Chronic venous insufficiency Part 2
Venous leg ulcers are a common complication of chronic venous insufficiency and are challenging to treat. A multi-disciplinary approach using guidelines from the Society of Vascular Surgeons is discussed for those ulcers that are termed "pure" venous leg ulcers, i.e. no other co-morbidities are contributing to the lack of healing potential.
Chronic venous insufficiency wounds
Which of the following modalities has been recommended for treatment of lower extremity wounds due to chronic venous insufficiency?
- Infrared therapy
- Low level laser therapy
- Low-frequency, non-contact ultrasound
- Ultraviolet light
Answer C (see below for explanation)
The Journal of Vascular Surgery published extensive clinical practice guidelines for the treatment of venous leg ulcers (VLU) in 2014. The accepted definitions of VLUs differentiated between “pure” and “mixed” causes. Pure VLUs are defined as “directed axial great saphenous vein reflux or incompetent perforator reflux directly into the ulcer bed” and indicates that there are no other co-morbidities that will inhibit the wound healing, e.g. arterial disease, diabetes, nutritional deficits, lymphedema, autoimmune disorders, or infections. A summary of the recommended guidelines are as follows:
- Serial wound measurements and extremity girth measurements are needed for outcome measurements.
- Wound cultures are obtained only when clinical evidence of infection is present (fever, leukocytosis, worsening pain, purulence, cellulitis, malodor, increased exudate, friable granulation tissue, biofilm, or increasing tissue necrosis and ulcer progression.
- Tissue biopsy is recommended if the wound does not improve with standard care after 4-6 weeks.
- Arterial pulse examination and ankle-brachial index on all patients with VLU. This is so often overlooked and especially important in determining the type and amount of compression to use. Any ABI <0.90 is abnormal, and <0.5 is considered critical limb ischemia, both requiring additional vascular studies.
- Venous duplex ultrasound testing is advised to evaluate for obstructive and reflux patterns of venous disease for any patient with a VLU.
- Wound cleansing with non-toxic solutions should be performed at every dressing change.
- Debridement by sharp or surgical techniques; enzymatic or biological debridement is recommended only if the patient cannot tolerate sharp or surgical techniques.
- Systemic gram-positive antibiotics is recommended for cellulitis of the surrounding tissues, but NOT for VLU colonization or biofilm without clinical evidence of infection in which case topical antimicrobials are recommended.
- Selection of a primary wound dressing that will adequately manage the exudate under compression, e.g. alginate, cellulose, or foam is a vital part of standard care.
- Protection of periwound skin wound under the compression is achieved with skin lubricants around the wound.
- Compression systems (multi-layered compression systems or short-stretch bandages in conjunction with other materials) that “do not give way to the expanding muscle during walking” are most effective in promoting healing and should be applied by a trained professional.
- Continued compression therapy after the wound heals is recommended in order to decrease the risk of recurrence. (Transition from compression therapy to compression stockings needs to be monitored closely through the remodeling phase of healing when the epithelium is fragile and vulnerable to tearing from friction. My note!)
- Intermittent pneumatic compression is suggested only when other compression options are not available or have failed to help VLUs heal.
- Nutritional assessment and treatment is recommended if needed.
- Two suggested systemic medications are 1) micronized purified flavonoid fraction (protects the microcirculation from damage induced by venous hypertension) and 2) pentoxifylline (a vasodilator that inhibits cytokine-mediated neutrophil activation, white cell adhesion to endothelium, and oxidative stress).
- Supervised active exercise to improve the action of the venous pump, increase ankle range of motion, and to decrease venous pressure and edema is advised for healing and for prevention of recurrence.
- Ultraviolet light, negative pressure therapy, electrical stimulation, and ultrasound therapy were all reviewed in the guidelines and were not recommended due to lack of sufficient evidence to support efficacy. Since the guidelines were published, however, two studies have shown positive outcomes with the use of non-contact, low-frequency ultrasound plus standard care as compared with standard care alone. (White 2016 and Gibbons 2015).
Successful treatment of VLUs is challenging and requires diligent medical and wound treatment to both heal an ulcer and to prevent recurrence. Further information on the pathology; medical, surgical, and wound treatment; and follow-up care can be found in the following references:
Gibbons GW, Orgill DP, Serena TE, et al. A prospective, randomized, controlled trial comparing the effects of noncontact, low-frequency ultrasound to standard care in venous leg ulcers. Ostomy Wound Management. 2015;61(1):16-29.
O’Donnell TF, Passman MA, Marston WA, et al. Management of venous leg ulcers: Clinical practice guidelines of the Society for Vascular Surgery® and the American Venous Forum. Journal of Vascular Surgery. 2014;60(2S):3S-59S. Available at https://www.jvascsurg.org/article/S0741-5214(14)00851-9/pdf.
White J, Ivins N, Wilkes A, Carolan-Rees G, Harding KG. Non-contact low-frequency ultrasound therapy compared with UK standard of care for venous leg ulcers: a single-center, assessor-blinded, randomized controlled trial. Int Wound J. 2016;13(5):833-842.
Woelfel S, Ochoa C, Rowe VL. Vascular wounds. In Hamm R (Ed), Text and Atlas of Wound Diagnosis and Treatment: 2nd edition. New York: McGraw Hill Education. 2019, 101-143. Available at https://accessphysiotherapy.mhmedical.com/book.aspx?bookid=1334.