Chronic leg ulcers: the impact of venous disease

Influence of gene polymorphisms in ulcer healing process after superficial venous surgery

OBJECTIVE

Role of superficial venous surgery in reducing the time it takes for ulcers to heal is still controversial, although all studies confirm a significant reduction in ulcer recurrences. Recently, the HFE-C282Y and FXIII-V34L gene variants demonstrated a role in the risk of venous ulceration in primary chronic venous disorder (CVD) and in modulating lesion size in chronic venous ulcer (CVU), respectively. This study was conducted to investigate the role of HFE-C282Y and FXIII (V34L and P564L) gene variants in ulcer healing time after superficial venous surgery, by assessing the outcome of a cohort of homogeneous CVU patients.

METHODS

The study selected 91 patients affected by primary CVU (CEAP C6, Ep, Asp, Pr), with the exclusion of any other comorbidity factor involved in delayed healing process, who underwent surgery. We assessed the ulcer area and the healing time. Patients were genotyped by polymerase chain reaction for FXIII (V34L and P564L) and for HFE-C282Y substitutions.

RESULTS

Globally, CVU cases had a postoperative mean healing time of 8.5 +/- 5.7 weeks. For the subset of cases above and below the median value (M = 8.0 weeks), FXIII-V34L genotype distribution significantly differed (P < .0001). In addition, Kaplan-Meier analysis yielded specific healing time profiles for the different FXIII-V34L classes of genotype (P = .00001), with an increased risk of delayed healing for the FXIII-VV genotype (hazard ratio, 4.14; 95% confidence interval, 2.1 to 8.2; P = .00005). Although FXIII-P54L genotype distributions did not differ, homozygous 564LL cases (P = .005) and double carriers for both FXIII variants (P < .0001), had a significantly reduced healing time vs wild types. No differences in healing time were observed between carriers and noncarriers of the HFE-C282Y variant, whereas when these cases were stratified by FXIII-V34L genotypes, the L34 carriers had a significantly shorter healing time, irrespective of the HFE genotype.

CONCLUSION

The FXIII-34L variant was significantly associated with shorter healing time after superficial venous surgery, suggesting a role in the healing and tissue regeneration phases. Conversely, HFE-C282Y, despite its role in ulcer establishment, did not affect the postoperative healing time. In perspective, the identification of patients with a poor prognosis may give clinicians the opportunity to modify management and to target tailored therapies in the view of a new and alternative concept of treatment based on pharmacogenomics.

Dystrophic calcification as a cause for non healing leg ulcers

Despite advances in molecular biology and a repertoire of other therapeutic options, chronic venous leg ulcers remain a significant problem within our society. There are various reasons, both local and systemic, which contribute to the non healing nature of such wounds. Among them, dystrophic calcification (DC) or calcified deposits within the ulcer bed, although rare, is an overlooked and a seldom reported cause. In the presence of DC, wound healing cannot proceed through a timely and orderly manner resulting in a non healing ulcer. In this article, we discuss the aetiology, pathophysiology and the management options of this rarely reported condition. We also report their clinical prognosis using a series of patients with venous ulcers complicated by DC leading to difficulties in healing.

Venous ulcers

Veneous ulcers are extremely common, accounting for a large proportin of all lower extremity ulcers. Due to their chronicity and relatively high prevalence, their impact on the cost of healthcare and the lives of the patients affected is quite significant. There has been progress in understanding the pathophysiology, clinical features, and diagnosis of these ulcers, but the basic principles of care have remained consistent for almost a half century. To allow for optimal healing, it is important to maintain a clean moist wound bed, treat any clinically significant infection, and decrease surrounding edema.

A sociodemographic, clinical study of patients with venous ulcer

BACKGROUND

Venous ulcer is the most serious consequence of chronic venous insufficiency and is responsible for almost 70% of chronic leg ulcers. The main purpose of this research was to describe social, demographic and clinical characteristics of patients with venous ulcers and to identify some professional repercussions of this pathology.

SUBJECTS AND METHODS

We evaluated patients with a clinical picture compatible with venous ulcer. The sociodemographic characteristics of the patients, and the clinical characteristics and professional repercussions of the pathology were studied. We used the ankle-brachial index to identify associated arterial disease. The body mass index (BMI) was used for the classification of the nutritional condition of the patients.

RESULTS

A total of 120 patients were included in the study (90 females and 30 males; 80.8% White; 44.2% > 60 years old). Ninety-one per cent of the patients had been in education for less than 4 years, and 89.7% were on the poverty line. Thirty-five per cent were retired, 2.5% were receiving government help due to disease and 4.2% were unemployed. About 16% of patients were out of work due to the disease, and 49.2% presented some degree of disability in terms of work tasks. The ulcer area was less than 30 cm(2) in 69.1% of patients. The first ulcer episode occurred in 13.4 years on average, and 64.2% of patients had recurrent episodes. Females presented on average 5.65 pregnancies, and 75.4% of patients were overweight.

CONCLUSION

Venous ulcer occurred mainly in the low-income population, who presented with little formal education. Generally, the ulcers were present for a long time and were recurrent, with repercussions for the capabilities of patients to work.

Venous ulcer: epidemiology, physiopathology, diagnosis and treatment

This review discusses the epidemiology, pathogenesis, diagnosis and current therapeutic options for venous ulcer. Venous ulcer is a severe clinical manifestation of chronic venous insufficiency (CVI). It is responsible for about 70% of chronic ulcers of the lower limbs. The high prevalence of venous ulcer has a significant socioeconomic impact in terms of medical care, days off work and reduced quality of life. Long-term therapeutics are needed to heal venous ulcers and recurrence is quite common, ranging from 54 to 78%. Thrombophlebitis and trauma with long-term immobilization predisposing to deep venous thrombosis are important risk factors for CVI and venous ulcer. The most recent theories about pathogenesis of venous ulcer have associated it with microcirculatory abnormalities and generation of an inflammatory response. Management of venous leg ulcers is based on understanding the pathogenesis. In recent years novel therapeutic approaches for venous ulcers have offered valuable tools for the management of patients with this disorder.

Leg Perforator Vein Incompetence: Functional Anatomy

PURPOSE

To retrospectively determine the anatomic patterns of reflux of incompetent perforator veins (IPVs) at the sites of their highest prevalence in relation to the anatomic distribution of valvular incompetence in the veins of the calf and thigh, with emphasis on the deep system, across the clinical spectrum of chronic venous disease (CVD).

MATERIALS AND METHODS

This study was granted institutional ethics committee approval; the need for patient consent was waived. Five hundred five limbs in 359 consecutive subjects who were suspected of having CVD but did not have arterial disease, prior venous thrombosis (<1 year), venous or orthopedic surgery, or vascular malformations were clinically stratified for CVD according to the clinical, etiologic, anatomic, and pathophysiologic (CEAP) system and underwent venous hemodynamic investigation with duplex ultrasonography. One hundred thirty limbs were CEAP clinical classes C(0-1), 262 limbs were classes C(2-3), and 113 limbs were classes C(4-6). IPV reflux patterns and anatomic distribution of deep venous reflux in the lower limb were determined across the clinical classes of CVD. Statistical analysis was performed with Spearman rank correlation, chi(2), and Mann-Whitney testing.

RESULTS

Valvular incompetence in limbs with IPVs increased with CEAP clinical class (P < .01) in femoral, popliteal, posterior tibial, peroneal, gastrocnemial, and soleal veins; reflux was distributed evenly across these veins. Of 554 IPVs found, 377 (68.0%) occurred at four sites: middle third of medial calf (n = 165 [29.8%]), lower third of medial calf (n = 85 [15.3%]), middle third of medial thigh (n = 73 [13.2%]), and middle third of posterior calf (n = 54 [9.7%]). IPVs with superficial and deep reflux in adjoining veins, as compared with IPVs with superficial reflux alone, increased as clinical class increased from C(2) to C(6) (P < .02) at all four sites of highest IPV prevalence; determined in detail, reflux patterns of IPVs were linked to CEAP clinical class (P < .05) but not anatomic site (P > .2). Most IPVs in C(1-3) limbs had superficial reflux alone. IPVs with superficial reflux outnumbered IPVs with superficial and deep reflux even in C(4-6) limbs, where deep venous incompetence was most prevalent. Axial venous reflux (proximal-to-distal) changes (P > .4) were small in superficial and deep veins across the spectrum of CEAP clinical classes C(2-6).

CONCLUSION

Patterns of perforator reflux were linked to clinical severity of CVD in the CEAP classification and displayed an even distribution anatomically. IPVs with deep and superficial reflux in adjoining veins increased with CEAP clinical class, in line with valvular incompetence in the deep veins of the calf and thigh.

Catheter-directed thrombolysis for deep venous thrombosis

Venous thromboembolism (VTE) represents a significant clinical problem, affecting patients of all age groups, nationalities, and socioeconomic strata. Despite its prevalence, the paradigms for care are largely centered around primary or secondary prophylaxis, with less emphasis on actual treatment of the thrombus. With the recent rapid development of advanced endovascular techniques, it is now feasible to dissolve many thrombi using catheter-directed thrombolysis (CDT), and favorable clinical experience has been reported in over 600 patients. If performed safely, the purported benefits of CDT for DVT include a decreased incidence of persistent phlebitic symptoms, improved quality of life and, possibly, a decreased incidence of recurrent thrombotic events.

Varices. Insuffisance veineuse chronique. Ulcères des membres inférieurs. Point de vue

PURPOSE

Lower limbs chronic venous disorders are still considered as a minor disease from a university hospital point of view, yet it is a very common problem, affecting the quality of life, generating disability, and expensive for healthcare resources. Its teaching is neither satisfactory nor easy to do.

KEY POINTS

Apart from the fact that it rarely causes death, the complexity of venous anatomy and physiopathology, the lack of animal model, common practices lumping together visible varicose veins and chronic venous insufficiency, and moreover a certain carelessness in the vocabulary probably largely explain these difficulties. Our purpose is to discuss chronic venous disorders (varicose veins, chronic venous insufficiency, venous ulcers) on the basis of semantic, of anatomical, haemodynamic and clinical forms and finally of nosology.

'Real' epidemiology of varicose veins and chronic venous diseases: the San Valentino Vascular Screening Project

The aim of this study was to evaluate the prevalence and incidence of venous diseases and the role of concomitant/risk factors for varicose veins (VV) or chronic venous insufficiency (CVI). The study was based in San Valentino in Central Italy and was a real whole-population study. The study included 30,000 subjects in eight villages/towns evaluated with clinical assessment and duplex scanning. The global prevalence of VV was 7%; for CVI, the prevalence was 0.86% with 0.48% of ulcers. Incidence (new cases per year) was 0.22% for VV and 0.18% for CVI; 34% of patients with venous disease had never been seen or evaluated. The distribution of VV and CVI in comparison with duplex-detected incompetence (DI) indicates that 12% of subjects had only VV (no DI), 2% had DI but no VV, 7.5% had DI associated with VV, 2% apparent CVI without DI, 3% DI only (without CVI), and 1.6% both CVI and DI. VV associated with DI are rapidly progressive and CVI associated with DI often progresses to ulceration (22% in 6 years). VV without significant DI (3%) and venous dilatation without DI tend to remain at the same stage without progression for a lengthy time. New cases per year appear to have a greater increase in the working population (particularly CVI) possibly as a consequence of trauma during the working period. In older age (>80 years), the incidence of CVI tends to decrease. Ulcers increase in number with age. Only 22% of ulcers can be defined as venous (due to venous hypertension, increased ambulatory venous pressure, shorter refilling time, obstruction and DI). Medical advice for VV or CVI is requested in 164 subjects of 1,000 in the population. In 39 of 1,000, there is a problem but no medical advice is requested and in only 61 of 1,000, the venous problem is real. In VV in 78% of limbs, there is only reflux, in 8% only obstruction, and in 14% both. In CVI, 58% of limbs have reflux, 23% obstruction, and 19% both. In conclusion, VV and CVI are more common with increasing age. The increase with age is linear. There was no important difference between males and females. These results are the basis for future real, whole population studies to evaluate VV and CVI.

State-of-the-art treatment of chronic venous disease

The article summarizes the epidemiology, classification and differential diagnosis of venous disease and its complications. Theories of venous ulceration and diagnostic and treatment modalities are reviewed.

Chronic venous insufficiency and venous leg ulceration

Venous ulcers are the most common form of leg ulcers. Venous disease has a significant impact on quality of life and work productivity. In addition, the costs associated with the long-term care of these chronic wounds are substantial. Although the exact pathogenic steps leading from venous hypertension to venous ulceration remain unclear, several hypotheses have been developed to explain the development of venous ulceration. A better understanding of the current pathophysiology of venous ulceration has led to the development of new approaches in its management. New types of wound dressings, topical and systemic therapeutic agents, surgical modalities, bioengineered tissue, matrix materials, and growth factors are all novel therapeutic options that may be used in addition to the "gold standard," compression therapy, for venous ulcers. This review discusses current aspects of the epidemiology, pathophysiology, clinical presentation, diagnostic assessment, and current therapeutic options for chronic venous insufficiency and venous ulceration. (J Am Acad Dermatol 2001;44:401-21.)

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be familiar with the 3 main types of lower extremity ulcers and should improve their understanding of the epidemiology, pathogenesis, risk factors, clinical presentation, diagnostic assessment, and current therapies for chronic venous insufficiency and venous ulcers.