Terminal Interruption of the Reflux Source (TIRS) as a Therapeutic Modality in Chronic Venous Ulceration: A Systematic Review

Abstract

Objectives: Terminal interruption of the reflux source (TIRS) is purported to be a viable method of treating chronic venous ulcers through the temporary reduction of venous hypertension. This technique involves the injection of foam sclerotherapy into venous branches in close proximity to the ulcer bed under ultrasound guidance. This systematic review aims to provide an understanding of the body of published evidence on the value of TIRS in the management of chronic venous ulceration. Methods: A search strategy encompassing MEDLINE, Scopus, the Cochrane database and Google Scholar was developed to identify peer-reviewed articles published prior to April 2018. The search terms used were as follows: ‘venous’, ‘ulcer’, ‘sclerotherapy’, ‘terminal interruption reflux source’, and ‘TIRS’. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 guidelines were followed for data selection and extraction. Results: 3 published articles pertaining to TIRS were identified. 2 studies consisted of case series of 6-14 patients who were treated with ultrasound guided foam injection, followed by compression. 1 randomised controlled trial compared compression alone (n=11) with ultrasound guided microphlebectomy and compression (n=9). Healing time ranged from 6-16 weeks in the case series. Ulcer size reduction was significantly lower in the microphlebectomy cohort in the RCT. Conclusion: There exists a paucity of evidence regarding the utility of TIRS in the management of chronic venous ulceration. A randomized clinical trial is required to eludicate the role of this treatment option.