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Technique to Heal Venous Ulcers: Terminal Interruption of the Reflux Source (TIRS ) 2012 PowerPoint Presentation
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Technique to Heal Venous Ulcers: Terminal Interruption of the Reflux Source (TIRS ) 2012
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  1. Technique to Heal Venous Ulcers: Terminal Interruption of the Reflux Source (TIRS) 2012 Ronald Bush, MD, FACS Midwest Vein & Laser Center Dayton, Ohio

  2. 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)

  3. 8-Weeks Post Injection • Ulcer healed • Perforator remains patent • Venous tributaries under ulcer bed clotted • Concept of TIRS developed (www.veinexperts.org, 2012)

  4. 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)

  5. Other Adjuncts in Treatment • Eschar Study shows that stripping of the saphenous vein < recurrence rates but does not promote healing • Pharmacological aids controversial • Rutosides • Aspirin • Pentoxifylline (Barwell, 2008) (Gohel, 2009) (Falanga, 1999)

  6. Other Considerations • Multiple 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

  7. Foam Sclerotherapy • Numerous 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

  8. 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%

  9. 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)

  10. TIRS TECHNIQUE • All 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

  11. TIRS TECHNIQUEUS (www.veinexperts.org, 2012)

  12. TIRS TECHNIQUE (www.veinexperts.org, 2012)

  13. TIRS TECHNIQUE (www.veinexperts.org, 2012)

  14. TIRS TECHNIQUE

  15. 8-Weeks After Treatment (www.veinexperts.org, 2012)

  16. 6-Weeks After Treatment (www.veinexperts.org, 2012)

  17. Conclusion • TIRS 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

  18. 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

  19. 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