- Leg ulceration is common
- Most are due to venous hypertension
- 40% of venous ulcers are due to superficial venous disease
- Rare causes include:
- Rheumatoid arthritis
- Malignancy
- Syphilis
- Surgical correction of superficial venous disease often results in
healing
Assessment
- Clinical assessment should
- Identify previous DVT
- Assess arterial disease
- Identify varicose veins and underlying valvular incompetencies
Picture provided by Mr Robert Hicks, Northampton
General Hospital, Northampton
- Assessment requires
- Clinical examination
- Hand held doppler assessment
- Possible duplex scanning
Venous hypertension
- Affects 1-2% of population
- Due to chronic venous insufficiency and distal vein hypertension
- Usually due to post thrombotic syndrome
- Can be due to primary valvular incompetence
Causes of chronic venous insufficiency
Gravitational reflux
- Venous insufficiency classified as primary or secondary
- Primary insufficiency has no obvious cause of valvular dysfunction
- Insufficiency results in early refilling of venous pool after muscle
contraction
- Causes progressive and sustained increase in calf vein pressure
- = Ambulatory venous hypertension
- Results in capillary dilatation and leakage of plasma proteins
Compartmental pressures
- Incompetent perforating veins exposes superficial veins to high
pressures during muscle contraction
- = hydraulic ram effect
- Produces localised venous hypertension and filtration oedema
- Continues until tissue pressures rise to restore equilibrium
Leucocyte trapping
- Accumulation of leucocytes occurs in dependent limbs of those with
venous hypertension
- Trapping of WC associated with activation
- Hypoxic endothelial cells stimulate adherence of WC
- Activate WC release O2 radicals, collagenases and
elastases which injure surrounding tissue
Evaluation of venous insufficiency
- History of chronic venous insufficiency
- Exclude other causes of leg ulceration
Signs of venous hypertension
- Perimalleolar oedema
- Pigmentation
- Lipodermatosclerosis
- Eczema
- Ulceration
Pictures provided by Mr Robert Hicks, Northampton
General Hospital, Northampton, United Kingdom and Suzanne Drinkwater,
St. Thomas' Hospital, London.
Doppler ultrasonography
- Used to assess presence of venous reflux
- LSV, SSV and perforators should be assessed
- Patency of femoral and popliteal veins should be checked
- Flow augmented by compression of calf, deep inspiration or Valsalva
manoeuvre
Duplex ultrasonography
- Allow anatomical and functional assessment
- Flow rate and anatomy can be measured
Treatment of venous ulceration
Compression
- Elastic compression stockings
- Provide graduated compression
- Produce local alteration of microvascular haemodynamics
- Minimal effect on deep vein dynamics
- Do not cure hypertension - Protect skin from the effects
- Occlusive arterial disease is a relative contraindication
- Gel paste gauze boots
- CirAid
- External pneumatic compression
- Drug treatment
- Systemic agents - minimally effective
- Zinc
- Fibrinolytic agents
- Pentoxifylline
- Topical agents - not recommended
- Antibiotics
- Free radical scavengers
- Hydrocolloid dressings
Surgery
- Aims of venous ulcer surgery are:
- Cure venous hypertension
- Heal the ulcer
- Combination of superficial venous surgery and compression may be
beneficial
- Surgical options include:
- Skin grafting
- Free flap grafting
- Superficial vein stripping
- Perforating vein interruption
- Valve plasty
- Thrombolysis, dilation, stenting
Marjolin's ulcer
- First described by Jean Nicholas Marjolin in 1828
- Marjolin's ulceration is a squamous cell carcinoma arising at sites
of chronic inflammation
- Recognised underlying causes include:
- Chronic venous ulceration
- Burns
- Osteomyelitis sinuses
- Usually a long-period between injury and malignant transformation
- This period my be 10-25 years
- 40% occur on lower limb
- Malignant change is usually painless
- Nodal involvement is uncommon
- Diagnosis is confirmed by biopsy of the edge of the ulcer
- Management involves adequate excision and skin-grafting or
amputation
Picture provided by Chris Allan, Nambour Hospital,
Queensland, Australia
Bibliography
Angle N Bergan J J.
Chronic venous ulcer.
Br Med J 1997; 314: 1019 - 1022.
Barwell J R, Davies C E, Deacon J et al. Comparison
of surgery and compression with compression alone in chronic venous
ulceration (ESCHAR study): randomised controlled trial.
Lancet 2004; 363: 1854-1859.
Bergan J J, Schmid-Schonbein G W, Smith P D et al. Chronic
venous disease. N Engl J Med 2006; 355: 488-498.
Coleridge-Smith P D.
Modern approaches to venous disease.
In: Johnson C D, Taylor I. eds.
Recent advances in surgery 23.
Edinburgh,
Churchill Livingstone, 2000 :
125-140.
Moffatt C J Franks P J.
The community management of venous ulceration.
Curr Pract Surg 1994;
6: 12-15.
Harding K G Leaper D J.
The hospital management of venous ulceration. Curr Pract Surg 1994;
6: 8-11.
Sarkar P K, Ballentyne S. Management of leg ulcers.
Postgrad Med J 2000; 76: 674-682
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