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Vasculitic and autoimmune wounds. J Vasc Surg Venous Lymphat Disord 2016; 5:280-292. [PMID: 28214498 DOI: 10.1016/j.jvsv.2016.09.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 09/01/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Chronic wounds are a major cause of morbidity and mortality. Approximately 20% to 23% of nonhealing wounds that are refractory to vascular intervention have other causes, including vasculitis, pyoderma gangrenosum, and other autoimmune diseases. The purpose of this article was to review the literature across medical and surgical specialties with regard to refractory chronic wounds associated with vasculitis and autoimmune diseases and to delineate clinical outcomes of these wounds in response to vascular and other interventions. METHODS An electronic search encompassing MEDLINE, PubMed, Cochrane Library, and Scopus was completed using the following search terms: rheumatoid arthritis; systemic sclerosis; systemic lupus erythematosus; antineutrophil cytoplasmic antibody-associated vasculitis; mixed connective tissue disease; antiphospholipid syndrome; pyoderma gangrenosum; thromboangiitis obliterans; cryoglobulinemia; hydroxyurea; sickle cell; atrophie blanche; livedoid vasculitis; cholesterol emboli; calciphylaxis; antiphospholipid antibodies; prothrombotic; combined with the terms: chronic wound and leg ulcer. Full-text articles published in English up to March 1, 2016, that investigated the clinical outcomes of chronic wounds associated with autoimmune diseases were included. Review articles and evaluations of management of chronic wounds were also reviewed. Primary outcomes included in the review were amputation, ulcer healing, reduction in wound size, overall survival, and freedom from reintervention. Owing to the heterogeneity of data reporting among articles, qualitative analysis is also reported. RESULTS Vasculitis and autoimmune diseases play a role in 20% to 23% of patients with chronic lower extremity ulcers. Furthermore, patients with autoimmune disease have a significantly high rate of split thickness skin graft failure (50% compared to 97% in patients without autoimmune disease; P = .0002). The management of leg ulcers associated with autoimmune diseases is discussed. CONCLUSIONS Autoimmune and vasculitic causes should be considered in patients with chronic wounds who do not respond to appropriate vascular intervention and standard local wound care. A multidisciplinary approach with the involvement of rheumatologists allows investigation for underlying systemic disease and improves clinical outcomes for many of these challenging patients.
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Hinojosa CA, Olivares-Cruz S, Laparra-Escareno H, Sanchez-Castro S, Tamayo-Garcia B, Anaya-Ayala JE. Impact of optimal anticoagulation therapy on chronic venous ulcer healing in thrombophilic patients with post-thrombotic syndrome. J Wound Care 2016; 25:756-759. [PMID: 27974007 DOI: 10.12968/jowc.2016.25.12.756] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Post-thrombotic syndrome (PTS) is the long-term sequelae of deep venous thrombosis (DVT). PTS clinical manifestations include chronic leg pain, oedema, lipodermatosclerosis and ulcers. The objective of this study is to determine in patients with documented history of thrombophilias and DVT whether the number of previous thrombotic events and optimal anticoagulation therapy are associated with the time to venous ulcer healing following the start of compression therapy. METHOD Retrospective analysis performed in thrombophilic patients under the age of 50 years old with chronic venous ulcers secondary to DVT at the wound clinic in the National Institute of Medical Sciences and Nutrition 'Salvador Zubirán ' in Mexico City. Variables such as the number or episodes of thrombotic events, type of hypercoagulable disorder, optimal anticoagulation therapy with Warfarin monitored by therapeutic International Normalised Ratio (INR) (2-3) and compliance to compression therapy were examined. Patients that underwent superficial or perforator vein interruption or endovascular recanalisation of deep veins were excluded from the study. RESULTS From a database of 29 patients with chronic venous ulcers followed in our clinic from January 1992 to September 2012, only 13 patients (61% female) met the inclusion criteria. Mean age±standard deviation (SD) was 32±12 years old. Of these, seven (54%) patients with suboptimal INR presented with an average of two previous thrombotic events and the remaining six (46%) patients with optimal INR only one event (p=0.28), the mean time to the clinical manifestation of a venous ulcer after the first episode of DVT was 39 months (range: 12-72) for patients with suboptimal INR and 82 months (range: 12-216) for those with optimal anticoagulation therapy (p=0.11). During the mean follow-up period of 52 months, all patients in optimal anticoagulation healed their ulcer; their mean time for wound healing was 44 months (range: 4-102). In the suboptimal INR group, only four healed the ulcers with an mean of 72 months (range: 2-204) (p=0.94). CONCLUSION There seems to be an association between an optimal anticoagulation therapy with Warfarin monitored by INR and wound healing rates in thrombophilic patients with chronic venous ulcers. Further research is warranted. DECLARATION OF INTEREST The authors have no conflict of interest.
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Affiliation(s)
- C A Hinojosa
- Instituto Nacional de Ciencias Medicas y Nutricion 'Salvador Zubiran'. Wound Clinic Department of Surgery, Section of Vascular Surgery and Endovascular Therapy Mexico City, Mexico
| | - S Olivares-Cruz
- Instituto Nacional de Ciencias Medicas y Nutricion 'Salvador Zubiran'. Wound Clinic Department of Surgery, Section of Vascular Surgery and Endovascular Therapy Mexico City, Mexico
| | - H Laparra-Escareno
- Instituto Nacional de Ciencias Medicas y Nutricion 'Salvador Zubiran'. Wound Clinic Department of Surgery, Section of Vascular Surgery and Endovascular Therapy Mexico City, Mexico
| | - S Sanchez-Castro
- Instituto Nacional de Ciencias Medicas y Nutricion 'Salvador Zubiran'. Wound Clinic Department of Surgery, Section of Vascular Surgery and Endovascular Therapy Mexico City, Mexico
| | - B Tamayo-Garcia
- Instituto Nacional de Ciencias Medicas y Nutricion 'Salvador Zubiran'. Wound Clinic Department of Surgery, Section of Vascular Surgery and Endovascular Therapy Mexico City, Mexico
| | - J E Anaya-Ayala
- Instituto Nacional de Ciencias Medicas y Nutricion 'Salvador Zubiran'. Wound Clinic Department of Surgery, Section of Vascular Surgery and Endovascular Therapy Mexico City, Mexico
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Shanmugam VK. Vasculitic Diseases and Prothrombotic States Contributing to Delayed Healing In Chronic Wounds. CURRENT DERMATOLOGY REPORTS 2016; 5:270-277. [PMID: 27833788 DOI: 10.1007/s13671-016-0157-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
PURPOSE Autoimmune diseases are a common cause of delayed wound healing and should be considered in patients with chronic wounds who do not respond to local wound care or who fail skin grafting in the absence of infection. RECENT FINDINGS Epidemiologic studies have shown that, of patients with chronic wounds evaluated in specialized wound healing clinics, 20-23% have autoimmune etiologies for their wounds including vasculitis, rheumatoid arthritis, systemic lupus erythematosus, scleroderma, pyoderma gangrenosum and other autoimmune diseases. SUMMARY In this article autoimmune diseases known to be associated with chronic wounds and delayed wound healing are reviewed and the importance of a multidisciplinary approach for patients with chronic wounds, with involvement of rheumatology and dermatology is highlighted. This approach allows for investigation of underlying systemic disease and improves clinical outcomes for many of these challenging patients.
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Affiliation(s)
- Victoria K Shanmugam
- Division of Rheumatology, The George Washington University, School of Medicine and Health Sciences, 701 Ross Hall, 2300 Eye Street, NW, Washington, DC 20037
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O'Donnell TF, Passman MA, Marston WA, Ennis WJ, Dalsing M, Kistner RL, Lurie F, Henke PK, Gloviczki ML, Eklöf BG, Stoughton J, Raju S, Shortell CK, Raffetto JD, Partsch H, Pounds LC, Cummings ME, Gillespie DL, McLafferty RB, Murad MH, Wakefield TW, Gloviczki P. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery ® and the American Venous Forum. J Vasc Surg 2014; 60:3S-59S. [PMID: 24974070 DOI: 10.1016/j.jvs.2014.04.049] [Citation(s) in RCA: 387] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Shanmugam VK, McNish S, Duncan J, Root B, Tassi E, Wellstein A, Kallakury B, Attinger CE. Late failure of a split-thickness skin graft in the setting of homozygous factor V Leiden mutation: a case report and correlative animal model from the Wound Etiology and Healing (WE-HEAL) study. Int Wound J 2013; 12:537-44. [PMID: 24028566 DOI: 10.1111/iwj.12156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 08/13/2013] [Indexed: 11/29/2022] Open
Abstract
We present the case of a 53-year-old Caucasian male smoker with remote history of left lower extremity deep venous thrombosis (DVT) and a strong family history of thrombosis, who presented to the Center for Wound Healing at MedStar Georgetown University Hospital with spontaneous left leg ulceration. Prothrombotic evaluation showed homozygosity for the factor V Leiden (FVL) mutation. Therapeutic anticoagulation was commenced with warfarin (Coumadin®) and the patient underwent successful debridement and Apligraf® followed by split-thickness skin graft (STSG) of two wounds. He had an uneventful postoperative course and on the 27th postoperative day the grafts were 95% intact. However, by postoperative day 41 there was 10% graft loss, and over the subsequent 2 weeks both grafts necrosed. On further questioning, it transpired that the patient had discontinued his warfarin on postoperative day 37 because he thought that it was no longer necessary. The patient is enrolled in the Wound Etiology and Healing (WE-HEAL) study, and at the time of the original graft, residual skin fragments from the STSG were transplanted onto a nude mouse for development of an animal model of wound healing. The mouse graft was successful and was harvested at postoperative day 87 for pathological examination. We review the mechanisms by which prothrombotic states, particularly FVL mutation, can contribute to skin graft failure and delayed wound healing. This case highlights the importance of considering prothrombotic conditions in patients with spontaneous leg ulcerations and the impact of therapeutic anticoagulation on healing. It further allows us to demonstrate the efficacy of the animal model in which residual fragments of STSG tissue are utilised for transplant onto nude mice for manipulation in the laboratory.
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Affiliation(s)
- Victoria K Shanmugam
- Division of Rheumatology, Immunology and Allergy, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Sean McNish
- Division of Rheumatology, Immunology and Allergy, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Joanna Duncan
- Center for Wound Healing, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Brandy Root
- Center for Wound Healing, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Elena Tassi
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Anton Wellstein
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Bhaskar Kallakury
- Department of Pathology, MedStar Georgetown University Hospital, Washington, DC, USA
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Kreidy R. Contribution of recurrent venous thrombosis and inherited thrombophilia to the pathogenesis of postthrombotic syndrome. Clin Appl Thromb Hemost 2013; 21:87-90. [PMID: 23892685 DOI: 10.1177/1076029613497423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Postthrombotic syndrome (PTS) is a common complication of deep vein thrombosis. This study aims to assess the role of recurrent venous thrombosis and inherited thrombophilia in the pathogenesis of PTS. A series of 206 patients diagnosed with lower extremity venous thrombosis were retrospectively reviewed. The PTS was observed in 30.58% of the patients. Recurrent venous thrombosis was identified in 3.4% of the patients without PTS and in 33.3% of patients with PTS (P < .001). Inherited thrombophilia alone or in association with recurrent venous thrombosis was more commonly detected when PTS was moderate to severe (P = .04 and <.001) or severe (P < .001). Recurrent venous thrombosis increases the incidence of PTS significantly. The severity of PTS raises when an underlying thrombophilia is present either alone or in association with recurrent venous thrombosis.
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Affiliation(s)
- Raghid Kreidy
- Department of Vascular Surgery, University of Balamand, Beirut, Lebanon
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Association between Thrombophilia and the Post-Thrombotic Syndrome. Int J Vasc Med 2013; 2013:643036. [PMID: 23762560 PMCID: PMC3665186 DOI: 10.1155/2013/643036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Revised: 04/04/2013] [Accepted: 04/17/2013] [Indexed: 11/17/2022] Open
Abstract
The post thrombotic syndrome (PTS) is a chronic condition that develops in 20%–40% of deep vein thrombosis (DVT) patients. While risk factors that predispose to the development of venous thromboembolism (VTE) are widely known, factors that influence the development of PTS after DVT have not been well elucidated. Over 10% of the general population is affected by one or more identifiable inherited thrombophilias which have been shown to underlie at least 1/3 of cases of VTE. The various thrombophilias are important risk factors for VTE, but it is unknown whether they also increase the risk for development of PTS. We performed a review of studies that have reported on the association between thrombophilia and the development of PTS in populations of patients with DVT and with chronic venous ulcers. Studies vary with regards to the definition of PTS, study design, follow-up period, and present conflicting results. Based on these results, the question of whether thrombophilia predisposes to the development of PTS remains unanswered.
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Karathanos C, Exarchou M, Tsezou A, Kyriakou D, Wittens C, Giannoukas A. Factors associated with the development of superficial vein thrombosis in patients with varicose veins. Thromb Res 2013; 132:47-50. [PMID: 23768449 DOI: 10.1016/j.thromres.2013.05.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 04/29/2013] [Accepted: 05/21/2013] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Superficial vein thrombosis (SVT) is a common and controversial clinical entity. Recent studies have demonstrated that SVT should be seen as a venous thromboembolism (VTE). The objective of this study was to investigate the prevalence of thrombophilia defects and to estimate the role of age, sex and body mass index (BMI) in patients with varicose veins (VVs) and SVT. MATERIALS AND METHODS A total of 230 patients with VVs, 128 with, and 102 without SVT underwent thrombophilia testing included factor V Leiden, prothrombin G20210A, methylenetetrahydrofolate reductase and plasminogen activator inhibitor- 1 mutations, protein C, protein S (PS), anti-thrombin III and plasminogen deficiencies and levels of A2 antiplasmin, activate protein C resistance and lupus anticoagulant. According to Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification patients were categorized in two subgroups: moderate disease (C2,3) and severe disease (C4,5,6). Age and body mass index were also assessed. RESULTS The prevalence of thrombophilia defects was significantly higher in patients with moderate disease and SVT (p=0.002). In the C2,3 group, SVT was associated with PS deficiency (p=0.018), obesity (p<0.001), male gender (p=0.047) and age (p<0.001). There were no significant differences in patients with severe disease. CONCLUSIONS Age, male sex, obesity and PS deficiency are factors associated with SVT development among patients with VVs having moderate disease (C2,3).
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Affiliation(s)
- Christos Karathanos
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessalia, Larissa, Greece.
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Thornsberry LA, LoSicco KI, English JC. The skin and hypercoagulable states. J Am Acad Dermatol 2013; 69:450-62. [PMID: 23582572 DOI: 10.1016/j.jaad.2013.01.043] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Revised: 01/19/2013] [Accepted: 01/25/2013] [Indexed: 11/19/2022]
Abstract
Hypercoagulable states (HS) are inherited or acquired conditions that predispose an individual to venous and/or arterial thrombosis. The dermatologist can play a vital role in diagnosing a patient's HS by recognizing the associated cutaneous manifestations, such as purpura, purpura fulminans, livedo reticularis, livedo vasculopathy (atrophie blanche), anetoderma, chronic venous ulcers, and superficial venous thrombosis. The cutaneous manifestations of HS are generally nonspecific, but identification of an abnormal finding can warrant a further workup for an underlying thrombophilic disorder. This review will focus on the basic science of hemostasis, the evaluation of HS, the skin manifestations associated with hypercoagulability, and the use of antiplatelet and anticoagulant therapy in dermatology.
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Affiliation(s)
- Laura A Thornsberry
- Department of Dermatology, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
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Wiwanitkit V. Inherited thrombophilia in patients with chronic and recurrent venous leg ulceration. Wound Repair Regen 2012; 20:444. [DOI: 10.1111/j.1524-475x.2012.00794.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Viroj Wiwanitkit
- Department of Laboratory Medicine Faculty of Medicine; Chulalongkorn University; Bangkok; Thailand; 10330
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