Treatment Of Venous Insufficiency Research Articles

Effects of a Dietary Supplement Composed of Baicalin, Bromelain and Escin for Venous Chronic Insufficiency Treatment: Insights from a Retrospective Observational Study.

Chronic venous insufficiency (CVI) represents a risk factor for cardiovascular events. The first-line treatment includes the use of compression stockings and lifestyle changes. Natural products, such as flavonoids, could be used to improve the effects of compression therapy due to their anti-inflammatory and anti-oxidant properties. This study aims to evaluate the effects of a dietary supplement containing baicalin, bromeline and escin in CVI patients. A retrospective cohort study was performed by using the medical records of CVI affected outpatients. Patients treated with the dietary supplement were defined as "users". A modified Venous Clinical Severity Score (VCSS) was calculated, including pain, inflammation, vessels induration and skin pigmentation. All clinical variables were evaluated at baseline (T0), after 30 (T1) and 90(T2) days in "users" and "non-users". Out of 62 patients, 30 (48.4%) were "users". No difference was observed between groups at baseline. A lower VCSS value was recorded in "users" than that observed in "non-users" at T2 (7.0 (4.0-9.0) vs. 9.0 (5.0-10.0); p = 0.025). Vessels' induration and pain significantly reduced in 53.3% and 43.3% of "users" and in 18.8% and 9.4% of "non-users". Only "users" (33.3%) showed a reduction of the inflammatory signs as well as a decrease in malleolar circumference, from 29.0 (26.5-30.0) to 27.5 (26.0-28.5) (p < 000.1). A reduction of C-reactive Protein levels was found in "users" compared to "non-users" at T2 (1.0 (0.9-1.2) vs. 1.3 (1.0-1.5); p = 0.006). These findings suggest that implementation of a dietary supplement could improve the clinical outcomes of CVI patients.

Radiofrequency ablation for the treatment of great saphenous venous insufficiency using a newly developed VENISTAR catheter: A preliminary study.

This study was aimed to assess the preliminary outcomes of radiofrequency ablation (RFA) using a newly developed catheter (VENISTAR) for the treatment of incompetent great saphenous veins (GSVs). In this prospective observational study, endovenous RFA using a VENISTAR catheter was performed on 16 saphenous veins in 12 patients between August and November 2019. Patients' pre- and post-procedural data were recorded. Doppler ultrasound imaging and clinical evaluation were performed at 1week and 1, 3, and 6months to determine the efficacy and safety of the treatment. Technical success and complete closure of the targeted GSVs immediately after the procedure were observed in all 16 limbs (100%). However, one patient (one limb) was found to have partial occlusion without significant reflux after 1week of follow-up. Kaplan-Meier analysis yielded a complete occlusion rate of 93% at 6months of follow-up. The Venous Clinical Severity Scores at the time of all follow-up were significantly lower than those at baseline (3.3 ± 1.1 at baseline to 0.6 ± 0.6, 0.3 ± 0.6, 0.1 ± 0.4, and 0.2 ± 0.4 at 1week and 1, 3, and 6months, respectively) (p < .001). Mild post-procedural pain was noted in 7 and 4 limbs at 1week and 1month, respectively. Grade 1 ecchymosis over the ablated segment was noted in 5 (35.7%) of 14 limbs at 1-week follow-up. Endovenous treatment of GSV insufficiency using a new VENISTAR radiofrequency catheter has been shown to be feasible, effective, and safe throughout the 6-month follow-up.

Plethysmography: A game changer for chronic venous insufficiency diagnosis, treatment, and follow-up.

Chronic Venous Insufficiency (CVI) presents a various clinical symptoms and treatment options. Although it is generally known which treatment option is more appropriate in which situations in CVI, it is even more difficult to find the right option in some uncertain situations. In this study, we aimed to evaluate the potential contribution of Digital Photoplethysmography (D-PPG) in the diagnosis of CVI and especially in the selection of treatment options. This retrospective study was conducted at Bursa Heart and Arrhythmia Hospital, involving 721 consecutive patients diagnosed with CVI and with Endovenous Laser Ablation (EVLA) indication. The patients were divided into 2 groups according to the extent of the failure in Doppler USG. In Group 1, the insufficiency ended above the knee, and in Group 2, the insufficiency progressed to below the knee. Patients were evaluated based on anamnesis, physical examination, Doppler USG, and D-PPG. Clinical classification, Venous Clinic Severity Score (VCSS), Quality of Life (QoL) assessment, venous pump capacity (VPC), and venous refill time (VRT) were measured. The study included 263 male and 458 female patients with a mean age of 52.37 ± 12.26years. Significant differences were observed between Group 1 (above knee reflux) and Group 2 (below knee reflux) patients in terms of VCSS, QoL, VPC, and VRT values. The mean values of VCSS, patient complaints, VPC, and VRT were higher in Group 2 patients. Similar findings were observed within the CEAP 2 subgroup. D-PPG shows potential as a valuable tool in the diagnosis and treatment of CVI. By providing information about venous hemodynamics and volume changes, it can assist in optimizing treatment decisions, including saphenous vein preservation. Combining D-PPG with Doppler USG may improve the comprehensive assessment of CVI and change the treatment option, especially for CEAP 2 patients. More research is needed to confirm these findings and explore wider applications of plethysmographic methods in the management of CVI.

Can plethysmography have a greater place in the diagnosis, treatment and follow-up of chronic venous insufficiency?

Objectives: Chronic venous insufficiency (CVI) is one of the most common venous diseases. CVI is an important clinical picture with a high prevalence, low quality of life, and high diagnosis and treatment costs. Therefore, diagnosis, follow-up, and treatment are important for the patient's socioeconomic and life quality. In this study, we aimed to better examine a test used in the diagnosis, treatment, and follow-up of CVI. Methods: In this retrospective study, 683 patients diagnosed with CVI, who had endovenous laser ablation (EVLA) indications were evaluated between June 2013 and November 2018. EVLA procedure performed on all patients. Preoperative, postoperative 1st and 6th month Doppler USG (ultrasonography), plethysmography, and VCSS (Venous Clinical Severity Score) questionnaire was made to all patients. Results: As a result of our study, we found that there was a significant difference between the preoperative plethysmography and VCSS results of the patients and the postoperative 1st and 6th month results. With the significant difference in the VCSS questionnaire, we have shown that plethysmography gives accurate results in the diagnosis and treatment of CVI since it is an individual, quantitative, and easy test. Conclusions: EVLA is an effective and safe method in patients with venous insufficiency. Since Doppler USG is person and device dependent, we think that plethysmography, which can be used in every clinical setting and provides quantitative results independent of the person, can be used more frequently in the diagnosis and treatment of venous insufficiency. In addition, we think that plethysmography can be used as a valuable additional method in the diagnosis and follow-up of such patients, due to the venous hemodynamic data that Doppler USG cannot provide.

The troubled course of the CHIVA Cure through clinical studies: a critical review

The treatment of Superficial Venous Insufficiency (SVI) encompasses a wide and disparate array of techniques, ranging from destructive procedures (endovascular ablation, stripping and sclerotherapy) to the conservative hemodynamic procedure (CHIVA). This variety of options betrays a wide degree of uncertainty on the recommended treatment, mainly due to technical biases in performing the CHIVA Cure that heavily affect the results from Randomized Controlled Trials (RCTs). In fact, the authors of the last Cochrane Review (CR) on the CHIVA Cure disowned its superiority based on the results from five RCTs in which more than 200 of the overall 419 participants allocated to the CHIVA arm had actually received treatments other than the CHIVA Cure. Further, the Guidelines (GLs) from both the American and the European Society for Vascular Surgery recommend the CHIVA Cure only to vascular surgeons experienced with this technique, contradicting what is expected of a specialist, i.e. mastery of the treatment of diseases in his or her specialty. Finally, CRs and GLs do not take into any account the ethically relevant issue that destructive procedures, recommended for vascular surgeons not experienced in the CHIVA Cure, will fatally deprive the patient of the Great Saphenous Vein (GSV), which is the first-choice infra-inguinal graft for the treatment of severe peripheral artery disease and to ward off the severely disabling condition resulting from limb loss, when angioplasty/stenting is not feasible. In this paper we review and discuss the RCTs, CRs, and GLs concerning the CHIVA Cure available at June 2023 on Medline and Cochrane Central databases.

Safety of Ultrasound Guided Endovenous Management of Varicose Veins and How to Avoid Potential Complications

Background Endovenous laser ablation (EVLA) and radiofrequency ablation (RFA) have been used to treat superficial venous insufficiency, Ablation of veins has replaced operative saphenectomy as the procedure of choice for the treatment of superficial venous insufficiency. This change has likely taken place due to the minimally invasive nature and acceptable safety of endovenous ablation while remaining as efficacious and durable as saphenous ligation and stripping. Pattern of complications had been changed over the past decade, due to shifting from surgical stripping of varicose veins to endovenous procedures. The incidence of complications vary widely based on the level of operators as ecchymosis incidence post endovenous procedure range from (52-100%), parathesia (0.5 - 41.5%), phlebitis (0.5 – 5.5%), burn (0.46%), DVT (0.27%), and pulmonary embolism in 0.02% of cases. Aim of the Work assessing the incidence of complications during endovenous procedures of varicose veins and possible preventive measures. Assessing incidence of complications during Endovenous laser ablation (EVLA), radiofrequency ablation and injection sclerotherapy. Assessing the preventive measures that could be conducted to decrease the incidence of complications of endovenous surgeries. Patients and Methods Type of study retrospective cohort study study setting the study will be conducted at Ain Shams University Hospitals, interventional radiology department study period 2 years study population patients admitted in interventional radiology department during the past 2 years and scheduled for varicose veins treatment. Results was conducted on 20 patients, 70.0% were males and 30.0% were females with mean age of the study group was 45.35 ± 11.34 years ranged from 28 to 65 years. Most patients with no known medical or surgical history 65.5%, 25.0% were diabetic and 5.0% were hypertensive. Conclusion because most of the side effects are minor, and major complications are rare, EVLA is a safe and minimally invasive procedure with excellent efficacy in the treatment of varicose veins. Because optimizing laser parameters and the EVLA procedure may reduce the incidence and severity of complications associated with EVLA, additional research is warranted.

Does the Treatment of Pelvic Venous Insufficiency Really Not Influence Lower Limb Venous Disease?

Pelvic venous insufficiency is a common problem in multiparous women. Besides burdensome symptoms, it correlates with the development of venous disease in the lower limbs. Therefore, the sequential treatment of abdominal/pelvic before leg veins could improve treatment effectiveness. The medical records of 243 patients with venous disease who were subjected to sequential treatment were analyzed retrospectively. The symptoms and patient satisfaction were assessed using dedicated questionnaires, both before and after treatment. Clinical effectiveness was verified using a Doppler scan, both before and after treatment. Among 243 analyzed cases, 195 underwent whole treatment; however, 48 women after embolization did not require further intervention. The total-symptom-score change (11.6 vs. 13.0, respectively) and the satisfaction score (1.6 vs. 1.5, respectively) did not differ between groups. After embolization, some patients, besides symptoms improvement, experienced reflux reduction and, hence, might avoid further intervention. A better explanation for this beneficial effect of the sequential/descending approach requires further studies.

The impact of invasive treatment of superficial venous insufficiency of the lower extremities on cardiac functions.

The aim of the study was to investigate the effect of invasive treatment for chronic venous insufficiency (CVI) on cardiac hemodynamics. Fifty three patients diagnosed with saphenofemoral junction or great saphenous vein insufficiency in a level above C3 according to Clinical-Etiology-Anatomy-Pathophysiology classification were included in the study. All the patients underwent 2D echocardiography before and 3months after the invasive treatment. In postinvasive treatment echocardiographic assessment, significant decreases in right ventricular end-diastolic diameter (p = 0.006), TAPSE (p = 0.006), tricuspid E wave velocity (p = 0.004), tricuspid E/A ratio (p < 0.001), sPAB (p = 0.017), tricuspid lateral s' wave velocity (p = 0.004), and right ventricular free wall longitudinal strain rate (p = 0.011) were observed. The invasive treatment of superficial venous insufficiency of the lower extremities may lead to reduction in the increased venous return in the supine position subclinically.

Comparison of endovenous laser ablation and cyanoacrylate embolization in the non-invasive treatment of superficial venous insufficiency in terms of patient satisfaction.

Ablation with n-butyl cyanoacrylate is a clinically newer technique than endovenous laser ablation and other interventional techniques in the treatment of chronic venous insufficiency (CVI). The aim of this study was to compare the endovenous laser ablation (EVLA) and n-butyl cyanoacrylate (NBCA) interventional techniques in terms of benefit, effectiveness, and patient satisfaction. The study was conducted at Yozgat City Hospital and Bozok University Research Hospital Cardiovascular Surgery clinics between November 2016 and February 2021. A total of 260 symptomatic patients with 130 randomized cases in each intervention group were included. NBCA patients constituted Group 1 and EVLA patients Group 2. The saphenous vein was evaluated by color Doppler ultrasonography (CDUS) of the lower extremity. Patients with saphenous veins over 5.5mm in diameter and a saphenous-femoral reflux time of 2s or longer were included in the study. The patients were asked about their satisfaction and symptoms in the first postoperative week during an outpatient clinic follow-up with CDUS investigation at the first and sixth months. Although vena saphenous magna (VSM) closure results were similar with the two methods, satisfaction rates were found to be higher with the NBCA procedure. Comparison of the new methods used in the treatment of CVI revealed similar VSM closure rates in the two methods, but the satisfaction rate was higher with the NBCA technique in this study.

Techniques for Embolization of the Ovarian Vein and Pelvic Reservoir

Pelvic venous disorders are a common and under diagnosed cause of chronic pelvic pain in women, presenting with chronic, noncyclical pelvic pain for greater than 6 months and the presence of pelvic varicosities. Pelvic varices and ovarian vein reflux are a strong indicator of venous origin chronic pelvic and may benefit from embolization. This most commonly occurs in multiparous, premenopausal women with symptoms of gravity dependent pelvic pain and postcoital pain. Additional causes of pelvic venous disorders include iliac vein compression, internal iliac vein reflux, and renal vein compression, however for the purposes of this article we will focus on ovarian vein insufficiency. The mainstay of treatment for pelvic venous insufficiency is Ovarian Vein Embolization and embolization of the pelvic venous reservoir. This article will focus on the patient presentation and workup, followed by a detailed summary of how to perform this procedure, current research to support treatment, possible technical challenges and complications, and finally future research priorities.

A pictorial essay of ultrasound findings after endovascular procedures for superficial chronic venous disease

To date endovascular surgical techniques represent an effective and widely used choice in the treatment of superficial venous insufficiency. In recent years, tumescent ablative techniques (endovenous laser ablation, radiofrequency ablation) have been joined by non-tumescent ablative techniques (mechanical-chemical ablation and cyanoacrylate glue embolization). The Duplex ultrasound (DUS) is the survey mostly used to evaluate the outcome of these procedures. The aim of this work was to provide an updated overview of the ultrasound aspects that can be found in the follow-up of patients undergoing endovascular procedures. Specifically, the characteristic imaging pictures will be described in the immediate and short/medium term follow-up. The DUS is a fundamental element of the investigation of venous system of the lower limbs after the surgical and endovascular treatment of varicose veins. Therefore, it is necessary to update one’s knowledge regarding ultrasound patterns related to new endovascular procedures.

Comparison of Radiofrequency Ablation and Saphenous Vein Stripping for the Treatment of Recurrent Lower Extremity Venous Insufficiency.

To compare the efficiency and safety of radiofrequency ablation (RFA) and saphenous vein stripping (SVS) for the treatment of recurrent lower extremity chronic superficial venous insufficiency (CSVI). Patients who underwent SVS and RFA for recurrent lower extremity CSVI following RFA and patients who had 2-year follow-up results were enrolled into the study. Total, 37 patients who underwent a second RFA session with 2-year follow-up results were available. Then 37 patients were selected from 88 patients who underwent SVS for recurrent lower extremity CSVI to achieve a 1:1 ratio for comparison. Groups were compared based on preoperative properties, operative parameters, postoperative outcomes, complications and follow-up results. Duration of the procedure was 20.7minutes in the RFA group and 30.7minutes in the SVS group (P = .001). Postoperative pain at first hour, sixth hour and 24thhour were significantly lower in patients who underwent RF (P = .001 for each parameter). Moreover, hospitalization time (18.1hours vs 24.6hours, P = .001) and time to return to normal daily activities (1.6days and 2.5days, P = .001) were significantly shorter in the RFA group. Success of the procedure did not statistically significant at first year follow-up (P = .304). However, success was significantly higher for the SVS group at second year follow-up (73% for RFA group and 91.9% for SVS group, P = .032). We achieved significantly shorter procedure time, less postoperative hospitalization time, and a shorter time to return to daily activities with RFA. In contrast, the success rate of SVS was significantly higher at the second year follow-up, but not the first year follow-up in comparison with RFA.

Outpatient treatment of truncal veins insufficiency

Abstract Introduction: Chronic venous disease is a common clinical problem with an increasing incidence that constitutes a financial burden for healthcare. Minimal invasive techniques and procedures in an outpatient basis may help decompressing the healthcare system. The aim of this study is to evaluate the effectiveness and safety of endovenous closure of the truncal veins with n butylcyanoacrylate adhesive on an outpatient basis. Methods: We treated 100 cases of venous insufficiency with endovenous NBCA glue closure of the truncal veins on an outpatient basis. Patients were usually admitted to the vascular surgery department at the time of the procedure. The surgery took place in the general operation room, under local anesthesia. We didn’t use compression stockings and patients were instructed to walk immediately after the operation. Results: There was a 100% successful obliteration of the target vein in day 0, 2weeks, 3-months and one year. The majority of patients (98%) reported improvement of the symptoms, whereas 60 patients (60%) had complete elimination of symptoms. The appearance of varicose veins improved in 96% of the cases. There were no major adverse effects observed during follow-up. A percentage of 28% presented erythema and tenderness along GSV and 15 of those patients were treated with anti-inflammatory drugs (Ibuprofen) and 5 with antibiotics (Amoxicillin-Clavulanic acid). Conclusion: Outpatient treatment of venous insufficiency with endovenous glue closure is a safe and efficient method. It increases patient satisfaction, permits rapid return to normal activities and reduces the risk of hospital transmission of infectious diseases and hospitalization costs.

Hypersensitivity Reactions after Cyanoactylate Closure for the Treatment of Incompetent Superficial Venous Insufficiency

Hypersensitivity Reactions after Cyanoactylate Closure for the Treatment of Incompetent Superficial Venous Insufficiency

Horse Chestnut Saponins–Escins, Isoescins, Transescins, and Desacylescins

Escins constitute an abundant family of saponins (saponosides) and are the most active components in Aesculum hippocastanum (horse chestnut-HC) seeds. They are of great pharmaceutical interest as a short-term treatment for venous insufficiency. Numerous escin congeners (slightly different compositions), as well as numerous regio-and stereo-isomers, are extractable from HC seeds, making quality control trials mandatory, especially since the structure-activity relationship (SAR) of the escin molecules remains poorly described. In the present study, mass spectrometry, microwave activation, and hemolytic activity assays were used to characterize escin extracts (including a complete quantitative description of the escin congeners and isomers), modify the natural saponins (hydrolysis and transesterification) and measure their cytotoxicity (natural vs. modified escins). The aglycone ester groups characterizing the escin isomers were targeted. A complete quantitative analysis, isomer per isomer, of the weight content in the saponin extracts as well as in the seed dry powder is reported for the first time. An impressive 13% in weight of escins in the dry seeds was measured, confirming that the HC escins must be absolutely considered for high-added value applications, provided that their SAR is established. One of the objectives of this study was to contribute to this development by demonstrating that the aglycone ester functions are mandatory for the toxicity of the escin derivative, and that the cytotoxicity also depends on the relative position of the ester functions on the aglycone.

CHIVA strategy in the treatment of venous insufficiency

The approach to the diagnosis and treatment of venous insufficiencies involves two opposing attitudes: demolition and conservation of the venous system. CHIVA is based on knowledge of the pathophysiology of venous insufficiency. Through an accurate and standard echo color Doppler investigation, a mandatory method that must be within the capabilities of a modern phlebologist, the causes of the increase in transmural pressure are identified, a map is prepared and finally a therapeutic strategy aimed at normalizing the transmural pressure is planned. CHIVA represents a scientific progress in the approach to venous insufficiency. The CHIVA strategy is applied mainly, but not only, with conservative surgical tactics based on the faithful reproduction of the strategy planned with the cartography. CHIVA respects venous function and seeks to preserve the GSV useful for all arterial surgery needs. Studies performed according to the rules of evidence-based medicine, Cochrane reviews and meta-analyses certify the validity of the CHIVA strategy in the treatment of venous insufficiencies of the lower extremities.

Randomized controlled trial comparing immediate and delayed treatment of varicose veins following mechanochemical ablation

ObjectiveThe standard treatment of superficial venous insufficiency consists of endovenous thermal ablation of the refluxing main trunk, combined with side branch treatment, if needed. Side branches are often treated with phlebectomy concurrently or as a staged procedure. Whether the delayed treatment is justifiable, taking into consideration the long-term outcomes of the treatment and the need for later interventions, remains an open question. The objective of this study is to evaluate the necessity of immediate treatment of varicosities and to compare it with delayed treatment after mechanochemical ablation of the main trunk of the great saphenous vein (GSV). MethodsVenous outpatient clinic patients with varicosities (clinical classification C2-C4) resulting from GSV insufficiency were randomized to receive mechanochemical ablation only or mechanochemical ablation with concurrent phlebectomies at a ratio of 1:1. After eligibility assessment of 1149 patients, 85 met the inclusion criteria, which were age 20 to 70 years, ultrasound-verified GSV insufficiency, mean GSV diameter of 5 to 10 mm in the thigh, and provision of written informed consent. The exclusion criteria were deep venous reflux, peripheral arterial disease, pregnancy, lymphedema, body mass index of >40 kg/m2, an allergy to the sclerosant, a history of deep vein thrombosis, and/or any form of coagulopathy. The primary outcome was the need for sclerotherapy at 3 months after treatment. The secondary outcome measures, which were assessed at 3 months and 1 year, were complications, duration of sick leave, overall patient satisfaction, and GSV occlusion rate. ResultsAt 3 months, 13.2% of the patients randomized to delayed treatment needed sclerotherapy. No statistically significant difference was found in the occlusion rate of the GSV at either 3 months (mechanochemical ablation only group, 94.7%; mechanochemical ablation with phlebectomy group, 100%; P = 1.000) or 1 year (mechanochemical ablation only group, 89.7%; mechanochemical ablation with phlebectomy group, 94.4%; P = 1.000). The groups were also similar in terms of disease-specific quality of life (P = .964), health-related quality of life (P = .337), and the other outcome measures within the study period. ConclusionsThe need for reintervention did not increase and the patients' quality of life and satisfaction with the procedure were similar at 1 year when mechanochemical ablation only was compared with mechanochemical ablation plus phlebectomy.

High Intensity Focused Ultrasound for saphenous vein sparing

High Intensity Focused Ultrasound (HIFU) allows delivery of energy through the skin in a minimally invasive way, thus repeated treatments can be performed without too much Inconvenience for the patient. We present in this paper different options for saving refluxing Saphenous trunks using HIFU. 1 / ULTRASOUND VALVULOPLASTY. Was the first application proposed for venous insufficiency treatment. The aim was to mimic cuffing of the dilated annulus at the level of a valve insertion without any incision or puncture. 2 / ULTRASONIC CHIVA consists in closing short segments of a saphenous trunk or of a tributary by using a heating probe transcutaneously. 3 / Ultrasonic ASVAL is performed using CAVITATION. Microbubbles are generated in the blood.They implode and release mechanical energy able to ablate the endothelium of the vessel for a sclero-like effect. Cavitation does not induce a temperature rise, so the skin will not be damaged. 4 / GLOBAL SHRINKAGE of the dilated vein can be achieved. This reduces the refluxing volume,while preserving a draining saphenous trunk.

Low-dose topical recombinant human granulocyte-macrophage colony-stimulating factor (rhu GM-CSF) therapy for chronic venous leg ulcers, 10-year follow-up

The treatment of leg ulcers is an enormous problem worldwide. Chronic venous ulceration affects 1% of the population and often has aprotracted course. Recurrence rate is high, ranging up to 69% in the first year after healing. To determine whether topical application of low-dose topical recombinant human granulocyte-macrophage colony-stimulating factor (rhu GM-CSF) is safe in venous leg ulcer treatment, and whether it accelerates healing rates and reduces recurrence rates. Consecutive patients with chronic venous leg ulcers received topical treatment with low-dose rhu GM-CSF (10 µg/mL 0.9% sodium chloride solution; 1.0-2.3 µg rhu GM-CSF/cm2) in combination with treatment of venous insufficiency. All patients were previously treated with other topical wound remedies for several weeks (median 8weeks) without success. In 119 of 130patients, the wounds healed completely (91.5%). No local or systemic adverse reactions were observed. The mean time to healing was 24weeks (median 14weeks). Median follow-up of the 119patients with healed ulcers was 84months. The recurrence rates were 5.2% after 1year, 18.9% after 4years and 32.0% after 10years. Topical low-dose rhu GM-CSF proved to be safe and highly effective. Healing rates were comparable to those reported in the ESCHAR study (Effects of Surgery and Compression on Healing And Recurrence in venous ulceration) and recurrence rates were the lowest reported in the literature. Topical therapy with rhu GM-CSF can be applied in an outpatient setting and does not require hospitalization.

Specific management of lipodermatosclerosis (sclerotic hypodermitis) in acute and chronic phase.

Lipodermatosclerosis or sclerotic hypodermitis is presented as a complication of venous insufficiency and in particular of post-thrombotic syndrome with a high risk of progression to leg ulcers. However, it has also been described in obese patients without venous insufficiency, and even in the course of various systemic diseases including scleroderma. It most often affects middle-aged women and is usually bilateral, with a typically "inverted champagne bottle" leg appearance. The pathogenic role of venous hypertension explains why compression with bands or stockings is the basis of treatment. In acute phase, which may precede or complicate chronic forms, the pain is so severe that compression is not tolerated. In acute phase, non-steroidal anti-inflammatory drugs, intra-lesional use of triamcinolone, and capsaicin transdermal patches indicated for neuropathic pain have been proposed. In chronic forms, the treatment of superficial venous insufficiency and/or incontinent perforating veins, documented during a Duplex ultrasound scan, is usually proposed, whenever possible. In association with elastic compression, pentoxifylline and colchicine have been used without clear evidence of clinical efficacy. Finally, in the most advanced clinical presentation with the appearance of a sclerotic gaiter associated with ulcerations, surgical treatment with excision-cutaneous grafting associated or not with perforating veins ligation and a fasciotomy may be discussed as a last resort for treatment.