Venous stasis ulcers
What are venous ulcers?
Chronic venous insufficiency (CVI) with ulceration is a common condition affecting 2-5% of the population. Ulcers are wounds or open sores that will not heal or keep returning. Many among these patients have a history of decades of inadequate and frustrating thera peutic attempts. Historically, CVI was known as postphlebitic syndrome and postthrombotic syndrome, both of which refer to the etiology of most cases. However, these names have been abandoned because they fail to recognize another common cause of the disease, the congenital absence of venous valves.
What are the symptoms of ulcers?
Ulcers may or may not be painful. The patient generally has a swollen leg and may feel burning or itching. There may also be a rash, redness, brown discoloration or dry, scaly skin.
What are the types of leg and foot ulcers?
The three most common types of leg and foot ulcers include:
- Venous stasis ulcers
- Arterial (ischemic ulcers)
- Neurotrophic (diabetic)
Ulcers are typically defined by the appearance of the ulcer, the ulcer location, and the way the borders and surrounding skin of the ulcer look.
Venous stasis ulcers
Typically, these lesions occur around the inner side just above the ankle, where venous pressure is greatest due to the presence of large communicating veins. The base of a venous ulcer is usually red. It may also be covered with yellow fibrous tissue or there may be a green or yellow discharge if the ulcer is infected. Fluid drainage can be significant with this type of ulcer.
The borders of a venous ulcer are usually irregularly shaped and the surrounding skin is often discolored and swollen. It may even feel warm or hot. The skin may appear shiny and tight, depending on the amount of edema (swelling). The skin may also have brown or purple discoloration about the lower leg, known as "stasis skin changes."
Venous stasis ulcers are common in patients who have a history of leg swelling, long standing varicose veins, or a history of blood clots in either the superficial or the deep veins of the legs. Ulcers may affect one or both legs.
Venous ulcers affect 500,000 to 600,000 people in the United States every year and account for 80 to 90% of all leg ulcers.
What causes venous ulcers?
Risk factors associated with chronic venous insufficiency
- Age: Incidence of CVI rises substantially with age.
- Family history: History of deep vein thrombosis (DVT), which renders venous valves incompetent, causing backflow and increased venous pressure, is a risk factor.
- Lifestyle: A sedentary lifestyle minimizes the pump action of calf muscles on venous return, causing higher venous pressure. CVI occurs more frequently in women who are obese. Vocations that involve standing for long periods predispose individuals to increased venous pressure in dependent lower extremities. A higher incidence of CVI is observed in men who smoke.
- Diseases like diabetes and polyneuropathy
How are leg ulcers diagnosed?
Clinical history and inspection of venous ulcer
First, the patient's medical history is evaluated. Lack of appropriate clinical assessment of patients with limb ulceration in the community has often led to long periods of ineffective and often inappropriate treatment. It is therefore advisable that diagnosis of ulcers should be based on a thorough clinical history and physical examination, as well as appropriate laboratory tests and haemodynamic assessment. This will assist identification of both the underlying cause and any associated diseases and will influence decisions about prognosis, referral, investigation and management. If the practitioner is unable to conduct a physical examination, they must refer the patient to an appropriately trained professional.
Following may be indicative of venous disease
. family history
. varicose veins (record whether or not treated)
. proven deep vein thrombosis in the affected leg
. phlebitis in the affected leg
. suspected deep vein thrombosis (for example, a swollen leg after surgery, pregnancy, trauma or a period of enforced bed rest)
. surgery or fractures to the leg
. episodes of chest pain, haemoptysis, or history of a pulmonary embolus
The staging of pressure ulcers is as follows:
| Stage I | Non-blanchable defined area of persistent erythema of intact light toned skin. In darker skin tones, the area may appear with persistent red, blue or purple hues. Observable pressure alteration of intact skin whose indicators are compared to an adjacent or opposite area on the body may include one or more of the following: . Skin temperature (warmth or coolness) . Tissue consistency (firm or boggy) . Sensation (pain or itching) |
| Stage II | Partial thickness skin loss involving epidermis and/or dermis. This superficial ulcer presents clinically as an abrasion, blister or shallow crater. |
| Stage III | Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. This ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. |
| Stage IV | Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures (e.g., tendon, joint capsule). |
How are leg ulcers treated?
Each patient's treatment plan is individualized, based on the patient's health, medical condition and ability to care for the wound.
Treatment options for all ulcers may include:
- Antibiotics, if an infection is present
- Anti-platelet or anti-clotting medications to prevent a blood clot
- Topical wound care therapies
- Compression garments
- Prosthetics or orthotics, available to restore or enhance normal lifestyle function
Medical therapy: Non-surgical treatments for CVI include the following:
Dressings
It is of the outmost importance to keep the wound clean and moist. The type of dressing prescribed for ulcers is determined by the type of ulcer and the appearance at the base of the ulcer. Types of dressings include:
- Moist to moist dressings
- Hydrogels/hydrocolloids
- Alginate dressings
- Collagen wound dressings
- Debriding agents
- Antimicrobial dressings
- Composite dressings
- Synthetic skin substitutes
Leg elevation
By keeping the legs elevated, venous flow is augmented by gravity, lowering venous pressures and ameliorating edema. While sitting, the legs should be above the thighs. Supine, the legs should be above the level of the heart.
Compression stockings
Venous ulcers are treated with compression of the leg to minimize oedema or swelling due to venous hypertension. Compression treatments include wearing compression stockings, multilayer compression wraps, or wrapping an ACE bandage or dressing from the toes or foot to the area below the knee. The type of compression treatment prescribed is determined by the physician based on the characteristics of the ulcer base and amount of drainage from the ulcer.
Unna boots
First described by Unna in 1854, the Unna boot now is the mainstay of treatment for people with venous ulcers. Unna boots are rolled bandages that contain a combination of calamine lotion, glycerin, zinc oxide, and gelatin.
Vacuum-assisted wound closure
Negative topical pressure, the general category to which the trademarked VAC therapy belongs, is not a new concept in wound therapy. It is also called subatmospheric pressure therapy, vacuum sealing, vacuum pack therapy, and sealing aspirative therapy. The VAC therapy system is trademarked by Kinetic Concepts, Inc., or KCI . It was first reported on in 1997 by a German surgeon.
The aim of the procedure is to use negative pressure to create suction, which drains the wound of exudate (i.e., fluid, cells, and cellular waste that has escaped from blood vessels and seeped into tissue) and influences the shape and growth of the surface tissues in a way that helps healing. During the procedure, a piece of foam is placed directly over the wound, and a drain tube is placed over the foam. A large piece of transparent tape is placed over the whole area, including the healthy tissue, to secure the foam and drain. The tube is connected to a vacuum source, and fluid is drawn from the wound through the foam into a disposable canister. Thus, the entire wound area is subjected to negative pressure. The device can be programmed to provide varying degrees of pressure either continuously or intermittently. It has an alarm to alert the provider or patient if the pressure seal breaks or the canister is full.
VAC therapy may be used for patients with chronic and acute wounds; subacute wounds (dehisced incisions); chronic, diabetic wounds or pressure ulcers; meshed grafts (before and after); or flaps. It should not be used for patients with fistulae to organs/body cavities, necrotic tissue that has not been debrided, untreated osteomyelitis, wound malignancy, wounds that require hemostasis, or on patients who are taking anticoagulants. The VAC system should not be placed on exposed blood vessels or organs or where there is active bleeding.
It may be considered for patients with a chronic cutaneous ulcer when all of the following criteria are met:
. Present for at least 30 days
. Failure of the ulcer to heal despite an adequate wound therapy program consisting of all of the following:
. Debridement of necrotic tissue if present,
. Stage III or IV stasis ulcers
. Leg elevation and ambulation for venous insufficiency ulcers
It is also used following anti-reflux surgery or sclerotherapy of the venous system
Dressing are changed at 2-4 days intervals
Injection sclerotherapy
Injection of sclerosing agent directly into veins usually is reserved for telangiectatic lesions rather than CVI.
Surgical therapy: Chronic venous insufficiency (CVI) and its complications of chronic pain, intractable ulceration, and infection are important conditions to treat by modern surgical techniques. Approximately 8% of patients require surgical intervention for CVI. Surgical treatment is reserved for those with discomfort or ulcers refractory to medical management.
The decision to operate on a patient with venous obstruction in the deep veins should be made only after a careful assessment of symptom severity and direct measurement of both arm and foot venous pressures. Venography alone is not sufficient because many patients with occlusive disease have extensive collateral circulation, rendering them less symptomatic. Clot lysis (eg, tissue plasminogen activator [TPA], urokinase) and thrombectomy have been tried but have largely been abandoned owing to extremely high recurrence rates.
Following surgical procedure are performed:
. Leg vein and perforator ligation
. Subfascial endoscopic perforator surgery (SEPS) is gaining in popularity as a means of treating CVI. Endoscopic techniques are used to find and ligate perforating veins. Preliminary reports are encouraging. Ulcers treated with SEPS heal 4 times faster than ulcers treated conventionally. In addition, morbidity of SEPS is significantly lower than traditional operations. Long-term results are pending.
. Endoscopic fasciotomy and subfascial perforator division
. A new possibility is endovenous laser treatment of perforating veins. The light faser is introduced into the vein under the ulcer. This method is only performed by our group and is under clinical study at present
Complications of Surgery
Haematoma, sural or saphenous nerve damage, and infection are possible complications of venous surgery.
Wound Care at Home
Patients are given instructions to care for their wounds at home. These instructions include:
- Keeping the wound clean
- Changing the dressing as directed
- Taking prescribed medications as directed
- Drinking plenty of fluids
- Following a healthy diet, as recommended, including plenty of fruits and vegetables
- Exercising regularly, as directed by a physician
- Wearing appropriate shoes
- Wearing compression wraps, if appropriate, as directed
The treatment of all ulcers begins with careful skin and foot care.
Foot and skin care guidelines:
Inspecting your feet and skin is very important, especially for people with diabetes. Detecting and treating foot and skin sores early can help you prevent infection and prevent the sore from getting worse. Here are some guidelines:
- Gently wash the affected area on your leg and your feet every day with mild soap and lukewarm water. Washing helps loosen and remove dead skin and other debris or drainage from the ulcer. Gently and thoroughly dry your skin and feet, including between the toes. Do not rub your skin or area between the toes.
- Every day, examine your legs as well as the tops and bottoms of your feet and the areas between your toes. Look for any blisters, cuts, cracks, scratches or other sores. Also check for redness, increased warmth, ingrown toenails, corns and calluses. Use a mirror to view the leg or foot if necessary, or have a family member look at the area for you.
- Once or twice a day, apply a lanolin-based cream to your legs and soles and top of your feet to prevent dry skin and cracking. Do not apply lotion between your toes or on areas where there is an open sore or cut. If the skin is extremely dry, use the moisturizing cream more often.
- Care for your toenails regularly. Cut your toenails after bathing, when they are soft. Cut toenails straight across and smooth with an emery board.
- Do not self-treat corns, calluses or other foot problems. Go to a podiatrist to treat these conditions.
- Don't wait to treat a minor foot or skin problem. Follow your doctor's guidelines.
How can ulcers be prevented?
Controlling risk factors can help you prevent ulcers from developing or getting worse. Here are some ways to reduce your risk factors:
- Keep your skin moist
- Wear compression stockings
- Control your blood cholesterol and triglyceride levels by making dietary changes and taking medications as prescribed
- Limit your intake of sodium (salt)
- Manage your diabetes and other health conditions, if applicable
- Exercise - start a walking program after speaking with your doctor
- Lose weight if you are overweight
- Quit smoking