Schedule a Consultation
716-839-3638
Venous Stasis Ulcers
Comprehensive Evaluation and Treatment of Venous Stasis at the Vein Treatment Center for Canadian Patients

 

Epidemiology of Venous Stasis Ulcers


It has been estimated that the prevalence of venous stasis ulcers in the general population is around 0.3 per cent or 3 patients per 1,000. It has also been borne out in the scientific literature that for every patient with an open venous stasis ulcer, there are 4 patients with healed venous stasis ulcers, giving healed venous stasis ulcers a prevalence of 1.3 per cent or 13 patients per 1,000.

 


Gaiter areas where Venous Ulcers Occur



Men versus women - sex is a risk factor for venous stasis ulcers

 

The prevalence of men with venous stasis ulcers is higher than the prevalence of women with venous stasis ulcers by a factor of 2. Women tend to live longer than men, so this seems to be an equalizing factor when calculating prevalence of a disease in the general population.

 

Does the prevalence of venous stasis ulcers increase with age ?

 

The prevalence of venous stasis ulcers increases with age with a peak prevalence between ages 60 and 80. It has been shown that the vast majority of patients have their first ulcer before age 60.

 

Ambulatory venous pressure and risk of developing venous stasis ulcers

 

A linear relationship has been observed with ambulatory venous pressures with aging and the risk of venous ulcer formation. In patients with an ambulatory venous pressure measurement less than 30 mm Hg, the risk of venous ulceration is very small. In patients with ambulatory venous pressures at the ankle exceeding 80 mm Hg, the likelihood of developing venous stasis ulceration is vary high.

 

DVT is a risk factor for developing venous stasis ulcers

 

A very important observation has also been that there is a 1 in 6 chance that patients with venous ulcers have had a history of deep vein thrombosis. So, deep vein thrombosis (DVT) is a risk factor for the development of venous stasis ulcers.

 

Venous stasis ulcers are expensive to treat according to the Center for Mediare and Medicaid Services (CMC)

 

Venous stasis ulcers are not only debilitating but costly. In one U.S. study, the cost per year per patient with a venous stasis ulcer exceeds $ 40,000 (2003 U.S. dollars). The total impact on the healthcare system is over 1 billion dollars per year. I have evaluated patients who have lived with a venous stasis ulcer for 20 years ! Although this is not a common occurence, typically patients come to see us after they have failed to get adequate treatments by their primary care physicians or by wound care centers. A large number of hospital based wound care centers have opened in the last 5 years. In most cases, they lack expertise in managing venous stasis ulcers and their repertorire of care is limited to compression bandages, electrical stimulation therapy and hyperbaric oxygen therapy. This may not be adequate for most patients with venous stasis ulcers.

 

 Diagram of Venous Stasis Ulcer

 

'10 Points of Care for the Healing of Venous Stasis Ulcers by Dr. Karamanoukian'

 

A clear understanding of the role of venous valvular dysfunction is necessary to not only treat an existing venous stasis ulcer, but also to prevent recurrence of venous stasis ulcers. Treatment requires 1) expertise in the diagnosis and treatment of superficial and deep venous insufficiency, 2) expertise in diagnosis and treatment of perforator venous reflux disease, 3) expertise in the management of post thrombotic syndrome, 4) expertise in sophisticated diagnostic Duplex venous studies, 5) expertise in ultrasound guided foam sclerotherapy, 6) expertise in the management of chronic wounds, 7) expertise in the diagnosis and management of thrombophilic disorders, 8) expertise and coordination of care with infectious disease specialists, 9) exertise and coordination of care with physical therapy and rehabilitation experts, 10) adjunctive or coopertive working relationship with a certified wound care and lymphedema specialist. At the Vein Treatment Center, we provide expertise and access to all of the above '10 Points of Care for the Healing of Venous Stasis Ulcers by Dr. Karamanoukian'.

 

 

Duration of Venous Stasis Ulcers

 

What is the average duration of venous stasis ulcers at presenttion ? 

 

In our practice at the Vein Treatment Center (data from www.VeinsVeinsVeins.com), a recent survey and analysis of our database of patients with venous stasis ulcers was notable for patients treated as early as age 26 and as old as age 86. The vast majority are in the 4th decade of life and associated with a significant family history of venous insufficiency. Venous insufficiency is also called venous reflux disease and can originate at the saphenofemoral junction, saphenopopliteal junction, or along named perforator veins. A large proportion of patients (64%) recall a family member who had trophic changes in the legs, whether they were pigmented and brown discoloration of the legs (bronzing, hemosiderosis) or with a history of venous stasis ulcers. This is not an uncommon finding in patients who have venous stasis ulcers. Three out of 4 patients in our analysis state that they were told for many years by their physicians that "nothing can be done for the discoloration of the skin"!  Nothing could be farther from the truth. 

 

In a study from Scotland, researchers demonstrated similar results to those found at the Vein Treatment Center and www.VeinsVeinsVeins.com (Dr. Karamanoukian's database). 1 in 5 patients had unhealed ulcers after 2 years. Eight per cent of patients had open venous stasis ulcers for 5 years before they presented for care. Twenty one per cent of patients had ulcers between 5 and 10 years at presentation to a wound facility!

 

 

What is the bacteriology of debridement specimens from healed venous stasis ulcers ?

 

 

In a recently published study from the Journal of the American College of Surgeons 2012 (December), volume 215: 751-757, Blumberg et have shown that methicillin sensitive Staph aureus (MSSA) and MRSA and pseudomonas species  are the most commonly cultured organisms.

 

 

What is the bacteriology of debridement specimens from poorly healing stasis venous ulcers ?

 

 

In a recently published study from the Journal of the American College of Surgeons 2012 (December), volume 215: 751-757, Sheila Blumberg and colleagues from NYU showed that in a group of patients with nonhealing venous stasis ulcers, wound cultures most commonly grow the following : methicillin sensitive Staph aureus (MSSA), pseudomonas species and Enterococcus faecalis. 

 

 

Recurrence of Venous Stasis Ulcers

 

What is the recurrence rate for venous stasis ulcers ? 

 

 Now that we have written about how long patients have had venous stasis ulcers before they seek treatment, how about the likelihood of venous stasis ulcer recurrence after treatment ? A third of patients who present with venous stasis ulcers have had 4 or more previous episodes of venous stasis ulcers. Recurrence is 30 % with the use of compression stockings and 70 % with skin grafting alone. Recurrence rates are intermediate (15 % to 45 %) with surgical vein stripping. Newer techniques with laser ablation of sapphenous veins, laser ablation of perforator veins, radiofrequency ablation of saphenous veins, mechanical chemical ablation of saphenous veins and ultrasound guided sclerotherapy have provided minimally invasive alternatives to surgery with high likelihood of venous stasis ulcer healing and reduction of recurrence.

 

 

Obtaining a good history from the patient with venous stasis ulcers

 

 

history of recent soft tissue injury may have prompted soft tissue breakdown and formation of a non-healing or poorly healing wound

 

history of deep vein thrombosis in 1/3 of patients

 

history of thrombophilia in 2/5 of patients 

 

 

Examination of the patient with venous stasis ulcer(s)

 

 

most commonly found on the medial aspect of the leg, the medial malleolus

 

the ulcer may be near circumferential, encircling or nearly encircling the lower leg

 

association with corona phlebectasia (ankle flare) - the whole ankle having spider veins, reticular veins and small varicose veins - this may extend into the medial (inside) arch of the foot, dorsum (top) of the foot and lateral ankle and foot (outside ankle)

 

there may be associated lipodermatosclerosis (hardening of the skin and fatty tissue) with brown back discoloration of the skin

 

infection of the surrounding tissue (redness and foul smelling drainange) or cellulitis (red streaks that are warm and run up the leg and down into the foot)




Venous Stasis Ulcer Video - Dr. Karamanoukian's Videos



watch a video of venous stasis ulcers Buffalo 


 

 

 

 

 

 

 

 

 

 

 

Towards an Evidence Based Approach to Treating Venous Stasis Ulcers with Compression Stockings, Bandages, Dressings ... 

 

 

  1. Evidence for the use of expensive dressings is lacking
  2. Cochrane collaboration did not find that any dressing is better than another
  3. The VULCAN trial did not show any benefit of silver impregnated dressings in regards to ulcer healing
  4. Compression therapy is the mainstay of any treatment for venous stasis ulcers
  5. Any compression is better than no compression in the healing of venous stasis ulcers
  6. Four layer bandages are better in healing venous stasis ulcers than short-stretch bandages
  7. Multilayer bandages with elastic components are better for ulcers than those with inelastic components
  8. Adjustable compression boots are as effective as compression bandages in healing venous stasis ulcers

 

 

 

 

What is the CEAP Classification ? 



Varicose vein doctors now use the CEAP classification in order to objectively classify vein problems in patients.  In our Los Angeles vein clinic, we incorporate the CEAP classification in the management of varicose veins and vein disease.  Clinical Disease state (C), Etiology (E), Anatomic Distribution (A), and Pathophysiology (P).



Class 0 No visible signs of vein disease
Class I Telangiectasias / Spider Veins and or Reticular Veins  < 2 mm
Class II Varicose Veins, tortuous superficial veins with incompetent valves with > 4 mm
Class III Varicose Veins with Leg Edema (swelling of the leg, ankles, or feet)
Class IV Varicose Veins with advanced skin changes: dark pigmentation, eczema, lipodermatosclerosis
Class V Varicose Veins with advanced skin changes and a healed venous ulcer
Class VI Varicose Veins with advanced skin changes and an active open venous ulcer

 

 

Types of Dressings for Venous Stasis Ulcers

 

 

  1. Absorbent dressings
  2. alginate dressings
  3. antiseptic dressings
  4. silver dressings
  5. foam dressings
  6. hydrocolloid dressings
  7. hydrogel dressings
  8. low adherent dressings
  9. zinc dressings

 

 

Venous Stasis Ulcers that are NOT likely to heal ...

 

  1. ulcers with dense fibrosis
  2. ulcers with mild to moderate inflammation
  3. ulcers with decreased cellularity
  4. ulcers with mature collagen

 

Ulcers that lack the above histologic characteritics are more likely to heal according to Blumberg et al. in a recently published article in the Journal of the American College of Surgeons, volume 215, no. 6, December 2012.

 

 

 

Venous Stasis Ulcer Update

 

 

It is thought that venous stasis ulcers result from sustained high pressures in the venous system, even during ambulation, where the pressure in the venous system should be the lowest (compared to at rest measurements). This is called ambulatory venous hypertension:

 

1) from superficial and/or deep venous reflux with or without deep vein thrombosis

 

2) miccrovascular dysfunction

 

3) congenital and acquired thrombophilia

 

4) obesity and diet

 

5) dysfunction of the calf muscle pump from muscle loss (sarcopenia)

 

6) skin inflammatory conditions like lipodermatosclerosis

 

7) recruitment of white blood cells

 

8) production and secretion of cytokines

 

9) stimulation of adhesion molecules and metalloproteinases

 

10) disordered fibroblast function andmatrix rearrangement

 

11) bacterial colonization;

 

12) failure of epithelialization

 

13) acute and chronic wound necrosis

 

adapted from Mannello and Raffetto, Am J Transl Res 2011;3(2):149-15 

 

© 2011. All rights reserved.