Weddell JM. Varicose veins: pilot study. Br J Surg ; Hobsley M. Pathways in surgical management. London: Edward Arnold, The survey of sickness.
Studies on medical and population subjects no. London: General Register Office, The committee on the Danish national morbidity survey. The sickness survey of Denmark.
European Society for Vascular Surgery | Guidelines
Copenhagen, US Department of Health. Education and welfare: national health survey Washington, DC, Illness and health care in Canada. Canadian Sickness Survey Ottawa, Je suis Heures de jeu :. Best practice 7. Grade 2; Level of evidence, C 8. Grade 1; Level of evidence, C 9.
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Grade 1; Level of evidence, B Guideline 5. Grade 2; Level of evidence, C. Considering the most recent AVF—SVS guidelines, the treatment of venous ulcers requires a multispecialty approach, involving compression, local wound care, sclerotherapy, stenting, reconstruction, ablation, phlebectomy, or drug therapy. Reference 1. J Vasc Surg. Surgical management of venous ulcers Mark Malouf, Australia Treating the cause of venous hypertension and addressing the ulcer or wound are two considerations that require surgical management in patients with venous ulcers.
Deep vein reflux and obstruction at different levels may also be present and should be considered, especially for a nonresponding ulcer. When treating a venous ulcer, the role played by the calf muscle pump and the possibility of coincidental arterial disease in the affected limb must not be ignored. Comorbid illnesses, such as diabetes, anemia, vasculitis, obesity, cardiac failure, or immobility, may be just as important as the diseased veins themselves.
Detailed venous duplex mapping is essential to develop a tailored treatment plan to reduce the venous hypertension. Depending on the mapping results, several surgical and minimally invasive treatment options are available to treat the venous pathology, similar to the options available for C 2 patients.
The availability of thermal ablation is increasing and the cost is going down; therefore, worldwide use is growing. Meanwhile, sclerotherapy is cheap, repeatable, and a very good option, especially in developing countries. The worldwide frequency of open surgery on superficial veins is going down, but this option may still be preferable in some countries. Ambulatory phlebectomy under local anesthesia is very effective in reducing local venous hypertension around a venous ulcer, often combined with sclerotherapy.
We must never lose sight of the fact that there may also be proximal venous obstruction, especially for ulcers that are difficult to manage, which can be treated with endovascular techniques. Deep vein surgery is being performed in selected centers around the world for certain patients who have had both the superficial venous disease and perforators corrected and still suffer from ulcers.
Deep vein surgical procedures include endovenectomy, creation of new vein valves, or if valve cusps do exist, restoration of deep vein competence using external or open valvuloplasty. Adequate treatment of superficial venous reflux is expected by many practitioners to speed the healing rate of the venous ulcers, to reduce its recurrence, and to extend the ulcer-free intervals, which is also supported by some data. Skin grafting for large or recalcitrant ulcers is commonly performed, but only after treating the underlying venous hypertension and excluding the malignancy or vasculitis on biopsy.
Methods of skin grafting include a split thickness graft, which may or may not require meshing, or pinch grafting under local anesthesia to stimulate healing. The management of venous leg ulcers is still a challenge. Nevertheless, areas of venous reflux or obstruction should be treated with whatever methods are available in the office, clinic, or operating room; the functional factors and lifestyle should be improved; the wounds should also be treated, with surgery, if necessary; and the recommended guidelines should be observed.
Many ulcers can have a multifactorial etiology. In leg ulcers, Koerber et al showed that 5. Malignant conditions must be excluded to make a differential diagnosis.
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Compression improves the healing of ulcers, multicomponent compression systems are more effective than single-component compression systems, high compression is more effective than lower compression, and medical compression stockings are more effective than short-stretch bandages. Several adjunctive therapies may help heal venous ulcers. As such, negative wound pressure treatment that creates a negative pressure on the ulcer bed favors granulation tissue and shortens healing time.
Leg elevation for 10 minutes every 24 hours produces significant fluid drainage from the legs, promoting tissue dryness and blood flow to the skin around the ulcer. Nadroparin may play an adjuvant role in treating venous ulcers because it favors pain relief and improves quality of life, even if it does not improve healing. The application of an autologous platelet-rich gel in nonhealing vascular ulcers can be helpful. Compression remains the most useful and effective method of treating venous ulcers and a multilayer technique is the most effective.
The Unna boot remains the gold-standard treatment, and differential diagnoses and new methods should be considered, especially for poorly healing ulcers. References 1. Genese des ulcus cruris. Ankle motility is a risk factor for healing of chronic venous leg ulcer.
Laser ablation of perforating veins in C5 patients with postthrombotic syndrome does not prevent ulcer recurrence Igor Zolotukhin, Russia A randomized controlled trial to establish whether laser ablation of perforators decreases the recurrence rate of postthrombotic ulcers at a 1-year follow-up was presented. For the study, 63 patients were randomly assigned to either endovenous laser ablation of incompetent calf perforating veins with subsequent compression treatment using class 3 stockings or to compression alone. There were 91 incompetent calf perforating veins on 31 limbs with diameters ranging from 0.
Laser ablation was performed with a nm device and the amount of energy delivered depended on the perforator caliber from at least 75 J for 0. Number of ablated veins ranged from 1 to 7 per leg. Mean venous clinical severity score after follow-up was 12 in both groups. Laser ablation of incompetent calf perforating veins performed with the usual amount of energy does not prevent either the incompetent perforating veins from recanalizing or the ulcer from reoccurring in patients with a clinical, etiological, anatomical, physiological CEAP class of C 5 and a postthrombotic syndrome.
Ernesto Nieves Colombia discussed the results of a prospective, randomized clinical trial comparing conventional treatment of venous ulcers with conventional treatment plus ultrasound-guided foam sclerotherapy. The healing rate within the group receiving sclerotherapy was Istvan Rozsos Hungary focused on measuring transcutaneous oxygen tension before and after treating ulcers with ultrasound-guided foam sclerotherapy. Atsushi Tabuchi Japan discussed the traditional surgical approach of using subfascial endoscopic perforator vein surgery for treating venous stasis ulcers.
The healing rate for the ulcers was No side effects were reported. Venous filling index, venous volume, and residual volume fraction were assessed pre- and postoperatively and improvements were observed months postprocedure. Francine Heatley UK introduced the trial design of the EVRA ulcer trial Early Venous Reflux Ablation , a randomized clinical trial comparing early with delayed endovenous treatment of superficial venous reflux in patients with chronic venous ulcers.
The objective of the trial is to clarify the controversy surrounding the timing of superficial venous intervention. The in vivo performance of compression stockings using air plethysmography Christopher Lattimer, UK Manufacturers extensively test compression stockings to quantify compression strength, pressure graduation, surface contour, and knit. Despite this testing, compression stockings are not tolerated by some people and they could even cause harm. Furthermore, he stressed that compliance is a major issue.
These factors may be related to how stockings augment venous return. This study compared the in vivo performance of elastic compression stockings between healthy controls and patients with varicose veins, postthrombotic syndrome, and lymphedema using air plethysmography. Stocking ejection force was tested by measuring the reduction in calf volume of a congested calf after sudden deflation of a thigh cuff outflow fraction. The ability of a stocking to resist increases in calf volume after incremental thigh-cuff inflations was tested by measuring incremental thigh-cuff pressure causing maximal increase in calf volume IPMIV.
A total of 12 legs were tested in each group using no compression, knee-length class 1 18 to 21 mm Hg compression, and then class 2 23 to 32 mm Hg compression. The values of the outflow fraction, IPMIV, venous filling index, and venous drainage index were quantified in each of the four groups. Stockings significantly improved the outflow fraction and IPMIV both in controls and patients with varicose veins. The venous filling index improved significantly in patients with varicose veins.
Epidemiology and clinical characteristics of chronic venous disease in Romania
There was a 6-fold improvement in the venous drainage index in the only postthrombotic syndrome patient with an iliac occlusion from 2. Results of stocking performance tests that measure acute volume changes in vivo in response to provocation maneuvers may explain why the legs of some patients improve with a stocking and why other legs may not benefit to the same extent.
The hemodynamic performance of stockings could be quantified in vivo, and as such, the overall results show that patients with postthrombotic syndrome gained the least benefit from using stockings, but others showed significant hemodynamic improvements. For patients with postthrombotic syndrome, stockings should perhaps be prescribed after air plethysmography has been performed to identify which patients will definitively benefit. Pressure and stiffness: the two sides of the compression coin Eberhard Rabe, Germany Compression therapy of the lower limbs is a fundamental component in the management of acute and chronic venous disease and lymphatic diseases.
The treatment can be performed using compression bandages, compression stockings, and intermittent pneumatic compression devices. Medical compression stockings are made of elastic textiles. According to the exerted pressure, different compression classes are available. The pressure profile of each compression class responds to the resting pressure in the ankle region. The pressure exerted on the leg should compress the veins and improve the function of the muscle pumps.
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This can be demonstrated in the supine position; however, in the upright position, even 30 to 40 mm Hg elastic compression stockings may not be able to sufficiently compress the veins. A second mode of action is the pressure changes during muscle contraction or walking. The ability to withstand the circumference enhancement of the leg during muscle activity or simply after changing from the supine to the upright position depends on the stiffness of the material.
Stiffness is defined as pressure increases with an increase in leg circumference. The static stiffness index SSI is measured as the in vivo pressure while standing upright minus the pressure in the supine position. A high SSI means that the pressure under the stocking will rise significantly in the upright position and it will be able to improve the venous function better than material with a low SSI.