Dr Jason Toniolo

Venous Ulceration

Venous ulcers occur between the knee and the ankle and are caused by damaged leg veins.

They are a debilitating form of ulceration, which is extremely hard to fix, painful and expensive due to the high burden of wound care and dressings that are required.

Causes

Venous ulcers are a venous circulation problem. The exact cause of the failed venous drainage can be multi-faceted.

  1. Varicose veins (see the section on varicose veins) are the most common cause of venous ulceration. The incompetent, bulging veins are under pressure and lead to localised damage and inflammation to the soft tissue around the venous ulcer, which is continuous and eventually causes skin breakdown
  2. Deep venous incompetence – damage to the deep veins is caused by previous deep vein thrombosis (clot in the deep veins). The deep veins can open up again after being blocked with a clot (recanalise). However, they never return to their previous, normal function. The valves are broken, and the wall is scarred. They often reflux blood, which limits their utility and ability to drain blood back to the heart
  3. Obesity – When a patient is overweight, particularly in the midsection, the bulky abdominal tissue compresses the veins as they pass from the leg through to the abdomen, increasing the pressure down the veins and impeding blood return to the heart. Obesity promotes engorgement, venous hypertension and promotes ulceration
  4. Failure of the calf muscle pump: The calf muscle functions as a pump every time you walk. The blood within the deep veins (underneath the muscle, next to the bones and arteries) is massaged up the leg by the rhythmic contraction and relaxation of the calf muscle with each step. Patients who have fused ankles, or stiff ankles from arthritis or diabetes, often move their leg relying on their hip joint with little to no movement at the ankle, worsening the venous return of the leg

Risk factors

Ageing – A patient may have had varicose veins for twenty years, and then one day, they begin to develop ulcers. Advanced age is a risk factor for ulcers because:

  1. Being older allows many years of venous hypertension and chronic inflammation to then thin the skin enough to form ulcers
  2. As we age, our ability to rejuvenate and heal damage gets reduced. The drive to develop ulceration remains, whereas the ability to combat the ulceration and rejuvenate drops, resulting in ulcers

Malnutrition – Whilst being overweight increases pressures in veins (mentioned above in the causes section), being malnourished impedes one’s ability to rejuvenate and recover tissue that is being damaged. This can promote ulcers

Genetics – Some families are more prone to venous disease

Leg trauma or surgery – People who have undergone surgery on the ankles or lower legs, often orthopaedic trauma from broken bones and car accidents, are more prone to venous disease. It is not uncommon to see a patch of pigmentation from venous disease around old traumatic injuries

Pregnancy – As mentioned in the deep vein thrombosis and varicose vein sections, pregnancy hormones and expanded blood volume place one at higher risk of varicose veins. As this is a cause of venous ulcers, pregnancy is a risk factor for venous ulcers.

Smoking – Causes damage to blood vessels, delays wound healing and contributes to the formation of venous ulcers.

Prolonged standing or sitting – Jobs that do not enable pumping of the calf muscle, with prolonged periods of sitting and standing, generally have pooling of blood in their lower limbs, promoting venous hypertension and vein damage.

Management

Compression garments

The most important intervention to heal a venous ulcer is applying compression bandages. The compression bandages should be medical-graded compression, tighter around the foot and ankle, and gradually less tight going up towards the knee. They should be changed as frequently as required to squeeze out the oedema of the leg and prevent fluid that leaks out of the ulcer from damaging the surrounding skin that isn’t ulcerated (i.e., change the dressings when they are soiled, depending on how much fluid is coming out of the ulcer). Dressing changes are done three times per week in the first week, then dropped to twice weekly when less fluid in the soft tissue leaks out of the leg.

Arterial revascularisation

Before compression garments can be applied, the arteries supplying the foot must be adequate to provide blood to the toes. However, still, after the tight compression garments go on, Patients with blocked arteries may have terrible complications from compression garments if their blocked arteries are not managed first. If a patient has blocked arteries and damaged veins, we call the ulcer a ‘mixed’ ulcer rather than purely a venous ulcer. See the section on peripheral arterial disease to learn more about these treatments.

Superficial vein surgery

If varicose veins are identified, treating these varicose veins improves circulation and reduces venous hypertension, speeds up venous ulcer healing and reduces venous ulcer recurrence. See the section on varicose veins to learn about these treatments.

Deep venous reconstruction

The larger iliac vessels in the pelvic may be chronically occluded.  These large vessels can be corrected with stents placed through keyhole surgery.  This can only be done if there is enough flow into the stent, or else the stent will block.  Your leg should be assess for suitability for deep venous reconstruction prior to undergoing any procedure.  If there are blocked vesels in the groin or pelvis, with relatively healthy flow in the veins below these larger vessels, then deep venous intervention can help venous return immensely, resulting in symptom resolution and even ulcer healing.

Dr Jason Toniolo

Comprehensive range of conditions

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