MDNews - Cleveland-Akron-Canton

+++++++++++++++++++++++++++++++++++++++++ + +++ +CARDioVASCuLAR SPECiAL SECTioN ��� +++ +++++++++++++++++++++++++++++++++++++++++ by gregory rogers, mD Chronic venous Insufficiency and Leg Ulceration C Hronic VenoUS inSUfficiencY (CVI) is a common condition often ignored by patients and poorly understood by many healthcare providers. CVI is a significant health problem in the United States with 2% to 5% of Americans having some form of CVI, 24 million Americans with varicose veins, and six million individuals with skin changes in the lower extremities due to venous insufficiency. The more serious condition of venous stasis leg ulcers is found in 500,000 Americans. Clinical manifestations range from cosmetically unsightly veins, to increasing sizes of varicosities. Patients also may present increasing levels of edema, skin color changes, dermatitis, fibrosis of the subcutaneous tissue and eventually ulceration. Many patients are asymptomatic; however, most patients complain of aching discomfort, heaviness in the calves and progressive skin changes with ulcerations that may become painful. Long-standing edema of the lower extremities due to CVI can progress to venous stasis dermatitis with tan or reddish-brown pigmentation changes. Located in the dermis, they are the result of breakdown products from red cells that have extravasated through the blood vessels due to increased hydrostatic pressure. This venous hypertension leads to leukocyte trapping, release of proteolytic enzymes, free radicals and plasma proteins. Subsequent decreased oxygen diffusion results in chronic tissue damage termed lipodermatosclerosis, which can worsen with skin breakdown and ulceration. Due to a wide spectrum of presentation, treatment of leg ulceration can be challenging. Treatment modalities are divided into four categories: mechanical, wound dressings and care, drug therapy and surgical options. The primary underlying process is the venous hypertension associated with CVI. The mainstay of therapy is mechanical compression and leg elevation. Studies show measurable improvements by simply elevating the legs for 30 minutes or more, four times a day. However, for most patients, compliance appears to be difficult. Compression therapy is an essential component for the treatment of CVI. Compression garments made to apply at least 20-30 mm of mercury pressure at the 14 | Cleveland/Akron/Canton MD News ��� MDneWS.coM ��� MarcH -april 2013 ankle and up to 50-60 mm of pressure may be required in some patients. Multi-layer compression bandages or wraps are an essential component of therapy when the leg wounds are weeping or ulcerated. Various dressings are available to treat the ulceration in association with the compression wrapping. Typically, occlusive dressings are indicated and these include hydrocolloid, gel dressings or alginates. The actions of these dressings are to provide a moist wound healing environment, control CVI and weeping, and provide a degree of passive debridement. Adjunctive drug therapy is used to treat the problem at various levels. The use of aspirin at 325 mg daily has been shown to improve wound healing. Likewise, pentoxifylline may be useful for its anti-sludging and hemorheologic effect. The routine use of antibiotics is not recommended. Topical antibiotics have no role in the therapy of ulceration. Systemic antibiotics should be reserved for only relevant clinical evidence of infection. These wounds will have bacterial contamination, but this does not need to be treated in most cases. Evidence of infection includes significant surrounding cellulitis, erythema, lymphangitis, or an inflamed and rapidly enlarging ulceration. Drug therapy may include the very judicial, short-term use of diuretics in patients requiring edema control and the use of topical glucocorticoid creams for dermatitis. Surgical therapy can be utilized in treating the cause of the venous insufficiency and at the local wound care level at the ulceration itself. Significant saphenous vein insufficiency can be treated with various forms of venous stripping and/or endovenous ablation. For relevant significant perforator incompetence, judicious and appropriate use of subfascial perforator ligation has a role. Surgical intervention may have a limited effect on rates of wound healing but has been shown to diminish ulcer recurrence rates. Patients who have large recalcitrant ulcers, especially if present for more than 12 months, can be helped with wound debridement and application of human skin equivalent grafts. Dr. Gregory Rogers is a vascular surgeon and a member of the medical staff at Southwest General Health Center. ���

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