Management Of Chronic Venous Ulcers Research Articles

The management of venous leg ulcers: Effects of four-layer bandage system

Aim: Chronic Venous Ulcer (CVU) accounts for nearly 70% of all chronic leg ulcers (CLU), seriously impacting the quality of life and creating a heavy economic burden. Here, we present CVU therapy with a four-layer bandage system in 113 patients retrospectively treated by the General Surgery Chronic Wound Unit and Cardiovascular Surgery Department. Material and Methods: From January 2022 to January 2023, 113 patients with CVU were evaluated retrospectively. All patients were documented by color Doppler ultrasonography (CDUS), ulcer size, and demographics. If there were multiple ulcers, the largest one was assessed. Immobile patients and patients with an Ankle Brachial Index (ABI) of <0.7 were excluded. Debridement, exercise, venoactive drugs, and a four-layer bandage system were performed for all patients. The primary outcome was to assess the ulcer healing, and the secondary outcome was to obtain the recurrence rate and the treatment compatibility of patients. Results: The mean age of the patients was 60.73±11.3 (28-91) years and 77.9% were male. Body Mass Index (BMI) was 30.4±7.7 kg/m2 (min:18-max:51 kg/m2). The mean follow-up period was 18.82±13.4 weeks. Pseudomonas aeruginosa (38%) and Staphylococcus aureus (31.8%) were the most identified microorganisms. Four patients experienced recurrence of the CVU (3.5%). The older patients had larger ulcers than the younger patients. Female patients had larger-sized ulcers (p=0.001). Completely healed ulcers were 26.5% of the total. The four-layer compression bandage was applied 12 times for per patient. The mean healing period was 23.2±13.8 weeks. The mean healing rate was 4.17±3.78% for a week. The multivariant analysis revealed that age and pain had negatively affected the ulcer healing. Conclusion: The management of CVU is challenging and needs a multidisciplinary approach. Compression is the main goal of the treatment. Surgical or endovenous therapies may be beneficial for decreasing ulcer recurrence. For patients with slow ulcer healing, adjuvant treatment modalities such as patient education, smoking cessation, diet and lifestyle modification, and exercise should be recommended.

A New Powder Dressing for Management of Chronic Venous Ulcers.

A new powder dressing (TPD) is a methacrylate-based powder formulation that transforms in situ into a shape-retentive matrix upon hydration to create optimum moist wound healing conditions. The following randomized, controlled, clinical study aimed to evaluate the role of TPD in the management of chronic venous ulcers (CVU). The randomized controlled prospective study enrolled 60 CVU patients. After randomization, patients in the treatment group ( n = 30) were treated with TPD, whereas those in the control group ( n = 30) received conventional compression dressing therapy. After treatment, patients in the TPD group had significantly higher rates of complete ulcer healing at 12 weeks (43.3% vs 10.0%, p = .004) and 24 weeks (86.7% vs 40.0%, p = .001) when compared with conventional dressing group. Moreover, patients in the TP dressing group had significantly shorter time to complete ulcer healing [mean (95% CI): 16.7 (14.1-19.3) versus 37.0 (30.8-43.2) weeks, p = .001]. In addition, patients in the TPD group had significantly fewer number of dressings, less severe pain after dressing, and lower need for systemic analgesics. Use of TPD in management of CVUs was associated with significantly higher healing rates, shorter duration to healing, and lower pain.

A CLINICAL STUDY TO EVALUATE THE EFFICACY OF JATYADI GHRITA VIKESHIKA DRESSING IN THE MANAGEMENT OF DUSHTAVRANA W.S.R. TO VENOUS ULCER

Venous ulcers are a frequently encountered problem in the present era produced commonly as a complication of varicose veins and it causes long-term agony to the patient. The properties of a venous ulcer-like non-healing na- ture, severe discharge pain itching etc. come under the umbrella of Dushtavrana explained by Acharya Sushruta. Management of chronic venous ulcers is a challenging one. Commonly practised gauze dressing for chronic ulcers may be disruptive for wound healing as it gets adhered to wound bed hampering breathing of wound and causing damage to granulation tissue during its removal. These factors may be responsible for delayed wound healing. In modern science, there are plenty of sterilized, packed dressing materials available in the market. But nowhere Ayurvedic ready to use dressing material is manufactured or made available in the market. Keeping these into con- sideration, Jatyadi Ghrita Vikeshika i.e., the cloth containing Jatyadi Ghrita is prepared, packed and sterilized. This is compared with the Sofra-tulle of modern science. In the present comparative study, 40 patients were select- ed and divided into 2 groups of 20 patients each and trial group patients were treated with Jathyadi Ghrita Vike- shika dressing & control group patients were treated with Sofra-tulle dressing for 28 days. The study revealed highly significant results in both groups statistically. On observation except for pain, in all other parameters, Jatyadi Ghrita Vikeshika was found more effective. Hence Jatyadi Ghrita Vikeshika can be undoubtedly used in Dushtavrana which promotes both Shodhana (Cleansing) and Ropana (Healing)of Vrana. Keywords: Dushtavrana, Venous Ulcer, Jatyadi Ghrita Vikeshika, Sofra-Tulle dressing.

THE COMBINED EFFECT OF VIRECHANA AND VRANABASTI IN TREATING CHRONIC VENOUS ULCER- A CASE REPORT

Sushruta has explained various methods for Vrana Chikitsas. Virechana is vital to remove the vitiated Dosha from the body in turn normalize them and prevent recurrence of the wound. The local application of Vranabasti is one of the best substitutes for of chronic wound healing and Jathyadi Taila has better Shodhana & Ropana effect. Case: A case of 45 year old man, who presented with complaints of two venous ulcers in medial and lateral aspect of right ankle associated with pain, discharge, slough, oedema and discolouration of the skin since 2 years has been taken for the current study. Method: After initial Deepana and Pachana, Snehapana was administered with Mahatiktaka Ghrita. After Abhyantara and Bahya Snehana and Svedana, Virechana was administered with Avipattikara Churna. Vranabasti, was done every day for 30 minutes after the Samsarjana Karma Results: There was significant improvement in the size of the wound and nature of the surrounding tissues. Conclusion: The combination of Virechana and Vranabasti can be used as a line of treatment for the management of Chronic Venous Ulcer.

ROLE OF PLATELET RICH PLASMA IN TREATMENT OF CHRONIC NON-HEALING VENOUS ULCER

Introduction: Venous ulcers are wounds that are thought to occur due to improper functioning of venous valves, usually of the lower limbs. Considering that PRP is a source of growth factors, and consequently has mitogenic, angiogenic, and chemotactic properties, it represents an adjunctive treatment for recalcitrant wounds. Moreover, PRP provides the wound with adhesive proteins, such as fibrinogen, which are important in wound healing. PRP contain more amount of platelets, cytokines and growth factors which are dispersed in a very small amount of plasma which can be prepared from a sample of centrifuged autologous blood. Application of PRP has been reported to be effective in both acute as well as chronic non healing venous ulcers. 
 Aim and Objective: To evaluate the efficacy of autologous platelet rich plasma in the management of chronic venous ulcer. Material and Method: A Prospective study conducted on 100 patients of chronic venous ulcers admitted in Sir T. Hospital Bhavnagar from June 2018 to June 2019 after fulfilled our inclusion and exclusion criteria. PRP then injected intalesionally inside and around the periphery of the wound/ulcer. This process was done once/week for 12 weeks. At every week, the area and volume of ulcer was calculated and photographs were taken. 
 Result: All the patients showed healing of the ulcer with reduction in size of ulcer more than 90% was observed in 72 patients, followed by 80–90% reduction in wound size in 18 patients after the 12 weeks follow-up. Overall, significant reduction in size of ulcer was observed in all the treated patients.
 Conclusion: Autologous platelet rich plasma (PRP) as an autologous method, it is biocompatible, simple, safe, affordable and less expensive procedure in the treatment of chronic venous ulcers. PRP is found to be useful in improving and enhancing the healing process in chronic venous leg ulcers without any side effect.
 Keywords: Venous ulcer, Platelet rich plasma

Role of Four Layer Compression Dressings in Management of Chronic Venous Ulcers

Abstract Introduction Nonhealing venous ulcers are one of the most common forms of lower extremity ulcers in the present population. It is cumbersome to treat and is associated with high-morbidity and immense treatment expenses. The current treatments include compression therapy. Four-layer compression dressings have proven to be an effective treatment for venous ulcers. Objective This study aimed to evaluate the efficacy of four-layer compression dressings and to study the rate of healing and duration of treatment with four-layer compression dressings. Materials and Methods A prospective randomized study conducted at MS Ramaiah Medical college which included 70 patients who completed the course of weekly dressings depending on the size of ulcer. The regular four-layer dressings were done by a trained podiatrist in vascular outpatient department (OPD) once a week. The area of the ulcer was calculated using the modified Gilmen formula. Results A total of 70 patients who were compliant with the treatment were included in the study. A considerable percentage (74%) of patients were male and all the ulcers were located at the gaiter area. Most belonged to the age group between 41 to 50 years (25%). The healing rate of ulcers at the end of 4, 8 and 12 weeks were 46.87, 28.12, and 25%, respectively. At the end of 12 weeks, all the ulcers healed.

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

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.

A systematic literature review of the management of chronic venous ulcers with autologous fibrin matrix with or without growth factors

Aim: To evaluate available evidence for the effective management of venous leg ulcers with fibrin matrix with or without growth factors.

The Effect of Use of Platelet Rich Plasma (PRP) on Venous Ulcer Size in Comparison to the Usual Method of Dressing and Compression Bandage

Aim: To compare the clinical efficacy of platelet rich plasma in the management of chronic venous ulcers (as regards the time of complete ulcer healing or shrinkage in size) with the conventional methods of treatment of venous ulcers (compression and dressing alone). Patients & methods: A case control study was conducted over 40 patients having lower limb chronic venous ulcers, attending the outpatient clinic of vascular surgery, Ain Shams university hospitals in the period from July 2013 till January 2015. Twenty patients with chronic venous ulcers (cases) were treated with platelet rich plasma - topically applied to the ulcer then dressed by vasline gauze and compressed by graduated elastic stocking - for 6 sessions with one week interval between sessions. The second group (control) included the other 20 patients who were managed conservatively by compression using graduated elastic stockings below the knee and dressing using saline and vasline guaze weekly for 6 weeks. Results: We noticed that the percentage of change in size, length and width of the ulcer after the end of treatment showed highly statistically significant difference between cases and controls after 6 weeks of treatment, where complete healing and shrinkage in size of the ulcer were more obvious in cases treated with PRP than those who were treated only by the conservative method, who showed mild improvement after 6 weeks of conservative treatment. 35% of patients in cases group achieved complete healing compared to 0% of patients in control group. Conclusion: Platelet rich plasma shows promise as an effective treatment modality in the setting of chronic venous leg ulcers. It was found to be effective in enhancing wound healing in chronic venous leg ulcers when compared to conventional methods of treatment (compression + dressing), as regards length, width and size of the ulcer and treatment outcome

Treatment of Chronic Venous Ulcers Using New Four Layers Compressive Bandage Dressing

Lower-extremityulcersrepresent the largest group ofulcerspresenting to an outpatient department. It is a cumbersome, difficult to treat disease, which causes high morbidity and huge cost for the patient and healthcare system. Current standardtreatmentincludes compression therapy. However, majority of patients need long term treatment with minimal efficacy. Aim of our study is to evaluate efficacy of four layers compressive bandages for the management of chronic venous ulcers. In Group A, we have prospectively included 20 patients with chronic venous ulcers on lower limbs for four layers hosiery bandage using Velfour bandage. Other 15 patients, Group B, were treated with conventional wound dressing. Velfour and crepe bandage were done once weekly for three weeks. DVT was cause of chronic venous ulcer in 70% patient in group A and in 73.3% in Group B. Majority of patients were having left sided chronic venous ulcers. The mean duration of theulcerswas 15.6 vs 10.86 months (group A vs. group B). At the end of 3rd week, in 55% wounds in Group A were healed except few big and deep wounds remained. Most of these wounds also became smaller with minimal discharge. Size of wounds significantly decreased in Group A vs. Group B patients (0.7±0.81 cm vs. 1.73±0.77 cm, p<0.00031). However, cost of treatment in group A remained higher than group B. Our study has shown that four layer compressive bandage using Velfour is an easy, effective, and reproducible method of treatment for the chronic venous ulcer.

A Prospective Study of Human Viable Wound Matrix in the Management of Chronic Venous Ulcers

A Prospective Study of Human Viable Wound Matrix in the Management of Chronic Venous Ulcers

Four layer dressing in the management of chronic venous ulcers in the outpatient setting of a tertiary hospital in India

Chronic venous ulcers are quite commonly seen in vascular surgery outpatient clinics in India. Understanding the pathophysiology and identification of the primary cause forms the cornerstone of treatment. However there are many management challenges especially in developing countries. To study the role of four layer bandage dressing in chronic venous ulcer management by assessing healing rates, the time to heal and compliance rate in the outpatient setting. This is a retrospective study of patients with chronic venous ulcers presenting to vascular surgery outpatient department from September 2012 to July 2013 who were treated with four layer dressings. A total of 202 patients were treated with four layer dressings during this period. Of these 32 were excluded for various reasons. Of the 170 patients studied, healing was seen in 87.6%. Most of the ulcers healed by 4 weeks (50.6%). There was 90% patient compliance. Four layer dressing is effective in the healing of venous ulcers in the outpatient setting with good patient compliance.

Clinical Unity and Community Empowerment: The Use of Smartphone Technology to Empower Community Management of Chronic Venous Ulcers through the Support of a Tertiary Unit

BackgroundChronic ulcers affect roughly 60,000 Irish people, at a total cost of €600,000,000, or €10,000 per patient annually. By virtue of their chronicity, these ulcers also contribute a significant burden to tertiary outpatient vascular clinics.ObjectiveWe propose utilizing mobile phone technology to decentralise care from tertiary centres to the community, improving efficiency and patient satisfaction, while maintaining patient safety.MethodsBespoke mobile software was developed for Apples iPhone 4 platform. This allowed for the remote collection of patient images prospectively and their transmission with clinical queries, from the primary healthcare team to the tertiary centre. Training and iPhones were provided to five public health nurses in geographically remote areas of the region. Data were uploaded securely and user end software was developed allowing the review and manipulation of images, along with two way communication between the teams. Establishing reliability, patients were reviewed clinically as well as remotely, and concordance analysed. Qualitative data were collected through focus group discussion.ResultsFrom October to December 2011 eight patients (61–83 yrs, mean 75.3 yrs) with chronic venous ulceration and their five public health nurses were recruited. Data were transmitted using 3 G, Edge, GPRS and WiFi, at a mean speed of 69.03 kps. Concordance was 100% for wound bed assessment, 80% for skin integrity/colour and 60% for exudate assessment. Focus group analysis explored the concept, practicalities and future applications of the system.ConclusionsWith an evolving national data network, the secure transmission of clinical images is a safe alternative to regular clinic appointments for patients with chronic venous ulceration. With further development, and packaged as a freely downloadable application, this has the potential to support the community care of chronic wounds.

Chronic venous leg ulcer treatment: Future research needs

The prevalence and costs of chronic venous ulcer care in the US are increasing. The Johns Hopkins University Evidence-Based Practice Center recently completed a systematic review of the comparative effectiveness of advanced wound dressings, antibiotics, and surgical management of chronic venous ulcers. Of 10,066 citations identified in the literature search, only 66 (0.06%) met our liberal inclusion criteria for providing evidence on the effectiveness of interventions for chronic venous ulcers. Based on review of those studies, members of our team and a panel of informed stakeholders identified important research gaps and methodological deficiencies and prioritized specific future research needs. Based on that review, we provide the results of our assessment of future research needs for chronic venous ulcer care. Advanced wound dressings were considered to have the highest priority for future research, followed by venous surgery and antibiotics. An imperative from our assessment is that future research evaluating interventions for chronic venous ulcers meet quality standards. In a time of increasing cost pressure, the wound care community needs to develop high-quality evidence to justify the use of present and future therapeutic modalities.

Duplex guided foam sclerotherapy plus compression for the treatment of chronic venous ulcer

Background and objectiveVenous ulcers are the most severe and debilitating sequel of chronic venous insufficiency (CVI) and venous hypertension. They account for nearly 80% of all lower extremity ulcers, with an overall prevalence of approximately 1–2%. The majority of these patients are otherwise healthy individuals suffering from chronic ulceration during the most productive period of life. ObjectiveThe aim of this work is to prospectively evaluate the using of foam sclerotherapy guided by duplex ultrasound for injection of incompetent perforators to treat venous ulcer. Materials and methodsThis study was done on forty patients who were referred to management of chronic venous ulcer. All patients were subjected to: pre-treatment evaluation, Ankle brachial pressure index and venous duplex scan. ResultsAs regards healing of leg ulcers in the 40 patients under this study: At 1, 3, and 6months after treatment: 5 ulcers (12.5%), 28 ulcers (70%) and 38 ulcers (95%), respectively had healed completely 3 ulcers had recurred (8%) during the follow up period. ConclusionsCompared to surgical intervention, the relative freedom from serious complications and its evident success, make this the first line treatment for venous ulcer.

Autologous platelet rich plasma in chronic venous ulcers: Study of 17 cases

Background:Venous ulcers are wounds that are thought to occur due to improper functioning of venous valves, usually of the legs. They are the major cause of chronic wounds, occurring in 70% to 90% of chronic wound cases. The treatment of venous ulcers also entails substantial costs. Autologous platelet rich plasma (PRP) is a simple office based procedure which helps in enhancing the wound healing by releasing many growth factors like platelet derived growth factors, fibroblast derived growth factors and epidermal growth factors.Aim:To study the efficacy of autologous platelet rich plasma in the management of chronic venous ulcer.Methodology:12 patients with 17 venous ulcers were treated with PRP and treatment outcome was measured by percentage of improvement in area and volume of the ulcer.Results:12 patients with 17 ulcers were treated with PRP. The mean age of the patients was 33.5 years (SD 9.82). 10 were males and 2 were females. The mean duration of the healing of the ulcers was in 5.1 weeks (SD 3.1). The mean percentage improvement in the area and volume of the ulcer was 94.7% (SD 11.12) and 95.6% (SD 10.19) respectively.Conclusions:PRP is safe, simple and effective procedure in treating chronic venous ulcers

Effective use of negative pressure wound therapy provides quick wound‐bed preparation and complete graft take in the management of chronic venous ulcers

Venous ulcers are characterised by longstanding and recurrent loss of skin integrity. Once occurred, healing is slow and recurrence is high because of inappropriate conditions of the wound bed. This study involves 20 patients with chronic venous ulcers at least 6 weeks of duration treated with negative pressure wound therapy (NPWT). Patients underwent a radical debridement of all devitalised tissues in the first operation. After adequate haemostasis, silver-impregnated polyurethane foam was applied. Once the wounds were determined to be clean and adequate granulation tissue formation was achieved, split-thickness skin grafts were applied. Black polyurethane foam was applied over them. All wounds completely healed without the need for further debridement or regrafting. The mean number of silver-impregnated foam dressing changes prior to grafting was 2·9 (one to eight changes). The mean number of NPWT foam changes was 2·6 after skin grafting (two to five changes). Two patients who did not use conservative treatments for chronic venous insufficiency (CVI) after discharge from the hospital had recurrence of venous ulcers in the follow-up period. Application of NPWT provides quick wound-bed preparation and complete graft take in venous ulcer treatment.

Venous ulcer: Current concepts

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HYPERBARIC OXYGEN THERAPY VERSUS LASER THERAPY ON THE ACCELERATION OF VENOUS LEG ULCER HEALING

The purpose of the current study was to determine the effectiveness of hyperbaric oxygen therapy(HBOT) or laser therapy in the acceleration of chronic venous ulcer healing. Thirty hospital inpatients with venous ulcers participated in this study for a treatment period of five weeks. They were divided randomly and equally into three groups (2 treatment groups and one control group). Patients in group (1) (HBOT group) received two 90 minutes treatments daily with 2 to3 L of humidified oxygen / minute at 22 mmHg. On the other hand, patients in group (2) (laser therapy group) received 1 J/cm2 infrared laser (Ga As), three times weekly. Patients in group (3) (control group) received standard wound care only. Wound surface area (WSA) and wound volume (WV) were used to measure the outcomes before starting the study and after the 3rd and 5th weeks posttreatment. It was found that, at the 5th week post-treatment there was a significant reduction in both WSA and WV in both the HBOT group and the laser therapy group when compared to the control group (P<0.0001), also there was a significant reduction in WSA and WV in the laser therapy group at the 5th week post-treatment when compared to the HBOT group (P<0.001). The findings strongly suggest that the application of infrared laser therapy at a dose of 1J/cm2, three times/week is more effective than the application of HBOT daily in the management of chronic venous ulcers.

Randomized trial of two foam dressings in the management of chronic venous ulceration

A multicenter prospective randomized clinical trial was undertaken to compare two foam dressings (Allevyn Hydrocellular, Smith & Nephew and Mepilex, Molnlycke Health Care AB) in the management of chronic venous leg ulceration. Patients were also randomized to two compression bandage systems (4-layer vs. cohesive short stretch) as a factorial design. Those with causes of ulceration other than venous disease were excluded. In all, 156 patients met the entry criteria and were randomized from the 12 clinical centers with a median (range) ulcer size of 4.33 (0.33-123.10) cm(2). After 24 weeks a total of 100 (64.1%) patients had complete ulcer closure, 46 (29.5%) had withdrawn from the trial, nine (5.8%) remained unhealed and one patient died. Of the patients randomized to Mepilex, 50/75 (66.7%) had complete ulcer healing compared with 50/81 (61.7%) on Allevyn. The hazard ratio for healing after adjustment for bandage type and trial center was 1.48 (95% C.I. 0.87-2.54, p=0.15), which only marginally changed following adjustment for baseline variables, neither of which achieved statistical significance (p=0.16). Withdrawal rates were similar between groups (23, 30.7% Mepilex vs. 23, 28.4% Allevyn). Pain improved following treatment with both dressings (p<0.001), but with no difference between dressings.