“Veins first” versus “artery first” approach for management of mixed arterial venous leg ulcers (MAVLU): Systematic review and meta-analysis

Mohammed Alagha, Ahmed Alagha, Aoife Lowery, Stewart R Walsh
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Abstract

IntroductionMixed Arterial and Venous Leg Ulcers (MAVLU) are challenging. The optimal intervention sequence (artery-first vs vein first) is unclear. This review evaluates current evidence on surgical intervention sequencing.MethodsMEDLINE, PUBMED, SCOPUS and EMBASE were searched using the term ‘mixed arterial venous leg ulcers.’ Studies were eligible if they reported ulcer healing outcomes in MAVLU patients. Pooled proportions were calculated by random effects modelling.ResultsThe search yielded 606 studies, eight of which contained sufficient data to include in the analysis. There were no randomized controlled trials. Initial modified compression (MCT) and rescue revascularisation in MAVLU with ABI 0.5 to 0.85 achieved a pooled healing rate of 75% (95% CI 69% to 80%) compared to 79% (95% CI 61% to 93%) in patients with standard VLUs. The pooled rescue revascularisation rate for MAVLU patients with moderate arterial disease was 25% (95% CI 6% to 51%). Patients with severe arterial disease (ABI <0.5) who underwent arterial intervention first were less likely to heal (pooled proportion 40%; 95% confidence interval 16% to 66%). No studies compared either MCT or venous ablation with arterial revascularisation as first-line in patients with moderate arterial disease (ABI 0.5 to 0.85) alone or severe arterial disease (ABI <0.5) alone. There was marked heterogeneity between studies with respect to ulcer healing outcomes reported, definitions of ulcer healing, duration and size of ulcers at presentation, use of adjunct procedures such as skin grafting, unit of measurement (legs vs patients) and duration of follow up.ConclusionA ‘veins first’ approach to MAVLU is plausible but robust data are lacking and should be evaluated in a randomized controlled trial.
治疗混合性动脉静脉腿部溃疡(MAVLU)的 "静脉先行 "与 "动脉先行 "方法:系统回顾和荟萃分析
导言动脉和静脉混合性腿部溃疡(MAVLU)具有挑战性。最佳干预顺序(动脉先行还是静脉先行)尚不明确。本综述评估了目前有关手术干预顺序的证据。方法 使用 "混合性动脉静脉腿部溃疡 "这一术语对MEDLINE、PUBMED、SCOPUS和EMBASE进行检索。如果研究报告了混合性动静脉腿部溃疡患者的溃疡愈合结果,则符合条件。通过随机效应模型计算了汇总比例。其中没有随机对照试验。在ABI为0.5至0.85的MAVLU患者中,初始改良加压(MCT)和抢救性血管再通的总治愈率为75%(95% CI为69%至80%),而标准VLU患者的总治愈率为79%(95% CI为61%至93%)。中度动脉疾病的 MAVLU 患者的总抢救性血管再通率为 25% (95% CI 6% 至 51%)。先接受动脉介入治疗的重度动脉疾病(ABI <0.5)患者痊愈的可能性较低(汇总比例为 40%;95% 置信区间为 16% 至 66%)。对于仅患有中度动脉疾病(ABI 0.5 至 0.85)或仅患有重度动脉疾病(ABI <0.5)的患者,没有研究将 MCT 或静脉消融与动脉血管再通作为一线治疗进行比较。在所报告的溃疡愈合结果、溃疡愈合定义、溃疡持续时间和大小、植皮等辅助手术的使用、测量单位(腿部与患者)以及随访时间等方面,各研究之间存在明显的异质性。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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