IV. Venous ulceration session

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IV. Venous ulceration session

Novel treatments for intractable leg ulcers
Alfred Obermayer (Vienna, Austria)
Detecting the source of local venous hypertension straining the skin by duplex ultrasound is an important maneuver. Great saphenous vein reflux causes axial-type medial ulcers and small saphenous vein reflux causes axial-type lateral ulcers. On the contrary, small saphenous vein reflux can cause crossover-type medial ulcers. The presence of a swinging blood column is the evidence for the diagnosis of a venous ulcer. A crossover pattern or a small diameter may lead to inaccurate treatment and early recurrence. Sourcing helps to detect the responsible superficial reflux routes that are particularly likely in cases with postthrombotic syndrome and peripheral arterial disease (mixed ulcers). The technique of lateral fasciectomy sparing the superficial peroneal nerve with a simultaneous mesh graft is a procedure to treat nonlateral leg ulcers of diverse vascular origin and includes excising the fascia, taking particular care to protect the thin subfascial perimysium and peritendineum. The nerves are sometimes embedded in inflammatory scar tissue leading to pain. Following subcutaneous fasciotomy, transposition of the peroneal nerve can be performed by fixing two antagonistic muscles by running an absorbable suture followed by a mesh graft implantation. Lateral fasciectomy is a new procedure to treat only hardto- treat ulcers and it is suitable for different ulcer types. After 3 months, 91% ulcer healing was obtained in 98% of the patients. No local recurrence in follow-up and no major complications were observed.

How to maximize implementation and post-EVRA results
Alun Davies (London, UK)
The global management of venous leg ulceration survey showed a diversity of management pathways internationally and it is clear that it should help inform best practice. Only four of the clinical practice guidelines were deemed to be of good quality with respect to development. Conflicting guidance and no impact on early referral and leg ulcer necessitated a study like EVRA (early vs deferred endovenous ablation in leg ulceration). It showed the potential for even better results if patients are seen and treated within 2 weeks. Studies have also shown promise for the cost effectiveness of an early intervention. The blockages to this policy are education, system failure, adequate facility, and perception of cost. The global pathway is diagnosis, compression, vascular investigation, venous intervention, and long-term compression. Education hurdles are a lack of information for patients, a lack of interest in the disease from politicians, and the lack of health care staff referral and championing. System failure comprises a scarcity of pathways and guidance. An adequate facility must be constructed for scanning and nursing.

Optimal assessment and treatment pathways for recalcitrant leg ulcers
Thomas O’Donnell (Boston, MA, US)
Recalcitrant venous leg ulcers refer to ulcers that fail to heal within a specified time, the majority of which is within 6 months. Parkers et al1 reviewed 27 studies to analyze significant risk factors for nonhealing venous leg ulcers by 6 months and potentially treatable causes were identified as increased size of the ulcer, long duration, deep venous disease, decreased ankle mobility, nutrition that leads to either an increased BMI or a deficiency, and heavy wound exudate. Mixed ulcers were excluded. The VIDIO study (Venogram vs IVUS for Diagnosing Iliac vein Obstruction)2 showed that intravascular ultrasound is more sensitive for assessing treatable iliofemoral vein stenosis compared with multiplanar venography and it frequently led to revised treatment plans and the potential for improved clinical outcomes. Thomas O’Donnell’s group also showed that vein valve transplantation is a durable procedure for preventing recurrent venous ulcers. Maleti’s “neovalve open technique3” succeeded in healing 88.8% of ulcers within a median of 12 weeks with no ulcer recurrence to date. An improvement in hemodynamic values (venous filling index, ejection fraction, and residual volume was maintained during the follow-up phase.

1. Parker CN, Finlayson KJ, Edwards HE. Predicting the likelihood of delayed venous leg ulcer healing and recurrence: development and reliability testing of risk assessment tools. Ostomy Wound Manage. 2017 Oct;63(10):16-33.
2. Gagne PJ, Tahara RW, Fastabend CP, et al. Venography versus intravascular ultrasound for diagnosing and treating iliofemoral vein obstruction. J Vasc Surg Venous Lymphat Disord. 2017;5(5):678-687.
3. Maleti O, Lugli M. Neovalve construction in postthrombotic syndrome. J Vasc Surg. 2006;43(4):794-799.

Novel wound dressings to meet the challenge of recalcitrant venous ulcers
Keith Harding (Cardiff, UK)
Conventional management of vascular wounds includes keeping the wound clean, correcting moisture levels, supporting the stages of wound healing, treating infection, debriding nonviable tissue, and revascularizing if the ulcer is arterial or applying compression if the source is venous. A proportion of wounds do not respond to conventional management, which is a huge burden on the patient, needs district nurses, and primary care and outpatient services. Chronic wounds are usually a manifestation of an underlying disease process. A comprehensive assessment is the key to successful treatment. Underlying systemic, metabolic, and local factors must be assessed and addressed. These factors must be corrected, kept in balance, and maintained until the wound heals and then ways to influence or reduce must be considered.

A passive dressing is an ordinary dressing (eg, gauze) that covers and conceals the wound, an interactive dressing is capable of modifying the physiology of the wound environment to optimize healing by promoting debridement, enhancing granulation/ re-epithelization, reducing exudate levels, and bacterial load, and a bioactive dressing delivers active substances, such as antimicrobials/antibiotics, which have a direct role in changing the chemical and cellular environment of the local wound, stimulating healing. Current dressing categories are basic dressings, absorbent dressings, alginates, antimicrobials, films, foams, honey dressings, and hydrocolloids that obtain odor control, protease modulation, scar management, skin protection, and wound contact layers. Modern dressing types have their own shortcomings. Options of how to measure success in wound patients include healing of the wound, wound-free days, decrease in pain, odor, or exudate, eradication of infection, increase in the patient’s quality of life, changes in the patient/care giver experience, and improved cost effectiveness.

Keith Harding stated that it is unrealistic to use complete healing as a primary outcome measure and that it is more appropriate to adopt a broader approach; several new options were discussed:

• Chitosan is the second most abundant naturally occurring carbohydrate polymer derived from chitin that is present in the shells of crustaceans. Chitosan has biocompatible, biodegradable, nontoxic, antimicrobial, hydrating, fibroblastgrowth factor retaining, dermal fibroblasts stimulation, and deposition properties. It can potentially be developed into forms of dressings that can deliver inflammation regulatory peptides, such as neurotensin.
• The Neotherix scaffold is an electrospun scaffold made from a bioresorbable “suture” polymer of nano/micron scale fibers. The scaffold is attractive to healthy cells from adjacent tissue following creation of an acute wound. Fibroblasts migrate into scaffold and along the fibers to repair the wound.
• The SpinCareTM device obtains a no contact dressing for all clinical settings. It is applied 20 cm from the wound and offers excellent adherence to the wound bed.
• A color-changing dressing in the presence of an infection avoids the unnecessary use of antibiotics.
• Dressings for local pain relief include carboxymethyl cellulose dressings layered with ibuprofen, biocellulose wound dressing, sheet hydrogel dressings, and topical opioids.
• Topical O2 systems: Natrox® Oxygen Wound Therapy is a class II medical device that consists of an O2 generator, a delivery line, and a disposable wound interface. It runs off a battery and electrolyzes airborne moisture. Other topical O2 systems are available and normobaric vs hyperbaric and gaseous O2 vs carrier compounds are available. In general, most studies agree that topical O2 shows promise. It should probably be part of our wound care armamentarium. It is not exactly clear how it works, but it seems to help with the healing pain. However, as with so much of wound healing, there is a paucity of large, high-powered, well-controlled trials.
• The gekoTM is a daily disposable strap-on device that electrically stimulates the common peroneal. It induces muscle contractions and mimics the physiological effect of walking. This device is useful for a range of lower limb applications as well as venous leg ulcers (eg, mixed ulcers), postoperative edema, venous thromboembolism prophylaxis, and it has an effect on venous and arterial flow and microcirculation.
• Cold plasma can also be applied for ulcers. The interaction between cold plasma and biological material is deeply complex. The chemical character of the plasma has a large effect on the biological consequences.

From the scale of the problem of recalcitrant ulcers, novel approaches are needed.