My Journey with Venous Stasis Ulcers

 

My Journey with Venous Stasis Ulcers

 

Several friends of mine have off and on enquired about my leg ulcers. I have already thanked each of them personally through their WhatsApp.  One of them has even offered me a “cure” using Traditional Chinese Medicine.

I cherish all their concern and friendship. Thank you once again to each of them.  Since my history with this ulcer is a very long one, it would not be possible to keep repeating the same story for each of them. Allow me instead to write this common article to explain to each of them although I have already thanked each of them personally without writing lengthy explanation.   

But first, let me quote a study in this link:

 

https://onlinelibrary.wiley.com/doi/full/10.1111/iwj.14272.

 

“Venous leg ulcers (VLU) are a major clinical challenge and the result of chronic venous insufficiency (CVI) and venous hypertension. They manifest on the lower limb and represent between 60% and 80% of all leg ulcerations. Their three-months healing rate is estimated at 40% and once healed up to 80% of patients develop a recurrence within 3 months. The prevalence of VLUs is reported around 1.08%⁶ and the incidence being up to 1.33%. The latter numbers are primarily based on estimates because of the lack of clinical registries for VLU. The prevalence and incidence of VLU increase with age. Age does negatively affect healing and recurrence as well as treatment adherence. People with VLUs often report having reduced health-related quality of life because these wounds can be painful, malodorous, and exuding”.

My first journey with my venous stasis leg ulcers started in early 2017, involving my left leg.

At that time, I tried for some 3 months to manage it myself, but when it persisted, I decided to go to hospital for better care. But the hospital did not do much except gave me regular wound dressing which I have already done on my own at home.

I then decided to go to a private wound care centre in Petaling Jaya on July 9, 2017, to stay there for regular wound care. I stayed there for 35 days till August 13 before I discharged myself when the wound did not get any better.

On the same night on August 13, 2017, I decided to get myself admitted to Kuala Lumpur Hospital where I was hospitalized for 4 months, 3 days (Sunday, August 13, 2017, till December 15, 2017). Fortunately, I was eligible to a one-bedded room all for myself which was much more comfort than in other wards. After more than 4 months in that ward with regular dressing and bed rest my wound finally almost healed. It finally completely healed a month later after I was discharged from hospital. That was my first journey with my left leg. That is now history.  

Then in early 2022, the same venous stasis ulcer affected my right leg. Today this is my second journey with this problem. This time I sought surgical instead of medical treatment. But before we go into this, let us look at what causes this problem by understanding its causes, its pathology and treatment below:

 

Pathophysiology:

Venous stasis ulcers typically develop due to chronic venous insufficiency, a condition where the veins in the legs have difficulty returning blood back to the heart. Here's a breakdown of the pathophysiology:

1. Venous Insufficiency: Venous insufficiency occurs when the valves in the leg veins are damaged or weakened. Normally, these valves prevent blood from flowing backward, ensuring it moves towards the heart. When these valves malfunction, blood can pool or flow backward, causing increased pressure in the veins of the lower legs.
2. Increased Venous Pressure: The increased pressure in the veins leads to venous hypertension, especially in the lower extremities. This pressure buildup compromises the integrity of the venous system, causing further valve damage and stretching of the vein walls.
3. Capillary Perfusion Disturbances: The elevated venous pressure impairs capillary perfusion, the process by which oxygen and nutrients are delivered to tissues. As a result, the surrounding tissues become hypoxic (lack oxygen) and ischemic (lack blood supply).
4. Inflammatory Response: Chronic venous hypertension triggers an inflammatory response in the affected tissues. Inflammation contributes to tissue damage and further compromises wound healing processes.
5. Tissue Hypoxia and Necrosis: Prolonged hypoxia and ischemia lead to tissue damage and necrosis (cell death). The lack of oxygen and nutrients impairs the ability of cells to repair and regenerate, further exacerbating tissue breakdown.
6. Ulcer Formation: Eventually, the combination of tissue hypoxia, inflammation, and impaired healing mechanisms results in the formation of venous stasis ulcers. These ulcers typically occur around the ankles and lower legs, where venous pressure is highest and blood flow is slowest.
7. Chronic Wound Cycle: Venous stasis ulcers often become chronic wounds, as the underlying venous insufficiency persists. The impaired circulation perpetuates the cycle of tissue damage, inflammation, and delayed healing, making it difficult for the ulcers to heal without appropriate intervention.

 

Management:

Treatment of venous stasis ulcers involves addressing the underlying venous insufficiency, promoting wound healing, and preventing recurrence. This may include compression therapy, elevation of the legs, wound debridement, topical medications, and lifestyle modifications.

Compression therapy together with leg elevation during sleep is usually a cornerstone in managing venous stasis ulcers, as it helps improve venous blood flow and reduces oedema. While compression stockings are commonly used due to their effectiveness, compression bandages can also be used, especially in cases where stockings are not feasible or tolerated well. Leg elevation during bedtime allows gravity to help drain the flow of blood towards the heart.

I have used both types of compression therapies most of the time even during bedtime, but it does not seem to help.

I then underwent two operations for my right leg venous stasis ulcers. The first one was done using radio frequency ablation (RFA) in September 2022.

The vascular surgeon could only close up two out of three of the affected veins. He could not close up the third one as it was too near a nerve as the heat of RFA can damage the nerve. Hence, I believe this was the reason why it did not heal very well.  

I then underwent the second surgical operation using VenaSeal or clue procedure. This was also done in September, a year later on 18 September 2023. It was performed by two surgeons, one from Malaysia and the other from Singapore who was on an assignment here at a major hospital in Kuala Lumpur.

The VenaSeal technique delivers a small amount of a specially formulated medical adhesive to close the diseased vein, rerouting blood to nearby healthy veins. This is a minimally invasive non thermal treatment for vein disease and varicose veins. The glue they used I believed was cyanoacrylate.

Unfortunately, this second surgical operation made my ulcer larger and worse than the first one causing my feet now to swell with oedema.

The hospital has done Duplex ultrasound scans many times before the operations in 2022, but they did not do it again just before the second one, probably because they already have my records.

Duplex ultrasound involves using high frequency sound waves to look at the speed of blood flow, and structure of the leg veins.  When the ulcers did not heal after the second operation using VenaSeal procedure they did a duplex ultrasound again, and found the veins have closed up completely?  But ulcers are still not healing, and the feet have now developed oedema. Why is it so? Could it possibly be due to overdoing it with radio frequency ablation (RFA) plus the glue method such that all the veins were closed up that there is now very little opening or passage for the blood to return to the heart.

I asked the senior consultant surgeon about this possibility, but he did not think so because if there was no venous return, then according to him, the entire leg would be swollen like elephantiasis (a disease caused by lymphatic filariasis), not just the feet. But he assured me it will finally heal, but it will take some time because he said it has been a chronic condition and some damages have already been done in the vasculature and tissues.

 According to a study after VenaSeal surgery, the median wound healing time was significantly shorter for VenaSeal than for RFA (43 vs 104 days; P = 0. 001). Two RFA patients developed a post procedure infection. The ulcer recurrence rate was 19.3% (22.1% for RFA vs 13.7% for VenaSeal. But mine currently is already over 7 months since the second surgery.

According to several studies published in the medical journals, several botanical medicines such as horse chestnuts, butchers bloom, diosmin and hesperidin, pine bark, Centella asiatica (Indian pennywort) are helpful in managing venous insufficiencies. I have also tried them on my own, and even my last surgeon has also prescribed diosmin and hesperidin (HemoRid tablets) for me together with Celecoxib, a nonsteroidal anti-inflammatory drug (NSAID), plus an antibiotic Unasyn. None works.

 While radiofrequency ablation (RFA) and Venaseal are normally said to be both effective treatments for venous insufficiency, complications can arise.

The closure of veins with these procedures is intended to redirect blood flow to healthier veins and alleviate the symptoms of venous insufficiency, including leg ulcers. However, since the ulcers persist and oedema worsens despite the closure of the veins, there might be some other underlying issues that need to be addressed.

Below are some of my own personal suspicions on other underlying causes as a clinician myself. Unfortunately, none of my 4 – 5 surgeons and other doctors treating me has offered to explain other causative factors to me.

Here are several other causative factors that could contribute to my persistent ulcers and oedema. Here are my views:

1. Deep Vein Thrombosis (DVT): It's possible that you might have developed DVT in deep veins, which can impede blood flow and contribute to oedema and ulceration.
2. Inadequate Venous Drainage: Closure of veins may not always lead to sufficient venous drainage, especially if there are other underlying venous issues or if collateral circulation pathways are insufficient.
3. Lymphatic System Dysfunction: Oedema could also be a result of lymphatic system dysfunction, especially if the ulcers are not responding to treatment as expected.
4. Chronic Inflammation: In some cases, chronic inflammation around the ulcer site can impede the healing process which I currently suffer.

Given the complexity of my situation, it's crucial to consider the reasons I highlight above so that further evaluation and appropriate management can be instituted. This may include:

• Further imaging studies such as CT venography or magnetic resonance venography to assess venous and lymphatic flow.
• Evaluation for underlying conditions such as DVT or lymphatic system dysfunction.
• Specialized wound care techniques such as debridement, dressings, or advanced therapies like negative pressure wound therapy (NPWT) or bioengineered skin substitutes.
• Management of oedema through compression therapy, elevation, and possibly diuretic medications.
• Consideration of other interventions such as angioplasty, stenting, or surgical bypass if indicated.

I need to address these symptoms and to investigate further to ensure a more comprehensive and personalized care if my present ulcer is not yielding the desired results.

What I have mentioned above is based on my trained medical knowledge, and as a former senior medical researcher, but in practice I cannot do the investigations on myself or treat myself. I need some competent endovascular surgeons from outside to help. I hope my journey will end as soon as possible as my body is my best friend and healer

Jb lim