Understanding CEAP Classification: Insights from an Italian Survey on Corona Phlebectatica and Recurrent Active Venous Ulcers by Vascular Specialists.

Background and Objectives: The clinical relevance of "corona phlebectatica" and the management of risk factors for recurrence of venous ulcers in patients with chronic venous disease may be variable based on vascular specialists in different geographical areas of Italy. The aim of the present survey is to evaluate the management of patients with chronic venous disease by vascular specialists in different areas of the national territory. In particular, this involves ascertaining the clinical/prognostic relevance attributed to the presence of the "corona phlebectatica" as well as to the management of risk factors related to recurrence of venous ulcers. Materials and Methods: The web-based survey aimed at vascular medicine specialists with particular interest in venous disease. A questionnaire was developed, based on 12 questions, in relation to clinical assessment, risk factor management, and therapy in patients with chronic venous disease. Results: Almost all of the specialists involved actively participated in the survey, declaring that they personally manage chronic venous disease overall. There was a strong agreement in the prognostic consideration attributed to the presence of "corona phlebectatica" and to the management of risk factors for venous ulcer recurrence, regardless of the different geographical areas of interest. Conclusions: Accordingly with the results of this self-assessment survey, the skills and experience of the specialists involved appear to be of a good standard, both in the clinical evaluation and in the management of the progression of chronic venous disease. However, the need to reach more cultural insights into the correlations between chronic venous disease and risk factors correlated with disease progression emerges. Moreover, there was the need for a greater and tighter overall clinical control of a patient with chronic venous disease, also in relation to the presence of comorbidities.

The profile of patients with venous leg ulcers: A systematic review and global perspective.

BACKGROUND: A holistic profile that includes demographic, medical history and wound characteristics of individuals with venous leg ulceration is lacking. Lack of such a profile negatively impacts the ability to develop interventions to improve patient outcomes. OBJECTIVES: To describe the profile of the patient population with venous leg ulceration from published observational (non-interventional) studies and to identify gaps in the knowledge base for future research in this area. METHODS: A systematic review of observational studies that included more than 50 patients, from any world region, of any age and in any care setting. RESULTS: twenty studies, involving 3395 patients, from all world regions met our criteria. Demographic characteristics were well reported and showed a female to male ratio of 1.2:1, average age of 47-65 years, high levels of co-morbidities including hypertension (53-71%) and diabetes (16-20%), and only one study reporting ethnicity. When reported, approximately 4-30% had high levels of depression. The average wound size was 18.6-43.39 cm2; mean wound duration was 13.8-65.5 months, mean number of recurrences was four. No study reported on demographic factors plus medical history plus wound characteristics together. CONCLUSION: a comprehensive, holistic profile of the population with VLU is lacking. There is a critical need for more comprehensive profiling to enable the development of targeted interventions to improve outcomes.

Definition and Characteristics of Chronic Tissue Injury: A Unique Form of Skin Damage.

BACKGROUND: The purpose of this article is to examine the evidence related to a unique phenomenon of purple-maroon discoloration of the buttocks found in homecare patients and to recommend a label for this phenomenon. CASES: Initially, we searched the literature to identify and retrieve any evidence related to this unique form of purple-maroon discoloration of the buttocks. No evidence was found. To illustrate the condition, we compared 4 cases of what we have labeled chronic tissue injury to 6 patients with purple-maroon discoloration of the buttocks from different causes. CONCLUSION: Chronic tissue injury is characterized by a persistent purple-maroon discoloration located on the fleshy portion of the buttocks that does not improve or deteriorate. Unlike other causes of purple discoloration such as deep tissue pressure injury, there is minimal change in the discoloration over time. Additional research is needed to further our understanding of the histopathology of this phenomenon.

Validation of inpatient international classification of disease ninth revision codes as predictors of venous leg ulcers.

Venous leg ulcers (VLU) comprise about 70% of lower leg wounds and cost more than 14 billion USD per year. Patients with VLU are often admitted to the hospital; however, epidemiological study of this important patient subset is challenged by lack of validated database search protocol. Five International Classification of Diseases (ICD) 9 codes were identified for their relationship with VLUs (454.0, 454.2, 459.11, 707.9, and 707.10). The ICD9 code was considered to successfully predict a VLU if the wound was located in the gaiter area and had either relevant clinical findings, a positive venous study, and/or a diagnosis of VLU written in the physician note. The code 454.0, when combined with length of admission and subjects' age, yielded high specificity (100%) and positive predictive value (100%), sacrificing sensitivity (34.4%). This formula represents a viable search criterion to identify VLU patients in large-scale datasets to examine patients' outcomes, costs, and comorbidities.

[A standard data set for the evaluation of venous leg ulcers in selective contracts : National consensus]. / Standarddatensatz für die Evaluation bei Selektivverträgen bei Ulcus cruris : Nationaler Konsensus.

BACKGROUND: Selective agreements are becoming increasingly important in health care management. To date, no standard recommendations for the evaluation of selective contracts are available. OBJECTIVES: Against this background, a recommendation on the evaluation of selective contracts in patients with leg ulcers (LU) was developed and approved by the nationwide consensus conference. MATERIALS AND METHODS: Based on a systematic literature review and followed by a manual search through other possible evaluation indicators in the care of patients with LU, a Delphi-based consensus process was performed by various scientific societies, professional associations, insurances and supply networks. RESULTS: For the evaluation of efficiency and quality of care, a recommendation on the evaluation of selective agreements with patients with LU was consented in six meetings and in five multistage online surveys. In total, 44 evaluation indicators were identified in the quality subareas structure, process, and outcome. The outcome indicators are divided into clinical, patient-related, and cost-related indicators. CONCLUSIONS: The developed evaluation indicators represent the quality of care in patients with LU. The indicators can be applied individually, depending on the agreed contract-specific supply target. After implementation of this national standard, the comparability of selective agreements in the management of patients with LU can be ensured and consolidated.

Clinical Characteristics of Mixed Arteriovenous Leg Ulcers: A Descriptive Study.

PURPOSE: The purpose of this study was to identify the clinical characteristics of mixed arteriovenous leg ulcers (MLU) that differentiated them from venous leg ulcers (VLU). DESIGN: Secondary analysis of data from larger electronic database. SUBJECTS AND SETTING: The sample comprised 1007 persons with lower extremity ulcers. Two hundred sixty three individuals with MLU were compared to 744 individuals with VLU; their ankle brachial indices were 0.51-0.90 and 0.91-.30 respectively. Subjects were drawn from community care settings from across Canada. METHODS: Data concerning baseline demographic and pertinent clinical characteristics including ulcer history were collected using multiple validated instruments. The Leg Ulcer Assessment Tool was used to collect demographic and pertinent medical history, The Short Form Health Survey 12 and the Euro Wuol 5D (EQ-5D) were used to measure health related quality of life, the numeric pain scales was used to measure character and intensity of pain. Groups were compared using χ or Mann-Whitney U. RESULTS: Individuals with MLU were significantly older, has lower body mass index, a history of smoking, and more comorbid conditions than subjects with VLU. In many cases, clinical presentation was indicative of significant arterial insufficiency including cool extremities, shiny, cracked and inelastic skin, impaired capillary refill, and weak pedal pulses. Ulcer pain was highly prevalent, but overall pain rating was similar between groups. Mixed arteriovenous leg ulcers were associated with lower health related quality of life, greater mobility impairments, and more deficits in self-care and usual activities. CONCLUSION: Greater knowledge and understanding of the distinct characteristics of MLU is critical for appropriate screening, prevention, assessment and management of persons with this form of leg ulcer. Pain and health related quality of life factors are important considerations when evaluating and managing these patients.

[Etiology, nomenclature and pathophysiology of chronic venous insufficiency]. / Ätiologie, Nomenklatur und Pathophysiologie der chronisch venösen Insuffizienz.

This article presents current notions and conceptions of the aetiopathogenesis of primary varicosis and chronic venous insufficiency, as well as an updated version of the nomenclature and terminology of venous disorders, which was recently agreed on in an international consensus conference. Furthermore, both CEAP-classification and venous severity score system are discussed.

The wound/burn guidelines - 5: Guidelines for the management of lower leg ulcers/varicose veins.

Varicose veins are treated at multiple clinical departments, but as patients often visit the dermatology clinic first due to leg ulcers, the present Guidelines for the Management of Lower Leg Ulcers/Varicose Veins were prepared in consideration of the importance of the dermatologist's role. Also, the disease concept of chronic venous insufficiency or chronic venous disorders and the CEAP classification of these disorders are presented. The objective of the present guidelines is to properly guide the diagnosis and treatment of lower leg ulcers/varicose veins by systematically presenting evidence-based recommendations that support clinical decisions.

Tratamiento de la úlcera venosa con escleroespuma frente a un método convencional. Ensayo clínico, prospectivo y aleatorizado / Venous ulcer treatment with sclerofoam versus a conventional treatment: randomized prospective clinical trial

INTRODUCCIÓN: Las úlceras venosas (UV) son las úlceras más frecuentes de la extremidad inferior, ellas generan alta morbilidad con importantes costos para los sistemas de salud. OBJETIVO: Determinar el porcentaje de curación de UV mediante un tratamiento convencional frente al mismo tratamiento más oclusión venosa endoluminal con escleroespuma ecoguiada. MATERIAL Y MÉTODOS: Ensayo clínico prospectivo y aleatorizado, realizado en la consulta externa de cirugía vascular del Hospital Occidente de Kennedy-Bogotá, entre los años 2011 y 2012. Se incluye a 44 pacientes mayores de 18 años, portadores de una UV e índice tobillo-brazo mayor a 0,8. Se analizaron en total 48 extremidades. Los pacientes fueron aleatorizados en 2 grupos: a) control (cura local húmeda más vendaje no compresivo) y b) ensayo: al tratamiento del grupo control se asocia inyección de escleroespuma (técnica de Tessari) en el sistema venoso superficial insuficiente, guiado por ecodoppler. Se realizaron controles a las 3, 8, 12 y 24 semanas. RESULTADOS: Al final del seguimiento (24 semanas), la curación de UV fue del 83,3% (20 extremidades) en el grupo de oclusión endoluminal con espuma ecoguiada frente al 12,5% (3 extremidades) del grupo control o convencional (p = 0,0005). No se observaron complicaciones mayores, derivadas de los tratamientos, en ningún grupo. CONCLUSIÓN: La oclusión endoluminal venosa con escleroespuma ecoguiada es segura y efectiva. Las tasas de curación de UV con esta técnica, mínimamente invasiva, son superiores a las del tratamiento conservador con curas húmedas y vendaje no compresivo

INTRODUCTION: Venous ulcers (VU) are the most common ulcers of the lower limb. It has a high morbidity and is a financial strain on the health system. OBJECTIVE: The aim of this study was to determine the rate of healing VU with a conventional treatment versus the use of conventional treatment plus ultrasound-guided foam endoluminal occlusion. MATERIAL AND METHODS: A prospective randomized clinical trial was conducted on patients attending the Vascular Surgery clinics in the Hospital Occidente de Kennedy-Bogotá during 2011-2012. A total of 44 patients age 18 years and over, with venous insufficiency, VU, and an ankle-brachial index greater than 0.8, were included. A total of 48 extremities were analyzed in the two groups; one group a) Control: (conventional treatment with non-compressive bandages, vaseline gauze, and wound care) and b) Study group: control treatment plus endoluminal occlusion with ultrasound-guided foam in the superficial venous system by Tessari method using 1% lapidium hydrochloride (sklerol). Follow-up was carried out at week 3, 8, 12 and 24. RESULTS: The healing rate of the ulcer at week 24 was 20 (83.3%) extremities healed by the endoluminal occlusion with ultrasound-guided foam group vs. 3 (12.5%) extremities healed in the group using the conventional treatment (P=.0005). No major complications arising from treatment were observed in either group. CONCLUSION: The healing rates of the VU after endoluminal occlusion with ultrasound-guided foam is safe and effective. This minimally invasive technique is far superior to conventional treatment with non-compressive bandages, vaseline gauze, and wound care, exclusively. Registration number of this study: NCT01594658 in clinical trials

Tissue destruction classification systems.

Assessing the level of tissue destruction in wounds can be a confusing challenge. This important task is frequently accompanied by questions and the need for clarification to accurately classify the level of damage seen in wounds. The purpose of this article was to present several known classification systems to help clarify this issue for the clinician.

Is endovenous laser ablation possible while taking warfarin?

PURPOSE: The subgroup of patients with venous ulcers requiring anticoagulation for co-morbid conditions has traditionally created a therapeutic dilemma. Perioperative management of anticoagulation can be costly and increase the risk of surgical complications. This group of patients is often elderly and shows poor compliance with compression hosiery. The aim of this study was to investigate the outcome of endovenous laser ablation (EVLA) of the great saphenous vein (GSV) in patients remaining on therapeutic anticoagulation. MATERIALS AND METHODS: Fifteen consecutive patients (CEAP [clinical, aetiological, anatomical and pathological elements] classification 5 or 6) were treated with standard GSV EVLA using tumescent anaesthesia and a diode 1470-nm radial laser fibre while maintaining international normalized ratio at therapeutic levels. Clinical and duplex follow-up at six weeks and three, six and 12 months were performed. RESULTS: The GSV was successfully occluded in 14/15 (93%) of patients. The remaining patient had a second successful treatment three months later. No significant complications requiring intervention were encountered. CONCLUSION: EVLA using the diode 1470-nm radial fibre is efficacious with minimal complications in patients therapeutically anticoagulated. This treatment should be added to the armamentarium in this problematic patient group.

Superficial vein ablation for the treatment of primary chronic venous ulcers.

OBJECTIVE: This retrospective study was undertaken to review our experience with ablation of superficial veins with significant reflux, using VNUS ClosureFAST RF (radiofrequency) or laser 980 nm, in patients with primary chronic venous ulcers, and also determine its effects in ulcer healing and ulcer recurrence. METHOD: Included were 25 limbs (18 patients with chronic primary venous ulcers (clinical, aetiological, anatomical and pathological elements [CEAP] classification C6), who underwent endovenous ablation with RF for the axial veins or laser for the perforating veins during a two-year period. RESULTS: Of the 18 patients, there were eight men and 10 women. The median age of the group was 68 (range 37-89) years. The number of ablations done in each leg with an ulcer varied from one to eight, with a median of three. During a follow-up period of 6-12 months, one patient failed ulcer healing despite sequential ablations of refluxing veins. There was one case that developed recurrence of a small ulcer after six months and was successfully treated with a perforator ablation. CONCLUSION: Endovenous ablation of incompetent superficial veins improves the healing of chronic primary venous ulcers and decreases the recurrence rates.

[Complex management of lower extremity venous ulcers in elderly patients].

In this article we summarize our experience of combined treatment policy used in 213 patients with venous ulcers. The majority of patients (162 persons, 76%) was of elderly age. After preoperative conservative preparation of ulcers, 140 patients were subsequently operated. In elderly patients with many comorbidities and marked indurative lipodermatosclerosis a single-step operation may not be reasonable or technically feasible. 86 patients (57.7%) from the above-mentioned group were operated in 2 (or more) stages. Minimally invasive operative interventions were performed under local anesthesia at the first stage with the aim of eliminating vertical venous refluxes into superficial varicose veins. In delayed period (after 2-6 months) patients underwent operative ligation, endovenous laser coagulation or ultrasound-guided sclerotherapy of incompetent perforating veins. Data obtained from our experience reflect the safety and high effectiveness of staged combined management using minimally invasive operations under local anesthesia, endovenous laser ablation and microfoam sclerotherapy in prevention of embolic complications in patients with trophic ulcers.