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Venous leg ulcer

Definition
Venous leg ulcers are defined as open lesions in the skin of the lower extremities occurring due to the presence of venous hypertension.
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Pathophysiology
Venous hypertension (which may be due to DVT, perforator insufficiency, superficial and deep vein insufficiencies, arteriovenous fistulas, or calf muscle pump insufficiencies) causes a chronic inflammatory response that, over time, can cause venous ulceration. The inciting inflammatory injury is chronic extravasation of macromolecules and RBC degradation products with resultant iron overload.
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Epidemiology
The incidence of venous leg ulcers in the US is estimated at 50-2,200 cases per 100,000 person-years.
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Disease course
Ulcers are typically shallow, with an irregular edge and well-defined margins, and are characteristically located anterior to the medial malleolus, pretibial area, or lower third of leg. Capillary leaking causes edema leading to maceration, pruritus and scaling. Pain may be absent, mild or extreme, is usually worse at the end of the day and relieved by elevation of the leg.
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Prognosis and risk of recurrence
Chronic venous leg ulcers result in reduced mobility, significant financial implications, and poor QoL. Compression therapy results in healing rates of approximately 55-60% at 2 months.
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Key sources
The following summarized guidelines for the evaluation and management of venous leg ulcer are prepared by our editorial team based on guidelines from the European Society for Vascular Surgery (ESVS 2022), the Society for Vascular Medicine (SVM/SVS/ACP/AVF/IUP 2019), the European Dermatology Forum (EDF 2016), and the Society for Vascular Surgery (SVS 2014).
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Guidelines

1.Screening and diagnosis

Definition of venous ulcer: define venous ulcers as an open skin lesion of the leg or foot that occurs in an area affected by venous hypertension.
B
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2.Classification and risk stratification

Anatomic classification of disease: use the International Consensus Committee on Venous Anatomical Terminology for standardized venous anatomy nomenclature.
B

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  • Assessment of disease severity

3.Diagnostic investigations

Clinical history
Evaluate for evidence of chronic venous disease for all patients with suspected leg ulcers fitting the definition of venous leg ulcer.
B
Elicit a history of medical conditions that affect ulcer healing and other nonvenous causes of ulcers.
B

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  • Physical examination

  • Diagnostic imaging

  • Plethysmography

  • Wound cultures

  • Direct venous pressure assessment

  • Microcirculation assessment

  • Evaluation for thrombophilia

  • Evaluation for contact dermatitis

4.Diagnostic procedures

Wound biopsy: as per EDF 2016 guidelines, consider taking multiple biopsies if an ulcer does not respond or responds inadequately to therapy and has an atypical appearance.
E

5.Medical management

Venoactive agents: as per ESVS 2022 guidelines, consider offering micronized purified flavonoid fraction, hydroxyethylrutosides, pentoxifylline, or sulodexide as an adjunct to compression and local wound care to improve ulcer healing in patients with active venous leg ulceration.
B

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  • Antibiotics

  • Topical corticosteroids

  • Other medical therapies

6.Nonpharmacologic interventions

Lifestyle modifications: advise patients avoiding overweight and discourage smoking.
E

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  • Nutritional assessment

  • Physical therapy

  • Manual lymphatic drainage

  • Compression therapy

  • Balneotherapy

7.Therapeutic procedures

Indications for intervention: offer treatment of the incompetent veins to reduce the risk of ulcer recurrence in patients with superficial venous incompetence and healed venous leg ulceration.
A
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  • Sclerotherapy

  • Sclero-compression therapy

  • Endovenous thermal ablation

  • Venous angioplasty and stenting

  • UV phototherapy

8.Surgical interventions

Surgical ablation of incompetent veins: as per EDF 2016 guidelines, consider offering surgical ablation of superficial venous refluxes in all patients with venous leg ulcer.
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  • Subfascial endoscopic perforating vein surgery

  • Venous valve repair

  • Venous bypass or fistulas

  • Deep vein ligation

  • Wound care (non-surgical debridement)

  • Wound care (surgical debridement)

  • Wound care (dressing)

  • Wound care (skin grafting)

  • Wound care (cellular therapy)

  • Wound care (porcine small intestinal submucosal tissue)

  • Wound care (other adjuvant therapies)

9.Preventative measures

Primary prevention: consider providing patient and family counseling regarding regular exercise, leg elevation when at rest, careful skin care, weight control, and appropriately fitting footwear in patients with class C1-4 disease.
C
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10.Follow-up and surveillance

Procedural outcome assessment: assess outcomes following the use of procedures, including reporting of anatomic success, venous hemodynamic success, procedure-related minor and major complications, and impact on venous leg ulcer healing.
B