalities of the IVC are encountered predominantly in males, remaining for a long time latent to be newly manifested in the young age by symptoms of deep vein thrombosis (more often by right-sided iliac-femoral thrombosis). Suspecting this pathology should be followed by extended examination using SCT- or MRT-phlebography.
- Low-grade elastic compression regimen for venous leg ulcers - an effective compromise for patients requiring daily dressing changes. [JOURNAL ARTICLE]
- Int Wound J 2013 Nov 25.
Venous leg ulcers (VLUs) affect millions of patients worldwide and are a tremendous financial burden on our health care system. The hallmark of venous disease of the lower extremities is venous hypertension, and compression is the current mainstay of treatment. However, many patients are non-compliant, partly because of the complexity of the dressings and the difficulties with application and removal. The aim of our study was to test an effective compression dressing regimen for patients with VLUs who require changing the ulcer primary dressing twice daily. We used two layers of a latex-free tubular elastic bandage for compression. The primary endpoint of our study was increased wound-healing rate and our secondary endpoint was complete wound closure. All active study subjects had positive healing rates at week 4 and week 8. Two subjects achieved complete wound closure by week 8. We conclude that compression with a latex-free tubular elastic bandage can be safely used in patients with VLUs requiring frequent dressing changes. This type of compression allows for daily inspection of wounds, dressing changes at home, flexibility in the context of clinical trials, and is a compromise for patients who are intolerant to compression dressings.
- Neuropathy and Ankle Mobility Abnormalities in Patients With Chronic Venous Disease. [JOURNAL ARTICLE]
- JAMA Dermatol 2013 Nov 6.
IMPORTANCE How complications associated with chronic venous insufficiency (CVI) develop is not clear. The central source of the complications is likely a dysfunction of the calf muscle pump, which includes veins and their valves, the gastrocnemius and other lower leg and foot muscles as well as the nerves supplying the muscles, and ankle mobility limitations. The least well-studied source of complications is the relationship between range of ankle movement (ROAM), neuropathy, and the clinical severity of the disease. OBJECTIVE To study sensory neuropathic changes and ankle mobility in patients with CVI to help elucidate the pathophysiologic development of venous ulcers. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study took place from August 2011 to August 2012 at the outpatient wound clinic and the wound healing research clinic at the University of Miami Hospital. Sixty-four limbs from 42 individuals were evaluated and individually classified according to the clinical aspect of the clinical-etiology-anatomy-pathophysiology classification for CVI. MAIN OUTCOMES AND MEASURES Range of ankle movement was measured using goniometry, measuring active ankle combined plantarflexion and dorsiflexion and combined inversion and eversion. Peripheral neuropathy was measured subjectively through the Neuropathy Symptom Score and objectively through the Neuropathy Disability Score scales. RESULTS More patients with severe CVI had reduced plantarflexion-dorsiflexion ROAM compared with patients with mild CVI (25 [89%] vs 11 [31%]; P < .001) and reduced inversion-eversion ROAM (22 [79%] vs 4 [11%]; P < .001). Patients with worse CVI had significantly worse neuropathy with higher Neuropathy Symptom Score and Neuropathy Disability Score values compared with patients with less severe CVI. CONCLUSIONS AND RELEVANCE We found a relationship between reduced ROAM and worse neuropathy with increased severity of CVI. Management in patients with CVI should include testing for neuropathy and improving ankle mobility.
- Venous ulceration contaminated by multi-resistant organisms: larval therapy and debridement. [Journal Article]
- J Wound Care 2013 Oct; 22(10 Suppl):S27-30.
A 72-year-old female with venous insufficiency presented to a hospital-based multidisciplinary wound clinic after 20 years of recurrent episodes of venous leg ulcers. Examination showed bilateral leg ulcers with no evidence of arterial insufficiency, but complicated by considerable devitalised tissue, abnormally high bacterial load and the presence of multi-resistant organisms. The ulcers were initially treated with larvae to aid debridement and reduce the bacterial load, prior to skin grafting. Although ulcer free for a period of 4 months, further debridement was required when the skin condition deteriorated. Surgical intervention was chosen as the preferred method by the surgeons for a second acute care admission using hydrosugery, along with supplementary skin grafts and compression. Ongoing management, consisting of regular debridement, skin care and compression therapy, continues.
- A multicenter randomized controlled trial evaluating balneotherapy in patients with advanced chronic venous insufficiency. [JOURNAL ARTICLE]
- J Vasc Surg 2013 Oct 14.
Apart from compression therapy, physical therapy has scarcely been evaluated in the treatment of chronic venous disorders (CVDs). Spa treatment is a popular way to administer physical therapy for CVDs in France, but its efficacy has not yet been assessed in a large trial. The objective was to assess the efficacy of spa therapy for patients with advanced CVD (CEAP clinical classes C4-C5).This was a single-blind (treatment concealed to the investigators) randomized, multicenter, controlled trial (French spa resorts). Inclusion criteria were primary or post-thrombotic CVD with skin changes but no active ulcer (C4a, C4b, or C5). The treated group had the usual 3-week spa treatment course soon after randomization; the control group had spa treatment after the 1-year comparison period. All patients continued their usual medical care including wearing compression stockings. Treatment consisted of four balneotherapy sessions/d, 6/7 days. Follow-up was performed at 6, 12 and 18 months by independent blinded investigators. The main outcome criterion was the incidence of leg ulcers at 12 months. Secondary criteria were a modified version of the Venous Clinical Severity Score, a visual analog scale for leg symptoms, and the Chronic Venous Insufficiency Questionnaire 2 and EuroQol 5D quality-of-life autoquestionnaires.Four hundred twenty-five subjects were enrolled: 214 in the treatment group (Spa) and 211 in the control group (Ctr); they were similar at baseline regarding their demographic characteristics, the severity of the CVD, and the outcome variables. At 1 year, the incidence of leg ulcers was not statistically different (Spa: 9.3%; 95% confidence interval [CI], 5.6-14.3; Ctr: 6.1%; 95% CI, 3.2-10.4), whereas the Venous Clinical Severity Score improved significantly in the treatment group (Spa: -1.2; 95% CI, -1.6 - -0.8; Ctr: -0.6; 95% CI, -1.0 - -0.2; P = .04). A significant difference favoring spa treatment was found regarding symptoms after 1 year (Spa: -0.03; 95% CI, -0.57 - +0.51; Ctr: +0.87; 95% CI,+0.46 - +1.26; P = .009). EuroQol 5D improved in the treatment group (Spa: +0.01; 95% CI, -0.02 - +0.04) while it worsened (Ctr: -0.07; 95% CI, -0.10 - -0.04) in the control group (P < .001). A similar pattern was found for the Chronic Venous Insufficiency Questionnaire 2 scale (Spa: -2.0; 95% CI, -4.4 - +0.4; Ctr: +2.4; 95% CI, +0.2 - 4.7; P = .008). The control patients showed similar improvements in clinical severity, symptoms, and quality of life after their own spa treatment (day 547).In this study, the incidence of leg ulcers was not reduced after a 3-week spa therapy course. Nevertheless, our study demonstrates that spa therapy provides a significant and substantial improvement in clinical status, symptoms, and quality of life of patients with advanced venous insufficiency for at least 1 year.
- [Scores and stages in angiology]. [English Abstract, Journal Article]
- Ther Umsch 2013 Oct; 70(10):567-71.
For the classification of peripheral arterial disease the Fontaine's stages are mostly used in Switzerland whereas the Rutherford's categories are more common in the scientific literature. It is important to distinguish between the Rutherford classification for chronic peripheral artery disease and the one for the acute limb ischemia. The clinical classification of acute limb ischemia is a helpful tool for prognosis of the leg and urgency of revascularization. The Wagner as well as the Armstrong classification is used for diabetic foot ulcers. The advantage of the Armstrong stages is that important informations like wound infection or ischemia are considered. For chronic venous insufficiency the Widmer stages are widely used in Switzerland but have the disadvantage that patient-reported symptom severity is not considered. The CEAP classification includes anatomical information and the etiology and is mostly used for studies. The Wells score helps to define the probability for the presence of a deep vein thrombosis before further tests are performed.
- All-cause and disease-related health care costs associated with recurrent venous thromboembolism. [Journal Article]
- Thromb Haemost 2013 Nov 27; 110(6):1288-97.
It was the objective of this study to quantify the risk of complications and the incremental health care costs associated with recurrent VTE events. Health care insurance claims from the Ingenix IMPACT database from 01/2004-09/2008 were analysed. Subjects aged ≥18 years on the date of first recurrent VTE diagnosis with ≥12 months of baseline observation prior to the index recurrent VTE were matched 1:1 with no-recurrent VTE patients based on propensity scores. The risk of developing post-thrombotic syndrome (PTS) and other disease-related diagnoses (thrombocytopenia, superficial venous thrombosis, venous ulcer, pulmonary hypertension, stasis dermatitis, and venous insufficiency) was compared between the recurrent and no-recurrent VTE groups for up to one year. All-cause and disease-related costs per patient per year (PPPY) were calculated. The recurrent VTE and no-recurrent VTE cohorts (8,001 subjects in each group) were matched with respect to age, gender, and comorbidities. The risk ratios (RRs) indicated that the risk of developing post-event complications was significantly higher for the recurrent VTE group compared to the no-recurrent VTE group (RR [95% CI]: PTS: 2.7 [2.4 - 2.9], p-value <0.01). Patients with recurrent VTE had significantly higher average PPPY all-cause costs compared to no-recurrent VTE patients ($86,744 versus $37,525, cost difference: $49,219 [€33,617]; 95% CI= 46,253-51,989). Corresponding disease-related health care costs PPPY were also significantly higher for the recurrent VTE group ($11,120 vs $1,262, cost difference: $9,858 [€6,733]; 95% CI= $9,081-$10,476). In conclusion, in this large matched-cohort study, recurrent VTE patients had significantly higher risk of complications and health care costs compared to no-recurrent VTE patients.
- New Advances in Compression Therapy for Venous Leg Ulcers. [JOURNAL ARTICLE]
- Surg Technol Int 2013 Sep 30.
Leg ulceration, often caused by venous stasis, arterial insufficiency, or both, is a common chronic health condition often associated with a prolonged healing trajectory and frequent recurrence. It is estimated that approximately 1.5 to 3.0 per 1,000 adults have active leg ulcers, and the prevalence continues to increase due to an aging population. Management of chronic edema using compression is crucial to promote healing of venous leg ulcers. The principle of compression therapy is simple, involving the use of external pressure in the forms of bandages or wraps to move the fluid from the interstitial space back into the intravascular compartment and prevent reflux. This article synthesizes and appraises the evidence for various types of compression therapies. It also addresses best practice recommendations for the management of leg ulcers when arterial circulation is considered suboptimal.