A venous leg ulcer, also known as a venous stasis ulcer, is a sore on the lower leg by the ankle resulting from long standing venous insufficiency. Due to the difficulties that many patients experience in identifying leg wounds as venous stasis ulcers, patients are often unaware of early treatment options. Once a leg wound is recognized as being related to a vein problem, they can be referred for appropriate therapy and treatment can begin. The good news is that treatment can be very effective in many cases to help heal the wound, reduce the pain, and reduce the risk of the wound opening again in the future.
Initiating Venous Ulcer Treatment
Wound care is often the first step in treating venous stasis ulcers. This can range from straightforward to complex depending on the case. It’s very important to control the swelling with adequate compression in most cases (except in cases where there is concomitant limb threatening critical limb ischemia…or peripheral artery disease). Your care provider can aid in figuring this out and advise the best form of leg compression.
With wet, soupy wounds, we often start with an Unna boot. An Unna boot is a medicated paste-impregnated wrap covered by an elastic layer, generally an elastic wrap (“ACE” bandage) or self-adherent elastic bandage such as Coban. It is applied with the appropriate level of compression. It must be changed approximately every 3 to 7 days. Usually it needs to be changed more often at first, then less often once the swelling is reduced and the wound starts to heal.
The goal is for the wound to dry up, heal, then to get the patient into a graduated compression stocking. This is hard with open, wet wounds. But often, after a few weeks of Unna boots (sometimes longer), one can get into a graded compression stocking. It is important to keep in mind that the Unna boot is but one type of wound dressing. Sometimes other approaches are offered.
It’s imperative that compression stockings fit properly, so in these cases, we often refer to an expert stocking fitter, especially if there are any needs for custom fitting. The patient is advised they will need compression every day, often for many years to come.
If the patient cannot wear compression, the same cycle that led them to have the ulcer will return and the wound may re open sooner and more often than if they are able to use daily compression.
Depending on the complexity of the wound, we can advise on basic wound care, or we collaborate with local specialized wound care clinics when more complex wound management is needed.
In such a collaboration, we work from the vein perspective, working to combine the benefits of compression with endovenous ablation, while we collaborate with the wound care team for wound debridement, topical approaches, and negative pressure wound therapy (wound vacs) when needed.
Endovenous Ablation for Venous Ulcers
An important element of any venous leg ulcer treatment plan is to be considered for endovenous ablation and sclerotherapy.
Many patients will have severe venous reflux of their saphenous veins and large branches coming off that go to the ulcer bed. There are 4 saphenous veins in each leg and in most cases at least one is not functioning properly. While in the distant past, surgeons would “strip out” the saphenous veins and its branches, this can now be done in the office using a treatment called endovenous ablation and sclerotherapy.
Once this is completed, most venous leg ulcers will start to heal in the coming weeks. Given the complexity and the number of veins that need to be treated, this can take several separate treatment sessions. The doctor can help devise a treatment plan that is specific to your needs.
After endovenous ablation and wound healing, we encourage patients to be active and continue daily compression to reduce the risk of ulcers reopening and requiring more treatment in the future.
The Case for Earlier Venous Stasis Ulcer Treatment
Medical evidence is ranked by experts in national and international consensus conferences and the results are published to help guide other care providers globally. Level 1A is the strongest evidence that a particular treatment should be performed and it means the treatment is highly recommended by experts.
There is level 1A evidence that Venous Stasis Ulcer Treatment with Endovenous Ablation is the treatment of choice for venous leg ulcers and that the treatment should be started sooner rather than later.
In a recent randomized controlled study published in the New England Journal of Medicine (known as the EVRA trial), patients with venous leg ulcers were randomized to either:
- receive compression therapy and undergo early endovenous ablation of superficial venous reflux within 2 weeks after randomization (early-intervention group), or
- receive compression therapy alone, with consideration of endovenous ablation deferred until after the ulcer was healed or until 6 months after randomization if the ulcer was unhealed (deferred-intervention group).
Early endovenous ablation of superficial venous reflux resulted in faster healing of venous leg ulcers and more time free from ulcers than deferred endovenous ablation. This is a landmark study on Venous Stasis Ulcer treatment that supports the level 1A evidence-based consensus that doctors should treat these ulcers with ablation sooner rather than later.
Doctors and patients often wish to get started sooner as well, but some insurance carriers require a mandatory waiting period of at least 3-months before such procedures can be offered to the patients after initiation of conservative therapy.
Early treatment has advantages and important implications for everyone:
- For patients and doctors who are frustrated because they wish to treat these wounds with venous ablation early, hopefully, treatment and coverage paradigms will evolve to be more evidence-based.
- For payers, like the insurance companies, governments, and society at large, this may save millions of dollars each year by healing these wounds sooner and preventing recurrences quicker, which not only is of healthcare value to the patients but a great value to society in general.
Treating Venous Ulcers at Inovia Vein Specialty Centers
Our team can help make a plan that balances the recommendations of the experts and the requirements of insurance carriers to help optimize a treatment plan that is best suited for your goals.
Even if there is a delay after the initiation of wound care when the wound first appears, we can help treat the patient until the 3-month waiting period is up and then treat with endovenous ablation.
To learn more about venous stasis ulcer treatment, simply fill out our Online Appointment Request Form or call any of our clinics in Northwest Portland , Tigard, Happy Valley, Hillsboro or Bend, Oregon.