Standard, Appropriate, and Advanced Care and Medical-Legal Considerations: Part Two—Venous Ulcerations (A)
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The anatomic and pathophysiologic components of the classification will be made with these advanced tests.
The duplex scan has been shown to provide the most useful information and is considered by many to be the test of choice. This noninvasive, ultrasound-based test allows for the assessment of all three venous systems and provides anatomic extent and location of the disease. Duplex scanning also allows for the differentiation between obstruction and reflux. Other anatomic studies include ascending and descending venography, which are not utilized as frequently as they were in the past. A new tool, radionuclide venography, has been touted to detect incompetent perforating veins. Other examinations include photoplethysmography and strain-gauge plethysmography. A significant amount of work has been published on air plethysmography.[81,82] Physiological parameters, such as venous volume, ejected volume, and post-exercise residual volume, can be calculated using this device. Several measured parameters can be combined in useful ratio analyses, which correlate with the clinical severity of the venous disease. The American Venous Forum attempted to review the literature for clinicians to help them organize their approach to the diagnosis and classification of venous disease. Standard of care neglects the anatomical and pathophysiological components of the classification for venous disease. Many papers compare treatment techniques without classifying the underlying venous disease. Compression therapy may be inadequate if a patient has a large, incompetent perforator vein feeding the base of the ulcer. Compression therapy may also be inappropriate as sole therapy for recurrent ulcers. Appropriate care dictates that venous hemodynamics be completely analyzed in order to prescribe appropriate treatment plans.
The high prevalence of venous ulcers, variable healing rates, and costly new therapeutic options make it very important to attempt to identify patients who would benefit from these treatment options early in the course of therapy. Healing rates at 12 weeks range from 56 to 69 percent in one study based on the adequacy of the underlying arterial flow. Reported healing rates vary greatly in the literature, but very few wound healing papers have utilized the CEAP classification scheme, making comparisons impossible. One study noted improved healing outcomes in patients who were younger, who lacked deep vein involvement, who had wounds of shorter duration, and who had smaller initial surface areas. The initial rate of healing has been suggested to predict venous ulcer healing.[87–89] Authors are trying to identify predictive parameters to identify difficult-to-heal venous ulcer patients. Researchers disagree on terminology and study design.90 Interest has turned towards identifying biochemical markers that might offer predictions of subsequent healing. A recent paper describes the percentage change in area over four weeks as predictive for healing at 24 weeks. If validated by other researchers, this would be a simple, useful tool for stratifying patients and moving those patients identified as nonhealers into an “appropriate” care module instead of “standard” care.
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