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INTRODUCTION

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Venous and lymphatic circulation is an essential component of the vascular system. When one considers disorders of extremity circulation, arterial insufficiently usually comes to mind. However, an adequate peripheral vascular circulation must also include a healthy venous and lymphatic system, which is extremely important to complete the cycle. A healthy heart with normal cardiac pump ejection fraction is also, of course, an essential component of healthy circulation. Congestive heart failure, other organ system failures, and many other conditions may contribute to limb swelling in patients with venous hypertension or lymphatic obstruction.

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This chapter is dedicated to the types of direct treatment available for problem wounds related to abnormalities of the venous and lymphatic systems. Care of wounds as well as management of all of the factors contributing to venous and lymphatic diseases, as discussed previous chapters, is critical in the long-term care and prevention of venous and lymphatic wounds. This requires communication and professional interaction among all of the patients' physicians.

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Clinicians in practice have recently realized that management of recurrent venous ulcerations is difficult and is a long-term challenge. More than 40% of patients present with their first ulcer before 50 years of age, and recurrence rates are reported to be as high as 72% within 1 year of treatment.1 Other associated illnesses that have affected wound healing of venous and lymphatic ulcers are also discussed.

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WOUND PRESENTATION AND ASSESSMENT

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Most patients with wounds initially seek care from a primary care physician or nurse. In the early phase of lymphatic or venous skin ulcerations, simple treatment with Unna's boot, elevation, topical antiseptics, systemic antibiotics, and patient compliance may result in rapid healing. This is particularly true in younger patients and patients who have not had previous wounds. If the wound does not improve after 30 days of care or if the wound is unusual, it is appropriate for the initial treating physician or nurse to refer the patient to a wound treatment center or appropriate specialist for a more detailed evaluation and specialized wound care.

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ULCERS SECONDARY TO VENOUS DISEASE

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The venous system begins at the postcapillary level where venules join to form small veins, which coalesce to larger veins that travel from the skin and subcutaneous tissue to the more central location of the deep venous system. Deep veins are generally paired, having numerous anastomoses, and are located parallel with the respective artery in the calf, joining to the popliteal vein, which proceeds upward in the thigh as the femoral vein, where it joins the deep femoral vein and the greater saphenous vein to form the common femoral vein. The greater saphenous vein (GSV) is found anterior to the medial malleolus and may be bifurcated along its course. The saphenous vein in the calf is connected to the deep veins through numerous perforator veins. The majority of patients with ...

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