Medical Science Slogs Along
Medical science has not done a great job with chronic wound healing in general, and this is especially true for venous stasis ulcers. The healing rates for VSUs are typically poor with up to 50 percent of venous ulcers open and unhealed for nine months or longer. Venous ulcer recurrence rates are also troubling with up to one-third of treated patients experiencing four or more episodes of recurrence.

Adding to this problem is the fact that the clinical management of advanced varicose veins and severe chronic venous insufficiency (CVI) is poorly understood by most clinicians. This is mostly due to the fact that venous disease in general is under-represented in most clinical textbooks, medical school curricula and residency programs. As a consequence, when a patient with CVI and varicose veins develops a venous ulceration, the patient often finds their care to be uncoordinated and full of conflicting (and often ill-informed) opinions, not facts.  

The Standard Paradigm
For many years, the standard approach to venous stasis ulcers has been compression bandages of various types, with dressings applied to help moisturize wounds that are too dry, or dry wounds that are too moist, or kill bacteria, or debride mechanically as needed. The constant part of all standard treatment regimes has always included compression bandages, with off-loading and elevation designed to alleviate edema, and compression management of edema is still an appropriate mainstay of treatment.

Also for many years, an important part of the standard algorithm was to delay any treatment of the underlying varicose veins until the ulcer was healed. The rationale for this approach was logical and prudent in its time. No reasonable surgeon would subject his or her patient to the drastically increased risk of a serious wound infection by subjecting them to a vein stripping in the presence of an open, colonized or even infected venous stasis ulcer.  

This paradigm, however, created a bit of a clinical dilemma as to why would we want to delay the definitive treatment of the underlying cause of the ulcer?  Wouldn’t the ulcer heal more rapidly if we aggressively treated the varicose veins?
This clinical dilemma was managed by non-intervention, based (appropriately at the time) on the principle of primum non nocere. With the advent of new techniques and technologies to definitively treat chronic venous hypertension with truly minimally invasive means, the scales have tipped in favor of early intervention to reduce the venous hypertension as quickly as possible in order to speed the process of wound healing, and the principle of primum non nocere now means that we will be doing our patients more harm by not intervening aggressively to treat the underlying cause of their ulcer as expeditiously as possible.  

A New, Endovenous Paradigm

With the emergence of endovenous techniques and technologies, this clinical dilemma has now been solved. The fact that venous hypertension can be quickly and definitively treated without any significant surgical intervention has made the need for any delay of the treatment of the underlying cause of the VSU totally unnecessary. The literature now contains several small series of rapid healing of venous stasis ulcers after endovenous laser treatment (EVLT.

Instead of waiting for the ulcer to heal and then possibly treating the varicose veins and venous hypertension, the new paradigm is to treat the venous hypertension with EVLT as quickly as possible, and continue compression bandages, judicious debridements, and good local wound care. Dramatic and stunning results like the case illustrated below are not unusual.  Like any form of therapy, not everyone responds the same, but the case illustrated with this article is very typical of the rapid healing seen in patients with axial reflux and VSUs.

References

•  Bergan JJ, et al. Chronic venous disease. N Engl J Med 2006; 355 488-98.
•  Lopez A, Phillps T. Venous ulcers. Wounds. 1998; 10:149-157.
•  Thomas Hess C. Management of the patients with venous ulcer. Advances in Wound and Skin Care 2000.; 13:79-83.

Steven P. Rivard, MD, FACEP, is medical director at the The Midwest Vein Center in Glenview, Ill. As a practicing phlebologist with a background in emergency medicine, Dr. Rivard has years of clinical experience in treatments of the circulatory system. His special area of expertise in phlebology is in the emergency management of DVT, pulmonary embolism and hemorrhage from varicose veins. He can be contacted by calling 708-590-7150.