Jumpstarting VLUs with Tandem Venous Ligation and Acellular Fish Skin Application

Introduction: Almost 80% of VLUs heal by one year using conservative management, however, 6-month recurrence is as high as 50-70% when the underlying etiology is not also addressed.[1][2] In VLUs that fail to heal or that recur, cellular, acellular, and matrix-like products (CAMPs) are highly effective in accelerating healing and promoting closures. Acellular fish skin (AFS*), in particular, has demonstrated notable efficacy in accelerating healing of a variety of wound etiologies due to its rich composition of key, pro-regenerative elements, such as Omega-3 fatty acids, and its porous collagen structure that dissuades bacterial invasion and acts as a scaffold for regeneration and repair.[3] By using a tandem approach involving saphenous vein stripping followed by VLU debridement and the application of AFS*, we examined if accelerated wound closures were achievable in highly recalcitrant and recurrent VLUs that had failed multiple SOC therapies.Methods:Patients with highly recalcitrant VLUs underwent saphenous vein stripping in the OR. Hydrosurgical debridement was then performed and AFS* was cut to size and affixed using chromic sutures. A nonadherent dressing and secondary dressing for drainage management were then placed overlying, followed by triple compression. All patients followed up one week later in our outpatient clinic and continued to follow up weekly for wound assessment and dressing changes. At each follow-up, wound area reduction (WAR), wound health, subjective pain level, and amount of drainage were recorded.Results:One patient with a history of post-thrombotic syndrome had a recurrent left malleolar ulcer(42cm2) that failed to heal using SOC, serial living cellular matrix applications, and operative debridement. After repeat duplex, he underwent SSV striping, wound debridement and AFS* application. At one-week follow-up, his wound had complete engraftment with modest epithelialization at the wound edges, a 15% wound area reduction (WAR), and he endorsed significantly less pain and drainage. Another patient with a remote history of endovenous laser ablation therapy (EVLT) for CVI had a recurrent left malleolar VLU(7x9 cm). He underwent duplex, followed by GSV and perforator stripping, debridement, and AFS* application. At 1-week follow-up, his wound had decreased to 5.4x6.2cm and he endorsed significantly less drainage.Discussion: AFS* appears to facilitate rapid granulation and wound contracture in stagnant VLUs once the underlying etiology has been appropriately treated. Depending on the underlying VLU pathology, a more proactive management approach with earlier venous intervention, regardless of a VLUs capacity to heal with SOC, may be appropriate in some patients as a preventative measure for recurrence. References:1. James CV, Murray Q, Park SY, et al. Venous leg ulcers: potential algorithms of care. Wounds. Published online October 24, 2022. doi:10.25270/wnds/21160 2. Raffetto JD, Ligi D, Maniscalco R, Khalil RA, Mannello F. Why Venous Leg Ulcers Have Difficulty Healing: Overview on Pathophysiology, Clinical Consequences, and Treatment. J Clin Med. 2020;10(1):29. Published 2020 Dec 24. doi:10.3390/jcm10010029 3. Fiakos G, Kuang Z, Lo E. Improved skin regeneration with acellular fish skin grafts. Engineered Regeneration. 2020/01/01/ 2020;1:95-101. doi:https://doi.org/10.1016/j.engreg.2020.09.002