Revaskularisaatio

• Jos haavan taustalla on raajaa uhkaavan iskemian tasoinen valtimoverenkierron vajaus, haavan ainut parantava hoito on raajan revaskularisaatio (ks. Käypä hoito -suositus Alaraajojen tukkiva valtimotauti «Alaraajojen tukkiva valtimotauti»1).
• Kombinoituneella valtimo-laskimohaavalla ei ole vakiintunutta hoitoalgoritmiä «Lantis JC 2nd, Boone D, Lee L ym. The effect of percutaneous intervention on wound healing in patients with mixed arterial venous disease. Ann Vasc Surg 2011;25:79-86 »1, «Hedayati N, Carson JG, Chi YW ym. Management of mixed arterial venous lower extremity ulceration: A review. Vasc Med 2015;20:479-86 »2, «Mosti G, Cavezzi A, Massimetti G ym. Recalcitrant Venous Leg Ulcers May Heal by Outpatient Treatment of Venous Disease Even in the Presence of Concomitant Arterial Occlusive Disease. Eur J Vasc Endova»3.
  • Kyseessä on käytännössä heterogeeninen potilasryhmä, ja yksittäisen potilaan hoito riippuu siitä, miten valtimoverenkierron vajaus ja laskimovajaatoiminta painottuvat hänen sairastamansa haavan taustalla «Adam DJ, Naik J, Hartshorne T ym. The diagnosis and management of 689 chronic leg ulcers in a single-visit assessment clinic. Eur J Vasc Endovasc Surg 2003;25:462-8 »4, «Forssgren A, Nelzén O. Changes in the aetiological spectrum of leg ulcers after a broad-scale intervention in a defined geographical population in Sweden. Eur J Vasc Endovasc Surg 2012;44:498-503 »5.
  • Hoito voi vaatia sekä valtimo- että laskimotoimenpiteitä; valtimoverenkierron parantaminen ei kuitenkaan välttämättä ole aina ensisijainen toimenpide «Lim CS, Baruah M, Bahia SS. Diagnosis and management of venous leg ulcers. BMJ 2018;362:k3115 »6, «Treiman GS, Copland S, McNamara RM ym. Factors influencing ulcer healing in patients with combined arterial and venous insufficiency. J Vasc Surg 2001;33:1158-64 »7.
  • Haava voi parantua pelkällä kompressiohoidollakin, jos ABI on > 0,5 «Ghauri AS, Nyamekye I, Grabs AJ ym. The diagnosis and management of mixed arterial/venous leg ulcers in community-based clinics. Eur J Vasc Endovasc Surg 1998;16:350-5 »8, «Marston WA, Carlin RE, Passman MA ym. Healing rates and cost efficacy of outpatient compression treatment for leg ulcers associated with venous insufficiency. J Vasc Surg 1999;30:491-8 »9, «Humphreys ML, Stewart AH, Gohel MS ym. Management of mixed arterial and venous leg ulcers. Br J Surg 2007;94:1104-7 »10.
    • Verisuonikirurgia tulee kuitenkin konsultoida ennen hoidon aloittamista «Callam MJ, Ruckley CV, Dale JJ ym. Hazards of compression treatment of the leg: an estimate from Scottish surgeons. Br Med J (Clin Res Ed) 1987;295:1382 »11.
    • Tämä hoitovaihtoehto saattaa tulla kyseeseen, jos revaskularisaatio ei anatomisista syistä johtuen ole mahdollinen tai jos potilas ei sovellu tällaiseen toimenpiteeseen «Marston WA, Carlin RE, Passman MA ym. Healing rates and cost efficacy of outpatient compression treatment for leg ulcers associated with venous insufficiency. J Vasc Surg 1999;30:491-8 »9.
    • Kompressiohoito saattaa tässä tilanteessa jopa parantaa raajan valtimoverenkiertoa paikallisesti «Mosti G, Iabichella ML, Partsch H. Compression therapy in mixed ulcers increases venous output and arterial perfusion. J Vasc Surg 2012;55:122-8 »12.
    • Yksi mahdollinen strategia on aloittaa hoito ensisijaisesti kompressiolla ja edetä valikoivasti revaskularisaatioon niiden potilaiden kohdalla, joiden haava ei tällöin parane «Humphreys ML, Stewart AH, Gohel MS ym. Management of mixed arterial and venous leg ulcers. Br J Surg 2007;94:1104-7 »10, «Mosti G, Iabichella ML, Partsch H. Compression therapy in mixed ulcers increases venous output and arterial perfusion. J Vasc Surg 2012;55:122-8 »12.
    • Hoito edellyttää potilaan tiivistä seurantaa.
  • Myös pelkkä laskimovajaatoiminnan suonensisäinen hoito ilman valtimotoimenpiteitä voi tulla kyseeseen, jos ABI on > 0,5 «Mosti G, Cavezzi A, Massimetti G ym. Recalcitrant Venous Leg Ulcers May Heal by Outpatient Treatment of Venous Disease Even in the Presence of Concomitant Arterial Occlusive Disease. Eur J Vasc Endova»3.

Kirjallisuutta

1. Lantis JC 2nd, Boone D, Lee L ym. The effect of percutaneous intervention on wound healing in patients with mixed arterial venous disease. Ann Vasc Surg 2011;25:79-86 «PMID: 21172582»PubMed
2. Hedayati N, Carson JG, Chi YW ym. Management of mixed arterial venous lower extremity ulceration: A review. Vasc Med 2015;20:479-86 «PMID: 26206851»PubMed
3. Mosti G, Cavezzi A, Massimetti G ym. Recalcitrant Venous Leg Ulcers May Heal by Outpatient Treatment of Venous Disease Even in the Presence of Concomitant Arterial Occlusive Disease. Eur J Vasc Endovasc Surg 2016;52:385-91 «PMID: 27476154»PubMed
4. Adam DJ, Naik J, Hartshorne T ym. The diagnosis and management of 689 chronic leg ulcers in a single-visit assessment clinic. Eur J Vasc Endovasc Surg 2003;25:462-8 «PMID: 12713787»PubMed
5. Forssgren A, Nelzén O. Changes in the aetiological spectrum of leg ulcers after a broad-scale intervention in a defined geographical population in Sweden. Eur J Vasc Endovasc Surg 2012;44:498-503 «PMID: 22925998»PubMed
6. Lim CS, Baruah M, Bahia SS. Diagnosis and management of venous leg ulcers. BMJ 2018;362:k3115 «PMID: 30108047»PubMed
7. Treiman GS, Copland S, McNamara RM ym. Factors influencing ulcer healing in patients with combined arterial and venous insufficiency. J Vasc Surg 2001;33:1158-64 «PMID: 11389412»PubMed
8. Ghauri AS, Nyamekye I, Grabs AJ ym. The diagnosis and management of mixed arterial/venous leg ulcers in community-based clinics. Eur J Vasc Endovasc Surg 1998;16:350-5 «PMID: 9818014»PubMed
9. Marston WA, Carlin RE, Passman MA ym. Healing rates and cost efficacy of outpatient compression treatment for leg ulcers associated with venous insufficiency. J Vasc Surg 1999;30:491-8 «PMID: 10477642»PubMed
10. Humphreys ML, Stewart AH, Gohel MS ym. Management of mixed arterial and venous leg ulcers. Br J Surg 2007;94:1104-7 «PMID: 17497654»PubMed
11. Callam MJ, Ruckley CV, Dale JJ ym. Hazards of compression treatment of the leg: an estimate from Scottish surgeons. Br Med J (Clin Res Ed) 1987;295:1382 «PMID: 3121025»PubMed
12. Mosti G, Iabichella ML, Partsch H. Compression therapy in mixed ulcers increases venous output and arterial perfusion. J Vasc Surg 2012;55:122-8 «PMID: 21944912»PubMed