Autologous cultured keratinocytes on porcine gelatin microbeads effectively heal chronic venous leg ulcers.

We have established a specific bioreactor microcarrier cell culture system using porcine gelatin microbeads as carriers to produce autologous keratinocytes on a large scale. Moreover, we have shown that autologous keratinocytes can be cultured on porcine collagen pads, thereby forming a single cell layer. The objective of this study was to compare efficacy and safety of autologous cultured keratinocytes on microbeads and collagen pads in the treatment of chronic wounds. Fifteen patients with recalcitrant venous leg ulcers were assigned to three groups in a single-center, prospective, uncontrolled study: five underwent a single treatment with keratinocyte monolayers on collagen pads (group 1); another five received a single grafting with keratinocyte-microbeads (group 2); and the last five received multiple, consecutive applications of keratinocyte-microbeads 3 days apart (group 3). All patients were followed for up to 12 weeks. By 12 weeks, there was a mean reduction in the initial wound area of 50, 83, and 97 percent in the three groups, respectively. The changes in wound size were statistically significant between the first and third groups (p= 0.0003). Keratinocyte-microbeads proved to be more effective than keratinocyte monolayers on collagen pads when the former were applied every 3 days. Rapid availability within 10-13 days after skin biopsy and easy handling represent particular advantages.     

Oxidative stress in chronic venous leg ulcers

Venous leg ulcers are common and cause considerable morbidity in the population. As healing may be slow or may never be achieved, ulcers create persistent and substantial demands on clinical resources. Great efforts have been made to accelerate tissue repair in chronic venous leg ulcers with limited success. This may at least be partly due to the limited knowledge on the microenvironment of chronic wounds. In fact, the tremendous impact of the microenvironmental conditions on the outcome of wound healing has increasingly become apparent. Oxidative stress as a consequence of an imbalance in the prooxidant-antioxidant homeostasis in chronic wounds is thought to drive a deleterious sequence of events finally resulting in the nonhealing state. The majority of reactive oxygen species are most likely released by neutrophils and macrophages and to an unknown extent from resident fibroblasts and endothelial cells. As the inflammatory phase does not resolve in chronic wounds, the load of reactive oxygen species persists over a long period of time with subsequent continuous damage and perpetuation of the inflammation. In this article, we will critically discuss recent findings that support the role of oxidative stress in the pathophysiology of nonhealing chronic venous leg ulcers.     

下肢慢性静脉溃疡的综合治疗

目的探讨下肢慢性静脉溃疡的综合治疗方法。方法回顾性分析2012年7月~2013年1月我科收治的10例下肢慢性静脉溃疡患者（10条患肢）的临床资料,均采用大隐静脉高位结扎加抽剥并联合应用透光曲张静脉刨吸术、泡沫硬化剂注射、腔镜深筋膜下交通静脉结扎术等方法处理小腿病灶。分别在术前及术后3个月对临床症状的改善情况采集数据,按临床严重程度评分（VCSS）方法进行评估。结果患者均成功实施联合手术治疗方案,在术后的VCSS评分项目中得到改善[（12.3±2.06）v s （9.6±1.71）]。随访（6.70±1.45）个月,疼痛较前均有缓解,未发现患肢有曲张浅静脉残余或复发,8例溃疡基本愈合,仅有2例还有残余溃疡,但都控制在2 cm内,已愈合的溃疡未见复发。结论下肢慢性静脉溃疡经正确选择联合治疗方案进行处理后的效果是理想且安全的,而且其短期效果稳定。     

Localization of platelet-derived growth factor receptor subunit expression in chronic venous leg ulcers

Cellular responses to platelet-derived growth factor, which affects all phases of the wound healing process, are dependent on the interaction of the growth factor with its cell surface receptors. Recently, we have shown that the platelet-derived growth factor-receptor was not expressed in uninjured human skin. In acute human wounds healing by secondary intention, both platelet-derived growth factor-receptor subunits were coordinately expressed, whereas no expression was found after reepithelialization at day 47. Even though impaired wound healing may be due to uncoordinated expression or the failure to express platelet-derived growth factor-receptor subunits, little is known regarding their expression in chronic ulcers. We studied the localization of platelet-derived growth factor-receptor expression in chronic venous leg ulcers of 15 patients with a median age of 73 years. Cryostat sections of biopsy specimens were immunostained with the use of antibodies against the alpha- and the beta-platelet-derived growth factor subunits. RNA was extracted from biopsy specimens and subjected to Northern blot analysis with the use of oligolabeled complementary DNA for the platelet-derived growth factor-receptor. Platelet-derived growth factor-receptor alpha- and beta-subunit expression was found in fibroblast-like cells within the wound bed and in cells beneath the epidermis of the wound edge. Platelet-derived growth factor-receptor beta-subunit expression was detected in endothelial cells of the vessels, in the granulation tissue, and the wound edge, whereas platelet-derived growth factor-receptor alpha-subunit was not expressed in endothelial cells of the uninjured skin. This finding suggests that the platelet-derived growth factor alpha-subunit may be involved in vessel formation during tissue repair. Both platelet-derived growth factor-receptor subunits were expressed at the messenger RNA level indicating that the synthesis is at least partly regulated at a pretranslational level. As the cellular responsiveness to growth factors depends on their specific receptors, our finding that both platelet-derived growth factor-receptor subunits are expressed in chronic venous ulcers substantiates the concept of therapeutic trials with recombinant platelet-derived growth factor.     

A colour Doppler ultrasound study of venous reflux in patients with chronic leg ulcers.

OBJECTIVES: to evaluate the distribution of superficial and deep venous reflux in patients with chronic leg ulcers. MATERIALS: retrospective study of 186 patients with chronic leg ulcers (212 lower limbs). RESULTS: in 127 legs without arterial disease and a history of deep venous thrombosis (DVT), 62 (49%) had superficial, 45 (35%) had superficial and deep, and 14 (11%) had isolated deep venous reflux. In legs with a previous DVT, isolated deep venous reflux was more common (21/55, 38%) but superficial reflux, often in combination with deep reflux, still predominated (56%). CONCLUSIONS: a large part of the venous insufficiency causing venous leg ulcers is superficial and suitable for varicose vein surgery. In patients with chronic leg ulcers most reflux affects the superficial system and is potentially suitable for surgical correction.     

Surgery of venous leg ulcers.

Numerical data are presented to prove the endemic nature and importance of the varicose and postthrombotic syndrome. The fact that even in the most fortunate cases conservative therapy can bring about only temporary improvement, has directed attention to surgical methods. The surgical methods of treatment of varicos (VS) and postthrombotic (PS) syndrome are reviewed. The surgical procedure considered adequate is described. It consists of the following steps. After phlebography, in the case of satisfactorily functioning deep veins, the superficial venous system is extirpated according to Trendelenburg, Madelung and Babcock, the insufficient perforants are exposed and ligated, the ulcer is excised deeply and broadly into the intact tissue. The effect is covered at a later date with a semi-thick skin graft. The importance of supplemental conservative methods (preparation and postoperative treatment) is stressed. This complex therapy was applied in 112 severe cases of venous failure; in 96% the result was excellent, in 3% adequate and in 1% poor. The guiding principles for the successful solution of chronic venous failure are a correct diagnosis and a correctly performed operation. Only proper care can guarantee good results.     

Growth factors for treating chronic venous leg ulcers: A systematic review and meta-analysis

Chronic venous leg ulcers (VLU) are wounds that commonly occur due to venous insufficiency. Many growth factors have been introduced over the past two decades to treat VLU. This systematic review and meta-analysis evaluates the impact of growth factor treatments of VLU in comparison to control for complete wound healing, percent reduction in wound area, time to wound healing, and adverse events. A systematic review and meta-analysis of randomised trials was conducted. MEDLINE and EMBASE were searched up to December 2020. Studies were included if they compared a growth factor versus placebo or standard care in patients with VLU. From 1645 articles, 13 trials were included (n = 991). There was a significant difference between any growth factor and placebo in complete wound healing (P = 0.04). Any growth factor compared to placebo significantly increased the likelihood of percent wound reduction by 48.80% (P = <0.00001). There was no difference in overall adverse event rate. Most comparisons have low certainty of evidence according to Grading of Recommendations, Assessment, Development, and Evaluation. This meta-analysis suggests that growth factors have a beneficial effect in complete wound healing of VLU. Growth factors may also increase percent reduction in wound area. The suggestion of benefit for growth factors identified in this review is not a strong one based on the low quality of evidence.     

下肢慢性静脉性溃疡病因学的研究进展

下肢慢性静脉溃疡（CVLU）是下肢慢性静脉功能不全（CVI）最严重和难治的并发症,以下肢静脉系统持续高压为特征,其临床主要表现为皮肤破溃、下肢疼痛,常伴随有下肢静脉曲张及皮肤色素沉着等症状,多好发于小腿中下段前内侧、外踝以及足背,常为单发,也可为多发,久治不愈或是反复发作,给患者的生活及工作造成极大的影响,甚至使其丧失劳动能力,严重地影响了患者的健康,降低了患者的生活质量。高发病率、难治性及高复发率使CVLU成为临床工作中较为棘手的问题,其致病危险因素较多且复杂,病因及发病机制尚未完全统一,迄今已有多种不同的解释和理论,本文就近年来CVLU病因学的研究进展作一综述。     

Pinch grafts in the treatment of chronic venous leg ulcers

Summary 130 patients with 170 chronic recurrent venous ulcers of the leg treated with pinch grafts following elimination of underlying venous disease are presented. Pinch grafts, when used by the method described, form a soft, pliable and highly resistant skin cover which withstands the stresses of daily life.     

下肢慢性静脉性溃疡病因学及治疗研究

下肢慢性静脉性溃疡( CVLU)是下肢静脉功能不全的常见并发症.许多CVLU反复发作,久治不愈,形成难治性溃疡,成为临床治疗中的辣手问题.笔者就近年来CVLU病因学研究进展,分期疗法和个体化治疗方法进行评价及综述.     

Micropunch grafting for healing of refractory chronic venous leg ulcers

BackgroundChronic venous ulcers are a serious problem for both patients and physicians. The CEAP classification (clinical manifestations (C), etiologic factors (E), anatomic distribution of disease (A), and underlying pathophysiologic findings (P)) for chronic venous disorders (CVD) was developed in 1994. Published papers on CVD use all or part of the CEAP. Micropunch grafts, which are a variation of skin grafts, have been used with great success in plastic surgery for both esthetic and reconstructive purposes. This study aimed to assess the outcomes of micropunch grafting in the treatment of chronic refractory venous ulcers.MethodsPatients with chronic venous ulcers who did not respond to conservative treatment for more than 6 months were included in the study. All patients underwent ulcer coverage by micropunch skin grafts using a micrometer. The patients were discharged on the same day as the surgery. Micropunch skin grafts were manually counted per square centimeter intraoperatively and during follow-up using Dermlite Dermatoschope? II Pro HR. Patient satisfaction was assessed by using a questionnaire.ResultsTwenty patients underwent the surgery. Most of the patients were middle-aged males. The ulcers were predominantly small- and medium-sized. The mean operation time was 167.00 ?± ?86.01 ?min. After 6 months, the survival rate of the planted micrografts was 84%. Three ulcers had graft loss and two patients had an infection at the ulcer site, which was managed conservatively. The patients were followed-up for 14 months.ConclusionMicropunch grafting is a useful and convenient method for the treatment of difficult venous ulcers and can be performed on an outpatient basis.     

An exploration of the use of ultrasound in the treatment of chronic venous leg ulcers

A nurse-led multicentre randomised controlled trial will compare the clinical effectiveness of weekly ultrasound combined with standard care in the treatment of 'hard-to-heal' venous leg ulcers. Recruitment started last autumn.     

Compression and venous surgery for venous leg ulcers

This article reviews published data on the effects of surgery and compression in the treatment of venous ulcers and the best options for compression therapy. Randomized controlled studies reveal that surgery and compression have similar effectiveness in healing ulcers but surgery is more effective in preventing recurrence. Most leg ulcers have a venous pathophysiology and occur because of venous ambulatory hypertension caused by venous reflux and impairment of the venous pumping function. Proposed surgical interventions range from crossectomy and stripping to perforator vein interruption and endovascular procedures (laser, radiofrequency). More conservative procedures (foam sclerotherapy, conservative hemodynamic treatment) have also been proposed.     

Evaluation and treatment of leg ulcers associated with chronic venous insufficiency

The successful management of patients who have leg ulcers related to chronic venous disease requires optimal management of the wound bed, elimination of edema with compression, and correction of venous hypertension whenever possible. Healing of the wound itself requires compression, debridement, bacterial control, and stimulation of the wound bed. Prevention of ulcer recurrence is most effective if the patient is amenable to correction of the venous insufficiency. This is most successful when the superficial or perforator veins are the primary source. Quality diagnostic studies are critical in determining the anatomy and hemodynamic importance of various venous abnormalities and can guide appropriate interventional treatment. Venous corrective procedures usually can be performed using minimally invasive endovenous methods, which are associated with fewer complications and more rapid recovery than are major surgical techniques.     

Aetiology of chronic leg ulcers.

This study was undertaken to determine the relative prevalence of the factors causing chronic ulceration of the leg in the general population. Two hundred and fifty-nine patients with chronic ulceration of the leg were found on screening a Western Australian population of 238,000. (The prevalence of chronic ulceration of the leg was 1.1 per 1000 population.) Two hundred and forty-two of these patients (93%) with 286 chronically ulcerated limbs were fully assessed to determine the factors contributing to ulceration. In 239 limbs (84%) ulceration involved the leg; in these limbs venous disease was the most prevalent cause of ulceration (160 limbs). Arterial disease was found in 66 limbs, with both venous and arterial disease present in 35 limbs. Rheumatoid arthritis was a causative factor in 27 limbs and diabetes was found with 29 limbs with ulceration involving the leg. In 47 limbs (16%) ulceration was confined to the foot; arterial disease (35 limbs) and diabetes (23 limbs) were the most prevalent causes of ulceration in these limbs. Venous disease was infrequent (three limbs). No disorder of the circulation was found in 48 limbs (20%) with ulceration involving the leg, and in 58 (20%) of all ulcerated limbs. More than one aetiological factor was present in 93 limbs (33%). A cause for ulceration was not found in 10 limbs (3.5%).     

Surgical correction of isolated superficial venous reflux reduces long-term recurrence rate in chronic venous leg ulcers.

OBJECTIVES: surgical correction of isolated superficial venous reflux in ulcerated legs may reduce short term recurrence rates but the longer term benefits are unknown. DESIGN: prospective non-randomised cohort study. METHODS: consecutive patients with chronic leg ulcers were prospectively assessed at a one-stop clinic over a 4-year period from July 1995 to July 1999. All patients with ankle brachial pressure indices (ABPI)50.85 were initially treated with weekly four-layer bandaging. Venous duplex studies in all ulcerated legs assessed venous reflux pattern with surgery being offered to all those with isolated superficial reflux, of whom 56% accepted. Patients were advised to wear class two elastic compression stockings after healing. RESULTS: 766 legs in 669 patients were assessed. Six hundred and thirty-three legs had an ABPI50.85, 236 (39%) demonstrating isolated superficial venous reflux. Surgery was performed on 131 of these legs. Twelve and 24 week healing rates were 50% and 72% for operated legs and 62% and 74% for non-operated legs (p=0.67; Kaplan-Meier life table analysis). Recurrence rates at 1, 2 and 3 years were 14%, 20% and 26% for operated legs and 28%, 30% and 44% for non-operated legs (p=0.03; Kaplan-Meier life table analysis). CONCLUSION: surgical correction of superficial venous reflux in legs with chronic leg ulceration may reduce ulcer recurrence rate at 1, 2 and 3 years.     

A prospective multicenter study of the efficacy and tolerability of cryopreserved allogenic human keratinocytes to treat venous leg ulcers

Allogeneic human keratinocyte cultures have been used to treat burn wounds, donor sites, and chronic skin ulcers with some success. Cryopreservation of these cultures allows for the production of large standardized batches that are readily available for use. The aim of the study presented in this report was to study effects of cryopreserved cultured allogenic human keratinocytes (CryoCeal) on chronic lower extremity wounds. Parameters were measured to study efficacy, tolerability, pain associated with chronic wounds, and quality of life of patients. Twenty-seven patients with hard-to-heal venous leg ulcers received a maximum of 9 applications of CryoCeal in a prospective, uncontrolled multicenter study lasting 48 weeks. Eleven out of 27 patients (41%; 95% CI: 22%-61%) had complete wound closure within 24 weeks (1 week). The time required for complete wound closure in these 11 patients ranged from 4.1 to 24.9 weeks. Only 1 patient had recurrence of the ulcer at 48 weeks. Local (wound) pain scores decreased from a mean of 2.5 at baseline to 0.9 at week 24. Fifty percent of the patients attained a pain score of 0 after 12 weeks and remained stable at this score until the end of the study. Overall, the patient quality of life was better at week 24, compared to baseline values. The treatment was well tolerated, and wound infection was the most frequently occurring adverse event.     

The healing of chronic venous leg ulcers with prepared human amnion

Forty chronic venous leg ulcers were treated, before split skin grafting, with human amnion prepared in one of the four following ways: tissue-culture-maintained, frozen, fresh or lyophilised. Although there was no significant statistical difference in the results obtained with the different preparations of amnion, we found that lyophilised amnion was at least as good as the other preparations in promoting a good take of the skin grafts and was the simplest to store and use. It also produced the shortest healing times. Frozen and fresh amnion were easier to prepare than lyophilised amnion but gave a lower graft take and a longer healing time. Tissue-culture-maintained amnion was the most difficult to prepare and gave the poorest results. Its use was abandoned during the trial because of technical difficulties and a high infection rate.     

Proteolytic activity in wound fluids and tissues derived from chronic venous leg ulcers

Venous leg ulcers affect approximately 1% of the general population and 3.6% of those over the age of 65. The goal of the research described herein is to shorten the time to healing by developing wound care alternatives that are based on a comprehensive understanding of the venous ulcer wound environment. The proteolytic and inflammatory components in wound fluids and tissue biopsy samples were characterized in subjects with documented long-standing venous ulcers that had showed resistance to standard therapy. All wounds showed polymicrobial colonization with greater than 10⁶ CFU/g. Myeloperoxidase, a measure of leukocyte infiltration, was also markedly elevated in these wounds. Zymography revealed the presence of both pro-matrix metalloproteinase (MMP)-2 and pro-MMP-9 in wound fluids and to a lesser extent in tissue biopsies. Using an immunocapture activity assay we reveal a sevenfold excess of MMP-9 in wound fluid as compared to tissue, with 73% in the activated form. In contrast, MMP-8 total protein levels were nearly equal in wound fluids and biopsies. Fibronectin, a critical component of the extracellular matrix, was shown to be degraded in both wound fluids and biopsy samples. Finally, the potential of a novel wound dressing to neutralize several constituents of this hostile wound environment is shown.