Abstract
The management of chronic venous insufficiency with ulceration: the role of minimally invasive perforator interruption
CA Rueda, EN Bittenbinder, CJ Buckley, WT Bohannon, MD Atkins and RL Bush
Ann Vasc Surg 2013;27:89–95
This is a retrospective review of database collected from 2005 to 2011. Sixty-four patients with CVI stage C5/C6 underwent perforator interruption with subfascial endoscopic perforator surgery (SEPS) or radiofrequency ablation (RFA-IPV) as part of the management of their CVI. All patients were referred for evaluation after having failed conservative treatment with compression dressings. In addition to patient clinic appointments, follow-up was conducted by telephone assessments in those patients who missed their appointments. Forty-one (64%) patients underwent SEPS and 23 (36%) patients underwent RFA-IPV with ablation of the great saphenous vein. Mean follow-up was 37 months. There were no differences in patient demographics or risk factors. Twenty-three (88%) SEPS and 12 (100%) RFA-IPV patients (P = NS) with C6 disease went on to completely heal their venous ulcers with an average healing time of 5.2 (SEPS) and 4.4 (RFA-IPV) months (P = NS). Overall, seven (17%) SEPS and six (23%) RFA-IPV patients (P = NS) developed a recurrent ulcer after surgical treatment. Major complications only occurred in the SEPS group consisting of two major amputations caused by pain from nonhealing ulcers and one deep venous thrombosis. The authors stated that this study supports the premise that in patients with C5/C6, there may be a demonstrable benefit directly attributable to perforator elimination.
Chronic venous ulcer: minimally invasive treatment of superficial axial and perforator vein reflux speeds healing and reduces recurrence
PB Alden, EM Lips, KP Zimmerman, RF Garberich, AZ Rizvi, AS Tretinyak, JQ Alexander, KM Dorr, M Hutchinson and SL Isakson
Ann Vasc Surg 2013;27:75–83
Eight-six patients with chronic venous ulcers (CVU) presenting to a multispecialty wound clinic were retrospectively reviewed. All patients underwent duplex scanning for venous insufficiency. Compression group was compared to the intervention group treated with compression and minimally invasive interventions: thermal ablation of superficial axial reflux and ultrasound-guided foam sclerotherapy (UGFS) of incompetent perforating veins and varicosities. There was no statistical significant difference in age (67/71 years), body mass index or the number of recurrent ulcers in each group. Compared with the compression group, the ulcers in the intervention group healed faster (9.7% versus 4.2% per week; P = 0.001) and showed fewer recurrences at one-year follow-up (27.1% versus 48.9%; P < 0.015). Multivariate analysis showed use of intervention was the strongest determinant of healing with a coefficient of variation of 7.432, SE 2.406, P = 0.003. Analysis of just the intervention group before and after intervention using matched pairs showed acceleration of healing after intervention from ranging from a median of 1.2% (interquartile range (IQR), 14.3) to 9.7% (IQR, 11.3) per week (P ≤ 0.001). The authors concluded that minimally invasive ablation of superficial axial and perforator vein reflux in C6 patients leads to faster healing and decreased ulcer recurrence when combined with compression alone.
Cost-effectiveness of compression technologies for evidence-informed leg ulcer care: results from the Canadian Bandaging Trial
B Pham, MB Harrison, MH Chen and ME Carley; Canadian Bandaging Trial Group
BMC Health Serv Res 2012;12:346
We conducted a cost-effectiveness analysis using individual patient data from the Canadian Bandaging Trial evaluating high compression therapy with four-layer bandage (4LB) (n = 215) and short stretch bandage (SSB) (n = 209) for community care of venous leg ulcers. We estimated costs (in 2009–2010 Canadian dollars) from the societal perspective and used a time horizon corresponding to each trial participant's first year. 4LB was associated with an average 15 ulcer-free days gained, although the 95% confidence interval [–32, 21 days] – no treatment difference; an average health benefit of 0.009 QALYs gained [–0.019, 0.037] and overall, an average cost increase of $420 [$235, $739] (due to twice as many 4LB bandages used); or equivalently, a cost of $46,667 per QALY gained. If decision makers are willing to pay from $50,000 to $100,000 per QALY, the probability of 4LB being more cost-effective increased from 51 % to 63%. The authors’ findings differ from the emerging clinical and economic evidence that supports high-compression therapy with 4LB. When ulcer care is delivered by trained registered nurses using an evidence-informed protocol, both 4LB and SSB systems offer comparable effectiveness and value for money.
Chronic venous leg ulcers are associated with high levels of metalloproteinases-9 and neutrophil gelatinase-associated lipocalin
R Serra, G Buffone, D Falcone, V Molinari, M Scaramuzzino, L Gallelli and S De Franciscis
Wound Repair Regen 2013;21:395–401
The authors speculate that both matrix metalloproteinases (MMP) and neutrophil gelatinase-associated lipocalin (NGAL) could play a role in the healing process in chronic venous ulcer patients. Patients with chronic venous leg ulcers represented the test group (Group I), whereas patients without chronic ulcers represented the control group (Group II). Enzyme-linked immunosorbent assay test was used to evaluate the levels of MMP-9 and NGAL in plasma and wound fluid, whereas Western blot analysis was performed to estimate the expression of MMP-9 and NGAL in tissues. Enzyme-linked immunosorbent assay tests revealed higher levels of MMP-9 and NGAL in both plasma and wound fluid of patients with ulcers compared to patients without ulcers (P < 0.01). Moreover, Western blot analysis documented an increased expression of MMP-9 and NGAL in biopsy tissue of patients with ulcers compared to patients without ulcers (P < 0.01). The authors conclude that MMP-9 and NGAL may correlate with the clinical course of venous ulcers.
Upper body exercise increases lower extremity venous blood flow in deep venous thrombosis
K Caldwell, SJ Prior, M Kampmann, L Zhao, S McEvoy AP Goldberg and BK Lal
J Vasc Surg: Venous Lym Dis 2013;1:126–133
Sequential compression devices or ambulation may not be possible in patients with lower extremity surgery or trauma. The authors determined whether upper body exercise increases venous blood flow in the lower extremities as a potential means for preventing DVT. Measurements were made before, during, and after exercise using duplex ultrasound imaging in 15 healthy subjects and 10 patients with acute DVT. In healthy participants, a single 30-s bout of upper body exercise increased volume flow up to 39% for up to 10 min after exercise (P < 0.05). A single 3-min bout increased flow to a lesser extent and a single 1-min bout did not increase flow. An intermittent protocol of three 30-s bouts of exercise resulted in an increase of 34% to 57% in venous flow (P < 0.05) for an average increase of 179±53 mL/min. In patients with acute DVT, the intermittent 30-s upper body exercise protocol increased venous blood flow by 45% to 83% (P < 0.05) for an average increase of 250 ± 63 mL/min, an effect lasting >13 min. The authors concluded that intermittent 30-s bouts of low-intensity upper body exercise elicited the highest response for the least amount of effort and may represent an alternative or adjunct for prophylaxis of DVT in patients with restricted ambulation.
Endovenous management of venous leg ulcers
S Raju, OK Kirk and TL Jones
J Vasc Surg: Venous and Lym Dis 2013;1:165–173
The authors use minimally invasive corrective techniques to challenge the current “standard” of compression for venous leg ulcers. Among 192 consecutive limbs with venous leg ulcers, 189 were treated by (1) endovenous laser ablation (n = 30), (2) iliac vein stent placement (n = 89), or (3) both (n = 69). Residual deep reflux was not treated. No specialized wound care was used, and 38% of patients did not use stockings. Outcome measures were time to heal the ulcer and cumulative long-term healing. Sixty percent of the limbs were post-thrombotic and 37% had deep axial reflux. Postprocedural mortality was 0%, and 2% had deep venous thrombosis (<30 days). By 14 weeks, 81% of the small ulcers approximately < 1 inch in diameter had healed. Larger ulcers were slower in healing (P < 0.001). Healing was better in nonthrombotic limbs compared with post-thrombotic limbs (87% versus 66% at five years; P < 0.02) but was similar among the various demographic subsets, procedures, and whether or not patients used compression. Quality-of-life measures improved significantly. Cumulative long-term healing was unaffected by residual axial reflux and was unrelated to hemodynamic severity (air plethysmography, ambulatory venous pressure). Most venous leg ulcers in this consecutive series achieved long-term healing with the described minimally invasive algorithm and compression was not necessary to achieve or maintain healing after interventional correction.
Minimally invasive treatment of chronic iliofemoral venous occlusive disease
MAF de Wolf, CW Amoldussen, J Grommes, SG Hsien, PJ Nelemans, M Willem de Haan, R de Graaf and CH Wittens
J Vasc Surg: Venous Lym Dis 2013;1:146–153
In this retrospective observational study of patients with venous claudication or C4–6 disease the authors looked at midterm results of endovenous recanalization and angioplasty/stenting for chronic iliofemoral deep venous occlusions. Patients with recent DVT (<1 year) were excluded. Seventy-five procedures were performed in 63 patients (average age, 44 years; range, 18–75 years), of whom 86% had a history of DVT. The mean time between the initial DVT and treatment was 12 years (maximum, 31 years). May-Thurner syndrome was present in 57%. Forty-two procedures were performed in the left, six in the right, and 11 in both lower extremities. The vena cava inferior was partially stented in 25 patients. Primary patency was 74% after one year. Assisted primary and secondary patency rates were 81% and 96%, respectively, at one year. Secondary procedures included restenting, catheter-directed thrombolysis, endophlebectomy of the common femoral vein, and creation of an arteriovenous fistula. No pulmonary emboli noted, six bleeding complication occurred, and no deaths. Significant improvement of symptoms was achieved in 81%. The authors concluded that recanalization/stenting of chronically occluded iliofemoral vein segments is safe and effective with good short-term results, even when treatment takes place decades after the initial deep venous thrombosis.
First human use of cyanoacrylate adhesive for treatment of saphenous vein incompetence
Jl Almeida, JJ Javier, E Mackay, C Bautista and TM Proebstle
J Vasc Surg: Venous Lym Dis 2013;1:174–180
The primary objective of this study was to assess the feasibility of an endovenous cyanoacrylate (CA) adhesive implant, delivered with a catheter-based administration system engineered with a nonstick surface, for the treatment of incompetent great saphenous veins (GSVs). Thirty-eight incompetent GSVs in 38 symptomatic patients were treated by catheter deployment of CA under ultrasound guidance via a repetitive bolus injection algorithm. The primary safety end point was the rate of serious adverse events and the primary efficacy end point was vein occlusion during follow-up. Secondary end points included the rate of all adverse events and the change in Venous Clinical Severity Scores (VCSSs). Perivenous tumescent anesthesia and compression stockings were omitted. Duplex ultrasound imaging and clinical follow-up were performed immediately after the procedure, at 48 h, and one, three, six, and 12 months. The mean total volume of endovenous CA delivered was 1.3±0.4 mL (range, 0.6–2.3 mL). Kaplan-Meier analysis yielded an occlusion rate of 92% at 12 months of follow-up. Side effects were generally mild and self-limited. Eight patients (21.1%) showed thread-like thrombus extensions into the common femoral vein of a mean length of 12.6 mm (range, 3.5–35 mm), which resolved spontaneously without anticoagulation. VCSS improved in all patients from a mean of 6.1 ± 2.7 at baseline to 1.5 ± 1.4 at 12 months (P <.0001). At the 12-month follow-up, and without additional adjunctive treatment, 18 legs (50%) were free from visible varicosities and an additional eight legs (25%) showed limited varicosities. The authors concluded that endovenous CA may prove to be a feasible, safe, and effective alternative for the correction of saphenous incompetence.