1. No category

Chronic venous insufficiency
Theapy of leg ulcer
Dr. Éva Szabó PhD. med.habil.
Department of Dermatology
University of Debrecen
2014
Main topics of the lecture
• Venous circulation of the lower limbs
• Pathophysiology and classification of
chronic venous insufficiency
• Differential diagnosis of leg ulcer
• Treatment of chronic venous insufficiency
• Stages of wound healing
Treatment of leg ulcer
Venous circulation of lower leg:
superficial veins – perforator veins – deep veins
Common femoral vein (subfascial)
Dodd perforators (GSV- superfic.femoral vein )
Great saphenous (suprafascial)
vein (GSV)
Popliteal vein (subfascial)
Short saphenous
vein
Posterior tibial veins (subfascial)
Boyd perforators ( GSV - Posterior tibial veins)
Anterior tibial veins (subfascial)
Cockett perforators (GSV - Posterior tibial veins )
arcus venosum dorsalis pedis
Structure of the vessel wall
• tunica intima
endothelial cells
subendothelial connective tissue
• tunica media (the thickest layer in arteries):
smooth muscle
elastic fibers
• tunica adventitia (the thickest layer in veins)
collagen and ellastic fibers
Cross section of a vein
Valve
(duplicate of intima, bicuspidal)
Endothel
Basal membrane
Smooth muscle
Connective tissue
Function of the vein valves
• Vein valves: duplicate of intima, bicuspidal valves
• Valves are most numerous in the distal leg
• Function: blood flowing in one direction (back to the right
atrium of the heart)
• Muscle pump mechanism
Valve open
Contracted sceletal muscles
Valve closed
Relaxed sceletal muscles
Main topics of the lecture
• Venous circulation of the lower limbs
• Pathophysiology and classification of
chronic venous insufficiency
• Treatment of chronic venous insufficiency
• Stages of wound healing
Treatment of leg ulcer
Pathomechanism of chronic venous insufficiency
Hormonal effects
Genetic causes
Exogenous causes: lifestyle
(obesity, insuff. sport activity), Destroyed deep veins,
destroyed vein valves
profession (standing work)
Elevated pressure in veins
Low blood flow
Increased blood viscosity
Interaction and activation of
leukocytes-endothel cells
Expression of adhesion
molecules, cytokines,free radicals
Adhesion and
migration of leukocytes
through the vessel wall
Inflammation
Pericapillary fibrin cuff
Dept..Dermat.,
Debrecen
Classification of venous disease
(CEAP)
•
•
•
•
Clinical severity (C)
Etiology or cause (E)
Anatomy (A)
Pathophysiology (P)
Dept Dermatol., Debrecen
Classification of venous disease(CEAP)
Clinical classification
Dept Dermatol.,
Debrecen
C0: no visible or
palpable signs of
venous disease
C1: telangiectasias
or reticular veins
Dept. Dermatol.
Debrecen
Dept Dermatol., Debrecen
C2 varicose veins
C3: edema of
venous origin
Dept Dermatol., Debrecen
C4: eczema,
hyperpigmentation,
lipodermatosclerosis
Dept Dermatol., Debrecen
C5: healed venous ulcer
Dept Dermatol., Debrecen
C6: active venous ulcer
Classification of venous disease (CEAP)
Etiology or cause
• Congenital:
- arteriovenosus shunt
- parcial absence of the vein system,
vein malformations e.g.: Klippel-Trenaunay
syndrome (triad of port-wine stain, varicose
veins, and bony and soft tissue hypertrophy)
• Primary: multifactorial: genetic-, hormonal-,
exogenous causes
• Secondary: known cause e.g.: deep venous
thrombosis, postthraumatic
Dept Dermatol., Debrecen
Classification of venous disease (CEAP)
Anatomic classification
1. Superficial venous involvement
2. Perforator vein involvement
3. Deep vein involvement
2
3
1
Classification of venous disease (CEAP)
Pathophysiology
• Reflux caused by vein valve insufficiency
• Obstruction (thrombus)
• Both
Examination of a patient suffering from venous
disease, and/or leg ulcer
•
•
•
Patient history (family history , profession, symptomes start, previous
DVT, previous treatment)
Physical examination:
Inspection
– Skin symptoms (eczema, dermatoscler., pigmentation, ulcer)
– Varicose veins (large, tortuous veins)
– Edema
Examination by palpation
– Skin temperature
– Pitting oedema
– Touching the pulse of periferial arteries
Further examinations (if necessary):
– Doppler ultrasonography of lower limbs arteries and veins
– Doppler ankle-brachial index (normal Pleg/ Parm = 1)
– Lab tests (blood panel, CRP, Haemostasis, serum glucose)
If wound also exists (location, base, edge of the wound,
sorrounding tissue condition), biopsy can be necessary
Dept Dermatol., Debrecen
Main topics of the lecture
• Venous circulation of the lower limbs
• Pathophysiology and classification of
chronic venous insufficiency
• Treatment of chronic venous insufficiency
• Stages of wound healing
Treatment of leg ulcer
Main topics of the lecture
• Venous circulation of the lower limbs
• Pathophysiology and classification of
chronic venous insufficiency
• Treatment of chronic venous insufficiency
• Stages of wound healing
Treatment of leg ulcer
Complex treatment of
chronic venous insufficiency I.
1. Basic treatment:
•
Lifestyle changes
weight loss, regular exercise, smoking cessation
• Compression treatment
bandage, stocking,
lymphodrainage treatment
• Medicines
flavonoids, rutosids, Ca-dobesilat
Dept. Dermatol. Debrecen
Complex treatment of
chronic venous insufficiency II.
2. Treatment of varicose veins
• sclerotherapy (polidocanol injection)
Dept. Dermatol. Debrecen
Dept. Dermatol. Debrecen
• varicectomy (surgical removal of varicose vein)
3. Local treatment of the ulcer
Lymphodrainage treatment
Lymphodrainage
treatment
1. Manual massage
2. Pressure therapy
by special device
Multilayer wraps
Multilayer
compression
bandage
Dept. Dermat.. Debrecen
Dept. Dermatol. Debrecen
Dept. Dermat. Debrecen
..
Physiotherapy
Dept. Dermat.. Debrecen
Lymphodrainage with instrument
1.
2.
3.
4.
5.
Special cuff
Inflatable cells
Inflation of the cells
Deflation of the cells
Continuous massage
Main topics of the lecture
• Venous circulation of the lower limbs
• Pathophysiology and classification of
chronic venous insufficiency
• Treatment of chronic venous insufficiency
• Stages of wound healing
Treatment of leg ulcer
Phases of wound healing
1.Inflammation
Leukocyte (PMN, macrophage)
migration, phagocytosis,
mediator release, exudation
Dept. Dermatol. Debrecen
3.Maturation,
remodelling
Reepithelisation,
scar formation
2. Granulation,
proliferation
Fibroblast
proliferation,
collagen synthesis,
neovascularization
Dept. Dermatol. Debrecen
Dept. Dermatol. Debrecen
Wound cleaning: removal of adherent
inflammatory contaminants and dead
tissue from the wound surface I.
1. Necrectomy:
surgical removal of necrotic tissue
Dept. Dermatol. Debrecen
2. Enzymatic removal of dead tissue
(Enzymatic preparations contain fibrinolysin,
collagenase, papain or trypsin)
3. Topical disinfectants :
iodine solution,
silver nitrate solution (0,5%)
hydrogen peroxide solution (3%)
4. Ointment containing salicylic acid, boric acid)
Dept. Dermatol. Debrecen
Wound cleaning: removal of adherent
inflammatory contaminants and dead
tissue from the wound surface II.
Bandages based on moist wound healing
Autolytic debridement: uses the body's own wound fluid to
separate the dead tissue from the surface into the bangade
Hydrogel
Dept. Dermatol. Debrecen
Dept. Dermatol. Debrecen
Dept. Dermatol. Debrecen
Hydrocolloid bandage
Dept. Dermatol. Debrecen
Dept. Dermatol. Debrecen
Dept. Dermatol. Debrecen
Special methods for wounds not responding
to previously listed options I.
V.A.C. treatment (Vacuum Assisted Closure): Hypobaric
method: uses a foam bandage and a suction tube on the wound,
removes dead tissues and extra fluid
Dept. Dermatol. Debrecen
Dept. Dermatol. Debrecen
Dept. Dermatol. Debrecen
Dept. Dermatol. Debrecen
Special methods for wounds not responding
to previously listed options II.
Hydrosurgery:
A high pressure water jet
removes the debris.
Biosurgery:
Sterile maggot larvae are used, which
release enzymes that break down the
dead tissue. The larvae digest bacteria
in the wound.
Stimulation of granulation and
epithelisation of the wound
Hydrocolloid
Medical honey: honey of
manuka flower(Leptospermum
scoparium)
Dept. Dermatol. Debrecen
Impregnated gauze
(oil, iodine)
Film dressings: protection of
fresh epidermis
Dept. Dermatol. Debrecen
Additional treatment options
for leg ulcer
• split-thickness skin graft autotransplantation:
Dept. Dermatol. Debrecen, 2010
Dept. Dermatol. Debrecen, 2010
Dept. Dermatol. Debrecen, 2010
Dept. Dermatol. Debrecen, 2010
•Cultured autologous keratinocyte sheet is used
to cover the wound