Deep venous insufficiency of the lower extremities

Lower limbs chronic venous insufficiency (CVI) is a widespread pathologic condition. Prevalence of venous ulcer in Europe ranges between 0.5% and 1.0%. Venous ulceration can be due to insufficiency of the superficial system, although deep venous insufficiency is responsible for 75% of the cases. Morbidity and socio-economic costs are exceedingly high especially because of frequent recurrences. CVI recognises mainly two causes: 1) increased influx, due to arteriovenous fistulas; 2) difficult outflow usually secondary to postphlebitic or primitive valvular incompetence. The prevalence of CVI and venous ulceration is difficult to assess. Surgical treatment tends to cure the underlying hemodynamic problem. Homans in 1916 first introduced surgical treatment of CVI and venous ulceration: excision of the cutaneous lesion and ligature suprafascial of the communicating veins. Since then different various techniques have been introduced in the clinical practice: Linton in 1938 supported subfascial interruption of the perforating veins but still reported a recurrence rate of 47%. Stripping of internal saphenous vein associated with division of perforating veins is still controversial, because lacks evidence of its real effectiveness in preventing recurrences. Felder's surgical technique is preferred by some authors to Linton's technique, because of the possibility to divide and section incompetent perforating veins without a cutaneous incision in the severely diseased postphlebitic tissues. In personal experience (56 patients) treated by Felder's techniques, we reached a cutaneous ulceration healing rate of 36% has been obtained. Subfascial interruption of perforating veins under endoscopic vision associated to the stripping of the internal saphenous vein could be a valuable option in the treatment of CVI because of the shorter duration of the operation and hospital stay and lesser postoperative complications. Repair and/or replacement of deep venous valves, originally described by Kistner in 1968, could be curative of venous hypertension due to primitive valvular insufficiency (primitive or postphlebitic): the same author in 1975 reported positive results (80% at 5 years). Major advantages of indirect valvuloplastic surgical technique are: 1) venotomy is not necessary; 2) it does not introduce extraneous material in the vasal lumen; 3) clamping of the vein is avoided; 4) heparine or other antithrombotic measures are usually not necessary. Although preliminary encouraging results, subsequent clinical experiences have demonstrated that correction of the reflux of the main axial venous system alone is not curative and durable resolution of venous symptoms also depends on the concomitant correction of all incompetent perforating veins. Venous valves transplantation is theoretically good to correct the deep long reflux and to improve calf pump function, although clinical results are still limited and follow-up not prolonged enough in terms of symptoms resolution and complete ulcer healing.     

Subfascial endoscopic perforator vein surgery: indications and results.

Subfascial endoscopic perforator surgery (SEPS) is a new, minimally invasive technique performed in patients with advanced chronic venous insufficiency. The objective of the operation is to interrupt incompetent medial calf perforating veins to decrease venous reflux and reduce ambulatory venous hypertension in critical areas above the ankle where venous ulcers most frequently develop. Patients with stasis skin changes and healed or active venous ulcerations are potential candidates for the operation. Preoperative evaluation is performed with duplex scanning of the superficial, deep and perforator system, to diagnose both obstruction and valvular incompetence. Results of the North American SEPS Registry (NASEPS) as well as experience in several individual centers confirmed that the operation has significantly fewer wound complications than the classic open surgical techniques, and that rapid ulcer healing can be achieved. At the Mayo Clinic an ulcer recurrence rate of 12% was observed, with recurrence significantly more frequent in post-thrombotic limbs than in patients with primary venous valvular incompetence. The NASEPS Registry report confirmed a 2-year cumulative ulcer recurrence rate of 28%; ulcer recurrence was significantly more frequent in post-thrombotic limbs, especially in those with deep venous obstruction. SEPS is a new, low-risk, outpatient procedure that effectively decreases perforator reflux in patients with venous ulcerations, and should be added to our armamentarium to treat patients with advanced chronic venous disease. Long-term prospective and randomized studies are, however, still required to provide level I evidence of late efficacy.     

Chronic venous insufficiency and the therapeutic effects of Daflon 500 mg

Chronic venous insufficiency is linked to venous hypertension and forces of shear stress on the endothelium. Venous hypertension depends upon two forces: the weight of a column of blood from the right atrium transmitted through the valveless vena cava and iliac veins to the femoral vein, and pressure generated by contracting skeletal muscles of the leg transmitted through failed perforating veins. When valve failure occurs in superficial axial veins and perforating veins, the venous pressure in the veins and venules of the skin and subcutaneous tissue is raised. The skin changes in chronic venous insufficiency are directly related to the severity of the venous hypertension. Also, pathologic changes in the valves are linked to venous hypertension and leukocyte infiltration and activation. It is hypothesized that acute venous pressure elevations cause a shift in the venous hemodynamics with changes in wall shear stress. This initiates the inflammatory cascade. Daflon 500 mg ameliorates the effects of chronic inflammation. In randomized trials, 60 days of therapy with Daflon at a dosage of 500 mg 2 tablets daily was effective, in addition to elastic compression, in accelerating venous ulcer healing. Because venous insufficiency is linked to venous hypertension and an inflammatory reaction, it appears that Daflon 500 mg 2 tablets daily shows a great potential for accomplishing blockade of the inflammatory cascade.     

The role of perforating vein dissection in the treatment concept of venous ulcers--myths and evidence

Crural ulcers represent the most serious form of chronic venous incompetence (CVI). According to duplex studies superficial venous incompetence predominate in this stage of the disease, but combined refluxes of superficial and deep veins are also common. Despite a positive correlation between the number of incompetent perforators and the stage of CVI isolated incompetence of perforating veins in venous ulcers are rarely found. Additionally, only a minority of incompetent perforators depict larger reflux volumes. Therefore, doubts about a causal role of perforators incompetence in ulcer genesis are justified. According to phlebodynamometric studies the risk of crural ulcer development increases with the degree of hemodynamic compromise. Ulcer healing can only be achieved after complete normalization of ambulatory venous hypertension. In case of superficial refluxes and concomitant incompetence of perforating veins exclusion of the superficial component is sufficient to achieve this goal. Incompetent perforators normalize their function consecutively. In contrast, venous hypertension persists after exclusion of superficial refluxes in case of incompetent perforators and irreversible damage of the deep venous system. Surgical therapy studies exactly reflect the results of these hemodynamic examinations. Therefore, the role of endoscopic subfascial perforator dissection (ESPD) in the treatment of venous ulcers remains unclear. Future therapy studies should take into account that the definite role of ESPD in ulcer healing can only be examined without additional treatment of refluxes in the saphena system. Additionally, all study patients should be classified according to the CEAP nomenclature and Hach's classification of chronic compartment syndrome. Methodological differences in technique and extent of ESPD have also to be taken into account.     

Short-stretch or four-layer compression bandages: an overview of the literature

Venous ulcers are a common, costly occurrence. Treatment typically includes the use of short-stretch and four-layer bandages--both with demonstrated ability to increase venous return and healing rates. Which is superior is unclear. To determine whether short-stretch bandages or four-layer compression systems provide shorter healing times and fewer adverse events when used in adults with venous ulcers, a search of English-language literature was conducted using the search terms short-stretch bandages and wound care, compression bandages and wound care, compression and venous ulcers, four-layer compression and venous ulcers, and multilayer compression and venous ulcers. Data from 25 studies published between 1997 and 2006 were examined. Short-stretch and four-layer compression bandages were found to be equally as effective in managing the edema that compromises venous ulcer healing. Time to healing was found to be shorter using four-layer or one- to two-layer compression when compared to paste compression in 24 studies. Ankle brachial index is an important factor to consider in determining compression appropriateness. Generally, use of any compression system is better than no compression at all.     

Current surgical approaches to venous hypertension and valvular reflux

Venous hypertension in the lower extremity with and without ankle ulceration can be attributed to venous outflow obstruction, venous valve incompetence with massive reflux. Compression stocking and pneumatic pump cannot provide a long-term cure of this advance stage of venous pathology and ulcer recurrence is to be expected. Definitive treatment requires the following sequential order: (1) correction of potential underlying coagulopathy (deficiency in Protein C, Protein S, anthrombin III), (2) correction of venous outflow obstruction in the pop-fem-iliac or inferior vena cava with venous bypass (balloon angioplasty of venous stenosis has disappointing long-term results because fibrocollagen is resistant to dilation), (3) correction of valve incompetence in the following order of preference: valvuloplasty, vein transposition, and valve transplantation, (4) perforator ligation and saphenous vein stripping, (5) compression stocking and pneumatic pump to enhance venous return and reduce superficial venous congestion. In nonpostphlebitic venopathy, compression stocking + pneumatic boot pump can function as a substitute for perforator ligation + saphenous vein stripping. There is high incidence of incompetence in transplated valve (53%) that can be restored with open valvuloplasty.Presented at the 36th Annual World Congress, International College of Angiology, New York, New York, July 1994     

Endoscopic vs conventional vein harvesting: a prospective analysis

Minimally invasive vein harvesting is associated with better leg wound healing and a lower incidence of wound infections. We analyzed our experience in 2 prospectively enrolled groups of non-randomized patients undergoing elective coronary artery bypass grafting. Group 1 was 81 patients who had endoscopic vein harvesting; group 2 was 80 who had conventional open vein harvesting. The time taken for endoscopic harvest (skin incision to skin closure) was significantly less than that for open harvest (51.07 vs 75.94 min). The number of cases to reach a plateau on the learning curve for endoscopic vein harvest was 20 for 2 lengths of vein and 35 for 3 lengths of vein. Significantly more suture repairs per vein were required in group 1 (1.32) than group 2 (0.38). The incidence of wound infection was 1.2% in group 1 vs 8.8% in group 2. Endoscopic vein harvesting is not difficult to learn and it should be preferred over open vein harvest, given its benefits in wound healing.     

The venous reflux

Venous reflux is the most common cause of venous hemodynamic disorders. In this paper 2 issues are discussed: how and where does reflux arise and what are the hemodynamic consequences of retrograde flow. Pressure gradient and incompetent vein connecting both poles of the gradient are the prerequisite for venous reflux to arise. Ambulatory pressure gradient occurs during the activity of the calf muscle venous pump between deep veins of the thigh and the lower leg. Thus the incompetent reflux-carrying vein must connect the popliteal, femoral, profunda femoris, or iliac vein with 1 of the deep veins of the lower leg. Reflux can be considered as shunting of blood from thigh veins into the lower leg veins. The most frequently found incompetent veins are the long and short saphenous veins and perforators communicating with deep veins of the thigh. On the other hand, calf perforators emptying into the deep veins of the lower leg, where the lower pole of the pressure gradient is located, cannot be the feeding source of reflux. A physiological bidirectional flow takes place in calf perforators connecting superficial and deep veins of the lower leg and making them conjoined vessels. Venous reflux produces ambulatory venous hypertension. The quantity of reflux volume and not the localization of retrograde flow in superficial or deep veins is the most important hemodynamic factor. Reflux in superficial veins, when large enough, can cause the most serious symptoms of chronic venous insufficiency including leg ulcers. Plethysmographic findings have shown that incompetence of the femoral and calf perforating veins is hemodynamically unimportant. Large incompetent calf perforators are not the cause of venous abnormality but are the consequence of saphenous retrograde flow.     

Comparative study of different venous reflux duplex quantitation parameters.

The objective of this study was to compare different quantitation parameters of venous reflux by duplex scan in different venous disease manifestations. Duplex scan is a new modality to quantify venous reflux. Several studies propose different parameters. In addition, there is controversy about the importance of deep and superficial involvement in different disease manifestations. It is not clear whether there is an increased venous reflux associated with varied clinical stages. Venous conditions were classified in seven stages and their differences for several quantitation variables studied. Most quantitation variables, such as average and peak velocity, average and peak flow, and reflux volume disclosed significantly increased reflux from normal, pain only, and edema group to varicose vein, with or without edema, to lipodermatosclerosis and ulcer groups at every location in the lower extremity. Reflux time was not as consistent as other variables. Totalization of the results of every parameter for the whole extremity points to an increased reflux from pain only to edema and from lipodermatosclerosis to ulcer group. Chronic edema is not usually associated with increased venous reflux. The greater saphenous vein (superficial system) seems to be the main contributor to reflux in all stages of disease. Different quantitation methods of venous reflux are equivalent. Increased deep and superficial reflux and its totalization are associated with a more advanced disease stage. Reflux time may be the least useful variable. Chronic edema is frequently not associated with venous reflux. Greater saphenectomy may be the most useful intervention, even in the presence of deep vein reflux.     

Some effects of sustained compression on ulcerated tissues

Sustained leg compression is the first line of treatment for patients with chronic venous ulcers. The success rates of this treatment vary, and the mode(s) of action are not well understood. In this study, tissue oxygen tension (TcPO2), surface pH, and reactive hyperemia measurements were made to observe changes associated with sustained compression in patients with chronic venous ulcers. Patients with chronic venous ulcers (n = 20, 13 F, 7 M, median age 65.5 years, median ulcer size 13.9 cm2) were assigned to the same treatment, wound dressings, and 4-layer bandaging during a 24-week period. Duplex ultrasound, venous refilling time, skin tissue oxygen, and ulcer surface pH were measured at defined time points. Ulcer areas were calculated from contour traces done at regular dressing changes. The difference between ulcer surface pH and control values measured proximally on the same leg diminished with healing (p = 0.02), which occurred despite the evidence of deep venous reflux. Ulcers with smaller initial areas healed quicker (p = 0.003). A greater likelihood of healing was observed in women (p = 0.017). Sustained compression may potentiate healing by acting on the microcirculation in ulcerated tissues.     

Endoscopic vs. conventional vein harvesting: first results with a new, non-disposable system.

BACKGROUND: Most of the grafts used in coronary bypass surgery are still venous grafts. The preferred vein for bypass surgery is the long saphenous vein. Severe wound complications caused by saphenous vein harvesting occur in 1 % to 3 % of cases. Minor complications that do not need surgical revision occur in up to 43 % of cases. We developed an endoscopic harvesting technique using non-disposable instruments to reduce wound complications caused by vein harvesting. METHOD: In a retrospective study, the occurrence of wound complications, haematoma, postoperative pain, ambulation, sensory disturbances and patient satisfaction were studied (n = 182). Patients who had either endoscopically harvested (n = 91) or conventionally harvested (n = 91) saphenous vein grafts were reviewed. RESULTS: Results were collected for 173 patients. The overall prevalence of wound complications was 18.7 %. The incidence of wound healing complications could be reduced significantly (p = 0.015) from 15.3 % to 3.4 % using the endoscopic technique. In the endoscopic group, postoperative ambulation was significantly (p = 0.002) easier, patient satisfaction was significantly (p = 0.007) higher, and postoperative leg swelling (p = 0.003) and haematoma (p = 0.004) could be reduced significantly. The occurrence of postoperative pain and sensory disturbances did not differ significantly. COMMENT: We conclude that the used endoscopic vein harvesting is a safe and cost effective method that can significantly reduce wound complications. An ongoing prospective study should establish our demonstrated data.     

Growth factors in wound healing: the next great innovation?

Wound healing is a complex process that, in the vast majority of cases, normally leads to complete healing. It can be likened to the construction of a building, having many of the same requirements. As long as these requirements are satisfied, the healing of the acute wound proceeds uneventfully. Unfortunately, significant impediments to healing occasionally exist and the acute wound stops healing, becoming chronic. If these impediments can be controlled, most of these chronic wounds will eventually heal, albeit slowly. For example, the venous leg ulcer will heal once one applies proper compression therapy that provides the necessary support counteracting the underlying venous hypertension and provides appropriate wound care. Similarly, diabetic neuropathic foot ulcers will not heal until the disordered glucose metabolism is controlled and causative pressure on the foot is offloaded. Thus, successful healing of chronic wounds involves the treatment of underlying causes. Sometimes, however, proper management of these underlying diseases does not result in healing. Conventional therapy, unfortunately, does not have an answer for this dilemma. Growth factors provide a means by which cells are able to communicate with each other. They have profound effects on cell proliferation, migration, and extracellular matrix synthesis and release. Considering applying topically active growth factors directly to the wound surface in order to stimulate some aspect of the healing process has always been attractive. To date, Platelet-Derived Growth Factor (PDGF) has been the most researched of all the growth factors. Originally studied in the management of pressure ulcers, PDGF was eventually approved in North America for the treatment of diabetic lower extremity ulcers. The clinical data surrounding these indications will be reviewed. The future in growth factor research may require a greater understanding of how these substances interact with each other. Wound dressings of the future may include several growth factors, each with a specific function. In this way, the application of topically active growth factors to chronic ulcers just might be the next great innovation in wound healing.     

Use of intermittent pneumatic compression for treatment of upper extremity vascular ulcers

Ischemic vascular ulcerations of the upper extremities are an uncommon and frequently painful condition most often associated with scleroderma and small vessel inflammatory diseases. Digital amputation has been advocated as primary therapy because of the poor outcome with medical care. Intermittent pneumatic compression (IPC) pump therapy can improve ulcer healing in lower extremity ischemic ulcerations; however, the value of this treatment in upper extremity ischemic ulcerations is not known. This observational pilot study consisted of a consecutive series of 26 patients with 27 upper extremity ischemic vascular ulcers seen at the Mayo Gonda Vascular Center from 1996 to 2003. Inclusion criteria were documented index of ulcer size and follow-up ulcer size and use of the IPC pump as adjunctive wound treatment. Twenty-six of 27 ulcers (96%) healed with the use of the IPC pump. Mean baseline ulcer size was 1.0 cm2 (SD=0.3 cm2) and scleroderma was the underlying disease in 65% (17/26) of cases. Laser Doppler blood flow in the affected digit was 7 flux units (normal greater than 100). The mean ulcer duration before IPC treatment was 31 weeks. The average pump use was 5 hours per day. The mean time to wound healing was 25 weeks. Twenty-five of 26 patients reported an improvement in wound pain with pump use. Intensive IPC pump use is feasible and associated with a high rate of healing in upper extremity ischemic ulcers. A prospective, randomized, sham-controlled study of IPC is needed to determine whether IPC treatment improves wound healing compared to standard medical care.     

Development of a content-validated venous ulcer guideline

Evidence-based practice for venous ulcers may improve healing and reduce costs of care. The Association for the Advancement of Wound Care Government and Regulatory Task Force developed a content-validated venous ulcer guideline based on best available evidence supporting each aspect of venous ulcer care. After compiling all-inclusive lists of elements in venous ulcer algorithms published before August 2002, the Task Force objectively rated and summarized up to five best references from MEDLINE, CINAHL, and EMBASE literature searches covering each aspect of care. Sixteen multidisciplinary wound care professionals and educators used judgment quantification to content validate all steps. A 2004 email survey of AAWC members (N = 1,514) clarified effects of under-reimbursement on evidence-based venous practice. The Venous Ulcer Guideline containing all elements with A-level evidence plus those with a Content Validity Index >0.75 now resides on the AAWC and the Agency for Healthcare Research and Quality National Guideline Clearinghouse websites. However, a review of US healthcare environment components, including reimbursement policies, and the results of the survey identified many barriers to implementation of A-level evidence supported steps (sustained graduated high compression, autolytic debridement, and moist wound environments) in practice. Sufficient evidence supports improved venous ulcer care in the US but inadequate and/or inconsistent reimbursement policies impede quality evidence-based venous ulcer practice, delaying healing and increasing the burden of venous ulcers on society.     

彩色多普勒超声诊断下肢交通支静脉功能不全的临床价值

目的:研究彩色多普勒超声诊断下肢交通支静脉功能不全的临床价值。方法:回顾性分析行大隐静脉高位结扎加剥脱术、交通支静脉离断术的64例患者(82条肢体)的临床资料。术前应用彩色多普勒超声检出功能不全的交通支静脉并将其定位,与手术结果相对比。结果:与手术结果相比,彩色多普勒超声诊断准确率、敏感性、特异性、漏诊率、误诊率、约登指数、比数积、阳性预测值、阴性预测值及Kappa值为分别是95.8%、96.5%、88.2%、3.5%、11.8%、0.837、206.5、98.8%、71.4%及0.766。由于彩色多普勒超声的Kappa值为0.766>0.75,且(P<0.0001),说明其与手术结果非常吻合。结论:彩色多普勒超声能够准确诊断并定位功能不全的交通支静脉,为诊断和治疗提供重要的依据,具有很高的临床价值。     

Color Doppler sonography of arteries associated with perforating veins.

BACKGROUND: It has been known for some time that perforating veins had associated perforating arteries. There has been no way to investigate these arteries preoperatively. The newer high resolution ultrasonic devices enable us to investigate these arteries. We are able to localize, determine the frequency, and measure the size of the arteries associated with perforating veins of the lower extremities. METHODS: All patients were studied in our clinical vascular laboratory. Patients: 55 patients with different degrees of varicosities were studied. Measures: Each patient had their perforating veins and arteries investigated with a 7.5 MHz linear array transducer (Siemens, Type Elegra). RESULTS: 73% of the 233 perforating veins identified had an associated perforating artery. No preferred localization of the perforating veins was noted. The number of location did not correlate with the presence or absence of incompetence of the veins. The perforating arteries were located in close proximity to the perforating veins but did not go far into the subcutaneous fat. The maximum systolic velocity was 12+/-8 cm/sec. CONCLUSIONS: The preoperative detection of perforating arteries associated with perforating veins is possible using a color Doppler scanner. Their pathophysiological function and its relation to bleeding complications, wound healing and ulcer healing can be studied using this tool.     

Venous ulcers: pathophysiology and treatment options

Venous ulcers affect approximately 1% of the world's population, increasing healthcare expenditures and decreasing quality of life. Several hypotheses may help explain their origin. Incompetent veins or valves or impaired muscle function may lead to abnormal calf muscle pump function that can elevate ambulatory venous pressure (venous hypertension). This hypertension subsequently results in local venous dilatation and pooling, concomitantly trapping leukocytes that may release proteolytic enzymes that destroy tissues. Venous pooling also induces interendothelial pore widening and deposition of fibrin and other macromolecules that "trap" growth factors within them, rendering them unavailable for wound repair. Compression therapy, the mainstay treatment, reduces edema, reverses venous hypertension, and improves calf muscle pump function. Several treatment options can be employed as adjuvants to compression--eg, systemic therapy with pentoxifylline or aspirin, autologous grafts, tissue-engineered skin, growth factor therapy, and/or vein surgery. The epidemiology, pathophysiology, diagnosis, and management options regarding venous ulcers are reviewed.     

Conception of the venous hemodynamics in the lower extremity

Contradictory reports on the significance of several hemodynamic phenomena, such as femoral vein incompetence and incompetent calf perforators, impede orientation in venous hemodynamics. Venous pressure difference arising between the popliteal and the posterior tibial vein during the activity of the calf muscle venous pump was reported for the first time about 50 years ago, but regrettably, this important discovery continues to be unrespected. The venous pressure difference has since been termed ambulatory pressure gradient and seems to be the key factor triggering the venous reflux in the lower limb as well as the process leading to varicose vein recurrence. On the other hand, simultaneous recordings of the mean venous pressure in the posterior tibial and long saphenous veins demonstrated that the pressure curves have been identical at rest, during ambulation, and in the recovery period, a finding typical of conjoined vessels. Bidirectional flow within calf perforators taking place both in healthy subjects and in patients with varicose veins enables a quick equilibration of pressure changes between deep and superficial veins of the lower leg. Reflux disturbing the venous hemodynamics is in various degrees dependent on the quantity of retrograde flow; abolition of reflux restores normal venous hemodynamics. Reflux in superficial veins, if large enough, may cause the most severe form of chronic venous insufficiency. Femoral vein incompetence and incompetent calf perforators per se do not produce ambulatory venous hypertension and do not cause hemodynamic disturbance. This study discusses the controversial issues, tries to define and appraise the principal hemodynamic phenomena (ambulatory venous hypertension, ambulatory pressure gradient, venous reflux, superficial and deep vein incompetence, incompetent perforators), mentions a possible relation between deep vein incompetence and varicose veins, and attempts to present, based on proved facts, a comprehensive picture of the venous hemodynamics in the lower extremity.     

Prognosis of the infected diabetic foot ulcer: a 12‐month prospective observational study

Aims

To determine clinical outcomes and explore prognostic factors related to ulcer healing in people with a clinically infected diabetic foot ulcer.

Methods

This multicentre, prospective, observational study reviewed participants’ data at 12 months after culture of a diabetic foot ulcer requiring antibiotic therapy. From participants’ notes, we obtained information on the incidence of wound healing, ulcer recurrence, lower extremity amputation, lower extremity revascularization and death. We estimated the cumulative incidence of healing at 6 and 12 months, adjusted for lower extremity amputation and death using a competing risk analysis, and explored the relationship between baseline factors and healing incidence.

Results

In the first year after culture of the index ulcer, 45/299 participants (15.1%) had died. The ulcer had healed in 136 participants (45.5%), but recurred in 13 (9.6%). An ipsilateral lower extremity amputation was recorded in 52 (17.4%) and revascularization surgery in 18 participants (6.0%). Participants with an ulcer present for ~2 months or more had a lower incidence of healing (hazard ratio 0.55, 95% CI 0.39 to 0.77), as did those with a PEDIS (perfusion, extent, depth, infection, sensation) perfusion grade of ≥2 (hazard ratio 0.37, 95% CI 0.25 to 0.55). Participants with a single ulcer on their index foot had a higher incidence of healing than those with multiple ulcers (hazard ratio 1.90, 95% CI 1.18 to 3.06).

Conclusions

Clinical outcomes at 12 months for people with an infected diabetic foot ulcer are generally poor. Our data confirm the adverse prognostic effect of limb ischaemia, longer ulcer duration and the presence of multiple ulcers.     

Venous ablation therapy: indications and outcomes

Venous disease has long been recognized as a progressive, debilitating, and recurrent problem. Until recently, venous insufficiency was often undertreated due to a lack of therapeutic modalities. During the past decade, an explosion in the treatment options has occurred. Endovenous ablation therapy has nearly replaced the conventional surgical treatments for patients with superficial venous insufficiency. Dramatic changes in therapy are also available for deep venous thrombosis but are not the subject of this review. These newer techniques are much less invasive and consequently have reduced risks of wound complications or bleeding. In addition, they can be performed easily in the office setting with local anesthesia. Higher-risk patients can now be considered for these less invasive treatments to reduce their ambulatory venous hypertension. With the lower procedural risks and the dramatically shortened recovery times, earlier intervention can be entertained. This helps prevent the development of venous stasis ulceration and other sequelae of progressive venous insufficiency.