View
2
Download
0
Category
Preview:
Citation preview
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
D Naik MBchB FRACS DDU [Vascular]
Venous Ulcers
D Naik MBchB FRACS DDU [Vascular]
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
D Naik MBchB FRACS DDU [Vascular]
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
D Naik MBchB FRACS DDU [Vascular]
Neuropathic Ulcers
D Naik MBchB FRACS DDU [Vascular]
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
D Naik MBchB FRACS DDU [Vascular]
Clinical Examination
Bleeding
Eczema
Superficial thrombophlebitis
Ulceration
Deep vein thrombosis
D Naik MBchB FRACS DDU [Vascular]
Complications
0.06 and 1%
Rising prevalence in elderly
Peak prevalence age 70 years
F:M ratio 3:1
D Naik MBchB FRACS DDU [Vascular]
Epidemiology of Venous Ulcers
Venous insufficiency
Previous DVT
Chronic skin changes
Local trauma
Aggravation by co-existing conditions
D Naik MBchB FRACS DDU [Vascular]
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
D Naik MBchB FRACS DDU [Vascular]
Microvascular Changes
General measures
Adjuvant pharmacotherapy
Compression
Dressings
Sclerotherapy
Endovenous interventions
Surgery
D Naik MBchB FRACS DDU [Vascular]
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%
D Naik MBchB FRACS DDU [Vascular]
Management-General Measures
Choice is a matter of clinical judgement
Insufficient clinical trials to allow recommendation
D Naik MBchB FRACS DDU [Vascular]
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
D Naik MBchB FRACS DDU [Vascular]
The Ideal Dressing
Ambulant patients need bandages or stockings
20-30 mm Hg at ankle
Graduated
Sustained compression
D Naik MBchB FRACS DDU [Vascular]
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
D Naik MBchB FRACS DDU [Vascular]
Ideal Compression Bandaging System
Only in addition to compression Agents include :fibrinolytic agents fibrinolysis-enhancing hydroxyrutosides pentoxifylline prostaglandin E systemic antibiotics diuretics
D Naik MBchB FRACS DDU [Vascular]
Management- Adjuvant Pharmacotherapy
50-70% of venous ulceration is secondary to primary varicose veins and is curable with relatively simple venous interventions
D Naik MBchB FRACS DDU [Vascular]
Venous Ulceration
D Naik MBchB FRACS DDU [Vascular]
D Naik MBchB FRACS DDU [Vascular]
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
D Naik MBchB FRACS DDU [Vascular]
Epidemiology
Great Saphenous
Small Saphenous
Perforator veins
D Naik MBchB FRACS DDU [Vascular]
Primary Varicose Veins
A-V fistula
Deep venous obstruction
D Naik MBchB FRACS DDU [Vascular]
Secondary Varicose Veins
Duplex scan
Venography
CT venography
D Naik MBchB FRACS DDU [Vascular]
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
D Naik MBchB FRACS DDU [Vascular]
Duplex Scanning
D Naik MBchB FRACS DDU [Vascular]
Conservative
Sclerotherapy
Non-surgical saphenous ablation
Chemical
Radiofrequency
Laser
Surgery
D Naik MBchB FRACS DDU [Vascular]
Management
Weight loss
Exercise
Compression hosiery
D Naik MBchB FRACS DDU [Vascular]
Conservative treatment
Simple office procedure
Good results in appropriately selected patients
May buy time
Cheapest option
D Naik MBchB FRACS DDU [Vascular]
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
D Naik MBchB FRACS DDU [Vascular]
Ultrasound Guided Sclerotherapy [UGS]
D Naik MBchB FRACS DDU [Vascular]
D Naik MBchB FRACS DDU [Vascular]
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
D Naik MBchB FRACS DDU [Vascular]
Endovenous Laser Therapy
D Naik MBchB FRACS DDU [Vascular]
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
D Naik MBchB FRACS DDU [Vascular]
Radiofrequency Ablation
Varicose vein surgery
Valvuloplasty
Venous cuffs
Venous bypass
SSG
Flaps
D Naik MBchB FRACS DDU [Vascular]
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
D Naik MBchB FRACS DDU [Vascular]
Surgery
D Naik MBchB FRACS DDU [Vascular]
D Naik MBchB FRACS DDU [Vascular]
D Naik MBchB FRACS DDU [Vascular]
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
D Naik MBchB FRACS DDU [Vascular]
Management of Varicose Veins
UGS EVLT/RF SURGERY
Invasion + ++ +++
Cost + ++ +++
Discomfort ++ ++ +++
Recovery + + +- +++
Recurrence +++ ?? +
D Naik MBchB FRACS DDU [Vascular]
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
D Naik MBchB FRACS DDU [Vascular]
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
D Naik MBchB FRACS DDU [Vascular]
Epidemiology of PAD
Location
Duration
Progress
Distance
Time for relief
Associated rest pain
D Naik MBchB FRACS DDU [Vascular]
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
D Naik MBchB FRACS DDU [Vascular]
Examination
Duplex scanning
Arteriography
Angioplasty/stent
Vascular reconstruction
Debridement
Skin grafting
D Naik MBchB FRACS DDU [Vascular]
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
D Naik MBchB FRACS DDU [Vascular]
Interpreting Doppler Readings
Exercise ABI
Toe pressures
Pressure studies
Duplex scanning
Ultrasound
Doppler
Spectral analysis
D Naik MBchB FRACS DDU [Vascular]
Non-invasive Vascular Tests
D Naik MBchB FRACS DDU [Vascular]
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
D Naik MBchB FRACS DDU [Vascular]
CT angiography
MR angiography
Digital subtraction angiography
D Naik MBchB FRACS DDU [Vascular]
Invasive studies
Smoking
Antiplatelet therapy
Hypertension
Diabetes
Hyperlipidaemia
Statin
Cilastozol,Trental
Exercise
D Naik MBchB FRACS DDU [Vascular]
Best Medical Therapy
We favour an endovascular first policy
Our Approach
Angioplasty
Stenting
Atherectomy
Thombolysis
D Naik MBchB FRACS DDU [Vascular]
Endovascular Treatment
D Naik MBchB FRACS DDU [Vascular]
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
D Naik MBchB FRACS DDU [Vascular]
Angioplasty
D Naik MBchB FRACS DDU [Vascular]
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
D Naik MBchB FRACS DDU [Vascular]
Stenting
Aortoiliofemoral interventions
Femoropopliteal reconstructions
Distal arterial reconstruction
Sympathectomy
Amputation
D Naik MBchB FRACS DDU [Vascular]
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
D Naik MBchB FRACS DDU [Vascular]
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
D Naik MBchB FRACS DDU [Vascular]
Endovascular or Surgery?
D Naik MBchB FRACS DDU [Vascular]
D Naik MBchB FRACS DDU [Vascular]
D Naik MBchB FRACS DDU [Vascular]
D Naik MBchB FRACS DDU [Vascular]
D Naik MBchB FRACS DDU [Vascular]
D Naik MBchB FRACS DDU [Vascular]
D Naik MBchB FRACS DDU [Vascular]
D Naik MBchB FRACS DDU [Vascular]
D Naik MBchB FRACS DDU [Vascular]
D Naik MBchB FRACS DDU [Vascular]
D Naik MBchB FRACS DDU [Vascular]
D Naik MBchB FRACS DDU [Vascular]
D Naik MBchB FRACS DDU [Vascular]
Pain
Infection
Absent pulses
ABI < 0.8
Refractory ulcers
Cellulitis
Deteriorating ulcers
D Naik MBchB FRACS DDU [Vascular]
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
Recommended