Venous Ulcers

John J. Bergan, Cynthia K. Shortell, Cynthia Shortell

• Publisher: Academic Press
• Year: 2011
• eBook ISBN: 9780080549033
• Topic: Biological Sciences
• Subtopic: Biology
• Index: Biological Sciences

One of the only books discussing new advances in venous ulcer therapy, Venous Ulcers provides a comprehensive look at the molecular biology and pathophysiology of venous ulcers. It discusses the many new treatments currently being used that offer non-invasive treatment options to patients with venous ulcerations.- Leg ulcers are defined as a discontinuity of the epithelial surface; a local defect or excavation of the surface of the skin- Venous ulceration tends to take a number of months to heal followed by frequent relapse to further episodes- This work discusses the newest tools of patient investigation that have emerged in recent years that help to shorten patient recovery times and provide less invasive treatments

Section III

Theraputic Procedures for Chronic Venous Insufficiency

Outline

Chapter 11: RESULTS COMPARING COMPRESSION ALONE VERSUS COMPRESSION AND SURGERY IN TREATING VENOUS ULCERATION

Chapter 12: SUPERFICIAL SURGERY AND PERFORATOR INTERRUPTION IN THE TREATMENT OF VENOUS LEG ULCERS

Chapter 13: ENDOVASCULAR TECHNIQUES FOR SUPERFICIAL VEIN ABLATION IN TREATMENT OF VENOUS ULCERS

Chapter 14: TREATMENT OF CHRONIC VENOUS INSUFFICIENCY WITH FOAM SCLEROTHERAPY

Chapter 15: FOAM TREATMENT OF VENOUS LEG ULCERS: THE INITIAL EXPERIENCE

Chapter 16: FOAM TREATMENT OF VENOUS LEG ULCERS: A CONTINUING EXPERIENCE

Chapter 17: ULTRASOUND GUIDANCE FOR ENDOVENOUS TREATMENT

Chapter 18: REPAIR OF VENOUS VALVES IN SEVERE CHRONIC VENOUS INSUFFICIENCY

11

RESULTS COMPARING COMPRESSION ALONE VERSUS COMPRESSION AND SURGERY IN TREATING VENOUS ULCERATION

MANJIT S. GOHEL, JAMIE R. BARWELL, MARK R. WHYMAN and KEITH R. POSKITT

Publisher Summary

This chapter discusses the results comparing compression alone versus compression and surgery in treating venous ulceration. Chronic venous ulceration is widely accepted as a common, debilitating, and expensive health problem. Although most patients have superficial venous incompetence potentially amenable to surgical correction, evidence to support operative intervention has been scarce. Other researches strongly suggest that superficial venous surgery reduces venous ulcer recurrence and should be considered for all patients with chronic venous ulceration. Patients deemed suitable for surgical treatment should undergo color duplex venous mapping in order to identify superficial venous incompetence potentially suitable for surgical correction. Although the advantage appears greatest for legs with isolated superficial reflux, surgery may also reduce ulcer recurrence for some patients with deep venous incompetence, and hemodynamic assessment may be a useful selection tool. Despite any proven clinical benefit, it must be acknowledged that elderly patients with leg ulcers may be unfit for surgical intervention or unwilling to accept it. Local anesthetic surgery was performed in a quarter of patients, but long-term effectiveness is unlikely to match general anesthetic procedures. Residual venous reflux after venous surgery was common, although this was not associated with reduced hemodynamic function or clinical outcomes.

Chronic venous ulceration represents the worst extreme of a spectrum of venous disorders and is a common problem in the Western world. Multilayer compression bandaging providing 40 mmHg of pressure at the ankle and 17–20 mmHg at the calf is the mainstay of treatment for open ulcers. Surgically correctable superficial venous reflux is commonly seen in this population, although the benefit of operative intervention has been widely debated, particularly because many patients with venous ulcers are often elderly with extensive comorbidity and therefore unattractive surgical candidates. The ESCHAR venous ulcer study was a large, randomized controlled study aiming to investigate the influence of superficial venous surgery in addition to compression bandaging.

This chapter aims to summarize the clinical, anatomic, and hemodynamic findings from the ESCHAR study and other clinical trials comparing compression alone with compression plus surgery in the treatment of venous ulcers.

INTRODUCTION

EXTENT OF THE PROBLEM

Over 70% of chronic lower limb ulcers are thought to have a predominantly venous cause,^1,2 and the management of this group is estimated to cost U.S. health providers over $1 billion each year.³ This chronic and often recurrent condition is associated with a significant impact on patient quality of life.⁴ The unglamorous nature of chronic leg ulceration has meant that patient care has been supervised by nursing teams; community general practitioners; and plastic surgery, dermatologic, and vascular specialists, leading to inconsistencies in clinical practice. The true incidence and prevalence of chronic venous ulcers may be impossible to determine, although studies from Europe and the United States have estimated a prevalence of 0.5% to 1% in the adult population increasing to over 3% in those aged over 80 years.^3,5 For each patient with an open ulcer, a further 3 to 4 are thought to be at high risk of developing ulceration.⁶ In an aging population and with increasing awareness of vascular disorders, it is reasonable to assume that the incidence of chronic venous disease will continue to increase.

THE RATIONALE FOR SURGERY

The dogma that venous ulcers are due to deep venous disease has been largely disproved in recent years. Duplex studies have demonstrated that incompetence in superficial veins (greater or lesser saphenous) is present in 60% to 80% of legs with chronic ulcers.^7–9 This is occasionally in combination with deep venous reflux, although isolated incompetence in deep or perforating veins is uncommon.^8,9 Chronic venous hypertension, usually secondary to venous reflux, is generally accepted to play a major role in the pathogenesis of venous ulceration.¹⁰ Compression therapy and limb elevation are proven measures to counter this. However, compression bandages are uncomfortable and difficult to don, resulting in poor compliance and limited long-term efficacy. Surgical correction of venous incompetence may provide a more durable approach to the problem, and a number of strategies have been forwarded. Procedures to correct deep venous reflux are feasible but associated with high complication rates and questionable clinical benefit.¹¹ The surgical correction of superficial venous reflux has been suggested by a number of nonrandomized studies^12,13 but has lacked the endorsement of a large, randomized trial until recent years.

THE ESCHAR VENOUS ULCER STUDY

The ESCHAR study¹⁴ aimed to investigate the Effect of Surgery and Compression on Healing And Recurrence in patients with chronic venous ulcers and was set in three vascular departments in the United Kingdom serving a target population of approximately 800,000.

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Table of contents

• Cover image
• Title page
• Table of Contents
• EMBLEM OF HUNCZOVKSY
• CONTRIBUTORS
• FOREWORD
• PREFACE
• Section I: Etiology and Initial Evaluation of the Patient with Chronic Venous Insufficiency
• Section II: Nonoperative Management of Chronic Venous Insufficiency
• Section III: Theraputic Procedures for Chronic Venous Insufficiency
• Section IV: Special Topics
• EPILOGUE
• INDEX