What is the pathophysiological mechanism by which Chronic Venous Insufficiency (CVI) leads to the development of a Venous Leg Ulcer (VLU)?

From the Guidelines

Chronic venous insufficiency leads to ulcers due to sustained venous hypertension that damages skin and underlying tissues, and the most effective treatment is compression therapy with a minimum pressure of 20 to 30 mm Hg, as recommended by the most recent study 1. This condition occurs when damaged valves in leg veins fail to properly return blood to the heart, causing blood pooling in the lower extremities. The increased pressure forces fluid into surrounding tissues, creating edema and reducing oxygen delivery to skin cells. Over time, this oxygen deprivation causes tissue breakdown, inflammation, and fibrosis. The compromised skin barrier becomes vulnerable to minor trauma, which can initiate ulcer formation. Some key points to consider in the management of chronic venous insufficiency include:

• Compression therapy is the mainstay of treatment, with pressures of 30 to 40 mm Hg advised for more severe disease 1
• Improved ejection fraction in refluxing vessels and higher extrinsic pressures were achieved when higher pressures were exerted at the calf over the distal ankle (negative graduated compression bandage) 1
• Adherence to compression therapy should be encouraged with proper fitting, education, and detailed instructions 1
• There is evidence that compression therapy has value in preventing ulcer recurrence and healing ulcers, particularly with 30 to 40 mm Hg inelastic compression 1
• Caution is advised when the ankle-brachial index is <0.6, as it indicates an arterial anomaly needing revascularization 1
• The use of compression therapy has been shown to be effective in healing chronic venous ulcers, with a systematic review of 7 RCTs reporting that chronic venous ulcers healed more quickly with compression compared with primary dressings alone, noncompression bandages, and usual care without compression 1

From the Research

Chronic Venous Insufficiency and Ulcer Formation

• Chronic venous insufficiency leads to venous hypertension, which is thought to be the primary underlying mechanism for venous ulcer formation 2
• Venous hypertension is caused by venous reflux or obstruction, resulting in blood pooling, hypoxia, inflammation, swelling, and skin changes, ultimately leading to venous leg ulcers (VLU) 3
• The pathophysiology of VLU involves a cascade of morphological, physiological, and histologic abnormalities, including poorly functioning or incompetent venous valves, reduced venous return, and increased venous pressure 3

Risk Factors and Prognostic Signs

• Risk factors for the development of venous ulcers include age, family history of chronic venous insufficiency, higher body mass index, history of pulmonary embolism or superficial/deep venous thrombosis, and lower extremity skeletal or joint disease 2
• Poor prognostic signs for healing include ulcer duration longer than three months, initial ulcer length of 10 cm or more, presence of lower limb arterial disease, advanced age, and elevated body mass index 2

Treatment and Management

• Current evidence supports treatment of venous ulcers with compression therapy, exercise, dressings, pentoxifylline, and tissue products 2
• Endovenous ablation and surgical intervention to correct superficial venous reflux can improve healing and decrease recurrence rates 4
• Micronized purified flavonoid fraction (MPFF) and other venoactive drugs can be used as adjunct therapies to speed VLU healing and improve CVD symptoms 5