Venous Ulcers

2nd Edition - January 13, 2023
Editors: Cynthia K. Shortell, Jovan N. Markovic
Language: English
Paperback ISBN:
9 7 8 - 0 - 3 2 3 - 9 0 6 1 0 - 4
eBook ISBN:
9 7 8 - 0 - 3 2 3 - 9 8 5 8 7 - 1

Venous Ulcers, Second Edition, provides a comprehensive synthesis of evidence-based recommendations and the highest level of expertise from a leading group of doctors, which i… Read more

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Venous Ulcers, Second Edition, provides a comprehensive synthesis of evidence-based recommendations and the highest level of expertise from a leading group of doctors, which is a fundamental constituent for the appropriate management of nonhealing venous wounds in everyday practice. This book offers a fertile environment for a complete understanding of genetics and molecular and biochemical mechanisms that lead to the development and progression of venous ulcers, which is essential for elucidating the underlying pathophysiology and can be utilized for developing novel therapies and accessing previously inaccessible areas of research. Socioeconomic impact, impact on health-related quality of life, the clinical course of the disease, and diagnostic algorithms are elaborated in detail. All currently available treatment modalities are explained in a clinically applicable approach with particular emphasis on operative technique, technical feasibility, success rates (both clinical and technical), and side effects. Lastly, this book elaborates on special diagnostic considerations and management of the most complex patients, often requiring the highest level of expertise for successful treatment.

Cover image
Title page
Table of Contents
Copyright
List of contributors
Preface to Venous Ulcers
Section 1. Chronic venous insufficiency—basic considerations
Chapter 1. Pathophysiology of chronic venous disease: genetic, molecular, and biochemical mechanisms
Key points
Introduction
Content
Conclusions
Chapter 2. Venous hemodynamics and microcirculation in chronic venous insufficiency
Introduction
Hemodynamics and anatomy
Pathophysiology—superficial venous incompetence
Deep venous dysfunction
Perforating veins of the calf
Foot and calf pump function in venous hemodynamics
Microcirculation and interstitial edema
Regulation of capillary hydrostatic pressure
Blood flow and inflammation
Conclusions
Chapter 3. Venous ulcers of the lower extremity: etiology, risks, and predictive factors
Introduction
CEAP etiologies of CVD
Epidemiological data on CVI and its progression
Progression of venous disease
Clinical risk factors for first VLU (Table 3.5)
Genetic risk factors for VLU
Lymphatic involvement in VLU
Summary
Chapter 4. Venous ulcers of the lower extremity: epidemiology and socioeconomic burden
Role of epidemiology in the study and treatment of venous leg ulcers
Incidence and prevalence of venous leg ulcers
Distribution of chronic venous insufficiency and its subgroups within the population
Defining venous leg ulcers
Leg ulcer prevalence
Etiologic spectrum of leg ulcers
Venous ulcer prevalence
Incidence of venous ulcers
Age and sex distribution
Socioeconomic aspects
Venous ulcer natural history
Obesity
History of DVT
Healing and survival
Future trends
Section 2. Clinical evaluation and diagnostic modalities
Chapter 5. Initial clinical evaluation in patients with chronic venous insufficiency
Introduction
Medical history
Physical exam
Quality of life assessment
Classification and venous severity scoring
Summary
Chapter 6. Ultrasound evaluation of lower extremity chronic venous disease
Key points
Introduction
Diagnosis of obstruction
Chapter 7. The diagnosis of major venous outflow obstruction in chronic venous insufficiency
Introduction
Diagnosis of chronic venous insufficiency and venous hypertension
Diagnostic modalities
Chapter 8. Hypercoagulable states associated with chronic venous insufficiency
Protein C and protein S
Antithrombin
Factor V Leiden
Activated protein C resistance
Prothrombin G20210A gene mutations
Dysfibrinogenemia
Antiphospholipid syndrome
Paroxysmal nocturnal hemoglobinuria
Myeloproliferative neoplasms
Other hypercoagulable states that increase the risk of developing VTE and potential subsequent venous ulceration
Chapter 9. The chronically swollen leg with ulcers—finding the cause: theory and practice
Introduction and epidemiology
Assessment of edema
Physical examination
Diagnostic studies
Chapter 10. Lower extremity wounds associated with mixed venous and arterial insufficiency and relevant differential diagnosis
Introduction
Evaluation
Treatment
Differential diagnosis
Chapter 11. Assessment tools and wound documentation for patients with chronic venous insufficiency
Wound assessment tools
Section 3. Nonoperative management of chronic venous insufficiency and wound care
Chapter 12. Compression therapy in venous leg ulcers
Introduction
Compression devices
Medical compression stockings
Compression bandages
Elastic and inelastic bandages
“Single-layer” and multilayer bandages
Intermittent pneumatic compression
Pelottes and pads
Prevention of ulcer recurrence
Compression techniques—practical guidelines
Summary
Chapter 13. Wound healing: adjuvant therapy and treatment adherance
Introduction
Patient and wound assessment
Standard therapies for wound bed management
Wound dressings
Adjuvant therapy for venous ulcer wound healing
Optimizing care delivery
Chapter 14. Negative pressure wound therapy for venous leg ulcers
NPWT description and mechanism of action
Use of NPWT in patients with VLUs
Case study
Summary
Chapter 15. Medical therapies for chronic venous insufficiency
Pathophysiology
Lifestyle considerations
Compression therapy
Compression socks
Inelastic compression garments
Paste boots
Multilayer compression bandages
The bottom line on compression
Pneumatic compression
Dietary supplements
Physical activity
Medications
Animal models
Micronized purified flavonoid fraction
Calcium dobesilate
Pentoxifylline and sulodexide
Horse chestnut
Acetylsalicylic acid
Antibiotics
Biologic wound care products
Guidelines
Conclusions
Chapter 16. Treatment modalities for the management of nonhealing wounds in patients with chronic venous insufficiency
Introduction
Lifestyle modification
Medical therapy
Untreated arterial or deep venous disease
Compression
Identification and treatment of infection
Debridement
Dressings and local agents
External stimulants
Skin grafting, skin substitutes, and soft tissue substitutes
Conclusion
Chapter 17. Deep vein thrombosis and prevention of postthrombotic syndrome
Anatomic considerations in PTS
Hemodynamics of PTS
Collateralization and flow patterns in acute DVT
Microcirculation and capillary exchange
Anticoagulation to prevent PTS
Venoactive drugs
Elastic compression therapy
Thrombolysis/endovascular therapies to prevent PTS
Surgical thrombectomy
Our experience
A case study
Open surgical reconstructions
Ultrasound-accelerated thrombolysis
Venous ulcer care
Conclusion
Chapter 18. Improving treatment outcomes—management of coexisting comorbidities in patients with venous ulcers
Introduction
Diabetes mellitus
Arterial hypertension
Coronary artery disease and congestive heart failure
Reduced muscle pumping function
Other clinical conditions concurring with venous leg ulcers, venous ulcer occurrence, healing failure, and recurrence
Obesity
Chapter 19. Emerging modalities in local treatment of venous ulcers: advanced dressings, bioengineering, and biologics
Introduction
Mechanism of action
Wound bed preparation
Negative pressure wound therapy
Matrix metalloprotease modulation
Debridement in venous leg ulcers
Topical antimicrobial therapy
Combination therapy
Cellular and tissue-based therapies
Living skin cellular products
Extracellular matrix therapy (ECM)
Acellular human tissue
Acellular xenograft tissue
Biosynthetic
Placenta-derived tissue
Dehydrated PDT
Cryopreserved and other “viable PDT”
Our treatment algorithm
Conclusion
Section 4. Operative and endovascular procedures for chronic venous insufficiency
Chapter 20. Benefits of superficial venous intervention (surgery or endovenous ablation) in the treatment of venous leg ulceration
Introduction
The EVRA study
Implementation of ESCHAR and EVRA study results
Conclusions
Chapter 21. Superficial surgery and perforator interruption in the treatment of venous leg ulcers
Diagnosis
Treatment options for incompetent superficial truncal veins
Treatment options for incompetent perforator veins
Chapter 22. Endovenous techniques for superficial vein ablation for treatment of venous ulcers
Introduction
Preoperative planning
Endovenous thermal ablation techniques
Nonthermal endovenous ablation techniques
Outcomes
Conclusion
Chapter 23. Treatment of chronic venous insufficiency with foam sclerotherapy
Introduction
Complications and outcomes
Technique
Summary
Chapter 24. Ultrasound guidance for endovenous treatment
Introduction
Equipment
Preprocedure planning
Venous access
Periprocedural monitoring
Tumescent anesthesia administration
Postprocedure monitoring
Chapter 25. Iliac vein stenting in chronic venous leg ulcers
Introduction
Pathophysiology of venous ulcers
Clinical assessment
Etiology of venous ulcers
Investigations
Diagnosis of iliac vein stenosis
Treatment of chronic venous ulceration
Poor stocking compliance
Judicious wound care
Saphenous vein ablation versus iliac vein stenting in patients with chronic venous leg ulcers: determining the ideal procedure sequence
Other procedures
Iliac vein stenting and chronic venous ulcers
Sizing of stents
Stenting technique for routine cases
Technical success of procedure
Recanalization of chronic total venous occlusion
Management of iliac-caval confluence
Reinterventions in stented limbs
Factors affecting ISR and stent compression
Anticoagulation protocol
Thrombophilia and venous ulcers
Pentoxyfylline and venous ulcers
Stent surveillance in standard and recanalization cases
Stent occlusions after recanalization
Stent occlusion from ISR
Threshold stenosis for intervention
Dedicated self-expanding nonbraided nitinol venous stents
Special considerations and techniques
Hybrid approaches
Conclusions
Chapter 26. Venous valve reconstructions in patients with severe chronic venous insufficiency
Introduction
Deep venous reflux etiology
Hemodynamic and diagnostic evaluation
Indication for deep venous reflux correction
Surgical techniques
Transposition
Valve transplantation
Neovalve
Banding
Results
Conclusion
Section 5. Special considerations
Chapter 27. Treatment of recalcitrant venous ulcers with free tissue transfer for limb salvage
Introduction
Indications and preoperative planning
Flap selection
Surgical technique
Postoperative care
Discussion
Conclusion
Chapter 28. Management of venous ulcers in patients with congenital vascular malformations
Multidisciplinary approach
Classification
Diagnostic modalities
Treatment
Special consideration
Chapter 29. Lymphatic disorders in the pathogenesis of chronic venous insufficiency
Clinical staging of lymphedema
Clinical presentation
Diagnosis
Management of lymphedema
Index

Cynthia K. Shortell

Dr. Cynthia K. Shortell is a Professor of Surgery, Chief of Vascular and Endovascular Surgery, and Executive Vice Chair for the Department of Surgery at Duke University Medical Center. With Dr. John Bergan, Dr. Shortell was an editor for the 1st edition of Venous Ulcers book. For decades, Dr. Shortell has worked relentlessly to advance the management of patients with venous ulcers as well as in education and research. Dr. Shortell served as the Director of Duke University Vein Center, the Leader of Duke University Congenital Vascular Anomalies Team, the Medical Director of Duke University Vascular Non-Invasive Laboratory, Chair for Appointments, Tenure and Promotions Committee at Duke Medical Center, and Director of the Vascular Surgery Fellowship Program at Duke University School of Medicine. Nationally, Dr. Shortell holds distinguished recognition as Associate Editor of the Journal of Vascular Surgery and is an elected member of many national and international societies and organizations, including the Society for Vascular Surgery, the American Venous Forum, the American College of Phlebology, and the International Society of Surgery.

Affiliations and expertise

Duke University Medical Center Vascular Surgery, USA

Jovan N. Markovic

Dr. Jovan N. Markovic is a staff MD at Duke University Medical Center, where during his specialization in general surgery, he became extensively involved in advancing the care of patients affected by chronic venous insufficiency. Notably, Dr. Markovic was the first doctor (together with Dr. Shortell) to discover genes responsible for the pathogenesis and progression of chronic venous insufficiency by evaluating the entire human genome of patients affected by this highly prevalent and often significantly debilitating vascular disorder. Dr. Markovic currently serves as a reviewer for the Journal of Vascular Surgery and has authored numerous book chapters, peer-reviewed studies, and national and international guidelines on treating patients affected by vascular disorders. Dr. Markovic became a member of the American College of Phlebology when it was established in 2008. He is one of the authors of the Report of the Society for Vascular Surgery and the American Venous Forum on the Medicare Evidence Development and Coverage Advisory Committee panel on lower extremity chronic venous disease. He recently published a book as an Assistant Editor on congenital vascular malformations, a complex group of vascular disorders that can lead to venous ulcerations. In 2021, Dr. Markovic received “The Best New Reviewer” award for the Journal of Vascular Surgery: Venous and Lymphatic Disorders, indicative of his steadfast commitment to the principle of advancing the treatment of surgical patients.

Affiliations and expertise

Medical Doctor, Duke University Medical Center, USA

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Venous Ulcers

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Cynthia K. Shortell

Jovan N. Markovic