Critical issues in preventing post-thrombotic re-ulceration

Getting Ready for Wound Certification: Assessing and Managing Lower Extremity Venous Disease.

The definition of the venous ulcer

1. Co-chaired this panel2. University of South Florida, Tampa, FL3. Healthpoint Ltd., Fort Worth, TX4. University of California, San Francisco, CA5. University of Texas Medical Branch, Galveston, TX6. University of Cardiff, Cardiff, Wales, UK7. University of Pennsylvania, Philadelphia, PA8. Private practice, Warren, PA9. Private practice, Tamarac, FL10. University of Pittsburgh, Pittsburgh, PA11. St. Louis University, St. Louis, MO, and12. Washington University, St. Louis, MO

Venous leg ulcers represent the worst extreme within the spectrum of chronic venous disease. Affecting up to 3% of the adult population, this typically chronic, recurring condition significantly impairs quality of life, and its treatment places a heavy financial burden upon healthcare systems. The current mainstay of treatment for venous leg ulcers is compression therapy, which has been shown to enhance ulcer healing rates. Open surgery on the veins in the leg has been shown to reduce ulcer recurrence rates, but it is an unpopular option and many patients are unsuitable. The efficacy of the newer, minimally-invasive endovenous thermal techniques has been established in uncomplicated superficial venous disease, and these techniques are now beginning to be used in the management of venous ulceration, though the evidence for this treatment is currently unclear. It is hypothesised that, when used with compression, ablation may further reduce pressures in the leg veins, resulting in improved rates of healing. Furthermore, since long-term patient concordance with compression is relatively poor, it may prove more popular, effective and cost-effective to provide a single intervention to reduce recurrence, rather than life-long treatment with compression. To determine the effects of superficial endovenous thermal ablation on the healing, recurrence and quality of life of people with active or healed venous ulcers. In August 2013 we searched Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. There were no restrictions on the language of publication but there was a date restriction based on the fact that superficial endovenous thermal ablation is a comparatively new medical technology. Randomised clinical trials comparing endovenous thermal ablative techniques with compression therapy alone for venous leg ulcers were eligible for inclusion. Trials had to report on at least one objective measure of ulcer healing (primary outcome) such as proportion of ulcers healed at a given time point, time to complete healing, change in ulcer size, proportion of ulcers recurring over a given time period, or at a specific point, and ulcer-free days. Secondary outcomes sought included patient-reported quality of life, economic data and adverse events. Details of potentially eligible studies were extracted and summarised using a data extraction table. Data extraction and validity assessment were performed independently by two review authors, and any disagreements resolved by consensus or by arbitration of a third review author. No eligible randomised controlled trials were identified. There is an absence of evidence regarding the effects of superficial endovenous thermal ablation on ulcer healing, recurrence or quality of life of people with venous leg ulcer disease. The review identified no randomised controlled trials on the effects on ulcer healing, recurrence or quality of life, of superficial endovenous thermal ablation in people with active or healed venous leg ulcers. Adequately-powered, high quality randomised controlled trials comparing endovenous thermal ablative interventions with compression therapy are urgently required to explore this new treatment strategy. These should measure and report outcomes that include time to ulcer healing, ulcer recurrence, quality of life and cost-effectiveness.

Molecular characterization of post-thrombotic syndrome

Chronic venous insufficiency (CVI) is a major cause of recurrent venous leg ulcers (VLUs) and presents treatment difficulties for elderly patients. This case report describes an 88-year-old female with CVI, cardiomyopathy, hypertension, dyslipidemia, and left-sided hemiplegia who presented with a 10-day history of left lower leg tenderness and purple-red discoloration. Examination revealed bilateral varicosities and a stage 4 VLU over the medial malleolus with purulent drainage and surrounding erythema. After 12 days of compression therapy, the ulcer improved to stage 3. However, two months of non-adherence to the treatment led to recurrence with a new stage 2 ulcer. The patient was subsequently initiated into a structured program with demonstrations, written instructions, scheduled reminders, and weekly follow-ups. After 22 days of consistent compression therapy, the ulcer improved to stage 1. This case emphasizes the importance of consistent compression therapy and multifaceted approaches in managing recurrent VLUs.

We only identified evidence from four RCTs for valvuloplasty plus surgery of the superficial venous system for primary valvular incompetence. We found no studies investigating other surgical procedures for the treatment of people with deep venous insufficiency, or that included participants with secondary valvular incompetence or venous obstruction. None of the studies reported ulcer healing or recurrence, and few studies reported complications of surgery, clinical outcomes, QoL and pain (very low- to low-certainty evidence). Conclusions on the effectiveness of valvuloplasty for deep venous insufficiency cannot be made.

Leg and foot ulcers are symptoms of very different diseases. The aim of this paper is to demonstrate the differential diagnosis of leg ulcers. The majority of leg ulcers occur in the lower leg or foot. In non-venous ulcers the localization in the foot area is more frequent. The most frequent underlying disease is chronic venous disease. In 354 leg ulcers, Koerber found 75.25% venous leg ulcers, 3.66% arterial leg ulcers, 14.66% ulcers of mixed venous and arterial origin and 13.5% vasculitic ulcers. In the Swedish population of Skaraborg, Nelzen found a venous origin in 54% of the ulcer patients. Each leg ulcer needs a clinical and anamnestic evaluation. Duplex ultrasound is the basic diagnostic tool to exclude vascular anomalies especially chronic venous and arterial occlusive disease. Skin biopsies help to find a correct diagnosis in unclear or non-healing cases. In conclusion, chronic venous disease is the most frequent cause of leg ulcerations. Because 25% of the population have varicose veins or other chronic venous disease the coincidence of pathological venous findings and ulceration is very frequent even in non-venous ulcerations. Leg ulcers without the symptoms of chronic venous disease should be considered as non-venous.

Introduction: Post- thrombotic syndrome (PTS) is the most common complication of deep vein thrombosis (DVT), and develops in 20–50% of patients after a proximal DVT. Balneotherapy and hydrotherapy is justified in treatment of primary or post-thrombotic chronic venous insufficiency (CVI). M aterial: A review of articles was done in electronic databases Pubmed and Medline by keywords: postthrombotic syndrome, chronic venous insufficiency in conjunction with balneotherapy, hydrotherapy, kinesitherapy, coagulation. Results: Main risk of PST is considered as extensive proximal character of DVT, pre-existing CVI, older age, high body mass index, pre-existent varicosities. PTS refers to clinical manifestations of CVI, and is common cause of unilateral CVI. The thrombus itself may lead to venous valves destruction and reflux. The Villalta PTS scale may define and classify the severity of PTS Venous leg ulcers is the most advanced clinical manifestation of the disease. Prevention of PTS begins with prevention of initial and recurrent DVT includes use of compression stockings and anticoagulant medications. Treatment guidelines recommend anticoagulant therapy - five days with heparin followed by three months of oral anticoagulant after acute event, with subsequent long-term of extended therapy depending on patient’s risk of recurrence. Recent clinical trials indicate that the use of new anticoagulants (NOAS) reduces the incidence of PTS. Ultrasound compression test of the leg veins evaluates the degree of obstruction by clots. Medical therapy of CVI has still not efficient. Carbon dioxide baths and ozone baths have favorably affect hemostasis system. However there are only a few controlled studies evaluating effects of balneotherapy in primary and post-thrombotic CVI. The favorable effect of these mineral baths may result from both hydrostatic effects as well as the contribution with specific chemico-physical properties. The controlled trials (in patients with C3 -C5 stage) shown that balneohydrotherapy and kinesitherapy have decreased signs and symptoms in patients with primary and post - thrombotic CVI. Conclusions: The Health Resort treatment of patients with CVI in the mechanism of post-thrombotic syndrome should be preceded by evaluation of the venous system of the lower limb by compression ultrasound. Balneotherapy and hydroteraphy seem to be effective and safe procedures even in patients with advanced primary and post-thrombotic CVI stage.

Leg ulcers associated with chronic venous disease (CVD) are characterized by prolonged healing and high recurrence. This study describes the effectiveness and tolerability of venoactive drugs (VAD) combined with compression as part of conservative therapy for active venous leg ulcers among patients treated in routine clinical practice. This prospective, multicenter, observational, 6-month study recruited patients diagnosed with Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) clinical class C6 and active venous ulcer area, 5-30 cm2. VAD pharmacotherapy was at the discretion of the treating physician and consistent with national guidelines at the time of the study. Primary outcome was the proportion of patients with a healed venous ulcer at 6 months. Change from baseline in the mean Venous Clinical Severity Score (VCSS), the proportion of patients with a reduction in CEAP clinical class, and Quality of life (QoL - Chronic Venous Insufficiency Questionnaire [CIVIQ-14]) were also assessed. The study enrolled 349 patients: 66.8% were women; mean age was 61.0±12.7 years; and mean Body Mass Index (BMI) was 27.9±4.1 kg/m2. Mean duration of the reference venous ulcer was 18.3±23.0 weeks and mean ulcer area was 9.2±6.9 cm2. All patients were prescribed VAD at baseline, most commonly micronized purified flavonoid fraction (MPFF) (98.3% patients). Compression therapy was prescribed to 91.1% of patients. After 6 months, venous ulcers had completely healed in 69.6% of patients; 13.5% had experienced complete healing at 3 months. Mean physician-assessed VCSS decreased from 15.5±4.1 at baseline to 9.7±4.5 at 6 months (P<0.001). There was a progressive decrease in mean reference ulcer area from 9.2±6.9 cm2 at baseline to 1.2±2.8 cm2 at 6 months. QoL was significantly improved with a reduction in mean CIVIQ-14 global index score from 53.9±20.5 at baseline to 24.5±16.3 at 6 months (P<0.001). Treatment was well tolerated. Combined treatment with VAD and compression therapy was associated with complete venous leg ulcer healing in 70% of patients with a mean time to healing of 7.4 months. A significant improvement in QoL compared with baseline was also observed.

Chronic venous ulcer healing is a complex clinical problem that requires intervention from skilled, costly, multidisciplinary wound-care teams. Compression therapy has been shown to help heal venous ulcers and to reduce the risk of recurrence. It is not known which interventions help people adhere to compression treatments. To assess the benefits and harms of interventions designed to help people adhere to venous leg ulcer compression therapy, and thus improve healing of venous leg ulcers and prevent their recurrence after healing. In May 2013 we searched The Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; EBSCO CINAHL; trial registries, and reference lists of relevant publications for published and ongoing trials. There were no language or publication date restrictions. We included randomised controlled trials (RCTs) of interventions that help people with venous leg ulcers adhere to compression treatments compared with usual care, or no intervention, or another active intervention. Our main outcomes were number of people with ulcers healed, recurrence, time to complete healing, quality of life, pain, adherence to compression therapy and number of people with adverse events. Two review authors independently selected studies for inclusion, extracted data, assessed the risk of bias of each included trial, and assessed overall quality of evidence for the main outcomes in 'Summary of findings' tables. Low quality evidence from one trial (67 participants) indicates that, compared with home-based care, a community-based Leg Club® clinic that provided mechanisms for peer-support, assistance with goal setting and social interaction did not result in superior healing rates at three months (12/28 people healed in Leg Club clinic group versus 7/28 in home-based care group; risk ratio (RR) 1.71, 95% confidence interval (CI) 0.79 to 3.71); or six months (15/33 healed in Leg Club group versus 10/34 in home-based care group; RR 1.55, 95% CI 0.81 to 2.93); or in improved quality of life outcomes at six months (MD 0.85 points, 95% CI -0.13 to 1.83; 0 to 10 point scale). However, the Leg Club resulted in a statistically significant reduction in pain at six months (MD -12.75 points, 95% CI -24.79, -0.71; 0 to 100 point scale), although this was not considered a clinically important difference. Time to complete healing, recurrence of ulcers, adherence and adverse events were not reported.Low quality evidence from another trial (184 participants) indicates that, compared with usual care in a wound clinic, a community-based and nurse-led self-management programme of six months' duration promoting physical activity (walking and leg exercises) and adherence to compression therapy via counselling and behaviour modification (Lively Legs®) may not result in superior healing rates at 18 months (51/92 healed in Lively Legs group versus 41/92 in usual care group; RR 1.24 (95% CI 0.93 to 1.67)); may not result in reduced rates of recurrence of venous leg ulcers at 18 months (32/69 with recurrence in Lively Legs group versus 38/67 in usual care group; RR 0.82 (95% CI 0.59 to 1.14)); and may not result in superior adherence to compression therapy at 18 months (42/92 people fully adherent in Lively Legs group versus 41/92 in usual care group; RR 1.02 (95% CI 0.74 to 1.41)). Time to complete healing, quality of life, pain and adverse events were not reported. We found no studies that investigated other interventions to promote adherence to compression therapy. There is a paucity of trials of interventions that promote adherence to compression therapy for venous ulcers. Low quality evidence from two trials was identified: one promoting adherence via socialisation and support (Leg Club®), and the other promoting adherence to compression, leg exercises and walking via counselling and behaviour modification (Lively Legs®).These trials did not reveal a benefit of community-based clinics over usual care in terms of healing rates, prevention of recurrence of venous leg ulcers, or quality of life. One trial indicated a small, but possibly clinically unimportant, reduction in pain, while adverse events were not reported. The small number of participants may have a hidden real benefit, or an increase in harm. Due to the lack of reliable evidence, at present it is not possible either to recommend or discourage nurse clinic care interventions over standard care.

A venous leg ulcer (VLU) has a significant negative impact on quality of life. Prevention of a VLU is not yet imbedded in clinical practice because risk factors for developing a first VLU are not well known. To explore further the progression of chronic venous disease (CVD) into a first VLU from the patient's perspective. A qualitative study using semistructured interviews was conducted among male and female patients with a VLU. Patients from primary and secondary care, under and over 50 years of age, and with first and recurrent VLUs were included. The interviews were transcribed and analysed using a narrative approach to a thematic analysis. Transcripts were organized in chronological order and an iterative process was used to code the transcripts. Four key themes and the connections made between them emerged from the 11 narratives on the progression of CVD towards a first VLU: 'comorbidity', 'mobility', 'work and lifestyle' and 'acknowledgment of CVD'. Comorbidity was linked to reduced mobility and late acknowledgment of CVD. Comorbidity also affected work and lifestyle and vice versa. Work and lifestyle affected mobility and was linked to the acknowledgment of CVD. A reduction in mobility as a result of comorbidity and work and lifestyle occurred before the VLU developed. Patients did not recognize symptoms of CVD and did not acknowledge the chronicity of CVD. Healthcare professionals should be aware of reductions in mobility and the knowledge deficit in patients with CVD. What's already known about this topic? Not all patients with chronic venous disease (CVD) develop a venous leg ulcer (VLU). A patient's quality of life decreases significantly when a VLU develops. Risk factors for the development of a first VLU in patients with CVD are not well known, unlike risk factors for other chronic wounds like diabetic foot ulcer and pressure ulcers. What does this study add? The patient's narrative towards the development of a first VLU, a series of events. Insight into the events (comorbidity, mobility, work and lifestyle) that patients themselves link to the development of a VLU. Insight into the patients' acknowledgment of CVD in the progression of CVD towards a first VLU. What are the clinical implications of this work? More awareness is needed of CVD symptoms among patients and healthcare providers, as well as more awareness for prevention of a VLU in clinical practice. New insights (for further studies) are needed into the concept of mobility and the development of a VLU. Improved patient education and follow-up are needed for patients with CVD.

The varicose ulcer is the wound which occurs due to abnormal venous hypertension in the lower third of the leg ankle and dorsum of the foot. The pathogenesis starts with obesity and long standing due to dysfunction of venous valve causing venous hypertension around ankle lead to ulcer formation. If venous ulcer is not treated properly then it gets infected, leads to cellulitis and gangrene; so, may require amputation part of the limbs. The recurrence of venous ulcers is very common. The 70% of venous ulcer are healed within 12 weeks of period[1]. There are so many conservative managements in allopathy like, compression stocking, foot elevation, antibiotic and dressing of the wound which when fails may require surgical treatment like skin grafting, sclerotherapy, laser ablation. But its very costly and not much significant. In Ayurveda this disease can be correlated with sirajanya vran, dushta vran. A 32 years male patient having complaints of Nonhealing varicose ulcer over medial malleolus of bilateral leg since 10 months. Treatment like abhyanga , raktamokshana and dressing by using panchavalkal ointment given to patient. Significant healing of wound is observed and the complaints were gradually subsides. The wound were completely healed within 35 days of treatment.

Chronic venous disease is a circulatory system dysfunction that has the potential to lead to venous leg ulceration. Although research on the influence of specific gene variants on chronic venous disease has been limited, a few studies have reported an association between hemochromatosis and chronic venous disease. However, no studies have looked at the prevalence of lower-limb venous disease and leg ulcers in people with hemochromatosis. This study aimed to review the existing literature for any association between venous disease and hemochromatosis and investigate the prevalence of venous disease and leg ulcers in people with hemochromatosis. Scoping systematic literature review and cross-sectional study surveying people with hemochromatosis. This scoping systematic literature review included nine articles and indicated a link between hemochromatosis and venous disease/leg ulcers, although further studies are needed to support this link. Analysis of survey results from people with hemochromatosis found a 9.2% prevalence of leg ulcers in those with self-reported hemochromatosis, considerably higher than the 1% to 3% expected, suggesting that hemochromatosis gene variants may be associated with the pathogenesis of chronic venous disease and leg ulcers. This is the first known study to complete a review of the literature regarding hemochromatosis and venous leg ulcers and document the association between hemochromatosis and venous disease/leg ulcers. There is a lack of research in this area and hence limited evidence to guide practice.

Venous leg ulcers (VLUs) are the most severe manifestation of chronic venous disease (CVD). Due to their chronic nature, high recurrence rate and slow healing time, VLUs account for 80% of all leg ulcers seen in patients with CVD. VLUs impose a heavy burden on patients that reduces their quality of life; VLUs also represent a major socioeconomic impact due to the cost and duration of care. The primary medical approach to treating VLUs is local compression therapy in combination with venoactive drug (VAD) pharmacotherapy to promote the reduction of the inflammatory reaction initiated by venous hypertension. Micronized purified flavonoid fraction (MPFF; Daflon®) is the most widely prescribed VAD. MPFF counteracts the pathophysiologic mechanisms of CVD and ulceration and has proven to be an effective adjunct to compression therapy in patients with large and chronic VLUs. Two other non-VAD drugs, pentoxifylline and sulodexide, have also been shown to improve VLU healing and are also recommended in addition to compression therapy. However, MPFF is the only VAD with the highest strength of recommendations in the 2018 guidelines for the healing of VLUs.