General Surgery Rotation

General Surgery: Arterial/venous ulcer disease (ReelDx)

REEL-DX-ENHANCED

Venous Stasis

76 y/o with left leg pain and edema

Patient will present as → a 73-year-old female with complaints of heavy, restless legs and nocturnal cramping of her calves. She has a past medical history of obesity, hypertension, and previous deep venous thromboses after periods of long travel. On physical exam, her bilateral lower legs are edematous with brown hyperpigmentation around the ankles. There are no ulcers. She is scheduled for a duplex ultrasound.

Alternate presentation → a 62-year-old male with a 3.5 mm ulcerated area of the right medial malleolus. The wound is inflamed with associated edema. PMH is significant for varicosities.

Venous ulcers are defined as chronic defects of the skin that fail to heal spontaneously and persist for longer than 4 weeks.

  • Venous ulcers are most commonly located in the lower leg just above the ankle (gaiter region). They are a partial-thickness, irregularly shaped wound with well-defined borders with granulation tissue and fibrin present in the ulcer base.
  • Venous ulcers are relatively painless and are surrounded by brown-stained skin and/or dry, itchy, and reddened skin. In about 50% of patients, there are visible varicose veins in an aching, swollen leg.
  • In industrialized nations, up to 1.5% of the population will suffer from venous ulcers. In patients ≥65 yr, the incidence increases to 4%. In the United States, >500,000 people suffer from stasis ulcers.

Risk Factors: Obesity, increasing age, family history of chronic venous insufficiency, and history of deep venous thromboembolism.

Any ulcer in this location with surrounding edema, redness, and scale is typical of a stasis ulcer.

The history and clinical signs and symptoms of leg ulcers are often misleading and may not differentiate venous ulcers from other leg ulcers; about 30% of leg ulcers are not of venous origin.

  • Measurement of the ankle-brachial index (ABI) is essential in excluding peripheral arterial disease (PAD), which can be present in 20% of patients and is required before starting compression therapy. Arterial insufficiency is suggested by an ABI <0.9.
  • Patients with lower-extremity ulcers should also be evaluated for diabetes.
  • Coagulation defects have been found in 40% of patients with leg ulcers. This finding suggests that many patients with leg ulcers have a known or suspected history of deep venous thrombosis and a thrombophilia workup is indicated.
  • If vasculitis is suspected, a biopsy of the edge of the ulcer can confirm the diagnosis.
  • Any wound that has failed to improve after therapy of 4 wk should have a biopsy to rule out malignancy.

Imaging Studies

  • Duplex sonography to identify reflux in the superficial, deep, and perforating veins as well as possible obstruction of the deep veins.
  • If the ulcer appears to be infected, consider tissue for culture, plain x-ray films, and bone scan to evaluate for osteomyelitis.

The first-line treatment of ulcers includes below-knee compression stockings to improve venous return to the heart, thereby decreasing edema, inflammation, and tissue ischemia

  • Surgical debridement to remove all nonviable material can be accomplished in the office setting with the use of a topical Xylocaine gel.
  • Regular, brisk walking 30 min a day, five times a week is recommended.Elevate leg above heart level and raise the foot of bed with 3-in blocks to reduce edema.

Role of surgery: endovenous catheter ablation of superficial reflux showed no improvement in the healing rate of ulcers but did demonstrate a reduction of ulcer recurrence from 28% to 12% at 12 mo.

The overall prognosis for this condition is poor; the healing rate depends on the initial size of the ulcer.

  • Although 65% to 70% of venous ulcers are healed within 6 mo, the 5-yr recurrence rate of healed venous ulcers can be as high as 40%.
  • Maintenance of lifelong compression therapy is recommended.

Nonhealing ulcers with little to no improvement should also be referred to a wound care clinic.

osmosis Osmosis
Picmonic
Chronic Venous Insufficiency (Venous Stasis Ulcer) Assessment

IM_NUR_Chronicvenusinsufficiency_V1.3_

Chronic venous insufficiency is a condition that occurs when leg veins and valves fail to maintain blood movement. This can lead to the development of venous stasis ulcers, which are painful and debilitating. With this disorder, patients can have lower leg edema, bronze-brown skin pigmentation, and pruritus. Ulcerations are necrotic with uneven edges and typically occur in the medial malleolus, presenting with dull persistent pain. It is important to note that because the arterial flow is not compromised, the patient’s lower extremities are warm and still have palpable pulses.

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Chronic Venous Insufficiency (Venous Stasis Ulcer) Interventions

Chronic venous insufficiency is a condition that occurs when leg veins and valves fail to maintain blood movement. This can lead to the development of venous stasis ulcers, which are painful and debilitating. In order to promote healing and prevent ulcer recurrence, patients should avoid sitting for long periods of time, use elastic compression stockings, and apply appropriate wound dressings.

Play Video + Quiz

Question 1
A 71-year-old woman with a history of hypertension presents to the office with an ulcer on the anterior aspect of the right leg. She presents to the office because she shopped all day yesterday and has developed significant edema. The skin in the pretibial region appears thin and has excessive brown pigment. What is the most likely diagnosis?
A
venous insufficiency
B
arterial insufficiency
Hint:
Patients with arterial insufficiency complain of claudication and they are found to have decreased pulses, distal hair loss, thick nails, and pallor.
C
expected complication of diabetes mellitus
Hint:
Patients with diabetes that is well controlled may have no symptoms in the lower extremities.
D
peripheral neuropathy
Hint:
Peripheral neuropathies are not associated with pigmentation changes or edema, although ulcers may develop if the patients have lost their proprioception.
Question 1 Explanation: 
Patients with chronic venous insufficiency note occasional pain with prolonged standing, edema, hyperpigmentation, dermatitis, and erythema. Patients with arterial insufficiency complain of claudication and they are found to have decreased pulses, distal hair loss, thick nails, and pallor. Patients with diabetes that is well controlled may have no symptoms in the lower extremities. Peripheral neuropathies are not associated with pigmentation changes or edema, although ulcers may develop if the patients have lost their proprioception.
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