Treating Venous Stasis Ulcers In The Lower Extremity

By Mark Beylin, DPM
This facilitates blood flow from the superficial veins to the deep venous system through the perforating veins that now have open valves. At this point, the higher pressure in the superficial venous system favors flow to the deep venous system. Understanding The Etiology Of Venous Ulcers When venous insufficiency goes untreated, whether it is in the deep or superficial venous system, it can lead to leg pain, swelling, characteristic skin changes and eventual ulcer formation. Venous stasis ulcerations can result from sustained elevated pressure in the venous system of the lower extremities. Higher than normal pressures damage either the deep or superficial veins or both. A rise in the venous pressures and subsequent venous stasis leads to more permeability of capillaries. Protein leaks out of the vascular bed into the surrounding tissues. Subsequently, fibrinogen is converted into fibrin that coats the capillaries, thus interfering with the exchange of oxygen and nutrients.3 Tissue breakdown is almost inevitable and venous ulceration can occur. An early sign of longstanding venous insufficiency is edema in the ankles and legs that can lead to pain. Swelling results from the blood that has pooled in the veins due to abnormal valve function. This causes venous hypertension. As the edema and hypertension continue, the skin of the lower extremities may actually leak plasma. Eventually, the capillaries burst under the high pressure, releasing red blood cells and giving the area a typical reddish-brown discoloration. Hemosiderin and lipodermatosclerosis (indurated tissue) are common skin changes one would see in patients with venous disease.4 This skin is very vulnerable to even minor trauma as a scratch or bump can result in skin breakdown. Several theories have been proposed in reference to the exact mechanism of venous stasis ulcer formation. Some of these theories discuss white blood cell trapping, fibrin cuff hypothesis and local tissue hypoxia.5,6 Essential Diagnostic Keys Since many ulcers have certain characteristic and historic features, it is important to obtain a thorough patient history with a specific emphasis on detailing the duration and development of the ulcers. When asking the patient questions, one should determine the initial appearance of the ulcer, what possibly caused the ulcer, chronological steps in the ulcer’s development, and symptoms of the ulcer (if any). Clinicians should also ascertain whether the patient has attempted treatment, what medications he or she is currently taking, whether there is a history of any vascular diseases and if there is any pertinent family history. I go through a routine physical examination on every patient. A vascular component of the examination includes documenting the status of pedal pulses, capillary refill time, temperature gradient, edema, hair distribution, varicosities, skin color and appearance, and nail condition. I follow this exam with thorough neurological and orthopedic examinations. It is particularly important to perform a dermatological exam. One should accurately measure the ulceration, documenting its length, width and depth. Carefully examine the wound bed. Assess any present exudate for quantity and quality. Examine the borders of the wound to rule out the gross presence of an underlying skin cancer. It is important to note if the ulceration extends to deeper underlying tissues such as tendons, ligaments, capsules or bone. Carefully examine the surrounding skin. When it comes to ulcers resulting from venous insufficiency, one will often find them in the area of medial ankle or the gaiter area (in the area of the great saphenous vein). However, clinicians may find these ulcers laterally, anteriorly and posteriorly. They are usually more superficial than ulcers of other etiologies, with sharp or slanting borders and fibrotic material at the base. One will usually see moderate to high exudate due to venous hypertension. The patient may or may not have pain. One can relieve this pain by emphasizing leg elevation. When faced with a venous ulcer, it is crucial to determine the status of venous and arterial circulation in order to identify the primary cause of the wound. Non-invasive vascular studies such as Doppler flow studies, arteriography, venography and Doppler plethysmography offer good insight into diagnosing the ulceration. After determining the exact etiology, one can formulate an appropriate treatment plan.

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