A venous stasis ulcer is a wound on the leg, usually around the ankle, from long-standing venous insufficiency (also known as venous stasis or varicose veins). These are the most common wounds on legs. There is level 1A evidence that Venous Stasis Ulcer Treatment with Endovenous Ablation should be started sooner rather than later. But often, patients are unaware of early treatment options
Frustrations Around Non-Healing Leg Wounds:
When a patient visits one of our Oregon office locations (NW Portland, Tigard or Bend) with a venous stasis ulcer, they are often frustrated. Some have had the venous stasis ulcer for many years. Usually, this started with untreated varicose veins. Then brown and red skin changes by the ankle (stasis dermatitis). Once a small wound opens up, often it will become larger, and not heal. Thus the term “non-healing leg wound”, many of which are venous stasis ulcers. Often we hear:
- Patients may not have been told that their non-healing leg wound could, in fact, be due to venous insufficiency, a very common chronic condition that starts with varicose veins, then progresses to leg swelling, and can finally result in skin breaks in many of these cases.
- They often think they had a bug bite, or assume the wound is entirely due to an infection.
- Many patients have seen multiple doctors and clinics and have not had any luck figuring out what is wrong.
At Inovia Vein Specialty Centers we specialize in Venous Stasis Ulcer Treatment and we have the diagnostic tools and experience needed to help make an accurate diagnosis and develop a definitive short and long term treatment plan.
Leg Wound Care
The first step in venous stasis ulcer treatment is always wound care. This can range from straightforward to complex depending on the case. It’s really important to control the swelling with adequate compression in most cases (except in cases where there is concomitant limb threatening critical limb ischemia…or peripheral artery disease). Your care provider should figure this out and advise the best form of compression.
With wet, soupy wounds, we often start with an Unna boot. An Unna boot is a medicated paste-impregnated wrap covered by an elastic layer, generally an elastic wrap (“ACE” bandage) or self-adherent elastic bandage such as Coban. It is applied with the appropriate level of compression. The goal is to get into a graduated compression stocking. This is hard with open, wet wounds. But often, after a few days or weeks of Unna boots, one can get into a graded compression stocking.
It’s imperative that compression stockings fit properly, so in these cases, we often refer to an expert stocking fitter, especially if there are any needs for custom fitting. The patient is advised they will need compression every day, often indefinitely. In many cases, a procedure to seal the superficial incompetent veins contributing to this ulcer can result in rapid healing of the ulcer and fewer recurrences than if the procedures are not do not have an ablation procedure.
Depending on the complexity of the wound, we can advise on basic would care, or we collaborate with local specialized wound care clinics when more complex wound management is needed. In such a collaboration, we work from the vein perspective, working to combine the benefits of compression with endovenous ablation, while we collaborate with the wound care team for wound debridement, topical approaches, and negative pressure wound therapy (wound vacs) when needed.
The Case for Earlier Venous Stasis Ulcer Treatment
A big question in the field is when doctors should perform these procedures. Doctors and patients often wish to get started sooner, but many insurance carriers require a mandatory waiting period of at least 3-months before such procedures can be offered to the patients after initiation of conservative therapy.
From an evidence perspective, there is growing data to suggest sooner is better. A recent randomized controlled study was published in the New England Journal of Medicine (known as the EVRA trial) conducted at 20 centers in the United Kingdom. In the study, 450 patients with venous leg ulcers were randomized to receive compression therapy and undergo early endovenous ablation of superficial venous reflux within 2 weeks after randomization (early-intervention group) or to receive compression therapy alone, with consideration of endovenous ablation deferred until after the ulcer was healed or until 6 months after randomization if the ulcer was unhealed (deferred-intervention group). The primary outcome was the time to ulcer healing.
Early endovenous ablation of superficial venous reflux resulted in faster healing of venous leg ulcers and more time free from ulcers than deferred endovenous ablation. This is a landmark study in Venous Stasis Ulcer Treatment that constitutes level 1 evidence that doctors should treat these ulcers with ablation sooner rather than later.
This has important implications for everyone.
- For patients and doctors who are frustrated because they wish to treat these wounds with venous ablation early, hopefully, treatment and coverage paradigms will evolve to be more evidence-based.
- For payers, like the insurance companies, governments, and society at large, this may save millions of dollars each year by healing these wounds sooner and preventing recurrences quicker, which not only is of healthcare value to the patients but a great value to society in general.
About Inovia Vein Specialty Centers
Inovia Vein Specialty Centers specialize in varicose vein care and vein health. While many physicians treat superficial vein concerns, Inovia offers complete vein care, from expert diagnostics to the latest treatment options. Our Oregon based vein centers in NW Portland, Tigard and Bend combines the skills, training, and experience of leading vein surgeons in the field, using advanced techniques to help heal your vein problems and reduce the risk future of wound issues.