A Closer Look at Venous Insufficiency and Venous Leg Ulcers

Welcome back to Podiatry Today Podcasts, where we bring you the latest in foot and ankle medicine and surgery from leaders in the field. Today's episode is another edition of our wound care Q&A. This time with our guest, Dr. Alison Garten. Dr. Garten is a board certified podiatric surgeon, certified wound care physician and certified podiatrist. In addition to her wound care experience, she is an accomplished speaker on multiple limb salvage and wound management topics. She's a past president of the American Association for Women Podiatrists and is a member of the American Podiatric Medical Task Force for the National Board of Podiatric Medical Examiners. Thank you so much for being with us today, Dr. Garten, to discuss venous leg ulcerations. In your experience, what clinical findings are key when deciding on a management path for patients with venous leg ulcers?

Alison Garten, DPM: So venous leg ulcers can be a really tricky and difficult thing to treat. There's a few things that kind of come to mind when I think about clinical findings. Number one is when a patient comes into your office to the wound care center, no matter what type of environment you're seeing a patient who has a venous leg ulcer, the first thing and most important thing to do in my eyes, obviously we need to look at the overall patient's medical history, but we need to figure out does a patient have any type of arterial disease and really understand the level of their venous insufficiency.

So number one, I always get some basic noninvasive vascular arterial and venous studies. From that point on, I can then proceed with what the correct treatment plan is for that patient. So when you see the hemosiderin deposits and the anterior tibial area and the medial lower extremity, a lot of these patients have a lot of pain, a lot of discomfort, and typically these wounds drain a lot. So it's important to first identify is venous insufficiency the primary cause of this ulceration developing or failing to progress.

Jennifer Spector, DPM: So how do you advise patients? On that note, you mentioned about the hemosiderin deposits that we see in so many of these patients. How do you advise patients on the origin of that finding and what they can expect down the line with that?

Alison Garten, DPM: So yeah, a lot of patients come in, Dr. Spector, asking what is this discoloration of my legs? They might have a leg ulcer there, but they're focused on the discoloration and will this discoloration go away? So I really try to explain to them what venous insufficiency is and why you were prone to venous insufficiency. And as we all know, as we get older we're all more prone to it, especially women if they've had a child and just depending on what your occupation is. So making sure they're truly educated on what venous insufficiency is and how those hemosiderin deposits play a role and how that discoloration is likely not going to change. It might improve slightly with the use of compression, but it's not going to go away. So it is something that I try to spend a lot of time on with patients because that usually is one of their main focus is what is this discoloration and what can I do about it?

Jennifer Spector, DPM: It really is. It's interesting that you mentioned they come in with a venous leg ulcer and they're more concerned about the hemosiderin deposits and the staining than they are about the ulceration itself. So certainly education seems to be key for these patients.

Alison Garten, DPM: It's really interesting. You would think a patient comes in with a wound that would be their focus. But a lot of these patients that come in, they've had these wounds for months and months and months and have seen a lot of different clinicians. And so I try to redirect them really what should be the primary focus. The primary focus should be how can we heal your wound? Because these patients still have a high risk of infection, they have a high risk of limb loss and it's important they really buy into their treatment. We might be seeing the patients maybe once a week, every other week, every few weeks, but they need to understand it's going to take all the efforts, what we do as the doctor and everything they do in order to get these wounds healed.

Jennifer Spector, DPM: So do you think that's one of the biggest challenges is possibly managing expectations and encouraging true understanding of the pathology? Do you think that that's one of the biggest hurdles that clinicians might face?

Alison Garten, DPM: A lot of these patients have just become complacent with their treatment. They've had it for so long, they don't expect and they don't think the wound will ever heal. So kind of [inaudible 00:04:45] them that these wounds can heal, but getting them to buy into the treatments. And so I do feel like a big challenge, venous insufficiency, we really have to make sure these patients are elevating their legs. That is probably one of the biggest challenges, they need to elevate their legs. Yes, we can focus on compression, but some of these patients are compromised from an arterial standpoint that we can only use a very light compression.

So I would definitely say elevating of the legs, proper management with the amount of compression we can use and the patient tolerating compression. Even though compression theoretically should help the discomfort, should help progress the wounds, a lot of these patients cannot stand anything tight on their legs at all. So it's a constant balance. And again, back to the education piece, if they can understand why they need it, why they need to elevate their legs, why we need to use these compression sleeves or the compression wraps on them, then I feel like these patients then will continue with the treatments. They feel like they've been a part of the treatment plan and they tend to progress faster to healing.

Jennifer Spector, DPM: That's such a good point about the tolerance of the compression and we know that compression is such an important aspect of treatment. Are there any modalities or interventions Dr. Garten, that you find particularly helpful in treating VLUs?

Alison Garten, DPM: I typically, Dr. Spector have a very systematic approach to venous leg ulcerations. Number one is yes, like I mentioned, we need to look at the overall, what is their past medical history? Making sure we're getting either a vascular surgeon or an interventional radiologist involved early and getting these noninvasive vascular studies to determine what level of venous insufficiency they have. So from that point on, then I know where to go. If they have a normal arterial supply, I know I can compress the patient, but it's important to get the vascular specialist on board on day one because even though they have at that point documented venous insufficiency, it can take months for insurance to approve these treatment plans, these venous ablation procedures, these sclerotherapy injections, it can take months. So get these patients early on day one.

And during that time, yes we use the compression sleeves, the compression wraps, which are vital. But other ways to really cut down on the amount of edema is I do tend to use a lot of lymphedema pumps. Most of these patients who have chronic venous insufficiency also have a level of lymphedema and I've had very good results with using compression therapy along with lymphedema pumps. Another modality that's been very helpful, which I recently started to implement, I only use it a little bit in my last practice when I was in Washington DC, but I've begin to really refer to the lymphedema clinic and that bridging of different types of compression wraps, because a lymphedema wrap is going to be much different than a venous insufficiency wrap. And considering most these patients have both medical conditions, it's important to make sure you're utilizing your local lymphedema clinician. Now unfortunately there's not a lot clinicians, lymphedema clinicians out there, so let's make sure to kind of do your research and see who's that person in your area who is willing to treat those patients.

But Dr. Spector, I can go on and on about modalities because on day one, when they come in, yes we talk about it at a big picture, what are their medical conditions? But really when we want to look at the wound itself, usually these wounds drain a lot. They've been changing their dressing once, two times, three times a day, going through tons of dressings and the wound comes in, it smells bad, it could be infected already. What do we do to manage the wound bed? And that's something we have to think about as well. Yes, we have to look at it. How do we manage the venous insufficiency? How do we manage the edema? But at the wound bed level, we have to get this exudate under control and if we don't, these winds are going to progress to infection and then increase these patients risk of limb loss.

So like I said, I am typically very protocol oriented and on day one I usually implement an SAP dressing and my SAP dressing I use quite a bit is Zetuvit. It's just, it's like a foam on steroids and I know if I can manage that exudate aggressively on day one, I can really start controlling the wound bed and helping progress that wound bed out of the inflammatory phase into the proliferative phase. And that's something new I've used in the past couple years and I've had really good results with it in addition to everything else we're talking about. So these are very, very complicated patients who progress quite well, but we got to manage it at the wound bed level and then at the larger level, really making sure we're addressing the venous insufficiency and treating it. So getting those vascular specialists on board from day one.

Jennifer Spector, DPM: I have to imagine that the exudate is a problem from the periwound perspective as well because how many times do we see these patients with a lot of exudate from these venous ulcerations that then end up developing maceration and either new ulcerations or progression of the current ulcerations. So the wound bed management as you mentioned, sounds like a very key component in the process.

Alison Garten, DPM: You're right, Dr. Spector. We can't just think about the wound bed, we need to think about the periwound area. So if there is too much drainage, of course it's going to make the periwound skin more fragile and it's going to start breaking down that skin. And that's why these wounds tend to be larger ulcerations in itself just because the more exudate that sits there and the less that bandage, if it's not the correct dressing that's being used, if it's not absorbing and wicking away that moisture quickly, all it's doing is causing fragility of that periwound skin and causing that wound to worsen. So yes, they can be really difficult wounds to treat, but very manful with kind of the right team approach.

Jennifer Spector, DPM: For sure. And you mentioned about getting that wound out of the inflammatory phase. We all learn about the phases of wound healing in school as you know, but I think in day-to-day practice it may not be top of everybody's mind. Can you remind us a little bit about how we can integrate that didactic learning into our everyday practices?

Alison Garten, DPM: I haven't really thought about the phases of wound healing until the past few years when I really started diving a little bit deeper and how can I control the wound bed better with my dressing selection. As a podiatrist in my training I was thinking about what's the best negative pressure wound therapy device? What's the best skin substitute to use? Should I use a platelet derived growth factor product and debridement? But as I subspecialize and now I only do wound care, I realize that dressings play such a large role in managing these wounds and managing the different phases of wound healing. So when I think about the inflammatory phase, it's almost all the wounds I see on day one. It's rare that a patient comes in, there's a nice granular healthy wound and I am ready to use a skin substitute. I can't recall the last time that's ever happened.

So when I think about the inflammatory phase, it's really those wounds that are angry. There's a lot of drainage, there's a lot of periwound maceration, there's a malodor. It doesn't necessarily have to be an infectious odor, but there's a malodor, the patient's saturating their dressings having to change it two to three times a day. So that's really that inflammatory phase and we're trying to get that patient out of that phase into the next phase, which is proliferation to really progress to the remodeling or healing phase. A couple things is when I think about dressings and I think about, let's just think about gauze, which is a common type of dressing used and unfortunately to this day it's the most commonly used wound care dressing out there just because it's easily to, they get, it's in your drawer typically and it's inexpensive. The problem with it though, it has very poor absorption properties.

So if you put that on a draining wound, it's going to saturate that dressing and it's going to continue to hold that moisture directly against the wound bed. So all that does, it increases the level of MMPs in the wound bed. And so that's more drainage and the more MMPs you get, the more likely you're unfortunately going to get an infection. So we have to get this patient out of the inflammatory phase. So I typically like to use some antimicrobial agent. Mine of choice is IODOFLEX directly on the wound bed because even though these patients have had this wound for months, these wounds are colonized. And so I want to decrease the amount of bio burden. Even though there's not a systemic infection, there's a lot of colonization going on. So let's suppress that bacteria that's on the surface of the wound first, but at the same time we need to manage that exudate.And by managing that exudate, like I said, I like to use a super absorbent polymer dressing and I specifically use Zetuvit, that's going to get that moisture away from the wound bed quickly. And all that moisture is what's holding in those MMPs, it's holding in that exudate. That's the thing that's causing the increased risk of infection to occur in the wound. So if I can do that along with compression, I'm expediting basically this wound to get out of the inflammatory phase into the proliferation phase. And so at that point I should start to see a healthier looking wound. I shouldn't see that periwound maceration, I should see a nice granular wound where I'm like, okay, now this is the stage where I can really start to heal this wound. And that's when I started to think of negative pressure, platelet derived growth factors, CPTs, which cellular tissue products, which I still like the old name skin substitutes.

That's when you can start thinking of that. But these angry wounds with a lot of drainage, you have to think, okay they are in the inflammatory phase and let's get these patients out of that phase into the proliferation phase. So yeah, Dr. Spector, I kind of went through that quickly, but I kind of break it down in my mind when I'm seeing a patient. And almost all the patients we're going to see on day one, these wounds are going to be stuck in the inflammatory phase. So it's our job to treat these patients aggressively on day one so we can really get them to healing as soon as possible.

Jennifer Spector, DPM: It's a great reminder for all of us really to take it back to the basics on the cellular level. Is there anything else that you'd like the audience to really remember and take home when it comes to treating venous leg ulcers?

Alison Garten, DPM: I do think we have more of an opportunity to treat venous leg ulcerations. Sometimes they don't end up in our practice, but it's something that you can promote for your practice. I'm out of a wound care center and I'm out of a private practice setting as well and a lot of times the leg ulcerations end up in the wound center or seeing a general surgeon or seeing somebody who doesn't have a lot of experience with wounds. But it is something you can help to promote your practice. So that's one thing. Another thing is the biggest concern when it comes to the venous leg ulcers once they heal is twofold. Number one is they need to make sure they have follow up with that vascular specialist at least every six months to a year. Because these vein procedures are not going to last forever. The same thing when it comes to peripheral arterial disease.

If they've had vascular intervention, they still need to have a follow up at a six month period of time because there's a high, high rate of recurrence with venous leg ulcerations. So making sure the patient has that appointment lined up, making sure the patient understands that they need to follow up with that specialist. And as well as once a patient is discharged from my office or from the wound care center, we always discharge them on some amount of compression, especially at that point they probably, hopefully they've been maximized from an arterial standpoint. I usually get them either with a compression stocking or like a Juxtalite, which is a type of stocking that's a little easier to put on for most of our patients. It has a lighter compression sleeve as the base and then a Velcro strap type material where it's easier for the patient to put on.

But most of these patients need 30 to 40 millimeters of mercury of compression. Well, if you've ever worn compression and I tend to wear it in the office, I wear it when I'm flying or I'm traveling, it's really hard to put on 30 to 40 millimeters a compression of a compression stocking. So what I like to do is I try to figure out what is a patient actually going to wear. I'd rather have the patient wear a lower amount of compression and be more compliant than a higher amount where they never wear. So I've kind of adjusted my theory a little bit. And so now I usually have the patient purchase 15 to 20 or 20 to 30 just to hopefully ensure that they'll actually be able to put it on themselves and they'll wear it. So that's kind of been a little changed in how I've practiced and I think it's worked quite well.

But also continuing, if I did order the lymphedema pumps, they'll continue to use that twice a day. And that's been important, is also trying to prevent them having a recurrence because unfortunately these patients have a high level recurrence. If it's not in the same location, it's in a different location and the number one reason is because they weren't wearing their compression. So something to think about Dr. Spector. Trying to always reevaluate our protocols and every patient's a little different. We need to individualize patients care a lot of times. Some patients have a lot of family support, some patients have no family support, some patients are more mobile than others. So kind of customizing the care plan to meet the patient's needs is what I try to do as best as I possibly can.

Jennifer Spector, DPM: Thank you so much for being with us today, Dr. Garten. We are very grateful you could join us and thank you as well to the audience for tuning in. Be sure to check out past and future episodes at podiatrytoday.com. Spreaker, Apple Podcasts, iHeartRadio, and your favorite podcast platforms.