Treatment for Leg Ulcers
The treatment of venous disorders of the legs depends upon its severity and will depend upon the results your doctor's examination and investigations. the investigation of venous problems is becoming more sophisticated with the advent of better imaging with Duplex Doppler scanning and your doctor or specialist may wish to get this and other tests done prior to making recommendations.
Deep Veins
Thrombosis is normally treated conservatively with drugs which although they don't necessarily dissolve the clot, prevent it propagating thereby becoming dangerous. the aims of the treatment is to prevent the clot getting worse and thereby stop a large clot flying off up into the lung arteries with sometimes fatal results.
Superficial Veins
Small varicose veins can be satisfactorily treated with sclerosant injections providing there is no significant reflux from the major saphenous tributaries. If however, this is present injections tend to provide only temporary relief.
The standard treatment for varicose veins, the result of great and/or small saphenous vein reflux is vein stripping surgery. This usually comprises of an incision in the groin or in the case of the small saphenous vein, behind the knee and the tributaries running into the main saphenous trunk are identified, divided and tied off. The main trunk is then itself ligated flush where it joins the deep system. The great saphenous vein will usually be removed by the insertion of an instrument called a stripper into it down as far as the middle of the calf. The vessel is literally ripped out through a small calf incision through which the stripper is manipulated. Any other varicosities are then removed through tiny stab incisions so small, they do not require stitches. The results even if the procedure is carefully and thoroughly done, are poor with recurrence apparent in 20% cases at one year getting worse as time passes. At five years recurrence rates can vary between 70 - 95%. The reasons for this are multiple but we established with one of our research projects that it is possible to regrow the stripped vein either partially or completely in some cases and this is disappointing if you have been through an invasive, temporarily debilitating and painful procedure!
Most surgeons tend to ignore refluxing perforators which are present in about one-third of cases presenting to their doctor for the first time and in 70% of patients who have recurrent varicose veins. These figures would suggest that perforators are involved in recurrence despite the denials of a significant body of surgeons but evidence continues to build against the detractors. At the Whiteley Clinic we have always taken the view that if there is any part of the venous system leaking it should be fixed and not left to haunt you the patient later. Simply put, if you had a bucket with a large hole in the bottom and two or three smaller ones in the sides there seems little point in just tackling the large hole in the bottom since the bucket will still leak; less so admittedly but leak nevertheless. Furthermore the smaller holes left will tend to enlarge over time so the problem will recur. The overriding principle is that ALL sources of vein reflux or leak, whether it comes from the main truncal veins like the great and small saphenous, perforators or from the pelvis, must be attended to if a long lasting; top quality result is to be secured.
In 1999 we introduced a new technique to the UK called VNUS CLOSURE. This was the first of a new wave of treatments in Varicose Vein surgery - Keyhole or Pinhole varicose vein surgery. With VNUS Closure, the main saphenous vein was destroyed using radio frequency waves via a thin catheter introduced through a tiny stab incision just below the knee. The vein being a poor conductor of the radiofrequency wave energy heated up to 85 °C which denatured the protein in the wall of the vein and guaranteed that it could not merely thrombose and open up again. The vein became a cord of protein no longer recognised by the immune system. The white cells in the blood then enzymatically dissolved the vein away permanently as there was no stimulus, like in vein stripping, to grow another one. This spared the need for the groin incision and made for a comfortable and speedy recovery. The method was very new and innovative and the Whiteley Clinic went on to have the world's largest experience of this technique. We went on to develop many new ways of using this device to treat veins previously not able to be treated by VNUS or traditional methods. The advances were very exciting and none more so than the brilliant innovation by my colleagues Judy Holdstock and Mark Whiteley who devised the method of introducing the VNUS catheter into individual perforator veins under ultrasound control. This method called TRLOP (TRansLuminal Occlusion of Perforator) is now used by surgeons all over the world and a diagram showing how a cannula to carry the device is inserted is shown below.
The original VNUS device has now largely been superceded by improved designs that allow local anaesthetic methods to be employed.
Over the last decade, since we introduced these methods, we have developed our techniques further. We now perform EVLA (Endo Venous Laser Ablation) as well as RFA (radiofrequency closure) under local anaesthetic, which uses the same principle of killing the vein using heat - but uses laser rather than radiofrequency electric current. There are technical reasons for the choice which your surgeon will advise you as to suitability if you decide to come to see us.
We also use the new RFiTT device which works according to the same principles as the original VNUS instrument but can be used in a clinic office setting unlike VNUS which needed to be carried out under general anaesthesia and was technically much slower than the more modern devices. We also use Foam Sclerotherapy when appropriate and so we have a full range of techniques to suit all eventualities and different situations that may arise here at The Whiteley Clinic. This means that your treatment is not dictated by any single method and the best technique(s) is/are chosen to get you the best possible outcome.
For more information about the treatment of varicose veins and VNUS Closure, EVLA, RFiTT, Foam Sclerotherapy and TRLOP visit www.veins.co.uk
Ulcers
Assuming that the cause of the leg ulcer is due to venous insufficiency, the traditional mainstay of treatment is to provide enough compression bandage support to overcome the inadequate calf muscle pump and prevent blood refluxing into the leg. This with the addition of medicated dressings results in the healing of the majority of venous ulcers. Unfortunately, this method tends to be slow (24 weeks on average), tedious and painful for many sufferers and the recurrence rate of the ulcer is at least 25% at six months and 31% at 18 months but there are studies that quote higher figures than this to be found in the literature. In 2004 one study suggested that the NHS spent £400 million a year on the treatment of venous ulcers which will undoubtedly be more now and are sums of money the country can ill afford in such tough economic conditions. Compression bandaging especially 'four-layer' technique is an art form and it is all too easy to produce uneven compression which worsens the problem if inexpertly done. For example an obese swollen leg can wind up getting inadequate compression levels around the ankle (40 mmHg is suggested to be effective) and too much just below the knee making the tissue fluid retention worse whereas a thin bony limb can end up with dangerous high focussed pressure over bony points such as the ankle or shin leading to further skin loss from pressure necrosis. The other main problem with long term bandaging is that ankle movements are restricted by the layers of material and the normal muscle pump that drives the blood back to the heart is therefore markedly reduced.
Numerous dressings are recommended usually in the form of ointments, gels and impregnated gauze-like coverings. There are also occlusive dressings which cover the ulcer bed up and allegedly prevent the wound weeping through onto the bandages. The problem with this approach is that the weepy fluid does not go away it merely collects under the covering and macerates the surrounding skin chemically burning it because of the highly caustic nature of some of the enzymes in the fluid that have escaped from the circulation. The same goes for many of the ointments and gels which serve only to make the wound area soggy, swollen and sore. I can never understand why many patients who come to me have been advised that they mustn't get the ulcer wet i.e. wash it and yet daub large quantities of hydrated gels onto the ulcer bed as a medicated dressing! Most people would not allow any other part of their body to go unwashed for weeks on end and the skin around venous ulcers should be no different. The fear is that washing the ulcer will introduce infection; this is unfounded as the ulcer bed is teeming with bacteria so washing them off and diluting their presence must surely be of benefit? There is considerable confusion with regards to ulcer swabs that are taken; if you put a sterile swab in the middle of a smelly weeping leg ulcer, of course it will grow organisms in a Petri dish in the laboratory. This does not however, equate to infection. The bacteria are just hanging around in a warm soup of tissue fluid that contains everything bacteria need to grow and then if the area is covered up with minimal cleansing the conditions are absolutely ideal for bacterial overgrowth; nutrients, moisture and warmth - lovely!
So what is the alternative? At the Whiteley Clinic we are not out to junk traditional methods completely and there are some patients that will require bandaging in the short term but we aim to get patients out of bandages and into compression stockings to restore normal walking mechanisms as soon as possible. The main obstacle to overcome as any sufferer will tell you, is that the ulcer weeps constantly and if they wear stockings they will be wet in next to no time. Getting the excess fluid out of the limb is the key to the management in our view. Firstly, wash the leg; so hey, it's OK to have a bath! If getting in and out of a bath is difficult a simple bucket lined with a clean bin liner filled with warm water will suffice. Gentle cleansing of the immersed limb using a soft non-allergenic soap to allow old scales to be removed will improve the surrounding skin and stop it being eaten by the tissue fluid enzymes. Rinse off and dab dry gently then using a hair dryer on a cool setting dry the ulcer off - yes dry it! If it forms a scab all the better; this is natures covering and better than any dressing invented. New skin will grow under the scab and the ulcer will then shrink. Clearly, this method may not work immediately and the tissues may well need some help to get into the sort of condition to allow this approach. If the limb is swollen and the output from the ulcer bed high, we normally advise a course of manual lymphatic drainage, sequential bandaging, mechanical pumps to reduce the limb swelling which has the effect of reducing the fluid from the ulcer, improving the microcirculation in the capillaries to the wound edges and it never ceases to amaze me how often the pain in an ulcer is removed by applying these techniques. Once the oedema is controlled the patient can go into a stocking and things can move forward.
Despite all this the underlying problem still needs to be solved. It is essential that thorough investigation of the reflux be undertaken so that any superficial venous reflux can be treated as outlined above. Deep venous reflux can sometimes be treated surgically but it is a matter for fine judgment and case selection. Support hosiery alone is normally therefore recommended for this small group of patients. Perforator veins, if causing significant reflux into the ankle area, can be interrupted surgically by the use of a pinhole technique, invented by the Whiteley Clinic nearly a decade ago which involves blocking off the perforator beneath the deep fascia of the calf under ultrasound control (the deep fascia is a strong sheet of sinew that lies beneath the fat under the skin. It provides the familiar shape of the calf and ankle). Virtually all our surgery is carried out under local anaesthesia nowadays and it means that people are ambulant and can go about their business with minimal disturbance. These methods are covered in detail elsewhere on our numerous web sites.
