Venous trophic ulcers

Venous trophic ulcers are the result of a long, complicated course of chronic vascular insufficiency against a background of varicose or post-thrombophlebitic diseases, or (which is rare enough) of angiodysplasia. In the classical version, they are usually located in the area of the medial malleolus. In more rare cases, venous trophic ulcers may be located along the anterior, lateral surface of the tibia on the foot. In advanced cases with long periods of the disease, ulcerous defects become plural or circular, occur on both lower limbs, they are accompanied by a common lipo-dermatosclerosis with frequent relapses of dermatitis, eczema, acute indigestive cellulitis, erysipelas.

An important point of diagnosis is confirmation of vascular etiology, as well as differential diagnosis of various phlebopathologies. Detection of pathological vascular discharges of blood or violation of the patency of deep veins with ultrasonic dopplerography or duplex angioscanning confirms the diagnosis.

How to treat venous trophic ulcers?

Treatment is directed to their healing and prevention of relapse. The leading place in the therapy of venous trophic ulcers of the lower limbs belongs to surgical techniques, nevertheless conservative therapy is considered an important link in preparing the patient for pathogenetic surgical treatment. In a certain group of patients, when the operation 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 limbs, aimed at pathogenetic mechanisms of ulceration:

• operations on the superficial system of the lower limb (phlebectomy and sclerosing of the large or small subcutaneous veins);
• dissociation of deep and surface systems by dissection or sclerotherapy of perforating veins;
• intervention on deep veins (resection of posterior tibial veins, valvuloplasty, operation of Palma);
• a combination of different types of intervention on the veins of the limb.

Plastic surgery directly on the venous trophic ulcer:

• combined operations, combining interventions on the vascular system of the lower extremities and venous trophic ulcers, carried out 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. With the development of a ulcerative defect caused by the defeat of only the subcutaneous vascular system, surgical treatment is considered the most optimal. With the involvement of the deep system and perforating veins in the pathological process, a thorough functional examination is necessary to assess the contribution to the development of the lesion pathology of various parts of the vascular system in order to determine the optimal volume and mode of surgical intervention.

From the point of view of evidence-based medicine, the most effective treatment for venous trophic ulcers is demonstrated by compression therapy, interactive wound coverings and micronized diosmin (detralex), which can be used in a wide clinical practice. Of interest is the drug actovegin, which has a complex anti-ischemic, metabolic and wound-healing effect. At the same time, it should be borne in mind that the ongoing clinical trials comparing conservative and surgical methods of treatment primarily concern the prospects of healing and the frequency of relapses of small ulcerative defects. These venous trophic ulcers have a good tendency to healing with conservative therapy, but the situation in Russia is such that large and extensive ulcerative defects account for at least 20-30% of the total number. An adequate surgical manual with the elimination of pathological veno-venous discharges and skin plasty of a ulcerative defect in these conditions gives incomparably lower healing times than isolated veinectomy, and especially with a purely conservative treatment tactic.