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Technique to Heal Venous Ulcers: Terminal Interruption of the Reflux Source (TIRS) 2012
Ronald Bush, MD, FACSMidwest Vein & Laser Center
Dayton, Ohio
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)
8-Weeks Post Injection
Ulcer healed
Perforator remains patent
Venous tributaries under ulcer bed clotted
Concept of TIRS developed
(www.veinexperts.org, 2012)
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)
Other Adjuncts in Treatment
Eschar Study shows that stripping of the saphenous vein < recurrence rates but does not promote healing
Pharmacological aids controversialRutosidesAspirinPentoxifylline
(Barwell, 2008) (Gohel, 2009) (Falanga, 1999)
Other ConsiderationsMultiple 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
Foam SclerotherapyNumerous 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
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%
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)
TIRS TECHNIQUEAll 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
TIRS TECHNIQUEUS
(www.veinexperts.org, 2012)
TIRS TECHNIQUE
(www.veinexperts.org, 2012)
TIRS TECHNIQUE
(www.veinexperts.org, 2012)
TIRS TECHNIQUE
8-Weeks After Treatment
(www.veinexperts.org, 2012)
6-Weeks After Treatment
(www.veinexperts.org, 2012)
ConclusionTIRS 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
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
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