JUNE 2015
PURPOSE
WOUND EVALUATION
Best practice is used as the evidence for clinical evaluation of
the leg by a specialist in vascular care. The vascular specialist is
to examine the leg for signs of venous ulcers and the cause of
these ulcers, and to provide specific documentation of the size
and location of any venous ulcer location. Outcome measures after interventions, either beneficial or complications, need to be
documented well to show the impact on venous leg ulcers as a
best practice also. Recommend that all patients with venous
leg ulcer be classified on the basis of venous disease classification assessment, including clinical CEAP, revised Venous Clinical Severity Score, and venous disease-specific quality of life
assessment is also a best practice.1
The classification tools are known to nurses who specialize in
venous issues, but these scoring systems may be less well known
by other vascular nurses, so each will be explained briefly. CEAP
stands for Clinical, Etiologic, Anatomic, and Pathophysiologic
classifications. The CEAP measure developed in 1994 and
revised in 2004 is a static scale that is used extensively in clinical
and research settings to establish a baseline for venous disease.1,2
The basic CEAP (Table 1) is a less extensive version of the tool
TABLE 1
BASIC REVISED CLINICAL, ETIOLOGIC,
ANATOMIC, AND PATHOPHYSIOLOGIC (CEAP)
CLASSIFICATION SYSTEM
CEAP
Definition
Clinical classification
C0
No visible or palpable signs of venous disease
C1
Telangiectases or reticular veins
C2
Varicose veins
C3
Edema
C4a
Pigmentation and/or eczema
C4b
Lipodermatosclerosis and/or atrophie blanche
C5
Healed venous ulcer
C6
Active venous ulcer
CS
Symptoms, including ache, pain, tightness,
skin irritation, heaviness, muscle cramps,
as well as other complaints attributable to
venous dysfunction
CA
Asymptomatic
Etiologic classification
Ec
Congenital
Ep
Primary
Es
Secondary (post thrombotic)
En
No venous etiology identified
Anatomic classification
As
Superficial veins
Ap
Perforator veins
Ad
Deep veins
An
No venous location identified
Pathophysiologic classification (basic)
Pr
Reflux
Po
Obstruction
Pr,o
Reflux and obstruction
No venous pathophysiology identifiable
Pn
Modified from Ekl
of B, Rutherford RB, Bergan JJ, et al. Revision of the
CEAP classification for chronic venous disorders: consensus statement.
J Vasc Surg 2004; 40:1248-52 with permission from Elsevier.
PAGE 61
ment options.4 The original and revised VCSS have been shown
to be valid and reliable with the same and different observers over
time. A VCSS score may range from 0 to 30, but a score of >8
should alert the nurse to observe closely for progression of the
current venous problem.1,5
Post-thrombotic syndrome may be associated with venous ulcers in patients who have had deep vein thrombosis. Several
scales are available, but the guidelines recommend the use of
the Villalta score6 (Table 37) with the CEAP for the most accurate diagnosis of post-thrombotic syndrome, especially with a
C5 or C6.1 Mild post-thrombotic syndrome has a score of 5-9,
moderate is 10-15, and severe is >15 points or the presence of
a C6 ulcer.7 Disease-specific quality of life measures are recommended, but no specific tool is named in the guidelines.1
Strong recommendations are available for some diagnostic
procedures. All patients with suspected venous ulceration are
strongly recommended (grade 1B) to undergo venous duplex ultrasonography of the entire venous system, an anklebrachial index measurement and (grade 1C) wound biopsies if the wound
has not healed after 4-6 weeks of treatment.
Suggestions for diagnostics include (grade 2B) venous plethysmography when ultrasonography has been inconclusive, and
(grade 2C) laboratory testing for thrombophilia when venous ulcers recur chronically or a history exists of recurrent thrombosis
and against routine culture of wounds that do not show specific
signs of infection. A grade 2C suggestion to only do extensive
other testing when iliac vein obstruction is suspected or surgical
interventions are planned, so the diagnostics are a necessity is a
cost-saving measure. Cost savings is a consideration in the suggestions made where the benefitrisk balance is equal.
WOUND THERAPY
Many direct wound therapies are available for management
of venous leg ulcers. This section addresses the wound bed,
infection control, primary dressings, and adjuvant therapy. The
underlying venous hypertension must be controlled for these
measures to work, so each is used concurrently with compression
or other venous interventions that will be addressed elsewhere.1
Wound bed
Cleansers and debridement are the main ways of preparing
the wound bed, but neither is effective without good nutrition
and careful documentation at each dressing change.1 Nurses
may be the ones doing these dressing changes, so remembering
to measure height, width, and depth and documenting those on
a regular basis is necessary. Cleansing the wound with a nonirritating solution with minimal trauma from chemical or mechanical sources initially and during each dressing change is suggested
(grade 2C). Debridement during the initial evaluation is recommended (grade 1B) to remove the burden of necrotic tissue,
excess bacteria, and nonviable cells. Further debridement is suggested (grade 2B) on a maintenance basis to improve appearance
and ability of the wound to heal, although the method of debridement is left to the providers choice.1
Several methods of debridement are used with varying
recommendation. A strong recommendation (grade 1B) for the
use of local or stronger anesthesia was given for surgical debridement. The use of eutectic mixture of local anesthetics cream was
PAGE 62
TABLE 2
REVISED VENOUS CLINICAL SEVERITY SCORE
Characteristic
None (0)
Varicose veins
Varicose veins must be $3 mm in
diameter to qualify in the standing position
Skin pigmentation
Presumes venous origin; does not include
focal pigmentation over varicose veins or
pigmentation owing to other chronic
diseases
Inflammation
More than just recent pigmentation
(ie, erythema, cellulitis, venous
eczema, dermatitis)
Induration
Presumes venous origin of secondary
skin and subcutaneous changes
(ie, chronic edema with fibrosis,
hypodermitis). Includes white atrophy
and lipodermatosclerosis
None or
focal
Moderate (2)
Severe (3)
Limited to perimalleolar
area
Limited to perimalleolar
area
Limited to perimalleolar
area
Venous edema
Presumes venous origin
Mild (1)
JUNE 2015
$3
Not healed for >1 y
>6 cm
1
<3 mo
<2 cm
0
N/A
N/A
2
>3 mo but <1 y
2-6 cm
PAGE 63
Adjuvant therapy
Adjuvant wound therapy is recommended (grade 1B) for
wounds that have not healed after 46 weeks of other wound
therapy. The suggestion with the strongest evidence (grade 2A)
is for cellular therapy; cultured allogeneic skin replacements
that include the epidural and dermal layers of the skin are used
with compression therapy to increase the chances of healing
these venous leg ulcers. Split-thickness skin grafts are suggested
against as a primary therapy, but may be used with very large
venous ulcers in conjunction with compression therapy while
the wound decreases in size (grade 2B). The guidelines suggest
(grade 2C) compression therapy with wound bed control before
cellular therapy. Debridement of the wound bed before application of a bilayer graft and continued debridement as needed is
recommended (grade 1C). The guidelines recommend against
negative pressure therapy (grade 2C), electric stimulation (grade
2C) and ultrasound therapy (Grade 2B) on a routine basis.1
PAGE 64
TABLE 3
SUMMARY OF THE SCORING USED IN THE
VILLALTA SCALE
None Mild Moderate Severe
Symptoms
Pain
Cramps
Heaviness
Paresthesia
Pruritis
Signs
Pretibial edema
Skin induration
Hyperpigmentation
Redness
Venous ecrasia
Pain on calf
compression
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
Modified from Lattimer CR, Kldiki E, Assam M, Geroulakos G. Validation of the Villalta scale I assessing post-thrombotic syndrome using clinical, duplex, and hemodynamic comparators. J Vasc Surg: Venous Lymph
Dis 2014; 2(1):8-14 with permission from Elsevier.
COMPRESSION
Compression therapy comes in many different forms, but all
use the concept that pressure on the outside of the leg can counteract mechanically the venous hypertension and increase
venous blood return. Sustained compression can be obtained using several different types of single bandages, systems of bandages, or compression garments. Pneumatic compression
devices provide intermittent compression. Elastic bandage wraps
and elastic stockings alone can reduce edema, but they do not
counteract effectively venous hypertension as well as a stiff
bandage that will not expand with muscle contraction during
walking. Continuous compression can be provided using short
stretch textiles or multilayered bandages that may need to be
applied by trained staff or self applied short-stretch devices
with Velcro closures.1
Short-stretch textiles are used in graduated compression
stockings that provide a single layer of compression at a set
dose of compression when used alone. Compression stockings
combined with other dressing materials may become a multicomponent dressing with greater levels of compression. Four
different layers are used in 1 multicomponent dressing found
in the research reviewed for the guidelines, which applies overlapping layers of orthopedic wool, followed by crepe bandage,
elastic bandage, and an elastic cohesive outer layer (4LB).1
Describing all compression alternatives is beyond the scope of
this review; readers interested in more information about specific
compression therapies are referred to Up to Date (http://www.
JUNE 2015
uptodate.com/contents/compression-therapy-for-the-treatmentof-chronic-venous-insufficiency).
Current evidence does not differentiate between multiple
continuous compression techniques that are available for use
and conflicting evidence for 1 bandage system or another limits
the current level of evidence. The guidelines can strongly recommend (grade 1A) the use of compression with venous leg ulcers
(C6) as opposed to no compression. Reoccurrence of venous ulcers after they have healed (C5) is common, so the guidelines suggest the use of ongoing compression therapy (grade 2B).
Multicomponent compression bandages are suggested (grade
2B) over single-component bandages for the treatment of C6 unless the patient has severe arterial insufficiency. When the ankle
brachial index is <0.5 or the absolute ankle pressure is <60 mmHg,
the guidelines do not suggest the use of compression (grade 2C),
because the evidence has mixed results even with higher arterial
flow values.1 Arterial flow must be maintained for healing to occur
and compression pressures in the available garments and dressings vary from <20 to >50 mmHg, which may decrease flow to
the peripheral tissues by that amount of pressure.
Intermittent pneumatic compression is suggested (grade
2C) when sustained compression measures are ineffective or
cannot be used. Compression is valued highly in the guidelines
and is part of the standard therapy for any venous leg ulcer, no
matter what other therapy may be used.1 Many of the bandage
systems require special training that nurses receive before
applying the bandages. Clinics and other outpatient settings
are the likely location for the care that may take weeks to
months before healing is complete. Education for the patient
and family about maintenance of the dressing and timing of
dressing changes is provided by nurses in the outpatient or hospital settings. Careful application of compression and close
monitoring by nurses are needed when the patient has been
hospitalized for other reasons or changes in leg ulcer care
are made.
PAGE 65
Figure 1. Proposed algorithm for operative and endovascular treatment of patients with venous leg ulcer based on involved anatomic venous
system and presence of venous reflux or obstruction. The riskbenefit ratio is weighed for those procedures with more risk (lower, moderate,
higher) considered later in the treatment when the benefit is similar. Rx endo = endovascular treatment. Reprinted from Journal of Vascular
Surgery, 60, Thomas F. ODonnell, Marc A. Passman, William A. Marston, William J. Ennis, Michael Dalsing, Robert L. Kistner, Fedor Lurie,
Peter K. Henke, Monika L. Gloviczki, Bo G. Eklof, Julianne Stoughton, Sesadri Raju, Cynthia K. Shortell, Joseph D. Raffetto, Hugo Partsch
et al, Management of venous leg ulcers: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum,
34S, 2014, with permission from Elsevier.
combined with compression therapy. Ablation of both the pathologic perforator veins and superficial vein reflux is suggested
when both problems are present in patients with C6 ulcers.1 Subfascial endoscopic perforator vein surgery for perforator ablation
allowed concurrent treatment of superficial venous reflux in a
Dutch study, which found no significant difference in healing
(C6), but recurrent ulcers (C5 becomes C6) were more common
months later when both procedures were not completed at the
same time.8,9 The guidelines suggest ablation of the superficial
veins initially with the perforator vein ablation at the same
time or a later time to prevent ulcer formation in patients who
have not previously received ablation therapy when skin
changes (C4b) or a healed ulcer (C5) are associated with
pathologic perforator veins and superficial venous reflux to the
ulcer bed. When there is perforator vein pathology, but not
superficial vein involvement, the guidelines suggest ablation of
the perforator veins located beneath the active (C6) or healed
(C5) ulcer area. The least invasive therapy is recommended
(grade 1C) over open therapy when only the perforator veins
will be treated, because many percutaneous methods exist with
minimal risks and comparable benefits. Several methods are
listed, but none is favored over others at this time.1 Benefit
risk ratios may drive more of these procedures to be undertaken
in outpatient areas where nurses may be assisting with some
PAGE 66
Ancillary measures
The guidelines reviewed several ancillary measures,
including drug therapy, nutrition, physiotherapy, balneotherapy,
lymphatic therapy, and ultraviolet light therapy, to improve
healing in C6 ulcers or prevent recurrence for C5 ulcer areas.
The guidelines recommend (grade 1B) the use of 2 types of systemic drug in the treatment of large leg ulcers or long-standing
ulcer in combination with compression therapy. Studies of
several drugs were reviewed, but only pentoxifylline and
micronized purified flavonoid fraction (MPFF) were recommended.1 The 2 drugs are used worldwide, but MPFF is not
approved by the US Food and Drug Administration for use in
the United States and pentoxifylline use may be off-label in
JUNE 2015
CONCLUSION
The goal of this article was to summarize the guidelines that
address diagnosis and treatment recommendations published
jointly by the SVS and AVF, which may affect the nursing practice of vascular nurses. Specific sections included wound evaluation, therapies used on the wound bed itself, compression, and
operative or endovascular management. When the benefit
clearly outweighed the risks, a recommendation was provided
in the guidelines and the level of evidence noted. Suggestions
in the guidelines varied in research evidence strength, but addressed issues where there is not a clearly greater benefit than
risk for the difference in cost. Best practice guidelines were
also provided in areas where care is needed, but no clear evidence is available for care that is necessary. This article has provided a summary of the guidelines for the care of venous leg
ulcers published in the Journal of Vascular Surgery in
August 2014.
REFERENCES
1. ODonnel TF Jr, Passman MA, Marston WA, et al. Management of venous leg ulcers: clinical practice guidelines of the
Society for Vascular Surgery and the American Venous
Forum. J Vasc Surg 2014;60:3S-59S.
PAGE 67
6. Villalta S, Bagatella P, Piccioli A, et al. Assessment of validity and reproducibility of a clinical scale for the postthrombotic syndrome. [abstract]. Haemostasis 1994;24:158a.
7. Lattimer CR, Kldiki E, Assam M, et al. Validation of the Villalta scale in assessing post-thrombotic syndrome using clinical, duplex, and hemodynamic comparators. J Vasc Surg:
Venous Lymph Dis 2014;2(1):8-14.
8. van Gent WB, Hop WC, van Praag MC, et al. Conservative
versus surgical treatment of venous leg ulcers: A prospective,
randomized, multicenter trial. J Vasc Surg 2006;44:563-71.
9. van Gent W, Wittens C. Influence of perforating vein surgery
in patients with venous ulceration. Phlebology 2013 Dec 19.
[Epub ahead of print].
10. Carpentier PH, Blaise S, Satger B. A multicenter randomized
controlled trial evaluating balneotherapy in patients with
advanced chronic venous insufficiency. J Vasc Surg 2014;
59:447-54.