Venous stasis is when the blood .. therefore oxygen .. cannot
'reach' .. areas of the body .. either through .. stoppage .. or
inability to .. force its' way .. through .. the tiny little tubes
that are the blood flowing 'aqueducts' / piping.

The blood flowing aqueducts / piping consist of four different sizes
of pipe ..  large , big , medium , small.

Milkshake cannot flow through .. small.

Therefore the 'thicker' / more syrupy / sludge like .. the blood ..
the less .. the blood is able to perfuse / reach .. therefore .. lack
of oxygen therefore .. gangrene .. or hypoxia .. AT .. the POINT .. of
blood flow stoppage.

Hence the appearance of hemosiderin / iron FROM destroyed red blood
cells / hemolysis .. AT the .. point .. OF .. lack of blood flow /
venous stasis.

Red blood cells are destroyed WHEN .. blood stoppage happens.

<<snip>>
Hemosiderin staining is caused by the degradation of red blood cells
within the interstitial spaces in the epidermis and dermis. The skin
takes on a grayish brown color caused by the deposition of the iron-
containing pigment.
<<snip>>

Venous stasis can be caused BY **increased** red blood cells
PRODUCTION / erythrocytosis.

Erythrocytosis causes hyperviscosity / thick .. syrupy like .. blood.

Low-iron diet treats erythrocytosis.

http://www.medscape.com/viewarticle/548009_1

'It Hurts When I Walk:' Venous Stasis Disease - Differential Diagnosis
and Treatment
Posted 02/07/2007

Cynthia A. Worley, BSN, RN, COCN, CWCN

Author Information
Challenges are what make life interesting; overcoming them is what
makes life meaningful." - Joshua J. Marine

Introduction
I am in the process of redecorating my master bedroom and decided to
make a new duvet cover for the comforter. The only area in the house
large enough for cutting fabric is on the living room floor. Needless
to say, I've been crawling around on the floor a lot lately. And,
consequently, I've been taking a lot of over-the-counter pain
relievers as a result. I don't think I have arthritis or joint disease
(although I am of a certain age when one begins to think in those
terms and wonder "am I getting too old for some of the activities I
engage in?"). The pain associated with venous stasis disease is much
worse than ordinary musculoskeletal discomfort. Imagine that every
step you take feels like someone is driving a nail through your leg
and then connecting that nail to an electrical outlet so that the pain
travels up and down your leg. This type of pain is not relieved by
Advil®!

Chronic venous insufficiency is related to more than 70% of lower-
extremity ulcers and it is estimated that up to 1 million people in
the United States are affected by the disease. Approximately 3.5% of
the population 65 years of age and older are affected by chronic
venous insufficiency and 2 million workdays are lost annually
(Falanga, 1997; Rudolph, 1998). Patients experience increased stress,
pain, decreased quality of life, and difficulty in coping with the
symptoms and manifestations of the disease. In addition to the
psychosocial problems caused by venous leg ulcers, the financial costs
can be significant. Venous disease cannot be controlled without
certain permanent lifestyle changes. Notice, I said controlled not
cured.

Introduction
Some wound care professionals believe that patients with chronic
venous insufficiency and venous stasis ulcers are the most difficult
patients to treat because there is a significant lifestyle factor
involved in the etiology of the problem. We know that venous leg
ulcers are associated with pain and a decreased quality of life
(Phillips, Stanton, Provan, & Lew, 1994) and the incidence of
recurrence through improper diagnosis is high (Erikson et al., 1995).
So, in this article, diagnosis and treatment will be discussed.

Because venous, arterial, neuropathic, and mixed-etiology ulcers have
many characteristics in common, it is important to perform a thorough
assessment along with a history and physical in order to gather all
the information required to make an accurate determination. There are
several distinguishing characteristics of venous ulceration that will
separate its diagnosis apart from other lower-extremity ulcerations.
To further "cloud" the diagnosis is the fact that up to 26% of
patients with venous disease also have arterial insufficiency as well
(Nelzen, Bergqvist, & Lindhagen, 1997).

Differential Diagnosis
One of the initial signs of venous disease is venous congestion and
dilation of the saphenous vein along the medial area of the calf.
Pitting edema in the ankle area toward the end of the day is another
differentiating characteristic. Skin color changes also assist in
ruling out other types of insufficiency ulcers. The texture of the
skin will also change over time in the patient with untreated or
poorly controlled venous stasis disease.

Hemosiderin staining is caused by the degradation of red blood cells
within the interstitial spaces in the epidermis and dermis. The skin
takes on a grayish brown color caused by the deposition of the iron-
containing pigment. Venous dermatitis usually indicates longstanding
disease and is characterized by erythema and scaling. Large quantities
of exudates cause skin maceration and small breaks in skin integrity.
Absorption of topically applied substances leads to sensitization and
increases risk for allergic reaction or contact dermatitis in this
population. Atrophic blanche is another potential finding from the
assessment and is characterized by a white, avascular, sclerotic area.
Lipodermatosclerosis is the term used to describe the indurated, waxy,
and fibrotic texture of the skin in the "gaiter" area. Pulses in the
feet and ankle are not considered diagnostic of venous stasis disease.
The lower extremity has an inverted "champagne bottle" appearance.
Table 1 provides an outline of the major characteristics of venous
stasis ulcers.

Diagnostic Evaluation
Although the characteristics of the ulcer may lead the wound care
professional to diagnose chronic venous stasis disease, it is prudent
to perform diagnostic testing to confirm the suspected condition.
Ankle-Brachial Index, Doppler ultrasonography, tourniquet testing,
photoplethysmography (using a transducer and infrared light source),
venography, and duplex imaging are all accepted methods of determining
a differential diagnosis. It should be understood, however, that each
of these methods are used to determine the particular components of
the vascular system involved in the disease process and the specific
pathology. For example, tourniquet testing is used to identify
valvular incompetence in the superficial venous system. The Ankle-
Brachial Index (ABI) is determined by dividing the ankle systolic
pressure by the brachial systolic pressure (ABI of 0.7-0.9 generally
correlates with adequate perfusion; results below this benchmark
indicate arterial disease). Doppler ultrasound is used to verify if
pulses are present if the edema present prevents accurate palpation of
those pulses. Photoplethysmography is used to provide a measure of
venous filling times and venous reflux. Venography is used prior to
surgery to provide details of the venous system. Duplex imaging is the
standard diagnostic tool for assessing venous disease. It is a highly
sensitive testing method used to determine not only the viability of
the anatomy involved but also the hemodynamic function of all three
venous systems.

Management of the Patient with Venous Ulcers
Obviously, the first priority in management is to address the
underlying etiology of the condition. Restoring adequate venous return
reduces venous hypertension, thereby controlling edema and increasing
velocity of blood flow. This, in turn, decreases WBC margination and
extravasation into the surrounding tissues. Surgical and nonsurgical
strategies for correction of venous flow may include surgical
obliteration or ligation of the affected veins, valvular repair,
compression therapy, elevation and pharmacologic therapy.

Surgical management may be the treatment of choice if the ulcers are
resistant to more conservative therapies or if venous obstruction is
present. In the presence of primary superficial disease, vein ligation
or stripping may minimize venous congestion and hypertension. Valvular
procedures are used to correct deep vein pathology.

Compression therapy is the application of externally applied pressure
as a means of facilitating normal venous flow and has long been
considered a cornerstone of treatment and prevention of recurrence of
ulceration. The critical factor in the success of compression therapy
is patient compliance. Compression increases interstitial tissue
pressure, opposing extravasation of blood and fluid into surrounding
tissues, and also supports reabsorption of extravasated fluids. Com
pression also increases fibrinolytic activity and possibly also
inhibits platelet aggregation, which contributes to the management of
lipodermatosclerosis. The amount of compression is dependent upon the
severity of the disease and venous hypertension and the pressure must
be applied in a gradient fashion; the highest pressure is delivered to
the ankle, with the gradual lessening as the pressure approaches the
knee. Unna's boots, multiple layer compression bandages, sequential
compression boots (pneumatic devices), and other short and long-
stretch bandages can all be used to manage the patient's venous ulcer
during healing.

Elevation, along with compression therapy, contributes to the
reduction of edema. Patients should be encouraged to elevate the feet
above the thighs while sitting and above the level of the heart when
lying down to encourage venous return.

Pharmacologic agents have been studied for their supposed ability to
reduce edema, enhance fibrinolysis, and promote anti-coagulation. To
date, their efficacy in treating venous hypertension has not been
demonstrated. Only hemorrheologic agents have shown any benefit as
they decrease blood viscosity and WBC adhesion while increasing
fibrinolysis (pentoxifylline [Trental®]). Aspirin, heparin, ifetroban,
and prostaglandin E1 have been studied for a potential role in healing
of venous ulcers but have yet to demonstrate efficacy. Topical growth
factors have not shown benefit in treating venous ulcerations.

Summary
Venous stasis disease represents 70% to 90% of lower-extremity ulcers
treated. Venous hypertension brought about by inadequate venous return
and defective valvular systems is the main culprit. Positive outcomes
in patient care can be achieved by an ongoing partnership between the
health care provider and the patient to control the disease and its
effects. Appropriate assessment and management require a long-term
commitment by a multidisciplinary team to encourage and enhance
patient compliance and to prevent recurrence.

Who loves ya.
Tom

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