REGARDING "STASIS DERMATIS" STANDARD OF CARE
I believe that the "best practice" "standard of care" in the treatment of patients with stasis dermatitis must evolve to include definitive treatment directed specifically toward venous insufficiency. Incompetent valves cause backward flow in veins and the resulting increased flow and pressure, typically in the greater and lesser saphenous veins and in incompetent perforator veins, results in varicose veins and stasis dermatitis. I am writing this letter to encourage a "best practice" "standard of care" that includes definitive treatment.
A standard of care develops over decades and balances science, cost/benefit, safety, habits, and the expectations and convenience of both the practitioners and the patients. It reflects the prudence and caution required by a reasonable physician.
Over the past century, the definitive care alternative to topical medications and compression treatments for stasis dermatitis was saphenous vein stripping, a very painful and costly surgical procedure. Understandably, most physicians were reluctant, except in the most advanced cases, to recommend a stripping procedure to their patients. Unfortunately, with temporizing and palliative treatments, stasis dermatitis patients have had to suffer prolonged morbidity. They experience increasing sensitization to topical medications and the inconvenience and discomfort of compression therapy. Additionally, these patients are at continued risk from an increased incidence of superficial thrombo-phlebitis and of deep venous thrombosis, and they have increased susceptibility to infection, even sepsis.
Also, with the widespread use of coronary artery bypass grafts (CABG), saphenous veins were seen as a harvest resource. Most recently, however, arteries such as the radial and internal mammary arteries have become preferred vessels for use. These grafts stay patent longer and are easily accessible. In any case, diseased, widely dilated, incompetent saphenous veins from patients with venous insufficiency are not good candidates for use as grafts.
Now that relatively inexpensive and very effective endovenous ablation treatment is widely available on an outpatient basis, the "standard of care" for patients with "Stasis dermatitis" patients must evolve. These patients need workup and definitive treatment directed toward venous insufficiency:
1. Workup: Duplex Doppler Venous Ultrasound with ABI - This 30 minute procedure is done in the office. Ultrasound vascular assessment objectively identifies and documents saphenous vein reflux, vein dilation and incompetent perforating veins.
2. Definitive Treatment: Endovenous Ablation of the Saphenous Vein - This painless 45 minute procedure is done in the office using a catheter, local anesthetics and a laser fiber. This is procedure is 100% effective and patients return to normal activities immediately.
Endovenous ablation is definitive treatment directed at venous insufficiency, the cause of stasis dermatitis. The results are often as dramatic as those seen in treatment of varicose veins, another manifestation of venous insufficiency.
Varicose veins are only the 'tip of the iceberg' of venous insufficiency. Stasis dermatitis requires the same workup and same definitive treatment directed at its etiology, venous insufficiency.
Contributed by Daniel J. Mountcastle, MD, FAAEM
Director, Mountcastle Vein Center
Member of the American College of Phlebology
