Chronic Wounds

Chronic Venous insufficiency, 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%) or venous obstruction (20%) 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 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 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, 50-100% of patients have repeat ulcerations.

We have included images of some of the chronic wounds that we have treated at The Vein Center below.  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
The following patient had a chronic nonhealing 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 below 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 the improvement in the chronic rash-like areas in the front of the leg.  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 a severe, chronic (2 years) ulceration and severe leg pain 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.  4 days after treatment, the patient stated that his pain level had dropped from 9 out of 10 to 1 out of 10 (4 days after laser ablation and medical sclerotherapy).  He went on to complete ulcer healing over the next few weeks.

4 days after treatment with laser ablation and medical sclerotherapy

A nonhealing 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 nonresolution 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.

Pretreatment Photo

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 often 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.