Chronic venous ulcers.

The prevalence of lower extremity ulceration secondary to chronic venous disease (CVD) in European and Western populations is estimated to be 0.5% to 1%.12 Approximately 12% to 14% of patients with CVD in recent series 3’4have venous ulcers (clinical classes C5 and C6). Despite the high prevalence and the significant morbidity of this problem, it has always been relatively neglected. Even currently, many patients are offered conservative management only. Duplex ultrasound examination of the lower extremity veins was introduced in recent years and significantly improved our understanding of the etiology of CVD. Moreover, this non-invasive test has allowed precise identification of the malfunctioning vein segments and has contributed to a more rational therapeutic ap proach that targets the affected venous segment. The main mechanisms responsible for venous ulcers are reflux, venous outflow obstruction, or a combination of the two. Reflux is the most common cause of CVD and is seen in the vast majority of limbs with ulcers. Combined reflux and obstruction is more often seen in limbs belonging to classes C4 to C6.3 A recent prospective study demonstrated that a combination of reflux and obstruction had worst prognosis for developing limb ulceration compared to reflux or obstruction alone (odds ratio 3.5, 95% CI l.4-8.6). In contrast to what was previously thought, a documented episode of DVT is only seen in 33%50%60 of patients with ulceration and this prevalence is higher than in any other CVD class. 11 This prevalence is probably underestimated because many thrombi re main undetected and may resolve without leaving any evidence of luminal damage other than reflux due to destruction of the valves. The efficiency of calf muscle pump and amount of reflux are also associated with the development of ulceration. Nicolaides, et al, in a study of 220 unselected patients with CVD demonstrated that the prevalence of ulceration increased with higher ambulatory venous pressures.’ 2 The calf muscle function in terms of strength (peak torque/body weight) and endurance (total work) of patients with recently healed venous ulcers were significantly reduced compared to ageand sex-matched healthy subjects (p=O.O49, 95%CI 0.318.4% and p=O.OS, 95%CI 6.01-97.6 Nm respectively).’ 3It has also been shown that patients with ulceration had worst ejection fraction compared to patients with varicose veins only.’ 4 However, in an other study where the patients were matched for age and duration of disease, the amount of reflux was the most significant factor for the severity of CVD.’ 5 Several studies have shown that the site and extent of reflux are important determinants for the severity of CVD and the develop ment of ulceration. The greater saphenous vein is most often involved from the superficial veins. In fact, reflux involving both the above and below knee segments of this veins is the most common pattern of reflux in patients with ulceration. 7’9”6Reflux in the lesser saphenous vein alone rarely causes ulcers unless it is combined with reflux in the greater saphenous and/or the deep veins.’ 6”7The more deep veins involved the higher the prevalence of ulceration. How ever, among all deep veins, reflux in the popliteal vein has been shown to be very significant for ulcer development and it is also a predictor for poor healing.’ 72 ° Most recent studies have shown that reflux in the superficial system is seen in 79%-93% of limbs with ulceration. 3’7°Reflux confined to the superficial veins alone is responsible for 17% to 54% of venous ulcers 3’9whereas deep venous reflux alone accounts for 2.1% to 15%.46,95 The prevalence of deep venous reflux in patients with venous ulcers ranges between 50% and 70% in various re ports. 3’79 ”Most patients with ulcers (52%-70%) have incompe tence in more than one system 7-9’2and reflux in all three venous systems is seen in 16%_50%.3,79,15,21 When venous ulceration is due to superficial and perforator incompetence, surgical treatment may heal up to 90% of the ulcers with very good medium to long term results. 22 ’3 About 30-50% of patients with ulcers belong to this category. 6-9Superficial vein ligation and/or stripping has worst results, with very high recurrence rates at 5 years, when there is reflux in the deep venous system. 23 In these patients additional procedures that are designed to improve the underlying abnormality may be required, and several studies have shown encouraging results. 24 -7 The significance of incompetent perforating veins remains con troversial. Some investigators reported that incompetent perforators do not contribute to venous hypertension, 283 °whereas others sug gest that they are important. 9”°’ 3‘‘ Some recent reports have shown that subfascial ligation of these veins, combined with ligation and/ or stripping of the superficial incompetent veins, is associated with high rates of ulcer healing and improved disease free intervals. 32 ’3 A detailed study of the ulcerated lower extremity that will identify the etiology and outline the anatomic distribution of CVD is neces sary prior to planning a surgical intervention in order to achieve the best outcome.