Vein disease not easily repaired

Conway McLEAN, DPM

The care of chronic wounds is a favorite component of my profession. These can be an extremely challenging condition, developing due to a variety of problems, with different treatments required. Non-healing sores often have multiple causes, making the best care unclear. Still, I appreciate the challenge of determining how best to treat this common disorder.

Make no mistake about it, chronic wounds are a significant health problem, and affect an increasingly large number of people. In the U.S., for example, chronic wounds are reported to affect 6.5 million patients with more than $25 billion each year spent by the healthcare system on treating wound-related complications.

Diabetes is a disease that is becoming more common, and many of those so afflicted will develop chronic wounds, with studies revealing approximately 25 percent of diabetics experiencing an ulcer at some time in their life.

Unfortunately, chronic wounds are an underappreciated health problem. Often, they will be disguised as a secondary condition, and associated with some other disease like diabetes, arterial disease, or heart disease. Chronic wounds represent a silent epidemic that affects a large fraction of the world population. It is estimated that 1 to 2 percent of the population will experience a chronic wound during their lifetime (in developed countries).

What exactly is a chronic wound? It is defined as one that has failed to proceed through an orderly and timely reparative process, to produce an intact, functional skin layer, within a period of 3 months.

The reasons for a delay or interruption of the healing process can vary tremendously, often with multiple factors contributing. Statistically, the most common type of chronic wound in our culture is due to vein problems in the lower leg. Yet chronic venous disease is often overlooked by primary care and cardiovascular care providers, who underestimate its magnitude and impact. Chronic venous insufficiency is the general term used to describe this problem, whereby the veins in the legs are incapable of properly transporting blood upward, from the feet and legs.

This, in turn causes an increase in pressure in the venous system of the legs, leading to various pathologies that involve pain, swelling, and various skin changes, including thickening, irregularities in the surface, and discoloration.

Without altering the process in some way, venous disease will often result in small holes in the skin, with leaking of fluid. Eventually, large, ugly sores develop which can come to cover large areas of the lower leg. These are termed venous stasis ulcers. An estimated 1 percent of the U.S. population suffers from venous stasis ulcers, making it one of the most common types. These changes are due to a gradual poisoning of the skin of the lower leg, in which a component of blood is being deposited in the skin. This substance, hemosiderin, performs a critical function when part of the blood, where it is supposed to be. When it builds up in the skin, this substance has a variety of deleterious effects.

Untreated venous insufficiency results not only in a gradual loss of the normal cosmetic appearance, but also in a variety of complications, the major ones being persistent pain and discomfort, bleeding, superficial inflammation of blood vessels, and progressive skin changes that ultimately lead to ulceration. Because the root of the problem is one that generally has existed for years, the treatment program can be lengthy and difficult.

But who develops venous disease? The root cause is multifactorial. Occupations involving working long periods of time standing may produce a chronic enlargement of the veins, with incompetence of the valves developing over the time. It is these valves, found inside the deeper veins, which function to keep blood from flowing backwards, as gravity would tend to force it.

In women, vein walls and valves are affected by cyclical changes in hormone levels. These changes are worsened during pregnancy when the return of blood to the heart is restricted by the growing fetus. Advancing age also plays a part, with degenerative changes of the smooth muscle in the vein wall resulting in a greater susceptibility to enlargement of the vein. As with many problems, there also seems to be a hereditary component.

Treatment for this type of ulcer usually is based on the need to aid in the return of blood out of the legs, up into the largest veins, traveling towards the heart. This is best achieved with compression therapy, of which there are many forms.

Most individuals suffering from recognized venous disease, where treatment has been prescribed, are familiar with compression stockings. Many have had these garments prescribed, yet few use them consistently. Although available for many years, they can be extremely difficult to put on, and tend to be very uncomfortable when worn.

Some of the standard options for care of chronic wounds remain appropriate, including local wound care and debridement, dressings, antibiotics when infection is present, adjunctive therapies, and even surgery when it is an option. Health care providers need to be able to recognize the early manifestations of venous disease, and then choose specific treatments based on the severity of the disease, and some of the many other considerations. Wound care clinicians should be able to individualize therapy as appropriate to manage signs and symptoms of chronic venous insufficiency.

Recently, a new compression system was developed to address the compromised small vein disease which is the hallmark of venous insufficiency. Pneumatic Medicine is the term used to describe this technique. Simply defined, this is the use of external compression, via an electric air pump system, which can help to recreate the body’s own natural pumping system.

This concept, the use of an electrical pumping device, has been available for years, but the newest systems are far superior to those previously available. It can be used to treat a wide array of peripheral vascular diseases including venous insufficiency, lymphedema and chronic wounds. It is considered an important adjunct to other treatment options, including surgery, compression stockings and medications.

Whatever methods of treatment are used, it is an unfortunate hallmark of this disease that no real cure exists. Once vein disease has developed, it is a life-long condition. The consequences of CVI, specifically the skin changes, can be resolved (due to skin’s healing abilities, and its rapid rate of cell turnover), if an effective treatment regimen is instituted, and consistently utilized. But the success rate of valve repair surgery is not good, and many are forced to utilize compressive therapies on a permanent basis.

As a wound care specialist, I sometimes struggle to heal patient’s wounds that have stubbornly persisted for months, sometimes even years. The patient may have seen little real improvement, and at times the wounds may have actually worsened, despite the intervention of various healthcare practitioners and the time-consuming treatments utilized. I admit to great satisfaction when I have played a part in the healing of a patient’s longstanding wound, where multiple physicians may have attempted treatment. This is trivial, of course, when compared to their improved quality of life. If you know someone suffering from a wound that isn’t healing, recommend immediate care. The longer a wound goes untreated, the more likely it will become a chronic, non-healing wound. These can alter, perhaps forever, that person’s life, and thus, their quality of life.

Editor’s note: Dr. Conway McLean is a podiatric physician now practicing foot and ankle medicine in the Upper Peninsula, having assumed the practice of Dr. Ken Tabor. McLean has lectured internationally on surgery and wound care, and is board certified in both, with a sub-specialty in foot orthotic therapy. Dr. McLean welcomes questions, comments and suggestions at drcmclean@penmed.com.