Tufts University School of Medicine, Boston, Mass.
Tufts University School of Medicine, Boston, Mass; The CardioVascular Center at Tufts Medical Center, Boston, Mass.
J Vasc Surg Venous Lymphat Disord. 2019 Jan;7(1):98-105. doi: 10.1016/j.jvsv.2018.07.014. Epub 2018 Oct 24.
Despite regular treatment of venous leg ulcers (VLUs), some fail to heal. Although several risk factors have previously been identified to be associated with the failure of VLUs to heal, the majority of studies are limited to <24-week follow-up.
A retrospective cohort study was performed at an academic vascular and wound center. A total of 65 patients with VLUs who were observed for a year or more were identified. These patients underwent a variety of treatments following the Society for Vascular Surgery and American Venous Forum VLU guidelines. Risk factors, which were based on previously defined elements for failure of VLUs to heal after a period of treatment, were examined. Both univariate (unadjusted) and multivariate (adjusted) logistic regression analyses were used to assess the magnitude of effect that a given risk factor had on healing.
Of 65 patients treated for a minimum of 52 weeks, 19 (29%) remained unhealed. By univariate analysis, deep venous disease (P = .01; odds ratio [OR], 5.82; 95% confidence interval [CI], 1.49-22.72), history of deep venous thrombosis (P < .001; OR, 14.06; 95% CI, 3.77-52.39), and depression (P = .04; OR, 3.89; 95% CI, 1.10-13.80) were all shown to be significant risk factors for nonhealing. The patient's race (ie, being nonwhite; P = .02; OR, 103.45; 95% CI, 1.94-5.53 × 10), deep venous disease (P = .05; OR, 37.0; 95% CI, 1.05-1.31 × 10), and history of deep venous thrombosis (P = .01; OR, 122.4; 95% CI, 3.09-4.84 × 10), however, were all shown to be significant for nonhealing under multivariate analysis. In addition, identification of an incompetent perforator (P = .02; OR, 0.006; 95% CI, 9.27 × 10-0.44) was conversely shown to be a good prognostic factor for healing.
This study confirmed that risk factors known to be associated with the failure of a VLU to heal-deep venous disease and post-thrombotic etiology-were significant at 52 weeks, whereas depression and race (nonwhite) are novel risk factors. An analysis of markers of access to care showed no difference between white and nonwhite, suggesting other factors as a cause. The predominance of deep venous disease in the unhealed vs healed cohort (84% vs 48%) highlights the need for a viable treatment option for deep venous disease due to reflux. Overall, this study emphasizes the need to consider all risk factors when evaluating a patient for VLU to coordinate an effective treatment plan and to identify gaps in our treatment.
尽管静脉溃疡（venous leg ulcers，VLU）经常接受治疗，但仍有一些溃疡无法愈合。尽管以前已经确定了一些与 VLU 愈合失败相关的风险因素，但大多数研究仅限于 24 周的随访。
在一家学术血管和伤口中心进行了一项回顾性队列研究。共确定了 65 名 VLU 患者，他们的观察时间超过 1 年。这些患者根据血管外科学会和美国静脉论坛 VLU 指南接受了各种治疗。检查了先前定义的治疗后 VLU 愈合失败相关因素的风险因素。使用单变量（未调整）和多变量（调整）逻辑回归分析评估给定风险因素对愈合的影响程度。
在接受至少 52 周治疗的 65 名患者中，19 名（29%）仍未愈合。单变量分析显示，深静脉疾病（P =.01；优势比 [OR]，5.82；95%置信区间 [CI]，1.49-22.72）、深静脉血栓形成史（P <.001；OR，14.06；95% CI，3.77-52.39）和抑郁（P =.04；OR，3.89；95% CI，1.10-13.80）均为非愈合的显著风险因素。患者的种族（即非白人；P =.02；OR，103.45；95% CI，1.94-5.53×10）、深静脉疾病（P =.05；OR，37.0；95% CI，1.05-1.31×10）和深静脉血栓形成史（P =.01；OR，122.4；95% CI，3.09-4.84×10）在多变量分析中也均显示为非愈合的显著因素。此外，识别出功能不全的穿通静脉（P =.02；OR，0.006；95% CI，9.27×10-0.44）则被证明是愈合的良好预后因素。
本研究证实，与 VLU 愈合失败相关的已知风险因素（深静脉疾病和血栓后病因）在 52 周时仍具有重要意义，而抑郁和种族（非白人）则是新的风险因素。对获得治疗机会的标志物的分析显示，白人患者和非白人患者之间没有差异，表明存在其他因素导致这一差异。未愈合组与愈合组相比（84% vs 48%）深静脉疾病更为普遍，这突出表明需要有针对反流性深静脉疾病的可行治疗选择。总体而言，本研究强调在评估 VLU 患者时需要考虑所有风险因素，以制定有效的治疗计划，并确定我们治疗中的差距。
