Venous Stasis

Ulcers

By Trisha Guerrero & Sarah Hoover

Treatment requires an understanding of the underlying cause

What is venous insufficiency? Inability to return venous blood to the heart from

peripheral vasculature Progression to Chronic Venous Insufficiency (CVI) leads

to spontaneous (absence of trauma) ulcer formation CVI is the most common cause of leg ulcers Much higher incidence than arterial ulceration 80% of ALL leg ulcers are caused by venous disease

Etiology

Pathology leading to venous insufficiency

Congestive Heart Failure (CHF)

Chronic Venous Hypertension (CVH)

Early on: Spider & Varicose vein formation

Edema, feeling of heaviness in involved extremity Pitting edema

Fibrosis (hardening) of dermis Discoloration of skin Elevated skin temperature Itchiness of the area

Signs & Symptoms

Disease progression

Dysfunction of one-way valves

Backflow and blood pooling

Excess interstitial fluid Edema Skin Breakdown Ulcer formation

Clinical Presentation & Diagnosis

CAEP (clinical, etiology, anatomy, and pathophysiology) classification systemhttps://www.youtube.com/watch?v=xgKr6gjTF18

Location: The LE, proximal to the medial malleolus (most common) Can occur anywhere

Not significantly painful If there is pain, it can be relieved with elevation

Wound bed: Granulation tissue Slough Tissue appears wet, due to large amount of exudate

Once ulcer develops, venous wounds can exist for years

Venous wounds

CONTROLLABLE:Prolonged periods of standing/sitting (general inactivity)Obesity, DiabetesDietSmoking

INCONTROLLABLE: * Genetics

Heredity of venous hypertensionAgeSex (Female > Male)

Pregnancy, hormones

Lifestyle changes & implications

Conservative Management Ultrasound

Non-contact, non-thermal, low-frequency treatment

A sterile saline misted on wound bed

Enables ultrasound waves to be transferred from the device to the patient

Reduces bacteria, promotes healing (slow to heal)

Compression Therapy! Active Compression Pump Compression stockings Unna’s Boot

P : 104 participants with LE venous ulcers

I : Alternative treatments (HVS, US, LLLT, quasi CT)

C : Compression therapy

O: HVS and LLLT did not have hemodynamic effects inside the venous wounds. Quasi CT induced a thermal effect, but didn’t last long enough to be beneficial. Both US and CT showed a significant hemodynamic effect, promoting arterial microcirculation inside the venous ulcer which is an important mechanism of healing.

Physical Therapy in the treatment of venous leg ulcers: Biophysical mechanism

Positioning Avoid dependent positions Elevate involved limb

whenever possible

Appropriate forms of exercise to increase venous return

Pool exercise

Conservative management (cont’d)

Manual Lymphatic DrainageGentle stretch to the skin that enhances lymphatic capillary activityRemove excess fluidAlways promote movement toward axillary, inguinal, and/or popliteal areas

Conservative management (cont’d)

Pentoxifylline (Trental) and Aspirin

Inhibits platelet aggregation Decreases blood viscosity improved mobility of

microcirculation improve ulcer healing when combined with

compression therapy

Medications

Surgical Management

TYPES: Debridement: removal of necrotic tissue and bacteria

sharp, enzymatic, mechanical, biologic or autolytic.

Skin Grafting: autograft, allograft, or artificial graft

Surgery: to reduce venous reflux, and prevent reoccurrence

Subfascial Endoscopic Surgery Ablation of saphenous vein Stenting Removal of incompetent superficial veins by stripping,

phlebectomy, sclerotherapy, or laser therapy

https://www.youtube.com/watch?v=raCYxRJir4o

Laser Therapy

Hypertension History of Deep Vein Thrombosis (DVT) Congestive Heart Failure (CHF) Diabetes amputations

Associated Complications Loss of Mobility Infection

>Osteomyelitis

>Blood poisoning Loss of independence Emotional and psychological distress

Common comorbidities

Adaptive equipment

Specialized pillows to improve venous return

Specialized shoes

Manual Wheelchair with elevated leg rest

Prosthetic (post-amputation)

Acute ulcers (3 months or less) 71-80% chance of healing

after treatment

Chronic ulcers ( > 6 mo.) Only a 22% chance of

healing after 6 months of treatment

https://www.youtube.com/watch?v=9KFT08gMvAc

prognosis

*Instruct patient/family:> Pressure relief and appropriate

positioning> Smoking cessation> Appropriate skin care and skin checks> Independent therapeutic exercises, ROM> Safe mobility, activity progression

Patient and Family Education

• Discuss realistic expectations regarding wound healing

• Provide emotional support as needed

• Consider a patient’s learning style for effective communication and instruction

• Self-Care and Home Management

P: 80 pts with venous leg ulcers; followed for 3 years I: Surgical Management or compression with venous ulcer C: The Mann-Whitney U-test to get the difference

between the two randomized groups O: The median ulcerated area in the compression and

surgical groups were not significantly different. The healing rate was 96% within the first 21-180 days for the compression group and the healing rate was 100% within 17-53 days after surgery. Out of all, there were 9 reoccurrences in the compression group and 2 reoccurrences in the surgical group.

Minimally invasive surgical management of primary venous ulcers vs. compression treatment

Collins, MD, Lauren, and Samina Seraj, MD. "Diagnosis and Treatment of Venous Ulcers." - American Family Physician. Thomas Jefferson University Hospital, 15 Apr. 2010. Web. 27 Oct. 2014. http://www.aafp.org/afp/2010/0415/p989.html.

Kam, Katherine. "Diabetics' Shoes: Comfortable Shoes, Depth Shoes, Inserts, and More." WebMD. WebMD, n.d. Web. 27 Oct. 2014. http://www.webmd.com/diabetes/features/find-the-right-shoes-for-diabetes.

Zamboni, P., C. Cisno, F. Marchetti, P. Mazza, L. Fogato, S. Carandina, and M. De Palma. "Minimally invasive surgical management of primary venous ulcers vs. compression treatment." www.ejves.com. European Journal of Vascular and Endovascular Srugery, 14 June 2002. Web. 22 Oct. 2014. <http://www.ejves.com/article/S1078-5884(02)91871-X/abstract>.

Taradaj, J., Franek, A., Blaszczak, E., Polak, A., Chmielewska, D., Krol, P., & Dolibog, P. “Physical Therapy in the Treatment of Venous Leg Ulcers: Biophysical Mechanisms.” (2012). Wounds, 24(5), 138-145.

O’Sullivan, S.B., Schmitz, T.J.,& Fulk, G.D. (2014). Physical Rehabilitation (6th Edition). Philadelphia, PA: FA Davis.

references