Colin E. Davies MSc BSc(Hons) FAETC RGN Gloucestershire Leg Ulcer Service Cheltenham General...

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Colin E. Davies Colin E. Davies MSc BSc(Hons) FAETC RGNMSc BSc(Hons) FAETC RGN

Gloucestershire Leg Ulcer Service Gloucestershire Leg Ulcer Service Cheltenham General HospitalCheltenham General Hospital

Management of Leg UlcersManagement of Leg UlcersThe Role of the Gloucestershire Leg Ulcer ServiceThe Role of the Gloucestershire Leg Ulcer Service

IntroductionIntroduction

Common

Low healing

High recurrence

Poor assessment

Irrational treatment

Chronic problem

Expensive

Causes of Leg UlcersCauses of Leg Ulcers

Venous 70%

Arterial 10%

Arterial + venous 10-15%

Non-vascular 5%

Non-Vascular Co-Morbidities

• Malignancy• Trauma• Diabetes• Rheumatoid Arthritis• Vasculitis• Blood disorders • Metabolic disorders

95% OF LEG ULCERS WILL BE VASCULAR

Cause of Tissue BreakdownCause of Tissue Breakdown

Skin CapillaryOxygen

Nutrients

Oxygen

Nutrients

Carbon dioxide

Waste metabolites

Waste metabolites

Water

Fibrinogen

Carbon dioxide

Chronic Venous HypertensionChronic Venous Hypertension

Cause of Tissue BreakdownCause of Tissue Breakdown

Fibrin cuff deposition

White cell entrapment

Growth factor entrapment

Fibrin

Leucocytes

Chronic Venous HypertensionChronic Venous Hypertension

Oedema

Haemosiderin staining

Atrophy blanche

Ankle flare

Lipodermatosclerosis

Varicose veins

Varicose eczema

Non-Vascular Co-Morbidities

• Malignancy 1 – 2% • Trauma• Diabetes• Rheumatoid Arthritis• Vasculitis• Blood disorders • Metabolic disorders

Non-Vascular CausesNon-Vascular Causes

Ankle brachial pressure index

Colour venous duplex ultrasound

Arterial ultrasound scan

AssessmentAssessment

Re-vascularisationRe-vascularisation

ABPI 0.85-1.25ABPI 0.85-1.25

Fullcompression

Fullcompression

ABPI 0.5-0.85ABPI 0.5-0.85

Modified compression

Modified compression

ABPI <0.5ABPI <0.5

Refer to vascular surgeon

Refer to vascular surgeon

Deterioration Deterioration HealedHealed

IncompressibleIncompressible

Leg Ulcer ManagementLeg Ulcer Management

CompressionCompression

ElevationElevation

ExerciseExercise

Compression + Elevation + Exercise = Optimum HealingX X X Delayed Healing

Evidence-Based ApproachEvidence-Based Approach

However recurrence rates are high

Compression is lifelong

Concordance is poor

Venous Ulcers

Treatment Pathways

Ulcerated limb ABPI >0.85Ulcerated limb ABPI >0.85

Compression

Compression Compression + SurgeryCompression + Surgery

Monthly review

Monthly review

3 monthly review

3 monthly review

ESCHAR TrialESCHAR Trial

Superficial Venous RefluxSuperficial Venous Reflux

1260

100

80

60

40

20

0

Months

Healed limbs %

Surgery + compression

Compression alone

p<0.0001

31%

12%

ESCHAR ResultsESCHAR Results

Mixed superficial and segmental deep refluxMixed superficial and segmental deep reflux

120

100

80

60

40

20

0

Months

Healed limbs %

Surgery + compression

Compression

p=0.04

6

29%

9%

ESCHAR ResultsESCHAR Results

Lancet 2004 Jn 5; 363(9424): 1854-1859

41% refused surgery

ESCHAR ResultsESCHAR Results

n = 500

Barwell et al, 2004

Isolated superficial reflux61%24%

Superficial & segmental deep

reflux

15%

Superficial & total deep

Suitability for Further InterventionSuitability for Further Intervention

Established in 1995

Referral system

One-stop assessment

Nurse specialists

Community clinics

Vascular Unit link

Management Protocol

The Leg Ulcer ServiceThe Leg Ulcer Service

68 %

29 %0

20

40

60

80

100

Before After

%

23 %

54 %

0

20

40

60

80

100

Before After

%

Healing 24 Weeks

Recurrence 12 Months

P<0.01

P<0.01

Ghauri ASK, et al (1998) Eur J Endovasc Surg 16, 238-244

Established in 1995

Referral system

One-stop assessment

Nurse specialists

Community clinics

Vascular Unit link

Management Protocol

The Leg Ulcer ServiceThe Leg Ulcer Service

General Practitioners

Leg Ulcer Service

Community Nurses

Dermatologists

Patient Self-Referral

Ward Nurses

Other Specialists

Practice Nurses

Established in 1995

Referral system

One-stop assessment

Nurse specialists

Community clinics

Vascular Unit link

Management Protocol

The Leg Ulcer ServiceThe Leg Ulcer Service

Established in 1995

Referral system

One-stop assessment

Nurse specialists

Community clinics

Vascular Unit link

Management Protocol

The Leg Ulcer ServiceThe Leg Ulcer Service

Established in 1995

Referral system

One-stop assessment

Nurse specialists

Community clinics

Vascular Unit link

Management Protocol

The Leg Ulcer ServiceThe Leg Ulcer Service

GLOUCESTERCinderford

CHELTENHAMBourton-on-the-Water

Cirencester

Tewkesbury

Stroud

Moreton-in –the-Marsh

Established in 1995

Referral system

One-stop assessment

Nurse specialists

Community clinics

Vascular Unit link

Management Protocol

The Leg Ulcer ServiceThe Leg Ulcer Service

Community Leg Ulcer Clinics

Home

Specialist Nurses

Primary Care Teams

Hospital

Vascular Lab

Vascular Surgeon

Established in 1995

Referral system

One-stop assessment

Nurse specialists

Community clinics

Vascular Unit link

Management Protocol

The Leg Ulcer ServiceThe Leg Ulcer Service

1995 20122000 2005

Well Leg Clinic

Management StrategiesManagement Strategies

Foam

Biopsy

Multilayer Compression + Hosiery

One-Stop Assessment Clinic

Pinch Skin Grafting RCT

Superficial Venous Surgery ESCHAR

Larvae Therapy RCT

Improvement in OutcomesImprovement in Outcomes

Prospective database

November 1995 – December 2010

Healing

Recurrence

7481 legs on database

Excluded (n=2085)  Arterial, malignant, diabetic, rheumatoid, others  Lost to follow up

Data analysed prospectively for:

 24 week healing rates 12 month recurrence rates

Improvement in OutcomesImprovement in Outcomes

5396 legs

24 Week Healing24 Week Healing

0 2010 30 40

Weeks

100

80

60

40

20

0

Hea

led

(%

)

--- 2007 – 2010--- 2003 – 2006--- 1999 – 2002 --- 1995 – 1998

81%

63%29 %

12 Month Recurrence12 Month Recurrence

--- 2007 – 2010--- 2003 – 2006--- 1999 – 2002 --- 1995 – 1998

100

80

60

40

20

0

Rec

urr

ence

(%

)

0 20 10 30 40 50 60

Weeks

20.1%

13.5%33%

ConclusionsConclusions

Improved healing Improved healing

1995 - 19981995 - 1998

63%healed at 24 weeks

2007 - 20102007 - 2010

81%healed at 24 weeks

Before ServiceBefore Service

29%healed at 24 weeks

AuditAudit ProspectiveProspective

179%

ConclusionsConclusions

Reduced recurrence Reduced recurrence

1995 - 19981995 - 1998

20.1%recurrence at 12 months

2007 - 20102007 - 2010

13.5%recurrence at 12 months

Before ServiceBefore Service

54%recurrence

at 12 months

AuditAudit ProspectiveProspective

- 75%

Conclusions

Secondary care assessment

Specialist vascular-led clinics

Clearly defined, evidence-based protocols

Further intervention

Leg ulcer management benefits from…

Thank youThank you

www.cheltenhamvascularunit.co.ukwww.cheltenhamvascularunit.co.uk