Management of Lower Limb Ulcers - Pharmac€¦ · Varicose veins Deep venous thrombosis Claudication Rest pain Diabetes Injury Arthritis History Oedema Surrounding skin Site Pain

Management of Lower Limb Ulcers

D. NAIK MBChB FRACS DDU

A defect in the epithelium

Ulcer

A failure to heal

Ulcer

Venous insufficiency Macrovascular arterial insufficiency Infectious conditions Vasculitis/Microvascular insufficiency Malignancy Excessive pressure Lymphoedema Collagen vascular disorders Haemotologic abnormalities

D Naik MBchB FRACS DDU [Vascular]

Aetiology of Leg Ulcers

Gaiter area

Mild pain

Venous ooze

Shallow,irregular shape,round edges

Granulating base

Surrounding inflammation

Stasis dermatitis


Venous Ulcers


Atherosclerosis

Posttraumatic

Embolic

Acute or chronic thrombosis

Macrovascular arterial

Occur distally and over bony prominences Severe pain Little or no bleeding Irregular edge Poor granulation tissue Absent surrounding inflammation Trophic changes Absent pulses and low ABI


Ischaemic Ulcers

Diabetes microangiopathy

Hypertensive microangiopathy

Thromboangitis obliterans

Raynauds disorder

Vasculitis/Microvascular arterial insufficiency

Bacterial

Fungal

Mycobacterial

Treponemal/spirochaetal

Infectious conditions

Basal cell carcinoma

Squamous cell carcinoma

Malignant melanoma

Kaposi’s sarcoma

Lymphoma

Mycosis fungoides

Malignancy

Marjolin’s ulcer

Venolymphatic disease

Primary or secondary lymphatic insufficiency

Lymphangiosarcoma

Lymphatic obstruction /lymphoedema

Sickle cell anaemia

Polycythaemia

Dysproteinaemia

Haemotologic abnormalities

SLE

Scleroderma

Polyarteritis nodosa

Wegeners granulomatosis

Collagen vascular disorders

Diabetic neuropathy

Alcoholic neuropathy

Decubitus ulcer

Postoperative deformity

Bone spurs

Excessive pressure

Under calluses or pressure points

Painless

Bleeding maybe brisk

Punched out,with deep sinus

Surrounding inflammation

Demonstrable neuropathy


Neuropathic Ulcers


History

Physical examination

Ankle brachial index

Blood tests

Xrays

Vascular investigations

Biopsy

Management of the underlying condition

Management of ulcers

Varicose veins

Deep venous thrombosis

Claudication

Rest pain

Diabetes

Injury

Arthritis

History

Oedema

Surrounding skin

Site

Pain

Ulcer

Pulses

Stigmata of venous disease

Doppler indices


Clinical Examination

Bleeding

Eczema

Superficial thrombophlebitis

Ulceration

Deep vein thrombosis


Complications

0.06 and 1%

Rising prevalence in elderly

Peak prevalence age 70 years

F:M ratio 3:1


Epidemiology of Venous Ulcers

Venous insufficiency

Previous DVT

Chronic skin changes

Local trauma

Aggravation by co-existing conditions


Risk factors for Venous Ulceration

Macrovascular Changes

Ambulatory venous hypertension

Pericapillary fibrin deposition

Localised microvascular ischaemia

White cell adhaerence

White cell activation

Activity of inflammatory mediators


Microvascular Changes

General measures

Adjuvant pharmacotherapy

Compression

Dressings

Sclerotherapy

Endovenous interventions

Surgery


Management of Venous Ulcers

Address needs of the patient as a whole

Consider lifestyle,mobility,occupation,nutrition

Elevation of legs

Prop bed up by 10-15%


Management-General Measures

Choice is a matter of clinical judgement

Insufficient clinical trials to allow recommendation


Management - Dressings

Reduce ulcer pain

Allow excess exudate to escape

Be non-allergenic

Easy to change without discomfort

Leave no dressing residue

Inexpensive

Easy to apply


The Ideal Dressing

Ambulant patients need bandages or stockings

20-30 mm Hg at ankle

Graduated

Sustained compression


Management-Compression

Gradient of pressure Even pressure over anatomical contours Maintains pressure Remains in position Complements dressing functions Non-irritant and non-allergenic Comfortable Washable


Ideal Compression Bandaging System

Only in addition to compression Agents include :fibrinolytic agents fibrinolysis-enhancing hydroxyrutosides pentoxifylline prostaglandin E systemic antibiotics diuretics


Management- Adjuvant Pharmacotherapy

50-70% of venous ulceration is secondary to primary varicose veins and is curable with relatively simple venous interventions


Venous Ulceration



Disease of Western civilisation

10-20% men and 67% of adult women have physically identifiable varicosities

Varicose veins range from venectasia or telangiectasia to protuberant tortuous varicosities


Epidemiology

Great Saphenous

Small Saphenous

Perforator veins


Primary Varicose Veins

A-V fistula

Deep venous obstruction


Secondary Varicose Veins

Duplex scan

Venography

CT venography


Investigation

Combination of ultrasound and Doppler

Operator dependent

Significantly improved our understanding and management of varicose veins

Relatively cheap and non-invasive

Mandatory prior to any major intervention


Duplex Scanning


Conservative

Sclerotherapy

Non-surgical saphenous ablation

Chemical

Radiofrequency

Laser

Surgery


Management

Weight loss

Exercise

Compression hosiery


Conservative treatment

Simple office procedure

Good results in appropriately selected patients

May buy time

Cheapest option


Local Sclerotherapy

Now the gold standard for varicose vein treatment

Includes UGS and endovenous ablation

Minimally invasive therefore lower threshold for intervention

No general anaesthetic therefore suitable for high risk patients

Day case local procedures

Lower cost

Endovevous intervention

Minimally invasive

Poor results in large axial veins

Good option in selected patients

Systemic effects of sclerosants unknown

May require multiple treatments

Phlebitis and brown staining an issue

Poor long-term results in large axial


Ultrasound Guided Sclerotherapy [UGS]



First described by Bone in 1999 Diode laser forms steam bubbles in blood leading to

endothelial damage,coagulative necrosis and thrombotic occlusion of vein

Requires tumescent anaesthesia Deals with saphenous trunks only Requires adjunctive procedures for varices Early results favourable Day procedure


Endovenous Laser Therapy


First described by Goldman in 2000

Heat generated by radiofrequency probe causes local heating of vein wall

Requires tumescent anaesthesia

Deals with saphenous trunks only

Requires adjunctive procedures for varices

Day procedure


Radiofrequency Ablation

Varicose vein surgery

Valvuloplasty

Venous cuffs

Venous bypass

SSG

Flaps


Management –Surgical Therapy

Excellent results if performed well

Requires anaesthesia,cuts and more recovery

Neovascularisation in less than 7%

Cutaneous nerve injury and leg swelling are issues

Good long-term results

Everything treated in ‘one hit’

Good option in patients with very large varices


Surgery




Complications of Venous Interventions

Complicatio

ns

EVLT RFA SURGERY

Bruising 23-100 20-50 15-100

Pain 6-100 5-100 5-100

Parathesia 0-36 4-20 0-25

Phlebitis 0-12 3-20 0

Haemotom

a

0-5 0-7 0-31

Burns 0-5 0-7 0

Infection 0-3 0-20 2-15

Thrombosis 0-1 0-16 0-5

Femoral

art/vein

injury

0 0 0.02


Management of Varicose Veins

UGS EVLT/RF SURGERY

Invasion + ++ +++

Cost + ++ +++

Discomfort ++ ++ +++

Recovery + + +- +++

Recurrence +++ ?? +


There has been a paradigm shift in the management of

superficial venous insufficiency with most cases treated with an

endovenous approach

Atherosclerosis Emboli Arterial dissection Arteritis Aneurysms Arterial trauma Entrapment syndromes Adventitial cystic disease Vascular tumours


Äetiology of Arterial Occlusive Disease

Affects 12-14% of the general population

Affects upto 20% of patients over 75

Coexistent coronary artery disease and cerebrovascular disease are highly prevalent in patients with PAD


Epidemiology of PAD

Location

Duration

Progress

Distance

Time for relief

Associated rest pain


History

Rest pain Pain felt in the distal forefoot which is exacerbated by

elevation

Arterial palpation

Bruits

Pallor

Rubor

Temperature

Tissue loss

Integumentary changes

ABI


Examination

Duplex scanning

Arteriography

Angioplasty/stent

Vascular reconstruction

Debridement

Skin grafting


Management of Arterial Ulcers

>1 Normal arterial flow

0.9 Mild degree of arterial involvement

0.8 Lowest level at which compression can be safely applied

0.7 Significant arterial disease is present and full compression should not be used

0.5 Limb is at risk and urgent vascular opinion should be sought


Interpreting Doppler Readings

Exercise ABI

Toe pressures

Pressure studies

Duplex scanning

Ultrasound

Doppler

Spectral analysis


Non-invasive Vascular Tests


1.2

1.0

0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

1.1

0.1

0

Rest

Exercis

e Period

0 1 2 3 4 5 Minutes Post

Exercise

ABI Right Leg Left Leg


CT angiography

MR angiography

Digital subtraction angiography


Invasive studies

Smoking

Antiplatelet therapy

Hypertension

Diabetes

Hyperlipidaemia

Statin

Cilastozol,Trental

Exercise


Best Medical Therapy

We favour an endovascular first policy

Our Approach

Angioplasty

Stenting

Atherectomy

Thombolysis


Endovascular Treatment


Best in big arteries with short stenoses

Results below inguinal ligament best in focal lesions

Short occlusions

Myointimal hyperplasia affects results

Greater role in high risk patients

Improved technology with drug eluting balloons


Angioplasty


Good long term results in iliac arteries

Results below the inguinal ligament less durable

Stent fracture an issue in mobile arteries

Myointimal hyperplasia and in stent restenosis affect durability

Improved technology resulting in better outcomes in high risk patients

Drug eluting and biodegradable stents on the horizon


Stenting

Aortoiliofemoral interventions

Femoropopliteal reconstructions

Distal arterial reconstruction

Sympathectomy

Amputation


Surgical Treatment

Improved outcomes with better peri-operative care and surgical techniques

Operative mortality about 2-3 % Synthetic grafts work well in the aorta and iliacs

but autologous grafts preferred below the infra-inguinal ligament

5 year patency rates about 70-80% and limb salvage rates 80-90%

Appropriate work up prior to surgery essential


Surgical outcomes

BASIL trial

Life expectancy greater than 2 years limb salvage greater and mortality lower in surgery patients

Role of stenting still undefined but long-term patency and cost effectiveness remain an issue


Endovascular or Surgery?














Pain

Infection

Absent pulses

ABI < 0.8

Refractory ulcers

Cellulitis

Deteriorating ulcers


Ulcers When to refer

Aetiology of lower limb ulcers is often multifactorial

Management of leg ulcers should include an assessment and management of aetiological factors

Current management of vascular patients involves tailoring intervention according to the clinical and risk profile of the patient

As less invasive management options are available for intervention consideration of early specialist referral is appropriate

Conclusion

Documents

Management of Lower Limb Ulcers - Pharmac€¦ · Varicose veins Deep venous thrombosis Claudication Rest pain Diabetes Injury Arthritis History Oedema Surrounding skin Site Pain