Key Insights On Treating Chronic Venous Ulcers
Patients with venous ulcers can face daunting complications. Accordingly, our expert panelists provide pertinent pearls on diagnosis, compression therapy, debridement and how their patients have fared with vascular surgery procedures.
Q: How do you approach/work up the patient with a chronic venous ankle ulcer? Is there any need for venous ultrasound studies?
A: Kazu Suzuki, DPM, CWS, says many of the current estimates show that approximately 70 percent of leg ulcers in the United States are venous ulcers or of mixed-arterial/ venous etiology. When it comes to his patients with lower extremity ulcers, he approaches them as if they have some degree of venous insufficiencies, especially if they have visible edema, varicose veins or hemosiderin stain and/or a history of deep vein thrombosis (DVT).
Marc Katz, DPM, begins his workup by taking a thorough history. This includes checking for a family history of phlebitis, clotting disorders, vasculitis or venous insufficiency. He checks the patient’s basic blood work, assesses for possible anemia and evaluates nutritional status.
If Dr. Katz suspects infection, he sends a tissue sample for culture and sensitivity. He notes this approach is much more reliable than a swab, which can be inaccurate.
Dr. Katz will almost always order early venous studies that can
detect incompetent veins and perforators. He says these studies are very important as “fixing these problems can often be the key to healing.” When ordering the venous studies, Dr. Katz suggests having specific instructions to look for reflux, incompetent saphenous veins and perforators.
“I am not just ruling out DVT,” explains Dr. Katz. “However, it is actually surprising how often you will find a DVT in one of these screenings.”
Gerit Mulder, DPM, emphasizes the importance of the clinician establishing the etiology as a truly venous etiology prior to treatment. To this end, he recommends appropriate non-invasive vascular examinations. Drs. Mulder and Katz also note the importance of establishing arterial flow before applying compression wraps.
Dr. Katz emphasizes that an arterial exam is “crucial in many patients” to determine whether the patient’s wound has arterial etiology. He does not use aggressive compression when the patient’s ankle-brachial index (ABI) is less than 0.7. If Dr. Katz suspects an arterial etiology, he considers transcutaneous oxygen measurements around the wound to check for local ischemia. However, he warns that such tests may not be reliable if there is excessive edema.
If a wound is recurrent or has been present for about six months, Dr. Katz will biopsy the lesion in order to determine the presence of vasculitis or even malignancy.
Dr. Suzuki also notes that peripheral arterial disease (PAD) is often under-diagnosed in patients of advanced age. Ruling out PAD is important because ischemic wounds would never heal (regardless of the underlying vein status) and it is unwise to apply compression therapy to an ischemic limb, according to Dr. Suzuki. He uses skin perfusion pressure/pulse volume recording (SPP/PVR) tests to screen for PAD for all of his new lower extremity ulcer patients.
Dr. Suzuki suggests ultrasound studies if he thinks a patient would benefit from incompetent vein ablation procedures, ideally after the venous leg ulcer has completely healed. When it comes to venous ultrasound studies, Dr. Suzuki defers to his consulting vascular surgeon colleagues.
Venous refilling time and valve incompetence are common diagnoses based on ultrasound testing, according to Dr. Mulder. Additional evaluations before choosing a treatment modality include checking skin status, the ability to tolerate compression and the amount of drainage. Dr. Mulder’s clinic does a complete lower extremity workup prior to diagnosing a venous ulcer.
Q: What type of compression therapy do you prefer?