From Compression To Injections : Are Prostaglandins Paving A New Direction For Venous Ulcer Treatment
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1 ` From Compression To Injections : Are Prostaglandins Paving A New Direction For Venous Ulcer Treatment Dr. Vinay. K.S MS, M.Ch Vascular Surgery Assistant professor & Consultant Vascular Endovascular Surgery Bengaluru Dr. Rajendra Prasad B M S, DNB Vascular Surgery, FEVS Austria Associate Professor & Consultant Vascular Endovascular Surgery M S Ramaiah Hospitals Bengaluru
2 Introduction Venous ulcers - highly morbidity Incidence : % Poor tendency to heal Long treatment Longer follow up Origin Multifactorial VENOUS HYPERTENSION - STASIS
3 Review of Literature Milio G, Mina C, Cospite V et al - 100% healed <100 days, 84.2% in placebo G Rudofsky et al - PGE1 (40%) : Placebo (9%) healing Beitner H, Hammar H, Olsson A et al : PGE1 (90%) Milio G, Mina C, Cospite V, et al.efficacy of treatment with prostaglandin E-1 in venous ulcers of lower limbs.journal of Vascular surgery 2005; 42(2):304-8 P J Franks, N Bosanquet,D Brown.Percieved health in a randomized trial of treatment of chronic venous ulceration.european journal of vascular endovascular surgery 1999; Beitner H, Hammar H, Olsson AG. Prostaglandin E1 treatment of leg ulcers caused by venous or arterial incompetence. Acta Derm Venereol.980;60(5):
4 PG- E1 Metabolite of polyunsaturated di homo-gamma-linoleic acid Acts on membrane receptors of intercellular adenylcyclase - camp Reduction of endothelial permeability and inhibition of vasoconstrictive activity of thromboxane A2, serotonin, leukotrienes, and endothelin
5 Other Actions PG E1 Reduction of the adhesiveness and platelet aggregation Inhibition of the proliferation of the smooth muscle cells of the media Reduction of the hematic viscosity Pro-fibrinolytic effect Inhibition of chemotaxis and activation of white cells, stimulation of formation and growth of collateral circulation
6 Adverse Effects Cardiac Others Bradycardia Injection-site haematoma Cardiac arrest Pain: Back, Pelvic, Penile, Urethral Congestive heart failure Prolonged erection Tachycardia Seizures Ventricular fibrillation Apnea Hypotension Bleeding: Cerebral, Urethral Shock Diarrhea, Fever DIC, Edema
7 Aim Evaluate efficacy : PGE-1 on healing of refractory venous ulcers
8 Method of Study 44 patients - venous leg ulcers homogeneous for dimensions and characteristics PGE1 + 4 layer compression VS plain 4 layer compression Dimension and number of ulcers Monitoring done every 21 days up to 3 months (until complete recovery)
9 Method of Study INCLUSION CRITERIA Venous ulcers of lower limbs, defined as non-healing wound of the skin of the lower extremities caused by impaired venous return Proved clinically & by Doppler examination. No contraindication to PGE-1 EXCLUSION CRITERIA Not willing Congenital Venous insufficiency Arterial insufficiency (ABI < 0.7), Diabetic non healing ulcer, neurotrophic ulcer Vasculitis.
10 Management Distribution Prostaglandin + Compression Compression
11 Study Dose : 500mcg/ml diluted in 4ml NS (1 ml each into 100 ml NS Follow up was 3 weekly Size of ulcer was measured during follow up First day Observed in ICU Percentage of Recovery was observed from initiation of therapy up to 3 months, or till the ulcer healed
12 Baseline Patient Characteristics PGE-1 + Compression Compression Number of Patients Mean Age 46 ± ± 9.5 Sex (Males %) 90.5% 84.6% Total / Partial Obstruction 14 (31.81%) 10 (22.72%) Superficial Venous Incompetence 12 (27.27%) 8 (18.18%) Deep Venous Reflux 9 (20.45%) 7 (15.90%) Junctional / Perforator Incompetence 4 (0.9%) 6 (13.63%) 20.5 ( 6 48 ) 19.4 ( 8 40 ) Doppler Findings Ulcer Features Area (cm2)
13 Patient Distribution PTS 26 Post Surgery Junctional Incompetence not willing for SX Perforator Incompetence Iliac Stenting
14 Results Ulcer healing % % P+C C < 30 days < 60 days < 90 days < 120 days
15 Complication Hypotension (3) Bradycardia (1) Diarrhoea (1)
16 Cases
17 Cases
18 Cases
19 Cases
20 Conclusion Pharmacologic treatment with PGE layer bandage and local therapy, has a favorable effect on the healing of venous ulcers Side effects of treatment acceptable Drug well tolerated by patients High Quality RCT : Confirm Efficacy and Safety
21 23RD ANNUAL CONFERENCE OF THE VASCULAR SOCIETY OF INDIA & 2ND CONGRESS OF WORLD FEDERATION OF VASCULAR SOCIETIES
22 LETS CONTINUE SAVING OUR VEINS
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