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