Managing Venous Ulcers In The Lower Extremity
Given the potentially serious nature of venous ulcers in the lower extremity, our expert panelists take a closer look at key risk factors and share their treatment approaches to this condition. Drawing from their experience, they also discuss topical treatments, the use of bioengineered skin substitutes and surgical procedures. Q: What risk factors predispose patients to the development of lower extremity venous ulcers? A: Mark Hirko, MD, and Lawrence Karlock, DPM, agree that risks include prior deep venous thromboses (DVT), morbid obesity, lower extremity trauma and chronic venous hypertension, which can lead to perforator vein incompetence. Allen Holloway, MD, agrees and emphasizes that venous hypertension is the primary factor associated with the development of venous ulcers. He notes this may be secondary to previous DVT, either deep, superficial or perforator vein incompetence or severe edema from the dependent position. According to Dr. Hirko, other less common risk factors include changes in the progesterone-estrogen ratio, pregnancy, increased intraabdominal pressure and chronic phlebitis leading to venous hypertension. Q: What is your traditional treatment protocol in managing these ulcers? A: After an in-depth patient history and physical exam, Drs. Hirko and Holloway will proceed with a venous duplex study of the lower extremities and, based upon the severity and/or location of the ulceration, include compression as a first-line treatment. Drs. Holloway and Karlock agree that compression is the most important aspect of treating venous ulcers. Simple forms of compression include an elastic bandage (ACE) wrap or a compression stocking, according to Dr. Holloway. However, he says simple compression may not be practical in heavily draining wounds. In these cases, Dr. Holloway will employ an Unna’s boot or a multilayer compression bandage. He emphasizes that these modalities, which are commonly changed weekly, provide compression and absorb drainage. When treating serious, chronic cases with extensive lower extremity ulcerations and/or necrotic skin, Dr. Hirko combines judicious debridement with compression. He says the compression could include ace wraps with skin moisturizers, the traditional Unna’s boot and the newer multilayer compression boots. Drs. Holloway and Karlock emphasize the importance of elevating the involved legs as much as possible in order to decrease the venous hypertension and edema. In severe cases, Dr. Holloway says using a venous compression pump can be a useful adjunct. When healing has occurred, Drs. Karlock and Holloway advocate the use of compression stockings in order to prevent recurrence. Q: What topical products do you prefer to use for these ulcers? A: When drying is a problem in smaller ulcers, Dr. Holloway says he frequently uses a calcium alginate or newer silver-containing dressing, and applies a vaseline gauze dressing over it in order to keep the wound moist and protect the surrounding skin. If the wound has extensive moisture, bordering on maceration, Dr. Hirko considers using sheets of Kaltostat. He says this seaweed-based agent helps dry the wound, remove excessive fluid and provides a moist hydrogel layer in the same setting. Dr. Karlock agrees, adding that he prefers using Aquacel or Kaltostat on highly draining venous wounds. When using these modalities, Dr. Karlock notes that he will first apply an Adaptic dressing, directly to the wound. If the wound has extensive contamination, Dr. Hirko recommends using an iodine-based gel such as Iodosorb. If the wound is somewhat dry and nearly healed, he says using hydrogel-type wound products is appropriate. When extensive chemical debridement is called for, Dr. Hirko says he will use Accuzyme. When it comes to irritated, dry skin or a necrotic ulceration, Dr. Hirko says you can perform gentle debridement with a combination of Santyl and Polysporin powder. Q: Do you see any role for bioengineered skin substitutes in the treatment of these ulcers? A: 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? A: 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.