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Ten tips for chronic venous ulcers
The underlying pathophysiology of chronic venous insufficiency is complex and involves many factors. Studies have shown that average venous ulcers may need 6-12 months for complete healing with an anticipated recurrence rate exceeding 2/3 cases in 5 years. These numbers reflect the magnitude of the problem and mandate deploying all efforts to stop progression of the disease. Our group has found the following 10 tips have significantly improved our healing rates.
1. First, rule out any associated arterial, immunologic, endocrine, or other systemic causes for leg/foot ulceration.
2. Be aggressive to stop progression of the disease (fight CEAP 6): any local tenderness at the site of discolored skin at the gaiter area for venous ulcers should initiate a prompt reflux study to evaluate for incompetent perforators.
3. Venous ulcers are associated with an incompetent perforator within 2 cm of the ulcer area.
4. Recurrent venous ulcers at the same location may be associated with venous outflow obstruction, (May-Thurner syndrome is an underestimated pathology) which affects mainly the left leg.
5. When performing iliac vein venograms, make liberal use of intravascular ultrasound.
6. Exudative venous ulcers need multilayer compression dressings and appropriate antibiotics if infection exists.
7. Pentoxifylline (Trental) 800 mg, 3 times daily.
8. Frequent debridement and frequent objective evaluation for ulcer area with each office visit.
9. Bi-layered living cell treatment (Apligraf?) to promote healing.
10. Office/clinic visit every 3 months after complete healing (CEAP 5) and further testing as needed.
Dr. Mousa is an associate professor at the Department of Surgery, West Virginia University, Morgantown.
The underlying pathophysiology of chronic venous insufficiency is complex and involves many factors. Studies have shown that average venous ulcers may need 6-12 months for complete healing with an anticipated recurrence rate exceeding 2/3 cases in 5 years. These numbers reflect the magnitude of the problem and mandate deploying all efforts to stop progression of the disease. Our group has found the following 10 tips have significantly improved our healing rates.
1. First, rule out any associated arterial, immunologic, endocrine, or other systemic causes for leg/foot ulceration.
2. Be aggressive to stop progression of the disease (fight CEAP 6): any local tenderness at the site of discolored skin at the gaiter area for venous ulcers should initiate a prompt reflux study to evaluate for incompetent perforators.
3. Venous ulcers are associated with an incompetent perforator within 2 cm of the ulcer area.
4. Recurrent venous ulcers at the same location may be associated with venous outflow obstruction, (May-Thurner syndrome is an underestimated pathology) which affects mainly the left leg.
5. When performing iliac vein venograms, make liberal use of intravascular ultrasound.
6. Exudative venous ulcers need multilayer compression dressings and appropriate antibiotics if infection exists.
7. Pentoxifylline (Trental) 800 mg, 3 times daily.
8. Frequent debridement and frequent objective evaluation for ulcer area with each office visit.
9. Bi-layered living cell treatment (Apligraf?) to promote healing.
10. Office/clinic visit every 3 months after complete healing (CEAP 5) and further testing as needed.
Dr. Mousa is an associate professor at the Department of Surgery, West Virginia University, Morgantown.
The underlying pathophysiology of chronic venous insufficiency is complex and involves many factors. Studies have shown that average venous ulcers may need 6-12 months for complete healing with an anticipated recurrence rate exceeding 2/3 cases in 5 years. These numbers reflect the magnitude of the problem and mandate deploying all efforts to stop progression of the disease. Our group has found the following 10 tips have significantly improved our healing rates.
1. First, rule out any associated arterial, immunologic, endocrine, or other systemic causes for leg/foot ulceration.
2. Be aggressive to stop progression of the disease (fight CEAP 6): any local tenderness at the site of discolored skin at the gaiter area for venous ulcers should initiate a prompt reflux study to evaluate for incompetent perforators.
3. Venous ulcers are associated with an incompetent perforator within 2 cm of the ulcer area.
4. Recurrent venous ulcers at the same location may be associated with venous outflow obstruction, (May-Thurner syndrome is an underestimated pathology) which affects mainly the left leg.
5. When performing iliac vein venograms, make liberal use of intravascular ultrasound.
6. Exudative venous ulcers need multilayer compression dressings and appropriate antibiotics if infection exists.
7. Pentoxifylline (Trental) 800 mg, 3 times daily.
8. Frequent debridement and frequent objective evaluation for ulcer area with each office visit.
9. Bi-layered living cell treatment (Apligraf?) to promote healing.
10. Office/clinic visit every 3 months after complete healing (CEAP 5) and further testing as needed.
Dr. Mousa is an associate professor at the Department of Surgery, West Virginia University, Morgantown.
Stopping the ooze
Many of us will do anything or use any product available to stop oozing from suture needle holes. After all, waiting for bleeding to stop is usually not something most vascular surgeons enjoy. Most hemostatic agents are quite expensive and some don’t work very well at all.
Our group has found a cheap alternative that is freely available in every OR and, although not perfect, works well enough in most cases – the standard ultrasonic transmission Doppler gel that you use to listen to arteries in the operative field. We usually have these available in sterile packets (Fig. 1). We cut off one end and squeeze the contents as a large glob onto the patch or anastomosis (Fig. 2). Presumably the weight of the material is enough to stop the needle-hole bleeds.
Active bleeding will usually only occur between stitches and is evidence that another stitch would be prudent. Since the gel is clear, any bleeding is easily seen. We routinely also use protamine reversal for our carotid artery endarterectomies and bypasses and so we leave the jelly on until all the protamine has been given. By that time, the bleeding has almost always stopped.
The jelly can be sucked away (it makes a great sounding noise in the suction!) or just diluted out with saline. I do note on the package insert that Doppler gel is not for internal use, and it is not FDA approved for this indication, but I believe we all use it anyway?
Dr. Samson is a clinical associate professor of surgery (vascular), Florida State University Medical School and a member of Sarasota Vascular Specialists, Sarasota, Fl., and the Medical Editor of Vascular Specialist.
[Editor’s Note: Please submit your own helpful tips and tricks for inclusion in this column to vascularspecialist@frontlinemedcom.com.]
Many of us will do anything or use any product available to stop oozing from suture needle holes. After all, waiting for bleeding to stop is usually not something most vascular surgeons enjoy. Most hemostatic agents are quite expensive and some don’t work very well at all.
Our group has found a cheap alternative that is freely available in every OR and, although not perfect, works well enough in most cases – the standard ultrasonic transmission Doppler gel that you use to listen to arteries in the operative field. We usually have these available in sterile packets (Fig. 1). We cut off one end and squeeze the contents as a large glob onto the patch or anastomosis (Fig. 2). Presumably the weight of the material is enough to stop the needle-hole bleeds.
Active bleeding will usually only occur between stitches and is evidence that another stitch would be prudent. Since the gel is clear, any bleeding is easily seen. We routinely also use protamine reversal for our carotid artery endarterectomies and bypasses and so we leave the jelly on until all the protamine has been given. By that time, the bleeding has almost always stopped.
The jelly can be sucked away (it makes a great sounding noise in the suction!) or just diluted out with saline. I do note on the package insert that Doppler gel is not for internal use, and it is not FDA approved for this indication, but I believe we all use it anyway?
Dr. Samson is a clinical associate professor of surgery (vascular), Florida State University Medical School and a member of Sarasota Vascular Specialists, Sarasota, Fl., and the Medical Editor of Vascular Specialist.
[Editor’s Note: Please submit your own helpful tips and tricks for inclusion in this column to vascularspecialist@frontlinemedcom.com.]
Many of us will do anything or use any product available to stop oozing from suture needle holes. After all, waiting for bleeding to stop is usually not something most vascular surgeons enjoy. Most hemostatic agents are quite expensive and some don’t work very well at all.
Our group has found a cheap alternative that is freely available in every OR and, although not perfect, works well enough in most cases – the standard ultrasonic transmission Doppler gel that you use to listen to arteries in the operative field. We usually have these available in sterile packets (Fig. 1). We cut off one end and squeeze the contents as a large glob onto the patch or anastomosis (Fig. 2). Presumably the weight of the material is enough to stop the needle-hole bleeds.
Active bleeding will usually only occur between stitches and is evidence that another stitch would be prudent. Since the gel is clear, any bleeding is easily seen. We routinely also use protamine reversal for our carotid artery endarterectomies and bypasses and so we leave the jelly on until all the protamine has been given. By that time, the bleeding has almost always stopped.
The jelly can be sucked away (it makes a great sounding noise in the suction!) or just diluted out with saline. I do note on the package insert that Doppler gel is not for internal use, and it is not FDA approved for this indication, but I believe we all use it anyway?
Dr. Samson is a clinical associate professor of surgery (vascular), Florida State University Medical School and a member of Sarasota Vascular Specialists, Sarasota, Fl., and the Medical Editor of Vascular Specialist.
[Editor’s Note: Please submit your own helpful tips and tricks for inclusion in this column to vascularspecialist@frontlinemedcom.com.]