Chapter 157 - Chronic venous disorder - nonoperative Flashcards
Percentage of CVD that develop ulcers
20%
Micronized purified flavonoid fraction uses
treatment of large and long standing ulcers from venous disease
Lifestyle modifications for CVD
1) exercise
2) leg elevation (30 cm above heart)
Normal standing resting venous pressure
60-80 mmHg
Highest pressure safety limit for compression stocking
60 mmHg
Benefit of compression therapy
1) improve venous pump function
2) enhance venous flow velocity
3) improve cutaneous microcirculation?
4) Decreased TNFalpha and VEGF
Types of compression garments
1) gradient elastic stockings
2) circaid garment
3) Unnaboot (paste gauze boot
4) layered elastic and nonelastic compression bandages
5) intermittent pneumatic compression
Gradient elastic stockings developed in
1950’s
4 strengths of gradient compression stockings
Class 1: 10-15 mmHg
Class 2: 20-30
Class 3: 30-40
Class 3 high compression: 40-50
Timing to replace compression garments
6-9 months
Measuring compression stockings at levels in the leg
1) thigh
2) midcalf
3) ankle
People that benefit from Class 1 compression
1) symptom control in CEAP 1
2) varicose vein in pregnancy
3) prevention of leg edema related prolonged standing/sitting
4) prevention of VTE in non-ambulation
Evidence on class 2 compression in varicose vein prevention and treatment
weak evidence overall
REACTIV trial key points
Randomised clinical trial, observational study and assessment of cost-effectiveness of treatment of varicose veins
Three groups
group 1: minor VV, conservative vs sclero
Group 2: moderate varicose with reflux, conservative vs surgery
Group 3: severe varicose: conservative vs surgery
Surgery provided better symptom relief and QOL and pt satisfaction
Sclerotherapy not really
Gradient compression type for C4-6 disease
Class 3 stockings
Compliance is poorer however than Class 2
SOX trial
Compression stocking to prevent PTS after DVT
410 patients
Class 3 vs placebo
no difference
CircAid garment
1) non elastic compression with multiple Velcro bands
2) Adjustable for limb size and improved comfort
Unna boot
1) developed by Paul Gerson Unna 19th century end
2) multi layer compression dressing
3) gauze with calamine, zinc oxide, glycerin, sorbitol, gelatin and magnesium aluminum oxide, elastic wrap
4) stiff with drying
5) pressure 50-60 mmHg
6) change weekly depending on drainage amount
Better healing than polyurethane dressing
Dressing classes
1) Hydrocolloid: mild exudating ulcers
2) Foam dressing: heavy exudating ulcer, painful ulcer
3) Alginate: infected ulcer, hemorrhagic and exudating ulcer
4) Hydrogel: necrotic ulcer/dry ulcer
5) Hydrofibers (Aquacel): infected ulcer, heavy exudate
6) Impregnated mesh dressing (adaptic, mepitel): mild exudate
7) Hyaluronic acid based dressing: mild exudate
8) Charcoal dressing: foul smelling ulcers
9) Silver dressing (Acticoat, aquacel Ag): infected exudating
10) Protease modulating: hard to heal ulcer
11) Paraffin/petroleum gauze (jelonet)
Elastic and non-elastic bandages
ELASTIC - easier to apply but uncomfortable
1) Ace
2) sure press
3) perfecta
NONELASTIC - may lose pressure over time as swelling down
4) putter
5) comprilan
6) coban
Intermitten pneumatic compression dressing evidence
helps with reducing edema
ulcer healing evidence poor
ACTitouch device
Adaptive pressure multichamber system
50 mmHg at foot/ankle
45 mmHg at midcalf
40 mmHg at knee
improved QOL, ease of use, skin protection but no change in ulcer healing
ESCHAR study
Effect of surgery and compression on healing and recurrence
500 patients
compression vs compression + surgery
Healing rates similar
recurrence rate 2 year better in surgery
Function of zinc in body
1) cofactor for enzyme process
2) humoral and cell mediated immunity response and wound healing
Pharmacologic treatment of CVD that have no evidence
No evidence for diuretic, zinc, fibrinolytic, horse chestnut (prostaglandin F), aspirin, ifetrobane (thromboxane A2 antagonist)
Pentoxifylline function
1) competitive non-selective adenylate cyclas inhibitor
2) increase intracellular cAMP
3) activate protein kinase A
4) inhibit TNF
5) promote leukotriene synthesis
Red blood cell deformity and inhibit platelet aggregation and thrombus formation
Antiinflammatory effect
Evidence on pentoxifylline in ulcer healing
overall more effective with pentoxifylline
there’s some controversy
Phlebotropic agent definition
medication with multiple pharmacologic microcirculatory activities
Micronized purified flavonoid fraction component
90% micronized diosmin
10% flavonoids
Action of MPFF
1) inhibit granulocyte and macrophage infiltration
2) phleotropism prevent apoptosis of endothelial and prevent valve degeneration
MPFF effect with studies
1) reduce edema
2) improve ulcer healing
Prostaglandin E1 effect
Attenuate WBC activation
improve ulcer healing
Calcium dobesilate
Reduce capillary permeability
improve edema
no effect on ulcer healing
