Search

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, TcPO(2)), and carbon dioxide (transcutaneous pressure of carbon dioxide, TcPCO(2)) measurements and capillaroscopy. These techniques provide significant pathophysiologic and prognostic information. TcPO(2) and TcPCO(2) diagnose and classify the extent of arterial disease in the leg ulcers caused by arterial disease; the prognostic value is recognized, though doubts about its prognostic potential exist in the case of leg ulcer. Laser Doppler flowmetry is able to identify the first functional impairment in the early stages of the arterial disease and in the complicated venous insufficiency. Capillaroscopy gives us morphological and quantitative parameters of the capillary bed that is damaged in arteriopathic and venous ulcers; nevertheless, it does not provide us with definite prognostic indexes. Combining the 3 methods may contribute to yield objective measures in the clinical management of lower extremity ulcers. [ABSTRACT FROM AUTHOR]

Background: C0S patients have symptoms of chronic venous disorders (CVDs), though an anatomical or pathophysiological explanation is lacking. C0 and C1 classified lower limbs can present with valve incompetence from the second to sixth generation of tributaries of saphenous veins despite the absence of a detectable saphenous truncal reflux. We hypothesized that C0S venous symptoms could stem from the second to sixth generation of saphenous tributaries and small veins that are not connected to the saphenous system. The aim was to explore these veins in C0S subjects and compare them with asymptomatic C0A subjects., Methods: This was an open, controlled study enrolling 36 subjects, where C0S patients (N.=18) were compared with asymptomatic C0A subjects (N.=18). The VAS (visual analog scale) was used to assess leg pain. Veins were assessed using B-flow ultrasound (valve anatomy), continuous-wave (CW) Doppler (flow patterns), biomicroscopy (visualization of nutritional vessels), laser Doppler flowmetry (quantify supine microvascular perfusion) and quantitative digital photo-plethysmography (PPG) (measuring post-exercise venous refilling time [VRT])., Results: There were no significant differences between C0S and C0A subjects in terms of microvascular perfusion (laser-Doppler), nutritional vessels (biomicroscopy) and VRT (PPG). B-flow ultrasound was unable to acquire sufficient data in second generation saphenous tributaries. However, the CW Doppler identified two different flow patterns: uni- and bidirectional. Bidirectional flow was significantly (P=0.05) higher in C0S versus C0A patients., Conclusions: CW Doppler, using a flat high-sensitivity probe, revealed the presence of a bidirectional flow that was significantly (P=0.05) higher in C0S than in control patients, suggesting the presence of reflux in non axial veins. These data give a new perspective on the management of C0S patients.

The successful use of an extract of Hypericum flowers (Hypericum perforatum) and nimh oil (Azadirachta indica; Hyperoil) in foot wounds with exposed bone in a patient with bilateral advanced diabetic ulcers, has been reported previously. It was hypothesised that this amelioration was linked with the improved glycaemic control and peripheral microvascular circulation. In this case report, the surprisingly successful outcome of another patient using Hyperoil for infection damaged diabetic foot, without prior use of surgical procedure, is described. The patient had no macrovascular pattern impairment. Diabetic foot healing paralleled with controlled local infection and enhanced glycaemic control. The outcome of this patient suggests that the effectiveness of this inexpensive therapy using Hyperoil for diabetic foot is not only linked with the presence of severe microvascular disorder, but also with the appropriate local treatment for ulcer being a must for its recovery., (2014 BMJ Publishing Group Ltd.)

This is the first case reporting the results of using an extract of Hypericum flowers (Hypericum perforatum) and neem oil (Azadirachta indica) in foot wounds with exposed bone in a patient with bilateral advanced diabetic ulcers. The effective use of this cheap treatment in patients with diabetic lesions on the feet, if confirmed in a wide controlled study, might allow the caregivers to take care of patients at home.

This is the first case reporting the effective use of 2 weeks of ozone therapy for the treatment of Buruli ulcer (BU), a dramatic disease caused by Mycobacterium ulcerans, an epidemic in central Africa. This simple and cheap treatment could become an effective option for managing BU as an alternative to antibiotic or surgical treatments.

Objectives: This study was conducted to define bandage pressures that are safe and effective in treating leg ulcers of mixed arterial-venous etiology., Methods: In 25 patients with mixed-etiology leg ulcers who received inelastic bandages applied with pressures from 20 to 30, 31 to 40, and 41 to 50 mm Hg, the following measurements were performed before and after bandage application to ensure patient safety throughout the investigation: laser Doppler fluxmetry (LDF) close to the ulcer under the bandage and at the great toe, transcutaneous oxygen pressure (TcPo(2)) on the dorsum of the foot, and toe pressure. Ejection fraction (EF) of the venous pump was performed to assess efficacy on venous hemodynamics., Results: LDF values under the bandages increased by 33% (95% confidence interval [CI], 17-48; P < .01), 28% (95% CI, 12-45; P < .05), and 10% (95% CI, -7 to 28), respectively, under the three pressure ranges applied. At toe level, a significant decrease in flux of -20% (95% CI, -48 to 9; P < .05) was seen when bandage pressure >41 mm Hg. Toe pressure values and TcPo(2) showed a moderate increase, excluding a restriction to arterial perfusion induced by the bandages. Inelastic bandages were highly efficient in improving venous pumping function, increasing the reduced ejection fraction by 72% (95% CI, 50%-95%; P < .001) under pressure of 21 to 30 mm Hg and by 103% (95% CI, 70%-128%; P < .001) at 31 to 40 mm Hg., Conclusions: In patients with mixed ulceration, an ankle-brachial pressure index >0.5 and an absolute ankle pressure of >60 mm Hg, inelastic compression of up to 40 mm Hg does not impede arterial perfusion but may lead to a normalization of the highly reduced venous pumping function. Such bandages are therefore recommended in combination with walking exercises as the basic conservative management for patients with mixed leg ulcers., (Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Debridement plays an essential role in the wound-bed preparation of necrotic and sloughy ulcers, being a mandatory step to achieve a well-debrided bed, proceeding towards healing. This study reports our experience with Versajet [Versajet Hydrosurgery System (Smith & Nephew, Hull, UK)], a new device for the debridement of exudating ulcers, based on Fluidjet technology, which excises and aspirates the unwanted tissue by using the Venturi effect. In a 10-month time period, a total of 68 patients, out of a setting of 167 patients, hospitalised as affected by chronic, hard-to-heal leg ulcers, stuck in the inflammatory phase, were treated with Versajet. Based on ulcer characteristics and clinical conditions, the remaining 99 patients underwent traditional debridement with moist dressings (controls). In the majority of Versajet-treated cases (46), an adequately debrided wound bed was achieved with one operative procedure; two and three procedures were required in 17 and 5 patients, respectively. Almost all the procedures were performed in the ward at the patient's bedside. This procedure is quick (mean time per treatment is about 5 minutes); when compared with a traditional treatment with moist dressings, Versajet considerably shortens the in-hospital stay and promotes a quicker healing process. When used by an experienced surgeon, Versajet allows a selective debridement, as it makes it possible to remove only the tissue centred in the working end and spare the healthy tissue. Debriding with Versajet is highly effective in reducing the bacterial load of the ulcer bed. The pain caused by Versajet is well tolerated, especially when set for gentle debridement. If multiple treatments are required, the combined use with moist dressings is synergistic, as the dressings soften the necrotic tissue, thus facilitating the following Versajet debridement. The results indicate that Versajet offers more precision than standard mechanical debridement and, at high settings, offers an alternative to surgical debridement.

Background: The quantification of venous reflux is rarely made but it is valuable for studying the natural history of CVI, its prognostic implications and the therapy effectiveness. We have evaluated some parameters of chronic venous insufficiency, caused by valvular incompetence, by means of duplex scanner and light reflection rheography searching for a better correlation with the clinical stages of vein disease., Methods: We have examined 107 patients (35 males, 72 females; aged 22-78, mean 61.5 +/- 14.3) with long saphenous insufficiency in different clinical stages and measured the venous reflux, the reflux duration, the reflux grade, the vein diameter near the saphenofemoral junction with the duplex scanner and the refilling time with the light reflection rheography. The reproducibility of the studied techniques has been determined by examining 20 legs four times each in the same day or on different days. Statistical analysis of the data was performed by means of the variance analysis followed by the Waller-Duncan test., Results: The venous reflux, the venous diameter and the refilling time can easily range between mild and severe insufficiency: reflux is 6.3 +/- 2.5 ml/sec at stage I; 27.5 +/- 10.1 at stage III; venous diameter is 6.04 +/- 1.4 at stage I; 10.6 +/- 2.2 at stage III; refilling time is 23.6 +/- 9.6 at stage I; 5.4 +/- 2.4 at stage III. The reflux time and reflux grade are unable to separate the various CVI stages., Conclusions: The measurement of venous reflux, venous diameter and refilling time is simple, quick, reproducible; these indices are able to differentiate mild from severe CVI but unable to separate patients at the second stage of the venous disease from those at the third stage and then ineffective in the ulcer risk assessment but the reflux is highly predictable. The ulcer risk is practically absent for reflux < 12 ml/sec; highly probable for reflux > 15 ml/sec (20/46 cases; 43.4%).

Background: The increase in aortic Pulse Wave Velocity (PWV) is considered a surrogate marker of vascular disease; it can be non-invasively assessed by means of an indirect method calculating the time that the pulse wave takes to travel a definite distance along the vasculature; the distance/time ratio corresponds to the velocity measure. The presentation of a new calculation method is the aim of the present study., Methods: A duplex scanner at the common carotid artery, the abdominal aorta at the prebifurcation site and the femoral common artery levels, was performed on 127 out-patients with risk factors, 38 of which were affected by clinical vascular disease, and on 50 healthy subjects (control group). The spectral analysis from these three sites was registered simultaneously with an ECG trace and the interval between the R wave apex and the spectral complex systolic foot was measured. The Transit Time (TT) was calculated by the difference between the values obtained from the proximal and distal measurement sites and PWV dividing the distance between them by the TT (PWV = Distance/TT); statistical significance and intra and inter observer variation coefficient, expressed as mean +/- standard deviation, were calculated by the analysis of variance and Turkey test, the correlation with the major risk factors and the intima-media thickness by the multivariate analysis., Results: The PWV is increased in the patients group compared to control group (p < 0.001). Multivariate analysis shows a positive correlation with age, hypercholesterolemia, arterial hypertension, diabetes mellitus, intima-media thickness and arterial disease, no correlation was found with the smoking habit. The "patients" group shows an increased PWV in those with atherosclerotic plaques and/or clinical vascular disease compared to non atherosclerotic patients with risk factors (p < 0.001); the intra and inter observer variation coefficient ranged between 4.87 +/- 1.82% and 8.06 +/- 3.16% respectively., Conclusions: The proposed PWV measurement method is simple, quick, reproducible and repeatable, it can separate healthy subjects from patients with risk factors, atherosclerotic plaques and clinical vascular disease. Due to the strong correlation with age, normal values in different age groups are necessary before the PWV can be used as a marker of vascular disease.

Background: The first results of a multicentric study dealing with recurrent varicose veins after surgery are presented. The aims of the study are: identifying the type of varicose vein, specifying the most frequent complaints (esthetical or functional), locating the causes of recurrence, establishing the causes and the most frequent seat of recurrence, clarifying whether it is enough to call recurrent all the varicose veins which appear after surgery or whether it is necessary to distinguish various typologies., Methods: 194 patients (139 women and 55 men) aged 51.6 average (range 28-87), have been studied up to now with duplex and color scanner following a precise protocol which consisted of three stages: before treatment, within 2 months from treatment and after recurrence of varicose veins or venous insufficiency symptoms., Results: Recurrent varicose veins represented 65.7%, residual ones 14.3%, new ones 2.5%. It has not been possible to identify the type of varicose vein in 8.3% of cases. Stripping of the great saphenous veins was carried out in 88% of cases, short stripping in 4.1%, stripping of the short saphenous veins in 6.9%. Recurrent varicose veins were due to technical error in 78.7% of cases, to diagnostic error in 9.2%, to unidentifiable causes in 12% of cases., Conclusions: Data relating to the prospective study of the research will be published in subsequent papers.

The aim of this work was to test whether calcium channel blockers interfere with skin vasoconstrictor reflexes that minimize postural increases in capillary pressure and avoid fluid extravasation and eventually subcutaneous edema. Studies were conducted in 23 untreated mild to moderate essential hypertensives; drugs, either calcium channel blockers or not, were given for 2 weeks according to a crossover, sequence-randomized design. Skin blood flow was measured by laser Doppler flowmetry in two skin areas: (1) the dorsum of the foot, where arteriovenous anastomoses are poorly represented, and (2) the plantar surface of the great toe, where those anastomoses are predominant. Determinations were obtained both with the foot at heart level and with it placed passively 50 cm below the heart level; percent flow changes from the horizontal to the dependent position were the measure of postural vasoconstriction. Two dihydropyridine derivatives, amlodipine (10 mg UID) and nifedipine (60 mg UID), and verapamil (240 mg BID), a chemically unrelated compound, diminished to similar extents the postural fall in skin blood flow at the dorsum of the foot. Blockade of alpha1-adrenergic and AT-1 subtype angiotensin II receptors by doxazosin (4 mg UID) and losartan (50 mg UID), respectively, exerted no effect. Postural skin blood flow responses at the plantar surface of the great toe were unmodified during the pharmacological trials. Thus, calcium channel blockers of different chemical origins antagonized postural skin vasoconstriction at the dorsum of the foot. The data indicate altered postural capillary blood flow regulation, since arteriovenous anastomoses are anatomically absent at this site; the effect was independent of either alpha1-adrenoceptor or angiotensin II receptor antagonism. Interference with skin postural vasoconstrictor mechanisms may result in net filtration of fluid to the extravascular compartment. This mechanism might explain the as yet unknown pathogenesis of ankle edema during treatment with calcium antagonists.