Venous Insufficiency Ulcers

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Basics

  • Venous insufficiency is a condition that occurs when the venous wall and/or valves in the leg veins are not working effectively, making it difficult for blood to return to the heart and causing stasis.
  • Signs of chronic venous insufficiency include edema, bulging veins, hyperpigmentation, dermatitis, woody fibrosis, lipodermatosclerosis, and ulcers.
  • Venous stasis ulcers are the most serious consequence of chronic venous insufficiency.
  • Venous stasis ulcers affect up to 3% of adults in developed countries at some point during their lives.
  • The annual estimated treatment cost of chronic venous ulcers is $2.5 to $3.5 billion dollars per year.

Description

  • Irregular and shallow skin defect with surrounding hyperpigmentation and well-defined borders
  • Most frequently located in the lower leg or ankle over the bony prominences
  • Present for >30 days and fails to heal spontaneously
  • May only have mild pain unless infected

Epidemiology

80% of leg ulcers are caused by venous disease vs. 10–25% arterial disease

Incidence

  • The overall incidence of venous ulcers is 18/100,000 persons; more common in women than in men (20.4 vs. 14.6/100,000), incidence increases with age in both men and women.
  • >20,000 patients are newly diagnosed with venous ulcers in the United States yearly.

Prevalence

  • Venous ulcers are seen in ~1% of the adult population and up to 4% in adults ≥80 years old in industrialized countries.
  • 70% of ulcers recur within 5 years of closure.

Etiology and Pathophysiology

  • In a diseased venous system, venous pressure in the deep system fails to fall with ambulation, causing venous hypertension.
  • Venous hypertension comes from the following:
    • Venous obstruction
    • Incompetent venous valves in the deep or superficial system
    • Inadequate muscle contraction (e.g., arthritis, myopathies, neuropathies)
  • Venous pressure transmitted to capillaries leads to venous hypertensive microangiopathy and extravasation of RBCs and proteins (especially fibrinogen).
  • Increased RBC aggregation leads to reduced oxygen transport, slowed arteriolar circulation, and ischemia at the skin level, contributing to ulcers.
  • Leukocytes aggregate to the hypoxic areas and increase local inflammation.
  • Prolonged chronic inflammation and bacterial infection promote the persistence of ulcers.

Risk Factors

  • History of leg injury
  • Age >55 years
  • High BMI
  • Congestive heart failure (CHF)
  • History of deep venous thrombosis (DVT)
  • Failure of the calf muscle pump (e.g., ankle fusion, inactivity)
  • Previous varicose vein surgery or ulcers
  • Smoking
  • Prolonged standing
  • Pregnancy
  • Family history

General Prevention

  • Primary prevention after symptomatic DVT: Prescribe compression hose as soon as feasible, to be used for at least 2 years (≥20 to 30 mm Hg compression).
  • Secondary prevention of recurrent ulceration includes compression, correction of the underlying problem, and surveillance.
  • Encourage exercise to improve muscle pump function.

Commonly Associated Conditions

Up to 50% of patients have allergic reactions to topical agents commonly used for treatment.

  • Avoid triple antibiotic ointment, including anything containing neomycin sulfate.

-- To view the remaining sections of this topic, please or --

Basics

  • Venous insufficiency is a condition that occurs when the venous wall and/or valves in the leg veins are not working effectively, making it difficult for blood to return to the heart and causing stasis.
  • Signs of chronic venous insufficiency include edema, bulging veins, hyperpigmentation, dermatitis, woody fibrosis, lipodermatosclerosis, and ulcers.
  • Venous stasis ulcers are the most serious consequence of chronic venous insufficiency.
  • Venous stasis ulcers affect up to 3% of adults in developed countries at some point during their lives.
  • The annual estimated treatment cost of chronic venous ulcers is $2.5 to $3.5 billion dollars per year.

Description

  • Irregular and shallow skin defect with surrounding hyperpigmentation and well-defined borders
  • Most frequently located in the lower leg or ankle over the bony prominences
  • Present for >30 days and fails to heal spontaneously
  • May only have mild pain unless infected

Epidemiology

80% of leg ulcers are caused by venous disease vs. 10–25% arterial disease

Incidence

  • The overall incidence of venous ulcers is 18/100,000 persons; more common in women than in men (20.4 vs. 14.6/100,000), incidence increases with age in both men and women.
  • >20,000 patients are newly diagnosed with venous ulcers in the United States yearly.

Prevalence

  • Venous ulcers are seen in ~1% of the adult population and up to 4% in adults ≥80 years old in industrialized countries.
  • 70% of ulcers recur within 5 years of closure.

Etiology and Pathophysiology

  • In a diseased venous system, venous pressure in the deep system fails to fall with ambulation, causing venous hypertension.
  • Venous hypertension comes from the following:
    • Venous obstruction
    • Incompetent venous valves in the deep or superficial system
    • Inadequate muscle contraction (e.g., arthritis, myopathies, neuropathies)
  • Venous pressure transmitted to capillaries leads to venous hypertensive microangiopathy and extravasation of RBCs and proteins (especially fibrinogen).
  • Increased RBC aggregation leads to reduced oxygen transport, slowed arteriolar circulation, and ischemia at the skin level, contributing to ulcers.
  • Leukocytes aggregate to the hypoxic areas and increase local inflammation.
  • Prolonged chronic inflammation and bacterial infection promote the persistence of ulcers.

Risk Factors

  • History of leg injury
  • Age >55 years
  • High BMI
  • Congestive heart failure (CHF)
  • History of deep venous thrombosis (DVT)
  • Failure of the calf muscle pump (e.g., ankle fusion, inactivity)
  • Previous varicose vein surgery or ulcers
  • Smoking
  • Prolonged standing
  • Pregnancy
  • Family history

General Prevention

  • Primary prevention after symptomatic DVT: Prescribe compression hose as soon as feasible, to be used for at least 2 years (≥20 to 30 mm Hg compression).
  • Secondary prevention of recurrent ulceration includes compression, correction of the underlying problem, and surveillance.
  • Encourage exercise to improve muscle pump function.

Commonly Associated Conditions

Up to 50% of patients have allergic reactions to topical agents commonly used for treatment.

  • Avoid triple antibiotic ointment, including anything containing neomycin sulfate.

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