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Thrombophlebitis

Venous Thrombosis

Venous Stasis Skin Ulcers

Historically, humans have struggled with venous disease as far back as thousands of years. We know this because documents from 1,500 BC have been recovered and show ancient Egyptian images of varicose veins over a drawn characters' legs. Many other ancient cultures, such as Greek, also have historical evidence of varicose veins disease and their struggle to treat this condition. One of the oldest discoveries was wrapping the legs with a cloth soaked in herbal medication. It seems like in ancient times. It was found the pressure from wrapping will help with skin ulcers caused by the varicose veins. Varicose vein disease is one of the most common problems involving the western world's lower extremities. Close to 25% of the adult population is struggling with varicose vein disease. Overall, around 30% of women and 20% of men have varicose vein disease in the United States.

 

Furthermore, close to 2% of the US population are suffering from venous stasis skin ulcers. The treatment of varicose veins and varicose vein-related complications can be very complex if not cared for properly. About 35% of venous stasis ulcers have underlying multifactorial causes such as venous insufficiency, prolonged ambulation, post-thrombotic syndrome, genetic inheritance, or even arterial insufficiency. Varicose veins are associated with skin changes such as hyperpigmentation, inflammation or even ulcers. Other problems associated with varicose veins are limb heaviness, pain, lower leg swelling and or bleeding. Venous stasis ulcers result from venous hypertension, which triggers inflammatory response in the lower leg's most dependent part, creating skin ulcers. Traditionally, these skin ulcers have been treated with compression dressings. The extrinsic compression will decrease the venous pressure within the limb and reduce venous hypertension. This is one of the oldest methods of treatment for venous stasis ulcers. The compression treatment can be combined with venous ablation of the superficial vein, perforators, and deep vein stent angioplasty. However, about 10% to 20% of venous stasis ulcers are retractable. This means a patient can experience several episodes of these painful ulcers in a lifetime. If the venous stasis ulcers are associated with varicose veins and venous reflux disease, they can be treated with compression along with ablation of the diseased vein. Suppose the venous stasis ulcers are associated with DVT history with no venous reflux disease in superficial veins and reflux only in the deep veins. In that case, invasive procedures are required to reopen the scarred veins from the old DVT to achieve complete healing. The course of treatment is usually long, and the patient must be very compliant with treatment. These ulcers tend to turn into a lifelong struggle for patients, forcing them to early retirement even at a young age. Patients with venous stasis ulcers should be evaluated very carefully.

 

Samples should be taken from the wounds if it is suspicious for superimposed infection, and they should be treated with appropriate antibiotics. Compression dressing has been the cornerstone of treating venous stasis ulcers. There are several different types of dressings used to treat venous stasis ulcers. There is medicated soaked dressing as well as multi-layers dressing available. All provide a constant pressure close to 40mmHg over the lower leg, reduce venous pressure, and encourage venous blood to travel toward the heart. There are another group of patients who suffer from liver cirrhosis, kidney or cardiopulmonary failure. These patients commonly have severe swelling in their lower legs, with itchy, scaling skins, or severe eczemas like skin or massive skin ulcers. The key to treating these patients is proper medical management and fluid restriction, and supportive therapy such as compression dressing over the lower legs.

 

Morbid obesity is also one of the most significant risk factors for lower extremities venous stasis ulcers or lymphedema leading to skin ulcers. The large pannus and super heavyweight prevent these patients from ambulating correctly, and they mostly spend their time in a sitting position for many hours. Over months or years, this lifestyle will create congestion of lymphatic fluid in their lower legs, trigger skin to thicken (hyperkeratosis), form ulcers, leak fluids, and trigger hyperplasia of fatty tissues. The treatment of morbidly obese patients with lower extremities edema should start from changing their lifestyle and weight loss program. Obese patients are challenging to treat since the extra weight will make it challenging to diagnose venous disease and place them at additional risks for complication with any invasive surgical intervention. As a vascular surgeon in Los Angeles, I see many patients with morbid obesity, both in my clinic and as inpatients. Unfortunately, almost all these patients have one common denominator due to their morbidly obese state: They all spend most of their days sitting down since they have difficulty moving around. The lymphedema triggers fat cells to multiply in lower extremities in the late stage of the lymphedema, creating a permanent features of lower extremity edema, that is no longer will response to compression. Hyperkeratosis, or thickening of the skin occurs in almost all the patients with chronic lymphedema. If lymphedema is treated in early stages, the treatment can be providing some promising results. The best methods of treatment are pneumatic compression devices, with pressure greater than 40mmHg.

 

These devices, are worn by patient twice a day and cover the feet up to the thighs. They are designed to provide segmental sequential pressure squeezing extra fluid from the lower legs into the veins of the pelvic. Patients who fail to treat their lymphedema, may develop skin ulcerations. These ulcers will drain significant amount of serous fluid to a point, patients have difficult time to ambulate. The ulcers can become infected with bacteria. Patients with lymphedema skin ulcer infection, should be treated properly by vascular specialist. The wounds should be treated with proper antibiotics, debridement of the necrotic tissue. The underlying venous disease should be properly diagnosed and treated. Many patients with lymphedema may have underlying venous disease as well. Therefore, it is particularly important to perform the routine diagnostic testing for venous disease prior to designing a treatment plan for lymphedema. The diagnostic for the venous disease is usually done with ultrasound, and major deep and superficial veins in the lower legs are examined to see if a patient requires treatment for venous insufficiency, which should be done prior to treating the lymphedema. Compression dressing may help to decrease the drainage; however, the best method of treating lymphedema is weight loss, regular exercise, and the surgical removal of adipose tissue. Currently, some clinics offer liposuction to remove the adipose tissue, which is the least invasive method of providing an effective treatment for lymphedema.

 

Many patients with end stage lymphedema have a hard time wearing shoes since their feet are much larger than normal. Patient’s with lymphedema have an overall very poor quality of life. In severe cases, patients are forced to remain stationary and have difficult time ambulating. Therefore, it is extremely important to seek medical treatment early on during initial phase of the disease process. In many cases, effective medical treatment with diuretics and massage therapy with experienced physical therapy, weight loss, exercise, and pneumatic compressions treatment can save patients from becoming completely disabled.

 

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