The treatment of venous ulcers of the lower extremities

Abstract

Venous hypertension from failure of proper venous valve function in the veins of thelower extremities causes changes over time in the microcirculation of the skin of the distal extremity. These changes set the stage for the development of a chronic nonhealing ulceration, which typically occurs at the ankle. The mainstay of treatment has been conservative, with compression dressings and elevation of the extremity. However, results have been less than satisfactory because of delay in healing and high recurrence rates after successful healing. Elimination of the venous hypertension should be the goal of therapy using more recent minimally invasive surgical techniques, including ablation of incompetent truncal veins with laser or radiofrequency energy and use of ultrasound-guided foam sclerosant injections to close incompetent perforator veins that are frequently found in or near the ulcer bed. This approach will shorten ulcer healing time and reduce recurrence rates as well as patient suffering and expense.

Figure 1

The pathophysiology of venous ulcers. Reprinted from Venous Ulcers (8) with permission from Elsevier.

Figure 2

An ultrasound of an incompetent perforator vein.

Figure 3

(a) Chronic venous stasis ulcer treated by endovascular laser ablation of an incompetent great saphenous vein and ultrasound-guided injections of foam sclerosant into veins joining incompetent perforator veins in close proximity to the ulceration. (b) The same leg 26 days after treatment, showing healing of the ulceration.

Figure 4

The ulceration failed to heal after endovascular laser ablation of incompetent great and small saphenous veins and ultra-sound-guided injections of foam sclerosant solutions into incompetent veins and perforator veins in the vicinity of the ulceration. A biopsy showed basal cell carcinoma.