Venous trophic ulcers

Venous trophic ulcers are the result of a long, complicated course of chronic vascular insufficiency against the background of varicose or post-thrombophlebitic diseases or (which happens quite rarely) angiodysplasia. In the classical version, they are usually located in the area of the medial malleolus. In rarer cases, venous trophic ulcers can be located on the anterior, lateral surface of the shin on the foot. In advanced cases with long-term disease, ulcerative defects become multiple or circular, appear on both lower extremities, they are accompanied by widespread lipoderma-sclerosis with frequent relapses of dermatitis, eczema, acute indurative cellulitis, erysipelas.

An important point of diagnostics is confirmation of vascular etiology, as well as differential diagnostics of various phlebopathologies. Detection of pathological vascular blood discharges or obstruction of deep veins during ultrasound Dopplerography or duplex angioscanning confirms the diagnosis.

How to treat venous trophic ulcers?

Treatment is aimed at their healing and prevention of relapse. The leading place in the therapy of venous trophic ulcers of the lower extremities belongs to surgical methods, however, conservative therapy is considered an important link in preparing the patient for pathogenetic surgical treatment. In a certain group of patients, when surgery is contraindicated or impossible, conservative methods are the only possible type of medical care.

In surgical treatment, the following types of surgical interventions are distinguished.

Operations on the vascular system of the lower extremities aimed at the pathogenetic mechanisms of ulcer formation:

• operations on the superficial system of the lower limb (phlebectomy and sclerotherapy of the great or small saphenous veins);
• separation of the deep and superficial systems by dissection or sclerotherapy of perforating veins;
• deep vein interventions (posterior tibial vein resection, valvuloplasty, Palma operation);
• a combination of different types of interventions on the veins of the limb.

Plastic interventions directly on the venous trophic ulcer:

• combined operations that combine interventions on the vascular system of the lower extremities and venous trophic ulcers, performed simultaneously or in different sequences.

Surgical interventions on the vascular system of the lower extremities are indicated for patients with long-term non-healing or recurrent ulcerative defects. In the case of a first-time ulcerative defect, surgical intervention is resorted to in the absence of a positive effect from adequate conservative therapy (compression therapy, systemic pharmacotherapy and local therapy) for six weeks. In the development of an ulcerative defect caused by damage to only the subcutaneous vascular system, surgical treatment is considered the most optimal. If the deep system and perforating veins are involved in the pathological process, a thorough functional examination is necessary to assess the contribution of damage to various parts of the vascular system to the development of the pathology in order to determine the optimal volume and method of surgical intervention.

From the point of view of evidence-based medicine, the highest efficiency in the treatment of venous trophic ulcers is demonstrated by compression therapy, interactive wound dressings and the use of micronized diosmin (Detralex), which are advisable to use in wide clinical practice. The drug actovegin, which has a complex anti-ischemic, metabolic and wound-healing effect, is also of interest. At the same time, it should be taken into account that the clinical studies conducted comparing conservative and surgical methods of treatment primarily concern the prospects for healing and the frequency of relapses of small ulcerative defects. These venous trophic ulcers have a good tendency to heal with conservative therapy, but the situation in Russia is such that large and extensive ulcerative defects make up at least 20-30% of the total. Adequate surgical intervention with the elimination of pathological veno-venous discharges and skin grafting of the ulcer defect in these conditions provides incomparably shorter healing times compared to isolated venectomy, and even more so with purely conservative treatment tactics.