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Vascular Wound Treatment in Los Angeles

Dr. Lalezarian, a vascular wound doctor in Los Angeles, explains the often-missed vascular components of difficult-to-heal lower-extremity wounds, and how minimally invasive vascular interventions can bridge the gap between traditional wound care approaches and complete healing. Learn about arterial wound & venous wound differences, symptoms, treatment, and care.
Vascular doctor treating patient with a vascular wound

Non-healing wounds usually form on the back of the lower leg between the calf and ankle, causing itchiness, leg pain, and skin discoloration. While it’s true that these wounds can be caused by injury or other conditions like diabetes, chronic lower extremity wounds that take more than 2 weeks to heal or that lead to progressively worsening skin breakdown are more than likely attributable to underlying vascular disease, and therefore benefit significantly from vascular care. In fact, vascular disease contributes to more than 90% of chronic wounds.

Obstructed blood flow is the unifying disease process in many vascular diseases, underpinning peripheral artery disease (PAD) in the arteries, chronic venous insufficiency wounds (CVI) in the veins, and a number of other localized vascular conditions like May-Thurner Syndrome and venous thromboembolism. Throughout the course of several years, these diseases disrupt blood flow to tissues, eventually damaging skin, muscles, and nerves due to lack of adequate blood supply. Over 8.5 million people in the US suffer from PAD and more than 6 million live with CVI [1,2].

Vascular wound treatment specialist Dr. Michael Lalezarian in Los Angeles, California

Your Partner in Treatment for Vascular Wounds

Dr. Michael Lalezarian

Timely, accessible care is paramount in the effort against arterial wounds, venous wounds, and their complications.

Dr. Michael Lalezarian is a double-board certified Vascular Interventional Radiologist specializing in minimally invasive endovascular arterial revascularization. He is a committed partner in the battle against the devastating consequences of advanced vascular disease.

5-Star Arterial Ulcer and Venous Ulcer care in Los Angeles
“He is truly dedicated, and an extraordinary physician who’s really concerned with his patients!”

Adrianne S, October 2018

Arterial Wound vs Venous Wound

Skin ulceration can occur when either veins, arteries, or both malfunction. Many are surprised to learn that venous insufficiency contributes to approximately 70% of vascular wounds, while arterial disease accounts for 5 to 10%. At the same time, as many as 26% of leg ulcers have both venous and arterial causes [3,4].

Causes of Arterial Wounds

Patients with PAD have plaque build-up in their arteries as a result of diabetes, obesity, high blood pressure, high cholesterol, smoking (nicotine constricts blood vessels), or other vascular disease. Hardened plaques occlude the arteries, causing them to narrow and reduce blood flow to the rest of the body. As a result, patients will often experience muscle fatigue, leg pain, and/or leg cramping. As PAD progressively worsens and becomes severe, tissues can die due to lack of oxygen obtained from the blood supply. The resulting tissue death causes difficult-to-heal wound formation. Older age and diabetes are risk factors for PAD and arterial wounds, and despite the prevalence of these two risk factors, the vascular component of arterial wounds is frequently underdiagnosed [5].

Causes of Venous Wounds

Any vein abnormality causing restricted blood flow through the vessels of the leg contributes to venous insufficiency, which can arise from a single mechanism or multiple ones. Often, venous insufficiency occurs due to an increase in venous pressure, which is caused by impaired functioning of one-way valves in the veins or the obstruction of veins by blood clots (thrombus). If the muscles that support the contraction and dilation of veins are dysfunctional, this can also trigger venous insufficiency.

Ultimately, CVI results in limited blood flow toward the heart. Without the ability to return blood back to the body’s main circulatory pump, blood pools in the extremities and backs up in the veins. The increased blood volume surpasses the veins’ natural reservoir capacity and exerts increased pressure on the vessels, causing undue stress and eventual failure. As more of the venous system is affected and blood flow is further compromised, skin color changes in the lower leg and wounds form as tissue breaks down. Risk factors for venous wound formation include: older age, sedentary lifestyle, high body mass index, arterial hypertension, deep vein thrombosis, deep vein reflux, and a family history of venous leg wounds [6].

Comparison of deep arterial ulcer on leg and shallow venous ulcer on foot
Your Partner in Vascular Care
PAD Specialist in Los Angeles

Signs & Symptoms of Vascular Wounds

Arterial Wounds

Patients who develop arterial wounds usually have a history of peripheral artery disease and present with intermittent claudication, which is achy calf pain that worsens with activity but subsides with rest. Over time, skin breakdown occurs as a result of poor blood flow to tissues and wounds form.

Arterial wounds typically develop over bony parts of the foot as well as the heels and toes, past the point of vessel occlusion. These can be shallow or deep skin wounds with or without gangrene. Arterial wounds have well-defined edges and appear to be “punched out.” The center of the wound, the wound base, is pale in color (grey or yellow). Skin surrounding the arterial wound may be red, cold to the touch, shiny, and hairless [7].

Venous Wounds

In its early, non-severe stages, venous insufficiency produces spider veins. However, down the line, varicose veins develop as a result of reflux (backwards flow of blood). The leg may begin to intermittently swell starting past the vessel blockage with accompanying pain, cramping, itching, and fatigue. Elevation and rest provide symptom relief [11].

As vein disease increases in severity, constant swelling, fat destruction (lipodermatosclerosis), and skin discoloration and deterioration occur anywhere between the knee and ankle [4, 7-9]. Appearance-wise, the skin surrounding the wound looks shiny, thin, hairless, and hyperpigmented with a brown color. The wound itself has sloping edges, and exudate fluid may ooze from the wound. Venous wounds are shallow and irregularly shaped. Pain is usually less severe compared to arterial wounds unless there is an active infection or excessive swelling.

Your Partner in Vascular Care
PAD Specialist in Los Angeles

Treatment for Vascular Wounds

Treating vascular wounds isn’t just about addressing the visible leg ulcer, but also the underlying disease process that created them in the first place. The root cause of arterial and venous wound formation is vascular disease such as advanced peripheral artery disease and chronic venous insufficiency. However, many lower extremity wounds have a multifactorial set of causes (in addition to vascular disease), and therefore require multiple, simultaneous treatment approaches.

A multidisciplinary team consisting of wound care specialists, podiatrists, physical therapists, primary care physicians, and vascular interventionalists will provide the best care for a patient suffering from venous or arterial leg ulcerations attributable to vessel disease [2-3,10]. Vascular interventionalists include general and vascular surgeons, who are best-suited to treat advanced vessel disease through invasive surgeries. They also include interventional radiologists, who specialize in minimally invasive approaches to improve blood flow.

Vascular care used to treat wounds
Endovascular treatments can greatly speed healing in stubborn wounds, and are often necessary to achieve full recovery when vascular disease is involved.

Arterial Wound Treatments

Lifestyle Changes and Medicine

Initially, treatment for arterial wounds is focused on modifying risk factors. Patients are counseled on smoking cessation and healthier dieting and may be started on an exercise program. Medications can be used to reduce blood clots, thus preventing obstructions from occurring.

Arterial Wound Care

Patients who present with open, non healing arterial wounds are typically referred to a wound doctor who will clean the wound routinely and dress it with bandages to prevent infection and promote healing of the skin. Arterial wound dressing changes do not target the underlying arterial disease that causes the wounds, however, arterial wound care is still an essential part of healing and complements other treatments.

Minimally Invasive Revascularization

Revascularization aims to improve blood delivery by reestablishing adequate flow through the artery so that ulcerations can heal. Minimally invasive procedures such as atherectomy, angioplasty, and stenting are performed to achieve revascularization.
Arterial wound before (left) and after (right) minimally invasive revascularization by Vascular Specialist Dr. Michael Lalezarian
Arterial wound before (left) and after (right) minimally invasive revascularization by Vascular Specialist Dr. Michael Lalezarian.

Your Partner in Vascular Care

PAD Specialist in Los Angeles

Venous Wound Treatments

Compression Stockings

Primary care or family medicine doctors will prescribe compression stockings as first-line, conservative therapy for venous insufficiency. Lifestyle modifications including increased exercise and healthier dieting is encouraged as well. Compression stockings are most effective when continually used long-term and when utilized in conjunction with regular leg elevation. While they provide symptom relief by improving blood flow through the veins, compression stockings do not address the root, pathological cause of venous insufficiency [13].

Venous Wound Care

Patients who present with open, non healing venous wounds are typically referred to a wound care specialist who will clean the wound routinely and dress it with bandages to prevent infection and promote healing of the skin. Changes to the wound dressing for venous leg ulcers do not target the underlying vein disease that causes venous ulceration, however, venous wound care is still an essential part of healing and complements other treatments.

Superficial Vein Closure

Superficial vein closure is performed using minimally invasive methods to seal off varicose veins so that blood is re-routed through other healthy blood vessels. Vein closure can be accomplished by injecting a chemical foam or glue into the vein or applying thermal energy [12, 14]. Superficial vein closure procedures, which are performed by interventional and vascular specialists, are the gold standard for treating varicose veins contributing to venous ulceration.

Deep Vein Revascularization

Deep vein revascularization is another minimally invasive procedure performed by an interventional radiologist or vascular specialist. During this image-guided procedure, obstructions in the deep veins are removed to improve blood flow and thereby treat venous ulceration. A variety of techniques can be employed to accomplish this task, including angioplasty, thrombectomy, and stenting. During angioplasty, a balloon device is placed along the length of the obstructed vein and inflated to force the obstruction to open. A stent is a tubular device made of a special wire material that is inserted into the blood vessel to prop it open. During thrombectomy, a device is used to mechanically remove a clot in the vein.
Wound contributing May-Thurner obstruction before (left) and after deep venous revascularization (right) by Vascular Specialist Dr. Michael Lalezarian.
Image of wound contributing May-Thurner obstruction before (left) and after revascularization therapy (right) by Vascular Specialist Dr. Michael Lalezarian.

Vascular Wound Care Specialist in Los Angeles

At ProVascularMD, we provide minimally invasive arterial wound treatment and venous wound treatment. Our vascular and interventional radiologists specialize in revascularization techniques to treat peripheral artery disease, and vein closure treatment for venous insufficiency. Give us a call today to schedule your visit!

More Resources
Peripheral Artery Disease Screening: Why Early Detection is Critical in PAD
Peripheral Artery Disease Screening: Why Early Detection is Critical in PAD
PAD signs, symptoms, risk factors, and screening methods.
Endovascular Treatment of Lower Extremity Arterial Disease
Endovascular Treatment of
Lower Extremity Arterial Disease
A brief 101 on the treatment options available for arterial disease.
Los Angeles Vascular Specialist Dr. Michael Lalezarian
Vascular Specialist in Los Angeles
Learn more about Los Angeles Vascular Specialist Dr. Michael Lalezarian.
References

[1] Peripheral Arterial Disease (PAD) Fact Sheet. Centers for Disease Control and Prevention; 2016. https://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_pad.htm. Accessed November 25, 2019.
[2] Patel SK, Surowiec SM. Venous Insufficiency. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2019. http://www.ncbi.nlm.nih.gov/books/NBK430975/. Accessed November 25, 2019.
[3] Agale SV. Chronic Leg Ulcers: Epidemiology, Aetiopathogenesis, and Management. Ulcers. 2013;2013:1-9.
[4] Hedayati N, Carson JG, Chi Y-W, Link D. Management of mixed arterial venous lower extremity ulceration: A review. Vasc Med. 2015;20(5):479-486.
[5] Shu J, Santulli G. Update on peripheral artery disease: Epidemiology and evidence-based facts. Atherosclerosis. 2018;275:379-381.
[6] Meulendijks AM, de Vries FMC, van Dooren AA, Schuurmans MJ, Neumann HAM. A systematic review on risk factors in developing a first‐time Venous Leg Ulcer. J Eur Acad Dermatol Venereol. 2019;33(7):1241-1248.
[7] Grey JE, Harding KG, Enoch S. Venous and arterial leg ulcers. BMJ. 2006;332(7537):347-350.
[8] Salcrido, R. C. Arterial vs Venous Ulcers: Diagnosis and Treatment: Advances in Skin & Wound Care. 2001;14(3):146-147.
[9] Dean SM. Cutaneous Manifestations of Chronic Vascular Disease. Progress in Cardiovascular Diseases. 2018;60(6):567-579.
[10] Foy White-Chu E, Conner-Kerr TA. Overview of guidelines for the prevention and treatment of venous leg ulcers: A US perspective. J Multidiscip Healthc. 2014;7:111-117. doi:10.2147/JMDH.S38616
[11] Meissner (2016). What is effective care for varicose veins? Phlebology, 31(1_suppl), 80–87.
[12] Gohel (2018). A Randomized Trial of Early Endovenous Ablation in Venous Ulceration. New England Journal of Medicine, 378(22), 2105–2114.
[13] Kankam (2017). A summation analysis of compliance and complications of compression hosiery for patients with chronic venous disease or post-thrombotic syndrome. European Journal of Vascular and Endovascular Surgery, 55:406-416.
[14] Lohr (2010). Radiofrequency Ablation: Evolution of a Treatment. Seminars in Vascular Surgery, 23(2), 90–100.

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