Vascular—Venous Stasis Ulcer
Concept
Spectrum of valvular incompetence and chronic venous outflow obstruction with resultant venous hypertension, edema, cellulitis, ulcers. Valvular incompetence accounts for 90% cases, DVT for other 10%.
Way Question May be Asked?
“A 49 y/o female G4P4comes to your office complaining of pain and swelling in the lower legs, varicose veins, and a non-healing ulcer on the medial aspect of her right ankle.
What do you want to do?” May even be given the increased skin pigmentation and the varicosities.
How to Answer?
History
Vascular disease h/o DVT
Clotting disorders Prior treatments
Professions with “long standing” periods Pregnancy
Physical Exam
Complete vascular exam
Varicosities (size, location, firmness) Calf tenderness/swelling (DVT) Edema
Brawny induration/discoloration Dermatitis
Ulceration (most occur medial)
Brodie-trendelenburg test (elevate leg until drained of venous blood, place tourniquet below knee, have pt stand, see if more blood flows into varicosities when tourniquet released after they fill from arte- rial pressure (30 seconds)→tests superficial reflux
Data
Labs including PT/PTT, Factor V Leiden, Protein C and S, ATIII level
Check ABI (if < 0.6, question your diagnosis)
Duplex scanning to determine sites of obstruction and incompetence (deep, superficial, perforators), evaluate for DVT
Surgical Treatment
(1) Conservative treatment with:
compression therapy leg elevation/antibiotics
weekly application of Unna boots topical agents (PDGF, EGF)
if ulcer heals (on the exam, it won’t), pt is fitted for graduated compression stockings (30–40 mmHg)
(2) For superficial vein incompetence alone→ high lig- ation and stripping of greater saphenous vein surgery
(3) For superficial and perforator incompetence→ subfascial endoscopic perforator veins
(4) For deep vein obstruction→ air plethysmography to delineate anatomy and choose appropriate surgical procedure
(a) deep venous obstruction from femoral/iliac thrombosis→ cross femoral and/or sapheno- popliteal bypass
(b) deep venous reflux→ valvuloplasty
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(5) May also need STSG for healing of ulcer
Common Curveballs
Conservative therapies will fail
Trying to get you do to variceal ablation in pt with deep vein obstruction/incompetent perforators
Asking you to describe physical exam tests—
Trendelenburg test
Pt will have associated vascular disease (changing sce- nario)
Pt will be pregnant
Pt will have recent DVT Pt will have some coagulopathy
Strikeouts
Confusing with arterial ischemic ulcer Not performing adequate H+P Not trying conservative therapies Not performing duplex scan
Performing variceal ablation in pt with deep vein obstruction (this is an important collateral in these pts and can cripple venous outflow)
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