Venous Ulcer

Question 1

Aetiology of venous ulcers

Answer 1

Venous hypertension
Chronic venous insufficiency:
- Deep due to DVT
- Superficial due to varicose veins

Superficial or deep venous incompetence leads to venous hypertension and an increased hydrostatic pressure → tissue oedema → impaired microcirculation (leakage of fibrinogen and fibrin build up impairs oxygen delivery) → tissue necrosis/ulceration

Question 2

Symptoms and signs of venous ulcers

Answer 2

Ulcer:
Classically found in the “Gaiter area” (above medial malleolus > lateral)
Painless
Warm
Heavy exudate (wet)
Large shallow ulcer with sloped edges

Heaviness
Leg ache, worse on STANDING
Ankle swelling
Pruritus
Varicose veins
Skin changes:
- Lipodermatosclerosis: inflammation of the subcutaneous fat
- Varicose eczema: Increased pressure → RBC leak out and break down → inflammation
- Haemosiderin deposition: RBC breakdown → Hb released into ECM
- Atrophie blanche: Smooth, white stellate scars due to fibrinolytic disruption

Question 3

Investigations for venous ulcers

Answer 3

ABI: <0.9 = mild-moderate PAD | < 0.4 = severe PAD
Microbiology swab: ?infection

CK: check for muscle damage

Duplex USS: peak systolic velocity ratio >2 (stenosis)
Continuous wave Doppler USS: Pulsatility index decrease

Catheter angiography, CT angiogram, MR angiography: anatomical detail of stenoses or occlusion

Question 4

Management for venous ulceration

Answer 4

Advice: Leg elevation, Mobility

First line: graded compression stockings (knee or full-length depending on insufficiency)
- TED stockings (Thrombo-Embolism Deterrent)
- Multi-component compression bandaging (Usually 4 layer compression)
- Method: put on first thing in the morning and removed only when the patient is recumbent

± peripheral vasodilator: PO pentoxifylline
± Abx for infection

Second line (12 weeks later OR >10cm2): skin grafting

Surgery
- Endovascular or open surgical treatment of varicose veins
- Does not speed healing but helps to reduce recurrence

Severe → lifelong graded compression stockings (30-40mmHg)

Question 5

What are the classes of stocking

Answer 5

Class 1 (light compression): control oedema
Class 2 (medium compression)
Class 3 (high compression): more advanced venous insufficiency

Question 6

Complications of venous ulceration

Answer 6

Chronic wound
Infection
Recurrence
Marjolin’s ulcer (malignancy develops in long-standing ulcers)

Question 7

Prognosis for venous ulceration

Answer 7

Often chronic
Variable healing rates
Recurrence 25% within 1 year, 22% at 1.5 years