Venous Disease and Ulcers

Course #38630 - $20 • 5 Hours/Credits


Study Points

  1. Identify the different components of the venous system, and explain the pathophysiology of venous insufficiency.
  2. Discuss the epidemiology of venous disease.
  3. Outline the signs and symptoms of venous disease.
  4. Cite the various diagnostic tests used to identify and classify venous disease and ulcers.
  5. Evaluate the role of compression therapy and surgical interventions in treating venous disease and venous ulcers.
  6. Review the importance of patient education in preventing the reoccurrence of venous ulcers.

    1 . The middle layer of epithelial tissue in the veins is referred to as the
    A) tunica media.
    B) tunica intima.
    C) tunica externa.
    D) tunica intermedia.

    AN OVERVIEW OF LOWER EXTREMITY VENOUS ANATOMY

    Similar to the other vessels in the circulatory system, the vein walls are composed of three layers. The innermost layer of epithelial tissue is the tunica intima, the tunica media is the middle layer, and the outer layer is the tunica externa. The tunica externa is made up of collagen and elastic fibers and is the thickest layer of the vein walls [3].

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    2 . The common iliac veins are part of the
    A) superior vena cava.
    B) deep venous system.
    C) perforator vein system.
    D) superficial venous system.

    AN OVERVIEW OF LOWER EXTREMITY VENOUS ANATOMY

    Veins in the legs are divided into three major groups based on their relationship to the muscular fascia: deep veins, superficial veins, and perforator veins [5]. The deep venous system consists of the posterior and anterior veins and includes the common iliac veins, the femoral veins, and the popliteal veins [3]. These veins are located under the muscular fascia inside the muscle compartments of the leg, usually in close proximity to their companion arteries [5]. However, there is considerable variability in individual anatomy [6]. The deep veins are responsible for draining blood from the lower extremity muscles.

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    3 . Which of the following muscle pumps is responsible for the greatest pressures in the lower extremities?
    A) Toe muscle pump
    B) Calf muscle pump
    C) Foot muscle pump
    D) Thigh muscle pump

    AN OVERVIEW OF LOWER EXTREMITY VENOUS ANATOMY

    Among these three pumps, the calf pump is the most important and is responsible for the greatest pressures [6]. During ambulation, this pump is responsible for propelling 70% of the blood out of the calf [8]. When the calf muscle pump contracts, blood is pushed out of the veins and the resting pressure in the veins decreases. Because blood flows from areas of high pressure to areas of low pressure, this decrease in the pressure gradient in the deep venous system after contraction allows blood to flow from the superficial veins to the deep veins via the perforating veins [6]. As long as the valves of the venous system are functioning correctly, there is little retrograde blood flow [9].

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    4 . Chronic venous insufficiency is more common in which of the following racial groups?
    A) Black patients
    B) Asian patients
    C) White patients
    D) Hispanic patients

    EPIDEMIOLOGY OF VENOUS DISEASE

    There is some evidence that chronic venous insufficiency is more common in white individuals than in racial/ethnic minorities [16,17]. However, when present, venous disease in black patients is more likely to present at a more advanced stage at a younger age compared with white patients, resulting in increased ulcer debridement, deep vein thrombosis rates, and hospital charges [17].

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    5 . All of the following are risk factors for lower extremity venous disease, EXCEPT:
    A) Older age
    B) Underweight
    C) Multiple pregnancies
    D) Leg surgery or trauma

    ASSESSMENT AND DIAGNOSIS

    When taking a patient history, it is important to explore risk factors for lower extremity venous disease [9]. Some of the more common prevailing risk factors are [5]:

    • A history of deep vein thrombosis or leg ulcer(s)

    • A family history of venous disease

    • Multiple pregnancies, particularly in a short time span

    • Older age

    • Obesity

    • Leg surgery or trauma

    • Sedentary occupation and lack of exercise

    • Drug injections into the veins of the lower extremities

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    6 . Which of the following findings on physical examination is typical of advanced venous disease?
    A) Sudden unilateral edema
    B) Bilateral edema of the thighs
    C) Non-pitting edema that gradually lessens throughout the day
    D) Pitting edema around the ankle that worsens throughout the day

    ASSESSMENT AND DIAGNOSIS

    There are two forms of edema: pitting and non-pitting. Non-pitting edema presents as a swollen area that is hard to the touch. With pitting edema, pressure in the swollen area results in a persistent indentation. Pitting edema around the ankle that worsens through the day is a typical finding in advanced venous disease.

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    7 . What is often the first and most common skin change associated with venous disease?
    A) Venous ulcer
    B) Stasis dermatitis
    C) Atrophie blanche
    D) Hemosiderin staining

    ASSESSMENT AND DIAGNOSIS

    Stasis dermatitis, also known as venous dermatitis or venous eczema, is dry, scaling skin of the lower extremities [18]. The first presentation is a reddish-brown skin discoloration, typically of the medial ankle. As the disease progresses, eczematous changes may be present, with weeping patches and plaques. Stasis dermatitis is often the first and most common skin change associated with venous disease. It is extremely pruritic (with insidious onset), which is a source of significant discomfort for patients.

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    8 . Lipodermatosclerosis presents as
    A) atrophic areas of white or pale skin.
    B) an open wound on the lower extremities.
    C) brownish or grayish discoloration of the skin.
    D) hard, waxy, hyperpigmented tissue with swelling of the surrounding areas.

    ASSESSMENT AND DIAGNOSIS

    Lipodermatosclerosis is an inflammation and hardening of the subcutaneous fat and dermal tissue found in longstanding venous insufficiency. It is caused by protein accumulation in the tissues, most noticeably in the "gaiter area" of the leg (between the knee and ankle) [18]. Lipodermatosclerosis presents as hard, waxy, hyperpigmented tissue with swelling of the surrounding areas. This has given rise to the description of a "bottle leg" formation [18].

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    9 . Which of the following statements regarding assessment of the pulses and temperature of the lower extremities in patients with suspected venous disease is TRUE?
    A) The pedal pulses are more likely to be palpated in older patients.
    B) Individuals with venous disease have lower skin temperatures around the ankle than the general population.
    C) A sudden elevation in ankle or leg temperature more than 4 degrees Fahrenheit may be indicative of a developing leg ulcer.
    D) All of the above

    ASSESSMENT AND DIAGNOSIS

    During the physical examination, the femoral and pedal pulses should be assessed. The pedal pulses include the dorsalis pedal pulses, located between the first (great) toe and the second toe on the dorsum of the foot, and the posterior tibial pulse, located behind the medial malleolus. In younger patients, it may be possible to palpate these pulses; however, in older patients, use of a handheld Doppler is often necessary to detect a pulse beat [22].

    It has been documented that individuals with venous disease and those who progress to venous ulceration have higher skin temperatures around the ankle than the general population [5]. A sudden elevation in temperature more than 4 degrees Fahrenheit may be indicative of a developing leg ulcer [5].

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    10 . What is the most reliable noninvasive test for diagnosing venous insufficiency?
    A) Duplex ultrasound
    B) Air plethysmography
    C) Photoplethysmography
    D) Magnetic resonance venography

    ASSESSMENT AND DIAGNOSIS

    Venous ultrasound is an important tool to determine the source of venous insufficiency [18]. A duplex ultrasound is used to locate malfunctioning perforator veins that may exist between the superficial and deep veins [10]. The American College of Phlebology has also recommended assessment of the patency and competency of the common and popliteal veins [25]. Duplex ultrasound is regarded as the most reliable noninvasive test for diagnosing venous insufficiency [5].

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    11 . An ankle-brachial index (ABI) value of 0.9 indicates
    A) severe arterial disease.
    B) primarily venous disease.
    C) probable thromboembolism.
    D) mixed venous and arterial pathology.

    ASSESSMENT AND DIAGNOSIS

    All patients with venous insufficiency should have ankle-brachial index (ABI) studies done regularly, usually every three months [5]. The ABI is a noninvasive, indirect measurement of arterial blood flow to the lower extremities. Approximately 26% of those with venous problems also have arterial insufficiency, and the ABI value will help determine if the diagnosis is severe arterial disease, mixed arterial and venous pathology, or primarily venous disease [26,27]. An ABI value greater than 0.8 indicates primarily venous disease, while a value of 0.5–0.8 suggests a mixed etiology [24]. An ABI value less than 0.5 points to severe arterial disease, and compression therapy is not recommended for these patients [5].

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    12 . The most accurate ABI results are obtained from patients
    A) flexing their legs.
    B) who are ambulatory.
    C) in a standing position.
    D) who are relaxed in a supine position.

    ASSESSMENT AND DIAGNOSIS

    ABI testing is done by comparing the systolic blood pressures in the ankle to the systolic brachial blood pressures [28]. When obtaining an ABI reading, start by explaining the procedure to the patient and allowing him or her to rest in the supine position. The most accurate results are obtained when the patient is relaxed in a comfortable position with an empty bladder [26]. After about 15 minutes, take brachial blood pressure readings in both arms; the higher of the systolic pressure readings will be used to calculate the ABI value.

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    13 . According to the CEAP classification system, C2 is assigned to patients with
    A) varicose veins.
    B) telangiectasias.
    C) lipodermatosclerosis.
    D) a healed venous ulcer.

    ASSESSMENT AND DIAGNOSIS

    CEAP CLASSIFICATION FOR VENOUS DISEASE

    Clinical
    C0No visible or palpable signs of venous disease
    C1Telangiectasias or reticular veins
    C2Varicose veins
    C3Edema
    C4aPigmentation and eczema
    C4bLipodermatosclerosis and atrophie blanche
    C5Healed venous ulcer
    C6Active venous ulcer
    SSymptoms including ache, pain, tightness, skin irritation, heaviness, muscle cramps, and/or other complaints attributable to venous dysfunction
    AAsymptomatic
    Etiology
    EcCongenital
    EpPrimary
    EsSecondary (post-thrombotic)
    Anatomy
    AsSuperficial veins
    ApPerforator veins
    AdDeep veins
    Pathophysiology
    PrReflux
    PoObstruction
    Pr,oReflux and obstruction
    PnNo venous pathophysiology identifiable
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    14 . Venous ulcers normally develop in all of the following locations, EXCEPT:
    A) Above the knee
    B) Over a perforating vein
    C) On the medial malleolus
    D) Along the route of the great saphenous vein

    ASSESSMENT AND DIAGNOSIS

    Venous ulcers normally develop on the medial malleolus, ankle, or posterior calf; over a perforating vein; or along the route of the great or small saphenous veins. They do not occur above the knee or in the area of the forefoot [20,22]. In appearance, the ulcers are usually irregular and shallow, with granulation tissue and fibrin evident in the wound bed [11].

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    15 . If a venous ulcer has not yet developed, a primary goal of treatment of chronic venous insufficiency is to
    A) prevent ulceration.
    B) promote venous stasis.
    C) increase venous pressure.
    D) decrease arterial pressure.

    TREATMENT

    If a venous ulcer has not yet developed, the primary goal of treatment of chronic venous insufficiency is to reduce venous hypertension and prevent ulceration. The plan of care for these patients will include weight management, compression therapy, leg elevation, setting realistic goals to become more physically active, and patient education. If an ulcer is present, the goal is to achieve complete healing and prevent ulcer reoccurrence.

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    16 . The compression provided by an Unna boot is
    A) inelastic.
    B) adapted to changes in the patient's leg size.
    C) low when walking but high when the patient is resting.
    D) more effective for non-ambulatory patients than multilayer compression bandages.

    TREATMENT

    The Unna boot provides inelastic compression, meaning that the pressure gradient is high while the patient is walking but low (or lacking) when the patient is resting. As such, multilayer compression bandages may supply more effective compression for non-ambulatory patients than the Unna boot. The Unna boot also does not adapt to changes in the patient's leg size, which can lead to complaints of pain and discomfort [11].

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    17 . The most appropriate level of compression for venous ulcer wound healing is
    A) less than 10 mm Hg.
    B) 8–18 mm Hg.
    C) 20–30 mm Hg.
    D) 35–40 mm Hg.

    TREATMENT

    The degree of compression therapy can be categorized as light, moderate, or high [5]. Light compression applies 20–30 mm Hg of pressure to the ankle area and is recommended for patients with venous insufficiency who are unable to tolerate higher levels of compression. Approximately 35–40 mm Hg of compression (moderate) is regarded as the most appropriate level for venous ulcer wound healing. A high level of compression is obtained with a pressure gradient of 40–50 mm Hg. As noted, there is strong evidence that approaches that achieve higher levels of compression (i.e., 35 mm Hg or greater), including multilayer elastic systems, achieve the best healing outcomes [9].

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    18 . What is the major drawback of compression stockings?
    A) Patients may find them difficult to don.
    B) They must be replaced every three weeks.
    C) They are only available from specialty stores.
    D) They cannot be worn with the patient's normal footwear.

    TREATMENT

    Compression stockings are available in most large stores or pharmacies or mail ordered from several companies and can be worn with the patient's normal footwear. Patients and caretakers should be advised to buy at least two pairs of stockings to facilitate washing and drying. Manufacturer instructions should be followed for washing, but in most instances, hand-washing and air-drying are preferred. Lower levels of compression are better than no compression at all or stockings that are "left in the drawer" [9]. However, patients should be informed that nonmedical support hosiery and anti-embolism stockings (with a pressure gradient of 8–18 mm Hg) are not suitable for compression therapy and were not made for this purpose [5].

    The major drawback is that people may find it difficult to don the stockings independently, especially if they have arthritis or neurologic deficits. There are stockings available with a side zipper that makes them easier to apply and remove, although they may be more expensive. It is also possible to purchase an inner silk lining sleeve to facilitate sliding the compression stocking on and off. Several brands of compression stockings also come with a wide band at the top, which provides a better grip [10]. Some people find that wearing rubber gloves helps to get the stockings on easily, but others do not find this helpful.

    Compression stockings have been described as "operator dependent," meaning they must be worn to be effective [10]. It should be emphasized to patients and caregivers that compression therapy is a lifetime commitment. Many patients may mistakenly believe that the stockings are only worn until swelling is abated, but all at-risk patients should continue to use them.

    Patients and their families should also be educated about the correct use of compression. Compression stockings should be put on first thing in the morning, before the patient gets out of bed; patients should not wait until swelling is noticed to apply the stockings. It is not advisable to apply moisturizing lotion to the legs just before putting on the stockings, as this makes the skin sticky and can make it more difficult to get the stockings on [10].

    Compression stockings should be replaced about every six months to maintain maximal level of compression. It is important to note that Medicare and most private insurances will only cover the cost of compression stockings if a venous ulcer is present; there is no reimbursement for compression therapy to prevent the reoccurrence of venous ulcers.

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    19 . Bioengineered therapy in conjunction with compression therapy is an option for the treatment of
    A) edema of the lower extremities.
    B) mild chronic venous insufficiency.
    C) venous ulcers with closed wound edges.
    D) venous ulcers that have not healed after 30 days.

    TREATMENT

    Bioengineered therapy in conjunction with compression therapy is an option for the treatment of venous ulcers that have not healed after 30 days [30]. Single-layered and bilayered bioengineered skin cellular substitutes do not provide a graft covering to the wound, but rather donate multiple growth factors to the wound bed to stimulate healing [24]. The Wound Healing Society states that bilayered artificial skin in conjunction with compression therapy is better than compression and a simple dressing [41].

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    20 . Patient education for individuals with venous disease and/or ulcers should include
    A) concrete suggestions for physical activity.
    B) an honest discussion of what treatment will entail.
    C) instruction on how to assess the wound during dressing changes at home.
    D) All of the above

    PATIENT AND FAMILY EDUCATION

    Patients with venous ulcers and their caregivers should be taught how to assess the wound with each dressing change done in the home. This should include the signs of wound infection, such as changes in the amount of wound drainage, odor, and the color of the wound bed (e.g., changing from a bright red to a dark ruddy color). Changes in the periwound area, including alterations in appearance, swelling, tenderness, and pain level, are also important to note. The occurrence of any of these symptoms should prompt the patient and/or caregiver to contact his or her physician immediately.

    An honest discussion should be held with the patient and significant others about what treatment is going to entail, including the necessity for weekly visits to the wound clinic for debridement and dressings changes. If a patient has difficulty keeping appointments, treatment will not be successful and healing may not be achieved.

    It is vital to listen carefully to patients' concerns about treatment. Patients may be worried about missing work, transportation to appointments, wound care at home, and/or the cost of supplies. All members of the team caring for the patient should be aware of the concerns and support the patient to explore solutions. The input of the team social worker and/or case manager is particularly important at this time.

    Many individuals with venous disease do not have sufficient knowledge to manage their condition successfully in the long term. The focus should be extended beyond wound healing and to making changes to maintain a healthy lifestyle. If a patient smokes, the benefits of smoking cessation for wound healing should be discussed. Weight management, safe exercise (e.g., walking), and prevention of trauma to the lower extremities should be explored with the patient/family. Concrete suggestions are better than general recommendations. For example, a patient may be instructed to take a brisk walk every day, not to cross his/her legs, and not to stand for more than 30 minutes at a time.

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