靜脈性潰瘍WhydopatientswithchronicvenousinsufficiencydevelopVLU?CVImostcommoncauseofVLUVLUpatientshavevenoushypertension,orabnormallysustainedelevationofvenouspressureonwalkingCausedbyveinvalvereflux,outflowproblemsorbothVenousoutflowissuesVenousobstructionPoorfunctionofcalfmusclepumpimpairsvenoussystem'sabilitytoreturnvenousbloodtoheartAnklemovementlimitationscontributetocalfmusclepumpfailureWhataretheriskfactorsforVLU?Ageolderthan55yearsFamilyhistoryofCVIUlcerhistory,parentalhistoryofankleulcersHigherbodymassindexHistoryofpulmonaryembolismVenousrefluxindeepveins,historyofsuperficial/DVTLowerextremitiesskeletalorjointdiseaseNumberofpregnanciesPhysicalinactivitySeverelipodermatosclerosisAretheremeasuresthatcanpreventVLUortheirrecurrence?AggressivemanagementofreversibleriskfactorsControlofrelevantcomorbidconditions(CHF,PVD)Healthydiet,appropriateexercise,weightcontrolManagementofahypercoagulablestateStockingsthatachieveatleast20-30mmHgpressurePatientsshouldusehighestlevelofcompressiontolerableSurgicalvenousablationCLINICALBOTTOMLINE:Prevention...CVIistheleadingcauseofVLUVenoushypertensionwithcalfmusclepumpdysfunctionManagecomorbidriskfactorsCVI,obesity,hypercoagulablestatesSkeletalandjointdiseaseofthelowerextremitiesCompressionstockingsForprimaryandsecondarypreventionVenousinterventionForsecondarypreventionWhatsymptomsandphysicalfindingsaresuggestiveofCVI?Swellingandachingoflegs,worseatendofdayandimprovedbylegelevationHistoryofulcerrecurrence,particularlyatsamelocationDependentedema,telangiectasias,varicoseveins,reddish-brownpigmentationandpurpura,andsubsequenthemosiderindepositionEczematouschangeswithredness,scaling,pruritusSmooth,ivory-white,stellateatrophicplaquesofsclerosiswithtelangiectases(atrophieblanche)Chroniclipodermatosclerosis(LDS)andacuteLDSChronicvenousinsufficiencyAtrophieblancheWhatsymptomsandphysicalfindingssuggestthatVLUareduetoCVI?VLUmaybepainful—dull,aching,orburningpainLocationovermediallowerthirdofthelegsUsually1ulcerw/irregular,flat,oronlyslightlysteepbordersUlcerbedshallow,withgranulationtissueorfibrinousmaterialWoundsurfacerarelyshowsnecrosis,exposedtendons,boneVenousdermatitis,LDS,oratrophieblanchearoundankleAssessment:TestforneuropathySeverityofCVIcorrelateswithdecreasedrangeofmotionatankleandisassociatedwithperipheralneuropathyVLUpainneuropathicinorigininsomepatientVenouslegulcerWhatotherconditionsshouldbeconsideredduringevaluationofapatientwithpossibleVLU?CommoncausesoflowerextremityulcersCVIArterialinsufficiencyDiabeticneuropathyProlongedpressureLesscommoncausesTraumaInflammatoryormetabolicconditionsCancerInfectionsWhatistheroleoflaboratorytesting?NosinglelaboratorytestisdiagnosticTestingmaybeindicateddependingonspecificpatienthistory,comorbidities,andfamilyhistoryInpatientswithhistoryofrecurrentulcerationorthrombosis,evaluateforhypercoagulablestatesWhatistheroleofnoninvasivetests,suchasankle-brachialindexandduplexultrasonography?Ankle-brachialindexshouldbeperformedForPADscreening:concomitantarterialdiseasein~20%CompressiontherapycouldworsenanarterialulcerColorduplexultrasonographyForaccuratediagnosisandtoprovideprognosticinfoPhotoandairplethysmography Whole-limbvenoushemodynamicsatrestandafterexerciseCTexamIntractableedemaassociatedwithpaindespitecompressionWhatistheroleofroutinetestingforinfection?Swabculturetestingunwarrantedw/osignsofinfectionIfatypicalinfectionsuspected:sendtissuefromwoundbiopsyformicroscopicexaminationandcultureUseantibiotictherapyonlyforclinicallyinfectedulcersEvidencesupportstopicalcadexomeriodineforhealingNoevidencesupportsuseofsystemicantibioticsWhenshouldcliniciansconsiderobtainingabiopsyorreferringthepatienttoasurgicalornonsurgicalspecialistfordiagnosis?ToruleoutothercausesofVLU,especiallycancerWhenulcersareatypical-appearingulcersWhenulcershavenothealedafter4weeksofactivetreatmentCLINICALBOTTOMLINE:Diagnosis...TypicallybasedonclinicalhistoryandphysicalexaminationPresenceofCVISingle,painfululcerwithirregular,flatbordersandgranulatingorfibrinousbedonmediallowerthirdoflegsColorduplexultrasonographytocharacterizevenousdiseaseinallpatientsAnkle-brachialindextoexcludeconcurrentPADIfVLUdonotimprovewithin4weeksofactivetherapy:considerreferraltospecialistorbiopsyWhatistheoverallapproachtotreatment?TreatmentgoalsReduceedemaandpainHealulcersPreventrecurrenceSystematicapproachneededAssessfrequentlyandescalatetreatmentifunresponsiveSimplesttreatment:bedrestwithlegelevationElevatelegsaboveheart30minutes,3to4x/d+atnightReducesswelling,improvesvenousmicrocirculationMostpatientsstruggletofollowthisrecommendationWhatistheroleofcompressiontherapy?CornerstoneoftherapyBecausesustainedlegelevationoftendifficulttoachieveGoldstandard:multipleelasticlayersforgraduatedcompressionIncreasesinterstitialhydrostaticpressureImprovesvenousreturnReducesvenoushypertensionandedemaImprovesulcerhealingratesUsecautiouslywithCHFandwitharterialinsufficiencyDon’tusewithseverearterialinsufficiencyHowlongshouldcliniciansprescribecompressiontherapy?ContinueuntiltheulcerhealsContinueindefinitelyafterhealingtopreventrecurrenceToenhanceadherence,instructhowtoputonstockingsEnsurepropermeasurementandfitAssistivedevicesmayhelparthritic,obese,elderlypatientsReplaceatleastevery6monthsWhatistheroleofmedication?ToimprovehealingincombinationwithcompressionAspirin(300mgdaily)Pentoxifylline(400-800mg3x/d)

ToreduceLDSinflammation,pain,indurationStanozololOxandroloneHorsechestnutseedextract(activeingredient:aescin)

Toreducepain(basedonneuropathicorigin)Amitriptyline,gabapentin,pregabalinWhatistheroleofgrowthfactors?Granulocytemacrophagecolony-stimulatingfactorTopicalandperilesionalinjectionincreasesulcerhealingPromoteswoundhealingthroughmanymechanisms(homeostasis,inflammation,proliferation,maturation)IncreasesvascularizationFDA-approvedforneutropeniabutnotwoundhealingPhase3trialsstoppedduetobonepainassociatedwithperilesionalinjectionsWhatistheroleofphysicaltherapyorexercise?Aim:toimproverangeofanklemovementandcalfmusclepumpfunctionMightenhanceulcerhealingButevidenceconflictingandRCTslackingRCTunderway:comparingcompressiontherapywithcompressiontherapy+12weeksofsupervisedexerciseWhatistheroleofhyperbaricoxygentherapy?AdjuncttostandardwoundcareControversialbecauseevidencefortreatingVLUextremelylimited100%oxygenat2-2.5atmosphereabsolutefor60-to120-minuteperiodsover15-30sessionsGoal:increasepartialpressureofoxygenatthewoundRoleinpathogenesisandtreatmentunclearFibrincufftheory:fibrincuffsformedaroundprecapillaryvesselsmayresultinwoundhypoxia,soincreasedoxygenmightaidhealingWhatistheroleofsurgicaldebridementorskingrafting?DebridementRemovesnonviabletissuetoachieveanappropriatewoundbedwithgranulationtissueStandardcaredespitelackofcontrolleddataonhealingSkingraftingEnhanceshealingforlargeorslow-healingulcersMayrapidlydecreasepainandaidfunctionalstatusPinchgrafts,split-thicknessskingrafts,andmicro-skingraftsusedsuccessfullybutRCTslackingSkinequivalents(cellular,acellular)mayaidhealingWhatistheroleofvenoussurgeryintreatmentandprevention?VenoussurgeryDoesn’timprovehealingbutreducesrecurrenceOpensurgeryhassignificantpotentialmorbidityCochranereviewfoundnoevidenceforbenefitorharmSubfascialendoscopicperforatorsurgerySafer,possibleimprovedhealing,decreasedrecurrenceMinimallyinvasiveproceduresTreatCVIandrecurrenceEndovenousthermalablation(laser,radiofrequency,steam)US-guidedfoamsclerotherapy;cyanoacrylateembolizationWhenshouldcliniciansconsiderreferringthepatienttoasurgicalornonsurgicalspecialistfortreatment?PrognosticfactorsassociatedwithslowerhealingLargerwoundarea(>5cm2)andlongduration(>6months)LDSandulcerhistory,BMI>33kg/m,physicalinactivityProlongedvenousfillingtime,deepvenousinsufficie