Venous Ulcers (CEAP 5, CEAP 6)

The most severe gradation of the CEAP scale C5 and C6 states refer to the problems of chronic venous ulceration which tends to be an ongoing and recurring problem for patients with severe venous insufficiency. This usually results from Postphlebitic Syndrome or from a combination of Superficial Vein Insufficiency and/or Perforator Vein insufficiency. These will appear as shallow irregular ulcers that occur just above the ankle on either the inner or outer side of leg and are surrounded by brown stained skin (lipodermatosclerosis, hyper pigmentation) and frequently associated with varicose veins or blown out perforators. They can be distinguished from arterial insufficiency ulcers (dry gangrene) because the heel and rest of the foot are spared. Traditional therapy has been chronic compression stockings or a non stretch Unna Boot, local wound care and leg elevation. However the recurrence rate with these measures alone is notoriously high. Adjunctive therapy with hyperbaric oxygen, skin grafting, and medications to address alterations in the collagen metabolism, blood viscosity and metalloproteinase alterations has not proved to be significantly beneficial. The most promising methods of treatment are directly aimed at controlling the perforator and primary superficial venous reflux with laser or radiofrequency ablation and/or ultrasound guided foam sclerotherapy. In severe cases relieving ambulatory venous hypertension by means of enzymatic or mechanical thrombolysis, angioplasty or stents will give a better result. One of the most promising new developments has been popularized by Dr. Ronald Bush of the Midwest Vein and Laser Center who has recognized that surrounding these ulcers are a network of incompetent reticular varices which are under a lot of pressure. Dr. Bush realized if we can achieve a Terminal Interruption at the Reflux Source (TIRS) the ulcers will heal much faster. The TIRS technique involves ultrasound guided foam sclerotherapy around the ulcer in addition to ablation closure of the superficial and larger perforator veins. This is also my preferred method of treatment and this approach has shortened venous ulcer healing from a couple of months to just a few weeks and has eliminated the need for questionable adjunctive therapies. Venous ulceration is a reflection of chronic end stage damage to the venous system therefore it is important to realize that lifelong follow up care and control of venous hypertension with stockings or a non compression device like CircAid is still necessary.