Cardiology >  Stasis Ulcers

Background

Stasis ulcers, also known as venous stasis ulcers or venous leg ulcers, are chronic wounds that occur primarily on the lower extremities due to chronic venous insufficiency (CVI). Prolonged venous hypertension leads to capillary leakage, inflammation, and tissue hypoxia, resulting in ulceration—most commonly around the medial malleolus.

II) Classification/Types

By Chronicity:

• • Acute venous ulcers: New onset, usually painful with inflamed borders.
  • Chronic venous ulcers: Recurrent or non-healing ulcers present for >6 weeks.

By Clinical Features:

• • Wet/exudative ulcers
  • Dry/sloughing ulcers
  • Infected ulcers (colonized or overt infection)

By CEAP Classification (Chronic Venous Disorders):

• • C6: Active venous ulcer
  • C5: Healed venous ulcer

III) Pathophysiology

Chronic venous hypertension, often due to valve incompetence, impairs forward blood flow. This results in:

• • Venous stasis
  • Capillary leakage (fibrin cuff formation)
  • Inflammatory cell infiltration
  • Tissue hypoxia and poor nutrient delivery
    These factors delay healing and promote skin breakdown and ulceration, particularly over pressure points.

IV) Epidemiology

• • Sex: More common in females due to hormonal and pregnancy-related effects on veins
  • Age: Most prevalent in individuals >65 years
  • Geography: Higher prevalence in industrialized countries with sedentary lifestyles
  • Comorbidities: Strongly associated with varicose veins, obesity, prior DVT, and immobility

Etiology

I) Causes

• • Chronic venous insufficiency (valvular reflux)
  • Post-thrombotic syndrome (after DVT)
  • Superficial venous reflux (e.g., varicose veins)
  • Venous outflow obstruction
  • Prolonged standing or immobility
  • Venous trauma or surgery

II) Risk Factors

• • Advanced age
  • Obesity
  • Pregnancy
  • History of deep vein thrombosis
  • Varicose veins
  • Sedentary lifestyle or prolonged standing
  • Family history of venous disease

Clinical Presentation

I) History (Symptoms)

• Non-healing wound over medial ankle or shin
• Aching, heaviness, or leg fatigue worsened by standing and relieved by elevation
• Skin itching or burning sensation
• Recurrent ulceration in same area
• Possible foul-smelling or purulent drainage (if infected)

II) Physical Exam (Signs)

Skin and Vascular Findings:

• • Ulcer: Irregular, shallow with granulation tissue base, commonly at medial malleolus
  • Surrounding skin: Hyperpigmentation (hemosiderin), lipodermatosclerosis, atrophie blanche
  • Edema (pitting or non-pitting)
  • Varicose veins
  • Venous dermatitis (stasis eczema)
  • Pulses usually intact

Infected Ulcers:

• • Erythema, warmth, increased exudate
  • Foul odor or systemic signs (fever)

Differential Diagnosis (DDx)

• • Arterial ulcers (punched out, painful, distal toes)
  • Diabetic ulcers (over pressure points, painless)
  • Pressure ulcers
  • Pyoderma gangrenosum
  • Vasculitic ulcers
  • Malignancy (Marjolin ulcer)

Diagnostic Tests

Initial Tests:

• • Duplex venous ultrasound: First-line; evaluates venous reflux and obstruction
  • Ankle-brachial index (ABI): Rules out arterial insufficiency (important before compression therapy)

Additional Tests:

• • Wound culture: Only if signs of infection present
  • Skin biopsy: Consider if atypical features or poor response to treatment
  • HbA1c and glucose: Evaluate for diabetes
  • Albumin and nutritional panel: Poor healing may reflect malnutrition

Treatment

I) Medical/Conservative Management

Wound Care:

• • Debridement of necrotic tissue (enzymatic, mechanical, or surgical)
  • Moist wound dressings (hydrocolloid, alginate, foam, etc.)
  • Topical antibiotics only if infected

Compression Therapy:

• • Mainstay of treatment
  • Graduated compression stockings or multi-layer bandaging
  • Contraindicated if ABI < 0.5 (severe PAD)

Adjunctive Measures:

• • Leg elevation
  • Calf muscle exercises
  • Manage edema (diuretics in select cases)
  • Optimize glucose, protein intake

Pain Management:

• • NSAIDs or acetaminophen for mild pain
  • Opioids may be needed for severe ulcers

II) Interventional/Surgical

Endovenous Interventions:

• • Radiofrequency or laser ablation
  • Sclerotherapy for superficial reflux
  • Vein stripping (less common now)

Surgical Options:

• • Skin grafting for large or non-healing ulcers
  • Subfascial endoscopic perforator surgery (SEPS)
  • Vein bypass (rare)

Patient Education, Screening, Vaccines

Education:

• • Importance of lifelong compression use
  • Leg elevation several times a day
  • Avoid prolonged standing or sitting
  • Daily skin inspection and hygiene
  • Proper footwear to avoid trauma

Lifestyle Modifications:

• • Weight loss
  • Regular walking and calf muscle activation
  • Smoking cessation

Vaccinations:

• • Influenza
  • Pneumococcal (especially if elderly or immunocompromised)
  • Tetanus booster (if ulcer traumatic or dirty)

Consults

• • Vascular Surgery: If considering ablation or vein procedures
  • Wound Care Specialist: For difficult-to-manage ulcers
  • Dermatology: If diagnosis unclear or suspicion for vasculitis or malignancy
  • Infectious Disease: If severe or refractory ulcer infection
  • Endocrinology or Nutrition: For diabetes or malnutrition

Follow-Up

Regular Monitoring:

• • Weekly to monthly wound assessment (size, depth, exudate)
  • Monitor for infection or cellulitis
  • ABI reassessment periodically if compression used

Ulcer Healing Time:

• • Most heal within 3–4 months with proper care
  • Recurrence common (up to 70% within 5 years)

Long-Term Goals:

• • Maintain compression therapy
  • Prevent recurrence
  • Optimize chronic disease management (obesity, diabetes, mobility)