WHY WON’T THIS VENOUS WHY WON’T THIS VENOUS ULCER HEAL?ULCER HEAL?

Noel Parent MD, FACS, RVTNoel Parent MD, FACS, RVT

SENTARA VASCULAR SPECIALISTSSENTARA VASCULAR SPECIALISTS

Virginia Beach, VAVirginia Beach, VA

Variety of leg ulcer etiologyVariety of leg ulcer etiology

Decubitis (pressure)Decubitis (pressure) at points of contactat points of contact

Ischemic (arterial)Ischemic (arterial) malperfusionmalperfusion

InfectiousInfectious Foreign bodyForeign body Rheumatologic or Rheumatologic or

autoimmuneautoimmune VenousVenous

Venous hypertensionVenous hypertension

Venous ulcer characteristicsVenous ulcer characteristics

Ulcer location is Ulcer location is medial lower calf just medial lower calf just above the ankleabove the ankle

Hemosiderin Hemosiderin depositiondeposition

LipodermatosclerosisLipodermatosclerosis EdemaEdema Size variableSize variable Varicose veins +/-Varicose veins +/-

It all begins with loss of venous It all begins with loss of venous valve function (venous reflux)valve function (venous reflux)

Importance of the perforating veinsImportance of the perforating veins

Elevated pressure within the veins of Elevated pressure within the veins of the calf skin is the pathophysiologythe calf skin is the pathophysiology

How to decrease venous pressure?How to decrease venous pressure?

Traditional surgical treatmentTraditional surgical treatment

Why vein ulcers…Why vein ulcers…

……did not heal in the did not heal in the past:past: INADEQUATE INADEQUATE

DIAGNOSTIC DIAGNOSTIC IMAGINGIMAGING

IMPRECISE IMPRECISE INVASIVE INVASIVE TREATMENTSTREATMENTS

……why they may heal why they may heal now:now: DUPLEX DUPLEX

ULTRASOUND ULTRASOUND IMAGING FOR VEIN IMAGING FOR VEIN MAPPINGMAPPING

EVLT IS PRECISE EVLT IS PRECISE AND MINIMALLY AND MINIMALLY INVASIVEINVASIVE

Duplex ultrasound perforator vein Duplex ultrasound perforator vein imaging to access for ablationimaging to access for ablation

Percutaneous fiberoptic laser Percutaneous fiberoptic laser delivery of thermal energydelivery of thermal energy

SVS Vein Center of VirginiaSVS Vein Center of Virginia

Perforator vein identified by duplex scanPerforator vein identified by duplex scan

Perforator vein cannulationPerforator vein cannulation

Insertion of laser fiberopticInsertion of laser fiberoptic

Tumescence anesthesiaTumescence anesthesia

Ablation of perforator veinAblation of perforator vein

Case example #1Case example #1

Very dirty ankle venous Very dirty ankle venous ulcer in an elderly female.ulcer in an elderly female.

Complex PVL showing: chronic Complex PVL showing: chronic thrombus in GSV. Note associated thrombus in GSV. Note associated SSV reflux and two incompetent SSV reflux and two incompetent calf perforator veins.calf perforator veins.

Case example #1, cont’dCase example #1, cont’d PVL confirms successful PVL confirms successful

ablation of GSV, SSA and ablation of GSV, SSA and perforators. perforators.

6 weeks post endovenous laser 6 weeks post endovenous laser treatment: ulcer healing for the treatment: ulcer healing for the FIRST TIME IN A YEARFIRST TIME IN A YEAR!!

Case example #2Case example #2

Pre treatmentPre treatment Post treatmentPost treatment

Retrospective study of EVLT for Retrospective study of EVLT for venous ulcers in SVS/VCVvenous ulcers in SVS/VCV

Compared 3 groups of patientsCompared 3 groups of patients

Incidence of ulcer healingIncidence of ulcer healing

Improvement in VCSSImprovement in VCSS

Minimal complicationsMinimal complications

SummarySummary Leg ulcers are commonly due to elevated Leg ulcers are commonly due to elevated

venous pressure in skin from valve weakness venous pressure in skin from valve weakness resulting in reflux.resulting in reflux.

Results from traditional therapies of Unna Results from traditional therapies of Unna boots, stockings, and open surgery are boots, stockings, and open surgery are disappointing. (Costly, morbid, disabling)disappointing. (Costly, morbid, disabling)

A contemporary treatment consisting of A contemporary treatment consisting of duplex scan diagnosis of perforating veins, duplex scan diagnosis of perforating veins, then treatment by EVLT, may become the then treatment by EVLT, may become the new standard of care.new standard of care.

The End – thank youThe End – thank you