The Evaluation of Lower-Extremity Ulcers

 

 Buy Article Permissions and Reprints

ABSTRACT

Lower-limb ulceration is prevalent in Western countries. There are many different types of ulcers with several causes. The most prevalent are those due to vascular disease, of which venous is the most common, accounting for over two-thirds of all types of ulcers. There are also many other causes for ulceration such as malignancy, infections, and skin, drug-induced, and autoimmune diseases. The ulcers have different characteristics, which may be differentiated by the history and clinical examination of the patients. However, objective documentation for the ulcer etiology is necessary prior to instigating treatment. The methods for diagnosing the causes for the ulcers include plethysmography, ultrasound, angiography, computer tomography, magnetic resonance imaging, and skin biopsy. All these tests should be used in conjunction with the clinical presentation of the patient. They should be performed in a cost-effective manner to avoid delays in diagnosis and reduce costs and usage of resources.

REFERENCES

• 1 Hume M. A venous renaissance?.  J Vasc Surg. 1992;  15 947-951
  CrossrefPubMedGoogle Scholar
• 2 Lawrence P F, Gazak C E. Epidemiology of chronic venous insufficiency. In: Gloviczki P, Bergan J Atlas of Endoscopic Perforator Vein Surgery. London; Springer-Verlag 1998
  PubMedGoogle Scholar
• 3 Adam D J, Naik J, Hartshorne T, Bello M, London N JM. The diagnosis and management of 689 chronic leg ulcers in a single-visit assessment clinic.  Eur J Vasc Endovasc Surg. 2003;  25 462-468
  CrossrefPubMedGoogle Scholar
• 4 Nelzén O, Bergqvist D, Lindhagen A. Venous and non-venous leg ulcers: clinical history and appearance in a population study.  Br J Surg. 1994;  81 182-187
  CrossrefPubMedGoogle Scholar
• 5 Nicolaides A N, Allegra C, Bergan J et al.. Management of chronic venous disorders of the lower limbs: guidelines according to scientific evidence.  Int Angiol. 2008;  27 1-59
  PubMedGoogle Scholar
• 6 Labropoulos N, Patel P J, Tiongson J E, Pryor L, Leon Jr L R, Tassiopoulos A K. Patterns of venous reflux and obstruction in patients with skin damage due to chronic venous disease.  Vasc Endovascular Surg. 2007;  41 33-40
  CrossrefPubMedGoogle Scholar
• 7 Nicolaides A N, Hussein M K, Szendro G, Christopoulos D, Vasdekis S, Clarke H. The relation of venous ulceration with ambulatory venous pressure measurements.  J Vasc Surg. 1993;  17 414-419
  CrossrefPubMedGoogle Scholar
• 8 Pappas P J, You R, Rameshwar P et al.. Dermal tissue fibrosis in patients with chronic venous insufficiency is associated with increased transforming growth factor-β1 gene expression and protein production.  J Vasc Surg. 1999;  30 1129-1145
  CrossrefPubMedGoogle Scholar
• 9 Bergan J J, Schmid-Schönbein G W, Smith P D, Nicolaides A N, Boisseau M R, Eklof B. Chronic venous disease.  N Engl J Med. 2006;  355 488-498
  CrossrefPubMedGoogle Scholar
• 10 Lazarides M K, Giannoukas A D. The role of hemodynamic measurements in the management of venous and ischemic ulcers.  Int J Low Extrem Wounds. 2007;  6 254-261
  CrossrefPubMedGoogle Scholar
• 11 Mekkes J R, Loots M A, Van Der Wal A C, Bos J D. Causes, investigation and treatment of leg ulceration.  Br J Dermatol. 2003;  148 388-401
  CrossrefPubMedGoogle Scholar
• 12 Renner R, Simon J C. Current therapeutic options of chronic leg ulcers.  J Dtsch Dermatol Ges. 2008;  6 389-401
  PubMedGoogle Scholar
• 13 Hirsch A T, Criqui M H, Treat-Jacobson D et al.. Peripheral arterial disease detection, awareness, and treatment in primary care.  JAMA. 2001;  286 1317-1324
  CrossrefPubMedGoogle Scholar
• 14 Bartholomew J R, Olin J W. Pathophysiology of peripheral arterial disease and risk factors for its development.  Cleve Clin J Med. 2006;  73(Suppl 4) S8-S14
  PubMedGoogle Scholar
• 15 Paraskevas K I, Baker D M, Vrentzos G E, Mikhailidis D P. The role of fibrinogen and fibrinolysis in peripheral arterial disease.  Thromb Res. 2008;  122 1-12
  CrossrefPubMedGoogle Scholar
• 16 Leon L R, Rodriguez H E, Labropoulos N. Arterial occlusion: thrombotic versus embolic. In: Mansour M, Labropoulos N Vascular Diagnosis. Philadelphia, PA; Elsevier Saunders 2005: 223-236
  PubMedGoogle Scholar
• 17 Schweitzer M E, Morrison W B. MR imaging of the diabetic foot.  Radiol Clin North Am. 2004;  42 61-71, vi
  CrossrefPubMedGoogle Scholar
• 18 Khachemoune A, Kauffman C L. Diagnosis of Leg Ulcers. The Internet Journal of Dermatology. http://Available at: www.ispub.com 2002 1(2)
  PubMedGoogle Scholar
• 19 Hafner J, Schneider E, Burg G, Cassina P C. Management of leg ulcers in patients with rheumatoid arthritis or systemic sclerosis: the importance of concomitant arterial and venous disease.  J Vasc Surg. 2000;  32 322-329
  CrossrefPubMedGoogle Scholar
• 20 Treiman G S, Copland S, McNamara R M, Yellin A E, Schneider P A, Treiman R L. Factors influencing ulcer healing in patients with combined arterial and venous insufficiency.  J Vasc Surg. 2001;  33 1158-1164
  CrossrefPubMedGoogle Scholar
• 21 Padberg Jr F, Cerveira J J, Lal B K, Pappas P J, Varma S, Hobson II R W. Does severe venous insufficiency have a different etiology in the morbidly obese? Is it venous?.  J Vasc Surg. 2003;  37 79-85
  CrossrefPubMedGoogle Scholar
• 22 Labropoulos N, Manalo D, Patel N P, Tiongson J, Pryor L, Giannoukas A D. Uncommon leg ulcers in the lower extremity.  J Vasc Surg. 2007;  45 568-573
  CrossrefPubMedGoogle Scholar
• 23 Koshy M, Entsuah R, Koranda A, Kraus A, Johnson R, Bellvue R. Leg ulcers in patients with sickle cell disease.  Blood. 1989;  74 1403-1408
  PubMedGoogle Scholar
• 24 Dean S. Leg ulcers—causes and management.  Aust Fam Physician. 2006;  35 480-484
  PubMedGoogle Scholar
• 25 Androulakis A E, Giannoukas A D, Labropoulos N, Katsamouris A, Nicolaides A N. The impact of duplex scanning on vascular practice.  Int Angiol. 1996;  15 283-290
  PubMedGoogle Scholar
• 26 Mansour M, Labropoulos N. Vascular Diagnosis. Philadelphia, PA; Elsevier Saunders 2005
  PubMedGoogle Scholar
• 27 Needham T. Physiologic testing of lower extremity arterial disease: segmental pressures, plethysmography, and velocity waveforms. In: Mansour M, Labropoulos N Vascular Diagnosis. Philadelphia, PA; Elsevier Saunders 2005: 215-222
  PubMedGoogle Scholar
• 28 Labropoulos N, Leon L. Evaluation of chronic venous disease. In: Mansour M, Labropoulos N Vascular Diagnosis. Philadelphia, PA; Elsevier Saunders 2005: 447-462
  PubMedGoogle Scholar
• 29 Met R, Bipat S, Legemate D A, Reekers J A, Koelemay M J. Diagnostic performance of computed tomography angiography in peripheral arterial disease: a systematic review and meta-analysis.  JAMA. 2009;  301 415-424
  CrossrefPubMedGoogle Scholar
• 30 Uhl J F, Gillot C. Embryology and three-dimensional anatomy of the superficial venous system of the lower limbs.  Phlebology. 2007;  22 194-206
  CrossrefPubMedGoogle Scholar
• 31 Poschenrieder F, Hamer O W, Herold T et al.. Diagnostic accuracy of intraarterial and i.v. MR angiography for the detection of stenoses of the infrainguinal arteries.  AJR Am J Roentgenol. 2009;  192 117-121
  CrossrefPubMedGoogle Scholar
• 32 Morasch M, Collins J. The current role of MRA in planning interventions for lower extremity ischemia. In: Mansour M, Labropoulos N Vascular Diagnosis. Philadelphia, PA; Elsevier Saunders 2005: 293-306
  PubMedGoogle Scholar
• 33 Froehlich J B, Prince M R, Greenfield L J, Downing L J, Shah N L, Wakefield T W. “Bull's-eye” sign on gadolinium-enhanced magnetic resonance venography determines thrombus presence and age: a preliminary study.  J Vasc Surg. 1997;  26 809-816
  CrossrefPubMedGoogle Scholar
• 34 Neglén P, Hollis K C, Olivier J, Raju S. Stenting of the venous outflow in chronic venous disease: long-term stent-related outcome, clinical, and hemodynamic result.  J Vasc Surg. 2007;  46 979-990
  CrossrefPubMedGoogle Scholar
• 35 Masuda E M, Kistner R L. Long-term results of venous valve reconstruction: a four- to twenty-one-year follow-up.  J Vasc Surg. 1994;  19 391-403
  PubMedGoogle Scholar
• 36 Ayerdi J, Hodgson K. Principles of arteriography. In: Rutherford R Vascular Surgery. 6th ed. Philadelphia, PA; Elsevier Saunders 2005: 271-299
  PubMedGoogle Scholar
• 37 Buckley C J, Arko F R, Lee S et al.. Intravascular ultrasound scanning improves long-term patency of iliac lesions treated with balloon angioplasty and primary stenting.  J Vasc Surg. 2002;  35 316-323
  CrossrefPubMedGoogle Scholar

Nicos LabropoulosPh.D. 

Professor of Surgery and Radiology, Department of Surgery

HSC T19 Rm90, Stony Brook University Medical Center, Stony Brook, NY 11794-8191

Email: nlabrop@yahoo.com