The recalcitrant venous leg ulcer – a never ending story?

Summary

Introduction: In general, four particular causes of recalcitrant venous leg ulcers may be distinguished. These are foot pump insufficiency, chronic venous compartment syndrome and non-re-canalized popliteal vein thrombosis. The fourth cause of recalcitrant venous leg ulcers is lipodermatosclerosis as a symptom of severe chronic venous insufficiency.

Methods: We reviewed the literature and based on this we describe four main causes of recalcitrant venous leg ulcers and their specific treatment.

Results: Foot pump insufficiency arises when the plantar foot veins are not able to empty. Treatment should consist of physical therapy, a mechanical foot pump device and an insole. Lipodermatosclerosis may be treated by excision and split-thickness skin grafting (Vigoni procedure). Chronic venous compartment syndrome is usually caused by post-thrombotic syndrome and treatment consists of a fasciectomy, but is rarely used nowadays. Patients with non-re-canalized popliteal vein thrombosis may be supported by intermittent pneumatic compression, walking exercises, alternate standing and walking with lying down. All patients with recalcitrant venous leg ulcers must wear medical elastic compression stockings with high stiffness and high compression lifelong.

Conclusions: Patients with recalcitrant venous leg ulceration are challenging. More specific treatment will heal more of these ulcers.

Zusammenfassung

Einleitung: Chronische Venenerkrankungen kommen häufig vor und führt zu Ulzerationen in 1% der Westlichen Bevölkerung. Venöse Beinulzerationen können in drei Gruppen eingeteilt werden: unkompliziert, persistierend und rezidivierend. Es gibt vier Ursachen für persistierende Beinulzerationen: Insuffizienz der Muskel-Venen-Pumpe des Fußes, Lipodermatosklerose, chronisch-venöses Kompartment-Syndrom und nicht-rekanalisierte Throm bose der Vena poplitea.

Methode: Wir haben eine Literatursuche durchgeführt und beschreiben vier Hauptursachen von persistierenden Beinulzerationen und deren Behandlung.

Ergebnisse: Die Insuffizienz der Fußpumpe entsteht, wenn die Venen der Fußsohle sich nicht leeren können; die Therapie besteht in Physiotherapie, einer mechanische Fußpumpe und einer Einlegesohle. Lipodermatoskle-rose wird behandelt mit ambulanter Kompressionstherapie, Exzision des Ulkus und Spalthauttransplantation (Verfahren von Vigoni).

Das chronisch-venöse Kompartment-Syndrom wird meistens verursacht durch das postthrombotische Syndrom, das zur Erhö-hung des venösen Drucks führen kann. Die Behandlung besteht aus einer Fasziotomie. Patienten mit einer nicht-rekanalisierten Thrombose der Vena poplitea können unterstützt werden durch intermittierende pneumatische Kompression, Gehübungen und abwechselndes Stehen, Laufen und Liegen. Alle Patienten mit persistierende venöse Beingeschwüre sollten lebenslang medizinische Kompressionsstrümpfe mit einer hohen Steifigkeit tragen.

Schlussfolgerungen: Einsicht in die zugrunde liegende Pathologie persistierender venöser Beinulzerationen ist entscheidend, um die Behandlung dieser diagnostisch und therapeutisch anspruchsvollen Patienten zu optimieren. Die sorgfältige Analyse der Ursachen und der Behandlung wird die Ergebnisse verbessern und die Zahl erfolgreich behandelter Ulzerationen erhöhen.

Keywords

Recalcitrant venous leg ulcer - pathophysiology - therapy

Schlüsselwörter

Persistierende Beinulzerationen - Pathophysiologie - Behandlung

• References

• 1 Beebe HG, Bergan JJ, Bergqvist D, Eklof B, Eriksson I, Goldman MP. et al. Classification and grading of chronic venous disease in the lower limbs. A consensus statement. Eur J Vasc Endovasc Surg 1996; 12 (04) 487-491.
• 2 Rabe E, Guex JJ, Puskas A, Scuderi A, Fernandez Quesada F. Epidemiology of chronic venous disorders in geographically diverse populations: results from the Vein Consult Program. Int Angiol 2012; 31 (02) 105-115.
• 3 Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML. et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 2011; 53 (Suppl. 05) 2S-48S.
• 4 Deutsche Gesellschaft für Phlebologie. Guidelines for diagnosis and therapy of venous ulcers (version 8 2008). ICD 10: 183.0 (without inflammation) and 183.2 (with inflammation). Phlebologie 2008; 37: 308-329.
• 5 Coleridge-Smith P, Labropoulos N, Partsch H, Myers K, Nicolaides A, Cavezzi A. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part I. Basic principles. Eur J Vasc Endovasc Surg 2006; 31 (01) 83-92.
• 6 Cavezzi A, Labropoulos N, Partsch H, Ricci S, Caggiati A, Myers K. et al. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part II. Anatomy. Vasa 2007; 36 (01) 62-71.
• 7 Reeder SWI, Wolff O, Neumann HAM. Comparison of ambulatory venous pressure measurement and anterior compartment pressure measurement in relation to the CEAP clinical classification of chronic venous disease. Submitted 2013
• 8 O’Meara S, Cullum N, Nelson EA, Dumville JC. Compression for venous leg ulcers. Cochrane Database Syst Rev 2012; 11: CD000265.
• 9 Gohel MS, Barwell JR, Taylor M, Chant T, Foy C, Earnshaw JJ. et al. Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomised controlled trial. BMJ 2007; 335 7610 83.
• 10 Nicolaides AN. Investigation of chronic venous insufficiency: A consensus statement (France, March 59, 1997). Circulation 2000; 102 (20) E126-63.
• 11 Margolis DJ, Berlin JA, Strom BL. Which venous leg ulcers will heal with limb compression bandages?. Am J Med 2000; 109 (01) 15-19.
• 12 Reeder SWI, Wolff O, Partsch H, Nicolaides AN, Mosti G, Cornu-Thenard A. et al. Expert consensus document on direct ambulatory venous pressure measurement. Int Angiol 2013. Accepted for publication
• 13 Reeder S, de Roos KP, de Maeseneer M, Sommer A, Neumann HA. Ulcer recurrence after in-hospital treatment for recalcitrant venous leg ulceration. Br J Dermatol 2013; 168 (05) 999-1002.
• 14 Neumann HAM. Haut, Venen und Beine. Phlebologie 2011; 40: 344-355.
• 15 Araki CT, Back TL, Padberg FT, Thompson PN, Jamil Z, Lee BC. et al. The significance of calf muscle pump function in venous ulceration. J Vasc Surg 1994; 20 (06) 872-877; discussion 878-879.
• 16 Pappas PJ, Brajesh K.L, Padberg Jr. F.T, Zickler R.W, Duran W.N. Pathophysiology of Chronic Venous Insufficiency. In: Bergan JJ. editor. The Vein Book. San Diego: Elsevier Academic Press; 2007: 89-102.
• 17 Palfreyman SJ, Nelson EA, Lochiel R, Michaels JA. Dressings for healing venous leg ulcers. Cochrane Database Syst Rev. 2006; (03) CD001103
• 18 Maessen-Visch MB, Koedam MI, Hamulyak K, Neumann HA. Atrophie blanche. Int J Dermatol 1999; 38 (03) 161-172.
• 19 Neumann HA, van den Broek MJ, Boersma IH, Veraart JC. Transcutaneous oxygen tension in patients with and without pericapillary fibrin cuffs in chronic venous insufficiency, porphyria cutanea tarda and non-venous leg ulcers. Vasa 1996; 25 (02) 127-133.
• 20 Blaauw GH, Neumann HA, Berretty PJ. La lipodermatosclerose et l’epaisseur dermale. Etude preliminaire. Phlebologie 1993; 46 (01) 25-31.
• 21 Neumann HA, Van den Broek MJ. Increased collagen IV layer in the basal membrane area of the capillaries in severe chronic venous insufficiency. Vasa 1991; 20 (01) 26-29.
• 22 Burnand KG, Whimster I, Naidoo A, Browse NL. Pericapillary fibrin in the ulcer-bearing skin of the leg: the cause of lipodermatosclerosis and venous ulceration. Br Med J (Clin Res Ed) 1982; 285 6348 1071-1072.
• 23 Lejars F. Les veines de la plante du pied. Archives de physiologie. 5° série. 1890
• 24 De Roos KP, Neumann HA. Muller’s ambulatory phlebectomy for varicose veins of the foot. Dermatol Surg 1998; 24 (04) 465-470.
• 25 Le Dentu A. Circulation veineuse du pied et de la jambe. Paris: Adrien Delahaye; 1867
• 26 Uhl JF, Gillot C. Anatomy of the foot venous pump: physiology and influence on chronic venous disease. Phlebology 2012; 27 (05) 219-230.
• 27 Mali JW, Kuiper JP, Hamers AA. Acro-angiodermatitis of the foot. Arch Dermatol 1965; 92 (05) 515-518.
• 28 van Bemmelen PS, Spivack D, Kelly P. Reflux in foot veins is associated with venous toe and forefoot ulceration. J Vasc Surg 2011; 53 (02) 394-398.
• 29 Thiery L. Physiology of the muscular veins. In: Raymond-Martimbeau F, Prescott R, Zummo M. editor. Phlébologie 92. Paris: Éditions John Libbey Eurotext; 1992: 82-84.
• 30 Uhl JF, Chahim M, Allaert FA. Static foot disorders: a major risk factor for chronic venous disease?. Phlebology 2012; 27 (01) 13-18.
• 31 Hach W. Das arthrogene Stauungssyndrom. Gefässchirurgie 2003; 8: 227-233.
• 32 Vigoni M. Au sujet du traitement de l’hypodermite sclereuse du membre inferieur. Acta Chir Belg 1958; 57 (03) 232-239. discussion 240-241.
• 33 Schmeller W, Gaber Y. Surgical removal of ulcer and lipodermatosclerosis followed by split-skin grafting (shave therapy) yields good long-term results in „non-healing“ venous leg ulcers. Acta Derm Venereol 2000; 80 (04) 267-271.
• 34 Pflug JJ, Zubac DP, Kersten DR, Alexander ND. The resting interstitial tissue pressure in primary varicose veins. J Vasc Surg 1990; 11 (03) 411-417.
• 35 Grattenthaler C, Thoms KM, Kretschmer L. Paratibiale Fasziotomie beim Ulcus cruris postthromboticum mit dem Fasziotom nach Vollmar. J Dtsch Dermatol Ges 2007; 5 (12) 1144-1145.
• 36 Styf J, Korner L, Suurkula M. Intramuscular pressure and muscle blood flow during exercise in chronic compartment syndrome. J Bone Joint Surg Br 1987; 69 (02) 301-305.
• 37 Hach W, Prave F, Hach-Wunderle V, Sterk J, Martin A, Willy C. et al. The chronic venous compartment syndrome. Vasa 2000; 29 (02) 127-132.
• 38 Wentel TD, Neumann HA. Management of the postthrombotic syndrome: the Rotterdam approach. Semin Thromb Hemost 2006; 32 (08) 814-821.
• 39 Kolbach DN, Neumann HA, Prins MH. Definition of the post-thrombotic syndrome, differences between existing classifications. Eur J Vasc Endovasc Surg 2005; 30 (04) 404-414.
• 40 Delis KT, Bountouroglou D, Mansfield AO. Venous claudication in iliofemoral thrombosis: long-term effects on venous hemodynamics, clinical status, and quality of life. Ann Surg 2004; 239 (01) 118-126.
• 41 Neglen P, Egger JF, Olivier J, Raju S. Hemodynamic and clinical impact of ultrasound-derived venous reflux parameters. J Vasc Surg 2004; 40 (02) 303-310.
• 42 Galanaud JP, Kahn SR. The Post-Thrombotic Syndrome: A 2012 Therapeutic Update. Curr Treat Options Cardiovasc Med. 2013
• 43 Nelson EA, Bell-Syer SE. Compression for preventing recurrence of venous ulcers. Cochrane Database Syst Rev 2012; 8: CD002303.
• 44 Meissner MH, Eklof B, Smith PC, Dalsing MC, DePalma RG, Gloviczki P. et al. Secondary chronic venous disorders. J Vasc Surg 2007; (Suppl. 46) 68S-83S.