Chronic Venous Leg Ulcers

A Narrative Review

Authors

Keywords:

Venous, Ulcer, Chronic, Management

Abstract

Background: Chronic venous leg ulcers are known to be very common and debilitating. Treatment is arduous and recurrence rates are high. The prevalence of chronic venous disease (CVD), especially leg ulcers, rises with age. Slow healing and recurrence continue to weigh down the patients. There is a great need to understand the aetio-pathogenesis and eliminate the recurrence of the pathological processes leading to chronic venous leg ulcers. This review therefore, aims at enlightening the medical community by harnessing available literature and knowledge of chronic venous disease with a view to improving prognosis and decreasing recurrence especially of chronic venous leg ulcers.

Methods: Materials were sourced from available publications and internet search of Google scholar, Pubmed and Hinari. Only full articles were included.

Results: The prevalence of chronic venous leg ulcers increases with age, even though it is not restricted to the elderly and it is commoner in women. Chronic venous leg ulcers are most commonly caused by venous hypertension and valvular incompetence. Results improve drastically with early presentation and recurrence rates decrease with better compliance with treatment modalities.

Conclusion: Chronic venous leg ulcers remain a great source of concern to clinicians and patients. To improve treatment outcomes and reduce recurrence rates, appropriate diagnosis and a combination of measures to prevent or reduce recurrence should be instituted. In spite of all options for the management of chronic venous leg ulcer, the age long method of graduated compression bandaging still appears to be a very effective and reliable method and so should be maintained.

References

O’Meara S, Al-Kurdi D, Ovington LG. Antibiotics and antiseptics for venous leg ulcers.

Cochrane Database Syst Rev, 2008; (1): CD003557.

Kahle B, Hermanns HJ, Gallenkemper G. Evidence based treatment of chronic leg ulcers.

Deutsches Arzteblatt International, 2011; 108 (14): 231-237

Evans CJ, Fowkes FGR, Ruckley CV, Lee AJ. Prevalence of varicose veins and chronic

venous insufficiency in men and women in the general population: Edinburgh Vein Study.

J Epidemiol Community Health 1999; 53: 149- 153

Kurz X, Kahn SR, Abenhaim L, Clement D, Norgren L, Baccaglini U, et al. Chronic venous

disorders of the leg: epidemiology, outcomes, diagnosis and management: summary of an

evidence-based report of the VEINES task force. Int Angiol 1999; 18: 83- 102

Moffatt CJ, Franks PJ, Doherty DC, Martin R, Blewett R, Ross F. Prevalence of leg

ulceration in a London population. QJM 2004; 97: 431- 437

Labropoulos N. Hemodynamic changes according to the CEAP classification.

Phlebolymphology 2003; 40: 130- 136

Lee AJ, Evans CJ, Allan PL, Ruckley CV, Fowkes FG. Lifestyle factors and the risk of varicose

veins: Edinburgh Vein Study. J Clin Epidemiol 2003; 56: 171- 179

Fowkes FG, Lee AJ, Evans CJ, Allan PL, Bradbury AW, Ruckley CV. Lifestyle risk factors for

lower limb venous reflux in the general population: Edinburgh Vein Study. Int J Epidemiol

; 30: 846- 852

Laurikka JO, Sisto T, Tarkka MR, Auvinem O, Hakama M. Risk indicators for varicose veins

in forty- to sixty-year-olds in the Tampere varicose vein study. World J Surg 2002; 26: 648-

Chiesa R, Marone EM, Limoni C, Volonte M, Schaefer E, Petrini O. Demographic factors

and their relationship with the presence of CVI signs in Italy: the 24-cities cohort study.

Eur J Vasc Endovasc Surg 2005; 30: 674- 680

Jin Y, Xu G, Huang J, Zhou D, Huang X, Shen L. Analysis of the association between an

insertion/ deletion polymorphism within the 3’ untranslated region of COL1A2 and

chronic venous insufficiency. Ann Vasc Surg 2013; 27(7): 959- 963

Bharath V, Kahn SR, Lazo-Langner A. Genetic polymorphisms of vein wall remodeling in

chronic venous disease: a narrative and systematic review. Blood 2014; 124: 1242- 1250

Hotoleanui C, Jurj C. The involvement of genetic factors in chronic venous insufficiency.

Rom J Intern Med 2008; 46(2): 119- 123

Bergan JJ, Schmid-Schonbein GW, Smith PD, Nicolaides AN, Boisseau MR, Eklof B.

Chronic venous disease. N Engl J Med 2006; 355: 488- 498

Neglen P, Raju S. A rational approach to detection of significant reflux with duplex

Doppler scanning and air plethysmography. J Vasc Surg 1993; 17: 590- 595

Barron GS, Jacob SE, Kirsner RS. Dermatologic complications of chronic venous disease:

medical management and beyond. Ann Vasc Surg 2007; 21: 652- 662

Raju S, Owen S Jr, Neglen P. Reversal of abnormal lymphoscintigraphy after placement

of venous stents for correction of associated venous obstruction. J Vasc Surg 2001; 34:

- 784

Grzela T, Bialoszewska A. Genetic risk factors of chronic venous leg ulceration: Can

molecular screening aid in the prevention of chronic venous insufficiency complications?

Mol Med Rep 2010; 3(2): 205- 211

Wallace HJ, Vandongen YK, Stacey MC. Tumor necrosis factor-alpha gene polymorphism

associated with increased susceptibility to venous leg ulceration. J invest Dermatol 2006;

(4): 921- 925

Ashworth JJ, Smyth JV, Pendleton N, Horan M, Payton A, Worthington J, et al.

Polymorphisms spanning the 0N exon and promoter of the estrogen receptor-beta

(ERbeta) gene ESR2 are associated with venous ulceration. Clin Genet 2008; 73(1): 55- 61

Kistner RL, Eklof B, Masuda EM. Diagnosis of chronic venous disease of the lower

extremities: the “CEAP” classification. Mayo Clin Proc 1996; 71: 338- 345

Mitchell DC, Grasty MS, Stebbings WSL, Nockler IB, Lewars MD, Levison RA, Wood RFM.

Comparison of duplex ultrasonography and venography in the diagnosis of deep venous

thrombosis. Br J Surg. 1991; 78: 611- 3

Lensing AA, Prandoni P, Brandjes D, Huisman PM, Vigo M, Tomasella J, et al. Detection of

deep vein thrombosis by real-time B-mode ultrasonography. N Engl J Med 1989; 320:

- 5

Coleridge Smith PD. The microcirculation in venous hypertension. Vasc Med 1997; 2:

- 213

Travers JP, Brookes CE, Evans J, Baker DM, Kent C, Makin GS, Mayhew TM. Assessment

of wall structure and composition of varicose veins with reference to collagen, elastin and

smooth muscle content. Eur J Vasc Endovasc Surg 1996; 11: 230- 237

Porto LC, Ferreira MA, Costa AM, da Silveira PR. Immunolabelling of type IV collagen,

laminin, and alpha-smooth muscle actin cells in the intima of normal and varicose

saphenous veins. Angiology 1998; 49: 391- 398

Wali MA, Eid RA. Changes of elastic and collagen fibres in varicose veins. Int Angiol 2002;

: 337- 343

de Araujo T, Valencia I, Federman DG, Kirsner RS. Managing the patient with venous

ulcers. Ann Intern Med 2003; 138(4): 326- 334

Etufugh CN, Philips TJ. Venous ulcers. Clin Dermatol 2007; 25(1): 121- 130

Green J, Jester R, McKinley R, Pooler A. Chronic venous leg ulcer care - are we missing a

vital piece of the jigsaw? Wounds UK 2017; 13(1): 32- 40

van Korlaar I, Vossen C, Rosendaal F, Cameron L, Bovill E, Kaptein A. Quality of life in

venous disease. Thromb Haemost 2003; 90: 27- 35

Nemeth KA, Harrison MB, Graham ID, Burke S. Understanding venous leg ulcer pain:

results of a longitudinal study. Ostomy Wound Manage 2004; 50: 34- 46

Franks PJ, Moffatt CJ. Health related quality of life in patients with venous ulceration;

use of the Nottingham health profile. Qual Life Res 2001; 10: 693- 700

Raju S, Neglen P. Chronic venous insufficiency and varicose veins. N Engl J Med 2009;

: 2319- 2327

Alguire PC, Mathes BM. Chronic venous insufficiency and venous ulceration. J Gen Intern

Med 1997; 12: 374- 383

Labropoulos N, Leon M, Nicolaides AN, Giannoukas AD, Volteas N, Chan P. Superficial

venous insufficiency: correlation of anatomic extent of reflux with clinical signs and

symptoms. J Vasc Surg. 1994; 20: 953- 8

Thibault PK. Duplex examination. Dermatologica. 1995; 21: 77- 82

Zagzebski JA. Physics and instrumentation in Doppler and B-mode ultrasonography. In:

Zwiebel WJ, ed. Introduction to vascular ultrasonography. Philadelphia, Pa: WB Saunders

Co; 1992: 19- 43

Dauzat MM, Laroche JP, Charras C, Blin B, Domingo-Faye MM, Sainte Luce P, et al. Real-

time, B-mode ultrasonography for better specificity in the noninvasive diagnosis of deep

venous thrombosis. J Ultrasound Med 1986; 5: 625- 31

Killewich LA, Bedford GR, Beach KW, Strandness DE. Diagnosis of deep venous

thrombosis. A prospective study comparing duplex scanning to contrast venography.

Circulation. 1989; 79: 810- 4

Aitken AGF, Godden DJ. Real-time ultrasound diagnosis of deep vein thrombosis: a

comparison with venography. Clin Radiol 1987; 38: 309- 13

Nicolaides AN, Miles C. Photoplethysmography in the assessment of venous

insufficiency. J Vasc Surg 1987; 5: 405- 412

Christopoulos D, Nicolaides AN, Szendro G. Venous reflux: quantification and correlation

with clinical severity. Br J Surg 1988; 75: 352- 356

Criado E, Farber MA, Marston WA, Daniel PF, Burnham CB, Keagy BA. The role of air

plethysmography in the diagnosis of chronic venous insufficiency. J Vasc Surg 1998; 27:

- 670

Kamida CB, Kistner RL, Eklof B, Masuda EM. Lower extremity ascending and descending

venography. In Gloviczki P, Yao JS, eds. Handbook of venous disorders. 2nd ed. New York,

NY: Arnold; 2001: 132- 139

Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation 2005; 111: 2398-

Masuda EM, Arfvidsson B, Eklof B, Kistner RL. Direct venous pressure: role in the

assessment of venous disease. In: Gloviczki P, Yao JS, eds. Handbook of venous disorders.

nd ed. New York, NY: Arnold; 2001: 140- 145

Nicolaides AN, Zukowski AJ. The value of dynamic venous pressure measurements.

World J Surg 1986; 10: 919- 924

Nicolaides AN, Hussein MK, 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

Raju S, Fredericks R. Venous obstruction: an analysis of one hundred thirty seven cases

with hemodynamic, venographic, and clinical correlations. J Vasc Surg 1991; 14: 305- 313

Raju S, Neglen P. High prevalence of nonthrombotic iliac vein lesions in chronic venous

disease: a permissive role in pathogenicity. J Vasc Surg 2006; 44: 136- 143

Negus D, Fletcher EW, Cockett FB, Thomas ML. Compression and band formation at the

mouth of the left common iliac vein. Br J Surg 1968; 55: 369- 374

Kibbe MR, Ujiki M, Goodwin AL, Eskandari M, Yao J, Matsumura J. Iliac vein compression

in an asymptomatic patient population. J Vasc Surg 2004; 39: 937-943

Al-Qaisi M, Nott DM, King DH, Kaddoura S. Ankle Brachial Pressure Index (APBI): An

update for practitioners. Vasc Health Risk Manag. 2009; 5: 833- 841

Abu-Own A, Scurr JH, Coleridge Smith PD. Effect of leg elevation on the skin

microcirculation in chronic venous insufficiency. J Vasc Surg 1994; 20: 705- 710

Kiev J, Kerstein MD. Venous insufficiency and graded compression therapy. Wounds

; 5: 280- 283

Mayberry JC, Moneta GL, De Frang RD, Porter JM. The influence of elastic compression

stockings on deep venous hemodynamics. J Vasc Surg 1991; 13: 91- 100

Nehler MR, Moneta GL, Woodard DM, Defrang RD, Harker CT, Taylor LM. Perimalleolar

subcutaneous tissue pressure effects of elastic compression stockings. J Vasc Surg 1993;

: 783- 8

Abu-Own A, Shami SK, Chittendon SJ, Farrah J, Scurr JH, Coleridge Smith PD.

Microangiography of the skin and the effect of leg compression in patients with chronic

venous insufficiency. J Vasc Surg 1994; 19: 1074- 83

Gjores JE, Theulesius O. Compression treatment in venous insufficiency evaluated with

foot volumetry. Vasa 1977; 6: 634- 8

Partsch H. Compression therapy of the legs. A review. J Dermatol Surg Oncol 1991; 17:

- 805

McGeown JG, McHale NG, Thornbury KD. The role of external compression and of

movement in lymph propulsion in the sheep hind limb. J Physiol 1987; 387: 83- 93

Allenby F, Pflug JJ, Boardman L, Calnan JS. Effects of external pneumatic intermittent

compression on fibrinolysis in man. Lancet 1973; 2: 1412- 4

Tarnay TJ, Rohr PR, Davidson AG, Steve,nson MM, Byars EF, Hopkins GR. Pneumatic calf

compression, fibrinolysis and prevention of deep venous thrombosis. Surgery 1980; 88:

- 96

Nilsson IM, Robertson B. Effect of venous occlusion on coagulation and fibrinolytic

components in normal subjects. Thromb Diath Haemorrh 1968; 20: 397- 408

O’Meara S, Tierney J, Cullum N, Bland JM, Franks PJ, Mole T. Four layer bandage

compared with short stretch bandage for venous leg ulcers: systematic review and meta-

analysis of randomized controlled trials with data from individual patients. BMJ 2009;

: b1344

Margolis DJ, Berlin JA, Strom BL. Which venous leg ulcers will heal with limb

compression bandages? Am J Med 2000; 109: 15- 19

Motykie GD, Caprini JA, Arcelus JI, Reyna JJ, Overom E, Mokhtee D. Evaluation of

therapeutic compression stockings in the treatment of chronic venous insufficiency.

Dermatol Surg 1999; 25: 116- 120

Mayberry JC, Moneta GL, Taylor LM, Porter JM. Fifteen-year results of ambulatory

compression therapy for chronic venous ulcers. Surgery 1991; 109: 575- 581

Karlsmark T, Agerslev RH, Bendz SH, Larsen JR, Roed-Peterson J, Andersen KE. Clinical

performance of a new silver dressing, Contreet Foam, for chronic exuding venous leg

ulcers. J Wound Care 2003; 12: 351- 35471. Jones SA, Bowler PG, Walker M, Parsons D. Controlling wound bioburden with a novel

silver-containing Hydrofiber dressing. Wound Repair Regen 2004; 12: 288- 294.

Colletta V, Dioguardi D, Di Lonardo A, Maggio G, Torasso F. A trial to assess the efficacy

and tolerability of Hyalofill-F in non-healing venous leg ulcers. J Wound Care 2003; 12:

- 360

Nicolaides AN. From symptoms to leg edema: efficacy of Daflon 500mg. Angiology. 2003;

: S33- S44

Colgan MP, Dormandy JA, Jones PW, Schraibman IG, Shanik DG, Young RAL.

Oxpentifylline treatment venous ulcers of the leg. BMJ. 1990; 300: 972- 975

Dale JJ, Ruckley CV, Harper DR, Gibson B, Nelson EA, Prescott RJ. A randomised double

blind placebo-controlled trial of oxpentifylline in the treatment of venous leg ulcers.

Phlebology 1995; Suppl 1: 917- 918

Alinovi A, Bassissi P, Pini M. Systemic administration of antibiotics in the management of

venous ulcers. A randomized clinical trial. J Am Acad Dermatol 1986; 15: 186- 91

Padberg FT, Johnston MV, Sisto SA. Structured exercise improves calf muscle pump

function in chronic venous insufficiency: a randomized trial. J Vasc Surg 2004; 39: 79- 87

Kahle B, Leng K. Efficacy of sclerotherapy in varicose veins: prospective, blinded,

placebo-controlled study. Dermatol Surg 2004; 30: 723- 728

Merchant RF, DePalma RG, Kabnick LS. Endovascular obliteration of saphenous reflux: a

multicenter study. J Vasc Surg 2002; 35: 1190- 1196

Neglen P, Raju S. Intravascular ultrasound scan evaluation of the obstructed vein. J Vasc

Surg 2002; 35: 694- 700

Sarin S, Scurr JH, Coleridge Smith PD. Stripping of the long saphenous vein in the

treatment of primary varicose veins. Br J Surg 1994; 81: 1455- 1458

Aremu MA, Mahendran B, Butcher W, Khan Z, Colgan MP, Moore DJ, Madhavan P,

Shanik DG. Prospective randomised controlled trial: conventional versus powered

phlebectomy. J Vasc Surg 2004; 39: 88- 94

Barwell JR, Davies CE, Deacon J, Harvey K, Minor J, Sassano A, Taylor M, Usher J, Wakely

C, Earnshaw JJ, Heather BP, Mitchell DC, Whyman MR, Poskitt KR. Comparison of surgery

and compression with compression alone in chronic venous ulceration (ESCHAR study):

randomized controlled trial. Lancet 2004; 363: 1854- 1859

Gloviczki P, Bergan JJ, Rhodes JM, Canton LG, Harmsen S, Ilstrup DM. Mid-term results of

endoscopic perforator vein interruption for chronic venous insufficiency: lessons learned

from the North American subfascial endoscopic perforator surgery registry. The North

American Study Group. J Vasc Surg 1999; 29: 489- 502

Kistner RL. Surgical repair of the incompetent femoral vein valve. Arch Surg 1975; 110:

- 1342

Raju S, Berry MA, Neglen P. Transcommissural valvuloplasty: technique and results. J

Vasc Surg 2000; 32: 969- 976

Amouzou KS, Haidara TM, Malonga-Loukoula EJ, Diouri M, Ezzoubi M. Use of domestic

negative pressure wound therapy in traumatic wounds for a cost-effective wound

closure. Nigerian J Plast Surg 2017; 13: 64-8

Chronic Venous Leg Ulcers: A Narrative Review.

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Published

09-05-2022

How to Cite

1.
Otene CI, Akpo EE, Uchendu JO, Odion-Obomhense HK, Sefia ET, Ikubor JE, Oriakhi S- nation, Orugbo VP, Odatuwa-Omagbemi DO, Obanovwe CE. Chronic Venous Leg Ulcers: A Narrative Review. AJTMBR [Internet]. 2022 May 9 [cited 2022 Aug. 11];5(1):18-30. Available from: https://ajtmbr.org.ng/index.php/home/article/view/56