Clinical update


postoperative thrombosis. The early recurrent thromboses were treated and all patients were discharged with patent reconstructions. Patients were evaluated preoperatively and


postoperatively using the Villalta scale, a validated measure of postthrombotic syndrome, and the Venous Clinical Severity Score (VCSS), which identifies clinical characteristics of chronic venous disease[4,5]


. The mean


preoperative Villalta score was 14 and the mean VCSS was 17.


Conclusion With careful case selection (recognising that there will be contra-indications ) in patients with chronic post- thrombotic iliofemoral venous obstruction, common femoral endovenectomy with endoluminal recanalisation of the iliac veins reduces post-thrombotic morbidity and improves quality of life. This procedure offers advantages over conventional bypass, however, it is still in evolution. Anthony Comerota, Adjunct Professor, University of Michigan and Jobst Vascular Institute, Toledo (USA)


1. Labropoulos N, Volteas N, Leon M, et al. The role of venous outflow obstruction in patients with chronic venous dysfunction. Arch Surg 1997; 132(1): 46–51.


2. Comerota AJ, Grewal NK, Thakur S, Assi Z. Endovenectomy of the common femoral vein and intraoperative iliac vein recanalization for chronic iliofemoral venous occlusion. J Vasc Surg 2010; 52(1): 243–7.


3. Vogel D, Comerota AJ, Al-Jabouri M, Assi ZI. Common femoral endovenectomy with iliocaval endoluminal recanalization improves symptoms and quality of life in patients with post-thrombotic iliofemoral obstruction. J Vasc Surg 2011; In press.


4. Kahn SR. Measurement properties of the Villalta scale to define and classify the severity of the post-thrombotic syndrome. J Thromb Haemost 2009; 7(5): 884–8.


5 Meissner MH, Natiello C, Nicholls SC. Performance characteristics of the venous clinical severity score. J Vasc Surg 2002; 36(5): 889–95.


Managing leg ulcers in a Swedish specialist clinic


T


his short report describes the challenges, frustrations and practical problems


experienced when dealing with patients attending a specialist leg ulcer clinic in Stockholm, Sweden. In Swedish primary care and nursing


homes, knowledge about leg ulcer treatment is still very limited and there is a genuine lack of education. One


of the biggest challenges is that many of the patients seen in our clinic have been in primary care for long periods of time without having a proper diagnosis or adequate bandaging. Usually, patients have been managed with only a simple wound dressing and no compression at all. Economic factors also cause problems and limit optimum


treatment. Bandages are expensive and leg ulcer patients can take up a substantial amount of the district nurse’s time. Even


11 Wounds International Vol 2 | Issue 4 | ©Wounds International 2011


when patients attend clinic, which should in theory reduce the amount of nursing time, caregivers often fail to use the recommended dressings and compression because of cost. In some Swedish hospitals and units the patient is required to pay a small amount (less then 10 euros for a consultation with a nurse and about 25–30 euros for a medical consultation), although when the total reaches 90 euros in any one-year period the consultation are free the rest of that year. The bandage and dressings are included in the fee for the consultations. In Sweden there are only a few specialist centres (probably


five multidisciplinary specialist units in total) for treating leg ulcer patients. In spite of this, we have huge numbers of elderly people with leg ulcer problems. Historically, leg ulcer patients in Sweden have been treated in primary care by nurses. In our specialist unit, a vascular surgeon and a dermatologist visit once a month to assesses the patients. In our clinic (the Department of Dermatology and Venereology


at South General Hospital, Stockholm), diagnosis is undertaken by a doctor and this is always the first step in the treatment pathway before the patient is seen by a dermatologist or a vascular surgeon. Ankle brachial pressure index (ABPI) is seen as very important, and is used to facilitate the decision to use compression and the level of compression needed. In the


vascular assessment the following questions are addressed: n Is the circulation normal, ie greater than 0.8? n Is the APBI lower than normal (compression is not used


at all if the ABPI is less than 0.6)? If the ABPI is less than 0.6 the patient is referred for Duplex ultrasound and to the vascular team


n Is the patient likely to be compliant? n How mobile is the patient? n Has the patient had any allergic reactions (eg latex)? The wound management protocol includes cleansing the


wound, usually with tap water. Sometimes when the wound is infected or critically colonised, polyhexamethylene biguanide (PHMB) solution, acetic acid solution, iodine or silver dressing are used. Oral antibiotics are also used if the wound has clinical signs of infection. A local anaesthetic is used prior to any necessary debridement, which is often sharp. However, we have just started to use a new mechanical debridement product (Debrisoft®


;


Activa), which has had positive initial results. The type of dressing used depends on the condition of


the wound (ie the amount of exudate, odour, pain, condition of the surrounding skin and presence of allergies). Dressings commonly used for patients with leg ulcers include Hydofiber dressings, polyurethane foam, non-adherent dressings, absorbent dressings, iodine and silver dressings. In the future, the focus must be on better education with


greater attention to the management of leg ulcers within the nursing and medical curriculum. The hope is that the status of leg ulcers as a specialty will improve and that physicians will become more interested in the subject. We must work towards raising standards nationally with better and more equal access to specialist services. Agneta Bergsten is a Registered Nurse at the South General hospital (Stockholm)


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