32-year-old Traumatic Arteriovenous Fistula Presenting With Leg Ulcer and High-output Heart Failure.

Traumatic arteriovenous fistula (AVF) is not a common disorder, and dermatological signs and heart failure caused by AVF are rarely reported. We present the case of a 55-year-old woman who was referred for congestive heart failure symptoms. Echocardiography revealed preserved left ventricular ejection fraction. Due to edema of the right leg with a long-standing leg ulcer and palpable femoral thrill, duplex ultrasonography was performed. It showed an AVF between the right superficial femoral artery (SFA) and the right femoral vein (FV). The patient recalled a 32-year-old gunshot injury that was not medically treated. After the diagnosis of AVF she was referred to a surgeon for an AVF ligation, with subsequent resolution of her symptoms. The differential diagnosis of leg ulcer with leg edema should include the possibility of AVF as a cause.

Application of StyleGAN Architecture for Generating Venous Leg Ulcer Images.

Leg ulcers caused by impaired venous blood return are the most typical chronic wound form and have a significant negative impact on the lives of people living with these wounds. Thus, it is important to provide early assessment and appropriate treatment of the wounds to promote their healing in the normal trajectory. Gathering quality wound data is an important component of good clinical care, enabling monitoring of healing progress. This data can also be useful to train machine learning algorithms with a view to predicting healing. Unfortunately, a high volume of good-quality data is needed to create datasets of suitable volume from people with wounds. In order to improve the process of gathering venous leg ulcer (VLU) data we propose the generative adversarial network based on StyleGAN architecture to synthesize new images from original samples. We utilized a dataset that was manually collected as part of a longitudinal observational study of VLUs and successfully synthesized new samples. These synthesized samples were validated by two clinicians. In future work, we plan to further process these new samples to train a fully automated neural network for ulcer segmentation.

Microcirculatory Flux and Pulsatility in Arterial Leg Ulcers is Increased by Intermittent Neuromuscular Electrostimulation of the Common Peroneal Nerve.

BACKGROUND: Neuromuscular electrical stimulator (NMES) devices increase blood flow to the lower limb by a process of intermittent muscular contraction initiated by a transdermal stimulus to the common peroneal nerve. However, its effects on localized microvascular blood supply to lower limb wounds are unknown. This study is a single-center open label study measuring the effect of neuromuscular stimulation of the common peroneal nerve on the microvascular blood flow within the wound bed of arterial leg ulcers. METHODS: Eights patients with ischemic lower limb wounds had an NMES (geko™) applied to the common peroneal nerve. Baseline and intervention analysis of blood flow to the wound bed and edge was performed using Laser Speckle Contrast Imaging. Mean flow (flux) and pulse amplitude (pulsatility) were measured. RESULTS: Stimulation of the common peroneal nerve with the NMES resulted in a significantly increased flux and pulsatility in both the wound bed and the wound edge in all 8 patients. CONCLUSIONS: Neuromuscular electrical stimulation immediately increases microcirculatory blood flow to the wound bed and edge in patients with ischemic lower limb wounds. These data may provide mechanistic insight into the clinical efficacy of NMES in healing wounds. www.clinicaltrials.gov NCT03186560.

Diagnostic Accuracy of Point-of-Care Fluorescence Imaging for the Detection of Bacterial Burden in Wounds: Results from the 350-Patient Fluorescence Imaging Assessment and Guidance Trial.

Objective: High bacterial load contributes to chronicity of wounds and is diagnosed based on assessment of clinical signs and symptoms (CSS) of infection, but these characteristics are poor predictors of bacterial burden. Point-of-care fluorescence imaging (FL) MolecuLight i:X can improve identification of wounds with high bacterial burden (>104 colony-forming unit [CFU]/g). FL detects bacteria, whether planktonic or in biofilm, but does not distinguish between the two. In this study, diagnostic accuracy of FL was compared to CSS during routine wound assessment. Postassessment, clinicians were surveyed to assess impact of FL on treatment plan. Approach: A prospective multicenter controlled study was conducted by 20 study clinicians from 14 outpatient advanced wound care centers across the United States. Wounds underwent assessment for CSS followed by FL. Biopsies were collected to confirm total bacterial load. Three hundred fifty patients completed the study (138 diabetic foot ulcers, 106 venous leg ulcers, 60 surgical sites, 22 pressure ulcers, and 24 others). Results: Around 287/350 wounds (82%) had bacterial loads >104 CFU/g, and CSS missed detection of 85% of these wounds. FL significantly increased detection of bacteria (>104 CFU/g) by fourfold, and this was consistent across wound types (p < 0.001). Specificity of CSS+FL remained comparably high to CSS (p = 1.0). FL information modified treatment plans (69% of wounds), influenced wound bed preparation (85%), and improved overall patient care (90%) as reported by study clinicians. Innovation: This novel noncontact, handheld FL device provides immediate, objective information on presence, location, and load of bacteria at point of care. Conclusion: Use of FL facilitates adherence to clinical guidelines recommending prompt detection and removal of bacterial burden to reduce wound infection and facilitate healing.

Wound Size Imaging: Ready for Smart Assessment and Monitoring.

Significance: We introduce and evaluate emerging devices and modalities for wound size imaging and also promising image processing tools for smart wound assessment and monitoring. Recent Advances: Some commercial devices are available for optical wound assessment but with limited possibilities compared to the power of multimodal imaging. With new low-cost devices and machine learning, wound assessment has become more robust and accurate. Wound size imaging not only provides area and volume but also the proportion of each tissue on the wound bed. Near-infrared and thermal spectral bands also enhance the classical visual assessment. Critical Issues: The ability to embed advanced imaging technology in portable devices such as smartphones and tablets with tissue analysis software tools will significantly improve wound care. As wound care and measurement are performed by nurses, the equipment needs to remain user-friendly, enable quick measurements, provide advanced monitoring, and be connected to the patient data management system. Future Directions: Combining several image modalities and machine learning, optical wound assessment will be smart enough to enable real wound monitoring, to provide clinicians with relevant indications to adapt the treatments and to improve healing rates and speed. Sharing the wound care histories of a number of patients on databases and through telemedicine practice could induce a better knowledge of the healing process and thus a better efficiency when the recorded clinical experience has been converted into knowledge through deep learning.

Use of a bacterial fluorescence imaging system to target wound debridement and accelerate healing: a pilot study.

OBJECTIVE: Optimal wound-bed preparation consists of regular debridement to remove devitalised tissues, reduce bacterial load, and to establish an environment that promotes healing. However, lack of diagnostic information at point-of-care limits effectiveness of debridement. METHOD: This observational case series investigated use of point-of-care fluorescence imaging to detect bacteria (loads >104CFU/g) and guide wound bed preparation. Lower extremity hard-to-heal wounds were imaged over a 12-week period for bacterial fluorescence and wound area. RESULTS: A total of 11 wounds were included in the study. Bacterial fluorescence was present in 10 wounds and persisted, on average, for 3.7 weeks over the course of the study. The presence of red or cyan fluorescent signatures from bacteria correlated with an average increase in wound area of 6.5% per week, indicating stalled or delayed wound healing. Fluorescence imaging information assisted in determining the location and extent of wound debridement, and the selection of dressings and/or antimicrobials. Elimination of bacterial fluorescence signature with targeted debridement and other treatments correlated with an average reduction in wound area of 27.7% per week (p<0.05), indicative of a healing trajectory. CONCLUSION: These results demonstrate that use of fluorescence imaging as part of routine wound care enhances assessment and treatment selection, thus facilitating improved wound healing.

Real-time bacterial fluorescence imaging accurately identifies wounds with moderate-to-heavy bacterial burden.

OBJECTIVE: Clinical evaluation of signs and symptoms (CSS) of infection is imperative to the diagnostic process. However, patients with heavily colonised and infected wounds are often asymptomatic, leading to poor diagnostic accuracy. Point-of-care fluorescence imaging rapidly provides information on the presence and location of bacteria. This clinical trial (#NCT03540004) aimed to evaluate diagnostic accuracy when bacterial fluorescence imaging was used in combination with CSS for identifying wounds with moderate-to-heavy bacterial loads. METHODS: Wounds were assessed by study clinicians using NERDS and STONEES CSS criteria to determine the presence or absence of moderate-to-heavy bacterial loads, after which the clinician prescribed and reported a detailed treatment plan. Only then were fluorescence images of the wound acquired, bacterial fluorescence determined to be present or absent and treatment plan adjusted if necessary. RESULTS: We examined 17 VLUs/2 DFUs. Compared with CSS alone, use of bacterial fluorescence imaging in combination with CSS significantly improved sensitivity (22% versus 72%) and accuracy (26% versus 74%) for identifying wounds with moderate-to-heavy bacterial loads (≥104 CFU/g, p=0.002). Clinicians reported added value of fluorescence images in >90% of study wounds, including identification of wounds incorrectly diagnosed by CSS (47% of study wounds) and treatment plan modifications guided by fluorescence (73% of study wounds). Modifications included image-guided cleaning, treatment selection, debridement and antimicrobial stewardship. CONCLUSION: Findings from this pilot study suggest that when used in combination with CSS, bacterial fluorescence may: (1) improve the diagnostic accuracy of identifying patients with wounds containing moderate-to-heavy bacterial loads and (2) guide more timely and appropriate treatment decisions at the point-of-care.

Interim Results of the PROMISE I Trial to Investigate the LimFlow System of Percutaneous Deep Vein Arterialization for the Treatment of Critical Limb Ischemia.

OBJECTIVE: To investigate the feasibility, safety, and effectiveness of the LimFlow stent-graft system in performing percutaneous deep vein arterialization (pDVA) for treatment of critical limb ischemia (CLI) patients ineligible for conventional endovascular or surgical revascularization procedures. METHODS: Ten no-option CLI patients (mean age, 67 ± 11 years; 30% women) were enrolled. All patients were classified as Rutherford class 5 or 6 and were deemed by a committee of experts to be ineligible for endovascular or surgical procedures to restore blood flow. Eighty percent were categorized as stage 4 (high risk of amputation) based on Society for Vascular Surgery wound, ischemia, and foot infection (SVS WIfI) scoring index. The primary safety endpoint was amputation-free survival (AFS) at 30 days. A secondary safety endpoint evaluated AFS at 6 months. Other secondary endpoints included primary patency, wound healing, and technical success. RESULTS: Amputation-free survival was achieved in 100% of patients, with no deaths or index limb above-ankle amputations observed at 30 days and 6 months. Technical success rate was 100%. No procedural complications were reported. Primary patency rates at 1 month and 6 months were 90% and 40%, respectively, with reintervention performed in 30% of patients. By 6 months, 30% of patients experienced complete (100%) wound healing, half of patients had 84%-93% wound healing, and 20% of patients experienced 60% healing. CONCLUSION: pDVA using the LimFlow system is a novel approach for treating patients with no-option CLI and may reduce amputation in this population for whom it would otherwise be considered inevitable. Initial findings from this early feasibility trial are promising and additional study is warranted.

Dynamic Optical Coherence Tomography Is a New Technique for Imaging Skin Around Lower Extremity Wounds.

Chronic wounds such as venous leg ulcers invariably heal slowly and recur. In the case of venous leg ulcers, poor healing of chronic wounds is variously attributed to ambulatory hypertension, impaired perfusion and diffusion, presence of chronic inflammation at wound sites, lipodermatosclerosis, and senescence. The aim of this study was to investigate whether a new technique, optical coherence tomography (OCT), which permits imaging of blood capillaries in the peri-wound skin, can provide new insights into the pathology. OCT and its recent variant, dynamic OCT, permit rapid noninvasive depth-resolved imaging of the capillaries in the superficial dermis via a handheld probe, showing the morphology and density of vessels down to 20 µm in diameter. We used dynamic OCT to investigate 15 chronic wounds and assess characteristics of the vessels at the 4 poles around the wounds, the wound bed, adjacent dermatosclerosis, and unaffected skin. The results of the study show that both vessel morphology and density in the wound edges are dramatically different from that in healthy skin, showing clusters of glomuleri-like vessels (knot-like forms or clumps) and an absence of linear branching vessels, and also greater blood perfusion. Such vessel shapes are reported to be associated with tissue growth. The OCT imaging procedure was rapid and well tolerated by patients and provided new information not available from other devices. Thus, OCT appears to have great promise as a tool for the evaluation and study of chronic ulcers.

Retrograde administration of ultrasound-guided endovenous microfoam chemical ablation for the treatment of superficial venous insufficiency.

OBJECTIVE: This study measured patient outcomes among symptomatic patients with superficial chronic venous insufficiency who were treated with retrograde ultrasound-guided polidocanol microfoam 1% in a community setting. METHODS: Between March 2015 and June 2017, 250 symptomatic patients with C2-C6 chronic venous insufficiency received polidocanol microfoam 1% and were followed for 16 ± 7 months. Sixteen of the 250 patients (6.4%) had skin ulcers, and 56 (22.4%) were treated previously with thermal or surgical interventions. All patients underwent a duplex ultrasound venous incompetence study to map perforators and veins to be treated. Incompetent veins were accessed with a micropuncture needle distal to the midthigh perforator, approximately 10 cm above the knee fold. The leg was then elevated 45°. Under ultrasound guidance, the incompetent greater saphenous vein was closed with polidocanol microfoam 1%. A second injection was administered through the same catheter directing the microfoam to flow in a retrograde fashion through the incompetent venous valves to the ankle. RESULTS: All patients completed the initial treatment; 55 (22.0%) required planned secondary treatment during the follow-up period for residual venous reflux in the below-knee greater saphenous vein. Complete elimination of venous valvular reflux and symptom improvement was documented in 236 patients (94.4%). Minor adverse events included asymptomatic deep vein thrombi (n = 2), common femoral vein thrombus extension (n = 1), and superficial venous thrombi (n = 4). Of the 16 patients with skin ulcers, 10 were C6 patients and 80% experienced wound closure within 4 weeks of treatment. CONCLUSIONS: Retrograde administration of polidocanol microfoam 1% is a safe and effective treatment with important clinical benefit for superficial venous insufficiency in community practice.

Hyperspectral imaging of tissue perfusion and oxygenation in wounds: assessing the impact of a micro capillary dressing.

OBJECTIVE: Experimental tests of non-invasive multi- or hyperspectral imaging (HSI) systems reveal the high potential of support for medical diagnostic purposes and scientific biomedical analysis. Until now the use of HSI technologies for medical applications was limited by complex and overly sophisticated systems. We present a new and compact HSI-camera that could be used in normal clinical practice. METHOD: We assessed the use of the HSI system on the hands of 10 healthy volunteers, looking at control parameters, and those following venous occlusion, arterial occlusion and reperfusion, including tissue oxygenation, tissue haemoglobin index, perfusion in 4-6mm depth=near infrared spectroscopy (NIR), and tissue water index. Pseudo colours used ranged from 0% (blue) to 100% (red). We also assessed differences in the wounds of three patients. RESULTS: The results show good potential in all parameters in the healthy volunteers, which had high conformity with validated reference oximetry measurements. In three wounds, different levels of oxygenation were identified in the wound area, although interpretation of these results is complex. In Cases 2 and 3, following the application of a micro capillary dressing, improvements were seen in perfusion and reduction of the tissue water index (TWI). CONCLUSION: The camera system proved to be quick, flexible and yielded data with high spatial and spectral resolution. These data will be used to perform a power analysis for a randomised controlled study.

Diagnostic and Therapeutic Ultrasound on Venous and Arterial Ulcers: A Focused Review.

GENERAL PURPOSE: To provide information about the use of ultrasound for diagnostic and therapeutic treatment of venous and arterial ulcers. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After completing this continuing education activity, you should be able to: ABSTRACT: To review the diagnostic and therapeutic use of ultrasound on venous and arterial ulcers. METHODS: PubMed was searched for peer-reviewed articles using the search terms "ultrasound for venous ulcers" and "ultrasound for arterial ulcers." The search yielded 282 articles on ultrasound for venous ulcers and 455 articles for ultrasound on arterial ulcers. Data from 36 articles were selected and included after abstract review. RESULTS: Ultrasound is an established diagnostic modality for venous and arterial disease and is indicated for wound debridement. Recent evidence continues to support its superiority over standard of care in healing venous ulcers, but findings conflict in terms of the effectiveness of low-frequency ultrasound over high-frequency ultrasound. There are currently no standardized treatment protocols for ultrasound. CONCLUSIONS: Diagnostic ultrasound is used to assess venous and arterial disease and guide appropriate treatment for ulcers. Therapeutic low-frequency ultrasound is used to debride the wound bed, as an adjunctive topical wound treatment with standard of care, and to guide the application of other advanced therapies to chronic wounds. Better trial designs and consistent data are needed to support the effectiveness of ultrasound therapy on venous and arterial ulcers.

ANALYSIS OF TISSUE OXYGENATION IN CHRONIC LEG ULCERS BY COMBINATION OF A MULTI-SPECTRAL CAMERA AND A HYPER-SPECTRAL PROBE.

Objective evaluation of chronic wounds, such as leg ulcers, by the use of non-invasive techniques is of importance for diagnosis, monitoring treatment response, and probably leads to improved treatment strategies. We performed a feasibility study for the combined use of a multi-spectral camera and a hyper-spectral probe to evaluate chronic leg ulcers with a focus on tissue oxygenation. Sixty patients - 40 females and 20 males were enrolled in the study. The age range was 46 to 85 years for males (mean 65.8 years, median 73.0 years) and 51 to 91 years for females (mean 74.4 years, median 77.0 years). Measurements were performed by hyper-spectral wound (HySkinII) probe and multi-spectral (DeMuk) camera on wounds and surrounding skin. The investigation results demonstrate a high variability of oxygenation within ulcers and the surrounding tissue. The methods allow an investigator to independently assess of tissue oxygenation in superficial and deeper layers. Non-invasive multi- and hyper-spectral imaging techniques offer new opportunities of an objective assessment of chronic wounds.

Three-dimensional digital imaging is as accurate and reliable to measure leg ulcer area as transparent tracing with digital planimetry.

OBJECTIVE: An accurate and reliable method for measuring venous leg ulcer (VLU) area is important in assessing treatment effects. The new three-dimensional (3D) LifeViz digital imaging system (QuantifiCare S.A., Valbonne, France) combines a compact, easy to use stereovision camera and image management software to provide 3D medical images. The aim of this prospective study was to investigate whether the 3D LifeViz digital imaging system could be considered a suitable alternative to manual transparent wound tracing for the measurement of VLU area and 4-week healing rates. METHODS: A prospective cohort study was conducted in two tertiary centers between November 2013 and January 2014. The intrarater variability of the digital imaging system was assessed by comparison of the target wound (TW) areas obtained at the inclusion visit (W0) and 2 days after W0 for each local rater. The inter-rater variability of the two methods at W0 and the study end visit was assessed using the TW area measurements obtained by local and central raters. RESULTS: A total of 36 consecutive outpatients, each presenting with at least one VLU and representing a total of 44 TWs, were recruited. At inclusion, comparable results were observed with both methods in terms of mean VLU area, showing a good correlation of the digital imaging method with the transparent tracing method (concordance correlation coefficient [CCC], 0.989; 95% confidence interval [C], 0.983-0.992). Furthermore, this system detected the same changes in the 4-week healing rate as the transparent tracing method, showing that both methods were equivalent in measuring changes in VLU areas over time (CCC, 0.996; 95% CI, 0.994-0.997). Strong intrarater and inter-rater concordances demonstrated good reproducibility of the digital imaging system for VLU area measurements (CCC, 0.994 [95% CI, 0.992-0.995] for intrarater variability; and CCC ≥0.99 for each center for inter-rater variability). Moreover, regardless of the operator measuring the VLUs, the reliability of image capture and image quality remained excellent. CONCLUSIONS: The 3D LifeViz digital imaging system is a noncontact stereophotographic method that provides measurements of VLU area or changes in VLU areas that are as accurate and reliable as those obtained using the planimetry method and in conditions as close as possible to those of a clinical trial.

Dermoscopic Features of Basal Cell Carcinoma on the Lower Limbs: A Chameleon!

BACKGROUND: Lower limbs represent an uncommon location for basal cell carcinoma (BCC) and only few reports have described dermoscopic features of BCC in this body site. Since BCCs of the lower limbs frequently display nonclassic BCC dermoscopic criteria, they can simulate other benign or malignant lesions. OBJECTIVE: Our aim was to describe the dermoscopic features of BCC located on lower limbs and to define which criteria were more associated with their benign- or malignant-looking appearance. METHODS: We conducted a retrospective study enrolling consecutive patients with histologically confirmed BCCs of the lower limbs. Lesions were classified in 7 categories according to the clinical and dermoscopic global appearance. Clear BCC, squamous cell carcinoma (SCC) or Bowen disease-like, Kaposi disease-like, melanoma-like, and aspecific pattern were considered malignant-looking lesions; however, seborrheic keratosis-like and dermatofibroma-like were considered benign-looking. To define which dermoscopic criteria were independently associated with benign- or malignant-looking appearance, we conducted a multivariate logistic regression analysis. RESULTS: A total of 81 BCCs were enrolled: 18 (22%) were benign-looking lesions (of which 11 were seborrheic keratosis-like and 7 dermatofibroma-like) and 63 (78%) were malignant-looking BCCs (of which 24 were clear-cut BCCs, 23 SCC-like, 2 Kaposi disease-like, 9 melanoma-like, and 5 had aspecific pattern). Multivariate regression analysis showed that erosions/ulceration and vessels were independently associated with malignant-looking appearance. The most represented vessels were glomerular and polymorphic, which are more frequently encountered in SCC, together with ulceration. CONCLUSION: BCC of the lower legs frequently simulates other benign or malignant lesions, with SCC being the main differential diagnosis.

Spectral Clustering for Unsupervised Segmentation of Lower Extremity Wound Beds Using Optical Images.

Chronic lower extremity wound is a complicated disease condition of localized injury to skin and its tissues which have plagued many elders worldwide. The ulcer assessment and management is expensive and is burden on health establishment. Currently accurate wound evaluation remains a tedious task as it rely on visual inspection. This paper propose a new method for wound-area detection, using images digitally captured by a hand-held, optical camera. The strategy proposed involves spectral approach for clustering, based on the affinity matrix. The spectral clustering (SC) involves construction of similarity matrix of Laplacian based on Ng-Jorden-Weiss algorithm. Starting with a quadratic method, wound photographs were pre-processed for color homogenization. The first-order statistics filter was then applied to extract spurious regions. The filter was selected based on the performance, evaluated on four quality metrics. Then, the spectral method was used on the filtered images for effective segmentation. The segmented regions were post-processed using morphological operators. The performance of spectral segmentation was confirmed by ground-truth pictures labeled by dermatologists. The SC results were additionally compared with the results of k-means and Fuzzy C-Means (FCM) clustering algorithms. The SC approach on a set of 105 images, effectively delineated targeted wound beds yielding a segmentation accuracy of 86.73 %, positive predictive values of 91.80 %, and a sensitivity of 89.54 %. This approach shows the robustness of tool for ulcer perimeter measurement and healing progression. The article elucidates its potential to be incorporated in patient facing medical systems targeting a rapid clinical assistance.

[Leg ulcers: Should general practitioners hospitalize their patients?]. / Ulcères de jambe: une expertise hospitalière est-elle souhaitable?

OBJECTIVES: Determine whether general practitioners have sufficient expertise in the field of leg ulcers. METHOD: A cross-sectional survey was conducted among 179 general practitioners working in the region Île-de-France to evaluate the implementation of leg ulcer guidelines issued by the Superior Health Authority (HAS) in 2006. Participating physicians were either internship supervisors or practitioners in Paris' 14th district. RESULTS: The first hundred usable answers (response rate 65%) came from 71 internship supervisors and 29 practitioners of Paris' 14th district. Only 40% of the physicians were aware of the guidelines, with no significant difference noted between the two groups. 9/10 practitioners examined less than 10 patients with leg ulcers per year. Physical examinations were done according to the guidelines and a venous Doppler was prescribed in two thirds of the cases. The ankle-brachial pressure index (ABPI) essential to diagnose lower limb arteriopathy was measured for only 10% of the patients. In accordance with the guidelines, compression was by far (73%) considered as the main treatment as compared to dressing (37%), but compression therapy was well prescribed in only one-third of the cases. Despite poor prognosis criteria (characteristic and time course), referral for a specialized opinion was rare. CONCLUSION: Even if they were not always aware of the detailed guidelines, the practitioners applied the main recommendations. Nevertheless, practices could be improved by measuring the ABPI, searching for a diagnosis of arteriopathy, and better prescription of compression therapy. General practitioners should refer patients with leg ulcers to a specialized hospital unit.