approach to leg ulcers

Sean Tierney,

Consultant Vascular Surgeon

Adelaide & Meath National Children’s Hospital,

Tallaght

Vascular assessment inLeg ulcers

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BarrierBarrier

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Balanced forcesBalanced forces

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Pathogenesis - destructionPathogenesis - destruction

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Pathogenesis – failure of repairPathogenesis – failure of repair

Oxygen >>>Nutrients

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Healing - neutrophilsHealing - neutrophils

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Healing - macrophagesHealing - macrophages

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Healing - macrophagesHealing - macrophages

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Healing - granulationHealing - granulation

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Healing - fibroblastsHealing - fibroblasts

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Healing - collagenHealing - collagen

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Healing - epithelialisationHealing - epithelialisation

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Normal healingNormal healing

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UlcersUlcers

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Causes of UlcerationCauses of Ulceration

• Venous disease 81%*– 1o

• deep venous failure• superficial venous failure• combined

– 2o DVT

• Arterial disease 10% • Mixed (arterial venous) 7%• Diabetic neuropathy 1%

• Malignancy 1%

• Rheumatoid 1%

* O Brien et al. “ Prevalence and aetiology of leg ulcers in Ireland.” Ir J Med Sci 2000

17%

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TraumaTrauma

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Venous insufficiencyVenous insufficiency

normalNormal microvasculature

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Venous insufficiencyVenous insufficiency

P P

Normal Venous hypertension

DVT & recanalisation

Superficial reflux

Defective deep valves

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Venous insufficiencyVenous insufficiency

↑ Pressure

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Venous insufficiencyVenous insufficiency

Normal

High pressure

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Venous ulcerVenous ulcer

• History of venous disease– DVT>>VVs

• Recurrent• “Painless”• Signs of venous hypertension

– haemosiderin,– lipodermatosclerosis,– eczema– ± flares/spider veins

Note• Normal ABIs• Pain

“sloping”

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Compression therapyCompression therapy

0

25

50

75

100

0 3 6

Cont rol Compression

* Diamond P. Management of leg ulcers in a rural community. J Wound Care 1994

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Role of SurgeryRole of Surgery

* Gohel et al. British Journal of Surgery 2005; 92: 291–297

• open or recently healed ankle ulceration (>4 weeks)• ABI < 0·85• Either

• superficial venous reflux• mixed superficial and deep venous reflux

• Excluded• No reflux, deep reflux only, deep occlusion

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Role of SurgeryRole of Surgery

* Gohel et al. British Journal of Surgery 2005; 92: 291–297

Healing Recurrence

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Dangers of compressionDangers of compression

↓ Pressure

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Quantifying arterial perfusionQuantifying arterial perfusion

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ABI techniqueABI technique

video

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ABI techniqueABI technique

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ABI techniqueABI technique

P

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ABI technique – calcified vesselsABI technique – calcified vessels

P

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Arterial ulcerArterial ulcer

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Arterial ulcerArterial ulcer

• History of intermittent claudication

• Pain• Absent pulses• Reduced ABIs

Beware• Colour, temperature, capillary

filling unreliable

“punched out”

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VasculitisVasculitis

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Vasculitic ulcerVasculitic ulcer

• History of inflammatory disease– RA

• Unusual distribution• Painful• No venous disease• Normal arterial system

Note• may coexist with arterial

or venous disease

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Neuropathic UlcerNeuropathic Ulcer

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Neuropathic ulcerNeuropathic ulcer

• History of neuropathic disease– MS, DM

• Pressure points• Loss of protective

sensation• Painless• ± venous disease• ± arterial disease

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DiabetesDiabetes

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“Biopsy”

MalignancyMalignancy

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InfectiveInfective

History

Differential diagnosis

Examination

Review differential diagnosis

Investigation

Treat

Review differential diagnosis

Evaluate response

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