Venous leg ulcers can occur when blood returning from veins in the legs to the heart is slow or obstructed. These ulcers can take a long time to heal (weeks or months) and can cause distress to patients, as well as being very costly to the health service. Compression bandages help blood to return to the heart from the legs, and there are a variety of types of bandage systems available; some are just a single bandage, while others require the application of several different types of bandages to the leg. Compression stockings are sometimes used as an alternative to compression bandages. This review examined the effectiveness of compression bandages versus no compression, and compared different types of compression bandages and stockings. We looked at how well these different treatments work in terms of ulcer healing. We found that applying compression was better than not using compression, and that multi-component bandages worked better than single-component systems. Multi-component systems (bandages or stockings) appear to perform better when one part is an elastic (stretchy) bandage. A very detailed analysis showed that a system called the 'four-layer bandage' or '4LB' (i.e. four different bandages applied to the leg, including an elastic one) heals ulcers faster than the 'short-stretch bandage' or 'SSB' (a type of bandage with very minimal stretch).

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Compression for venous leg ulcers

http://www.ejves.com/article/S1078588421009795/pdf

European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs.

SUMMARYObjective: To investigate the possibility of improving healing rates in ulcus cruris venosum by using an ulcer compression stocking (U-Stocking) (Venotrain* ulcertec) as compared to compression bandages.Research design and setting: Prospective, multicentre, open-labelled, randomized, active-controlled study with blinded assessment of the primary endpoint. Sixteen phlebology outpatient clinics in Germany or the Netherlands or German medical practices specialized in phlebology.Patients and methods: 134 patients with venous leg ulcers entered the study. Among others, patients with infected ulcer or obesity were excluded. 121 patients were eligible for primary efficacy analyses. U-Stocking or bandages applied for at least eight hours per day and for up to 12 weeks. The primary endpoint was the healing rate after 12 weeks as assessed by planimetric measures. The secondary outcome variables were time to healing, changes in ulcer size (planimetry), experience of use and patient compliance.Main outcome mea...

Efficacy and tolerability of an ulcer compression stocking for therapy of chronic venous ulcer compared with a below-knee compression bandage: results from a prospective, randomized, multicentre trial.

Purpose To investigate and compare the anatomical success rates and complications of the treatment modalities for small saphenous vein (SSV) incompetence. Methods A systematic literature search was performed in PubMed, EMBASE, and the Cochrane Library on the following therapies for incompetence of SSVs: surgery, endovenous laser ablation (EVLA), radiofrequency ablation (RFA), ultrasound-guided foam sclerotherapy (UGFS), steam ablation, and mechanochemical endovenous ablation (MOCA). The search found 49 articles (5 randomized controlled trials, 44 cohort studies) reporting on the different treatment modalities: surgery (n=9), EVLA (n=28), RFA (n=9), UGFS (n=6), and MOCA (n=1). A random-effects model was used to estimate the primary outcome of anatomical success, which was defined as closure of the treated vein on follow-up duplex ultrasound imaging. The estimate is reported with the 95% confidence interval (CI). Secondary outcomes were technical success and major complications [paresthesia and deep vein thrombosis (DVT)], given as the weighted means. Results The pooled anatomical success rate was 58.0% (95% CI 40.9% to 75.0%) for surgery in 798 SSVs, 98.5% (95% CI 97.7% to 99.2%) for EVLA in 2950 SSVs, 97.1% (95% CI 94.3% to 99.9%) for RFA in 386 SSVs, and 63.6% (95% CI 47.1% to 80.1%) for UGFS in 494 SSVs. One study reported results of MOCA, with an anatomical success rate of 94%. Neurologic complications were most frequently reported after surgery (mean 19.6%) and thermal ablation (EVLA: mean 4.8%; RFA: mean 9.7%). Deep venous thrombosis was a rare complication (0% to 1.2%). Conclusion Endovenous thermal ablation (EVLA/RFA) should be preferred to surgery and foam sclerotherapy in the treatment of SSV incompetence. Although data on nonthermal techniques in SSV are still sparse, the potential benefits, especially the reduced risk of nerve injury, might be of considerable clinical importance.

Treatment Modalities for Small Saphenous Vein Insufficiency: Systematic Review and Meta-analysis

A Systematic Review and Meta-analysis of Thrombotic Events Following Endovenous Thermal Ablation of the Great Saphenous Vein

Objective Treatment of chronic venous insufficiency of the great saphenous veins by endovenous laser ablation yields good short- and medium-term results, as assessed clinically and technically by echo-color-Doppler. At present, scarce data are available on the long-term results of endovenous laser ablation. We wanted to assess the long-term efficacy of endovenous laser ablation. Methods We performed a prospective 6-year follow-up cohort study, with recruitment between 2003 and 2004, and the follow-up completed in 2010. The setting was an ambulatory care/day surgery. Of 209 consecutive patients who underwent endovenous laser ablation at our institution during the recruitment period, five (2.4%) did not complete the procedure due to technical reasons. Of 204 patients who successfully completed the intervention, 14 (6.8%) were lost for follow-up, and 190 completed the planned 6-year follow-up. The intervention was an endovenous laser ablation using a 980-nm laser diode. Clinical and echo-color-Doppler evaluations were regularly scheduled for all patients during the planned follow-up period. The incidence of clinical and echo-color-Doppler confirmed endovenous laser ablation failures over a 6-year follow-up period. Potential associations between failures and patients’ characteristics, echo-color-Doppler findings, or surgical features were also investigated. Results Symptomatic clinical endovenous laser ablation failures occurred in 22 (11.6%; 95% confidence interval [CI], 7.4-17.0%) patients; while 57 (30.0%; 95% CI, 23.6-37.1%) had echo-color-Doppler-confirmed failures. Only two patients (1.1%; 95% CI, 0.1%-3.8%) had both symptomatic clinical and echo-color-Doppler-confirmed failures. Three features of the great saphenous vein: an “atypical” junction, a junction diameter ≥8 mm, and a mean trunk diameter ≥8 mm, were independently associated with echo-color-Doppler-confirmed failures on multivariate logistic regression analysis. Conclusions Six years after endovenous laser ablation, most patients were improved on clinical grounds, and more than two-thirds had no saphenous insufficiency at echo-color-Doppler. Only a minority had both clinical and echo-color-Doppler-confirmed failures. Anatomical features of the junction and the saphenous diameter both at the junction and at the trunk independently predicted echo-color-Doppler-confirmed failures.

Six-year follow-up of endovenous laser ablation for great saphenous vein incompetence.

Objective Endovenous laser ablation (EVLA) of great (GSV) and small saphenous vein (SSV) chronic insufficiency with 1470-nm diode laser and radial fiber yields good short-term results. The aim of this study was to assess its efficacy after at least 12 months of follow-up. Methods We performed a prospective interventional cohort study in an ambulatory care/day surgery setting. Consecutive patients with chronic, symptomatic GSV or SSV insufficiency were treated by EVLA with a 1470-nm diode laser and a radial fiberoptic. Patients were recruited between 2008 and 2011, and the follow-up was completed in 2012. All patients underwent clinical and echo color Doppler evaluations during follow-up. The primary outcome was the incidence of echo color Doppler-confirmed failures during follow-up. We also investigated potential associations between failures and patients' characteristics, echo color Doppler findings, or surgical features. The secondary outcome was the postoperative pain course. Results The planned 12-month follow-up was completed in 372 patients. Echo color Doppler-confirmed failures occurred in 37 (12%) of 310 patients with GSV insufficiency, whereas none of 62 patients with SSV insufficiency experienced a failure. Multiple Cox proportional hazards regression analysis showed a significant association of failures with a Clinical, Etiologic, Anatomic, and Pathologic class C ≥4 and a mean confluence of the superficial inguinal veins diameter ≥9 mm in patients with GSV insufficiency. Postoperative pain course was favorable. More than two thirds of the patients were asymptomatic at 7 days. Conclusions EVLA with 1470-nm diode laser and radial fiberoptic is effective for treatment of GSV and especially SSV insufficiency and is well tolerated by the patients.

Endovenous laser ablation of great and small saphenous vein incompetence with a 1470-nm laser and radial fiber

Ultrasound guided foam sclerotherapy (UGFS) proved to be effective in recurrent varices. In this observational study from 2006 and 2012 we treated 142 neovascularization, 155 inguinal recurrence and 28 popliteal recurrent varices. For neovascularization 0.3-0.5% polidocanol (POL) sclerosant foam (SF) was injected for vein having diameter <3 mm and 0.5-1% POL or sodium tetradecylsulphate (STS) SF for higher vein diameters. The patients with residual sapheno-femoral or sapheno-popliteal junctions were treated with 1% STS SF for diameter up to 5 mm, while for larger veins 3% STS was used. From 1 to 3 sessions were necessary in both groups with 4 to 10 ml injected per session. In the group of neovascularization the 3-5years follow up revealed good results in 90.8% of the cases. In the group of popliteal recurrences the 3-5 years follow up showed 60.7% of good results, while in the group of inguinal recurrences we observed 80% of good results at 3-5 years. We did not have major complication. As minor complications we had 0.2% of gastrocnemial vein thrombosis, 0.1% of minor neurological problems, 2.8% of superficial vein thrombosis, 3.9% of pigmentation and light to mild post-treatment pain in 16.5% of the cases. In conclusion our data show that UGFS is a well tolerate technique, preferred by previously operated patients, safe and easily repeatable with good medium-term results both in case of neovascularization and of recurrence from residual femoral or popliteal stump.

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Ultrasound guided foam sclerotherapy of recurrent varices of the great and small saphenous vein: 5-year follow up

Histological damage of saphenous venous wall treated in vivo with radial fiber and 1470 nm diode laser

BACKGROUND Recurrent varices after surgery are a complex problem. Many studies regarding the causes of recurrence and the best procedures that can be used to study them have been conducted but few studies on the natural history of the operations performed for recurrence. OBJECTIVES To evaluate the efficiency of reintervention in controlling the varicose disease, its symptoms, and patient satisfaction. MATERIALS AND METHODS Of 71 patients operated on for surgical recurrence related to an inguinal cavernoma between 1996 and 2004, 51 were reassessed in May 2006 with a clinical and Duplex examination. Surgical and anesthesiological data were collected. RESULTS The average follow-up after reintervention for the 51 of the 71 treated patients who came to the examination was 5.8 years; 38 (74.5%) of the patients were very satisfied, and one patient (2%) was dissatisfied. Thirty-five (68.6%) of the patients still had varices, but only 17 of these had real varices at the original site; 18 patients showed persistent or residual varices (3 patients, 5.8%) or a progression (15 patients, 29.9%) of the varicose disease. CONCLUSIONS Surgical intervention on an outpatient basis may have a significant role in controlling the varicose disease with few complications.

Enzo Giraldi

Papers

Six-year follow-up of endovenous laser ablation for great saphenous vein incompetence.

Endovenous laser ablation of great and small saphenous vein incompetence with a 1470-nm laser and radial fiber

Ultrasound guided foam sclerotherapy of recurrent varices of the great and small saphenous vein: 5-year follow up

Histological damage of saphenous venous wall treated in vivo with radial fiber and 1470 nm diode laser

Natural history of recurrent varices undergoing reintervention: a retrospective study.