Venous Leg Ulcers

1. Venous Leg Ulcers

2. Why do patients with chronic venous insufficiency develop VLU? • CVI most common cause of VLU • VLU patients have venous hypertension, or abnormally sustained elevation of venous pressure on walking • Caused by vein valve reflux, outflow problems or both • Venous outflow issues • Venous obstruction • Poor function of calf muscle pump impairs venous system's ability to return venous blood to heart • Ankle movement limitations contribute to calf muscle pump failure

3. What are the risk factors for VLU? • Age older than 55 years • Family history of CVI • Ulcer history, parental history of ankle ulcers • Higher body mass index • History of pulmonary embolism • Venous reflux in deep veins, history of superficial/DVT • Lower extremities skeletal or joint disease • Number of pregnancies • Physical inactivity • Severe lipodermatosclerosis

4. Are there measures that can prevent VLU or their recurrence? • Aggressive management of reversible risk factors • Control of relevant comorbid conditions (CHF, PVD) • Healthy diet, appropriate exercise, weight control • Management of a hypercoagulable state • Stockings that achieve at least 20-30 mm Hg pressure • Patients should use highest level of compression tolerable • Surgical venous ablation

5. CLINICAL BOTTOM LINE: Prevention... • CVI is the leading cause of VLU • Venous hypertension with calf muscle pump dysfunction • Manage comorbid risk factors • CVI, obesity, hypercoagulable states • Skeletal and joint disease of the lower extremities • Compression stockings • For primary and secondary prevention • Venous intervention • For secondary prevention

6. What symptoms and physical findings are suggestive of CVI? • Swelling and aching of legs, worse at end of day and improved by leg elevation • History of ulcer recurrence, particularly at same location • Dependent edema, telangiectasias, varicose veins, reddish-brown pigmentation and purpura, and subsequent hemosiderin deposition • Eczematous changes with redness, scaling, pruritus • Smooth, ivory-white, stellate atrophic plaques of sclerosis with telangiectases (atrophie blanche) • Chronic lipodermatosclerosis (LDS) and acute LDS

7. Chronic venous insufficiency

8. Atrophie blanche

9. What symptoms and physical findings suggest that VLU are due to CVI? • VLU may be painful—dull, aching, or burning pain • Location over medial lower third of the legs • Usually 1 ulcer w/ irregular, flat, or only slightly steep borders • Ulcer bed shallow, with granulation tissue or fibrinous material • Wound surface rarely shows necrosis, exposed tendons, bone • Venous dermatitis, LDS, or atrophie blanche around ankle • Assessment: Test for neuropathy • Severity of CVI correlates with decreased range of motion at ankle and is associated with peripheral neuropathy • VLU pain neuropathic in origin in some patient

10. Venous leg ulcer

11. What other conditions should be considered during evaluation of a patient with possible VLU? • Common causes of lower extremity ulcers • CVI • Arterial insufficiency • Diabetic neuropathy • Prolonged pressure • Less common causes • Trauma • Inflammatory or metabolic conditions • Cancer • Infections

12. What is the role of laboratory testing? • No single laboratory test is diagnostic • Testing may be indicated depending on specific patient history, comorbidities, and family history • In patients with history of recurrent ulceration or thrombosis, evaluate for hypercoagulable states

13. What is the role of noninvasive tests, such as ankle-brachial index and duplex ultrasonography? • Ankle-brachial index should be performed • For PAD screening: concomitant arterial disease in ~20% • Compression therapy could worsen an arterial ulcer • Color duplex ultrasonography • For accurate diagnosis and to provide prognostic info • Photo and air plethysmography • Whole-limb venous hemodynamics at rest and after exercise • CT exam • Intractable edema associated with pain despite compression

14. What is the role of routine testing for infection? • Swab culture testing unwarranted w/o signs of infection • If atypical infection suspected: send tissue from wound biopsy for microscopic examination and culture • Use antibiotic therapy only for clinically infected ulcers • Evidence supports topical cadexomer iodine for healing • No evidence supports use of systemic antibiotics

15. When should clinicians consider obtaining a biopsy or referring the patient to a surgical or nonsurgical specialist for diagnosis? • To rule out other causes of VLU, especially cancer • When ulcers are atypical-appearing ulcers • When ulcers have not healed after 4 weeks of active treatment

16. CLINICAL BOTTOM LINE: Diagnosis... • Typically based on clinical history and physical examination • Presence of CVI • Single, painful ulcer with irregular, flat borders and granulating or fibrinous bed on medial lower third of legs • Color duplex ultrasonography to characterize venous disease in all patients • Ankle-brachial index to exclude concurrent PAD • If VLU do not improve within 4 weeks of active therapy: consider referral to specialist or biopsy

17. What is the overall approach to treatment? • Treatment goals • Reduce edema and pain • Heal ulcers • Prevent recurrence • Systematic approach needed • Assess frequently and escalate treatment if unresponsive • Simplest treatment: bed rest with leg elevation • Elevate legs above heart 30 minutes, 3 to 4x/d + at night • Reduces swelling, improves venous microcirculation • Most patients struggle to follow this recommendation

18. What is the role of compression therapy? • Cornerstone of therapy • Because sustained leg elevation often difficult to achieve • Gold standard: multiple elastic layers for graduated compression • Increases interstitial hydrostatic pressure • Improves venous return • Reduces venous hypertension and edema • Improves ulcer healing rates • Use cautiously with CHF and with arterial insufficiency • Don’t use with severe arterial insufficiency

19. How long should clinicians prescribe compression therapy? • Continue until the ulcer heals • Continue indefinitely after healing to prevent recurrence • To enhance adherence, instruct how to put on stockings • Ensure proper measurement and fit • Assistive devices may help arthritic, obese, elderly patients • Replace at least every 6 months

20. What is the role of medication? • To improve healing in combination with compression • Aspirin (300 mg daily) • Pentoxifylline (400-800 mg 3x/d) • To reduce LDS inflammation, pain, induration • Stanozolol • Oxandrolone • Horse chestnut seed extract (active ingredient: aescin) • To reduce pain (based on neuropathic origin) • Amitriptyline, gabapentin, pregabalin

21. What is the role of growth factors? • Granulocyte macrophage colony-stimulating factor • Topical and perilesional injection increases ulcer healing • Promotes wound healing through many mechanisms (homeostasis, inflammation, proliferation, maturation) • Increases vascularization • FDA-approved for neutropenia but not wound healing • Phase 3 trials stopped due to bone pain associated with perilesional injections

22. What is the role of physical therapy or exercise? • Aim: to improve range of ankle movement and calf muscle pump function • Might enhance ulcer healing • But evidence conflicting and RCTs lacking • RCT underway: comparing compression therapy with compression therapy + 12 weeks of supervised exercise

23. What is the role of hyperbaric oxygen therapy? • Adjunct to standard wound care • Controversial because evidence for treating VLU extremely limited • 100% oxygen at 2-2.5 atmosphere absolute for 60- to 120-minute periods over 15-30 sessions • Goal: increase partial pressure of oxygen at the wound • Role in pathogenesis and treatment unclear • Fibrin cuff theory: fibrin cuffs formed around precapillary vessels may result in wound hypoxia, so increased oxygen might aid healing

24. What is the role of surgical debridement or skin grafting? • Debridement • Removes nonviable tissue to achieve an appropriate wound bed with granulation tissue • Standard care despite lack of controlled data on healing • Skin grafting • Enhances healing for large or slow-healing ulcers • May rapidly decrease pain and aid functional status • Pinch grafts, split-thickness skin grafts, and micro-skin grafts used successfully but RCTs lacking • Skin equivalents (cellular, acellular) may aid healing

25. What is the role of venous surgery in treatment and prevention? • Venous surgery • Doesn’t improve healing but reduces recurrence • Open surgery has significant potential morbidity • Cochrane review found no evidence for benefit or harm • Subfascial endoscopic perforator surgery • Safer, possible improved healing, decreased recurrence • Minimally invasive procedures • Treat CVI and recurrence • Endovenous thermal ablation (laser, radiofrequency, steam) • US-guided foam sclerotherapy; cyanoacrylate embolization

26. When should clinicians consider referring the patient to a surgical or nonsurgical specialist for treatment? • Prognostic factors associated with slower healing • Larger wound area (>5 cm2) and long duration (>6 months) • LDS and ulcer history, BMI >33 kg/m, physical inactivity • Prolonged venous filling time, deep venous insufficiency • Ulcer depth >2 cm, atypical ulcer location (posterior calf) • Refer to wound specialist when wounds fail to decrease in size during first month of treatment • Expertise may be found in a variety of specialties • Vascular medicine and surgery, podiatry, dermatology

27. How should clinicians educate patients? • Encourage patients to adhere to compression therapy • Provide educational materials on pathophysiology, management, and prevention • Consider video-based educational interventions to teach patients about the disease • Consider patient support groups for education on self-management

28. CLINICAL BOTTOM LINE: Treatment... • Goals: reduce edema, improve pain and LDS, heal ulcer, prevent recurrence • Maintenance: • Moist wound bed and regular sharp debridement • Infection control • Compression with elastic multilayer bandages • If no improvement in 4 weeks: consider referral to wound expert and adjuvant therapies • Prevent recurrence: indefinite use of compression stockings and vascular intervention