Case and Research Letters
Treatment of a Refractory Venous Ulcer With Terminal Interruption of the Reflux Source
Tratamiento de úlcera venosa refractaria mediante la «interrupción terminal de la fuente de reflujo»
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Mendieta-Eckert, J.L. Azpiazu-Macho, N. Landa-Gundin" "autores" => array:3 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Mendieta-Eckert" "email" => array:1 [ 0 => "mmendieta@dermitek.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J.L." "apellidos" => "Azpiazu-Macho" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "N." "apellidos" => "Landa-Gundin" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Clínica Dermitek, Vizcaya, Bilbao, España" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Flebología, Clínica Dermitek, Vizcaya, Bilbao, España" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento de úlcera venosa refractaria mediante la «interrupción terminal de la fuente de reflujo»" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 878 "Ancho" => 1309 "Tamanyo" => 192054 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Venous ulcer before treatment. B, Complete resolution 4 weeks after beginning treatment, with evident improvement of the surrounding skin.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Venous ulcers are the main cause of chronic leg ulcers. They have a high prevalence, high morbidity, and a marked socioeconomic impact. Venous ulcers are frequently encountered in dermatology and vascular surgery consultations, require long-term treatment, and commonly recur.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Compressive therapy is the treatment of choice. However, these ulcers can often become chronic and fail to respond to multiple local treatments and dressings. If a significant improvement is not observed within 4 to 12 weeks, conservative treatment is unlikely to result in cure.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe the case of a 69-year-old man, with no medical history of interest, who was seen for a painful venous ulcer on the ankle that had appeared 6 months earlier. The patient had undergone conservative treatment with a compressive bandage and local wound treatment, and had twice received oral antibiotic treatment for superinfection. Physical examination revealed an internal inframalleolar ulcer of 4 cm and 2 adjacent incipient lesions (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A), as well as varicose veins with secondary dermatosclerosis and skin hyperpigmentation. Triplex ultrasound (3–13-MHz probe) revealed incompetence of the great saphenous vein, with tributaries projecting towards the ulcer bed, and an adjacent incompetent perforator vein. Ultrasound-guided sclerotherapy of the ulcer bed was performed using the terminal interruption of the reflux source (TIRS) technique. In total, the patient underwent 4 sessions at 1-week intervals using a mixture consisting of 1 part 1% polidocanol foam (0.5<span class="elsevierStyleHsp" style=""></span>mL per session) to 4 parts CO<span class="elsevierStyleInf">2</span>O<span class="elsevierStyleInf">2</span> (Tessari method). Complete re-epithelialization was observed by the fourth week (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B). The great saphenous vein was simultaneously ablated by intravenous laser (VascuLife, 1470 nm) to treat the proximal reflux and prevent ulcer recurrence. Six months after treatment the patient remains asymptomatic with no lesion recurrence.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Foam sclerotherapy was proposed as a first-line treatment for venous ulcers in 2004.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> The TIRS technique consists of the treatment of incompetent veins in close proximity to the ulcer bed to generate a sort of internal compressive bandage.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> At the first consultation Doppler ultrasound is performed to examine the vessels of the ulcer bed and to map the venous system. The target vessels are the incompetent perforators and the incompetent veins of the ulcer bed with continuity with the source of the reflux. Foam sclerotherapy is performed and a compressive bandage applied until the next session. Sessions are carried out at weekly intervals until all incompetent target vessels have been obliterated.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In the cases described in the literature TIRS is effective in almost 90% of cases, with a mean healing time of 4 to 8 weeks.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4,5</span></a> We reported comparable outcomes in a series of 6 clinical cases.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> Compared with conservative treatments or treatment of proximal reflux by sclerotherapy alone, TIRS appears to be a more effective technique, with a shorter healing time.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6–9</span></a> The beneficial effects of foam sclerotherapy have also been demonstrated in several studies of large series of patients with long-term follow-up. Because it directly targets the source of the venous ulcer, foam sclerotherapy offers better outcomes than other therapies with low quality of evidence ratings, such as venotonic drugs, stem cells, and growth factors. The risk of recurrence appears to be lower than that reported for the treatment of proximal reflux alone.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4,6,7</span></a> However, the importance of compression stockings or bandages in preventing venous ulcers should not be overlooked.</p><p id="par0025" class="elsevierStylePara elsevierViewall">TIRS can be performed on an outpatient basis, and improvements in ulcers and associated clinical signs can be observed within 2 weeks. The most feared complication is accidental perforation of the posterior tibial veins and consequent thrombosis. The most commonly described adverse effects are pain, bruising, and discomfort caused by the bandages applied after treatment. Other less commonly reported complications of sclerotherapy include transient neurological adverse effects, intra-arterial injection and subsequent ischemia, pulmonary thromboembolism, and deep-vein thrombosis.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We believe that TIRS is a promising and safe technique with a minimum recovery time.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Mendieta-Eckert M, Azpiazu-Macho JL, Landa-Gundin N. Tratamiento de úlcera venosa refractaria mediante la «interrupción terminal de la fuente de reflujo». Actas Dermosifiliogr. 2019;110:74–75.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 878 "Ancho" => 1309 "Tamanyo" => 192054 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Venous ulcer before treatment. B, Complete resolution 4 weeks after beginning treatment, with evident improvement of the surrounding skin.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Venous ulcer: Epidemiology, physiopathology, diagnosis and treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "L.P. Abbade" 1 => "S. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 9 | 4 | 13 |
| 2024 Octubre | 92 | 43 | 135 |
| 2024 Septiembre | 130 | 23 | 153 |
| 2024 Agosto | 135 | 50 | 185 |
| 2024 Julio | 133 | 34 | 167 |
| 2024 Junio | 126 | 49 | 175 |
| 2024 Mayo | 88 | 29 | 117 |
| 2024 Abril | 92 | 47 | 139 |
| 2024 Marzo | 69 | 26 | 95 |
| 2024 Febrero | 74 | 41 | 115 |
| 2024 Enero | 62 | 25 | 87 |
| 2023 Diciembre | 57 | 20 | 77 |
| 2023 Noviembre | 79 | 47 | 126 |
| 2023 Octubre | 80 | 55 | 135 |
| 2023 Septiembre | 73 | 33 | 106 |
| 2023 Agosto | 78 | 19 | 97 |
| 2023 Julio | 81 | 32 | 113 |
| 2023 Junio | 65 | 24 | 89 |
| 2023 Mayo | 55 | 28 | 83 |
| 2023 Abril | 60 | 17 | 77 |
| 2023 Marzo | 66 | 30 | 96 |
| 2023 Febrero | 71 | 34 | 105 |
| 2023 Enero | 48 | 32 | 80 |
| 2022 Diciembre | 57 | 31 | 88 |
| 2022 Noviembre | 37 | 20 | 57 |
| 2022 Octubre | 42 | 18 | 60 |
| 2022 Septiembre | 29 | 36 | 65 |
| 2022 Agosto | 36 | 38 | 74 |
| 2022 Julio | 38 | 35 | 73 |
| 2022 Junio | 34 | 28 | 62 |
| 2022 Mayo | 89 | 48 | 137 |
| 2022 Abril | 88 | 27 | 115 |
| 2022 Marzo | 92 | 53 | 145 |
| 2022 Febrero | 97 | 28 | 125 |
| 2022 Enero | 96 | 35 | 131 |
| 2021 Diciembre | 47 | 40 | 87 |
| 2021 Noviembre | 55 | 45 | 100 |
| 2021 Octubre | 60 | 52 | 112 |
| 2021 Septiembre | 58 | 39 | 97 |
| 2021 Agosto | 68 | 32 | 100 |
| 2021 Julio | 58 | 22 | 80 |
| 2021 Junio | 32 | 28 | 60 |
| 2021 Mayo | 38 | 37 | 75 |
| 2021 Abril | 121 | 99 | 220 |
| 2021 Marzo | 76 | 27 | 103 |
| 2021 Febrero | 84 | 23 | 107 |
| 2021 Enero | 53 | 17 | 70 |
| 2020 Diciembre | 38 | 17 | 55 |
| 2020 Noviembre | 36 | 19 | 55 |
| 2020 Octubre | 22 | 13 | 35 |
| 2020 Septiembre | 54 | 21 | 75 |
| 2020 Agosto | 30 | 21 | 51 |
| 2020 Julio | 18 | 20 | 38 |
| 2020 Junio | 26 | 20 | 46 |
| 2020 Mayo | 15 | 12 | 27 |
| 2020 Abril | 11 | 11 | 22 |
| 2020 Marzo | 21 | 9 | 30 |
| 2020 Febrero | 3 | 0 | 3 |
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