A5. Leg ulcer

Leg ulcer

• Etiology
  • Chronic venous disease
  • Peripheral artery disease
  • Neuropathic ulcer
    • Diabetes
  • Decubitus
  • Trauma
  • Infections
  • Dermatoses (SLE, pyoderma gangrenosum)
  • Neoplastic
• Morphology
  • Venous ulcer
    • Above the ankle
    • Mild pain
      • Pain improves when raising leg
    • Shallow ulcer
  • Arterial ulcer
    • Punched-out well-defined ulcer
    • Pressure points of the legs (malleolus, toes)
    • Severe pain
      • Pain worsens when raising leg
• Treatment
  • Underlying disease
  • Surgical
    • Irrigation
    • Debridement
      • Removal of dead, damaged or infected tissue
    • Wet dressing
    • Skin grafting
  • Local therapy
    • Wound healing
    • Compression
  • Treating adjacent skin

Peripheral artery disease

Peripheral artery disease (PAD) is the manifestation of atherosclerosis of the peripheral arteries supplying the legs and feet. Atherosclerosis diminishes perfusion of the legs and feet, in most cases only during activity, but in severe cases even in rest. As an atherosclerotic disease, it mostly co-exists with other atherosclerotic diseases like coronary artery disease and cerebrovascular disease. Peripheral artery disease is a disease of elderly smokers.

Clinical features

In severe cases (Fontaine stage III and IV), ischaemia in rest is severe enough to cause pain in rest, ulcers, gangrene, or necrosis. These are indicative of critical limb ischaemia, which need urgent treatment.

Fontaine classification

The Fontaine classification classifies PAD according to the severity of the symptoms:

• Stage I – asymptomatic
• Stage II – pain on exertion
  • Stage IIa – Claudication at walking distance > 200 m
  • Stage IIb – Claudication at walking distance < 200 m
• Stage III – pain at rest
• Stage IV – necrosis/gangrene/ulcers

Diagnosis and evaluation

Physical examination is important and may show signs of chronic ischaemia. Feeling for peripheral pulses is important, including comparing both sides and comparing to the upper limb. Decreased pulse is a characteristic finding. A bruit may be auscultated above the affected artery. Pain in rest which improves with the limb hanging low (like from the bed) is characteristic, as gravity improves blood flow.

Measurement of the ankle-brachial index or toe-brachial index is essential and gives a good objective measurement of lower limb perfusion.

The diagnosis of Fontaine stage I – II can be made clinically based on the presence of typical risk factors and clinical features.

Treatment

Treatment involves lifestyle changes, exercise, medical treatment, as well as revascularisation procedures in severe cases. Smoking cessation is especially obligatory, as the disease will progress regardless of measures taken as long as smoking continues.

Graded exercise therapy involves the patient walking up to the point where the pain occurs (and preferably a little more than that), before resting and repeating again. This should be performed for 30 minutes 3 – 5 times a week. Graded exercise therapy stimulates development of collateral circulation, which can significantly increase the distance which the patient can walk without pain. It's important to remind patients that the pain is not dangerous.

Medical treatment involves antithrombotic therapy (aspirin/P2Y12 inhibitor) and statins in all cases, as well as antihypertensives and antidiabetics to control risk factors, if necessary.

Surgical treatment

Surgical treatment involves endovascular and/or open surgery. It is indicated if the patient has severe symptoms which don’t improve after conservative treatment, or if the patient has Fontaine stage III or IV PAD. Critical limb ischaemia must be treated urgently to prevent loss of limbs.

Chronic venous disorder

Chronic venous disorder (CVD) is an umbrella term for chronic disorders of the veins of the legs. It’s more common in women and includes disorders like varicose veins and chronic venous insufficiency. CVD is very common (as varicose veins are very common) but is mild in most cases.

Chronic venous insufficiency (CVI) is a severe form of CVD, where there is oedema, skin changes, or ulceration (clinical stage C3 or higher). CVI is relatively common and affects up to 5% of US adults.

Classification

Chronic venous disorders are classified according to the CEAP classification, which stands for Clinical, Etiological, Anatomical and Pathophysiological. The clinical part of it is the most important and shows the clinical manifestations of CVD from least severe to most.

Clinical features

There are many clinical stages of CVD, with different clinical manifestations. General symptoms include a feeling of heaviness in the leg, oedema, and pain. This pain is worsened when standing and having the leg below the body, but relieved by walking (which is, notably, opposite of that of PAD).

Telangiectasia, also called spider veins, are small dilated intradermal veins. Varicose veins are superficial veins which have become dilated and tortuous to the point where they’re visible and palpable on the legs.

Skin changes can occur and cause itching, stasis dermatitis, and pigmentation changes. Lipodermatosclerosis is a localised inflammation and fibrosis of the skin, which causes induration and pain. White atrophy refers to white atrophic plaques of skin, which are white due to the absence of capillaries in the fibrotic plaques.

Diagnosis and evaluation

Chronic venous disorders are mostly a clinical diagnosis, but duplex ultrasound can show retrograde flow (reflux) and/or obstruction in the veins. Ultrasound is especially important in those considered for surgery as the presence of reflux and/or obstruction influences the choice of treatment.

Treatment

Conservative treatment is indicated for all patients and includes:

• Compression stockings
• Frequent elevation of legs
• Physical therapy
• Manual lymphatic drainage by massage
• Avoiding long periods of standing

Skin changes can be managed with moisturiser and topical glucocorticoid. Ulcers require typical wound treatment, including debridement, skin care, and wound dressings. Skin grafts may be necessary in larger ulcers.

For most patients, conservative treatment is sufficient. Surgery is indicated if symptoms persist, or in case of severe symptoms. There are many options for surgical treatment:

• For superficial veins
  • Injection sclerotherapy
  • Vein ligation
  • Vein stripping
  • Endovenous laser treatment
  • Radiofrequency ablation
• For perforating veins
  • Subfascial endoscopic perforator surgery (SEPS)
  • Cockett operation
• For deep veins
  • Palma operation (femoro-femoral crossover saphenous bypass)
  • Vein segment transplantation (of a segment containing intact valves)
  • Valvuloplasty (valve repair)
  • Vein transposition