Key Insights On Treating Chronic Venous Ulcers

Clinical Editor: Lawrence Karlock, DPM

A: Dr. Suzuki leaves the decision on these procedures to his consulting vascular surgeons. He cites the use of the VNUS Closure (Medical Technologies) radiofrequency catheter as one of the most promising, minimally invasive endovenous procedures. Dr. Suzuki says the procedure is clinically proven to be less painful with a faster recovery rate than traditional vein stripping surgeries.
   Dr. Katz has had the best results with the VNUS Closure system and the endovenous laser systems. In more extensive cases, he says some doctors are using the TriVex system (Smith & Nephew).
   Based on his conversations with vascular surgeons, Dr. Katz says there seems to be more emphasis on the saphenous veins and less on the perforators, which previously held more importance.
   “There can be dramatic healing following the use of the VNUS system, endovenous laser systems or the TriVex system,” says Dr. Katz.
   Dr. Mulder maintains that procedures for venous ulcers are still limited to split thickness skin grafts (STSG). He says these grafts “frequently fail and do not address the underlying disease.” He notes lifelong compression for patients is still a requirement.
   There are centers that are still doing sclerotherapy with purported success, according to Dr. Mulder, but he notes these procedures are also limited to select patients as injections are involved. Dr. Katz believes sclerotherapy is “falling out of favor.”

Q: Do you have any debridement pearls?

A: Venous ulcers of a longstanding duration (usually greater than six months) may require more extensive debridement to remove biofilm in the tissue, according to Dr. Mulder. He says curettage may not be sufficient for wound bed preparation and patients may require surgical intervention (if eligible) in the OR. The Versajet (Smith and Nephew) is a particularly useful tool for debridement, according to Dr. Mulder.
   For those who cannot undergo surgical debridement, Dr. Mulder says topical enzymes may be useful but these patients will still require compression therapy.
   Dr. Katz advocates sharp debridement. He believes in debriding patients weekly and concentrating on the periphery of the wound. Dr. Katz adds that he does not get good results with enzymatic creams when it comes to venous lesions. In addition, he says if a venous wound gets bigger with debridement, one should think about pyoderma and stop debridement.
   Over the past few months, Dr. Suzuki has used the Qoustic Wound Therapy System (Arobella Medical) ultrasound wound debridement device and has had “wonderful results.” He notes the ultrasound curette causes cavitations (microbubbles) within the wound bed to separate non-viable tissues from the healthy, viable granulation bed.
   Dr. Suzuki also notes this device is a lot less painful than a scalpel. He says the system is particularly useful when it comes to venous ulcers, which tend to be large and shallow with irregular wound shapes.

Q: Do you have topical dressing preferences when it comes to venous ulcerations?

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