Synergistic Effects of Vashe and Ovine Forestomach in Chronic Venous Disease

Pure Hypochlorous Acid is a non-cytotoxic, pH-balanced solution topical wound cleanser used to clean and irrigate acute and chronic wounds, formulated with hypochlorous acid (HOCl), a naturally occurring molecule that is produced by white blood cells to fight infection. Evidence shows that pHA is effective in reducing wound bioburden, promoting wound healing, and reducing the risk of infection. It is well-tolerated by patients and has a low risk of adverse reactions. It is effective against a broad range of microorganisms, including bacteria, viruses, and fungi. It can be used on a variety of wound types, including pressure ulcers, diabetic foot ulcers, venous stasis ulcers, surgical wounds, and burns.

Utilizing pHA in conjunction with ovine forestomach can lead to excellent results compared to STSG alone. For patients with these exposed structures such as tendons, or a significant volumetric defect, the ovine forestomach ECM helps achieve a robust granulation; this is likely due to the source of the tissue being highly vascular with the residual channels. It is a structure that is very used to a hostile environment of digestive enzymes, and so it seems to work well in these wounds that have significant microbial adherent aggregates and are difficult to heal; it may just be the ideal tissue for this difficult problem.

Considering the importance of maintaining volume and edema reduction of the leg following grafting, the compressive therapy and aftermath of the skin graft is vital. Immediately after surgery, after the negative pressure is applied, it is advisable to apply a 4 or 5 layer compression wrap; the Urgo K-Two wrap (Urgo K-Two, Urgo Medical North America, Fort Worth, TX) is an excellent option that is typically used in the clinical setting. A comproflex wrap can be applied on top, potentially as layer 5 for their long term compressive control, and also a venous edema leg pump can be used.

The biggest struggle must be considered recurrent ulcers due to recurrent edema, and so patient education is crucial, or they could be in the same condition again; an integrated approach to making sure that message is very clear is important.

Again, comparing using STSG alone to using the ECM layer, the latter has clearly given a better contour on the overall end result of the leg. Considering case 3, this patient had significant 1cm contour deficit and although that tissue was viable, and could have tolerated an early skin graft, much more robust coverage and an excellent cosmetic result was achieved by utilizing a staged approach with the ECM with negative pressure.

Finally, it is worth noting that working with vascular surgeons and having evaluations conducted by the vascular team can be very beneficial.

This allows the patients to undergo evaluation by a vascular team and maybe some interventions, to treat the underlying venous problems. For the venous gangrene patient (case 4), the vascular team was consulted on admission, leading to an endovascular venoplasty; the expression ‘no flow no go’ is appropriate; improve the inflow and improve the outflow, and occasionally that is done outpatient or inpatient depending on the appropriateness of the setting, but this must be optimized before grafting, or there may be a failure of the graft.

New Venous Ulcer Treatments

The Society for Vascular Surgery and the American Venous Forum have published excellent guidelines, although it must be said that more recent venous ulcer guidelines are needed.

These guidelines need upgrades frequently, not only because there are a large number of new venous ulcer treatments that are not interventional, but because there have been tremendous changes in vascular reconstruction because of the endovascular revolution; during the last 2 decades, vein care has been changed forever.

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