Venous hypertension and leg ulceration

  • 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

Arterial ulcer

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
Lipodermatosclerosis Venous 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

Marjolin's ulcer

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.

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

Stacey M C.  Investigation and treatment of chronic venous ulcer disease.  Aust NZ J Surg 2001;  71:  226-229.

 

 
 

Last updated: 05 January 2008

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