Venous ulcers: etiology and care of patients treated with human skin equivalent grafts

Care for a patient with a venous ulcer is complex, necessitating collaboration of a multidisciplinary team to achieve the goal of providing comprehensive wound care and optimally managing complications, current conditions, and healing time. Patients often have venous ulcers for a long time, and they frequently have multiple diagnoses. Chronic ulcers that do not heal necessitate closure with a graft. Apligraf, (Novartis Pharmaceutical Corp, East Hanover, NJ), a human skin equivalent, is often used in nonhealing or difficult-to-heal ulcers. Knowledge of how to care for the grafted wound and protection of the grafted site is essential.

[The results of combined surgical treatment of the occlusive forms of the deep vein thrombosis with the trophic ulcers in the lower extremities]

The results of treatment of 156 patients with occlusion forms of the deep veins thrombosis of the lower extremities and trophic ulcers are adduced. The partial or complete thrombectomy the shunting, Linton and Cockett operations, plastic interventions, the pulmonary artery embolism prophylaxis were conducted, and the late terms--the vibro- and hydromassage.

Lipodermatosclerosis is characterized by elevated expression and activation of matrix metalloproteinases: implications for venous ulcer formation

Lipodermatosclerosis refers to skin induration of the lower extremities and is associated with patients preceding venous ulcerations. To better understand the pathogenesis of ulcer formation we investigated the expression of matrix metalloproteinases (MMP) and tissue inhibitors of metalloproteinases (TIMP) in lipodermatosclerosis. By preparing biopsies from healthy skin and liposclerotic lesions, MMP-1, MMP-2, MMP-9, TIMP-1, and TIMP-2 were analyzed by using reverse transcriptase-polymerase chain reaction, western blot, zymography, hydrolysis of [3H]labeled collagens, and immunohistochemistry. Our investigations provide evidence that mRNA and protein expression of MMP-1, MMP-2, and TIMP-1 were significantly increased in lipodermatosclerosis, whereas the total amount of MMP-9 and TIMP-2 mRNA and protein was not altered. Western blot of liposclerotic lesions revealed an inactive proMMP-1-TIMP-1 complex, whereas MMP-2 was prominent as an active 66 kDa band. Increased proteolytic activity of MMP-2 could be proven in lesional in comparison with healthy skin by zymography and [3H] collagen degradation. Increased diffuse staining was found for MMP-1 in the epidermis and dermis in comparison with controls. In lipodermatosclerosis, MMP-2 was predominantly localized in the basal and suprabasal layers of the epidermis, in perivascular regions, and in the reticular part of the dermis. Furthermore, MMP-2 was imbalanced by locally reduced expression of TIMP-2 in the basement membrane zone of lesional skin. Our findings indicate lipodermatosclerosis to be characterized by elevated matrix turnover.

[Differential ulcus cruris diagnosis]

Most leg ulcers are of venous or arterial origin (85%). Advanced chronic venous insufficiency is the most common underlying condition (65%), followed by advanced peripheral arterial occlusive disease (10%), and combined chronic venous insufficiency and peripheral arterial occlusive disease (10%). Chronic ulcers in diabetic feet (5%) are of great socio-economic importance, as well. They are a consequence of diabetic polyneuropathy which in part of the patients may be combined with peripheral arterial occlusive disease, usually of the calf arteries. However, a leg ulcer can also be caused by a large array of other underlying conditions, such as ulcerating skin tumours, trauma followed by disturbed wound healing, infectious ulcerations, ulcerations in angiodysplasias, vasculitic ulcerations, pyoderma gangrenosum, cholesterol-embolism, idiopathic livedo reticularis with ulceration, primary and secondary antiphospholipid-antibody-syndrome, coumarin-necrosis, calciphylaxis in chronic renal insufficiency, necrobiosis lipoidica, different forms of panniculitis, hematologic disorders, autoimmun diseases and autoimmun-bullous dermatoses. The following article discusses the differential diagnosis, examination and treatment of leg ulcers in these less common underlying conditions.

[Ulcus cruris--vascular etiology and surgical treatment options]

Leg ulcers comprise a problem with various contributing factors requiring selective therapy adapted to the underlying cause. The majority can be classified as arterial (approx. 20%) or venous (approx. 80%) ulcers. Arterial ulcers as well as most mixed (arterial-venous) ulcers can be treated by arterial reconstruction and subsequent skin grafting, with additional ligation of perforator veins or (segmental) stripping of the saphenous vein. Leg ulcers due to chronic insufficiency of the deep venous system are most often the result of previous deep venous thrombosis followed by recanalization and development of a postthrombotic syndrome. Compression regimens remain standard therapy with emphasis on preventing ulcer formation. Ulcer healing can be achieved by compression therapy although recurrence rates are high. Surgery is not the treatment of first choice for leg ulcers, however, in selected cases surgical therapy is indicated. To prevent recurrence, continued consistent compression, keeping the patient well-informed and offering supportive guidance are imperative.

Pathophysiology and management of venous ulcers

Venous ulcers account for the majority of chronic lower extremity wounds. The cause of venous ulceration is not completely understood; however, risk factors, such as a history of deep venous thrombosis (DVT) and a family history of venous ulceration, have been identified. Venous ulceration is postulated to occur when fibrin cuffs form, leading to increased diffusion distance and impaired local perfusion. This article will review the cause, pathophysiology, clinical manifestations, and management of venous ulcers.

Nutrition, tissue oxygenation, and healing of venous leg ulcers

The purpose of the prospective study described in this article was to explore nutrition, tissue oxygenation, and healing in venous ulcer patients. Nutritional risk, anthropometric measures, biochemical indices, two 3-day dietary records, and transcutaneous tissue oxygen levels were obtained. Wound surface area was evaluated 2 times, 4 weeks apart. A convenience sample of 25 English-speaking persons with 1 or more venous ulcers participated (mean age 59.8 years, 60% men, 48% white). Moderate or high nutritional risk existed in 84% of the persons in the sample. Based on body mass index, more than 50% of the persons in the sample were obese. Nonetheless, 17 of 25 persons in the sample had 1 or more abnormal biochemical nutritional indices. In addition, caloric intake (17 of 20), protein intake (15 of 20), and zinc intake (17 of 20) were inadequate to meet the needs for healing. No statistically significant relationships were found between biochemical nutritional indices, tissue oxygenation, and healing. The women in the sample were more likely to heal than were the men (P < 0.05). This study begins to document the problems of overnutrition and undernutrition in the venous ulcer population. Future studies need to explore the effects of obesity and inadequate intake on the healing of venous ulcers. Additional examination of the differences between men and women also is warranted to identify predictors of venous ulcer healing.

Venous leg ulcers

Venous ulcers are the most common form of leg ulcers and their incidence is increasing as the population ages. The diagnosis should be confirmed with tests for venous insufficiency and an assessment of arterial disease determined by a Doppler Ankle-Brachial ratio. The most important component of venous ulcer treatment is the use of high compression bandages for pitting edema. Non-healing ulcers may require a skin biopsy of the edge to confirm the diagnosis, medical treatment for woody fibrosis, adjustment of compression therapy, or use of a skin substitute or biological preparation.

Anatomy, physiology and venous ulceration

For many years it was believed that disease within the deep venous system, such as a deep vein thrombosis or post-phlebitic limb, was the main cause of venous ulceration. There is, however, increasing awareness of the impact of both deep and superficial venous valvular incompetence and reflux on the aetiology and healing of venous ulceration. It is now widely accepted that superficial venous disease alone can result in increased venous pressure at the ankle and subsequent skin damage and ulceration.

The 4 rights of compression therapy for patients with chronic venous insufficiency and venous ulceration

Compression therapy has become an ever increasing component in the care of patients with Chronic Venous Insufficiency (CVI) and venous ulcerations. Although compression therapy is of great benefit to many of these patients, this treatment option does not come without risks. The increased use of compression therapy has coincided with an increase in its improper application. This article simplifies the principles of compression and highlights the common pitfalls of its use, with an emphasis on the home healthcare setting.

Dermal oedema assessed by high frequency ultrasound in venous leg ulcers

Oedema is considered a key pathogenic factor in the development of venous leg ulcers. The purpose of this study was to determine the localization of oedema in legs with ulcers. Twelve patients with 13 venous leg ulcers (one bilateral), with a duration of 7-18 months, were examined by high-frequency B-mode ultrasound scanner. This was performed at three sites in the leg (low, middle and upper sites of the lower leg). In the same group of patients, the legs without ulcers were used as controls. The echogenicity and the thickness of the whole dermis were quantified by digital image analysis; the echogenicities of the upper (papillary) and lower portions of the dermis were measured. In the upper site no significant difference was found between the legs with ulcers and controls. In the middle and low sites of legs with ulcers, the dermal echogenicities were 34% and 64% (P < 0.01) less than those in controls, and the dermal thicknesses were 0.4 mm and 0.8 mm (P < 0.01) thicker than those in controls, respectively. This indicated intradermal oedema existing in the lower part (gaiter area) of the legs with ulcers. The ratios of low echogenic pixels in the upper and lower portions of the dermis, in the middle and low sites of legs with ulcers, were 0.5 and 0.9 (P < 0.05 and P < 0.01), respectively, higher than those in controls, suggesting the papillary dermis as a preferential site of oedema formation. The present study demonstrates that in the low sites of legs with ulcers, a marked increase in oedema was seen in the papillary dermis. This may add to the understanding of the origin of leg ulcers in the gaiter area of the leg.

Venous leg ulcers. Part 1: Aetiology

A sound knowledge of the physiology of the venous system is necessary to understand how venous leg ulcers develop. The main risk factors are thrombus formation and venous incompetence and nurses should be alert to the signs of these conditions.

Foot venous pressure measurement for evaluation of lower limb venous insufficiency

PURPOSE

Foot venous pressure measurement is considered to be useful for assessing lower limb venous insufficiency, because venous hypertension is the main factor predisposing to venous insufficiency. In this study, we investigated the utility of foot venous pressure measurement in the evaluation of venous insufficiency.

METHODS

A total of 148 limbs of 101 patients with venous insufficiency associated with varicose veins and treated over 5 years were studied. The measurements assessed were percentage decrease in foot venous pressure with manual calf compression (%drop), rate of increase in foot venous pressure during a 4-second period after release of compression (4SR%), and time to 50% recovery of foot venous pressure (RT50).

RESULTS

A higher incidence of skin changes (clinical, etiologic, anatomic, and pathophysiologic classification classes 4 to 6) caused by venous insufficiency was associated with %drop, 4SR%, and RT50 values. Skin changes were found in more than 50% of the limbs with a %drop less than 50%, 4SR% more than 50%, or RT50 less than 4 seconds. After tourniquets were applied to occlude the superficial veins, limbs with severe below-knee deep venous reflux (%drop 60.3 +/- 14.6, 4SR% 36.7 +/- 30.2, RT50 13.9 +/- 14.7) showed significantly worse values than those with no reflux (%drop 79.9 +/- 3.2, 4SR% 8.1 +/- 3.1, RT50 48.9 +/- 17.9) or with mild above-knee reflux (%drop 77.0 +/- 5.0, 4SR% 7.1 +/- 3.2, RT50 46.9 +/- 26.7). After sclerotherapy or surgical treatment, including deep venous reconstruction for severe below-knee reflux, all limbs showed significant improvement in clinical manifestations and foot venous pressure values (%drop 68.1 +/- 7.5 to 76.5 +/- 5.8, 4SR% 33.1 +/- 12.9 to 12.7 +/- 7.6, RT50 7.5 +/- 4.2 to 20.1 +/- 6.5).

CONCLUSION

Foot venous pressure measurements showed a good correlation with clinical severity and degree of venous reflux and were very useful for evaluating the outcome of therapy for venous insufficiency.

[Comparison of combined treatment for venous ulcers in postphlebitic syndrome and use of PGE-1--introductory remarks]

We have included PGE-1 to the clinical management of varicose ulcers of the leg. We found the results very interesting and promising. The literature on using PGE-1 for this disease entity is rather poor and the biomechanics is still unclear.

A straightforward venous ulcer. Or is it?

Venous ulcers are common in clinical practice. They are due to end stage skin and subcutaneous damage from sustained venous hypertension. The common cause may be post thrombotic syndrome or primary superficial venous insufficiency. This case illustrates the need to think of inherited thrombophilia as a primary cause.

A review of the factors influencing nonrecurrence of venous leg ulcers

The literature on external prevention strategies for recurrence of venous leg ulcers is reviewed to assess the extent of existing knowledge and the effectiveness of preventive practices currently employed. Although there is some evidence that the use of compression hosiery is effective in reducing the incidence of recurrence, other strategies cited for ulcer prevention are not supported by documented research. It is also evident that patient compliance with wearing compression hosiery could be improved and that an evaluation of the effectiveness of hosiery currently available is overdue. With district nurses spending up to 50% of their time treating venous leg ulcers, not only are they in a key position to disseminate information on effective prevention to patients, but in so doing they should contribute to a reduction in their leg ulcer treatment caseload. To do this, nurses need to be more informed on aspects of venous leg ulceration and prevention strategies.

Hydrostatic leg ulcers: a new classification

The classification of leg ulcers into standard aetiologies was conducted using a sample of 205 patients referred to the department of dermatology, Malmö University Hospital in Sweden. Patients with venous ulcers formed the largest group (51%). Classification was not possible in 31 patients (approximately 15%) and this formed the second largest group. A comparison of ulcer characteristics between this unclassified group and the venous ulcer group showed that the unclassified ulcers occur in patients with little or no venous disease and display different characteristics from venous ulcers. As a result of these differences, we propose that there should be a further classification of ulcers, known as 'hydrostatic' ulcers. The identification of this type of ulcer has important consequences for future ulcer management as these patients will not require venous surgery or further compression therapy following healing.