Until recently, medical literature and the practice of vascular medicine focused on the cosmetic aspects of venous disease and the advanced stages of venous insufficiency such as painful varicose veins and venous ulcers. The systemic effects of venous insufficiency resulting from a reduction of venous return and increased transit time of blood from the lower extremities that can mimic heart failure are only recently being recognized. This article reviews the diagnosis and treatment options for the patients with venous insufficiency, and increases awareness about the systemic effects of venous disease and its role in the practice of cardiovascular medicine.

OBJECTIVE:

To examine patient and wound variables presumed to influence healing outcomes in the context of therapeutic trials for chronic venous leg ulcers.

METHODS:

This double-blind, vehicle-controlled study was conducted with randomized assignment to one of four cell therapy dose groups (n = 46, 43, 44, 45) or vehicle control (n = 50). A 2-week run-in period was used to exclude rapid healers and those with infection or uncontrolled edema. This was a multicenter (ambulatory, private, hospital-based and university-based practices, and wound care centers in North America) study. Adults ≥18 years old with chronic venous insufficiency associated with an uninfected venous leg ulcer (2-12 cm(2) area, 6-104 weeks' duration) were included in the study. Excluded were pregnant or lactating women, wounds with exposed muscle, tendon or bone, patients unable to tolerate compression bandages, or patients who had exclusionary medical conditions or exposure to certain products. Exclusion during run-in included patients with infection, uncontrolled severe edema or with healing rates ≥0.349 cm/2 wk. Screen fail rate was 37% (134/362), and the withdrawal rate was ∼10% (23 of 228). Growth-arrested neonatal dermal fibroblasts and keratinocytes were delivered via pump spray in a fibrin sealant-based matrix, plus a foam dressing and four-layer compression bandaging. Treatment continued for 12 weeks or until healed, whichever occurred first. Patient demographic and wound-related variables were evaluated for influence on complete wound healing in all patients, as well as the subsets of treated and control patients.

RESULTS:

Wound duration (P = .004) and the presence of specific quantities of certain bacterial species (P < .001) affected healing in the vehicle group, while healing in the cell-treated groups was influenced by wound duration (P = .012), wound area (P = .026), wound location (P = .011), and specific quantities of certain bacterial species (P = .002). Age, sex, race, diabetes, HbA1C, peripheral neuropathy, and serum prealbumin did not significantly affect healing. Body mass index was positively associated with healing in cell-treated patients.

CONCLUSIONS:

Wound duration is a quantifiable surrogate for one or more undefined variables that can have a profound negative effect on venous leg ulcer healing. Although cell therapy overcame barriers to healing, the only specific barrier identified was the presence of certain bacterial species. Interventional trials of potentially effective new therapies can be most informative when patients with suspected barriers to healing are included. The specific measurement of candidate barriers such as microbial pathogens, wound inflammatory state, and fibroblast function should be considered in future randomized trials to improve our understanding of the basis for chronicity.

This study compared ankle range of motion (AROM) including dorsiflexion, plantar flexion, inversion and eversion, and venous refill time (VRT) in leg skin inflamed by venous disorders, before and after a new cryotherapy ulcer prevention treatment. Fifty-seven-individuals participated in the randomized clinical trial; 28 in the experimental group and 29 received usual care only. Results revealed no statistically significant differences between the experimental and usual care groups although AROM measures in the experimental group showed a consistent, non-clinically relevant decrease compared to the usual care group except for dorsiflexion. Within treatment group comparisons of VRT results showed a statistically significant increase in both dorsiflexion and plantar flexion for patients with severe VRT in the experimental group (6.9 ± 6.8; p = 0.002 and 5.8 ± 12.6; p = 0.02, respectively). Cryotherapy did not further restrict already compromised AROM, and in some cases, there were minor improvements.

Venous leg ulcers are arguably the most common type of venous ulcers seen in clinical practice. Compression therapy is the essential intervention in venous leg ulcer treatment, but coexisting arterial vascular insufficiency must be excluded before compression is initiated. No single topical dressing has been shown to be superior for all wounds. Venous leg ulcers are chronic and often difficult to heal, with only 40% to 70% healing after 6 months of treatment. Surgical procedures to reduce venous hypertension do not accelerate healing of a chronic ulcer, but trials suggest a decreased rate of future recurrence after surgery.

OBJECTIVES:

Chronic venous disease (CVD) is a frequent disorder with a high socioeconomic impact. Little is known about the possible differences between healed ulcer (C5 group) and active ulcer (C6 group) in terms of disease severity and quality of life (QoL). Our aim was to determine the possible differences in severity disease and QoL between the C5-C6 and C1 (control) group.

METHODS:

Data from a national, multicentre, observational and cross-sectional study (n = 1598) were used to compare three groups of CVD: C1 (n = 243), C5 (n = 136) and C6 (n = 70). CVD severity was assessed with the Venous Clinical Severity Score (VCSS) and QoL with the Short Form 12 Health Survey (SF-12) and Chronic Lower Limb Venous Insufficiency Questionnaire (CIVIQ-20).

RESULTS:

Patients with active ulcers had a higher mean total VCSS than patients with healed ulcers (P < 0.05). Both SF-12 and CIVIQ-20 QoL questionnaires indicated a poorer QoL in patients with ulcers than in those with C1 (P < 0.05). Compared with the C5 group, patients with active ulcers (C6) had lower QoL scores, but the differences were not statistically significant.

CONCLUSIONS:

Patients with venous leg ulcers (C5-C6) are associated with high severity and poor QoL. However, the healing of a leg ulcer did not contribute to improvement of QoL.

to present a therapeutic algorithm for chronic venous insufficiency complicated with ulceration, using etiologic treatment combined with local treatment by negative pressure wound therapy (NPWT) before and after skin grafting.we are discussing a 59 years-old patient with a lower leg gigantic, circumferential trophic lesion. The aetiology was combined, post-traumatic and chronic venous insufficiency, with 30 years of evolution.the treatment was applied in two surgical steps. Initially the pathological refluxes were interrupted; secondarily a skin graft was applied, preceded and followed by NPWT until graft intake. The wound healed completely; patient developed secondary foot lymphoedema.1. Case treatment particularity consists in using a combination of etiologic and local treatment, combined with adjuvant NPWT. 2. Secondary lymphoedema developed due to circumferential location of the lesion. 3. Continuous NPWT has proven its efficiency in chronic ulcer before and after skin grafting, reducing costs and duration of treatment.

Non-healing venous leg ulcers are a cumbersome problem for the patient and the physician. Adequate compression therapy that reduces venous pressure is the cornerstone of treatment. For each patient treatment of superficial venous insufficiency should be considered. Adjuvant surgical, physical or biologic interventions can stimulate healing in case of refractory ulcers Treatment of a venous ulcer needs a tailored approach.

Venous insufficiency can be defined as a fixed venous outflow disturbance of the limbs. It is caused by the malfunction of the venous system, that may or may not be associated with venous valvular insufficiency and may involve the superficial or deep venous system of the lower limbs, or both. The CEAP scale includes clinical, etiologic, anatomic and pathophysiologic aspects and has been used in the assessment of venous insufficiency Clinical classification comprises of 7 groups. It takes into account the appearance of the skin of the lower limbs, presence of edema, teleangiectasis and varicose ulcers. CLINICAL GRADING: Group C0 - no visible changes in the clinical examination; Group C1 - telangiectasis, reticular veins, redness of the skin around the ankles; Group C2 - varicose veins, Group C3 - the presence of edema without skin changes; Group C4 - lesions dependent of venous diseases (discoloration, blemishes, lipodermatosclerosis); C5 Group - skin changes described above with signs of healed venous ulcers; Group C6 - skin lesions such as in groups C1 to C4 plus active venous ulcers. ETIOLOGICAL CLASSIFICATION INCLUDES: Ec - congenital defects of the venous system, Ep - primary pathological changes of the venous system, without identification of their causes; Es - secondary causes of venous insufficiency of known etiology (post-thrombotic, post-traumatic, etc.). There are many methods of assessing the venous system. One of the most accurate methods is an ascending phlebography which is especially useful in determining detailed anatomy of the venous system, venous patency and identification of perforans veins. The second method may be a descending phlebography useful in determining the venous reflux and morphology of venous valves. Another radiological method is varicography in which the injection of the contrast medium directly into the veins is performed. It is especially useful in the ,,mapping" of venous connections. Trans-uterine phlebography when contrast medium is injected into the bottom of the uterus and its flow is observed, is a very rare test. A similar method is used in a selective phlebography of the ovarian vein and internal iliac vein. This examination is performed when there is a suspicion of connections between varicose veins of the inferior extremities and the pelvis, in case of the occluded iliac and femoral veins. However these tests are highly invasive, causing a lot of discomfort and are connected with numerous complications, particularly the development of venous thromboembolism. An invasive study but not exposing to the emission of ionizing radiation, is a measurement of the marching pressure (known also as ambulatory venous pressure - AVP). Ultrasound Doppler is the "gold standard" in the diagnosis of venous system. Color Doppler technique is irreplaceable due to its non-invasiveness, availability constantly improving of the ultrasound machines and is the method of choice in pregnancy Unfortunately clinical correlation of Doppler ultrasound and thrombosis is bad. Invasive methods, which include various types of phlebographies, have been reserved only for cases of very high diagnostic doubt.

BACKGROUND:

The aim was to assess the outcome of a total pancreatectomy (TP).

METHODS:

From 1993 to 2010, 56 patients underwent an elective TP for intraductal papillary mucinous neoplasia (n = 42), endocrine tumours (n = 6), adenocarcinoma (n = 5), metastases (n = 2) and chronic pancreatitis (n = 1). Morbidity and survival were analysed. Long-term survivors were assessed prospectively using quality-of-life (QoL) questionnaires.

RESULTS:

Five patients developed gastric venous congestion intra-operatively. Post-operative morbidity and mortality rates were 45% and 3.6%, respectively. An anastomotic ulcer occurred in seven patients, but none after proton pump inhibitor therapy. There were five inappropriate TPs according to definitive pathological examination. Overall 3- and 5-year survival rates were 62% and 55% respectively; five deaths were related to TP (two postoperative deaths, one hypoglycaemia, one ketoacidosis and one anastomotic ulcer). Prospective evaluation of 25 patients found that 14 had been readmitted for diabetes and that all had hypoglycaemia within the past month. The glycated haemoglobin (HbA1c) was 7.8% (6.3-10.3). Fifteen patients experienced weight loss. The QLQ-C30 questionnaire showed a decrease in QoL predominantly because of fatigue and diarrhoea, and the QLQ-PAN26 showed an impact on bowel habit, flatulence and eating-related items.

DISCUSSION:

Morbidity and mortality rates of TP are acceptable, although diabetes- and TP-related mortality still occurs. Endocrine and exocrine insufficiency impacts on the long-term quality of life.