Venous Ulcer Taskforce: A Multi-Society effort to serve the neediest vein patients

Venous Ulcer Taskforce: A Multi-Society effort to serve the neediest vein patients

Marlin W. Schul, MD, RVT, FAVLS, DABVLM

As vein care clinicians, we know that venous ulceration presents not only a clinical challenge but also an excellent opportunity to help those patients most in need. The landmark New England Journal of Medicine study, Early Endovenous Ablation in Venous Ulceration, or the EVRA trial, gave real-world evidence on early intervention and time to healing.

Despite Level I evidence, many barriers continue to exist, delaying referral for vascular evaluation in those most in need of vein care. A group of physicians representing several disciplines came together in 2020 to launch a project to brainstorm how we might collectively change the narrative and move the needle to ensure those with a leg ulcer receive a prompt referral and diagnostic vascular assessment of the limb(s).

In sum, the task force’s charge is to support patient access to needed venous care by creating and disseminating evidence-based protocols for venous ulcers and diagnostic assessment of suspected venous ulceration. Particular emphasis is placed on reaching and educating providers who might not be vascular or venous specialists on how they need to work up suspected ulcer patients.

WHY NOW? HOW DID WE ARRIVE AT THE POINT?

Several factors served as motivation for the task force. Namely,

• The NEJM EVRA Trial showed how important early intervention was in healing venous ulcers.

• New LCDs for Novitas and First Coast allow prompt treatment for venous patients who would likely NOT benefit from a period of conservative care.

• Improving Wisely identified a global gap in care, suggesting that less than 1% of VLU patients acquire surgical intervention of ANY type.

• We all identify that the IW findings were not in error. We see patients in wound centers for years before they get a vascular referral.

• It is widely recognized that those treating venous ulcers in a wound center may not recognize venous leg ulcers, and often those that do recognize venous leg ulcers do not know to whom to refer their patients.

• The AVLS Registry and private data from the wound care community could be leveraged to give insight into key clinical questions.

• Current Multi-Society Composition of the Ulcer Taskforce: Marlin Schul- AVLS co-chair; Harold Welch- AVF co-chair; Joe Raffetto-AVLS; Eri Fukaya- SVM; Leigh Ann O’Banion- AVF, SVS; William Marston- AVF; William Ennis- AWCA, Healogics Medical director; Michael Vasquez- AVF; Samih Bittar- SVM; Mark Meissner- AVLS President

CURRENTLY, THE TASK FORCE IS FOCUSING ON A FEW KEY PATHWAYS

• VLU Algorithm: Expanding on some textbook materials already in use, the task force is developing a flow chart algorithm for care of VLU patients providing visual cues, H&P features, and the understanding that formal vascular evaluation is imperative early in the process. The task force is working on this collaboratively with hopes we’ll have something to share in the coming months.

• Up to Date: The task force has connected with the vascular surgeon who curates the venous ulcer section of Up to Date, the country’s leading database of care guidelines. Eri Fukaya is leading this effort with Hal Welch, Sam Bittar, and Leigh Ann O’Banion writing various content pieces that will be submitted to Up to Date for the dedicated Venous Leg Ulcer section. The sections below parallel the algorithm above, yet will be different channels to promote this message:

» Definition of a venous leg ulcer

» History & Physical Exam features.

» Images of findings including different ulcer types

» Pulses/ABI

» Diagnostic Ultrasonography - Deep & superficial systems, Arterial system, Importance of proper positioning for accuracy of diagnosis

» Ulcer Management

• Vein Intervention - timing, mixed deep and superficial, proximal obstruction

• Wound care principles - debridement, cleansing, infection mgmt,

• Reduction of edema - compression review, all options, pumps, etc.

» Nontypical features with or without venous/arterial findings - biopsy.

» Benchmarks in wound healing.

• 40% less within three weeks

• Adjunctive considerations

• Indications for biologics

• Indications for iliac stents

» Registry Project: Given the hurdles we have identified and made widely evident in the literature, we have realized we have nearly two thousand patients with leg ulcers. This population will be studied from the AVLS PRO Registry to determine the characteristics of leg ulcer subjects attending vein centers. Post-thrombotic, isolated SVI, mixed deep and superficial reflux, lymphedema wounds, etc. The end product here is a better characterization of all presenting with wounds to clinics participating in the registry.

• Long-term Project: The task force has opened the door to a longer-term project targeting the economic impact of deferred ulcer care and its impact on beneficiaries and costs to society. At this time, efforts are being taken to build bridges among multiple resources to try and accurately tackle this complex problem.

The task force represents an excellent multi-societal collaborative effort, focused on expanding awareness of venous leg ulcer pathology while meeting the collective needs of patients throughout the United States. This year should see substantive written guidance, as well as input to evidence-based protocols. Stay tuned for future updates.