Management of Lower Limb Ulcers. D. NAIK MBChB FRACS DDU
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1 Management of Lower Limb Ulcers D. NAIK MBChB FRACS DDU
2 Ulcer A defect in the epithelium
3 A failure to heal Ulcer
4 Aetiology of Leg Ulcers Venous insufficiency Macrovascular arterial insufficiency Infectious conditions Vasculitis/Microvascular insufficiency Malignancy Excessive pressure Lymphoedema Collagen vascular disorders Haemotologic abnormalities D Naik MBchB FRACS DDU [Vascular]
5 Venous Ulcers Gaiter area Mild pain Venous ooze Shallow,irregular shape,round edges Granulating base Surrounding inflammation Stasis dermatitis D Naik MBchB FRACS DDU [Vascular]
6 D Naik MBchB FRACS DDU [Vascular]
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8 Macrovascular arterial Atherosclerosis Posttraumatic Embolic Acute or chronic thrombosis
9 Ischaemic Ulcers Occur distally and over bony prominences Severe pain Little or no bleeding Irregular edge Poor granulation tissue Absent surrounding inflammation Trophic changes Absent pulses and low ABI D Naik MBchB FRACS DDU [Vascular]
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11 Vasculitis/Microvascular arterial insufficiency Diabetes microangiopathy Hypertensive microangiopathy Thromboangitis obliterans Raynauds disorder
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14 Infectious conditions Bacterial Fungal Mycobacterial Treponemal/spirochaetal
15 Malignancy Basal cell carcinoma Squamous cell carcinoma Malignant melanoma Kaposi s sarcoma Lymphoma Mycosis fungoides
16 Marjolin s ulcer
17 Lymphatic obstruction /lymphoedema Venolymphatic disease Primary or secondary lymphatic insufficiency Lymphangiosarcoma
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19 Haemotologic abnormalities Sickle cell anaemia Polycythaemia Dysproteinaemia
20 Collagen vascular disorders SLE Scleroderma Polyarteritis nodosa Wegeners granulomatosis
21 Excessive pressure Diabetic neuropathy Alcoholic neuropathy Decubitus ulcer Postoperative deformity Bone spurs
22 Neuropathic Ulcers Under calluses or pressure points Painless Bleeding maybe brisk Punched out,with deep sinus Surrounding inflammation Demonstrable neuropathy D Naik MBchB FRACS DDU [Vascular]
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24 D Naik MBchB FRACS DDU [Vascular]
25 Management of ulcers History Physical examination Ankle brachial index Blood tests Xrays Vascular investigations Biopsy Management of the underlying condition
26 History Varicose veins Deep venous thrombosis Claudication Rest pain Diabetes Injury Arthritis
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29 Clinical Examination Oedema Surrounding skin Site Pain Ulcer Pulses Stigmata of venous disease Doppler indices D Naik MBchB FRACS DDU [Vascular]
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35 Complications Bleeding Eczema Superficial thrombophlebitis Ulceration Deep vein thrombosis D Naik MBchB FRACS DDU [Vascular]
36 Epidemiology of Venous Ulcers 0.06 and 1% Rising prevalence in elderly Peak prevalence age 70 years F:M ratio 3:1 D Naik MBchB FRACS DDU [Vascular]
37 Risk factors for Venous Ulceration Venous insufficiency Previous DVT Chronic skin changes Local trauma Aggravation by co-existing conditions D Naik MBchB FRACS DDU [Vascular]
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40 Macrovascular Changes Ambulatory venous hypertension
41 Microvascular Changes Pericapillary fibrin deposition Localised microvascular ischaemia White cell adhaerence White cell activation Activity of inflammatory mediators D Naik MBchB FRACS DDU [Vascular]
42 Management of Venous Ulcers General measures Adjuvant pharmacotherapy Compression Dressings Sclerotherapy Endovenous interventions Surgery D Naik MBchB FRACS DDU [Vascular]
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45 Management-General Measures Address needs of the patient as a whole Consider lifestyle,mobility,occupation,nutrition Elevation of legs Prop bed up by 10-15% D Naik MBchB FRACS DDU [Vascular]
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47 Management - Dressings Choice is a matter of clinical judgement Insufficient clinical trials to allow recommendation D Naik MBchB FRACS DDU [Vascular]
48 The Ideal Dressing Reduce ulcer pain Allow excess exudate to escape Be non-allergenic Easy to change without discomfort Leave no dressing residue Inexpensive Easy to apply D Naik MBchB FRACS DDU [Vascular]
49 Management-Compression Ambulant patients need bandages or stockings mm Hg at ankle Graduated Sustained compression D Naik MBchB FRACS DDU [Vascular]
50 Ideal Compression Bandaging System Gradient of pressure Even pressure over anatomical contours Maintains pressure Remains in position Complements dressing functions Non-irritant and non-allergenic Comfortable Washable D Naik MBchB FRACS DDU [Vascular]
51 Management- Adjuvant Pharmacotherapy Only in addition to compression Agents include :fibrinolytic agents fibrinolysis-enhancing hydroxyrutosides pentoxifylline prostaglandin E systemic antibiotics diuretics D Naik MBchB FRACS DDU [Vascular]
52 Venous Ulceration 50-70% of venous ulceration is secondary to primary varicose veins and is curable with relatively simple venous interventions D Naik MBchB FRACS DDU [Vascular]
53 D Naik MBchB FRACS DDU [Vascular]
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56 Epidemiology Disease of Western civilisation 10-20% men and 67% of adult women have physically identifiable varicosities Varicose veins range from venectasia or telangiectasia to protuberant tortuous varicosities D Naik MBchB FRACS DDU [Vascular]
57 Primary Varicose Veins Great Saphenous Small Saphenous Perforator veins D Naik MBchB FRACS DDU [Vascular]
58 Secondary Varicose Veins A-V fistula Deep venous obstruction D Naik MBchB FRACS DDU [Vascular]
59 Investigation Duplex scan Venography CT venography D Naik MBchB FRACS DDU [Vascular]
60 Duplex Scanning Combination of ultrasound and Doppler Operator dependent Significantly improved our understanding and management of varicose veins Relatively cheap and non-invasive Mandatory prior to any major intervention D Naik MBchB FRACS DDU [Vascular]
61 D Naik MBchB FRACS DDU [Vascular]
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63 Management Conservative Sclerotherapy Non-surgical saphenous ablation Chemical Radiofrequency Laser Surgery D Naik MBchB FRACS DDU [Vascular]
64 Conservative treatment Weight loss Exercise Compression hosiery D Naik MBchB FRACS DDU [Vascular]
65 Local Sclerotherapy Simple office procedure Good results in appropriately selected patients May buy time Cheapest option D Naik MBchB FRACS DDU [Vascular]
66 Endovevous intervention Now the gold standard for varicose vein treatment Includes UGS and endovenous ablation Minimally invasive therefore lower threshold for intervention No general anaesthetic therefore suitable for high risk patients Day case local procedures Lower cost
67 Ultrasound Guided Sclerotherapy [UGS] Minimally invasive Poor results in large axial veins Good option in selected patients Systemic effects of sclerosants unknown May require multiple treatments Phlebitis and brown staining an issue Poor long-term results in large axial D Naik MBchB FRACS DDU [Vascular]
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70 Endovenous Laser Therapy First described by Bone in 1999 Diode laser forms steam bubbles in blood leading to endothelial damage,coagulative necrosis and thrombotic occlusion of vein Requires tumescent anaesthesia Deals with saphenous trunks only Requires adjunctive procedures for varices Early results favourable Day procedure D Naik MBchB FRACS DDU [Vascular]
71 D Naik MBchB FRACS DDU [Vascular]
72 Radiofrequency Ablation First described by Goldman in 2000 Heat generated by radiofrequency probe causes local heating of vein wall Requires tumescent anaesthesia Deals with saphenous trunks only Requires adjunctive procedures for varices Day procedure D Naik MBchB FRACS DDU [Vascular]
73 Management Surgical Therapy Varicose vein surgery Valvuloplasty Venous cuffs Venous bypass SSG Flaps D Naik MBchB FRACS DDU [Vascular]
74 Surgery Excellent results if performed well Requires anaesthesia,cuts and more recovery Neovascularisation in less than 7% Cutaneous nerve injury and leg swelling are issues Good long-term results Everything treated in one hit Good option in patients with very large varices D Naik MBchB FRACS DDU [Vascular]
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78 Complications of Venous Interventions Complicatio ns EVLT RFA SURGERY Bruising Pain Parathesia Phlebitis Haemotom a Burns Infection D Naik MBchB FRACS DDU [Vascular]
79 Management of Varicose Veins UGS EVLT/RF SURGERY Invasion Cost Discomfort Recovery Recurrence +++?? + D Naik MBchB FRACS DDU [Vascular]
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82 There has been a paradigm shift in the management of superficial venous insufficiency with most cases treated with an endovenous approach
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85 Äetiology of Arterial Occlusive Disease Atherosclerosis Emboli Arterial dissection Arteritis Aneurysms Arterial trauma Entrapment syndromes Adventitial cystic disease Vascular tumours D Naik MBchB FRACS DDU [Vascular]
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89 Epidemiology of PAD Affects 12-14% of the general population Affects upto 20% of patients over 75 Coexistent coronary artery disease and cerebrovascular disease are highly prevalent in patients with PAD D Naik MBchB FRACS DDU [Vascular]
90 History Location Duration Progress Distance Time for relief Associated rest pain D Naik MBchB FRACS DDU [Vascular]
91 Rest pain Pain felt in the distal forefoot which is exacerbated by elevation
92 Examination Arterial palpation Bruits Pallor Rubor Temperature Tissue loss Integumentary changes ABI D Naik MBchB FRACS DDU [Vascular]
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94 Management of Arterial Ulcers Duplex scanning Arteriography Angioplasty/stent Vascular reconstruction Debridement Skin grafting D Naik MBchB FRACS DDU [Vascular]
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96 Interpreting Doppler Readings >1 Normal arterial flow 0.9 Mild degree of arterial involvement 0.8 Lowest level at which compression can be safely applied 0.7 Significant arterial disease is present and full compression should not be used 0.5 Limb is at risk and urgent vascular opinion should be sought D Naik MBchB FRACS DDU [Vascular]
97 Non-invasive Vascular Tests Exercise ABI Toe pressures Pressure studies Duplex scanning Ultrasound Doppler Spectral analysis D Naik MBchB FRACS DDU [Vascular]
98 ABI Right Leg Left Leg Exe rcis e Per iod Rest Minutes Post Exercise D Naik MBchB FRACS DDU [Vascular]
99 D Naik MBchB FRACS DDU [Vascular]
100 Invasive studies CT angiography MR angiography Digital subtraction angiography D Naik MBchB FRACS DDU [Vascular]
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105 Best Medical Therapy Smoking Antiplatelet therapy Hypertension Diabetes Hyperlipidaemia Statin Cilastozol,Trental Exercise D Naik MBchB FRACS DDU [Vascular]
106 Our Approach We favour an endovascular first policy
107 Endovascular Treatment Angioplasty Stenting Atherectomy Thombolysis D Naik MBchB FRACS DDU [Vascular]
108 D Naik MBchB FRACS DDU [Vascular]
109 Angioplasty Best in big arteries with short stenoses Results below inguinal ligament best in focal lesions Short occlusions Myointimal hyperplasia affects results Greater role in high risk patients Improved technology with drug eluting balloons D Naik MBchB FRACS DDU [Vascular]
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113 Stenting Good long term results in iliac arteries Results below the inguinal ligament less durable Stent fracture an issue in mobile arteries Myointimal hyperplasia and in stent restenosis affect durability Improved technology resulting in better outcomes in high risk patients Drug eluting and biodegradable stents on the horizon D Naik MBchB FRACS DDU [Vascular]
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115 Surgical Treatment Aortoiliofemoral interventions Femoropopliteal reconstructions Distal arterial reconstruction Sympathectomy Amputation D Naik MBchB FRACS DDU [Vascular]
116 Surgical outcomes Improved outcomes with better peri-operative care and surgical techniques Operative mortality about 2-3 % Synthetic grafts work well in the aorta and iliacs but autologous grafts preferred below the infrainguinal ligament 5 year patency rates about 70-80% and limb salvage rates 80-90% Appropriate work up prior to surgery essential D Naik MBchB FRACS DDU [Vascular]
117 Endovascular or Surgery? BASIL trial Life expectancy greater than 2 years limb salvage greater and mortality lower in surgery patients Role of stenting still undefined but long-term patency and cost effectiveness remain an issue D Naik MBchB FRACS DDU [Vascular]
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142 Ulcers When to refer Pain Infection Absent pulses ABI < 0.8 Refractory ulcers Cellulitis Deteriorating ulcers D Naik MBchB FRACS DDU [Vascular]
143 Conclusion Aetiology of lower limb ulcers is often multifactorial Management of leg ulcers should include an assessment and management of aetiological factors Current management of vascular patients involves tailoring intervention according to the clinical and risk profile of the patient As less invasive management options are available for intervention consideration of early specialist referral is appropriate
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Management of Lower Limb Ulcers. D. NAIK MBChB FRACS DDU
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