How To Manage Venous Stasis Ulcers

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What You Should Know About Procedures For Vascular Insufficiency

In order to facilitate the healing of venous stasis ulcerations, podiatric physicians must ensure appropriate referrals to vascular specialists in order to address the underlying cause of venous insufficiency. Accordingly, here are a couple of minimally invasive options that have emerged for the treatment of patients with venous ulcers.

Sclerotherapy. Sclerotherapy is a microinjection procedure that requires no pain medication or surgery. It is a procedure used to treat blood vessels or blood vessel malformations. Some DPMs perform sclerotherapy themselves while others refer patients to a vascular surgeon for the procedure. Physicians have used sclerotherapy in the treatment of varicose veins for over 150 years.

Like varicose vein surgery, the technique of sclerotherapy has evolved over time in the treatment of venous ulcers. Modern techniques including ultrasound guidance and foam sclerotherapy are the latest developments in this evolution.

One would treat the abnormal veins by injecting a solution called a sclerosant. This will seal the vein off from the rest of the vein network in the leg, allowing the body to naturally redirect blood flow to healthy veins.

Endovenous laser treatment (ELT). Endovenous laser treatment is a quick, minimally invasive laser treatment for varicose veins that requires no hospitalization. With ELT, one would insert a small optic fiber through a needle into the varicose vein under ultrasound guidance. Once the laser is activated, as the fiber optic fiber is removed from the vein, it heats and closes the vein.

Once the vein is closed, the blood that was circulating through the vein naturally re-routes to other healthy veins. Overall, the laser energy minimizes the vein walls, shrinking them and closing the faulty vein so that blood cannot flow through it.

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How To Manage Venous Stasis Ulcers
How To Manage Venous Stasis Ulcers
How To Manage Venous Stasis Ulcers
How To Manage Venous Stasis Ulcers
How To Manage Venous Stasis Ulcers
By Tamara D. Fishman, DPM

Given the poor healing rates, high recurrence and castly nature of venous stasis ulcerations, this author offers a primer on key clinical signs, helpful insights on compression and wound care modalities, and underscores the importance of appropriate referrals.
In the United States, venous stasis ulcers have been estimated to cause the loss of 2 million working days and reportedly incur treatment costs of approximately $3 billion per year.1 The likelihood of developing venous stasis ulcerations increases with age. It is well known that patients with a history of venous insufficiency are more likely to develop venous ulcerations. Paraplegic patients are also more likely to develop venous ulcerations due to the fact that the calf muscle is immobile.

   Lower extremity venous ulcers have a variety of etiologies. However, chronic venous insufficiency (CVI) is the most common cause of lower extremity venous ulcers. Ulcer healing rates can be poor with up to 50 percent of venous ulcers open and unhealed for nine months or longer. Venous ulcer recurrence rates are also troubling with up to one-third of treated patients experiencing four or more episodes of recurrence.

   Chronic venous insufficiency is an advanced stage of venous disease caused by either superficial or deep venous pathology. Patients with CVI have an impaired venous return, which usually occurs over the course of multiple years and is caused by reflux, obstruction or calf muscle pump failure. This all leads to sustained venous hypertension and ultimately to various clinical complications such as edema, eczema, ulceration and lipodermatosclerosis. Chronic venous insufficiency results from dysfunctional valves that decrease venous return and subsequently increase venous pressure.

A Guide To Identifying Key Clinical Signs

The high venous pressure results in the presence of edema as well as the extravasation of red blood cells and large protein molecules that leak out from capillaries. Initially, clinicians will note a soft pitting edema but the skin becomes thickened over a long period of time. The venous hypertension also produces a fibrin cuff around capillaries. The fibrin cuff then inhibits oxygen diffusion to adjacent tissues, leading to local tissue atrophy and, eventually, skin ulceration. These clinical signs are often referred to as lipodermatosclerosis or postthrombotic syndrome.

   Podiatrists will most commonly locate venous stasis ulcerations on the medial or lateral aspects of the lower extremities. Characteristically, these ulcers have an irregular shape with well-defined margins. They present with edema, hyperpigmentation — due to the breakdown of the red blood cells and the deposition of hemosiderin and melanin — and skin induration (fibrosed skin). These patients may present with stasis dermatitis, erythema, fissuring, dryness, scaling of the skin and brown skin discoloration.

   When patients present with venous stasis ulcers, DPMs should also evaluate for signs and symptoms of any underlying systemic issues, such as congestive heart failure, hypoalbuminemia, malnutrition, diabetes and arterial insufficiency, and make appropriate referrals if warranted.

Critical Keys To Look For In The Diagnostic Workup

In regard to the treatment of venous stasis ulcerations, one must address the underlying cause, which is venous insufficiency. The etiology may include incompetent superficial veins and perforators as well as postphlebitic syndrome. These factors will result in persistent venous hypertension and a rise in capillary pressures with the leaking of fibrinogen into the tissues.

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Anonymoussays: June 3, 2010 at 3:46 pm

Great the point, concise. Thanks, JGF PA-C

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