Chronic venous insufficiency with superficial venous reflux and the resultant visible varicose veins is the underlying cause of many chronic wounds in the legs. The abnormally high pressures that result from either venous reflux (80% of cases) or venous obstruction (20% of cases) decreases the ability of the body to heal itself, either through decreased oxygen in the blood, decreased blood flow or due to toxins from the breakdown products of blood (blood that has been forced out of the vessels due to the high pressures).
It is important to differentiate between a supply problem (arterial blockage or decreased flow) and a problem with the venous system. Physical examination can provide clues to the probable cause and a thorough ultrasound examination can demonstrate the specific abnormal vessels. As always, skill and experience with the ultrasound examination is essential.
Different vessels produce ulcerations and pain in different locations of the leg. For instance, the most common cause of an ulceration in the medial (inside) side of the ankle is the greater saphenous vein (also referred to as the Long Saphenous Vein). Familiarity with the different patterns common in venous disease can lead to more rapid diagnosis and more accurate and predictable treatment results.
CEAP Classification is used to determine severity of venous reflux.
- Class 0: No signs of venous disease
- Class 1: Spider veins or reticular veins
- Class 2: Varicose veins
- Class 3: Edema
- Class 4: Skin changes
- Class 5: Healed ulceration
- Class 6: Active ulceration
In CEAP classifications 4-6, treatment is performed to promote wound healing and provide symptomatic relief. With successful treatment of the underlying reflux including significant perforators, healing for at least 3 years is seen in 70-90% of patients. Without successful treatment, the risk of persistent ulceration is high. (The treatment of venous ulcers of the lower extremities, Lonnie L. Whiddon, MD, Proc (Bayl Univ Med Cent). 2007 Oct; 20(4): 363–366.)
Below are images of some of the chronic wounds that we have treated at The Vein Center, images and text are the property of The Vein Center. Please note that some of the images are fairly graphic, please use good judgement on appropriate locations to view them.
Venous Ulcerations: Before and After treatment
This patient had a chronic non-healing wound for one year that was painful and had significant leg swelling despite aggressive management at a wound clinic. The healing of the chronic ulceration displayed in the after picture is typical of the response seen with definitive treatment of abnormal superficial venous reflux. The pain resolved nearly immediately following treatment.*
The dark discoloration seen in this patient is typical of that seen in chronic venous reflux disease. The before picture shows hemosiderin as well as an underlying reddish discoloration consistent with venous reflux. Please note the improved appearance both in coloration and in the chronic rash-like areas in the front of the leg 50 days following treatment with laser ablation and phlebectomy. Patients with superficial venous reflux often have significant itching with involuntary scratching at night which results in this appearance. The patient’s swelling, pain and itching (and shallow wounds) resolved after laser ablation and ambulatory phlebectomy.*
This patient had severe, chronic ulceration and severe leg pain for 2 years that would not heal despite aggressive, frequent and skilled treatment at a local wound center. Following treatment, the discoloration is much improved, the wound is becoming more shallow and the ulceration is healing. Often, drainage from the ulcer becomes more bloody after treatment, a good sign as it implies more blood flow (and therefore improved healing) to the ulcer. Four days after laser ablation and medical sclerotherapy treatment, the patient stated that his pain level had dropped from 9 out of 10 to 1 out of 10. He went on to complete ulcer healing over the next few weeks.*
A non-healing wound in the lateral (outside) aspect of the left leg after an injury. This had been treated at a local wound center with multiple debridements and dressings with non-resolution of the wound. The wound healed after laser ablation and medical sclerotherapy. No additional ulcers have developed since treatment, an important point as venous ulcers usually recur without treatment.*
This gentleman had undergone a coronary artery bypass graft 2 months prior to presentation to our clinic. The surgeon had attempted to remove the right greater saphenous vein for the heart surgery but did not remove it due to technical issues. The wound failed to heal. The right greater saphenous vein was noted to have abnormal reflux and given the risk in working at an open wound, treatment was performed with foam sclerotherapy below the wound to the level of the knee (closely monitored by ultrasound). Marked improvement resulted as shown on follow up pictures 4 days after the procedure. He continued to have a small area at the top of the wound that would not completely close and a laser ablation of a perforator at the upper end of the initial wound was performed and the wound closed completely. Staged treatment of ulcerations is sometimes necessary and we routinely have patients with ulcers return in 3 months to assure complete healing.*
This nice lady presented to our clinic with an incredibly painful ulceration in the medial (inside) aspect of her left leg for the last 8 months. Ultrasound examination was performed and showed a single abnormal perforating vein with high flow. Laser ablation of the perforating vein was performed as well as medical sclerotherapy. Note the improved blood flow, the more shallow nature and drier appearance of the wound. It healed completely in under 3 weeks and her pain was essentially resolved on her 6 day visit. Oddly enough, some insurance companies consider treatment of abnormal perforating veins to be investigational. Our experience, as well as that of other vein centers, has shown obvious patient improvement with treatment of abnormally functioning perforating veins and we often recommend treatment of these abnormally functioning vessels.*
*All Images and text are the property of The Vein Center. Please note, individual patient results may vary.