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Addressing the Root Cause of Chronic Leg Ulcers Through Perforator Ablation

Addressing the Root Cause of Chronic Leg Ulcers Through Perforator Ablation

A guest blog by Dr. Douglas H. Joyce, DO, FACOS, FACPh (pictured above). This is an 8-minute read.

At the Joyce Vein & Aesthetic Institute (JVAI) in southern Florida, we see patients who travel long distances to receive care for venous leg ulcers, chronic venous insufficiency, and other related conditions. I have patients who fly in from Germany, the United Kingdom, South Africa, and other places around the world.

Most of them have persistent leg ulcers that simply will not heal. It’s common that these patients have seen multiple other health providers and have tried other treatments over a very long period of time without positive outcomes. But with our treatment at JVAI, about 95% of these ulcers finally resolve.

Targeting the underlying cause of the ulcer is our primary approach. In this article, I’d like to share some background about our techniques and explain how we’re seeing such positive results, even for patients with advanced venous disease.

Understanding Superficial Venous Hypertension

First, let’s look at what is causing these chronic leg ulcers: superficial venous hypertension. If you look at the venous system of the leg, the superficial system drains into the deep system. As a person walks, pressure builds up and moves fluid all the way up to their heart.

In this system there are valves that open and close, and if these valves don’t function correctly, there is an imbalance of pressure that can reach as far as the skin. It is with these valves and pressures that we sometimes see a problem begin to occur.

There are about 150 perforator veins in a person’s leg and each has a valve that can malfunction. So when a valve isn’t functioning correctly, it creates pressure, almost like a pressure washer shooting up under the skin every time the person takes a step.

This causes the artery system supplying all of this movement to become overwhelmed. There’s so much back pressure involved that the skin is stretched and stressed. Sometimes, the patient nicks their skin and this is where a non-healing wound begins to form.

From this point, when the person is exercising - doing squats, running on a treadmill, or performing other movements that put pressure on the legs - they are creating enormous pressure on the deep system. The pressure sends blood shooting back up toward their heart, but at the same time, the pressure also shoots toward their skin. 

As a result, a single weak spot on the skin is getting bombarded with pressure over and over again. This is an example of how someone develops a venous ulcer that can be very difficult to heal without addressing the underlying issue.

Controlling the Pressure on the Perforators

Our goal is to control the pressure on the perforators and set the stage for wound healing. There are several methods of treatment in order to do this. 

One of the more traditional methods of treatment uses a viscous material that mixes into a foamy solution and is injected into the veins. However, this treatment is best for spider veins and isn’t recommended for the perforators we are discussing here.

Another well-known treatment is radiofrequency. We have found that a radiofrequency unit is about 87% effective after spending 7 to 9 minutes on each perforator. However, this solution is time-consuming, expensive, and can be somewhat painful for the patient.

At JVAI, we treat this condition using a newer and more efficient method: lasers. A laser doesn't impact the vein itself. It turns the blood at the tip of the laser into a ball of steam, which expands against the wall of the vein and destroys it.

The Perforator Ablation Procedure

During the procedure, we take the needle and place it in the center of the perforator, then slide a fiber into the middle of the needle. For about 20 seconds, we create the interaction needed to generate steam at the tip. Afterward, the perforator is gone.

Sometimes we treat a single perforator during a patient’s visit, and sometimes we do multiple sites at a time. I’ve seen patients with severe issues in their legs, including lymphedema and tremendous ulcerations, and all they could really handle is one perforator ablation per visit. We do what makes each patient comfortable and what makes the most sense for their individual health situation. 

We’ve done thousands of these procedures and our patients have been very happy with them. There is almost no risk of complications and the procedure works very well, even for people with extreme cases. In fact, people who have extreme cases are our specialty.

Lymphedema and Venous Disease

Many of my patients have a combination of lymphedema and venous disease. Therefore, they may wonder how much improvement they will see after the laser perforator ablation.

Here’s a general rule of thumb: If about 50% of the problem is being created by venous disease, you will see about 50% improvement, and if more is being caused by venous disease you may see more improvement.

Every single one of my patients has been satisfied to at least have the venous portion of their problem corrected. And, of course, the venous disease alone could be causing edema and creating an additional issue where oxygenation and tissue are compromised. 

By treating venous disease, we are preventing the progression of further problems that could become much worse over time. This provides the patient with a huge step forward in their health prognosis.

The Use of Compression Devices

Before laser treatment was available, I had all my patients start by using a sequential compression device. I would instruct them to use the compression device on their leg 2 or 3 times a day, and then add a tight stocking to maintain pressure. 

In terms of lymphatic disease and edema, these patients are experiencing a vicious cycle that has to be broken in some way. They are already prone to wounds and have delicate tissue. 

This is why the device is so important. Compression devices are phenomenal at breaking the cycle of fluid buildup and giving the tissues a chance to recover, yet they are gentle enough for frequent use.

I have seen patients with severe and stubborn wounds use compression devices and finally find some relief. They become ambulatory again, and the positive impact on their life is huge. Plus, the modern versions of these compression devices are light, portable, and so comfortable patients often find themselves falling asleep while using them.

In fact, now that laser treatment has become the go-to remedy for leg ulcers, I recommend using compression in conjunction with laser treatment. First, we should get to the root cause of the problem through laser ablation. Then we can provide additional support through compression.

I do recommend halting the use of the compression device for 5 or 6 days after each laser treatment. We don’t want to put pressure on the areas that have been recently treated, as they need some time to heal. Post-surgically, after the recommended waiting period, the patient can resume using the pump and continue reaping the benefits that come with it.

Wet vs. Dry Venous Ulcers

At JVAI, most of our patients have venous disease, with at least 40% to 50% of our patients experiencing a severe and advanced form of the disease. Before starting treatment, we examine each patient carefully to determine exactly what’s occurring in their body.

People who have venous disease tend to display either “wet” or “dry” forms of the disease, depending on the way the pressures are working and affecting the skin. In the dry case, they may have deposits that are hardening in the skin and creating spots that appear almost calloused. In the wet case, they often have weeping sores and a liquid component to the leg.

The wet form is more like edema or lymphedema. The dry form is primary venous disease. Of course, some patients have both types and experience a mix of wounds that form in their legs. 

As I encounter patients, I look for signs of edema and lymphedema and determine whether their wounds appear wet. If so, they have a fluid excess that may respond well to treatment with a compression device. I instruct them on using the device and walk them through it, step by step, to ensure they will use it correctly.

Sometimes my patients are a bit skeptical about trying a compression device, and I tell them I’ve never seen a patient that didn’t end up thinking it was wonderful.

Positive Patient Outcomes

The overall objective of our treatment at JVAI is to examine each person’s leg, find everything that’s not functioning well, work backward from the leg wound to discover the root causes involved, and methodically go in and correct each problem.

When we’re done, an ultrasound of the leg will show no remaining vein that is incompetent. Every vein is working correctly. Of course, some veins no longer exist, but all remaining veins are working properly and sending blood the right direction.

This makes all the difference in the world for our patients. We are thrilled to be helping so many people finally find relief from chronic venous ulcers.


About the author:

Douglas H. Joyce, DO, FACOS, FACPh, is a triple board-certified phlebology and cardiothoracic vascular and general surgeon who founded JVAI, the Joyce Vein & Aesthetic Institute in Punta Gorda, Florida. The center treats spider veins, varicose veins, venous leg ulcers, and chronic venous insufficiency. Dr. Joyce also has a background in pediatric heart surgery and level one trauma care.

About the article:

This article is part of an educational series created in conjunction with Medical Solutions Supplier and Lympha Press.

For 25 years, Medical Solutions Supplier has provided innovative compression pump home therapy equipment to support people with chronic and acute medical conditions. Medical Solutions Supplier works closely with organizations like LE&RN and medical professionals like Dr. Joyce to achieve the best possible patient outcomes.