Vascular Services

Venous Insufficiency and Ulcers

Venous insufficiency is a chronic condition in which blood does not flow normally up through the veins in the legs toward the heart. In normal veins a series of specialized, one-way valves work together, opening to allow blood to flow upward, then closing to keep the blood from flowing back toward the feet. Venous insufficiency occurs when valves are damaged or not functioning properly. As the valves deteriorate, blood leaks or flows backward and pressure in the vein increases, stretching and dilating the vessel. Blood stagnates (pools) in the veins of the lower legs, increasing the blood pressure in the legs, and causing chronic inflammation in the veins.

People with long-term, untreated venous insufficiency sometimes develop open sores in the skin called venous ulcers. Ulcerations develop in areas where blood collects and pools, as swelling there interferes with the movement of oxygen and nutrients through tissues. Over time a visible ulcer develops on the skin. Venous ulcers usually appear just above the ankle on the inside of the leg. If they are not treated they can become quickly infected or even gangrenous.

Risk Factors and Symptoms

The incidence of venous insufficiency rises with age, and is also linked to a family history of varicose veins, a sedentary lifestyle, or to jobs that require people to spend many hours on their feet. Venous insufficiency can also be caused by a partial blockage of the veins, for example by a blood clot (a condition called deep vein thrombosis or DVT).

The most common early symptom of venous insufficiency is chronically swollen ankles; the feet and calves may also swell. The swelling can be accompanied by a dull aching, cramping, or feeling of heaviness in the legs and feet that becomes worse after prolonged standing.

As the condition progresses, people with venous insufficiency develop brown patches and deteriorating (flaking or hardening) skin around the ankles. If venous insufficiency is not treated, venous ulcers may develop on the lower legs.

Doctors use an imaging test called a duplex ultrasound to determine if there is structural damage in the veins.


Minimally Invasive Procedures

Treatments for venous insufficiency are aimed at reducing swelling and improving the return of blood to the heart. Elevating the legs (above the heart) when not standing helps the blood return to the heart, decreases blood pooling, and ultimately decreases swelling. Exercise, which stimulates the calf muscles and increases circulation, may also be recommended.

Doctors treat venous ulcers by working to prevent infection and promote healing of the wound. Many novel treatments, outlined below, are now available to help heal venous ulcers.

Topical creams: Doctors sometimes advise patients to use a topical cream containing hydrocortisone to minimize itching, provided it is not applied to open skin. Anti-fungal creams can also prevent infection from developing on the skin of the feet and toes. However, people with venous insufficiency are advised not to use antibiotic creams because they worsen inflammation.

Compression stockings: The most common treatment for venous insufficiency is compression stockings. These special stockings apply constant, even pressure to the leg. This increases circulation and prevents blood from flowing backward, thereby reducing much of the swelling caused by the disorder. In addition, compression stockings can help prevent venous ulcers from forming or can help accelerate the healing of an existing ulcer. Compression stockings have to be worn daily to be effective. Doctors may also prescribe medication to thin the blood, particularly in patients with a high risk of blood clots.

Unna Boots: An Unna Boot is a moist gauze bandage that is applied around the lower leg, from the region of the ulcer to just below the knee. The gauze hardens to form a snug boot on the leg. The support from the boot helps improve blood flow in the veins and heal the ulcer. The boot stays on for 48 hours to two weeks and then is replaced if the wound has not healed.

Transparent Dressings: A transparent dressing is a clear, plastic-like film that is applied over the wound. The dressing is changed every 5 to 7 days. A support stocking is worn over the dressing to help hold it in place and improve circulation in the leg and foot.

Hydrocolloid Dressings: A hydrocolloid dressing is a specialized bandage with a breathable outer layer that keeps liquid, bacteria, and viruses out, and an inner layer that absorbs drainage from the wound to promote healing. The dressing also helps to remove any non-living tissue from the wound (a process called debridement). The dressing is changed every 1 to 7 days.

Growth Factors: Growth factors are investigational medications that doctors apply to the wound in the hope of promoting the growth of new tissue.

Traditional Surgery

Doctors may sometimes perform surgery to remove any non-living tissue from a wound to promote its healing. This surgery is called debridement.

Debridement: During debridement vascular specialists surgically remove all non-viable, infected tissue and bone from a non-healing ulcer. This process activates blood component called platelets and growth factors, which both promote healing.

Doctors often perform debridement if a patient with a venous ulcer shows signs of infection including fever, elevated white blood count, and persistent or increased drainage.