Managing Venous Ulcers In The Lower Extremity

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This is a one-week old bilayered skin prosthesis (Apligraf) overlying and overlapping a venous stasis ulcer. (Photo courtesy of Richard Stillman, MD)
Here is a view of a venous stasis ulceration on the lateral aspect of the patient’s right leg. This venous stasis ulcer is primarily due to sequelae of chronic venous insufficiency. (Photo courtesy of Tamara Fishman, DPM)
Clinical Editor: Lawrence Karlock, DPM

Q: Do you see any role for bioengineered skin substitutes in the treatment of these ulcers?
When using bioengineered skin substitutes, Dr. Holloway says one should ensure meticulous preparation of the wound bed with excellent underlying tissue. Dr. Hirko concurs. If the ulcerations are chronic, clean, free of bacterial contamination and the patient has no suitable harvest sites for split thickness skin graft, Dr. Hirko says it is appropriate to use bioengineered skin substitutes as an “intermediary step” to allow for epithelialization to occur.
Dr. Hirko adds that you can also apply these skin substitutes in the office, which alleviates the need for a possible hospital stay.

Dr. Karlock says he has used Apligraf with some success in managing recurrent lower leg venous ulcerations. Noting that most of these patients are not neuropathic, Dr. Karlock uses the Mepitel dressing to adhere the graft to the wound as opposed to staples or sutures.
While Dr. Holloway concedes bioengineered skin substitutes have shown moderate success for some, he maintains that the underlying venous hypertension “results in limited longevity.” Dr. Holloway emphasizes that there are no published clinical trials that show long-term success in using these modalities to treat venous ulcers.

Q: What surgical procedures do you advocate for the recurrent venous ulcer?
When it comes to treating chronic venous ulcers, surgical procedures generally have limited proven value, according to Dr. Holloway.
“Unless you can correct the underlying venous hypertension, these ulcers are frequently difficult to heal and commonly recur,” notes Dr. Holloway.
If the patient has saphenofemoral or saphenopopliteal venous incompetency, Dr. Hirko says ligation at these levels would be appropriate along with judicious debridement of the ulcer. Autolytic debridement is more common for venous ulcers, according to Dr. Holloway, who points out that sharp debridement is very painful and often must be done in the operating room.
When dealing with large ulcerations, Dr. Hirko says split thickness skin grafts may be indicated along with rotational skin grafts if necessary. However, Dr. Holloway cautions that skin grafts “frequently have poor take” due to the uncorrected and underlying venous hypertension and edema. If one does opt for skin grafts, Dr. Holloway says you must ensure optimal pre- and postoperative care, including leg elevation, in order for the procedure to be successful.
Reconstructive procedures, such as venous banding, vein transposition and vein interposition, are usually only done in large specialized centers, according to Dr. Holloway. Even when the procedures are performed in these centers, Dr. Holloway says the success rate is not high. One emerging option is endoscopic perforator ligation surgery (SEPS). Dr. Hirko says one can perform this procedure as a stand-alone surgical intervention or in combination with ligation of veins with incompetent proximal valves. Several groups have shown that the SEPS procedure is effective when it has been demonstrated that incompetent perforating veins are feeding into the ulcer.

Final Notes
In conclusion, Drs. Hirko and Holloway caution that venous ulcerations have a mixed etiology and emphasize the importance of measuring arterial flow via examination or noninvasive vascular testing. Dr. Hirko says this testing is essential prior to implementing any extensive compression as the ulcerations may become worse or the patient could lose the affected limb.

Dr. Hirko is an Associate Professor of Surgery at the Northeastern Ohio Universities College of Medicine. He is Chief of the Division of Peripheral Vascular Surgery and the Director of the General Surgery Residency Program at the Northside Medical Center, Forum Health in Youngstown, Ohio.

Dr. Holloway is the Director of Research within the Department of Surgery at the Maricopa Medical Center in Phoenix.

Dr. Karlock (pictured) is a Fellow of the American College of Foot and Ankle Surgeons and practices in Austintown, Ohio. He is a member of the Editorial Advisory Board for WOUNDS, a Compendium of Clinical Research and Practice.

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