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Venous insufficiency and ulceration: a review.
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Alguire and Mathes conducted a MEDLINE search to review the current state of knowledge and treatment of chronic venous insufficiency and ulceration.

Venous valves control the flow of blood from the superficial veins to the deep veins in a distal to proximal direction. Incompetent valves allow backflow of blood when the muscles of the leg relax, contributing to venous pressures that are higher than normal. This venous hypertension is a major factor in chronic venous insufficiency. A patient with chronic venous insufficiency will typically present with varicose veins, tan or reddish brown changes in skin color and weeping, excoriated skin. These symptoms can progress to lipodermatosclerosis, the development of induration at the medial ankle or even to the mid-leg area. Ultimately, a brawny edema above and below the area of fibrosis can be seen. Ulcerations may develop in the fibrotic areas.

Venous stasis ulcers are more common in older women. These ulcers are chronic and frequently recurrent. Postphlebitic syndrome is the combination of chronic leg edema with deep venous thrombosis, pigmentation and ulceration.

Diagnosis is achieved by duplex ultrasonography (both B-mode and directional pulsed Doppler). Descending venography does not correlate as well as duplex scanning with the amount of venous reflux. Since the treatment for venous ulcers is not appropriate in cases of arterial insufficiency, the latter must be ruled out. One way of screening for arterial insufficiency is with the ratio of ankle blood pressure to brachial blood pressure (ankle/brachial index), which is also measured with Doppler ultrasonography. A normal score is greater than or equal to 0.9, claudication is indicated by a score of 0.5 to 0.9, and patients with resting ischemic pain usually score less than 0.5.

Treatment of chronic venous insufficiency consists of elevating the legs above heart level for at least 30 minutes three or four times daily, using compression stockings and using wet or dry nonadherent dressings or bandages. Compression stockings should apply a gradually decreasing amount of pressure from the ankle to the knee and should be applied on awakening. Some stockings have zippered backs or Velcro closures, making them easier to apply. For obese patients or those with a great deal of edema, intermittent pneumatic compression pumps may be used, although the pumps should not be used in patients with uncompensated congestive heart failure. Studies of various dressings have shown no significant difference in the rate of healing of venous ulcers, although patients seem to prefer the occlusive-type dressings because of their convenience.

The authors conclude that severe edema occasionally may require treatment with short-term diuretics. Topical antibiotics have not been shown to improve healing of the ulcer, although systemic antibiotics may be required for clearly infected ulcers or for cellulitis. Topical antiseptics, such as povidone-iodine, should be avoided because of cellular toxicity. The effectiveness of enzymatic debriding agents has not been proved. Some studies advocate the use of silver sulfadiazine, but other studies have shown no improvement in healing of the venous ulcers. Surgery has a very limited role in the treatment of chronic venous insufficiency.

SOURCE:

--GRACE BROOKE HUFFMAN, M.D.

Alguire PC, Mathes BM. Chronic venous insufficiency and venous ulceration. J Gen Intern Med 1997;12:374-83.

COPYRIGHT 1997 American Academy of Family Physicians

COPYRIGHT 1998 Information Access Company

Portions of above Copyright © 1997-1998, Northern Light Technology LLC. All rights reserved.

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