The Evaluation of Lower-Extremity Ulcers

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.

KEYWORDS

Lower-limb ulcers - clinical examination - diagnostic tests

REFERENCES

• 1 Hume M. A venous renaissance?.  J Vasc Surg. 1992;  15 947-951
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 12 Renner R, Simon J C. Current therapeutic options of chronic leg ulcers.  J Dtsch Dermatol Ges. 2008;  6 389-401
• 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
• 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
• 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
• 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
• 17 Schweitzer M E, Morrison W B. MR imaging of the diabetic foot.  Radiol Clin North Am. 2004;  42 61-71, vi
• 18 Khachemoune A, Kauffman C L. Diagnosis of Leg Ulcers. The Internet Journal of Dermatology. http://Available at: www.ispub.com 2002 1(2)
• 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
• 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
• 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
• 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
• 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
• 24 Dean S. Leg ulcers—causes and management.  Aust Fam Physician. 2006;  35 480-484
• 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
• 26 Mansour M, Labropoulos N. Vascular Diagnosis. Philadelphia, PA; Elsevier Saunders 2005
• 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
• 28 Labropoulos N, Leon L. Evaluation of chronic venous disease. In: Mansour M, Labropoulos N Vascular Diagnosis. Philadelphia, PA; Elsevier Saunders 2005: 447-462
• 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
• 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
• 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
• 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
• 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
• 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
• 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
• 36 Ayerdi J, Hodgson K. Principles of arteriography. In: Rutherford R Vascular Surgery. 6th ed. Philadelphia, PA; Elsevier Saunders 2005: 271-299
• 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