Technique to Heal Venous Ulcers: Terminal Interruption of the Reflux Source (TIRS) 2012

Ronald Bush, MD, FACSMidwest Vein & Laser Center

Dayton, Ohio

One Injection of 1% Sotradecol® Foam

3-yr history of ulcer

Previous high ligation & stripping

Large posterior tibial perforator – 6mm adjacent to ulcer

3-cc 1% Sotradecol® Foam injected into perforator

(www.veinexperts.org, 2012)

8-Weeks Post Injection

Ulcer healed

Perforator remains patent

Venous tributaries under ulcer bed clotted

Concept of TIRS developed

 (www.veinexperts.org, 2012)

What We Know About Ulcers?

Associated with increased ambulatory venous pressure usually above 45 mmHg

Most therapy is directed at the local level with compression

Compression therapy is the standard of therapy

Compression alone, high recurrence rate.

(Erickson, 1995) (Scriven, 1998)

Other Adjuncts in Treatment

Eschar Study shows that stripping of the saphenous vein < recurrence rates but does not promote healing

Pharmacological aids controversialRutosidesAspirinPentoxifylline

(Barwell, 2008) (Gohel, 2009) (Falanga, 1999)

Other ConsiderationsMultiple dressings have been developed to help

promote healing

No one dressing has been found to be superior to another

Consider silver impregnated dressing if infection is present

Consider alginate dressings for wound drainage

Foam SclerotherapyNumerous reports of the effectiveness of foam

sclerotherapy in the treatment of venous ulcers

Most of these studies were directed at the saphenous vein reflux in association with venous ulcer

Literature Review Defining the

Value of Foam Sclerotherapy(Cabrera, 2004) Archives Dermatology - Healing

rate above 80%

(Hertzman, 2007) Phlebology – Rapid healing of venous ulcers after foam sclerotherapy

(Slim, 2012) J Vasc Surgery -  24 week healing rate was 70.7%1-year recurrence rate was 4.7%4-year recurrence rate was 4.7%

TIRS TECHNIQUE

Multiple patients treated with superficial & DVI and/or partial obstruction

Rapid healing in those with isolated superficial reflux (4-6 weeks)

Healing occurred more slowly in patients with DVI

(Bush, 2010)

TIRS TECHNIQUEAll but one healed at 4-months

TIRS targets only the distal draining vessels under the ulcer bed

Treatment begins at 1st visit

Repeat injections at 1-2 weeks if necessary

Consider this technique as an internal compression dressing

TIRS TECHNIQUEUS

 (www.veinexperts.org, 2012)

TIRS TECHNIQUE

 (www.veinexperts.org, 2012)

TIRS TECHNIQUE

 (www.veinexperts.org, 2012)

TIRS TECHNIQUE

8-Weeks After Treatment

 (www.veinexperts.org, 2012)

6-Weeks After Treatment

 (www.veinexperts.org, 2012)

ConclusionTIRS is a local treatment for a systemic problem

Promotes rapid sustainable reduction of high ambulatory venous pressure

Promotes skin healing by both reduction of venous HTN with resultant increase in skin blood flow

Possibly a marked inflammatory response after injection with macrophage & neutrophilic infiltration into wound bed

Conclusion

Rapid relief in pain after injection (3-7 days)

Less external compression needed

TIRS technique should be the 1st treatment for all patients with venous ulcers & possibly the only tx in patients with isolated DVI

References Barwell J, Davies C, Deacon J, et al. Comparison of surgery and compression with compression alone

in chronic venous ulceration (ESCHAR STUDY): randomized controlled trial. Lancer 2008;363:1854-1859.

Bush R. New technique to heal venous ulcers: terminal interruption of the reflux source (TIRS). Perspect Vasc Surg Endovasc Ther 2010;22:194-199.

Falanga V, Fujitani R, Diaz C, et al. Sytemic treatment of venous leg ulcers with high doses of pentoxifyline: efficacy in a randomized, placebo-controlled trial. Wound Repair Regen 1999;7:208-213.

Gobel M, Davies A. Parmacological agents in the treatment of venous disease: an update of the available evidence. Curr Vasc Pharmacol 2009;7:303-308.

Erickson C, Lanza D, Karp D, it al. Healing of venous ulcers in an ambulatory care program: the roles of chronic venous insufficiency and patient compliance. J Vasc Surg 1995;22;629-636.

Scriven J, Taylor L, Wood A, et al. A prospective randomized trial of four-layer versus short stretch compression bandages for the treatment of venous leg ulcers. Ann R Coll Surg Engl 1998;80-:215-220.

VeinExperts.org. Images retrieved online March 17, 2012, from www.veinexperts.org