4/5/2014 1 UCSF Vascular Symposium 204 Aggressive assessment and management are the keys to healing Peter J. Pappas, M.D Professor of Surgery Chariman, Department of Surgery The Brooklyn Hospital Venous Hypertension Secondary to Reflux Leukocytes with TGF-ß 1 Granules Leukocyte Diapedesis
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4/5/2014
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UCSF Vascular Symposium 204
Aggressive assessment and management are the keys to
healing
Peter J. Pappas, M.DProfessor of Surgery
Chariman, Department of SurgeryThe Brooklyn Hospital
Venous Hypertension Secondary to Reflux
Leukocytes with TGF-ß1 Granules Leukocyte Diapedesis
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TGF-ß1 Release TGF-ß1 Release
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TGF-ß1 stimulated fibroblasts differentiate into myofibroblasts.
Injury Stimulus causes cytokine releaseAnd RAS activation with possible
Senescence development and MMPSynthesis
RAS Activation RAS Activation
Normal wound healing process
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Impaired venous ulcer healing process
Treatment Options for Venous UlcersAnd Levels of Evidence
• Compression Therapy
• Vein Surgery
– Superficial
– Deep
– Perforator
• Skin Grafting
Compression modalities
Unna BootMulti layer Bandage
Circaid
CompressionStocking
Compression Rx: Evidence of Efficacy
• Cochrane library review
– Meta-analysis
• Reviewed over 200 studies of Rx of VSU
• Conclusions
– Overall dataset is relatively poor
– Appears clear that compression is better than no compression in healing VSU
– Sustained compression of high strength is better than non-sustained compression
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Recent Trials of Compression Methods
Primary author
Journal ref # pts % healed group A
% healed group B
P val
Nelson J Vasc Surg 2007;45:134
245; 4 layer vs single layer
67% 4 layer at 24 wks
49% single layer at 24 wks
.009
Nelson Br J Surg 2004 91:1292
387; 4 layer vs short str
92 days median for 4 layer
126 days median for SS
< .05
Partsch Vasa 2001;30:108
112; 4 layer vs short str
62% 4 layer at 16 wks
73% SS at 16 wks
NS
Franks Wound Rep Regen 2004;12:157
156; 4 layer vs SS
69% 4 layer at 24 wks
73% SS at 24 wks
NS
Polignano J Wd Care 2004;13:21
68; 4 layer vs Unna
74% 4 layer at 24 wks
66% Unna at 24 wks
NS
Percent healed at:
6 weeks 29%10 weeks 57%16 weeks 75%52 weeks 93%
1 amputation required (0.4%)
Weeks of Treatment
01020304050
60708090
100
0 4 8 12 16 20 24 28 32 36 40 44 48 52 56
Healing Rate for 252 Ulcers: UNC experience
J Vasc Surg Sept 1999
Weeks of Treatment
Percent healed at 10 weeks
of Rx:< 5 cm2 77%5 to 20 cm2 61%> 20 cm2 22% All curves significant difference (P < .01)
0
10
20
30
40
50
60
70
80
90
100
2 6 10 14 18 22 26 34 42 52
< 5 cm2 n = 91
5 - 20 cm2 n = 94
> 20 cm2 n = 67
Healing Rate by Initial Ulcer Size
Compression and Compliance
Mayberry et al. Surgery 1991; 81:575-581.
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Wrong Diagnosis: Venous Mimics
• Basal or squamous cell carcinoma.
• Rheumatoid, lupus, scleroderma and other collagen vascular disorders.
• Tuberculosis and syphilis.
• Pyoderma gangrenosum.
• AIDS.
• Arteriovenous malformations.
• Cryoglobulinemia and macroglobulinemia.
• Burns and insect bites.
Level of Evidence for Venous Ulcer SurgeryVersus Compression
Summation Data for Studies Prior to 2000
Howard et al. The role of superficial venous surgery in the management ofVenous ulcers: A systematic review. Eur J Vasc Endovasc Surg. 2008;36: 458-465.
Randomized Clinical Trials For Venous Ulcer Surgery
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C5-6 Disease - The ESCHAR Trial Barwell JR, Lancet 2004
• Prospective randomized trial
– High ligation, stripping, phlebectomy and
Compression versus
– Multilayer compression bandaging
• 500 patients with CEAP 5 and 6 disease
– Isolated superficial reflux - 300 (60%)
– Mixed superficial / deep reflux - 200 (40%)
• Endpoints
– 24 week ulcer healing
– 12 month ulcer recurrence
Barwell et al. Eschar Trial.Lancet 2004; 363: 1854-1859