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Giovanni Mosti,1 Stefano Gasperini2 1Barbantini Clinic, Lucca, Italy; 2Medical Advisor, Pisa, Italy Abstract: Chronic skin lesions are an important medical health problem. Chronic skin lesions are associated with high costs for the National Health Service and reduced quality of life for the patient. The availability of means to reduce the healing time of skin ulcers is a medical and public health priority. Within this context, for patients suffering from skin ulcers, great attention has been given to the use of particular frequencies of the light spectrum that have shown beneficial effects on both ulcer cleansing and healing stimulation. This article reports the observations made on three patients suffering from ulcers of the lower limbs who were treated with Photobiomodulation therapy using Blue Light in addition to the standard treatment at a private clinic. The results were encouraging and have prompted us to participate in a protocol of a multicenter randomized study on a significant number of patients. Keywords: photobiomodulation, blue light emitting diodes, wound healing, chronic leg skin lesion

The microcirculatory evaluation in patients affected by arteriopathic or venous ulcers is usually carried out using laser Doppler flowmetry, transcutaneous oxygen (transcutaneous pressure of oxygen, TcP[O.sub.2]), and carbon dioxide (transcutaneous [...]

Abstract BackgroundComplications from hyaluronic acid (HA) fillers are increasingly frequent, given the very high number of treatments performed every day worldwide. They are routinely treated with high doses of hyaluronidase, which can cause significant local and general unwanted effects. ObjectivesThe aim of our work is to demonstrate that when the origin of the complication is precisely identified and treated under ultrasound guidance, a few hyaluronidase units are enough to treat it effectively. MethodsFive young female patients came to our observation for vascular lesions from injection of HA fillers performed in the immediately preceding days, in 4 cases, and a few weeks earlier in the fifth case. All lesions were accurately identified by ultrasound and treated with hyaluronidase. ResultsThe 4 promptly treated patients fully recovered with a hyaluronidase dose of 87 ± 44 IU (range, 30-150 IU). The fifth patient, treated later, markedly improved regarding clinical picture and symptoms. No early or late side effects have been reported from this hyaluronidase dosage. ConclusionsOur data confirm that if the lesion at the origin of the skin damage is precisely localized with ultrasound examination and treated under ultrasound guidance, a few units of hyaluronidase, injected directly into the HA accumulation, effectively resolve the skin damage. At the doses we used, which were much lower than those usually recommended, hyaluronidase proved to be not only effective but also free of any side effects. Level of Evidence: 5

Objective: The aim of the study was to compare the efficacy of a microorganism-binding (MB) dressing with a silver-containing hydrofiber (SCH) dressing in controlling the bacterial loads of heavily colonised or locally infected chronic venous leg ulcers, before surgical management with homologous skin grafts. Method: A randomised, comparative, single centre study recruited patients presenting with hard-to-heal critically colonised or locally infected leg ulcers, who could be treated with skin grafting. Inclusion criteria included; ulcers of vascular aetiology, over 18 years old, a wound duration ≥ 6 months and ankle brachial index (ABPI) > 0.6. Patients were randomly assigned to treatment with SCH dressings (Aquacel Ag) or MB dressing (Cutimed Sorbact). Dressings were changed daily over a four-day observation period, after which they were taken for a skin grafting procedure. Swab samples from ulcer beds were taken in order to quantify the bacterial load at inclusion (D0) and at the end of the observation period day 4 (D4). No antibiotics were administered before or during the evaluation period. Results: Both groups (n = 20 SCH, n = 20 MB) were similar in gender, age, pathophysiology (both had 15 patients with venous leg ulcers and five with arterial leg ulcers), ulcer surface, ulcer duration, treatment-related pain and initial bacterial load. Analysing bacterial load variation showed a significant reduction of bacterial burden at D4 in both groups. In the SCH group, we found an average bacterial load reduction of 41.6%, with an average reduction of 73.1% in the MB group (p < 0.00001). No serious adverse events were reported. Conclusion: Our evaluation confirmed that MB and SCH dressings are effective in reducing the bacterial burden in critically colonised or locally infected chronic leg ulcers, without inducing adverse events, with MB dressings significantly more effective. [ABSTRACT FROM AUTHOR]

The compression pressure, which corresponds to the dosage of compression therapy, has been widely neglected up to now, not only concerning scientific literature, but also in clinical practice. It is evident that compression pressures in the upright position and during walking are clinically more relevant than just the resting pressure. The Static Stiffness Index (SSI), which is the difference between standing and resting pressure, is a valuable parameter characterising the efficacy of a specific compression product to narrow/occlude the venous lumen. This is a prerequisite for reducing venous reflux and exerting a massaging effect necessary to improve the venous pumping function during movement. This article provides an overview of the recent literature on the SSI, which supports the recommendations of the International Compression Club. In addition, it aims to provide an insight on the importance of the SSI in daily practice, as an educational tool as well as in defining the properties of applied compression therapy in clinical research. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study was to compare the efficacy of a microorganism-binding (MB) dressing with a silver-containing hydrofiber (SCH) dressing in controlling the bacterial loads of heavily colonised or locally infected chronic venous leg ulcers, before surgical management with homologous skin grafts. l Method: A randomised comparative single centre study recruited patients presenting with hard-to-heal critically colonised or locally infected leg ulcers, who could be treated with skin grafting. Inclusion criteria included; ulcers of vascular aetiology, over 18 years old, a wound duration ≥6 months and ankle brachial index (A BPI) >0.6. Patients were randomly assigned to treatment with SCH dressings (Aquacel Ag) or MB dressing (Cu timed Sorb act). Dressings were changed daily over a four-day observation period, after which they were taken for a skin grafting procedure. Swab samples from ulcer beds were taken in order to quantify the bacterial load at inclusion (D30) and at the end of the observation period day 4 (D4). No antibiotics were administered before or during the evaluation period. Results: Both groups (n=20 SCH, n=20 MB) were similar in gender, age, pathophysiology (both had 15 patients with venous leg ulcers and 5 with arterial leg ulcers), ulcer surface, ulcer duration, treatment-related pain and initial bacterial load. Analysing bacterial load variation showed a significant reduction of bacterial burden at D4 in both groups. In the SCH group, we found an average bacterial load reduction of 41.6%, with an average reduction of 73.1% in the MB group (p< 0.00001). No serious adverse events were reported. Conclusion: Our evaluation confirmed that MB and SCH dressings are effective in reducing the bacterial burden in critically colonised or locally infected chronic leg ulcers, without inducing adverse events, with MB dressings significantly more effective. [ABSTRACT FROM AUTHOR]

Background: Compression treatments used the following intervention for varicose veins range from no compression, to elastic stockings and compression bandaging. There is no consensus on the strength or duration of compression which should be applied following a particular treatment. The author reviews the evidence that has led him to reach his own viewpoint on this subject. Summary: Compression stockings are often prescribed after treatment of varicose veins, but these in general exert a much lower pressure in the thigh compared with firm inelastic compression bandages. It has been shown by objective investigation that it takes a pressure of 10-15 mmHg in the supine position and 40-50 mmHg in the standing position to occlude a superficial vein in the thigh. The author has published a study in which three groups of patients were studied following varicose vein surgery. One group received a strong medical compression stocking, the second group an inelastic bandaging system which achieved 63 mmHg compression in the standing position and an eccentric compression system which achieved 98 mmHg in the standing position. Adverse events after surgery were most frequent in the stocking group with fewer in the inelastic compression bandage group and fewest in the eccentric compression group. A further study has been published by another author in which elastic compression has been compared with eccentric compression following endovenous laser ablation of the saphenous vein. Eccentric compression reduced postoperative pain. Unfortunately, very little data are available to indicate the period for which compression should be applied following varicose vein treatment. Conclusions: In comparison to compression treatments following varicose vein surgery where the actual level of compression has been measured, higher levels of compression are more effective than lower levels in moderating postoperative pain and complications. Strong compression can be achieved by inelastic bandaging or by eccentric compression systems. Far fewer data are available to indicate the duration for which postoperative compression is required. [ABSTRACT FROM AUTHOR]

Wound dressings: ulcer dressings should create and maintain a moist environment on the ulcer surface. It has been shown that in an ulcer with a hard crust and desiccated bed, the healing process is significantly slowed and sometimes completely blocked so favouring infection, inflammation and pain. In contrast a moist environment promotes autolytic debridement, angiogenesis and the more rapid formation of granulation tissue, favours keratinocytes migration and accelerates healing of wounds. Apart from these common characteristics, wound dressings are completely different in other aspects and must be used according to the ulcer stage. In necrotic ulcers, autolytic debridement by means of hydrogel and hydrocolloids or with enzymatic paste is preferred. In case of largely exuding wounds alginate or hydrofibre are indicated. When bleeding occurs alginate is indicated due to its haemostatic power. Where ulcers are covered by granulation tissue, polyurethane foams are preferred. When infection coexists antiseptics are necessary: dressing containing silver or iodine with large antibacterial spectrum have proved to be very effective. In the epithelization stage polyurethane films or membranes, thin hydrocolloids or collagen based dressings are very useful to favour advancement of the healing wound edge. Despite these considerations, a Cochrane review failed to find advantages for any dressing type compared with low-adherent dressings applied beneath compression. Surgical debridement and grafting of wounds, negative wound pressure treatment: surgical and hydrosurgical debridement are indicated in large, necrotic and infected wounds as these treatments are able to get rid of necrotic, infected tissue very quickly in a single surgical session, thereby significantly accelerating wound bed preparation and healing time. Negative wound pressure treatment creating a negative pressure on ulcer bed is able to favour granulation tissue and shorten healing time. In case of hard-to-heal leg ulcers such as large, deep, infected and long-lasting venous ulcers, sharp debridement and skin grafting may favour and shorten ulcer healing. [ABSTRACT FROM AUTHOR]

Aim: To compare the efficacy of compression stockings and inelastic, high-pressure bandages concerning leg volume reduction in patients with chronic leg oedema. Material and methods: Forty-two legs of 30 patients with chronic leg oedema caused by venous stasis were randomized to receive a strong inelastic bandage (IB) or an elastic stocking (ES) exerting a pressure of 23-32 mmHg. Changes in leg oedema were assessed after two and seven days by water displacement volumetry, measurements of leg circumferences and of skin thickness by using Duplex ultrasound. Interface pressure was registered under the compression devices for seven days. Results: There was no significant difference between stockings and bandages, which both produced a significant reduction in leg volume after two days (29.6% [95% CI 7.5-11.8] by ES and 211.5% [95% CI 9.9-13.2%] by IB) and after seven days (213.2% [95% CI 10.4-16.2] by ES and 215.6% [95% CI 12.8-18.4] by IB). Bandages showed a more pronounced reduction in leg circumference and in skin thickness in the calf region. The pressure of IB in the lying position fell from initially 63 to 22 mmHg after two days, but only from 33 to 26 mmHg under ES (median values). The optimal pressure range concerning oedema reduction was found between 40 and 60 mmHg, while higher pressures produced by bandages showed a negative correlation with volume reduction. Conclusions: Compression stockings exerting a pressure of around 30 mmHg are nearly as effective as high-pressure bandages with an initial pressure over 60 mmHg in reducing chronic leg oedema. [ABSTRACT FROM AUTHOR]

The author reflects on research which has compared the effectiveness of elastic compression stockings with inelastic bandages in the treatment of ulcers and has found that elastic stockings are more effective. He suggests that if pressure is not measured no reliable conclusion can be drawn on different outcomes of the two treatments. He argues that additional research needs to be conducted to prove whether elastic stockings are better than properly applied nonelastic bandages.

Currently, there are no generally accepted definitions for wounds at risk of infection. In clinical practice, too many chronic wounds are regarded as being at risk of infection, and therefore many topical antimicrobials - in terms of frequency and duration of use - are applied to wounds. Based on expert discussion and current knowledge, a clinical assessment score was developed. The objective of this wounds at risk (W.A.R.) score is to allow decision-making on the indication for the use of antiseptics on the basis of polihexanide. The proposed clinical classification of W.A.R. shall facilitate the decision for wound antisepsis and allow an appropriate general treatment regimen with the focus on the prevention of wound infection. The W.A.R. score is based on a clinically oriented risk assessment using concrete patient circumstances. The indication for the use of antiseptics results from the addition of differently weighted risk causes, for which points are assigned. Antimicrobial treatment is justified in the case of 3 or more points. Copyright © 2011 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: A too high resting pressure of compression devices is poorly tolerated and may cause skin defects, especially in patients with concomitant arterial occlusive disease. Aim: To investigate whether low compression pressure will improve venous pumping function in patients with venous incompetence. Material and methods: Venous pumping function was assessed in 20 patients with severe reflux in the great saphenous vein by measuring ejection fraction (EF) using strain-gauge plethysmography. Measurements were repeated after application of knee-high medical compression stockings and of inelastic bandages applied with a pressure of 20, 40 and 60 mmHg in the supine position. Results: EF was significantly reduced compared with healthy controls. Compression stockings exerting a median pressure of 27 mmHg (interquartile range [IQR] 25-29) in the supine and 30.5 mmHg (IQR 28.25-34.25) in the standing position produced a moderate, non-significant improvement of EF of 17%. Inelastic bandages with a resting pressure of 20.5 mmHg (IQR 20-22) in the supine position resulting in a standing pressure of 36 mmHg (IQR 33-40.75) led to a significant increase of EF of 61.5% (P < 0.01). A further increase of the resting pressure to 40 and 60 mmHg achieved an increase of the EF of 91% and 98%, respectively (P , 0.001). Conclusions: In patients with venous pumping failure, inelastic bandages produce a significant pressure-dependent increase of EF. A significant improvement in venous pumping function was achieved with inelastic bandages even at a resting pressure of 20 mmHg. [ABSTRACT FROM AUTHOR]

Aim: To investigate the influence of compression bandages, manufactured using materials with different elastic properties, on the impaired venous pumping function in patients with venous insufficiency. Methods: Ejection volume (EV) and ejection fraction (EF) were measured using strain gauge plethysmography distal from the patella without and with elastic and inelastic compression bandages in a total of 30 patients with major venous reflux in the great saphenous vein. The interface pressure of the bandages was measured simultaneously in the medial gaiter area. Normal values of EV and EF were obtained from 15 healthy controls. Results: Patients with venous insufficiency showed a statistically significant reduction of EV and EF compared to controls. Elastic bandages with an average pressure of 42mmHg in the supine position achieved a moderate increase of EV and a significant improvement of EF (p < .01), while inelastic bandages applied with comparable resting pressure (41mmHg) raised EV and EF into a normal range (p < .001). The improvement of the ejection fraction correlates well with the pressure differences between standing and lying (Static Stiffness Index) and between muscle systole and diastole during exercise (Pearson r = 0.69 and 0.74 respectively, p < .001). Elastic bandages applied with high stretch in order to achieve standing pressures comparable to those of inelastic bandages (>60mmHg) led only to a minor improvement of the venous pumping function. Conclusions: Ejected volume and ejection fraction, which are severely reduced in venous insufficiency, can be increased by compression therapy. Inelastic compression is much more effective than elastic bandages, and is able to normalize venous pumping function. With elastic bandages EV and EF always remain below the normal range even when applied with high stretch producing a resting pressure that is barely tolerable. [ABSTRACT FROM AUTHOR]

The aim of this overview is to discuss the role of thigh compression for the management of venous and lymphatic diseases. The most important indications for thigh compression are prevention and treatment of sequelae of superficial vein procedures (surgery or endovenous procedures), prevention and therapy of deep vein thrombosis (DVT), postthrombotic syndrome and lymphoedema. The intended effects depend mainly on narrowing/occlusion of deep and superficial veins on which the body position and the applied pressure play a crucial role. While in the horizontal position thigh veins can be narrowed by the light pressure of a thromboprophylactic stocking, much higher pressure is needed to compress thigh veins effectively during standing and walking. This is shown by magnetic resonance imaging (MRI) performed in the supine and upright position. Using pads, rolls or specially designed devices, the local pressure under conventional compression garments or bandages over a treated vein can be increased considerably. In patients with deep valve incompetence, beneficial haemodynamic effects of strong thigh compression have been demonstrated, but clinical studies in this field are still lacking. Thigh compression reduces oedema in patients with DVT and lymphoedema. [ABSTRACT FROM AUTHOR]

Background: The aim of our study was to comparatively assess volume changes related to daily occupation of the whole leg (WLv), of the lower leg (LLv) and of the upper leg (ULv) in subject with no venous and lymphatic disorders., Method: WLv, LLv, and Ulv were evaluated by water displacement volumetry (WDV) in the morning and in the evening in 20 healthy subjects., Results: In the legs with occupational edema (OE), WLv increased by 7.07%, LLv by 5.25%, and ULv by 9.80%. In legs without clear OE, WLv increased by 2.41%, LLv by 1.35, and ULv by 3.38%., Conclusions: Surprisingly, the increase of ULv was greater than that of LLv. An evening increase in the leg volume also occurred in legs with no clear OE. In our series, a clinically evident OE was related to an increase of the WLv, LLv, and ULv greater than 5.83%, 8.68%, and 1.88%, respectively., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To report pressure and stiffness, in healthy volunteers, of a new compression device with an air bladder inflated by a pump to regulate pressure., Methods: The device was applied to 60 legs of 30 volunteers and set to exert different pressures of 20-50 mmHg. The exerted pressure was measured in supine and standing positions and during simple physical exercises; static stiffness index, dynamic stiffness index, and walking pressure amplitudes were calculated., Results: The exerted pressure showed a good correlation with the expected pressure at each pressure range. The stiffness indices were >10 mmHg in the range of inelastic materials. The device was considered very easy to apply and use by the testing researchers., Conclusions: The device stiffness is in the same range as the inelastic bandages. Consequently, similar hemodynamic effectiveness could be expected but must be proved. Unlike inelastic bandages, this device was easy to apply and use., Competing Interests: Declaration of conflicting interestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: AG and NL are consultants for Sun Scientific. GM and AO have no conflicts of interests.

Objective: To analyze the effects of lower limb muscle strengthening on interface pressure (IP), static stiffness index (SSI), dynamic stiffness index (DSI), and walking pressure amplitude (WPA) in older adults undergoing inelastic compression therapy., Method: Forty-three healthy older adults of both sexes (Age: 66.2 ± 4.4 years) met the eligibility criteria and completed all stages of the study (Resistance Training - RT: N = 20; Control - CONT: N = 23). Body composition, strength and functional mobility of lower limbs, IP, SSI, DSI, and WPA were evaluated before and after intervention., Results: The two-way ANOVA with repeated measures demonstrated a significant time-group interaction effect on muscular strength for 1-RM [F (1, 41) = 21.091; p ≤ 0.001], IP in the orthostatic position [F (1, 41) = 5.124; p ≤ 0.05], minimum WPA [F (1, 41) = 10.999; p ≤ 0.05], maximum WPA [F (1, 41) = 8.315; p ≤ 0.05], DSI minimum (F (1, 41) = 4.608; p ≤ 0.05), DSI maximum (F (1, 41) = 8.926; p ≤ 0.05), and on the delta DSI (F (1, 41) = 7.891; p ≤ 0.05)., Conclusions: In RT group, the increase in lower limb muscle strength was accompanied by an increase in IP in foot dorsiflexion and plantar flexion maneuvers, both in the standing position (DSI) and during gait (WPA)., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Although compression therapy (CT) is considered a crucial conservative treatment in chronic venous disease, strong evidence is missing for many clinical indications. This literature review aims to point out what strong evidence we have for CT and all the clinical scenarios where strong evidence still needs to be included., Methods: The research was conducted on MEDLINE with PubMed, Scopus and Web of Science. The time range was set between January 1980 and October 2022. Only articles in English were included., Results: The main problem with CT is the low scientific quality of many studies on compression. Consequently, we have robust data on the effectiveness of CT only for advanced venous insufficiency (C3-C6), deep vein thrombosis and lymphedema. We have data on the efficacy of compression for venous symptoms control and in sports recovery, but the low quality of studies cannot result in a strong recommendation. For compression in postvenous procedures, superficial venous thrombosis, thromboprophylaxis, post-thrombotic syndrome prevention and treatment, and sports performance, we have either no data or very debated data not allowing any recommendation., Conclusions: We need high-level scientific studies to assess if CT can be effective or definitely ineffective in the clinical indications where we still have a paucity of or contrasting data., Competing Interests: Disclosures None., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Chronic venous disorders (CVD) of the lower limbs can be treated with different strategies. Typically, conservative management is based on compression therapy, anticoagulants and venoactive drugs. Endovenous treatments remain the gold standard to treat saphenous insufficiency, with sclerotherapy and surgery maintaining a role in selected cases. In addition, several 'unconventional' approaches have been proposed to prevent CVD progression and complications, minimize symptoms and improve the quality of life and postoperative outcomes. Among these, balneotherapy and aquatic exercises are proving as valid and effective supporting treatments, as mentioned in a growing number of scientific publications. Moreover, aquatic protocols have been studied for both venous and lymphatic insufficiency. For these reasons, they were mentioned in the last CVD guidelines provided by the European Society for Vascular Surgery. The aim of this narrative review is to overview and summarize current literature evidences on the role and effectiveness of aquatic rehabilitative protocols in CVD, reviewing old and current literature. Furthermore, the physical basis of the effects of water immersion on lower limb venous and tissues modifications are also described., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Venous leg ulcers (VLUs) are the most severe complication caused by the progression of chronic venous insufficiency. They account for approximately 70-90% of all chronic leg ulcers (CLUs). A total of 1% of the Western population will suffer at some time in their lives from a VLU. Furthermore, most CLUs are VLUs, defined as chronic leg wounds that show no tendency to heal after three months of appropriate treatment or are still not fully healed at 12 months. The essential feature of VLUs is their recurrence. VLUs also significantly impact quality of life and could cause social isolation and depression. They also have a significant avoidable economic burden. It is estimated that the treatment of venous ulceration accounts for around 3% of the total expenditure on healthcare. A VLU-free world is a highly desirable aim but could be challenging to achieve with the current knowledge of the pathophysiology and diagnostic and therapeutical protocols. To decrease the incidence of VLUs, the long-term goal must be to identify high-risk patients at an early stage of chronic venous disease and initiate appropriate preventive measures. This review discusses the epidemiology, socioeconomic burden, pathophysiology, diagnosis, modes of conservative and invasive treatment, and prevention of VLUs.

Background: Sclerotherapy is a non-invasive procedure commonly used to treat superficial venous disease, vascular malformations and other ectatic vascular lesions. While extremely rare, sclerotherapy may be complicated by serious adverse events., Objectives: To categorise contraindications to sclerotherapy based on the available scientific evidence., Methods: An international, multi-disciplinary panel of phlebologists reviewed the available scientific evidence and developed consensus where evidence was lacking or limited., Results: Absolute Contraindications to sclerotherapy where the risk of harm would outweigh any benefits include known hypersensitivity to sclerosing agents; acute venous thromboembolism (VTE); severe neurological or cardiac adverse events complicating a previous sclerotherapy treatment; severe acute systemic illness or infection; and critical limb ischaemia. Relative Contraindications to sclerotherapy where the potential benefits of the proposed treatment would outweigh the risk of harm or the risks may be mitigated by other measures include pregnancy, postpartum and breastfeeding; hypercoagulable states with risk of VTE; risk of neurological adverse events; risk of cardiac adverse events and poorly controlled chronic systemic illness. Conditions and circumstances where Warnings and Precautions should be considered before proceeding with sclerotherapy include risk of cutaneous necrosis or cosmetic complications such as pigmentation and telangiectatic matting; intake of medications such as the oral contraceptive and other exogenous oestrogens, disulfiram and minocycline; and psychosocial factors and psychiatric comorbidities that may increase the risk of adverse events or compromise optimal treatment outcomes., Conclusions: Sclerotherapy can achieve safe clinical outcomes provided that (1) patient-related risk factors and in particular all material risks are (1a) adequately identified and the risk benefit ratio is clearly and openly discussed with treatment candidates within a reasonable timeframe prior to the actual procedure; (1b) when an individual is not a suitable candidate for the proposed intervention, conservative treatment options including the option of ' no intervention as a treatment option ' are discussed; (1c) complex cases are referred for treatment in controlled and standardised settings and by practitioners with more expertise in the field; (1d) only suitable individuals with no absolute contraindications or those with relative contraindications where the benefits outweigh the risks are offered intervention; (1e) if proceeding with intervention, appropriate prophylactic measures and other risk-mitigating strategies are adopted and appropriate follow-up is organised; and (2) procedure-related risk factors are minimised by ensuring the treating physicians (2a) have adequate training in general phlebology with additional training in duplex ultrasound, procedural phlebology and in particular sclerotherapy; (2b) maintain their knowledge and competency over time and (2c) review and optimise their treatment strategies and techniques on a regular basis to keep up with the ongoing progress in medical technology and contemporary scientific evidence.

Background: Calcifications in the subcutaneous layer (SCL) have been described by radiographic studies of legs with advanced chronic venous disease (CVD). However, SCL calcifications have rarely been included among the CVD-related changes. The aim of the present study was to evaluate the prevalence and morphology of SCL calcifications in legs with CVD of all grades of severity determined by ultrasound., Methods: A total of 500 legs in 250 patients (148 women and 102 men; mean age, 51 years; range, 18-87 years) referred to our vascular clinic for symptoms and signs of CVD were included. After duplex ultrasound evaluation of the deep, superficial, and perforating veins, the skin and SCL were investigated using duplex ultrasound. Those patients with other possible causes of SCL calcification were excluded., Results: Using the C component of the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, 43 legs were classified as C1, 189 as C2, 34 as C3, 16 as C4A, 45 as C4B or C, 18 as C5, and 16 as C6. Varicose veins were reported in 273 legs, and lipodermatosclerosis in 79 legs. Subcutaneous calcifications were demonstrated in 35 of 361 legs with CVD in two different locations: the wall of superficial varicose veins and in subcutaneous tissue unrelated to the path of the superficial veins. Superficial veins calcifications were found in 12 of 273 legs with varicose veins (4.4%) and were found in older patients with severe varicose vein disease (grade 3 using the venous clinical severity score and disease duration >30 years). Subcutaneous tissue calcifications (STCs) were found in 24 of 95 legs with a more advanced CVD stage (C4A-C6). No STCs were found in legs with a C1, C2, or C3 class., Conclusions: Superficial veins calcifications were found only in the legs with severe and long-lasting varicose veins and seemed to be related to chronic severe inflammation of the venous wall. STCs were independent of the vein wall and were found only in the damaged areas of legs with severe CVD (C4-C6). STCs are possibly related to chronic inflammation of the subcutaneous tissue. Their avulsion from the ulcer bed has been recommended to facilitate ulcer healing and prevent recurrence., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Compression therapy is an important part of the treatment of patients with lymphedema or chronic venous disease. However, there is no validated questionnaire evaluating the effect of compression and its acceptance by the patient. Therefore, the aims of this study were to construct a questionnaire evaluating the effect of compression and its acceptance by the patient, that is, the Dutch ICC Compression Questionnaire (ICC-CQ), to investigate its reliability and validity, and to translate it into English. Methods and Results: Eleven experts in applying compression and 51 Dutch patients with experience of using compression were involved in the construction process. One part of the ICC-CQ has to be completed by the patient and evaluates seven domains. The other part has to be completed by the health care provider and comprises three domains. Reliability and validity of the final version was investigated in a new group of 79 Dutch-speaking patients with lymphedema or chronic venous disease, wearing compression garments ( N  = 52) or bandages ( N  = 27). Except for one domain, the Intraclass Correlation Coefficients for test-rest/interrater reliability ranged from 0.55 to 0.93. Cronbach's alpha for internal consistency ranged from 0.71 to 0.97. Eighty-nine percent of the patients fully understood the questionnaire indicating good face validity, and 87% found it complete indicating good content validity. Construct validity was considered good since 10 out of 11 hypotheses were accepted. Conclusion: The ICC-CQ is the first reliable and valid questionnaire evaluating different kinds of compression and the experience by patients with lymphedema or chronic venous disease.

Background: Lower limb ulcers not responding to standard treatments after 8 weeks are defined as chronic wounds, and they are a significant medical problem. Blue light (410-430 nm) proved to be effective in treating wounds, but there is a lack of data on chronic wounds in clinical practice. The aim of the study was to determine if blue light photobiomodulation with EmoLED (Emoled Srl, Sesto Fiorentino, Florence, Italy) medical device in addition to standard of care is more effective compared to standard of care alone in promoting re-epithelialization of chronic wounds of lower limbs in 10 weeks., Methods: Ninety patients affected by multiple or large area ulcers were enrolled. To minimize all variabilities, each patient has been used as control of himself. Primary endpoint was the comparison of the re-epithelialization rate expressed as a percentage of the difference between the initial and final area. Secondary endpoints were: treatment safety, pain reduction, wound area reduction trend over time, healing rate., Results: At week 10, the wounds treated with EmoLED in addition to standard care showed a smaller residual wound area compared to the wounds treated with standard of care alone: 42.1% vs. 63.4% (P=0.029). The difference is particularly evident in venous leg ulcers, 33.3% vs. 60.1% (P=0.007). 17 treated wounds and 12 controls showed complete healing at week 10. Patients showed a significant reduction in pain (P=2×10 -7 )., Conclusions: Blue light treatment in addition to standard of care accelerates consistently the re-epithelialization rate of chronic wounds, especially venous leg ulcers and increases the chances of total wound healing in 10 weeks.