Podiatric Vein Care
The Venous Ulcer
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author details Jodi Schoenhaus, DPM

Clinical Insights June 26, 2019

When the patient presents to your office or wound care clinic with an ulceration, the appropriate stepwise approach for evaluation and management are done. It is imperative to evaluate the arterial system and make sure there is enough flow to the lower extremity to heal the wound. If the arterial system is intact and the wound is not due to trauma, venous ulceration should be considered. Typically venous ulceration is caused by an underlying perforating vein off of the posterior tibial vein (PVT). The PTV will send a perforating vein piercing the superficial fascia and a tributary will lie directly under the surface of the skin. With chronic venous insufficiency, the build-up of pressure due to reflux and backflow of the vessels will cause the release of matrix metalloproteinases from the vein, weakening the vessel wall. These acids reside in the subcutaneous and dermal tissue, causing gradual breakdown and ultimately a venous ulceration.

First line treatments typically include wound debridement, multi-layer compression therapy with changes in dressings every other day, at a minimum, and ultimately, wound grafting techniques. Hyperbaric oxygen is also commonplace. 

Studies recently published and confirmed do demonstrate the benefit and long-term outcomes of addressing the underlying vein insufficiency with ablative techniques. These techniques should be first-line treatments, as they treat the true underlying cause of the ulceration by relieving the venous hydrostatic pressure built up in a reflux vein. By addressing the chronic venous insufficiency, the ulceration can heal much faster and stay closed much longer. Endovenous ablation with laser, radiofrequency, or foam techniques are the standard of care. Post ablation, ultrasound guided injection therapy can directly target the underlying perforating vein. During treatment, continuation of the multilayered compression is advised and once the ulceration has healed, it is imperative that the patient continues with compression therapy.