MANAGEMENT OF

VENOUS ULCERS
Wahyu Wardana, dr., SpB(K)V
 DEFINITION

• Chronic defects of the skin that fail to heal

spontaneously and persist for longer than 4 weeks
• It is a result of sustained venous hypertension
• Account for about 70% of all lower extremity
ulcerations
• Usually located in Gaiter region
• Can be accompanied by varicose vein, edema,
hyperpigmentation, and lipodermatosclerosis
 RISK FACTORS

• Obesity
• Increasing age
• Family history of chronic venous
insufficiency (CVI)
• History of deep venous thromboembolism
(DVT)
• Genetics
 ETIOLOGY

• The exact mechanism remain uncertain

• Hemodynamic forces might play an important role:
• Venous hypertension
• Circulatory stasis
As both will induce inflammatory reaction accompanied by
leukocyte activation that clinically leads to fibrosclerotic
remodeling of the skin and then to ulceration
VENOUS ANATOMY

Sapheno-
Femoral Junction
 ETIOLOGY

• Normal Venous System:

• Thin wall, low pressure conduits
• Blood propel forward due to contraction of extremity muscle
• Valves, prevent retrograde flow or reflux
• Pathology
• Venous hypertension due to valve incompetence (most
common sequela of DVT); 20-50%
• Primary reflux (50-80%); possibly due to genetic vein wall
abnormalities that predispose to varix formation
 ETIOLOGY

• Chronic Venous Insufficiency (CVI) is the main

causes
• Venous reflux will increase hydrostatic pressure in
the vein, and transmitted to the skin and
subcutaneous tissue
• Reflux also potentiates blood flow stasis, with vein
distention and endothelial activation, followed by
leukocyte extravasation and transudative
macromolecules and iron.
 ETIOLOGY

• The leucocyte-trapping theory:

• Venous hypertension causes white blood cells trapped in
the venous microcirculation, which then migrate to dermal
interstitium and cause damage by releasing toxic
metabolites.
• The next step is extravasation of macromolecules and red
blood cells (RBC) into dermal interstitium
• RBC degradation products and interstitial protein
extravasation are potent chemoattractants and represent
the initial underlying chronic inflammatory signal for
leucocyte recruitment
D P
ANATOMY OF VENOUS ULCERS

The C4 Classification is typical with:

• Swelling
• Lipodermatosclerosis
• Hiperpigmentation
• Wine Glass appearance
ANATOMY OF VENOUS ULCERS

The C5-6 Classification is typical with:

• Ulcer, mostly painful, located in
Gaiter Area
• Difficult to heal
• Lipodermatosclerosis
• Hiperpigmentation
• Varicose vein with the sign of
valve incompetency (reflux)
ANATOMY OF VENOUS ULCERS

The ATYPICAL C5-6 Classification:

• Ulcer located NOT in Gaiter
Area
• No evidence of Varicose vein
or other signs of venous reflux
THE BASIC CEAP
CLASSIFICATION
 PRINCIPLES OF TREATMENT

• Clean the wound

• Infection treatment
• Proper wound dressing
• Compression bandage
• Drugs therapy
• Exercise
 GUIDELINES
• Venous duplex Ultrasound (GRADE - 1; LEVEL OF
EVIDENCE – B)
• Ulcers cleansed initially and at each dressing
change with a neutral, nonirritating, nontoxic
solution, performed with a minimum trauma.
[GRADE - 2; LEVEL OF EVIDENCE - C]
• Debridement [GRADE - 1; LEVEL OF EVIDENCE - B]
• Treatment of infection [GRADE - 2; LEVEL OF
EVIDENCE - C]

Management of venous leg ulcers: Clinical practice guidelines of the

Society for Vascular Surgery and the American Venous Forum. J Vasc
Surg 2014;60:3S-59S
 GUIDELINES: DRESSING
• Dressing to manage ulcer exudate and maintain a
moist, warm wound bed [GRADE - 2; LEVEL OF EVIDENCE
– C] – Alginate, foam
• No antimicrobial dressing for non-infected ulcers [GRADE
- 2; LEVEL OF EVIDENCE - A]
• Skin lubricant under bandage [GRADE - 2; LEVEL OF
EVIDENCE -C]
• STSG – not recommended for all ulcer [GRADE - 2; LEVEL
OF EVIDENCE - B]
• STSG – only for large ulcers that failed to heal [GRADE - 2;
LEVEL OF EVIDENCE - B]
• Routine use of negative pressure therapy – NOT
recommended [GRADE - 2; LEVEL OF EVIDENCE - C]
 GUIDELINES: COMPRESSION

• Compression bandage to increase healing [GRADE

- 1; LEVEL OF EVIDENCE - A]
• Compression therapy to reduce the risk of
recurrence in healed ulcers [GRADE - 2; LEVEL OF
EVIDENCE - B]
 CLASSIFICATION OF COMPRESSION
HOSIERY

Class Pressure Support Indication for use

I 14-17 mmHg Light Varicose veins

II 18-24mmHg Medium • Severe varicose vein

• Mild edema
• Prevention of ulcer recurrence
III 25-35mmHg Strong • Severe varicose veins
• Post-phlebitic limb
• Prevention of ulcer recurrence
• Chronic venous insufficiency
 GUIDELINES:
SYSTEMIC DRUGS THERAPY
Combination of drugs and compression therapy for
long-standing or large venous leg ulcer [GRADE - 1;
LEVEL OF EVIDENCE - B]
• Drug interacting with leucocyte activation:
micronized purified flavonoid fraction (MPFF)
• Pentoxyfylline
 GUIDELINES: PHYSIOTHERAPY

• Supervised active exercise to improve muscle pump

function and to reduce pain and edema in patients
with venous leg ulcers. [GRADE - 2; LEVEL OF
EVIDENCE - B]
Simple Below the Knee
Compression Bandage

The Bandage should

Start from below to
Upward, in concordance
To venous flow
26/02/2015 27/05/2015
11/05/2015

23/07/2015
29/06/2015

28/07/2015
 REFERENCES

• Rutherford Vascular Surgery, 8th edition, 2014

• The American Venous Forum guidelines
• Current Therapy in Vascular and Endovascular
Surgery Fifth Edition, 2014