All you need to know about Venous Leg Ulcers

Symptoms commonly seen with varicose veins include:

  • Dull aching or pain
  • Heaviness or the feeling of leg pressure
  • Swelling
  • Tiredness or fatigue
  • Restless legs at night
  • Nighttime cramping
  • Itching or burning

Patients with chronic venous insufficiency (CVI) develop skin changes resulting from high pressures in the veins that then affect the fat and skin most often around the ankle. It is seen as chronic swelling, more severe skin changes of thickening or fibrosis (lipodermatosclerosis) or dark color changes called hyperpigmentation, or with the most severe condition, venous stasis.After having CVI for a long time, the skin of the lower leg becomes shiny, hard and has a darker color than the surrounding skin. The skin is fixed or anchored to the underlying tissues making the skin tenser and less flexible. They skin may be very dry (dermatitis). White scar tissue (atrophie blanche) may also be present.

 

Venous Leg Ulcers Treatment

Diagnosis

The doctor will want to know of any other medical problems which might show how important or how likely your symptoms are due to venous disease. This includes:

  • A history of blood clots or other vein problems
  • Family history of blood clots or vein problems
  • Previous vein surgery
  • Your job and the need for standing for a long time
  • Any issues you have with weight control and constipation
  • A history of cancer, stroke, recent surgery illness
  • Orthopedic surgery or any injury to the leg.
  • When your symptoms happen and if they are getting worse
  • The use of compression stockings
  • Pregnancies or pregnancy complications
  • Any condition which affects the movement of the foot, ankle or leg

Doppler ultrasound is necessary non-invasive test used to diagnoses “faulty veins”. This allows the physician to directly see the vein and hear blood flow in the vein. This test uses sound waves which can go in to the body, hit the vein and be bounced back to detecting part of the machine. The test usually begins with testing to look for deep vein thrombosis (DVT) or chronic injury resulting from a previous blood clotting. Then the veins are studied with the patient standing to look for reflux (downward flow of the blood) in all of the deep and superficial veins.

In some cases, you may need a CAT scan (computed axial tomography) or MRI (magnetic resonance imaging) to evaluate the veins and make sure there is nothing blocking the blood from getting out of the vein (outflow obstruction).

Treatment

There is wide range of treatment options available and most are “key-hole surgery”. It will depend on the severity of patients venous disease and patients may choose from variety of options from open surgery to sclerotherapy. The modern and very efficient treatment for advanced venous disorders are clot dissolving, clot debulking, angioplasty or stent of the affected veins and laser surgery. Most are “day-case” treatment requiring NO hospital stay at all.

 

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Diagnosis & Treatment of Post Thrombotic Syndrome (PTS)

Incidence and Prevalence of PTS

Deep Vein Thrombosis (DVT) affects 1 to 3 of 1000 people in the general population annually (1,2)Between 20% to 50% of patients with DVT develop post thrombotic syndrome (PTS)(3-8). PTS usually develops within a few months to a few years after DVT. Incidence of PTS continues to increase, even 10 to 20 years after DVT diagnosis and up to 10% of patients develop severe PTS, which may include venous ulcers (9-10).

Signs and symptoms

Post-thrombotic syndrome symptoms and signs include swelling, heaviness, fatigue, itch, pain or cramps and also skin discolouration (pigmentation, redness, eczema) and skin breakdown (ulcers). Symptoms usually get worse at the end of the day or after standing, and improve with rest or limb elevation.

Post Thrombotic Syndrome

Pathophysiology of PTS

It is believed that that major trigger is venous hypertension(high pressure in the venous not arterial system). Normally, when an individual isat rest in the supine position, venous pressure is low. When a personstands up and remain motionless, venous pressure is highest. While an individual is walking, venous pressure is reduces asblood is ejected by contraction of the calf muscles. Well working venous valves then help out to keep blood moving towards the hart. Any damage to the venous valves impedes venous return.This leads to venous hypertension. Any obstruction in the venous system again works against the flow and increases venous pressure in the leg and foot. Combination of reflux and obstruction causes usually the worst symptoms 11).

Diagnosis

Clinical assessment, venous ultrasound scan and CT or MRI are usually necessary to correctly diagnose the problem.

In selected patients in whom iliac vein obstruction is suspected on also invasive imagining is needed and includes contrast venography with or without intravascular ultrasound (IVUS). In those cases where obstruction or compression was verified an endovascular techniques can be used at the same time to correct the problem.

Treatment

Compression should be used to treat all patients with venous ulcers. A number of reports describe the technical success rate and short-term outcome after percutaneous relief of iliac vein obstruction. The largest, most carefully studied cohort was that of Neglen et al,150 who reported results of venoplasty and stenting in 464 limbs of patients with PTS followed up for at least 5 years. Ulcer healing occurred in 55%. Resting arm-foot pres- sure differential and QoL significantly improved after venoplasty and stenting. Procedure-related thrombosis occurred in 2.6% (10). There are however number of other procedures to help to get the venous pressure under control. These include sclerotherapy, laser saphenous vein ablation, stripping, phlebotomy and other techniques. These have to be taken into account as every patient is different and all interventions have to be “tailored” individually.

References

  1. White RH. The epidemiology of venous thromboembolism. Circulation. 2003;107(suppl 1):I4–I8.
  2. Cohen AT, Agnelli G, Anderson FA, Arcelus JI, Bergqvist D, Brecht JG, Greer IA, Heit JA, Hutchinson JL, Kakkar AK, Mottier D, Oger E, Samama MM, Spannagl M: VTE Impact Assessment Group in Europe (VITAE). Venous thromboembolism (VTE) in Europe: the number of VTE events and associated morbidity and mortality. Thromb Haemost. 2007;98:756–764.
  3. Prandoni P, Lensing AWA, Cogo A, Cuppini S, Villalta S, Carta M, Cattelan AM, Polistena P, Bernardi E, Prins MH. The long-term clinical course of acute deep venous thrombosis. Ann Intern Med. 1996;125:1–7
  4. Kahn SR, Shrier I, Julian JA, Ducruet T, Arsenault L, Miron MJ, Roussin A, Desmarais S, Joyal F, Kassis J, Solymoss S, Desjardins L, Lamping DL, Johri M, Ginsberg J. Determinants and time course of the post-throm- botic syndrome after acute deep venous thrombosis. Ann Intern Med. 2008;149:698–707.
  5. Ginsberg JS, Hirsh J, Julian J, Vander LaandeVries M, Magier D, MacKinnon B, Gent M. Prevention and treatment of postphlebitic syn- drome: results of a 3-part study. Arch Intern Med. 2001;161:2105–2109.
  6. Stain M, Schonauer V, Minar E, Bialonczyk C, Hirschl M, Weltermann A, Kyrle PA, Eichinger S. The post-thrombotic syndrome: risk factors and impact on the course of thrombotic disease. J Thromb Haemost. 2005;3:2671–2676.
  7. Schulman S, Lindmarker P, Holmstrom M, Larfars G, Carlsson A, Nicol P, Svensson E, Ljungberg B, Viering S, Nordlander S, Leijd B, Jahed K, Hjorth M, Linder O, Becknam M. Post-thrombotic syndrome, recur- rence, and death 10 years after the first episode of venous thromboembo- lism treated with warfarin for 6 weeks or 6 months. J Thromb Haemost. 2006;4:734–742.
  8. Aschwanden M, Jeanneret C, Koller MT, Thalhammer C, Bucher HC, Jaeger KA. Effect of prolonged treatment with compression stockings to prevent post-thrombotic sequelae: a randomized controlled trial. J Vasc Surg. 2008;47:1015–1021.
  9. Kahn SR, Partsch H, Vedantham S, Prandoni P, Kearon C; Subcommittee on Control of Anticoagulation of the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis. Definition of post-thrombotic syndrome of the leg for use in clinical investigations: a recommendation for standardization. J Thromb Haemost. 2009;7:879–883.
  10. Kahn, S. The Postthrombotic Syndrome: Evidence-Based Prevention, Diagnosis, and Treatment Strategies A Scientific Statement From the American Heart Association. Downloaded from http://circ.ahajou1r6n3a6ls.org/ by guest on February 3, 2016.
  1. Prandoni P, Frulla M, Sartor D, Concolato A, Girolami A. Vein abnor- malities and the post-thrombotic syndrome. J Thromb Haemost. 2005;3:401–402.