Clinical Care Treatment Protocols, Venous Ulcer

What is the prevalence of venous stasis ulcers?

In any given year, more than 1,000,000 patients in the United States and Europe have venous leg ulcers.⁵⁴ It is estimated that at any given time 1 out of 1,000 patients in the United States have an unhealed venous ulcer.⁵⁵

Who is at risk for developing venous stasis ulcers?

Individuals who suffer from chronic venous insufficiency are at risk of developing venous stasis ulcers. Approximately 7 million people in the United States have chronic venous insufficiency.⁵⁶

What is venous insufficiency?

In normal venous functioning, blood is drawn from the superficial system to the deep system (and from distal to the proximal deep veins). This process lowers the superficial venous pressure. Valvular competency is essential to this process because competent valves prevent regurgitation during the relaxation of muscles, protecting the superficial veins and capillaries from a rise in venous pressure.⁵⁷ Valvular incompetency results in an increase in superficial venous pressure, called venous hypertension, which is integral to the development of tissue trauma and eventual ulceration.⁵⁸ This increase in pressure results in the dilation and elongation of veins and venules, which disturbs the normal microcirculation by increasing permeability and leakage of plasma and erythrocytes.^59-63

How are venous ulcers diagnosed?

A venous ulcer can occur anywhere there is reflux between the deep and superficial veins. The first test for a patient with venous reflux should be arterial pulse volume recordings (PVR) and ankle brachial indices (ABI) to determine if they have a mixed arterial and venous disease. Venous reflux testing, which is an ultrasounds, is particularly useful because it not only tells you the pathogenesis, it can also tell the clinician if a deep vein thrombosis is present.

What is a common error when an ultrasound is requested?

A common error is sending a person with a venous ulcer and swelling for an ultrasound to "rule out DVT." A more appropriate order is to "evaluate for venous reflux." An order to evaluate for venous reflux will lead the vascular laboratory to examine the deep system by protocol and determine whether a clot is present. Reflux testing, reflux, DVT, and perforators will all be visualized.

What should be done if infection occurs?

Oral antibiotics such as Levaquin® or Augmentin® are an excellent first choice when a patient presents with drainage or infection. However, if the cellulitis is not rapidly resolving and the drainage continues, a deep culture must be taken and parenteral antibiotics should be considered.

What type of topical therapy should be used?

Topical dressings may decrease the rate of infection and promote a moist environment that enhances autolytic debridement and facilitates growth of granulation tissue. Cadexomer iodine (e.g., Iodosorb® or Iodoflex®), has been shown in a number of well-conducted studies to promote healing of venous ulcers when used in combination with compression therapy. Long-acting silver products may also be useful.

When should a debridement take place?

It may be appropriate to perform debridement if a venous ulcer shows signs of infection as manifested by ≥1 of the following symptoms:

• Cellulitis
• Persistent or increased exudates
• Elevated WBC count
• Fever
• Persistent or increased drainage
• Nonhealing wound (suboptimal healing rates occur when the wound area decreases <10% over a two-week period).

The rationale for surgical debridement is focused on removing nonviable tissue, decreasing bacterial burden, and stimulating contraction and epithelization.

Why is a biopsy of the tissue that was debrided important?

Infections in these ulcers may include: cocci-like structures and bacteria-like rods around vessel walls in the viable ulcer bed; vasculitis-like inflammation of deeply situated vessels of viable tissues; and pseudomonas aeruginosa-specific.⁶⁷ Further, bacteria such as staphylococcus aureus (88%), enterbacter cloacae (74%), peptococcus magnus (29%), and fungi (11%) colonize the majority of leg ulcers.⁶⁸ Oral or intravenous treatment should be selected according to the patient's condition and pathogen.

Also, malignant transformation is a known but rare complication of chronic leg ulcers.^69,70 Appearance of squamous cell carcinoma (SCC) in a leg ulcer is easily overlooked and most often diagnosed as a deterioration of the ulcer until an exophytic tumor appears. SCC in venous leg ulcers can be fatal, especially if poorly differentiated. The etiological factor of the carcinogenesis of this disease is unknown. A biopsy can be performed efficiently with a minimal risk of complication.⁷⁰

What other treatments are used for healing venous stasis ulcers?

It must be emphasized that therapies to heal venous ulcers include compression therapy, debridement, cell therapy (e.g., Apligraf®). The first line of treatment for venous ulcers is compression. By reducing distension of superficial veins, compression reduces the vessel area and improves valve competence. In addition, compression assists the calf muscle pump by reducing the venous pressure and increasing blood flow, thereby reducing edema.

Debridement is the removal of all non-viable, infected tissue and bone from open wounds until a new border of healthy, bleeding soft tissue and uninfected bone are formed. Debridement results in activation of platelets to control the hemorrhage, at the same time releasing growth factors that begin the healing process.

Autologous skin grafts and muscle flaps are plastic surgical procedures that should be considered for any patient who can tolerate the procedure and who wants or needs immediate healing. The data on autologous skin is not known. Like all plastic surgical procedures, these are a part of the wound healing physician's armamentarium, but the risk/benefit ratio must be discussed with the Venous Ulcer patient. Split thickness grafts are recommended for larger or non-healing wounds. Meshing of split-thickness skin grafts is helpful for venous ulcers, as it permits drainage of wound fluid without disrupting graft adherence to the wound.