Venous Leg Ulcer Update

Tissue Viability Team

Feb 2018

What is a Venous Leg

Ulcer?

A Venous Leg Ulcer is defined as an open lesion between the knee and ankle joint that occurs in the presence of venous disease and takes more than 2 weeks to heal

NICE, 2013

Prevalence of Venous

Leg Ulceration 1.5 %of the Adult population have a Venous Leg Ulcer

At least 730,000 patients with Venous Leg Ulceration in the UK

1 in 170 Adults has a Venous Leg Ulcer

Guest et al, 2015

Those at risk of Venous

Leg Ulceration

Obesity or being over weight

This increases pressures known as hydrostatic pressures in the lower limbs

and abdomen

Reduced Mobility

This compromises venous return due to reduction in calf muscle pump usage

Previous history of DVT

Valves in the veins maybe damaged affecting venous return

Varicose veins

Malfunctioning valves cause swollen and enlarged veins

Previous limb injury or surgery

Such as bone fractures or flap surgery which may cause damage to the veins,

lymphatic's, mobility and gait

History of Intra venous drug

use

This increases the risk of DVT and vein damage

NHS, 2016

Increasing Age

This increases the risk of reduce mobility and conditions such as

arthritis which may restrict mobility

Chronic Oedema

Compromises skin and tissue condition

Family History

Maybe predisposed to varicose

veins increasing the risk malfunctioning valves

Why Venous Leg Ulcers

happen

Failure of the calf pump and the valves in the superficial veins which affect the

one way return uphill.

Reflux occurs downhill obstructing the veins

Results in pooling of blood in the lower part of the leg

Increased pressure causes fibrin deposits around the capillaries which inhibits

O2 and nutrients to the tissue

Signs of Venous Disease

Atrophie Blanche Oedema

Hemosiderin Staining

Ankle Flare Varicose Eczema

Varicose Veins

Hyperkeratosis

Cellulitis

Appearance of Venous Leg

Ulcer

Usually appear around the malleolus & gaiter region

Irregular in Shape

In the presence of the signs of Venous disease we have discussed

Shallow in appearance

Myths

A wound must be present on the

limb for at least 6 weeks to be

classed as a VLU and therefore treated with compression

A wound after 2 weeks should be

considered for compression

therapy

ABPI assessment confirms the presence of a

VLU

ABPI is not diagnostic

although it is a fundamental

component of assessment

If a wound is healing the

surrounding skin does not require

management

Surrounding skin should be protected

appropriately, with the safe removal of

hyperkeratosis and application of

emollient

Superabsorbent dressings should not be used under compression and should be applied

over if required

Superabsorbent dressings can be used as long as they manage the

exudate effectively, are not bulky and

protect the surrounding skin

Wounds UK, 2017

Quick refresher

Where are Venous Leg Ulcers usually located ?

What is the prevalence of Venous Leg Ulcers ?

What are the risk factors resulting in Venous Leg Ulceration?

Name some other causes of Leg Ulceration

What happens within the veins ?

What are the signs of Venous Disease?

Is completing ABPI a diagnostic tool ?

Cellulitis Venous Disease

May have pyrexia No pyrexia

Location - Anywhere Location – often lower third of limbs

Painful May be painful but pain often not acute

Inflamed erythema to specific location Discoloration around gaiter region

Bright red in colour Red/Brown, hyperpigmentation which may appear

inflamed when acute

Clearly defined edges No sharp defined edges

Tender to the touch Minimal tenderness

Warmth to skin Minimal/no warmth to skin

Cellulitis V’s Venous disease

Cellulitis Venous Disease

Skin can resemble orange peel Skin may have wooden appearance

No crusting Crusting can be evident

Oedema present to the surrounding

skin

General lower limb oedema

CRP, WCC may be raised No change to CRP or WCC

Unilateral Can be Unilateral but commonly

bilateral

Rapid onset Develops over weeks/ months

Primary Dressing Choice

Simple non-adherent dressings are recommended with the use of non-bulky absorbent layer if required for

exudate management

Silver dressings are not recommended in the routine treatment of patients with

venous leg ulcers when required to reduce local antimicrobial load apply

and reassess on a two weekly basis. If at re assessment there is no improvement or deterioration consider a different anti

microbial dressing

Myths

Hosiery kits are only for self caring patients

Hosiery kits can be applied by the patient, carer and health care

professionals

The compression system used determines the frequency of

changes required

This should depend on patient and presentation and not what

system is use

Compression should not be applied to the foot

Moderate to high compression must be applied at the foot to

prevent foot oedema

Venous leg ulcer are not painful

64% of patients with VLU’s report suffering with severe pain

Sterile water is required to wash VLU’s

VLU’s should be washed in a lined bucket or shower and are

not a sterile wound

Wounds UK, 2017

Doppler studies Explain the procedure to the patient

Lay the patient in the supine position for 15 minutes

Measure the Brachial systolic pressure, placing a cuff around the arm and applying gel to the brachial pulse. Gently

inflate the cuff whilst holding the Doppler probe over the pulse, once the signal is no longer heard deflate the cuff

slowly taking note of the pressure at which the pulse sound returns.

Repeat in for both arms

Do not be alarmed that arms may vary and use the highest value to calculate your ABPI

Next measure the ankle systolic pressure

Protect ulceration using appropriate covering (i.e. sterile bag from dressing pack)

Place appropriate sized cuff with the cables facing up the limb to avoid contact with the wounds and interruption

with the procedure above the malleoli

Locate Pulses using gel and probe, describing the sound, rhythm and strength

Monophasic (one sound)

Biphasic (Two sounds)

Triphasic (Three sounds)

Inflate the cuff as per brachial pressure listening for the signal returning. Complete this for 3 different pulses again

using the highest value to calculate your ABPI

Repeat on both limbs (limbs can vary)

Identifying Sounds

Mono-Phasic

(Compromised)

D-D-D-D DD-DD-DD DDD-DDD-DDD

Tri-Phasic

(Healthy)

Bi-Phasic

(Aging)

Interpreting Doppler

Studies

Calculate the ABPI

Highest Ankle Pressure (per Limb) ÷ Highest Brachial Pressure (Both Limbs) = ABPI

ABPI 0.5 and below – Potential critical ischemia, refer to vascular surgeons DO NOT COMPRESS.

ABPI 0.5 - 0.8 - Significant arterial disease, Refer to TVN.

ABPI 0.8 - 1.0 - Minor arterial disease, consider 20-40mmHg compression with holistic assessment.

ABPI 1.0 - 1.3 – Normal arterial flow, consider 40mmHg compression with holistic assessment.

Above 1.3 – Calcification may mean vessel cannot be compressed, Refer to TVN.

Evidence from Guest et al (2015)

• It appears that only 16% of patients with a leg or foot ulcer had a Doppler. However, national guidance in the UK for both leg ulcer management and the management of diabetic foot ulceration requires arterial assessment by Doppler ultrasound measurement of the ankle-brachial pressure index.

Choosing Compression

Therapy 40mmHg High compression multicomponent compression should be routinely used for the treatment of venous leg

ulcers.

Consider patient concordance when choosing the right compression

Check all patients 24-48 hours following the commencement of any compression

Compression should only be applied by staff with appropriate training in the specific component they are applying

LEG ULCER ALGORITHM – Adapted from the Best Practice Statement 2016.

[Type

Holistic Patient Assessment

including:

Past Medical History

Limb Assessment

Ulcer history

Consider other causes and refer

to appropriate specialist:

Dermatology

Malignancy

Pressure

Autoimmune

Arterial

Diabetes

ABPI less than 0.5

Urgent Referral to

vascular centre, NO

compression.

ABPI 0.5-0.8

Mixed disease, refer to

vascular/ Tissue

Viability team, reduced

compression

(20mmHg) following

specialist advice

PERFORM

ABPI

ABPI 0.8-1.3 No

evidence of significant

arterial disease, safe to

compress

ABPI over 1.3

Consider calcification. Assess

foot pulses, Doppler waveflow.

Consider referral to vascular.

Consider 20mmHG

compression.

Is the exudate

controlled within

topical dressing?

Consider why exudate is not

controlled with topical

dressings, is there any

evidence of infection or

increased bacterial load, is the

dressing size / choice

appropriate for exudate

amount?

If oedema present

apply:

ACTICO

Compression as

per instructions.

If no oedema

present apply:

ACTICO 2C

Or K-TWO

bandage systems

as per instructions

Once VLU is healed, refer to

Recommendations in Best Practice

Statement: Compression Hosiery (2nd

edition) Wounds UK.2015). Consider

referral to vascular services to assess

need for venous intervention to reduce

the risk of recurrence as per NICE

guidelines CG168 (2013)

Is there a large amount

of reducible oedema /

limb distortion?

Apply ACTICO

Compression

system

When oedema and

limb distortion

controlled, change to

European

classification hosiery

40mmHG kit

Compression

Hosiery kit

40mmHG

After 4 weeks of

treatment, if there is no

reduction in ulcer size

refer to vascular/ Tissue

Viability service for

review

Yes

No

Yes

No

Or

Reassess

Weekly

Any Questions?