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PRACTICE: Joseph E Grey, Keith G Harding, and Stuart Enoch Venous and arterial leg ulcers BMJ 2006; 332: 347-350 [Full text]

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Venous and arterial ulcers

Pedro Redondo, Pedro Lloret and Juan Cabrera   (22 February 2006)

Venous and arterial ulcers 22 February 2006
Pedro Redondo, Professor of Dermatology University Clinic of Navarra, Pamplona, Spain, Pedro Lloret and Juan Cabrera Send response to journal: Re: Venous and arterial ulcers	EDITOR-The clinical review of Venous and arterial leg ulcers by Grey et al is comprenhesive and clear, although some aspects deserve comment(1). We are agree that venous hypertension is the underlying cause of venous ulceration. Compression therapy is associated with a protracted course of healing and multiple recurrences. Skin closure occurs rapidly when venous hypertension is improved. The ablation of superficial and perforator vein incompetence provides clinical and hemodynamic improvement in patients with chronic venous ulcers(2). Subfascial endoscopic perforator surgery has become the surgical technique of choice for perforator ablation, although this approach cannot be adopted in all cases. Small interconnected collaterals between the perforators and the skin frequently convey the venous hypertension to the skin area, and surgical procedures are inherently unable to close these vessels. Surgical intervention has been successful but the advent of foam sclerotherapy has proven to be an attractive alternative to surgery and has added a new tool for the treatment of venous ulcers. Recently we have published 116 patients with chronic venous ulcers treated with ultrasound- guided injection of polidocanol microfoam (UIPM)(3). To reduce venous hypertension UIPM was used to selectively sclerose sources of incompetence. At 6-months`s follow-up, treatment with UIPM achieved complete healing in 83% of patients with median time to healing of 2.7 months. In comparison with the patients treated with allogeneic cultured human skin equivalent of a previously reported series, we obtained a highly significant advantage for our overall results (X2 test, P<.001). Foam sclerotherapy of superficial and perforating valveless veins is a well-tolerated and effective outpatient procedure. Major advantages of sclerosant in foam form with respect to classic liquid sclerosants include selective effect on endothelium, visibility on ultrasound examination, predictability of outcome, high sucess rate, and low frequency of recurrence. Foam sclerotherapy may well prove to be the gold standard for treatment of chonic venous ulcers in the future(4,5). 1.- Grey JE, Enoch S, Harding KG. Venous and arterial leg ulcers. BMJ 2006; 332:347-50. 2.- Pierik EG, van Urk H, Hop WC, Wittens CH. Endoscopic versus open subfascial division of incompetent perforating veins in the treatment of venous leg ulcerations: a randomized trial. J Vasc Surg 1997; 26: 1049-54. 3.- Cabrera J, Redondo P, Becerra A, et al. Ultrasound-guided injection of polidocanol microfoam in the management of venous leg ulcers. Arch Dermatol 2004; 140: 667-73. 4.- de Waard MM, der Kinderen DJ. Duplex ultrasonography-guided foam sclerotherapy of incompetent perforator veins in a patient with bilateral venous leg ulcers. Dermatol Surg 2005;31:580-3. 5.- Bergan J, Pascarella L, Mekenas L. Venous disorders: treatment with sclerosant foam. J Cardiovasc Surg 2006; 47:9-18. Competing interests: None declared