Approach to leg ulcers
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Transcript of 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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http://www.perfuse.netVascular surgery @ Tallaght
http://www.perfuse.netVascular surgery @ Tallaght
http://www.perfuse.netVascular surgery @ Tallaght
http://www.perfuse.netVascular surgery @ Tallaght