Standard, Appropriate, and Advanced Care and Medical-Legal Considerations: Part Two -- Venous Ulcerations

William J. Ennis, DO, MBA, FACOS, Patricio Meneses, PhD


Wounds. 2003;15(4) 

In This Article

Diagnosis and Classification

An initial classification system was developed by a subcommittee of the Society for Vascular Surgery (SVS) and the International Society of Cardiovascular Surgery (ISCVS) in 1988.[71] Because of the tremendous increase in diagnostic testing options and a broader understanding of venous disorders, a consensus statement was released by the American Venous Forum in 1994. The new classification system grouped venous patients into four categories known as CEAP (clinical, etiology, anatomic, pathophysiological).[72,73] Although the system is somewhat cumbersome, it is thorough and allows for a uniform language to help compare research findings and communicate with other clinicians on venous diseases issues. As clinical procedures continue to develop (i.e., subfascial endoscopic perforator surgery), the system will undergo modifications but appears to be clinically sound and an accepted standard.[74]

Any patient who presents with a leg ulcer needs to undergo a complete history and physical examination as the differential diagnosis is long and complex. Wound duration, location, factors that ameliorate/exacerbate, prior treatments, pain, drainage, and the condition of the surrounding skin should all be reviewed. A complete examination of the extremity should include checking pulses and assessing for secondary signs of venous insufficiency (hemosiderin deposits, eczematous dermatitis, atrophie blanche, lipodermatosclerosis, varicose veins, and edema).[75,76] Wound biopsy is an often neglected step in the standard workup of a venous ulcer patient. Biopsy should be considered as part of the workup if the wounds are greater than six months to one year in duration, have irregular appearances, or when concerns exist for underlying inflammatory conditions or carcinoma. Frequently, a patient who was treated with a provisional diagnosis of venous disease turns out to have another condition (e.g., lymphoma and rheumatoid arthritis).[77] The classic appearance of a venous ulcer involves a medial-leg, irregularly shaped, partial-thickness ulcer with well-defined borders surrounded by erythematous or hyperpigmented skin.[10] Telangiectatic veins are often present along the medial ankle known as a "corona phlebectatica." Arterial disease, which can exist in up to 30 percent of cases, must be ruled out. This can be done easily in the office by performing an ankle-brachial index.[21] In the absence of arterial insufficiency and a normal sensory exam, venous disease is confirmed in the majority of cases with a typical appearing ulcer. The addition of a disability score to the CEAP classification scheme is important in clinical practice, as many patients have work-related problems with venous disease.[78] Standard of care focuses on ruling out arterial disease. The proposed investigations focus on the macrocirculation. Patients with advanced lipodermatosclerosis have tissue oxygen deficits despite their normal macrovascular flow. Appropriate care would include assessment of the microcirculation in addition to standard testing (e.g., ankle/brachial index [ABI]).

The American Venous Forum recommendations begin with a complete history and physical to obtain the clinical and etiological components of the classification scheme. A tourniquet test demonstrating less than a 20-second refill time is a simple bedside test to confirm venous incompetence.[21] The use of a continuous wave Doppler can also be a useful screen. The lack of increased flow with augmentation or the presence of increased flow with compression can indicate obstruction or reflux respectively. Once the clinical and etiological components have been completed with the history and physical exam and a working diagnosis has been agreed upon, advanced testing options are selected. The anatomic and pathophysiologic components of the classification will be made with these advanced tests.

The duplex scan has been shown to provide the most useful information and is considered by many to be the test of choice.[79] This noninvasive, ultrasound-based test allows for the assessment of all three venous systems and provides anatomic extent and location of the disease. Duplex scanning also allows for the differentiation between obstruction and reflux. Other anatomic studies include ascending and descending venography, which are not utilized as frequently as they were in the past. A new tool, radionuclide venography, has been touted to detect incompetent perforating veins.[80] Other examinations include photoplethysmography and strain-gauge plethysmography.[79] A significant amount of work has been published on air plethysmography.[81,82] Physiological parameters, such as venous volume, ejected volume, and post-exercise residual volume, can be calculated using this device. Several measured parameters can be combined in useful ratio analyses, which correlate with the clinical severity of the venous disease.[83] The American Venous Forum attempted to review the literature for clinicians to help them organize their approach to the diagnosis and classification of venous disease.[84] Standard of care neglects the anatomical and pathophysiological components of the classification for venous disease. Many papers compare treatment techniques without classifying the underlying venous disease. Compression therapy may be inadequate if a patient has a large, incompetent perforator vein feeding the base of the ulcer. Compression therapy may also be inappropriate as sole therapy for recurrent ulcers. Appropriate care dictates that venous hemodynamics be completely analyzed in order to prescribe appropriate treatment plans.