Introduction
Problem
Ulcers of the lower extremities, particularly in individuals older than 65 years, are a common cause for visits to the podiatrist, wound care specialist, primary care physician, vascular surgeon, or dermatologist.
The great majority of vascular ulcers are chronic or recurrent. They cause a considerable amount of morbidity among patients with peripheral vascular disease, including work incapacity. The care of chronic vascular ulcers places a significant burden on the patient and the health care system. Additionally, these nonhealing ulcers place the patient at much higher risk for lower extremity amputation. For more information on wound care, visit Medscape's Wound Management Resource Center.
Frequency
In the United States, the prevalence of vascular ulcers in the general population is not known. However, as the obesity rate increases, the rate of vascular ulcers also increases because of the comorbidities that are associated with patients who are obese. In certain states, venous ulcers are seen in 2.5% of patients admitted to long-term care facilities. This rate is believed to be much higher than the overall population prevalence.
Internationally, studies performed in Ireland1 and Australia estimate the prevalence of current chronic leg ulcers at approximately 1%. Of these, most (approximately 80%) are thought to be caused by venous disease rather than arterial disease. A telephone survey performed in Sweden estimated the prevalence over time to be 9.8% for both healed and nonhealed ulcers in persons older than 70 years.
Etiology
Ulceration due to vascular causes is often multifactorial and can be caused by both arterial and venous disease. Hypertension and atherosclerosis of the peripheral vessels lead to arterial disease associated with ischemic ulcers. Chronic venous insufficiency and the resulting venous hypertension cause venous ulcers. Vasculitis such as Buerger disease (thromboangiitis obliterans) or Takayasu disease can also be associated with ulceration. The former tends to manifest with arterial or ischemic-type ulcers, while the latter manifests with cutaneous disease such as pyoderma gangrenosum or erythema nodosum.
When an ulcer does not respond to adequate medical and wound care, the potential for an underlying malignancy should be considered. Cutaneous malignancies that may masquerade as ulcers include nodulo-ulcerative basal cell carcinoma, squamous cell carcinoma, keratoacanthoma, nodular melanoma, tumor stage mycosis fungoides, lymphomatoid granulomatosis, lymphomatoid papulosis, angiosarcoma, and cutaneous metastases from internal malignancy. Healthcare providers must recognize these presentations and render appropriate therapeutic intervention.2
Labropoulos et al showed that most of these uncommon ulcers were located in the medial lower calf (n = 19). Specific causes revealed in the histology included neoplasia (5 patients), chronic inflammation (3 patients), sickle cell disease (2 patients), vasculitis (2 patients), rheumatoid arthritis (1 patient), pyoderma gangrenosum (1 patient), and ulcer due to hydroxyurea (1 patient). In 6 patients with ulcers, the histology did not reveal any specific cause.3 For more information on these causes of ulcers, complete the following Medscape CME activities:
- Number of Adenomas Strongest Predictor for Advanced Neoplasia
- Guidelines Discuss Use of Hydroxyurea in Treatment of Sickle Cell Disease
- Therapy Insight: Metabolic and Endocrine Disorders in Sickle-Cell Disease
- Managing Comorbidity in Rheumatoid Arthritis
- New Advances and New Targets in Rheumatoid Arthritis
Pathophysiology
Arterial (or ischemic) ulceration can be caused by either progressive atherosclerosis or arterial embolization. Both lead to ischemia of the skin and ulceration.
Venous (or stasis) ulceration is initiated by venous hypertension that develops because of inadequate calf muscle pump action and after the onset of either primary (with no obvious underlying etiology) or secondary (as seen after deep venous thrombosis) valvular incompetence. Two hypotheses have been proposed to explain venous ulceration once venous hypertension develops.
The first states that distension of the capillary beds occurs because of increased stasis. This leads to leakage of fibrinogen into the surrounding dermis. Over time, a fibrinous pericapillary cuff is formed, impeding the delivery of oxygen and other nutrients or growth factors to the affected tissue. The resulting hypoxic injury leads to fibrosis and then ulceration.
The other hypothesis suggests that the endothelium is damaged by increased venous pressure and leukocyte activation. Proteolytic enzymes and free radicals are released, escape through the leaky vessel walls, and damage the surrounding tissue, leading to injury and ulceration.
Presentation
Chronic leg or vascular ulcers typically manifest as arterial, neurotrophic, or venous ulcers. They are distinct with regard to their location, appearance, bleeding, and associated pain and findings.
Arterial ulcers
Arterial ulcers are often located distally and on the dorsum of the foot or toes. Initially they have irregular edges, but they may progress to have a better-defined appearance. The ulcer base contains grayish, unhealthy-appearing granulation tissue. With manipulation, such as debriding, these ulcers bleed very little or not at all. The patient may report characteristic pain, especially at night when supine, which is relieved by dependency of the extremity. Upon examination, characteristic findings of chronic ischemia, such as hairlessness, pale skin, and absent pulses, are noted.
Neurotrophic ulcers
Neurotrophic ulcers are characterized by a punched-out appearance with a deep sinus. These are often seen underlying calluses or over pressure points (eg, plantar aspect of the first or fifth metatarsophalangeal joint). They are commonly surrounded by chronic inflammatory tissue. Probing or debriding may lead to brisk bleeding. Because these patients usually have a neuropathy leading to hypesthesia and diminished positional sense or 2-point discrimination, these ulcers are frequently painless.
Venous ulcers
Venous ulceration is commonly noted in the "gaiter" region of the legs. This region is located circumferentially around the lower leg from approximately mid calf to just below the medial and lateral malleoli. Larger but shallower than other ulcers, stasis ulcers have a moist granulating base and an irregular border. This base oozes venous blood when manipulated. The tissue surrounding these ulcers may exhibit signs of stasis dermatitis. Patients often report mild pain that is relieved by elevation.
Indications
Surgical therapy is an integral part of the treatment of nonhealing wounds. Wounds with necrosis or infection usually require debridement or incision of the affected tissue. The goal is to achieve a clean, granulating bed upon which a split-thickness skin graft (STSG) may be placed for closure. In other circumstances, the wound bed may be unable to support a skin graft or debridement or disease may have resulted in the exposure of a structure such as a joint or bone. Under these conditions, local or free flaps of tissue may be used to provide coverage of the wound. These flaps may be performed in concert with or independent of arterial revascularization or venous repair procedures. Revascularization often causes even moderately sized ulcers to heal primarily.
Contraindications
Surgical therapy of vascular ulcers may be accomplished by a number of methods; tailor the choice to fit both the patient's and surgeon's expectations. Primary coverage and/or revascularization may be most appropriate in one patient and amputation with rehabilitation most suitable in another. Evaluate contraindications to treating an ulcer with either an STSG or pedicled or free flap based on the likelihood of survival of the coverage tissue versus the risks of undergoing the procedure, each of which is associated with varying degrees of morbidity.
Factors to consider when evaluating an ulcer to determine the likelihood of successful coverage include existing infection or the likelihood of developing infection at the surgical site; the perfusion of the surgical site; the condition of the surrounding tissue, such as edema or ischemia; the rehabilitation potential of the patient; any existing comorbid conditions; or habits of the patient that preclude survival of the graft or flap.
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Further Reading
Keywords
vascular disease, vascular diseases, vascular ulcer, leg ulcer, vascular legs, venous ulcer, diabetic ulcer, ischemic ulcer, vascular peripheral, foot ulcer, neurotrophic ulcer, vein ulcer, vascular surgery, arterial vascular, vascular diabetes, ulcer treatment, peripheral vascular disease, nonhealing ulcer, chronic ulcer, non-healing ulcer, hypertension, atherosclerosis, vasculitides, Buerger disease, thromboangiitis obliterans, Takayasu disease, Takayasu arteritis, leg ulceration, venous ulceration, ischemic ulceration, vein ulceration, chronic ulceration, arterial ulcer, neurotrophic ulcer, venous ulcer, stasis ulcer
