Modulation of urokinase-type and tissue-type plasminogen activator occurs at an early stage of progressing stages of chronic venous insufficiency

Chronic venous insufficiency (CVI) progresses through a series of clinical stages, from healthy skin to poorly healing leg ulcers. The aim of this study was to analyse the distribution pattern and activity level of urokinase-type (uPA) and tissue-type plasminogen activators (tPA) in normal skin and in tissue biopsies of progressing stages of CVI, prior to and including venous ulceration. Biopsies 6 mm thick were taken from 14 healthy volunteers and 37 patients with 5 different stages of CVI: telangiectases; stasis dermatitis; hyperpigmentation; lipodermatosclerosis; and leg ulcer. Changes in the enzymatic activity and spatial localization of uPA and tPA during the progression of CVI were examined using in situ histological zymography. Normal skin and skin with telangiectases showed a punctate PA activity, consisting of both uPA and tPA activity. As CVI progressed, an increase in the distribution of uPA and a decrease in tPA activity was observed. The spatial localization of uPA was widespread within the dermis of biopsies from stasis dermatitis and lipodermatosclerosis and was associated in particular with the dermoepidermal junction. Hyperpigmented skin revealed a pattern of PA expression similar to that of healthy skin. However, leg ulcer specimens exhibited peak levels of uPA with little tPA. Furthermore, a plasminogen-independent protease activity that was not present in any of the earlier stages of CVI appeared. Our results indicate that there are profound changes in PA activity during the progression of CVI and that these changes begin early in CVI, for example, in stasis dermatitis. We hypothesize that the balance or imbalance of the PA activity in the later stages of CVI is an important pathogenic factor for the development of venous leg ulcer.

Circulator boot therapy alters the natural history of ischemic limb ulceration

Despite numerous advances in interventional radiology and vascular surgery, the clinician continues to be confronted with inoperable vascular disease. Previous studies have shown that ulceration associated with a transcutaneous oxygen pressure (tcPO2) of <20 mmHg is refractory to all attempts at healing. External pneumatic compression for the treatment of peripheral vascular disease has been available for several years, although there is a relative paucity of data regarding its role in clinical practice as well as its efficacy. The objective of this study was to examine the experience with circulator boot therapy in the treatment of ischemic ulcers in the absence of osteomyelitis, and specifically to determine whether such therapy can be of benefit in ischemic limb ulceration associated with a tcPO2 of <20 mmHg. A retrospective chart review was undertaken of ail patients with a lower limb ulcer who, in the absence of osteomyelitis, underwent circulator boot therapy at the Gonda Vascular Center. A total of 98 patients was identified. Two patients died within 1 month of commencing therapy and were not included in further analysis. The tcPO2 data were unavailable in five patients. Outcome in the patient population was classified as favorable if (1)healing was achieved, (2)the ulcer decreased in size, or (3) the affected limb improved sufficiently to allow successful revascularization. An unfavorable outcome was one where a major amputation was performed or where the ulcer increased in size. Out of a total of 29 patients with a tcPO2 <20 mmHg at the area of ulceration, 19 had a favorable outcome following circulator boot therapy. Of the remaining 62 patients with a tcPO2 >20 mmHg, 54 had a favorable outcome. Circulator boot therapy is associated with improved outcomes in limb ulceration due to peripheral vascular disease. Complete ulcer healing as well as preservation of the affected limb can be achieved in most cases.

The clinical management and outcome of venous ulcers in legs with deep-venous obstruction

OBJECTIVE

as a result of a serious complication from compression bandaging in a patient with venous ulceration and deep-vein obstruction, a policy of incremental compression in such limbs has been developed. The purpose of this retrospective study is to review the outcome of this policy.

DESIGN

limbs with deep-venous obstruction (stenosis or occlusion) were treated initially with 3-layer compression bandaging and reviewed 24 h later. If 3-layer bandaging was tolerated, it was re-applied for a further 48 h. If there were no problems, then 4-layer bandaging was applied and the patient reviewed at 24 and 72 h. If 4-layer bandaging could not be tolerated, the limb was returned to 3-layer bandaging.

RESULTS

of 325 limbs seen in a venous-ulcer clinic, 22 (7%) had deep-vein obstruction. Fifteen (68%) limbs were able to tolerate 4-layer bandaging, five (23%) could tolerate 3-layer bandaging and two limbs (9%) could only tolerate class 2 compression hosiery. The overall 1-year healing rate was 55%. There were no serious complications from bandaging.

CONCLUSIONS

a protocol of incremental compression bandaging is safe in ulcerated legs with deep-vein obstruction and produces healing in up to 55% of cases.

The terminal complement complex is generated in chronic leg ulcers in the absence of protectin (CD59)

Loss of membrane complement regulators accompanied by complement activation is suggested to be involved in the pathophysiological processes leading to tissue damage in myocardial ischaemia. In the present study we have investigated whether the same phenomenon may occur in ischaemic and/or venous hypertension leg ulcers. The deposition of complement, plasma complement regulators and expression of membrane regulators were detected by immunohistochemical methods, including immunofluorescence with antibodies against C3d, the terminal complement complex (TCC), vitronectin, clusterin, decay-accelerating factor (CD55) and protectin (CD59). Eleven frozen biopsies from ischaemic leg ulcers, 10 biopsies from venous hypertension leg ulcers, and 10 biopsies from normal skin were studied. In 9 of 11 ischaemic and in 5 of 10 venous hypertension leg ulcers, marked staining for TCC was found around the capillaries, most often at the ulcer margin. No TCC staining was found in normal skin. Staining for TCC was always accompanied by staining for clusterin and vitronectin and C3d. In normal skin, CD59 was found on the elastic fibers in the dermis, on the muscle coat, the Schwann sheath and acinar cells. Semiquantitative measurement of CD59 showed marked increased staining intensity in the endothelium in venous hypertension ulcers and diminished intensity in ischaemic ulcers compared to normal skin. No such difference could be observed for CD55. When TCC was positive in the capillary walls, weak or no staining for CD59 was found. A significantly higher ratio of TCC/CD59 was found in the ischaemic compared to venous ulcers (p = 0.018). This was due to a marked difference between the ulcer margins (p = 0.013). Localized areas in the venous ulcers had the same pattern as that seen in the ischaemic ulcers. Our results suggest that loss of CD59 may enhance deposition of TCC and that complement-dependent inflammation may be an important factor in the tissue-damaging processes seen in chronic leg ulcers.

Comparative study of different venous reflux duplex quantitation parameters

The objective of this study was to compare different quantitation parameters of venous reflux by duplex scan in different venous disease manifestations. Duplex scan is a new modality to quantify venous reflux. Several studies propose different parameters. In addition, there is controversy about the importance of deep and superficial involvement in different disease manifestations. It is not clear whether there is an increased venous reflux associated with varied clinical stages. Venous conditions were classified in seven stages and their differences for several quantitation variables studied. Most quantitation variables, such as average and peak velocity, average and peak flow, and reflux volume disclosed significantly increased reflux from normal, pain only, and edema group to varicose vein, with or without edema, to lipodermatosclerosis and ulcer groups at every location in the lower extremity. Reflux time was not as consistent as other variables. Totalization of the results of every parameter for the whole extremity points to an increased reflux from pain only to edema and from lipodermatosclerosis to ulcer group. Chronic edema is not usually associated with increased venous reflux. The greater saphenous vein (superficial system) seems to be the main contributor to reflux in all stages of disease. Different quantitation methods of venous reflux are equivalent. Increased deep and superficial reflux and its totalization are associated with a more advanced disease stage. Reflux time may be the least useful variable. Chronic edema is frequently not associated with venous reflux. Greater saphenectomy may be the most useful intervention, even in the presence of deep vein reflux.

A new approach to an old and vexing problem: subfascial endoscopic perforator surgery

Chronic venous insufficiency with venous hypertension causes leukocyte trapping, lipodermatosclerosis, and finally, skin ulceration involving the lower extremity. Perforator vein incompetence has been identified as an important contributing factor to ulceration when abnormally elevated pressure is transmitted to areas of affected skin, usually at the ankle medially. Surgical techniques for ligation of incompetent communication veins were first popularized by Linton and Dodd from 1940 to 1950. Early techniques used extensive longitudinal incisions for subfascial ligation through indurated skin. These procedures were plagued with wound complications: delayed healing, skin necrosis, and infection. Techniques continued to evolve that used minimally invasive incisions and avoided zones of affected skin. With the availability of endoscopic, fiberoptic, and laparoscopic advances in surgery, instrumentation has been developed for minimally invasive endoscopic approach to accomplish subfascia endoscopic perforator surgery (SEPS) under direct vision. SEPS is now used alone and in combination with other venous interventions to reduce transmission of venous hypertension to affected skin areas. The SEPS procedure, its indications, and the history of surgical treatment of perforator vein incompetence are discussed. Unique problems related to short hospital stays and postoperative care are outlined. This review will help the vascular nurse understand the rationale and techniques of SEPS. This comprehension will enable provision of accurate information to the patient and a knowledge-based plan of care.

Venous stasis wounds

Lower extremity wounds related to venous insufficiency are increasing. As the number of adults over the age of 65 increases, so do wounds related to changes in the vascular system. Venous stasis wounds can present as a real challenge to experienced practitioners. This article describes the many factors associated with venous wounds as well as the need for a comprehensive treatment plan.

Management of patients with venous ulcers in the community setting

Venous ulcers, a chronic disabling condition, present a complex management challenge to the interdisciplinary team in the community setting. The incidence of venous ulcers is increasing as the population ages with such comorbidities as congestive heart failure (CHF), deep vein thrombosis (DVT), obesity, and others. Disability associated with venous ulcers may increase caregiver burden in accomplishing the patient's activities of daily living (ADL), and handicap may exist from difficulty in community participation because of impaired mobility. Venous hypertension, the primary culprit in venous ulcerations, must be managed with an arsenal of strategies to control the underlying condition, heal the wound, and prevent recurrence.

Patients with chronic leg ulcers show diminished levels of vitamins A and E, carotenes, and zinc

BACKGROUND

Nutrition plays an important role in the wound healing process, particularly in the elderly.

OBJECTIVE

Comparison of nutritional serum indices between patients with chronic leg ulcers and an age-matched control population.

METHODS

Seventeen patients with chronic leg ulcers (age range 47-90) were studied. A panel of vitamins (A, B1, B2, B6, B12, E), trace elements (zinc, copper, iron), folate, and carotene levels were screened on fasting blood samples. Study data were compared with data obtained from the nutritional status survey (NSS) in the greater Boston area.

RESULTS

Significantly lower levels of vitamin A (P < 0.0001), zinc (P < 0. 0001 men, P = 0.027 women) and carotenes (P = 0.0023 men, P = 0.0067 women) were found in chronic ulcer patients. Significantly lower levels of vitamin E (P < 0.009) were observed in the men with a tendency to lower levels in women.

CONCLUSION

Elderly Bostonian patients with chronic leg ulcers have low levels of vitamins A and E, carotenes, and zinc. Nutritional deficiency or increased consumption of nutritional elements in these patients may influence wound healing rates.

[Endoscopic fasciotomy and subfascial perforator division for chronic stasis ulcers]

Chronic venous ulcer disease is often refractory to conservative treatment modalities. After surgery of the superficial vein system, endoscopic methods can be used for division of incompetent perforators or to perform paratibial fasciotomy in cases of chronic functional compartment syndromes. We report on 13 endoscopically performed paratibial fasciotomies with or without concomitant endoscopic subfascial division of perforators (ESDP) in patients with stasis ulcers present for a median duration of 15 years. In all patients we observed immediate reduction of pain and edema. In 8 of 13 cases the ulcers healed within 3 months, another ulcer healed within 6 months and the remaining 4 ulcers showed a reduction in size of more than 75%. We conclude that endoscopically performed fasciotomy with or without ESDP is highly effective and has its place in the treatment of chronic venous ulcer disease.

Lipodermatosclerosis and the significance of proteolytic remodeling in the pathogenesis of venous ulceration (Review)

The preceding stage of venous ulceration represents a scleroderma-like hardening of the skin called lipodermatosclerosis. Clinical stages such as lipodermatosclerosis and venous ulceration, which succeed one another are highly associated to chronic venous insufficiency. Lipodermatosclerosis is characterized by fibrous scar tissue of the reticular dermis built up of collagen bundles and loss of cellular components, whereas venous ulceration is characterized by total loss of epidermis and partially of matrix structures in the upper dermis. There is a growing recognition that an excessive proteolytic activity by proteases, in particular that of matrix metalloproteinases and fibrinolytic factors of the plasminogen activation system may be a key feature in the pathophysiological understanding of venous leg ulcer formation. Lipodermatosclerosis displays an intense ongoing proteolytic process by elevated matrix metalloproteinase activity, as recently shown on different molecular and biological levels. Elevated expression on mRNA and protein level of matrix metalloproteinases and fibrinolytic factors of the plasminogen activation system have been detected in liposclerotic skin lesions. In addition, matrix metalloproteinases were proteolytically activated confirmed by zymography experiments and collagen degradation assays. Therefore it is well conceivable, that proteolytic enzymes of matrix metalloproteinases could initiate an elevated turnover of the extracellular matrix with subsequent breakdown of the matrix scaffold finally resulting in venous ulceration.

The management of patients with venous leg ulcers: new guidelines

The RCN Institute, the Centre for Evidence-based Nursing, and the University of York have recently produced guidelines on the management of patients with venous leg ulcers. These guidelines make recommendations with regard to assessment, compression therapy, cleansing, debridement, dressings, contact sensitivity, training/education and quality assurance (Cullum et al, 1998). They are evidence-based (Effective Health Care Bulletin, 1997), have been informed by expert opinion and are reflective of current good clinical practice. It is envisaged that they will be updated every 2 years. This article provides an outline of these guidelines. However, healthcare professionals must note that guidelines can simplify clinical decision making and this must be acknowledged when the guidelines' recommendations for practice are being implemented.

Pharmacological treatments for venous leg ulcers

A review of drug therapies used in the management of venous leg ulcers.

Leg ulcer care in the community

This case study reports on the assessment and treatment at home of an elderly man with a venous leg ulcer.

Use of a noncontact radiant heat bandage for the treatment of chronic venous stasis ulcers

A noncontact radiant heat bandage was used for the treatment of chronic venous stasis ulcers (mean duration 4.44 years) in inpatients who had failed aggressive inpatient and outpatient conventional therapy. The noncontact radiant heat bandage was placed over the ulcer for 5 hours daily: three 1-hour heating periods separated by two 1-hour nonheating periods during this 2-week trial. Wound size, status, and pain severity were recorded for each patient. A total of 17 patients with 31 total wounds were enrolled. No adverse effects were noted in any patient. There was improvement in 14/17 total patients during the 2-week inpatient trial and 8/17 patients healed completely after discharge. There was 1 recurrence during an 18-month follow-up. Pain scores were improved in most patients after the bandage was applied. The use of a noncontact radiant heat bandage is a safe and efficacious inpatient therapy for the management of chronic venous stasis ulcers in patients who have failed conventional therapy.

Venous ulcers: etiology and care of patients treated with human skin equivalent grafts

Care for a patient with a venous ulcer is complex, necessitating collaboration of a multidisciplinary team to achieve the goal of providing comprehensive wound care and optimally managing complications, current conditions, and healing time. Patients often have venous ulcers for a long time, and they frequently have multiple diagnoses. Chronic ulcers that do not heal necessitate closure with a graft. Apligraf, (Novartis Pharmaceutical Corp, East Hanover, NJ), a human skin equivalent, is often used in nonhealing or difficult-to-heal ulcers. Knowledge of how to care for the grafted wound and protection of the grafted site is essential.