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Ulceration related to varicose vein insufficiency

By Dr. Conrad Goulet, Chief Medical Director
Guylaine Lanctot Cliniques
(561) 624-5347

Studies conducted over the past few years have documented that varicose veins are more than just a cosmetic challenge for men and women. In mild to moderate cases, varicose veins may cause pain, swelling, fatigue, and restlessness. In severe cases, varicose vein insufficiency may lead to stasis dermatitis, hyperpigmentation, lipodermatosclerosis, atrophic Blanche, superficial and deep vein thrombosis and ulcerations. This article will discuss and outline how to recognize ulcerations and how to control and treat the problem.

1) Anatomy: 
The leg has two venous systems – 1) The deep system which is responsible for 90% of blood return1, and 2)the superficial system which is responsible for the remaining 10% of blood return. The superficial system is divided into two main systems – the greater saphenous and it’s tributary (run from the inner side of the ankle to the groin), and the lesser saphenous (runs from outer side of the ankle to the popliteal fossa, behind the knee).

2) Physiology: 
Once there is an insufficiency of the venous function (by destruction of the valves or dilatation of the veins), a venous stasis formation occurs in the lower section of the leg which brings an exudation of the blood component into the surrounding tissue, followed by an edema. This causes a decrease in the oxygenation of the tissue, and could result in ulceration.

3) Pathology: 

A. If the ulceration is secondary to deep venous insufficiency, we should find all of the characteristics of a post phlebitic syndrome (i.e. swelling in the lower leg, redness and warmness of the skin, and often brown pigmentation of the tegument) during an examination of the leg. In rare cases phlebothrombosis may exist, wherein the skin becomes very fibrotic, and the leg looks thin like an inverse bottle. This insufficiency is often accompanied by an insufficiency of the greater saphenous and the ulceration will be mainly on the inner side of the ankle.
B. If the ulceration if due to a superficial venous insufficiency, the examination of the leg will vary. If the leg is examined in the morning, there may not be a remarkable edema of the foot and ankle, but there will be all of the characteristics of venous insufficiency:
  • 1. Corona Phlebectatica (formation of multiple telangiectasia at the inner side of the foot).
  • 2. Pigmentation (hypo or hyper; more likely hyper) secondary to extravasation of the blood and deposits in the skin of hemosiderin.
  • 3. Finally, the formation of an ulcer (the surrounding skin will first appear very thick, then the center of the thickness will become white before ulceration).If the problem relates to the greater saphenous insufficiency, the ulcer will be at the inner side of the ankle. If the problem relates to the lesser saphenous, the ulcer will be on the outer side of the ankle.

4) Differentiation with an arterial ulcer: 
Arterial ulcers are typically located on the outer side of the ankle. Not all of the symptoms for venous insufficiency will show. The signs of an arterial insufficiency include cool skin, loss of hair, change in the nails, and decrease or absence of pulse.

5) Treatment: 
Traditionally, the basic treatment has been to control the stasis. Therefore, the primary treatment is typically the unnaboot. (I will not detail here the various mechanics of the unnaboot, or the different materials which can be used, such as duoderm, etc.). The most important goal is a good contention to improve the blood return and to decrease the stasis. The ultimate goal is to create a reverse gradient of 40mmHg at the ankle.

Once the ulcer is closed (normally, 6-8 weeks), the patient may proceed with the stripping of the saphenous involved, or closure of the saphenous vein(s) by ultrasound guidance sclerotherapy.

Ultrasound Guidance Sclerotherapy: 
With new technology, and the application of the duplex scan in the evaluation of the superficial veins, we can visualize (map) all of the primary veins, and determine through use of an integrated doppler the location of an insufficiency. If the problem is from the superficial veins, we can locate the point of reflux and using ultrasound guidance sclerotherapy, we can inject directly at the point of reflux.

Since the primary goal in healing an ulcer is to control the stasis, the earlier the leaking point is controlled and closed, the faster the ulcer will heal. To perform this technique, we do not need the ulcer to be closed. When stripping is under consideration, however, the ulcer normally must be closed prior to treatment.

6) Prevention:

1. Again, the primary point to understand in preventing ulcerations, is the need to prevent the stasis. This can be achieved with the help of a good support stocking (usually pressure of 30-40mmHg at the ankle will suffice). The patient must wear the stockings from morning (putting them on before getting out of bed) until night.
2. Encourage the patient to walk a minimum of one mile per day.
3. Control the patient’s weight.
4. Advise the patient to avoid standing or sitting in the same position for more than 20-30 minutes. If this is not possible, encourage them to wear support stockings.
5. When sitting, the patient should be encouraged to elevate the feet to waist level if possible.
6. Discourage sun exposure, very hot baths, and jacuzzis, etc. which can dilate the veins.
7. Advise women to avoid high-heeled shoes, which can decrease the pumping ability of the calf muscle.
8. Last, but not least, if the patient has superficial venous insufficiency, (regardless of whether patient has been previously treated via stripping and/or sclerotherapy), there is a genetic predisposition for the formation of new varicose veins. We recommend that the patient be seen at regular check-ups every 6-12 months. The exam using the duplex scan will immediately verify vein leakage and/or improperly functioning veins. An early diagnosis and prompt correction of the problem, in turn, can prevent ulcerations and other problems.

1The deep system is supported by the muscles and bones, and never becomes varicosed. The superficial system does not have the support of muscles and bone, and has the potential to dilate and form varicose veins. Therefore, the superficial veins are treated when speaking of varicose veins – the deep system is never treated.

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