1. Technique to Heal Venous Ulcers: Terminal Interruption of the Reflux Source (TIRS) 2012 Ronald Bush, MD, FACS Midwest Vein & Laser Center Dayton, Ohio

2. 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)www.veinexperts.org

3. 8-Weeks Post Injection Ulcer healed Perforator remains patent Venous tributaries under ulcer bed clotted Concept of TIRS developed (www.veinexperts.org, 2012)www.veinexperts.org

4. 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)

5. Other Adjuncts in Treatment Eschar Study shows that stripping of the saphenous vein < recurrence rates but does not promote healing Pharmacological aids controversial Rutosides Aspirin Pentoxifylline (Barwell, 2008) (Gohel, 2009) (Falanga, 1999)

6. Other Considerations Multiple 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

7. Foam Sclerotherapy Numerous 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

8. 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%

9. 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)

10. TIRS TECHNIQUE All but one healed at 4-months TIRS targets only the distal draining vessels under the ulcer bed Treatment begins at 1 st visit Repeat injections at 1-2 weeks if necessary Consider this technique as an internal compression dressing

11. TIRS TECHNIQUEUS (www.veinexperts.org, 2012)www.veinexperts.org

12. TIRS TECHNIQUE (www.veinexperts.org, 2012)www.veinexperts.org

13. TIRS TECHNIQUE (www.veinexperts.org, 2012)www.veinexperts.org

14. TIRS TECHNIQUE

15. 8-Weeks After Treatment (www.veinexperts.org, 2012)www.veinexperts.org

16. 6-Weeks After Treatment (www.veinexperts.org, 2012)www.veinexperts.org

17. Conclusion TIRS 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

18. Conclusion Rapid relief in pain after injection (3-7 days) Less external compression needed TIRS technique should be the 1 st treatment for all patients with venous ulcers & possibly the only tx in patients with isolated DVI

19. 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.orgwww.veinexperts.org