Compression treatment of venous and venous/arterial leg ulcers

The French National Authority for Health has recalled recommendations for the use of compression in the treatment of venous or venous/arterial leg ulcers. Different types of bandages and compression stockings must be used. The pressure to be achieved is between 30 and 40 mm Hg at the ankle (and below 30 mm Hg in case of mixed ulcers). In daily practice, beyond these recommendations, the choice of type of compression must also take into account the size of the ulcer, the appearance of the wound, the existence of leg dysmorphia, the volume of the oedema and also the general condition of the patient.     

The surgeon and venous and mixed venous/arterial ulcers

The treatment of leg ulcers encompasses several techniques: mechanical and surgical debridement under local anaesthetic, the excision of the ulcerous base followed by pinch skin or mesh grafting. Varicose vein surgery is based on stripping methods or ligation of the perforators with the aim of relieving the venous overload. These methods are evolving with the use of endoscopic techniques (endovenous laser, radio frequency technique).     

Recognizing and treating complications of venous and venous/arterial leg ulcers

Several signs can point to an infection of a leg ulcer and lead to the setting up of suitable treatment (new generation antiseptics and silver impregnated dressings). The observation of an increase in the number of bacteria characterises a pre-infectious phase. A biopsy can identify the germ responsible for the infection. A risk of cancerous degeneration is a possibility. Treatment is then generally surgical.     

Identifying relationships between symptom clusters and quality of life in adults with chronic mixed venous and arterial leg ulcers

The objective of this study was to identify symptom clusters and their effect on quality of life (QOL) of adults with chronic leg ulcers of mixed venous and arterial aetiology. A secondary analysis of data from four existing prospective longitudinal studies conducted by a wound healing research group in Australia was undertaken. A total of 110 patients who met the inclusion criteria were selected for this study. Exploratory factor analysis (EFA) was used to identify symptom clusters and correlational analyses to examine relationships between the identified symptom clusters and QOL. The EFA identified two distinct symptom clusters: a ‘systemic symptom cluster’ consisting of pain, fatigue and depressive symptoms; and a ‘localised‐leg symptom cluster’ including pain, fatigue, oedema, lower limb inflammation and exudate. Physical QOL correlated significantly with the systemic symptom cluster (r = ?0·055, P < 0·0001) and the localised‐leg symptom cluster (r = ?0·054, P < 0·0001), whereas mental QOL was associated only with the systemic symptom cluster (r = ?0·038, P = 0·01). The results suggest that appropriate intervention strategies targeting specific symptom clusters should be developed. Targeting patients with symptom clusters is particularly important because they are at high risk and the most vulnerable for reduced QOL.     

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.     

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.     

Layered shaving of venous leg ulcers

A method for the quick preparation of refractory venous ulcer beds for autografting is described. Irrespective of their clinical or bacteriological state, ulcer granulations and other products of frustrated healing are shaved in layers down to an even and surgically clean base using an ordinary skin grafting knife. Our experience with 32 consecutive patients (58 ulcers) is reported. The mean duration of hospital stay, the patient being completely healed on discharge, was 18.3 days. This represents a decrease of more than 3 weeks when compared to a previously used standard method. No investigation into the question of recurrence was carried out as available evidence, which is critically reviewed, indicates no significant relation between the method of grafting and the incidence of recurrence.     

Analysis of therapy-resistant venous leg ulcers

Chronic leg ulcers represent a major health-care problem with considerable socioeconomic impact. Patients with seemingly therapy-resistant leg ulcers are common to all clinics. The purpose of the present study was to (1) examine a group of patients with nonhealing venous leg ulcers treated with a double-layer bandage and (2) evaluate whether the addition of an interactive hydrocolloid wound dressing could initiate healing in these patients. Twenty-two patients with ulcers caused by venous insufficiency were included. The patients had a mean ulcer duration of 27.6 years. Duration of the present ulcer was at least 1 year (mean >/= 4.1 years). Twenty of the 22 patients showed massive lipodermatosclerosis. Before inclusion, all patients had used double-layer bandage consisting of a zinc-impregnated bandage or stocking and a self-adhesive compression bandage for 1 year or longer without improvement. The new regimen was a triple-layer treatment with the hydrocolloid water applied over the ulcer and the traditional double-layer bandage unchanged. Three patients were dropped from the study. Nineteen patients were followed until healing or for 10 months. Nine of the 19 patients who completed the study healed. Ulcer area was reduced by 70% or greater in 7 patients and by 30% to 40% in two patients. One ulcer did not respond to the treatment and worsened slightly. The results of this study were encouraging and indicate that the triple-layer treatment with the hydrocolloid dressing applied to the ulcer should be evaluated in a randomized, controlled study in patients with less pessimistic prognoses.     

Diagnosing venous and venous/arterial ulcers

A venous ulcer can be diagnosed on the basis of elements arising from the questioning and the clinical examination of the patient. A venous Doppler ultrasound can specify the type of reverse flow (superficial and/or deep). Measuring the ankle brachial pressure index helps to eliminate or confirm any arterial involvement. Depending on the systolic pressure index, the ulcer will be considered as purely venous, mixed (arterial-venous) or predominantly arterial.     

Neuromuscular stimulation of the common peroneal nerve increases arterial and venous velocity in patients with venous leg ulcers

Activation of the venous muscle pumps by neuromuscular stimulation of the common peroneal nerve has been previously shown to increase venous and arterial flow in the legs of healthy subjects. The aim of this study is to determine whether a similar effect is observed in patients with chronic venous leg ulcers. 1 Hz intermittent electrostimulation of the common peroneal nerve was applied to 14 patients with ulcers between 1 and 10 cm in diameter, eliciting a small, painless, regular, muscular twitch of the leg. Flow was measured using Duplex ultrasound in the popliteal vein and the popliteal artery. Peak arterial velocity increased from 57 to 78 cm/s (P = .001) in sitting position, and from 79 to 98 cm/s in recumbent position (P = .001). Peak venous velocity increased from 10 to 33 cm/s (P = .001) sitting, and from 14 to 47 cm/s (P = .001) recumbent. Significant increases were observed in both venous and arterial blood flow in the lower limb. This suggestsed that activation of the venous muscle pump and improvement of arterial flow assisted oxygen delivery at the wound site. Moreover this may be a worthwhile intervention to assist in the healing of venous leg ulcers, and may provide a mechanistic explanation for the increased healing rates previously reported with neuromuscular stimulation of the common peroneal nerve.     

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。