Venous ulcers: A reappraisal analyzing the effects of neuropathy, muscle involvement, and range of motion upon gait and calf muscle function

Narrative Review of the Pathogenesis of Stasis Dermatitis: An Inflammatory Skin Manifestation of Venous Hypertension

INTRODUCTION

Stasis dermatitis (SD), also known as venous dermatitis, is a form of inflammatory dermatitis of the lower extremities that typically occurs in older individuals and represents a cutaneous manifestation of venous hypertension. Venous hypertension (also known as sustained ambulatory venous pressure) is most often due to retrograde blood flow, which occurs due to calf muscle pump failure. This failure is most commonly secondary to incompetent venous valves, valve destruction, or obstruction of the venous system. Many of the common symptoms associated with SD are caused by inflammatory processes.

METHODS

This review summarizes the pathogenesis and key role of inflammation in SD by reviewing inflammatory biomarkers associated with SD. The literature was selected though a high-level PubMed search focusing on keywords relating to inflammation associated with SD.

RESULTS

Venous reflux at the lower extremities causes venous hypertension, which leads to chronic venous insufficiency. High venous pressure due to venous hypertension promotes the local accumulation and extravasation of inflammatory cells across the vascular endothelium. Leukocyte trapping in the microcirculation and perivascular space is associated with trophic skin changes. Cell adhesion molecules are linked with the perpetuated influx of activated leukocytes into inflammatory sites. Here, inflammatory cells may influence the remodeling of the extracellular matrix by inducing the secretion of proteinases such as matrix metalloproteinases (MMPs). The increased expression of MMPs is associated with the formation of venous leg ulcers and lesions. Phosphodiesterase 4 activity has also been shown to be elevated in individuals with inflammatory dermatoses compared to healthy individuals.

DISCUSSION

Because inflammation is a key driver of the signs and symptoms of SD, several of the highlighted biomarkers of inflammation represent potential opportunities to target and interrupt molecular pathways of cutaneous inflammation and, therefore, remediate the signs and symptoms of SD.

CONCLUSION

Understanding the pathogenesis of SD may help clinicians identify drivers of inflammation to use as potential targets for the development of new treatment options.

Plethysmographic features of calf pump failure in chronic venous obstruction and reflux

BACKGROUND

Calf pump failure (CPF) is a common concept in chronic venous disease. Dorsal vein pressures were originally used to define the pathophysiology. More recently, an abnormal ejection fraction (EF) and residual volume fraction (RVF) with air plethysmography (APG) have been substituted for its diagnosis. The relationship between reflux and calf pump function has been studied extensively. Reflux is thought to be the main cause of CPF, although other mechanisms may play a secondary role. Data mining in our dataset revealed that CPF is frequently found in nonrefluxive limbs-an unexpected finding. We analyzed the APG features of CPF in nonrefluxive limbs of a large cohort of patients investigated for chronic venous disease in our clinic. Data from refluxive limbs (control) seen over the same period was included for comparison. Venous obstructive pathology was variably present in both subsets. Iliac vein stent outcome in CPF limbs from both subsets is included. The role of obstruction in CPF is currently unknown.

METHODS

Records of 13,234 limbs in 8813 patients evaluated for suspected chronic venous disease over a 22-year period were analyzed. Prestent and poststent data in 406 CPF limbs (129 nonrefluxive; 277 refluxive) that underwent iliac vein stenting to correct associated stenosis are included. This is a single-center retrospective analysis of prospectively collected data. Duplex and APG data were available for included limbs. A RVF of more than 50% was defined as CPF. A reflux time of greater than 1 second elicited with automated cuffs in the erect position was defined as reflux.

RESULTS

There were 7780 (59%) limbs with reflux and 5454 (41%) that were nonrefluxive. Supine venous pressure, an index of venous obstruction, was elevated in both subsets. The incidence of CPF was 25% in refluxive limbs and 16% in nonrefluxive limbs totaling 2790 limbs. Venous volume and venous filling index were significantly elevated (P = .0001) in refluxive limbs compared to nonrefluxive limbs. The EF was diminished (<50%) in all CPF limbs except in a small fraction (n = 427 [3%]). Stent correction of iliac vein stenosis corrected CPF, normalizing the RVF in both subsets.

CONCLUSIONS

CPF frequently occurs in nonrefluxive limbs with incidence only slightly less than in refluxive limbs. An RVF of more than 50% seems to be a practical definition of a CPF; an EF of less than 50% is associated with a RVF of greater than 50% in 97% of analyzed limbs. Prospective identification of CPF in limbs with chronic venous disease may allow more detailed investigation of its cause (preload, afterload, neuromuscular pathology or joint immobility, etc) and direct more targeted treatment than currently practiced.

Clinical and immunologic differences in cellulitis vs. pseudocellulitis

Introduction: The immunologic mechanisms between cellulitis and pseudocellulitis differ greatly, even though their clinical presentations may overlap.Areas covered: This article discusses cellulitis and common entities within the pseudocellulitis spectrum including acute lymphedema, superficial venous thrombosis, allergic contact dermatitis, lipodermatosclerosis, stasis dermatitis, erythema nodosum, cutaneous gout, and bursitis. The literature search was conducted from PubMed search engine between March and May 2021.Expert commentary: While immunologic differences in cellulitis and the various entities of pseudocellulitis are clear, there is a practice gap in applying these differences to the clinic and hospital setting. Further, existing studies are weakened by the lack of a gold-standard diagnosis in this disease category. Additional work is necessary in developing a gold-standard for the diagnosis and secondly, to project these immunologic differences as biomarkers to differentiate sterile inflammation from a potential life threatening bacterial or fungal infection.

Comparative efficacy and safety of traditional Chinese medicine for lipodermatosclerosis: A protocol for systematic review and network meta-analysis

BACKGROUND

Lipodermatosclerosis (LDS) is a severe skin change accompanied by the development of chronic venous disease of the lower extremities. Its main clinical manifestations are erythema, induration, hyperpigmentation, and rough and thickened skin. It may also eventually lead to refractory ulcers, skin necrosis and even cancer. Conventional treatment methods mainly include the intake of oral anabolic hormones or androgen and pressure therapy. However, patients often refuse due to their drug resistance and intolerance. As a clinical irreplaceable treatment method for LDS, traditional Chinese medicine (TCM) has not been compared of the safety and effectiveness so far. Therefore, we cannot wait to use a method to compare the efficacy of TCM for LDS systematically, such as network meta-analysis (NMA).

METHODS

We will retrieve the relevant Chinese and English databases comprehensively. All the randomized controlled trials of TCM for LDS from January 2015 to September 2020 will be included. Under the guidance of inclusion criteria, 2 researchers will screen the literature, then assess the risk of bias and extract data. We will use Bayesian NMA to evaluate all available evidence in STATA 14.0 and WinBUGS software.

RESULTS

This study will use Bayesian NMA to evaluate the efficacy and safety of TCM for LDS.

CONCLUSION

This study provide a reliable theoretical basis for the clinical application of TCM in the treatment of LDS, and contribute to the formulation of treatment guidelines for LDS.

Ambulatory venous pressure, air plethysmography, and the role of calf venous pump in chronic venous disease

BACKGROUND

Ambulatory venous pressure (AMVP) records pressure dynamics with calf exercise. Air plethysmography (APG) measures related volume detail. APG has been suggested as a noninvasive surrogate for AMVP. We examine the correlations between APG and AMVP parameters and the role of "calf pump failure" in chronic venous disease (CVD).

METHODS

A total of 8456 limbs in 4610 patients investigated for CVD during a 20-year period were analyzed. APG and AMVP data were available in 4599 limbs for calculation of Pearson correlation coefficient; 1347 of these limbs had significant iliac vein stenosis, proven by intravascular ultrasound. Venn diagrams are used to explore overlapping incidence of APG and AMVP abnormalities.

RESULTS

APG calf volume and reflux (venous volume, venous filling index) showed progressively significant deterioration with advancing Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) clinical class, anatomic extent of reflux (superficial, deep, perforator), and reflux severity (axial reflux, segmental score). Notably, calf ejection volume increased in a nearly linear fashion (R = 0.71) to venous volume such that residual volume fraction (RVF) remained normal even in the worst of these categories. AMVP too progressively deteriorated with clinical disease and reflux severity. Venous filling time was the key parameter as the pressure drop alone was abnormal in only 4% of the limbs analyzed. There was no correlation between RVF and AMVP (R = 0.22) or between AMVP and many other APG parameters. Venn distribution showed only minor overlap (30%) between AMVP and key APG abnormalities overall, but the overlap increases from 40% to 70% in advanced clinical and reflux categories. AMVP was rarely abnormal (7%) when APG was normal. Median AMVP was normal in calf pump failure categories, however defined (subnormal ejection fraction, RVF, or both). Median AMVP is normal in venous obstruction without reflux, while AMVP abnormalities are associated three to seven times more with reflux than with obstruction.

CONCLUSIONS

APG (venous filling index) is a useful index of reflux. Calf pump ejection is a powerful and plastic compensatory mechanism, and calf pump failure is rare. Ambulatory venous hypertension is dominantly associated with reflux and less with obstruction. AMVP too worsens with clinical and reflux severity categories. However, there is little correlation between APG and AMVP parameters as APG measures volume and AMVP measures pressure, each in its own domain, and the volume-pressure curve is nonlinear. AMVP may be omitted in routine clinical testing if APG is normal, as the yield (7%) will be very low. AMVP reflects venous hypertension, the end stage in CVD. AMVP should be used to identify such cases when APG is abnormal.

A scoping review on Chronic Venous Disease and the development of a Venous Leg Ulcer: The role of obesity and mobility

OBJECTIVE

The risk factors obesity and reduced mobility are not well known in the development of a Venous Leg Ulcer (VLU). The aim of this scoping review is to explore the mechanisms by which obesity and reduced mobility contribute the development of a VLU in patients with Chronic Venous Disease (CVD).

METHODS

For this scoping review a search was performed in May 2019 in the Cochrane Library and Pubmed to identify studies on the working mechanisms of obesity and mobility in developing a VLU. Hand searches were performed to find additional studies explaining the working mechanisms (indirectly related to the VLU). Two reviewers independently reviewed the abstracts and full-text articles.

RESULTS

Twenty-eight studies met our eligibility criteria. Disturbed range of ankle motion and gait can lead to a reduced Calf Muscle Pump (CMP) function which leading to a venous outflow disorder. Increased abdominal pressure due to obesity can lead to a venous outflow obstruction and increased adipose tissue mass results in an increase in adipokine secretion. The venous outflow disorder, outflow obstruction and increased adipokine secretion can all lead to chronic systemic inflammation, increased endothelial permeability and hence microcirculatory dysfunction. This alone can result in a VLU.

CONCLUSION

Obesity and reduced mobility can lead to a reduction of the CMP function, an increase in abdominal pressure and an increase in adipose tissue mass. This can simultaneously lead to haemodynamic changes in the macro- and microcirculation of the lower extremities and eventually in a VLU. In patients with obesity and reduced mobility the microcirculation alone can lead to skin changes and eventually a VLU. Therefore, early recognition of CVD symptoms in patients with obesity and reduced mobility is crucial to diagnose and treat CVD to prevent a VLU.

Evaluation of osteopontin expression in chronic wounds: a potential prognostic and therapeutic biomarker

OBJECTIVE

Osteopontin (OPN) is abundantly expressed during tissue repair, acting as a powerful chemokine that recruits inflammatory cells such as neutrophils, macrophages, and Langerhans cells. The role of OPN in chronic wounds has not been explored. In this study, we assess the expression levels of OPN in chronic wounds to assess its potential contribution to the exacerbated inflammation seen in chronic ulcers, which is thought to contribute to poor healing.

METHODS

This retrospective study included archived biopsies of chronic wounds from several aetiologies. Immunohistochemical staining and blind analysis of OPN expression were carried out.

RESULTS

We assessed biopsies from venous leg ulcers (n=5), diabetic foot ulcers (n=5), pyoderma gangrenosum (n=5), squamous cell carcinoma ulcers (n=4), and calciphylaxis ulcers (n=3). The data revealed that all these sets of chronic ulcers expressed high levels of OPN.

CONCLUSION

This study provides strong histopathologic evidence that OPN expression is significantly increased in chronic wounds, suggesting that its upregulation could contribute to the exacerbated inflammation. Furthermore, further characterisation of the role of OPN in wound healing could aid the development of specific and efficient anti-OPN therapies for the treatment of chronic wounds.

Radiofrequency Thermal Ablation Heat Energy Transfer in an Ex-Vivo Model

Little work has been done to consider the temperature changes and energy transfer that occur in the tissue outside the vein with ultrasound-guided vein ablation therapy. In this experiment, a ex-vivo model of the human calf was used to analyze heat transfer and energy degradation in tissue surrounding the vein during endovascular radiofrequency ablation (RFA). A clinical vein ablation protocol was used to determine the tissue temperature distribution in 10 per cent agar gel. Heat energy from the radiofrequency catheter was measured for 140 seconds at fixed points by four thermometer probes placed equidistant radially at 0.0025, 0.005, and 0.01 m away from the RFA catheter. The temperature rose 1.5°C at 0.0025 m, 0.6°C at 0.005 m, and 0.0°C at 0.01 m from the RFA catheter. There was a clinically insignificant heat transfer at the distances evaluated, 1.4 ± 0.2 J/s at 0.0025 m, 0.7 ± 0.3 J/s at 0.0050 m, and 0.3 ± 0.0 J/s at 0.01 m. Heat degradation occurred rapidly: 4.5 ± 0.5 J (at 0.0025 m), 4.0 ± 1.6 J (at 0.0050 m), and 3.9 ± 3.6 J (at 0.01 m). Tumescent anesthesia injected one centimeter around the vein would act as a heat sink to absorb the energy transferred outside the vein to minimize tissue and nerve damage and will help phlebologists strategize options for minimizing damage.

Optimizing calf muscle pump function

Background The tip toe manoeuvre has been promoted as the gold standard plethysmography test for measuring calf muscle pump function. The aim was to compare the tip toe manoeuvre, dorsiflexion manoeuvre and a body weight transfer manoeuvre using the ejection fraction of air-plethysmography and evaluate which has the best pumping effect. Methods Sixty-six archived tracings on 22 legs were retrieved from an air-plethysmography workshop and analysed. Pumping performance was measured using the calf volume reduction after each manoeuvre. Results Expressed as median [inter-quartile range], body weight transfer manoeuvres resulted in a significantly greater ejection fraction (%) than tip toe manoeuvres at 59.7 [53.5-63.9] versus 42.6 [30.5-52.6], P < 0.0005 (Wilcoxon). There was no significant difference in the ejection fraction between the tip toe manoeuvre versus dorsiflexion manoeuvre, P = 0.615. The repeatability (confidence interval: 95%) of 66 ejection fraction tests was excellent: tip toe manoeuvre (±1.2), dorsiflexion manoeuvre (±1.3) and body weight transfer manoeuvre (±1.6). Conclusion The body weight transfer manoeuvre appears to be a better method of measuring the full potential of the calf muscle pump with a 40.1% relative increase in the ejection fraction compared to a tip toe manoeuvre. Exercises which involve body weight transfers from one leg to the other may be more important in optimizing calf muscle pump function than ankle movement exercises.

Effects of isokinetic calf muscle exercise program on muscle strength and venous function in patients with chronic venous insufficiency

Objective The aim of this study was to observe the change of the ankle joint range of motion, the muscle strength values measured with an isokinetic dynamometer, pain scores, quality of life scale, and venous return time in chronic venous insufficiency diagnosed patients by prospective follow-up after 12-week exercise program including isokinetic exercises. Methods The patient group of this study comprised 27 patients (23 female, 4 male) who were diagnosed with chronic venous insufficiency. An exercise program including isokinetic exercise for the calf muscle was given to patients three days per week for 12 weeks. At the end of 12 weeks, five of the patients left the study due to inadequate compliance with the exercise program. As a result, control data of 22 patients were included. Ankle joint range of active motion, isokinetic muscle strength, pain, quality of life, and photoplethysmography measurements were assessed before starting and after the exercise program. Results Evaluating changes of the starting and control data depending on time showed that all isokinetic muscle strength measurement parameters, range of motion, and overall quality of life values of patients improved. Venous return time values have also increased significantly ( p < 0.05). Conclusion In conclusion, increase in muscle strength has been provided with exercise therapy in patients with chronic venous insufficiency. It has been determined that the increase in muscle strength affected the venous pump and this ensured improvement in venous function and range of motion of the ankle. In addition, it has been detected that pain reduced and quality of life improved after the exercise program.

A specifically designed aquatic exercise protocol to reduce chronic lower limb edema

Objective Despite the fact that muscle pump activation is known to positively impact chronic lower limb edema, objective measurements of standardized exercises for venous-lymphatic rehab are lacking. The aim of this investigation is to determine the effectiveness of an addressed physical activity exploiting the advantages of an aquatic environment. Material and methods Thirty-two lower limbs of 16 patients affected by bilateral chronic leg swelling were included (12 females, 4 males). All the patients underwent a protocol of five sessions of physical exercises specifically conceived inside a pool. Volumetry, subcutaneous thickness, ankle range of motion and symptomatology were assessed as outcome measures. Results One week after the end of the protocol, the average reduction in lower limb volume was 303.13 ± 69.72 ml ( p = 0.00002) and 334.38 ± 62.50 ml ( p = 0.000003) in the right and left legs, respectively. Ankle range of motion and feeling of heaviness significantly improved. Conclusion A specifically designed aquatic protocol is able to positively impact chronic leg swelling offering a first line rehab for this medical condition.

The effect of ankle range of motion on venous ulcer healing rates

Limitation of ankle movement may contribute to calf muscle pump failure, which is thought to contribute to venous leg ulcer formation, which affects nearly 1 million Americans. We therefore wished to study ankle movement in patients with venous leg ulcers and its effect on healing. Using goniometry, we measured baseline ankle range of motion in venous leg ulcer patients from a Phase 2 dose-finding study of an allogeneic living cell bioformulation. Two hundred twenty-seven patients were enrolled in four active treatment groups and one standard-care control group, all receiving compression therapy. Goniometry data from a control group of 49 patients without venous disease, from a previous study, was used for comparison. We found patients with active venous leg ulcers had significantly reduced ankle range of motion compared with the control group (p = 0.001). After 12 weeks of therapy, baseline ankle range of motion was not associated with healing, as there was no significant difference between healed and nonhealed groups, suggesting that ankle range of motion is not important in venous leg ulcer healing or, more likely, is overcome by compression. However, patients with venous ulcers located on the leg (as opposed to the ankle) had significantly higher ankle range of motion for plantar flexion and inversion (p = 0.021 and p = 0.034, respectively) and improved healing with both cell bioformulation and standard care (p = 0.011), suggesting that wound location is an important variable for ankle range of motion as well as for healing outcomes.

Radiofrequency Ablation as First-line Treatment of Varicose Veins

Endovascular radiofrequency ablation is a minimally invasive method to safely treat symptomatic refluxing varicose veins. A retrospective chart review was used to determine patient demographics, disease severity, treatment algorithm, and outcome in patients who underwent radiofrequency ablation of symptomatic refluxing veins that had failed conservative management. Statistical analysis was done using GraphPad Demo Version (San Diego, CA). Two hundred forty-one limbs in 179 patients (average age, 53 years; 73% females, 27% males) were treated. Preprocedure Clinical Etiological Anatomic and Pathologic (CEAP) scores were C2s: 236, C3s: 4, and C5s:1. Procedures were performed in the office using tumescent anesthetic; all patients could ambulate immediately after the procedure. Postprocedure total occlusion (TO) rate was seen in 93 per cent of limbs (223 limbs) at 3 months and 91 per cent of limbs (220 limbs) at 12 months posttreatment. No relationship was found between patients who did not have total occlusion and age, sex, diameter of veins, CEAP scores, preoperative reflux time, and volume of tumescent anesthetic ( P > 0.05). The VNUS procedure is an in-office, minimally invasive procedure with a low complication rate and quick recovery. Total occlusion rates are high and there is improvement in disease severity after treatment.

The calf muscle pump revisited

BACKGROUND

Chronic venous disease (CVD) defines the spectrum of manifestations of venous disease that originate as a result of ambulatory venous hypertension. Thus far, the role of the calf muscle pump in the development and potentiation of CVD has been overlooked and understated in the clinical setting, with much greater emphasis placed on reflux and obstruction. The aim of this review is to explore the level of significance that calf muscle pump function or dysfunction bears on the development and potentiation of CVD.

METHODS

EMBASE and MEDLINE databases were searched with keywords "calf" AND "muscle" AND "pump" AND "venous" AND "insufficiency" AND ("lower limb*" OR "leg*"), screened for cross-sectional and longitudinal studies relating to chronic venous insufficiency, highlighting the role of the calf muscle pump in CVD and the extent to which the calf muscle pump is impaired in these cases. This resulted in the inclusion of 10 studies.

RESULTS

Compared with healthy subjects, patients with CVD have a reduced ejection fraction (15.9%; P < .001) and an increased venous filling index (4.66 mL/s; P < .001), indicating impairment in calf muscle pump ejection ability as well as poor venous competence. Calf muscle pump dysfunction is present in 55% of patients with CVD in the literature, but this did not reach significance on meta-analysis. Isotonic exercise programs in patients with active and healed ulcers have been shown to increase calf muscle pump function but not venous competence.

DISCUSSION

Calf muscle pump failure is a therapeutic target in the treatment of CVD. Evidence suggests that isotonic exercise treatment may be an effective method of increasing the hemodynamic performance of the calf muscle pump.

CONCLUSIONS

This review emphasizes the requirement for more attention to be placed on the treatment of calf muscle pump failure in cases of CVD by use of exercise treatment programs or other methods, which may be of clinical importance in managing symptomatic disease. To establish this in routine clinical practice, these results would need to be replicated in appropriate clinical trials. It would also be logical to look at other modifiable muscle pumps, such as the thigh and foot, and to explore the potential benefit of electrical devices acting on the leg (eg, electrical muscular or neuromuscular stimulation), especially for those patients in whom exercise capacity is limited.

The use of ultrasound in the evaluation of the efficacy of calf muscle pump function in primary chronic venous disease

OBJECTIVES

To evaluate popliteal vein blood flow during calf muscle contraction in chronic venous disease (CVD) patients and healthy controls using ultrasound imaging and to investigate the relationship between venous blood flow and gastrocnemius muscle (GM) morphology.

METHODS

Thirty-one subjects participated in this study (mean age: 40.3 [11.8] years), 15 healthy controls and 16 with CVD (clinical classification: C₁₋₄). Popliteal vein cross-sectional area and venous blood flow velocity (FV) were evaluated by Doppler ultrasound at baseline and during three sets of 10 tip-toe movement repetitions. Muscle thickness, muscle fascicle length and pennation angle of both medial and lateral GM were measured by ultrasound. Measures were repeated a week later in 17 participants in order to assess reproducibility with intraclass correlation coefficient (ICC) and Bland-Altman analysis.

RESULTS

Peak FV was lower in CDV group compared with Control group for both first (40.6 [11.8] versus 62.4 (22.1) cm²/second; P = 0.021) and last (30.4 [9.1] versus 49.5 (22.7) cm²/second; P = 0.024) contraction. In CVD group, peak FV during first contraction increased with GM's muscle fascicle length (r = 0.63; P = 0.041). Popliteal FV also increased with rising range of muscle fascicles pennation change between ankle dorsiflexion and plantar flexion (r = 0.70; P = 0.025). No associations were found between haemodynamics and medial or lateral GM thickness. Calf muscular architecture was similar in both CVD and control participants. Test-retest reliability of FV measured in the same session was high (ICC≈0.70) for measures taken in the first contraction of the set but lowered when using the last contraction (ICC<0.50). Reproducibility of ultrasound evaluation of calf pump is acceptable within the same session but is unsatisfactory when testing in separate days.

CONCLUSION

Patients with moderate CVD have lower FV during calf muscles contraction but similar muscle anatomical characteristics compared with healthy controls. Changes in calf muscles flexibility and fatigue resistance may be investigated as possible causes of calf pump dysfunction.

Epidemiology and aetiology of C4-6 disease

Although our understanding of chronic venous insufficiency (CVI) has improved, many important questions remain unanswered. Ensuring that patients are appropriately referred for specialist assessment and then receive evidence-based, cost-effective treatment continues to be challenging. The lifetime of risk of chronic venous ulceration (CVU) is around 1% with approximately 10% ulcers being open at any one time. The incidence skin changes disease is about 10 times greater (10%). However, many of the studies upon which these estimates are based are old and/or methodologically flawed. There is reason to believe that the incidence, prevalence and characteristics of CVI/CVU may have changed considerably over the last 10-20 years and that future change is likely. Further cross-sectional and longitudinal epidemiological studies are required to establish the size and nature of the health-care need going forward in developed and increasingly developing countries. CVI culminating CVU is primarily the result of sustained ambulatory venous hypertension, which in turn arises from superficial and/or deep venous reflux with or without deep vein obstruction. However, there are many other elements to this complex condition, for example, microvascular dysfunction; calf muscle pump efficiency; dermal inflammation; disordered fibroblast function and matrix production; failure of epithelialization; congenital and acquired thrombophilia; malnutrition, obesity and diet; and bacterial colonization. None of the currently available treatment modalities is entirely satisfactory and novel therapies based upon a clearer understanding of the disease at the psychological, genetic, mechanical, microvascular and microscopic level are required.

Routine diagnostic venous ultrasound and las for leg edema of unknown cause

OBJECTIVE

To verify the diagnostic efficiency of venous duplex ultrasound and lymphangioscintigraphy (LAS) in establishing the cause of leg edema and to clarify the pathology of these leg edemas.

MATERIALS AND METHODS

Between April 2009, and March 2010, 62 patients with leg edema of unknown origin were referred to the Edema Clinic of the Yamaguchi University Graduate School of Medicine. All patients underwent a venous duplex ultrasound scan and LAS.

RESULTS

Of 62 patients, lymphatic insufficiency, venous insufficiency or both was diagnosed in 42 (68%), and lymphedema, in 29 (47%). Venous duplex ultrasound detected obvious venous disorders in only 13 (21%), and for 20 patients, the ultrasound and LAS did not reveal any abnormalities; however, for 15 of the 20 (24% of all patients), venous edema was attributed to functional causes.

CONCLUSION

Venous duplex ultrasound and LAS assisted in the diagnosis of leg edema of unknown origin and also proved useful in establishing treatment strategies.