Social medicine importance and treatment strategy of chronic venous diseases

In European states chronic diseases of the veins are a remarkable social medical problem. Representative random investigations of the population in the GDR resulted in a medically significant chronic venous insufficiency of the legs in 14% of the adult population. The annual fresh disease rate concerning the medically significant type varicosis is 1.5%. The highest incidence rates are between the 20th and 40th year of age. A therapeutic need of recovery is the result. Only the early active therapy in the sense of a sanation of the disease is able to prevent severe forms of the course. Effective primary preventive measures are not yet known. The treatment of patients suffering from venous diseases is part of the basic medical care in the territory. The basis therapy should remain in the hands of the general practitioners.     

Isosorbide dinitrate for the relief of severe heart failure after myocardial infarction.

Severe congestive heart failure secondary to myocardial infarction remains a difficult management problem. Although intravenous vasodilators and mechanical assist devices have been reported to improve the depressed hemodynamic function, these interventions are limited to the intensive care unit and cannot be used for long-term management. This study evaluates the hemodynamic and symptomatic response to sublingual administration to isosorbide dinitrate (5 to 10 mg) in seven consecutive patients with severe congestive heart failure after anterior wall myocardial infarction. Serial measurements of mean right atrial and pulmonary arterial end-diastolic pressure, mean blood pressure, heart rate and cardiac output were obtained during the control period and during the 4 hours after administration of isosorbide dinitrate. The peak response occurred approximately 30 minutes after drug administration with an 83 percent reduction in mean right atrial pressure (from 6 to 1 mm Hg, P less than 0.02), a 36 percent reduction in pulmonary arterial end-diastolic pressure (from 25 to 16 mm Hg, P less than 0.0001) and a 6 percent reduction in mean blood pressure (from 94 to 88 mm Hg (P less than 0.05). There were small but statistically not significant increases in cardiac index (from 2.3 to 2.6 liters/min per m2 and stroke work index (from 26 to 32 gm/beat per m2). The total systemic vascular resistance was reduced by 5 percent from 1,605 to 1,518 dynes sec cm-5 (P less than 0.10). The baseline heart rate of 105 beats/min was not significantly changed. The reduction in pulmonary arterial end-diastolic pressure became statistically significant (P less than 0.05) between 15 and 30 minutes after administration of isosorbide dinitrate and remained significant for 3 to 4 hours. This reduction of pulmonary arterial end-diastolic pressure to less than 22 mm Hg was associated with relief of the patients' pulmonary symptoms. The response to nitroglycerin (0.4 mg) was similar in magnitude but of much shorter duration (approximately 15 minutes for nitroglycerin versus 4 hours for isosorbide dinitrate in patients with and without congestive heart failure. The slope (calculated by dividing the change in cardiac index or stroke work index by the change in pulmonary arterial end-diastolic pressure) was significantly (P less than 0.05) depressed in the patients with congestive heart failure. These data demonstrate that the symptomatic pulmonary venous hypertension can be effectively relieved by isosorbide dinitrate without further compromising left ventricular function.     

Effectiveness of mesoglycan topical treatment of leg ulcers in subjects with chronic venous insufficiency

BACKGROUND: Aim of the present comparative clinical study was to demonstrate the efficacy of the topical application of mesoglycan, a profibrinolytic agent, for healing of leg ulcers in patients with chronic venous insufficiency. METHODS: Forty patients, observed in our outpatients department, with venous leg ulcers have been randomized in two groups of twenty subjects, each treated with topical application of mesoglycan (1 or 2 vials/day) or vegetal stimulins and followed for two months, with controls after 15, 30 and 60 days. RESULTS: At the end of the observation period, ulcer healing rate was 95% in the mesoglycan group, while a lower healing rate was obtained in the stimulins group (80%). CONCLUSIONS: The present study confirms previous clinical experiences with mesoglycan and suggests its application in the topical treatment of venous ulcers.     

Patterns of venous reflux in limbs with venous ulcers. Implications for treatment.

AIM: To investigate the anatomic distribution of vein reflux in limbs with healed or active ulcers (CEAP V and VI). METHODS: Sixty limbs (58 patients) belonging to CEAP classes V and VI were identified from 798 limbs (519 patients) with ultrasonically proven chronic venous insufficiency (CVI). Age, gender, duration of the venous ulcer, and history of deep venous thrombosis were correlated to the anatomic distribution of the venous reflux. RESULTS: The prevalence of active or healed ulcers in limbs with CVI was 7.5%. Among 60 limbs with ulcers, primary CVI was present in 34 (56.7%) and post-thrombotic CVI in 26 limbs (43.3%). No difference in age and gender was found between the 2 groups (p=0.2 and p=0.8, respectively). However, the duration of the ulcer was longer in limbs with post-thrombotic CVI (p<0.05). The prevalence of perforator reflux was 41.2% (14/34) in limbs with primary CVI and 38.5% (10/26) in limbs with post-thrombotic CVI (p=0.8). Superficial venous insufficiency, with or without perforating vein reflux, was the commonest pattern in limbs with primary CVI; it was rare in limbs with post-thrombotic CVI (22/34 or 64.7% vs 2/26 or 7.7%, p<0.01). Deep vein insufficiency was present in 35.3% (12/34) of the limbs with primary CVI and in 92.3% (24/26) of the limbs with post-thrombotic CVI (p<0.01). CONCLUSION: Superficial venous insufficiency, with or without perforating vein reflux, was the commonest pattern in limbs with primary CVI, whereas, deep venous insufficiency was present in most of the limbs with post-thrombotic CVI. The prevalence of perforating vein reflux was comparable in both settings. Thus, elimination of superficial reflux is expected to result in ulcer healing of most limbs with primary CVI, whereas, the value of such treatment in post-thrombotic limbs is not clear.     

Contemporary treatment of venous lower limb ulcers.

The postphlebitic syndrome is a significant management problem that affects a large number of patients. Primary prophylaxis of deep-vein thrombophlebitis would reduce the risk of developing the postphlebitic syndrome and should be considered in high-risk patients. Patients who have had a phlebitis should be monitored with noninvasive tests of the deep venous circulation for the development of venous valve incompetence. Patients with venous hypertension should be placed in compression stockings to prevent the postphlebitic syndrome. In patients who progress to venous ulceration, several aggressive measures must be undertaken. Systemic treatment includes management of obesity, edema, immobility, poor nutrition, and comorbid illnesses. Some patients may require a short hospitalization of bed rest, lower limb elevation, and daily dressings and wound care. Outpatient therapy requires sustained compression of 35 to 40 mmHg at the ankle for many months to allow the ulcer to heal. The standard bandage material is Unna's boots, which is applied every one to two weeks by a trained nurse. Cadexomer iodide is an effective local treatment that helps debride the ulcer and accelerate healing. Finally, pentoxifylline therapy has also been shown to significantly improve the healing of venous ulcers.     

Best practices for the prevention and treatment of venous leg ulcers

Chronic venous insufficiency is the most common cause of leg ulcers. Its incidence increases as the population ages. Managing venous leg ulcers involves treating the cause, optimizing local wound care, and addressing patient-centered concerns. The cornerstone of the diagnosis of chronic venous insufficiency includes demonstrating venous disease. The clinician must rule out significant coexisting arterial disease by performing a thorough clinical assessment and obtaining an ankle brachial pressure index. The most important aspect of treatment is resolving edema through high compression therapy for those individuals with an ankle brachial pressure index greater than or equal to 0.8. Other components of successful chronic venous insufficiency management include increasing mobility and medical management. Selected patients may respond to surgery, biologicals, adjunctive therapies, and lifestyle enhancements. Twelve recommendations are made incorporating current best clinical practices and expert opinion with available research. The approach to venous disease is best accomplished through a multidisciplinary team that revolves around the active participation of patients and their families. The authors' intent is to provide a practical, easy-to-follow guide to allow healthcare professionals to provide best clinical practices.     

Conservative therapy adapted to findings of superficial chronic venous ulcers

A successful treatment of venous ulcers represents a special clinical challenge. The following conservative wound management of a high-risk patient presents an alternative to primary surgical treatment. A patient of 79 years in reduced general state with multiple underlying concomitant diseases is hospitalized with superinfected, necrotic and painful ulcers. Due to the severe morbidity of the patient the regular therapy of the underlying venous insufficiency consisting of stripping of great saphenous vein and ligation of perforator veins, is contraindicated. After interdisciplinary discussion conservative therapy is carried on. The conservative therapy includes initial local debridement, moist wound-healing dressings, compression therapy, systemic antibiotic and analgesic therapy, completed by stabilization of patient's general state. In regular intervals a photographic documentation of the wound is carried out. The period of treatment and observation is 63 days. Due to conservative wound management a clear improvement of the wound condition and of the patient's general state is observed. The period needed for change of wound dressing can be reduced from 2 hours to 30 minutes. The painscore is reduced from 8/10 to 4/10 as well as the analgesic need. The photographic documentation shows a clear progress of healing within 9 weeks. Under antibiotic therapy and conservative wound management the increased inflammation parameters are declining. By choosing a conservative therapeutical regime adapted to clinical findings superinfected, chronic venous ulcers are turned into a stable condition.     

Endovascular treatment options for chronic venous obstructions

Chronic venous obstructions have been treated by means of bypass surgery, until, in recent decades, it was surpassed by endovascular treatment options. Although techniques may differ, some issues should be universal. It is recommended that patients are treated under general anaesthesia. Secondly, obstructive lesions should be fully stented. Finally, self-expandable stents should mainly be used. Recanalization and stenting proved safe and efficient with excellent mid- and long-term patency rates. However, failures due to re-occlusion do occur and are basically related to imperfect stent design and/or suboptimal inflow. Therefore, the main focus should be on the development of optimal stent configuration, that is, sufficient length, highest possible radial force and flexibility. Moreover, the significance of endophlebectomy with or without creation of an arteriovenous fistula should be established.     

Decubitus ulcers: treatment through five therapeutic principles

Without relief of localized pressure, no healing is possible, and all other therapeutic measures are futile. If other factors are mistakenly blamed (incontinence, perspiration, malnutrition) attention may be diverted from the essential--relief of localized pressure and maintenance of patient mobility. Dressings should protect healing ulcers from mechanical damage and external bacterial recontamination after removal of pathogens by local disinfection. Dressings should be kept moist with Ringer's solution to create conditions that promote new granulation.     

Treatment of venous ulcers

Optional statement Underlying the pathogenesis of venous ulceration is venous hypertension. Therefore, the use of multilayered compression therapy is the gold standard in the treatment of a venous ulcer. As treatment progresses, an important determinant of response is wound assessment, which should be performed on initial visit and subsequently thereafter. Among the methods to assess improvement are digital photography and planimetry, which are objective methods to measure response to treatment and rate of wound healing. Lack of improvement over a 2-to 4-week period is predictive of eventual lack of response to therapy and suggests the need for adjunctive methods to achieve success, such as oral pentoxifylline, tissue-engineered skin, or skin grafting.     

Cost-effectiveness of Apligraf in the treatment of venous leg ulcers

Venous ulcers are the most common chronic wounds of the lower leg. Skin substitutes recently have been introduced to stimulate nonhealing wounds. To conduct an incremental cost-effectiveness analysis, a model was developed to compare the four-layer bandage system, with and without one application of skin substitute, for the outpatient treatment of venous leg ulcers. The model estimated the costs and consequences of treatment with and without the skin substitute application. Two analytic horizons were explored: 3 months and 6 months. Determined by seven physicians, data and assumptions for the 3-month model were based on information from a clinical trial, published studies, and clinical experience. Data for the 6-month model were extrapolated from the shorter model. The model results indicate that over 3 months, the use of the skin substitute provided a benefit of 22 ulcer days averted per patient at an incremental cost of $304 (societal). The incremental cost-effectiveness ratio was $14 per ulcer day averted. Over 6 months, the incremental cost-effectiveness ratio was less than $5 per ulcer-day averted. The skin substitute plus a four-layer bandage was more costly and more effective than the four-layer bandage alone. The skin substitute is increasingly cost-effective over a longer analytic horizon and in a subgroup of patients with ulcers of long duration (greater than 1-year duration at baseline). The results come from a model that is based on a series of estimates and assumptions, and accordingly, confirmation of this finding in a prospective study is encouraged.     

Efficacy of a 6-month treatment with Daflon 500 mg in patients with venous leg ulcers associated with chronic venous insufficiency.

AIM: Epidemiological data show that standard compression therapy for leg ulceration in chronic venous insufficiency (CVI) often fails to effectively improve patients' condition. This study assesses the contribution of Daflon 500 mg added to conventional therapy in the healing of hypostatic ulcers of CVI patients. METHODS: Patients of about 65 years were included, with ulcers > or = 2 and > or = 10 cm diameter on 1 or 2 limbs, Doppler ankle/arm pressure index > 0.9, and no recent history of skin graft. Controls (n=68) remained on compression alone while the tested group (n=82) also received Daflon 500 mg 2 tablets/day during 6 months. Treatment could be stopped as soon as the reference ulcer appeared fully healed. Primary endpoints were the rate of healed ulcers and the time to complete healing assessed by planimetry/photography and clinical examination. Variations of the ulcer surface, appearance of the skin, and clinical symptoms of CVI were the secondary criteria. RESULTS: Only 7% of Daflon 500 mg patients necessitated the full 6 month therapy. Whatever the lesion size, from W8 significantly more healed ulcers were observed under Daflon 500 mg (p=0.004), and the ulcer surface was more reduced (p=0.012). For large ulcers, the rate of healing was approximately 2-fold higher with Daflon 500 mg, and the percentage of ulcers healed before W24 was significantly higher (p=0.008). Heavy leg sensation was significantly improved by Daflon 500 mg from W4 (p < 0.05). No treatment-related side effects were reported and the acceptability was considered excellent by 85% of Daflon 500 mg patients. CONCLUSION: Six months of Daflon 500 mg in addition to compression significantly improve some clinical symptoms and accelerate the healing process in patients with ulcerous complications of CVI, with a good acceptability.