by Barbara S. Zuniga, MD, Medical Director, The Midwest Vein Center, Orland Park, IL
It has been estimated that the healthcare expenditures for venous stasis ulcers in the US amounts to an astounding three billion dollars per year1. In addition, venous stasis ulcers cause the loss of approximately 2 million working days per year in the US, and probably ten times that world-wide. The likelihood of developing a venous stasis ulcer (VSU) increases with age and the prevalence of VSUs in the United States is about 0.3%, which translates into about nine hundred thousand individuals affected by this painful and debilitating chronic disease.
MEDICAL SCIENCE SLOGS ALONG
Medical science has not done a great job with chronic wound healing in general, and this is especially true for venous stasis ulcers. The healing rates for VSUs are typically poor with up to 50 percent of venous ulcers open and unhealed for nine months or longer2. Venous ulcer recurrence rates are also troubling with up to one-third of treated patients experiencing four or more episodes of recurrence3.
Adding to this problem is the fact that the clinical management of advanced varicose veins and severe chronic venous insufficiency (CVI) is poorly understood by most clinicians. This is mostly due to the fact that venous disease in general is under-represented in most clinical textbooks, medical school curricula, and residency programs. As a consequence, when a patient with CVI and varicose veins develops a venous ulceration, the patient often finds their care to be uncoordinated and full of conflicting (and often ill-informed) opinions, not facts.
THE STANDARD PARADIGM
For many years, the standard approach to venous stasis ulcers has been compression bandages of various types, with dressings applied to help moisturize wounds that are too dry, or dry wounds that are too moist, or kill bacteria, or debride mechanically as needed. The constant part of all standard treatment regimes has always included compression bandages, with off-loading and elevation designed to alleviate edema, and compression management of edema is still an appropriate mainstay of treatment.
Also for many years, an important part of the standard algorithm was to delay any treatment of the underlying varicose veins until the ulcer was healed. The rationale for this approach was logical and prudent in its time. – no reasonable surgeon would subject his or her patient to the drastically increased risk of a serious wound infection by subjecting them to a vein stripping in the presence of an open, colonized or even infected venous stasis ulcer.
This paradigm, however, created a bit of a clinical dilemma – why would we want to delay the definitive treatment of the underlying cause of the ulcer? Wouldn’t the ulcer heal more rapidly if we aggressively treated the varicose veins? This clinical dilemma was often managed by non-intervention, often with a focus on what dressing was applied to the wound. With improved understanding based on ultrasound assessment and the advent of new techniques and technologies to definitively treat chronic venous hypertension with truly minimally invasive means, the focus is now on the underlying macrocirculatory cause of the ulceration. Early intervention to reduce the venous hypertension is often in order to speed the process of wound healing.
A NEW, ENDOVENOUS PARADIGM
With the emergence of endovenous techniques and technologies, this clinical dilemma has now been solved. The fact that venous hypertension can be quickly and definitively treated without any significant surgical intervention has made the need for any delay of the treatment of the underlying cause of the VSU totally unnecessary. The literature now contains several small series of rapid healing of venous stasis ulcers after endovenous thermal ablation.[SZ1]5
Instead of waiting for the ulcer to heal and then possibly treating the varicose veins and venous hypertension, the new paradigm is to promptly treat the venous hypertension with thermal ablation, and continue compression bandages, judicious debridements, and good local wound care. Like any form of therapy, not everyone responds the same, but the case illustrated below is very typical of the rapid healing seen in patients with axial reflux and VSUs.
A venous ulcer present for 5 years
Ulcer healed 2 weeks after EVLT. Note the decreased ankle and foot edema. Ulcer healed 2 weeks after endovenous thermal ablation of her short saphenous vein. Note the decreased ankle and foot edema.
1 Bergan JJ, et al. Chronic venous disease. N Engl J Med 2006; 355 488-98.
2 Lopez A, Phillps T. Venous ulcers. Wounds. 1998; 10:149-157.
3 Thomas Hess C. Management of the patients with venous ulcer. Advances in Wound and Skin Care 2000.; 13:79-83.
4 Marston, W. Evaluation and treatment of leg ulcers associated with chronic venous insufficiency. Clin Plast Surg. 2007 Oct;34(4):717-30.
5 Viarengo LM, et al. Endovenous laser treatment for varicose veins in patients with active ulcers: measurement of intravenous and perivenous temperatures during the procedure. Dermatol Surg 2007 Oct;33(10):1234-42; discussion 1241-2.
Dr. Zuniga is the Medical Director of the Midwest Vein Center in Orland Park, IL. Dr. Zuniga can be reached at: 877-510-VEIN (877- 510- 8346).