静脉性溃疡

Some important points in Venous Leg Ulcers,Why do patients with chronic venous insufficiency develop VLU?,CVI most common cause of VLU VLU patients have venous hypertension, or abnormally sustained elevation of venous pressure on walking Caused by vein valve reflux, outflow problems or both Venous outflow issues Venous obstructionPoor function of calf muscle pump impairs venous systems ability to return venous blood to heartAnkle movement limitations contribute to calf muscle pump failure,What are the risk factors for VLU?,Age older than 55 yearsFamily history of CVIUlcer history, parental history of ankle ulcersHigher body mass indexHistory of pulmonary embolismVenous reflux in deep veins, history of superficial/DVTLower extremities skeletal or joint diseaseNumber of pregnanciesPhysical inactivitySevere lipodermatosclerosis,Are there measures that can prevent VLU or their recurrence?,Aggressive management of reversible risk factorsControl of relevant comorbid conditions (CHF, PVD)Healthy diet, appropriate exercise, weight controlManagement of a hypercoagulable stateStockings that achieve at least 20-30 mm Hg pressurePatients should use highest level of compression tolerableSurgical venous ablation,CLINICAL BOTTOM LINE: Prevention.,CVI is the leading cause of VLU Venous hypertension with calf muscle pump dysfunctionManage comorbid risk factorsCVI, obesity, hypercoagulable statesSkeletal and joint disease of the lower extremitiesCompression stockings For primary and secondary preventionVenous intervention For secondary prevention,What symptoms and physical findings are suggestive of CVI?,Swelling and aching of legs, worse at end of day and improved by leg elevation History of ulcer recurrence, particularly at same locationDependent edema, telangiectasias, varicose veins, reddish-brown pigmentation and purpura, and subsequent hemosiderin deposition Eczematous changes with redness, scaling, pruritusSmooth, ivory-white, stellate atrophic plaques of sclerosis with telangiectases (atrophie blanche)Chronic lipodermatosclerosis (LDS) and acute LDS,Chronic venous insufficiency,Atrophie blanche,What symptoms and physical findings suggest that VLU are due to CVI?,VLU may be painfuldull, aching, or burning painLocation over medial lower third of the legsUsually 1 ulcer w/ irregular, flat, or only slightly steep bordersUlcer bed shallow, with granulation tissue or fibrinous material Wound surface rarely shows necrosis, exposed tendons, boneVenous dermatitis, LDS, or atrophie blanche around ankleAssessment: Test for neuropathySeverity of CVI correlates with decreased range of motion at ankle and is associated with peripheral neuropathyVLU pain neuropathic in origin in some patient,Venous leg ulcer,What other conditions should be considered during evaluation of a patient with possible VLU?,Common causes of lower extremity ulcers CVIArterial insufficiencyDiabetic neuropathyProlonged pressure Less common causes TraumaInflammatory or metabolic conditionsCancerInfections,What is the role of laboratory testing?,No single laboratory test is diagnostic Testing may be indicated depending on specific patient history, comorbidities, and family historyIn patients with history of recurrent ulceration or thrombosis, evaluate for hypercoagulable states,What is the role of noninvasive tests, such as ankle-brachial index and duplex ultrasonography?,Ankle-brachial index should be performedFor PAD screening: concomitant arterial disease in 20%Compression therapy could worsen an arterial ulcerColor duplex ultrasonographyFor accurate diagnosis and to provide prognostic infoPhoto and air plethysmographyWhole-limb venous hemodynamics at rest and after exercise CT exam Intractable edema associated with pain despite compression,What is the role of routine testing for infection?,Swab culture testing unwarranted w/o signs of infectionIf atypical infection suspected: send tissue from wound biopsy for microscopic examination and cultureUse antibiotic therapy only for clinically infected ulcersEvidence supports topical cadexomer iodine for healingNo evidence supports use of systemic antibiotics,When should clinicians consider obtaining a biopsy or referring the patient to a surgical or nonsurgical specialist for diagnosis?,To rule out other causes of VLU, especially cancerWhen ulcers are atypical-appearing ulcers When ulcers have not healed after 4 weeks of active treatment,CLINICAL BOTTOM LINE: Diagnosis.,Typically based on clinical history and physical examination Presence of CVI Single, painful ulcer with irregular, flat borders and granulating or fibrinous bed on medial lower third of legs Color duplex ultrasonography to characterize venous disease in all patientsAnkle-brachial index to exclude concurrent PAD If VLU do not improve within 4 weeks of active therapy: consider referral to specialist or biopsy,What is the overall approach to treatment?,Treatment goalsReduce edema and painHeal ulcersPrevent recurrence Systematic approach needed Assess frequently and escalate treatment if unresponsiveSimplest treatment: bed rest with leg elevationElevate legs above heart 30 minutes, 3 to 4x/d + at nightReduces swelling, improves venous microcirculation Most patients struggle to follow this recommendation,What is the role of compression therapy?,Cornerstone of therapy Because sustained leg elevation often difficult to achieveGold standard: multiple elastic layers for graduated compressionIncreases interstitial hydrostatic pressureImproves venous returnReduces venous hypertension and edemaImproves ulcer healing ratesUse cautiously with CHF and with arterial insufficiencyDont use with severe arterial insufficiency,How long should clinicians prescribe compression therapy?,Continue until the ulcer healsContinue indefinitely after healing to prevent recurrenceTo enhance adherence, instruct how to put on stockingsEnsure proper measurement and fit Assistive devices may help arthritic, obese, elderly patientsReplace at least every 6 months,What is the role of medication?,To improve healing in combination with compressionAspirin (300 mg daily)Pentoxifylline (400-800 mg 3x/d) To reduce LDS inflammation, pain, induration StanozololOxandroloneHorse chestnut seed extract (active ingredient: aescin) To reduce pain (based on neuropathic origin)Amitriptyline, gabapentin, pregabalin,What is the role of growth factors?,Granulocyte macrophage colony-stimulating factorTopical and perilesional injection increases ulcer healingPromotes wound healing through many mechanisms (homeostasis, inflammation, proliferation, maturation) Increases vascularizationFDA-approved for neutropenia but not wound healingPhase 3 trials stopped due to bone pain associated with perilesional injections,What is the role of physical therapy or exercise?,Aim: to improve range of ankle movement and calf muscle pump function Might enhance ulcer healingBut evidence conflicting and RCTs lackingRCT underway: comparing compression therapy with compression therapy + 12 weeks of supervised exercise,What is the role of hyperbaric oxygen therapy?,Adjunct to standard wound careControversial because evidence for treating VLU extremely limited100% oxygen at 2-2.5 atmosphere absolute for 60- to 120-minute periods over 15-30 sessionsGoal: increase partial pressure of oxygen at the woundRole in pathogenesis and treatment unclearFibrin cuff theory: fibrin cuffs formed around precapillary vessels may result in wound hypoxia, so increased oxygen might aid healing,What is the role of surgical debridement or skin grafting?,Debridement Removes nonviable tissue to achieve an appropriate wound bed with granulation tissueStandard care despite lack of controlled data on healing Skin graftingEnhances healing for large or slow-healing ulcers May rapidly decrease pain and aid functional statusPinch grafts, split-thickness skin grafts, and micro-skin grafts used successfully but RCTs lackingSkin equivalents (cellular, acellular) may aid healing,What is the role of venous surgery in treatment and prevention?,Venous surgeryDoesnt improve healing but reduces recurrence Open surgery has significant potential morbidity Cochrane review found no evidence for benefit or harm Subfascial endoscopic perforator surgery Safer, possible improved healing, decreased recurrence Minimally invasive procedures Treat CVI and recurrenceEndovenous thermal ablation (laser, radiofrequency, steam)US-guided foam sclerotherapy; cyanoacrylate embolization,When should clinicians consider referring the patient to a surgical or nonsurgical specialist for treatment?,Prognostic factors associated with slower healing Larger wound area (5 cm2) and long duration (6 months) LDS and ulcer history, BMI 33 kg/m, physical inactivityProlonged venous filling time, deep venous insuffi