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Objective To evaluate the healing of venous ulcers in the lower limbs (VLU) using dressings with hydrocolloid gel associated with Syzygium cumini extract (SHG) compared to standard hydrocolloid gel dressings (HG). Method This prospective, double-blind, randomized trial recruited 90 patients with VLU divided into: dressings with SHG ( n = 44) and dressings with HG ( n = 46). Primary endpoint was healing in the 14th visit. Secondary endpoints were healing rate, complete healing during follow-up, and improvement in the pain scale and in quality of life. Results There were no significant between-group differences in healing ( p = 0.15). The wound area made healing difficult ( p = 0.008). Age, body mass index, and wound time demonstrated a tendency to worsen the healing. Positive culture for Pseudomonas aeruginosa resulted in 88% reduction in the healing risk ( p < 0.0001). Conclusion There was no difference between the dressings evaluated. The presence of Pseudomonas aeruginosa significantly impaired wound healing.

Objectives This survey study evaluates current management strategies for venous ulceration and the impacts of the EVRA trial results. Methods An online survey was disseminated to approximately 15000 clinicians, through 12 vascular societies in 2018. Survey themes included: referral times, treatment times and strategies, knowledge of the EVRA trial and service barriers to managing venous ulceration. Data analysis was performed using Microsoft Excel and SPSS. Results 664 responses were received from 78 countries. Respondents were predominantly European (55%) and North American (23%) vascular surgeons (74%). Responses varied between different countries. The median vascular clinic referral time was 6 weeks and time to be seen in clinic was 2 weeks. This was significantly higher in the UK (p ≤ 0.02). 77% of respondents performed surgical/endovenous interventions prior to ulcer healing, the median time to intervention was 4 weeks. 31% of participants changed their practice following EVRA. Frequently encountered barriers to implementing change were a lack of operating space/time (18%). Conclusion Venous ulcers are not managed as quickly as they should be. An evaluation of local resource requirements should be performed to improve service provision for venous ulceration. When interpreting the results of this survey consideration should be given to the response rate.

Objective To assess the clinical efficacy of sulodexide, including a comparison with venoactive drugs (VAD) (micronized purified flavonoid fraction, MPFF; hydroxy-ethyl-rutosides, HR; calcium dobesilate;Ruscus extract combined with hesperidin methyl chalcone and vitamin C, Ruscus+HMC+VitC; horse chestnut seed extract, HCSE) and pentoxifylline in patients with chronic venous disease. Methods We performed a literature search in MEDLINE, Embase, and Cochrane Library for randomized controlled trials (RCTs) and observational studies. Proportion of patients with complete venous ulcer healing was the primary outcome and lower leg volume, foot volume, ankle circumference and symptoms were the secondary outcomes. Bayesian network meta-analysis (NMA) was perfomed with random effects models using only RCTs. A meta-analysis of observational studies was performed for sulodexide because no RCT could be included in NMA for symptoms or signs. Results Forty-five RCTs and eighteen observational studies were identified. Sulodexide was included only in a single NMA for the proportion of patients with complete ulcer healing and it showed to have the highest probability of being the best treatment (48%) compared with pentoxifylline (37%) and MPFF (16%). MPFF was the most effective treatment in reducing lower leg volume, CIVIQ-20 score and pain VAS scale while calcium dobesilate and Ruscus+HMC+VitC were the most effective in reducing foot volume and ankle circumference respectively. Meta-analyses of observational studies for sulodexide showed that it improves significantly the scoring of pain, feeling of swelling, heaviness and parasthesiae measured by Likert scales. Conclusions Sulodexide is at least as effective as pentoxifylline and more effective than MPFF in improving the rate of ulcer healing in patients with CVD. VADs are effective in improving venous symptoms and signs, as was also shown by sulodexide in the meta-analysis of observational studies. The relative effectiveness of sulodexide and VADs needs to be evaluated by an RCT in order to better inform clinical practice.

Introduction The mainstay of treatment for venous ulceration remains compression therapy. Velcro Wrap devices are being increasingly used in these patients despite limited evidence. This feasibility study aimed to compare standard bandaging to the JuxtaCures™ Velcro wrap device. Methods A single centre, unblinded RCT compared participants with venous ulceration randomised to either the JuxtaCures™ device or short stretch bandaging. Participants were followed up for 26 weeks. Results 160 participants were screened with 40 randomised. 3 participants in bandaging and 1 in JuxtaCures™ didn’t complete the study. 60% in JuxtaCures™ healed v 55% in bandaging despite larger ulcers in the JuxtaCures™ arm (9.33 cm2 v 6.97 cm2). There was no significant difference in time to healing (12.17 v 13.64 weeks). JuxtaCures™ showed improved ulcer reduction for those that didn’t heal (14.91–5.00 cm2 v 14.20–8.62 cm2; P = 0.06). JuxtaCures™ had more consistent sub-bandage pressure dropping from 39–36 mmHg versus 41–25 mmHg in bandaging between application and removal (P Conclusion This study has shown the feasibility and necessity of running a multicentre trial to evaluate the use of Velcro wrap devices for venous ulceration. It highlights the potential benefits of more consistent pressure, increased self-care, and potential with regards to ulcer healing, cost, nursing resource and quality of life.

Objectives The present study was designed to assess outcomes of patients undergone radiofrequency ablation (RFA) for their incompetent perforator veins (IPVs) with ClosureFast stylets. Methods Data of 165 IPVs in 138 limbs of 117 consecutive patients between July 2017 to Nov. 2019 were retrospectively reviewed. Primary endpoints (technical success rate, complications) and secondary endpoints (VCSS) were analyzed. Results The immediate technical success rate was 100%. There were no major complications. The rate of ecchymosis and induration was 5.8%. 129/165 IPVs in 79.5% (93/117) patients had achieved sonographic evaluation at 1 year followed-up, in which 3 perforators were recanalized. VCSS scores at pre-operation and 1-year follow-up were 5.77 ± 1.88 and 2.70 ± 1.39, respectively ( t= 29.644, P= .000). Conclusions In conclusion, RFA is safe and effective for the treatment of IPVs. At the 1-year follow-up, the RFA of IPVs showed a low recanalization rate and had a satisfactory improvement on VCSS.

Objective The aim of the study was to analyze bacterial flora in venous leg ulcers, empiric and targeted antibiotic therapy, and factors influencing healing time. Materials and methods Data from 30 patients with venous leg ulcers were retrospectively analyzed. Collected data included: sociodemographic data, wounds information, number of comorbidities, results of the microbiological examination, and empiric and targeted antibiotic therapy. To compare the empiric and targeted treatment in terms of their compatibility, the group of patients was divided into the four subgroups: NEA (no empiric antibiotics), NA (no antibiotics), ETA+ (compatibility of empiric and targeted antibiotic), ETA− (no compatibility of empiric and targeted antibiotic). Results The average ulcer healing time was 163.4 ± 97.1 (range 51.0 to 426.0) days and increased by 28 days with each additional bacterial strain in the ulcer (p = 0.041). Healing time did not differ between the four groups. Staphylococcus aureus and Pseudomonas aeruginosa were the most frequent bacteria. Amoxicillinium/acidum clavulanicum was the most common empirical antibiotic and amoxicillinium/acidum clavulanicum, and levofloxacinum was the most common targeted antibiotic. Conclusions Venous leg ulcer healing time was prolonged with each subsequent bacterial strain in the ulcer, and it was independent from systemic antibiotic therapy.

Objective Determine standards of referral and management of patients with venous leg ulceration in primary care after the release of the EVRA (A Randomized Trial of Early Endovenous Ablation in Venous Ulceration) study results. Methods An online questionnaire was disseminated over four months to professionals working within primary care. Results The survey received 643 responses. Of respondents, 90 (14%) had heard of the EVRA trial and 51 (8%) were familiar with the results. Of those who answered the following questions, 410 (69.1%) stated that referral to a vascular specialist must be made by the General Practitioner and 13 (2.2%) reported that they would always refer patients for secondary care assessment before the publication of EVRA. Considering the EVRA results, 128 (29%) reported that they would change practice regarding referral and would experience no barriers and 198 (45%) reported that they would like to refer earlier but is not their decision. Barriers to changing practice included local referral policies, training and time restrictions, 266 (59%) had heard of the NICE guideline (CG168) and 194 (43%) were aware of the recommendations for referral to a vascular service within two weeks for patients with an open or healed ulcer. Conclusion There is a considerable variation in local referral pathways for venous leg ulceration, and despite clinicians wanting to refer promptly, many primary care professionals are unable to. Unfortunately, the EVRA study alone may not change the overall practice, and work is needed to overcome barriers faced by primary care professionals.

BackgroundVenous leg ulcers, or static leg ulcers, are chronic wounds associated with ambulatory venous hypertension of the lower extremities as a consequence of venous valve reflux, reduce venous capacitance, poor calf venous pump, heart failure, or in conjunction with venous obstruction. A static ulcer with venous thrombosis in a pelvic or thigh vein responds favorably to anticoagulation agents. However, anticoagulation is less effective and even harmful when ambulatory venous hypertension has another cause such as venous reflux, poorly heart function, and poor calf venous pump.MethodTRiggered Angiography Non-Contrast-Enhanced (TRANCE) magnetic resonance imaging (MRI) exploits differences in vascular signal intensity during the cardiac cycle for subsequent image subtraction, providing detailed radiation-free venograms without the use of contrast agents. The method is a new tool for evaluating the presence of thrombosis in the venous systems. TRANCE-MRI was employed to document the existence of venous thrombosis within the eight patients in this study. Subsequently, we used a wireless wearable near-infrared spectroscopy device to compare deep vein thrombosis-associated and non-deep vein thrombosis-associated static ulcers. The sampling depths were 5 and 10 mm, representing the dermis and subcutaneous tissue, respectively.ResultThere are four patients with venous leg ulcers proven with venous thrombosis by TRANCE-MRI and are classified as deep vein thrombosis group. Compared with the non-deep vein thrombosis group, the deep vein thrombosis group had less deoxyhemoglobin, less total hemoglobin, and a significantly lower H2O signal in the 5-mm sampling depth (dermis level). And eight health participants were included as control group. Wounded patients (including deep vein thrombosis and non-deep vein thrombosis patients) have higher H2O concentration on the 5-mm depth sampling than control group. In the 10-mm sampling depth (subcutaneous level), the deoxyhemoglobin and tissue oxygen saturation of the deep vein thrombosis group were lower than those of the non-deep vein thrombosis group, and the H2O concentration was higher than non-deep vein thrombosis group. Patients with static foot ulcers and deep vein thrombosis had similar oxyhemoglobin, deoxyhemoglobin, total hemoglobin, and tissue oxygen saturation than did those without deep vein thrombosis in 5-mm depth sampling (dermis level). Notably, the H2O signal of patients with non-deep vein thrombosis-associated static ulcers was higher for the 5-mm sampling depth.ConclusionIn patients with static ulcers and deep vein thrombosis, the H2O level may be higher in the 10-mm sampling depth, indicating that those patients had more subcutaneous water. In patients with non-deep vein thrombosis static foot ulcer, the near-infrared spectroscopy (NIRS) indicated worse fluid retention in the dermis level. The H2O value in the NIRS may be different owing to underline the cause of the venous leg ulcers.

Objectives Compression therapy is the mainstay of treatment for patients with venous ulcer disease. There exists a lack of certainty as to the safety of compression therapy in patients with congestive heart failure. Methods A retrospective review of 95 patients with the diagnosis of congestive heart failure (systolic, diastolic, or combined), who underwent compression therapy at the wound care center of a large teaching hospital between January 2013 and June 2019, was performed. Patient outcomes including mortality, weight gain, admission for heart failure decompensation, and requirement for diuretic dose increase were compared to the general congestive heart failure population as well as to the registry data. Results In the compression cohort, with a mean compression period of 310 days, seven patients (7.3%) were admitted for congestive heart failure exacerbation and six (6.3%) underwent diuretic dosage increase. Two patients (2.1%) died during the compression period. These endpoints were not significantly higher than within the general congestive heart failure population. Conclusions Compression therapy appears safe amongst patients with stable congestive heart failure.

Aim Self-application of properly performed compression bandages is generally considered as problematic. Therefore, the aim of this study was to measure the pressure of self-applied short stretch adjustable compression wrap compression systems (Juxta fit™) and to compare the results with the pressure achieved by bandaging other legs using the same material. Methods In the two training courses for nurses, specifically interested in leg ulcer treatment, the new bandage type of adjustable compression wrap was explained and workshops were organized, in which the interface pressure achieved by Juxta fit™ was measured. In the first course, the nurses applied the compression system to each other, and in the second course, another group did it on their own legs. Bandagers were instructed to apply the system strongly, with a target range of more than 50–60 mmHg. Results In the first course with mutual application ( n = 34), the median pressure at the medial lower leg was 58.5 mmHg (minimal 31, maximal value 137 mmHg), in the second course in which self-application was tested ( n = 36), the corresponding values were 61.5 mmHg (minimum 35, maximum 102 mmHg). No pressures less than 30 mmHg were seen on the distal calf in either group. Conclusions In contrast to short stretch bandages that are frequently applied by bandagers with too low pressure, the adjustable compression wrap devices handled by the patients themselves produce more appropriate and more consistent pressure.

ObjectivesTo clarify the surgical methods and the clinical results of subfascial endoscopic perforator surgery in Japan.MethodsThis study included 1287 limbs of 1091 patients who underwent subfascial endoscopic perforator surgery in 14 hospitals. Simultaneous saphenous vein treatment was performed in 1079 limbs (83.8%), and 118 limbs (9.2%) had deep venous lesions. The venous clinical severity score was calculated before and 6 to 12 months after surgery. The ulcer healing rate and ulcer recurrence rate were calculated cumulatively.ResultsPreoperative venous clinical severity score was significantly decreased from 10.0 ± 6.6 to 3.1 ± 3.4 ( P ConclusionThese results indicate that subfascial endoscopic perforator surgery is an alternative to improve the long-lasting disease severity and/or clinical outcome.

Objectives The aim of the study is to compare proportions of venous leg ulcers healed in patients treated with two different sub-bandage pressure values in relation to age. Methods The study included 102 outpatients with venous leg ulcers, one group with moderate compression pressure of 35–40 mmHg and the second with high pressure >45 mmHg. Each group was divided into two subgroups according to the age (≥65 vs. Results Kaplan–Maier analysis showed high pressure leads to higher proportion of healed venous leg ulcers, compared to moderate pressure, in patients aged ≥65 years (57.6% vs. 28%) and in patients Conclusion The study showed that higher compression pressure leads to higher proportions of venous leg ulcers healed, independent of age and could be safely preferred in older patients.

Objective The goal of this American College of Phlebology Patient Reported Outcome Venous Registry analysis was to examine the clinical efficacy of compression stockings using short-form 6D questionnaire (SF-6D). Method SF-6D scores were modeled over time using linear mixed effects model. Changes of SF-6D score from baseline to the last encounter were examined using a paired t-test. Analysis of variance was used to compare changes from baseline in SF-6D scores between C classifications. All analyses were conducted using SAS software, version 9.4 (SAS Institute, Cary NC). Results Baseline mean SF-6D score was 0.83 and at follow-up, 0.85. Mean SF-6D change was +0.02 points (P = .001) over an average time period of 5.5 months. Patients’ SF-6D scores were estimated to increase by +0.03 points (P = .005) per year of usage of compression stockings. SF-6D score changes across C classifications did not demonstrate significant differences (P = .265). Conclusion There was an improvement of SF-6D score in the registry participants who used circular knit compression stockings.

Scope A systematic review of the clinical literature concerning medical management of chronic venous disease with the venoactive therapy Micronized Purified Flavonoid Fraction was conducted in addition to an investigation of the hemodynamics and mechanism of chronic venous disease. Methods The systematic review of the literature focused on the use of Micronized Purified Flavonoid Fraction (diosmin) which has recently become available in the US, in the management of chronic venous disease. The primary goal was to assess the level of evidence of the role of Micronized Purified Flavonoid Fraction in the healing of ulcers, and secondarily on the improvement of the symptoms of chronic venous disease such as edema. An initial search of Medline, Cochrane Database for Systematic Reviews and Google Scholar databases was conducted. The references of articles obtained in the primary search, including a Cochrane review of phlebotonics for venous insufficiency, were reviewed for additional studies. Studies were included if patients had a diagnosis of chronic venous disease documented with Doppler and Impedance Plethysmography. Studies excluded were those that had patients with arterial insufficiency (Ankle Brachial Index .6), comorbidity of diabetes, obesity, rheumatological diseases, or if other causes of edema were present (congestive heart failure, renal, hepatic or lymphatic cause), or if the patient population had recent surgery or deep vein thrombosis, or had been using diuretics (in studies of edema). Other elements of the study design were to note specifically the type of compression therapy used in conjunction with Micronized Purified Flavonoid Fraction. Results The literature review yielded 250 abstracts, 65 of which met criteria for further review and 10 papers were selected for consideration in the systematic review. Conclusion In summary, the general level of evidence supports the recommendation that the use of medical therapy with Micronized Purified Flavonoid Fraction has beneficial outcomes without serious adverse events. In the United States, diosmiplex is the only available prescription formulation of Micronized Purified Flavonoid Fraction. It is derived from the rinds of oranges and is categorized as a medical food and not as a drug; and may be a particularly attractive therapy for many chronic venous disease patients because of its favorable safety profile. The Working Group for chronic venous disease concurs with previous guidance by the International European Society for Vascular Surgery in 2015 which recommended the use of Micronized Purified Flavonoid Fraction for the healing of venous ulcers, alone and adjunctive to compression therapy, and for the reduction in symptoms of chronic venous disease such as edema.

Background Adequately excising varicose and incompetent perforating veins is necessary for reducing their recurrence rate of venous ulcer. Method In total, 66 venous ulcers (C6) in 1083 legs with primary varicose veins were managed through endoscopic-assisted surgery. In an endoscopic operative view, the nonvaricose, varicose, and incompetent perforating veins were clearly visualized and precisely dissected. The varicose and incompetent perforating veins were divided and completely excised. Result The varicose veins were traced to the base or periphery of the 55 ulcers. Moreover, 89.4% of the ulcers healed within 14 weeks. Kaplan–Meier analysis revealed a five-year recurrence rate of 0.0%, and the satisfaction mean score was 4.6. Conclusion Endoscopic-assisted surgery can be used to radically excise varicose veins complicated with venous ulcers; the surgery yields low recurrence and high satisfaction rates.

Chronic venous disease is a common condition with clinical signs and symptoms ranging from spider veins, to varicose veins, to active venous ulceration. Both superficial and deep venous dysfunction may be implicated in the development of this disease. Socio-economic factors are shaping our population, with increasing age and body mass index resulting in significant pressure on healthcare systems worldwide. These risk factors also lead to an increased risk of developing superficial and/or deep venous insufficiency, increasing disease prevalence and morbidity. In this chapter, the authors review the current and future burden of chronic venous disease from an epidemiological, quality of life and economic perspective.

Objectives The aim was to assess vein recanalisation and ulcer recurrence in patients with chronic venous ulceration following ultrasound-guided foam sclerotherapy. Method Open (CEAP 6) or recently healed (CEAP 5) chronic venous leg ulcers were treated with foam sclerotherapy between July 2010 and August 2012. Venous duplex scans were performed two weeks and one and two years post treatment, recording recanalisation and reflux. One- and two-year ulcer recurrence rates were calculated using Kaplan–Meier survival analysis. Results A total of 100 legs were treated in 92 patients; 86 were CEAP 5 and 14 were CEAP 6. At two weeks complete or short segment occlusion was demonstrated in 99/100 legs. Complete follow-up was 93% at one year and 88% at two years. Complete and segmental recanalisation with new reflux was recorded in 11/93 (12%) legs and 25/93 (27%) legs, respectively (overall 36/93; 39%) at one year; and 6/88 (7%) legs and 15/88 (17%) legs, respectively (overall 21/88; 24%) at two years. Kaplan–Meier survival analysis shows 64% ulcers healed at 24 weeks and 86% at one year. Ulcer recurrence rate at one and two years was 2.3% and 5.1%. Conclusions Over one-third of superficial veins treated with foam sclerotherapy recanalised at one year and just under a quarter of superficial veins recanalised at two years. Despite this, ulcer recurrence rates were low, and recanalisation failed to predict recurrence.

Objectives The aim of this article was to summarize the efficacy and safety of venous stents in chronic obstructive venous disease (COVD) including postthrombotic syndrome (PTS) and nonthrombotic iliac vein lesions (NIVL). Methods We searched PubMed for case series (prospective and retrospective) that focused on venous stents in the treatment of COVD published between 1st January, 2000 and 15th July, 2014. Then, we analyzed the perioperative complications, subsequent antithrombotic treatment, clinical outcomes, and long-term patency of this procedure. Results Overall, 1987 patients from 14 studies were included in our study. The incidence of the 30-day thrombotic events was 2.0% (4.0% in PTS vs. 0.8% in NIVL, p = 0.0002). The rates of access site complications and stent migration were 1.7% and 1.3%, respectively. The incidence of retroperitoneal bleeding and contrast extravasation was 1.8%. Back pain was more common with a rate of 62.9%. With stent placement, there was a significant pain and edema relief in COVD patients and the clinical–etiology–anatomy–pathophysiology scores declined. The rate of ulcer healing was 72.1% (70.3% in PTS vs. 86.9% in NIVL, p = 0.0022), and the ulcer recurrence rate was 8.7%. The primary, assisted primary, and secondary patency rates were 91.4%, 95.0%, and 97.8%, respectively, at 12 months and 77.1%, 92.3%, and 94.3%, respectively, at 36 months; however, the patency rates in PTS were lower than those in NIVL. Conclusions Stents may be a relatively effective and safe approach for PTS and NIVL patients because of the low incidence of perioperative complications and satisfying long-term patency. Some outcomes of stents in NIVL patients may be better than those in PTS patients.

Aim To review epidemiologic data on progression of venous pathology in varicose veins and from varicose veins towards chronic venous insufficiency. Methods We searched Medline and PubMed for epidemiologic studies concerning progression of venous pathology. Results The data suggest that reflux progression may develop from segmental to multisegmental superficial reflux. In younger age, reflux in tributaries and non-saphenous veins is more frequent. In older age, more saphenous reflux develops and more proximal sites seem to be affected. A high proportion of uncomplicated varicose vein (C2) develops skin changes and chronic venous insufficiency (C3–C6). Significant risk factors for the progression of varicose vein towards venous leg ulcers are skin changes, corona phlebectatica, higher body mass index and popliteal vein reflux. During a 13.4-year follow-up period, 57.8% (4.3%/year) of all chronic venous disease patients showed progression of the disease. Summary Studies on the progression of venous pathology show a high progression rate of chronic venous disease. More follow-up studies are still needed to get better information about the risk of varicose vein patients for progression to venous leg ulcers and to answer the question which patients may benefit from early varicose vein interventions.

The history of venous valve reconstruction extends back to 1968 when Robert L Kistner performed the first internal valve plasty to treat deep venous axial reflux. Throughout the past 50 years other techniques of reconstructive deep venous surgery (RDVS) were developed, not only to repair but also to replace venous valves. And the fact that several surgeons and centers have undertaken RDVS in the treatment of chronic venous insufficiency (CVI) reporting outcomes, has added knowledge to define more clearly the role of this kind of specialized surgery. Patients who may benefit from RDVS are among those where conventional treatment with compression stockings combined with superficial surgery has failed. Ulcer-healing rates of up to 70% have been reported after RDVS and ulcer-free periods of up to 36 months have been generated. But during five-year follow-up, freedom from ulceration period and clinical improvement rates were reduced significantly. This raises then the issue and challenge of durability of RDVS since the average age of patients who can benefit from it is about 50 years.

Objectives Slough in chronic venous leg ulcers may be associated with delayed healing. The purpose of this study was to assess larval debridement in chronic venous leg ulcers and to assess subsequent effect on healing. Methods All patients with chronic leg ulcers presenting to the leg ulcer service were evaluated for the study. Exclusion criteria were: ankle brachial pressure indices 1.25, no venous reflux on duplex and Results A total of 601 patients with chronic leg ulcers were screened between November 2008 and July 2012. Of these, 20 were randomised to 4-layer compression bandaging and 20 to 4-layer compression bandaging + larvae. Median (range) ulcer size was 10.8 (3–21.3) cm2 and 8.1 (4.3–13.5) cm2 in the 4-layer compression bandaging and 4-layer compression bandaging + larvae groups, respectively (Mann–Whitney U test, P = 0.184). On day 4, median reduction in slough area was 3.7 cm2 in the 4-layer compression bandaging group ( P 2 ( P Conclusions Larval debridement therapy improves wound debridement in chronic venous leg ulcers treated with multilayer compression bandages. However, no subsequent improvement in ulcer healing was demonstrated.

Objectives This study was performed to precisely define the underlying pathophysiology in patients with active venous ulcers. Methods A PubMed search was conducted from 1991 to 2013 to select papers reporting the anatomic and physiologic etiology of ulceration in CEAP Class 6 patients. Studies which did not decipher between active and healed ulcers, did not use clear definitions, or did not give detailed accounts on the distribution/extent of venous pathology were excluded. Using the PRISMA guidelines, 12 studies were selected for further analysis. Results Primary insufficiency was reportedly the most common etiology of ulcers. Reflux most frequently occurred in the superficial system, either isolated or in conjunction with perforating and/or deep systems. Combined superficial and deep disease was observed in a median of 11.6% of limbs (range of 0–48%). Triple system disease was seen in a median of 31.6% of limbs (range of 22–52%). Isolated deep reflux was infrequently reported (2.1–28.4% of limbs). Previous deep venous thrombosis, reported in a median of 33% of patients, is likely underreported as it may resolve without detectable damage. Conclusion There is a lack of data in the literature regarding the etiology of chronic active venous ulcers. Insufficiency of the superficial venous system from the micro- to the macro-vasculature has been frequently implicated in the development of venous ulceration. A prospective randomized controlled study is required for more conclusive results.

Objectives This study presents the results of catheter-directed foam sclerotherapy (CDS) for chronic venous ulcer refractory to compression treatment, four weeks and one year after treatment. Methods In sum, 31 patients (32 limbs) with refractory chronic venous ulcer and duplex-verified superficial insufficiency were offered CDS. CDS was conducted with 10 ml of sclerosant foam of 3% polidocanol. Four weeks and one year after treatment, the patients were evaluated regarding ulcer healing and ultrasound appearance of the saphenous trunk. Results CDS was successfully performed in all patients. After one year, 65% of the ulcers were healed. Only two (6%) recurred. 86% of the treated saphenous trunk were completely occluded, 3% was partly occluded and 10% were recanalised. No serious side effects occurred. Conclusions CDS is one alternative of eliminating superficial venous reflux when treating refractory venous leg ulcers. This study suggests that the treatment is safe and induce a quick ulcer healing.

found in patients in comparison to healthy controls but of pertinence to this editorial, an increased rate of ulcer healing (assessed by percentage reduction in ulcer size) occurred in patients receiving aspirin (47% of original ulcer size) compared with the placebo-treated group (69% of original ulcer size) at four months

Objectives Subfascial endoscopic perforator surgery (SEPS) is usually performed for posteromedial perforators in the supine position, but subfascial endoscopic perforator surgery for posterolateral perforators in the prone position has not been reported. Methods A 51-year-old male suffered from a venous stasis ulcer around his lateral malleolus because of reflux in the small saphenous vein and incompetent perforating veins around the ulcer. Results Stripping of the small saphenous vein and subfascial endoscopic perforator surgery utilizing screw-type ports was successfully conducted in the prone position. Conclusions: The prone position enables interruption of the posterolateral perforators, because gravity-dependent flattening of the muscles enables creation of sufficient subfascial space.

Objectives Chronic venous disease (CVD) is a frequent disorder with a high socioeconomic impact. Little is known about the possible differences between healed ulcer (C5 group) and active ulcer (C6 group) in terms of disease severity and quality of life (QoL). Our aim was to determine the possible differences in severity disease and QoL between the C5–C6 and C1 (control) group. Methods Data from a national, multicentre, observational and cross-sectional study ( n = 1598) were used to compare three groups of CVD: C1 ( n = 243), C5 ( n = 136) and C6 ( n = 70). CVD severity was assessed with the Venous Clinical Severity Score (VCSS) and QoL with the Short Form 12 Health Survey (SF-12) and Chronic Lower Limb Venous Insufficiency Questionnaire (CIVIQ-20). Results Patients with active ulcers had a higher mean total VCSS than patients with healed ulcers ( P < 0.05). Both SF-12 and CIVIQ-20 QoL questionnaires indicated a poorer QoL in patients with ulcers than in those with C1 ( P < 0.05). Compared with the C5 group, patients with active ulcers (C6) had lower QoL scores, but the differences were not statistically significant. Conclusions Patients with venous leg ulcers (C5–C6) are associated with high severity and poor QoL. However, the healing of a leg ulcer did not contribute to improvement of QoL.

Compression therapy is considered to be the most important conservative treatment of venous leg ulcers. Until a few years ago, compression bandages were regarded as first-line therapy of venous leg ulcers. However, to date medical compression stockings are the first choice of treatment. With respect to compression therapy of venous leg ulcers the following statements are widely accepted: (1) Compression improves the healing of ulcers when compared with no compression; (2) Multicomponent compression systems are more effective than single-component compression systems; (3) High compression is more effective than lower compression; (4) Medical compression stockings are more effective than compression with short stretch bandages. Healed venous leg ulcers show a high relapse rate without ongoing treatment. The use of medical stockings significantly reduces the amount of recurrent ulcers. Furthermore, the relapse rate of venous leg ulcers can be significantly reduced by a combination of compression therapy and surgery of varicose veins compared with compression therapy alone.

Chronic venous ulcers (CVUs) occur in approximately 1% of the general population. Risk factors for chronic venous disease (CVD) include heredity, age, female sex and obesity. Although not restricted to the elderly, the prevalence of CVD, especially leg ulcers, increases with age.1 CVD has a considerable impact on health-care resources. It has been estimated that venous ulcers cause the loss of approximately two million working days and incur treatment costs of approximately $3 billion per year in the USA.2 Overall, CVD has been estimated to account for 1–3% of the total health-care budgets in countries with developed health-care systems.1 The pathophysiology of dermal abnormalities in CVU is reflective of a complex interplay that involves sustained venous hypertension, inflammation, changes in microcirculation, cytokine and matrix metalloproteinase (MMP) activation, resulting in altered cellular function and delayed wound healing.3,4

Our objective was to study the prevalence and clinical pattern of chronic venous disease (CVD) in the Pakistani population. This was a multicentre cross-sectional study in which 100 primary care physicians examined 3000 subjects. The study population was aged 18–95 years (mean ± SD = 39 ± 13.2) comprised 47.4% women and 52.6% men. The prevalence of CVD was 34.8%, being significantly higher ( P < 0.04) among men (36.4%) than women (33.0%). The maximum prevalence was of C3 (36.7%), followed by C2 (15.8%). The most frequent symptom was pain in the legs (59.2%) followed by heavy legs (42.7%) and night cramps (34.4%). The prevalence of symptoms increased with age but was similarly distributed between men and women. Family history of CVD, blood clots in veins and lack of exercise were significant risk factors. The roles of age or gender as risk factors could not be established. In conclusion, the prevalence and presentation of CVD in Pakistan is similar to most other countries.

Introduction The ESCHAR trial showed that superficial venous surgery and compression in chronic venous ulceration achieved a 24-week healing rate of 65% and 12-month recurrence rate of 12%. Foam sclerotherapy treatment is an alternative to surgery. The aim of this study is to assess the effect of foam sclerotherapy on ulcer healing and recurrence in chronic venous leg ulcers. Methods Chronic venous leg ulcers (CEAP [clinical, aetiological, anatomical and pathological elements] 5 and CEAP 6) with superficial venous reflux were treated between March 2006 and June 2011 with ultrasound-guided foam sclerotherapy and compression. Venous duplex was performed on all legs before and after treatment. Twenty-four-week ulcer healing and one- and four-year ulcer recurrence rates were calculated using Kaplan–Meier survival analysis. Results Two hundred legs (186 patients) with chronic venous ulcers (CEAP 5: n = 163 and CEAP 6: n = 37) were treated with foam sclerotherapy. Complete occlusion was achieved in 185/200 (92.5%) limbs, short segment occlusion in 14/200 (7%) limbs and one leg segment failed to occlude. One patient suffered an asymptomatic non-occlusive deep vein thrombosis (DVT) diagnosed on duplex scan at one week and one presented with an occlusive DVT three weeks following a normal scan at one week. One patient developed an asymptomatic occlusive DVT at two weeks following a non-occlusive DVT diagnosed on initial one-week scan. Eighteen patients were lost to follow-up (3 moved away and 15 died of unrelated causes). The 24-week healing rate was 71.1% and one- and four-year recurrence rates were 4.7% and 28.1%, respectively. Conclusion Foam sclerotherapy is effective in abolition of superficial venous reflux and may contribute to similar ulcer healing and long-term recurrence rates to superficial venous surgery. Foam sclerotherapy is an attractive alternative to surgery in this group of patients.

Objective Increased intramuscular and subcutaneous tissue pressures are often found in patients with severe chronic venous insufficiency venous ulcer disease. Additional subcutaneous para-tibial fasciotomy promotes early ulcer healing. This study evaluates the mid-term effect of eradication of superficial reflux with additional fasciotomy in patients with increased tissue pressures. Method Between January 2006 and June 2009, 58 patients underwent fasciotomy. Tissue pressures (intramuscular and subcutaneous) were measured. Sixty-nine limbs with 91 venous ulcers were treated. Mean duration of the venous ulcer was 3.4 years. Underlying disease was post-thrombotic syndrome (PT) in 19 patients (33%, 24 limbs, 27 ulcers) and non-post-thrombotic (non-PT) severe chronic venous insufficiency in 39 (67%, 45 limbs, 64 ulcers). All patients were C6 at the time of surgery. Preoperative tissue pressures were 23.5 ± 6.1 mmHg (intramuscularly) and 9.8 ± 3.2 mmHg (subcutaneously). Results Ninety ulcers (99%) healed postoperatively (42 with and 48 without skin grafting). Tissue pressures significantly decreased following surgery and remained low at three months postoperatively. Ten ulcers in six patients recurred six to 20 months postoperatively (11%), resulting in 86.4 actuarial freedom from venous ulcer recurrence at three years following surgery. Four patients (1 non-PT and 3 PT) had re-fasciotomy; all healed initially but two ulcers (2 patients, PT) recurred at 11 and 12 months. Those patients underwent re-fasciotomy, one healed and one recurred six months later. Conclusion Eradication of superficial reflux with additional subcutaneous fasciotomy for chronic and recurrent venous ulcer improves ulcer healing or success of skin grafting. Mid-term results are excellent particularly in patients with non-PT disease. Recurrence is more frequently seen in patients with PT syndrome. In patients with ulcer recurrence and high tissue pressures, re-fasciotomy can be helpful to promote healing, particularly in patients with primary venous disease.

This review concentrates on the investigation of the patient with venous ulceration with a view to presenting current best practice. The aim is to maximize benefit for patients and their medical team by directing appropriate investigation leading to optimized results in the treatment of this highly prevalent, quality of life reducing and socioeconomically costly condition.

Although our understanding of chronic venous insufficiency (CVI) has improved, many important questions remain unanswered. Ensuring that patients are appropriately referred for specialist assessment and then receive evidence-based, cost-effective treatment continues to be challenging. The lifetime of risk of chronic venous ulceration (CVU) is around 1% with approximately 10% ulcers being open at any one time. The incidence skin changes disease is about 10 times greater (10%). However, many of the studies upon which these estimates are based are old and/or methodologically flawed. There is reason to believe that the incidence, prevalence and characteristics of CVI/CVU may have changed considerably over the last 10–20 years and that future change is likely. Further cross-sectional and longitudinal epidemiological studies are required to establish the size and nature of the health-care need going forward in developed and increasingly developing countries. CVI culminating CVU is primarily the result of sustained ambulatory venous hypertension, which in turn arises from superficial and/or deep venous reflux with or without deep vein obstruction. However, there are many other elements to this complex condition, for example, microvascular dysfunction; calf muscle pump efficiency; dermal inflammation; disordered fibroblast function and matrix production; failure of epithelialization; congenital and acquired thrombophilia; malnutrition, obesity and diet; and bacterial colonization. None of the currently available treatment modalities is entirely satisfactory and novel therapies based upon a clearer understanding of the disease at the psychological, genetic, mechanical, microvascular and microscopic level are required.

Objectives Ulceration of the lower limbs is a common debilitating complication of chronic venous hypertension. Detection of preulcerative skin changes would allow for identification of high-risk patients; early active treatment may prevent ulcer formation. Methods Patients with isolated venous disease and volunteers attending outpatient clinics underwent assessment of their clinical, aetiological, anatomical and pathological (CEAP) classification. We employed an industrial durometer, an instrument that measures the hardness of metals and plastic, to assess skin induration. The durometer probe was rested perpendicular on their skin 15 cm above the medial malleolus in non-ulcerated tissue, with the patient and limb in recumbency. The average of four measurements was derived. Results In 107 people, 203 lower limbs (mean age 55.6 years) were assessed. A significant difference in durometry readings was demonstrated between patients with CEAP classes 0, 1 and 2, and those with classes 4, 5 and 6 ( P < 0.0005). There was statistically significant evidence that age and CEAP classification correlated with durometry ( P < 0.0001). Conclusion Durometry is of potential value in the assessment and monitoring of preulcerative venous disease, and could help to identify high-risk patients. This would assist in the institution of timely and appropriate treatment.

Objectives Post-thrombotic syndrome (PTS) is a complication of deep vein thrombosis (DVT) characterized by chronic pain, swelling and heaviness, and may result in ulceration. Elastic compression stockings (ECS) worn daily after DVT appear to reduce the incidence and severity of PTS. The aims of our study were to investigate practices and perceptions of DVT patients and physicians regarding the use of ECS after DVT. Methods Two surveys were conducted. The first was sent to 225 staff and trainee clinicians and the second was administered to 150 DVT patients. Results The results demonstrated that the majority of senior staff (75%) believed that ECS were effective in preventing PTS and in managing venous symptoms. However, this was in contrast with junior trainees (21%) ( P < 0.05). This resulted in only 63% of patients being prescribed ECS post-DVT. There was a lack of consensus as regards the optimal timing of initiation of ECS, duration of therapy and compression strength. Nearly all DVT patients who were prescribed ECS purchased them, 74% wore them daily, and most (61%) reported that ECS relieved swelling and symptoms. Physicians correctly predicted the main reasons for non-compliance, but misjudged the scale of patient compliance with ECS. Conclusions Our findings suggest that there is a lack of consensus among doctors regarding ECS use after DVT and widespread education regarding the latest evidence of the benefit of ECS after DVT.

Objectives A variety of endovenous therapies for the treatment of superficial venous incompetence are currently available. The aim of this study was to evaluate the prevalence of endovenous techniques used by consultant vascular surgeons in the United Kingdom. Methods An anonymous online survey of 16 multiple choice questions relating to the nature and provision of treatment for varicose veins was devised. Consultant members of the Vascular Society of Great Britain and Ireland were invited to participate by email. Results A total of 108/352 (31%) surgeons completed the survey. The majority offered surgery as the first-line treatment for primary great saphenous vein (GSV) and small saphenous vein (SSV) incompetence (69% and 74%, respectively). Endovenous procedures were offered as first-line treatment by 32/108 (29.6%) for GSV reflux, 36/51 (70.6%) surgeons performed these under local anaesthetic and 21/51 (41.2%) were performed as an outpatient procedure. The most important factor influencing treatment decisions was considered to be patient preference by 77/108 (71.3%) surgeons, although 48/61 (78.7%) respondents were restricted by primary care trusts with regard to endovenous treatments, and 33/108 (30.6%) offered different treatments to private patients. Conclusion Traditional surgery remains the most commonly offered treatment for patients with varicose veins. The provision of endovenous therapies varies greatly, and there are significant differences in local availability regarding these treatments.

Thesis Venous ulcers (VU) consume considerable resources in healthcare systems, up to 1% of healthcare budgets in industrialized countries. Best practice guidelines (GLs) incorporate evidence-based diagnostic and therapeutic recommendations in a cost-effective manner and have been associated with improved and less costly outcomes for many diseases. Objectives To determine whether there are common elements in GLs for VU and their evidentiary strength. Methods A systematic analysis of GLs for VU that were identified through clinicaltrials.gov, a government-sponsored website, and from experts outside the USA. Results Ten of 12 GLs on VU (7 North America and 5 Europe) were evidence-based, with the majority using the GRADE method. Only two had been developed or updated within the last three years. Venous duplex and ankle ABIs were recommended in all. Debridement was suggested in two, while simple non-adherent wound dressings were favoured in nine, and hydrocolloid in two. Only one GL discussed a range of dressing options, dependent on the condition of the VU. High pressure multi-layer compression bandages were favoured in 10. Only two focused on the importance of improving ankle joint mobility. Conclusions While there are numerous evidence-based GLs for VU, the majority may lag recent developments in the field. There is consensus on the elements for dressings and compression among the various GLs, which should facilitate the development of a common consensus GL, similar to that for DVT/PE. To improve patient care and reduce wasted resources, it is imperative for specialty societies to develop this consensus document.

A 75-year-old woman presented with painful recurrent venous ulcers (VU) continuously for the past 33 months on a background of frequent intermittent problems for the last 16 years. She had previously been treated with varicose vein surgery and trials of compression bandaging. Subsequently, she underwent endovenous laser ablation (EVLA) targeting the distal incompetent remnant of her great and small saphenous veins. This resulted in complete healing of her ulcers within four weeks. The dramatic response demonstrated in this case suggests that EVLA may represent an effective intervention in the management of postsurgery refractory VU.

The fibrous process of chronic ulcerated lesions of lower limbs can impair the mobility of the affected limb. The aim of this work was to assess the benefits of lymph drainage in patients who suffer from this disease. Twenty female and five male patients with ages ranging from 53 to 69 years (mean age 60.6 years) were evaluated. All had a history of at least 10 years of varicose veins and/or ulcerated lesions of the lower limbs with initial dermatofibrosis, with the positive Godet sign during the physical examination of the limb. Patients with intermittent claudication, diabetes and trauma were excluded from the study, as well as patients with chronic dermatofibrosis, and in whom positive Godet sign was not seen. Patients with immobility or very limited movement of the ankle and with some limitation in the toe joints were selected. The patients were randomly divided into group A comprising 15 individuals, and group B 10. All the individual treatments were established before the start of the evaluation period. Lymph drainage was performed on the patients of group A four or five times per week. Group B was subjected to a type of massage for the same period and at the same frequency. The mobility of the ankle joints was evaluated using goniometry before the start and after 30 days of treatment. In all the patients who underwent lymph drainage, an improvement of the joint mobility was seen, whereas in the control, group B, there was no obvious change. In conclusion, lymph drainage gave an improvement in the mobility of the ankle joint after impairment due to initial dermatofibrosis in patients with chronic ulcerated lesions.