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Venous Ulcers
St. Peregrine, O.S.M.
Saint Peregrine dedicated his life to labors among the poor, the sick, and the sinful.
He accepted a commission to re-establish the Servite Monastery in his home town of
Forli. His tender care of the sick during a calamitous plague in Forli in 1323 secured
for him the everlasting gratitude and respect of the citizens.
One of the special penances he imposed on himself for 30 years was that he never
sat down and when he was forced to sleep he did so by leaning against a wall. Peregrine
spent 62 years of his life in his religious order. In the course of this period Peregrine
developed varicose veins and a huge ulcerative growth appeared on his leg, exposing
the bone and emanating the odor of gangrene. All medical treatment failed. He was
examined by the best physicians of the time who pronounced the lesion to be cancerous
and advised amputation. He is in the background carrying his saw. The night before
surgery was scheduled Peregrine spent much time in prayer before the crucifi ed Jesus
asking God to heal him if it was God’s will to do so.
In this painting from a Catholic Church in Vienna, we see an angelic nurse changing
the dressing on what appears to be a venous leg ulcer. Other paintings of Saint Per-
egrine also show that the lesion was on the medial lower leg in what Cockett described
was “the gaiter area”. Today we would attribute healing to effective compression dress-
ings applied by a more modern but still angelic nurse.
To continue the Peregrine legend, falling asleep at one point, Peregrine had a vision
of the crucifi ed Jesus leaving the cross and touching his leg. When Peregrine awoke,
the wound was healed and his foot and leg, seemingly miraculously cured, were saved.
He lived another 20 years, continued his work among the sick until he died on May 1,
1345, his 80th birthday.
St. Peregrine has been declared the universal patron Saint of Spain, and in Vienna
is cherished as the most popular saint. In 1967, George Pack, MD, who developed the
Gastric and Mixed Tumor services at the Memorial Hospital, New York eulogized Saint
Peregrine as the patron Saint of Cancer Patients in an issue of Ca A Cancer Journal
for Clinicians (1967;17;183–184) pointing out that this was the fi rst reported case of
spontaneous cure of cancer.
This fi gure was furnished by Dr Hugo Partsch of Vienna.
John Bergan, MD La Jolla, 2007
Venous Ulcers
EDITORS
JOHN J. BERGAN
vein institute of la jolla, california
university of san diego, school of medicine
CYNTHIA K. SHORTELL
duke university school of medicine
AMSTERDAM · BOSTON · HEIDELBERG · LONDON
NEW YORK · OXFORD · PARIS · SAN DIEGO
SAN FRANCISCO · SINGAPORE · SYDNEY · TOKYO
Academic Press is an imprint of Elsevier
Elsevier Academic Press
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525 B Street, Suite 1900, San Diego, California 92101-4495, USA
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This book is printed on acid-free paper.
Copyright © 2007, Elsevier Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopy, recording, or any information
storage and retrieval system, without permission in writing from the publisher.
Permissions may be sought directly from Elsevier’s Science & Technology Rights
Department in Oxford, UK: phone: (+44) 1865 843830, fax: (+44) 1865 853333, E-mail:
permissions@elsevier.co.uk. You may also complete your request on-line via the Elsevier
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Library of Congress Cataloging-in-Publication Data
Venous ulcers / editors, John Bergan, Cynthia Shortell.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-12-373565-2 (hardcover : alk. paper)
ISBN-10: 0-12-373565-3 (hardcover : alk. paper)
1. Venous insuffi ciency. 2. Veins–Ulcers. 3. Leg–Ulcers. I. Bergan, John J.,
1927– II. Shortell, Cynthia, K.
[DNLM: 1. Varicose Ulcer–diagnosis. 2. Varicose Ulcer–therapy.
WG 620 V464 2008]
RC700.V45V46 2008
616.1′43–dc22
2007002963
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
ISBN 13: 978-0-12-373565-2
ISBN 10: 0-12-373565-3
For all information on all Elsevier Academic Press publications
visit our Web site at www.books.elsevier.com
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https://t.me/med1917
Table of Contents
Emblem of Hunczovksy xi
Contributors xiii
Foreword xvii
Mark A. Talamini
Preface xix
John J. Bergan and Cynthia K. Shortell
SECTION I
Etiology and Initial Evaluation of the
Patient with Chronic Venous Insuffi ciency
1
Infl ammation and the Pathophysiology of
Chronic Venous Disease: Molecular
Mechanisms 3
Geert W. Schmid-Schönbein and Luigi Pascarella
2
Microcirculation in Chronic Venous
Insuffi ciency 15
Kevin Burnand and Said Abisi
v
Venous Ulcers
Copyright © 2007 by Academic Press, Inc.
All rights of reproduction in any form reserved.
https://t.me/med1917
vi Table of Con ten ts
3
Epidemiology of Venous Ulcers 27
Olle Nelzén
4
Lower Extremity Ultrasound Evaluation and
Mapping for Evaluation of Chronic Venous
Disease 43
Stylianos K. Tsintzilonis and Nicos Labropoulos
5
Hypercoagulable States Associated with
Chronic Venous Insuffi ciency 55
Jose L. Trani Jr. and Jeffrey H. Lawson
6
The Chronically Swollen Leg: Finding the
Cause: Theory and Practice 67
Warner P. Bundens
SECTION II
Nonoperative Management of Chronic
Venous Insuffi ciency
7
Compression Therapy in Venous Leg
Ulcers 77
Hugo Partsch
https://t.me/med1917
Table of Contents vii
8
Wound Healing: Adjuvant Therapy and
Treatment Adherence 91
Dale Buchbinder and Sharon B. Buchbinder
9
Negative Pressure Dressings in Venous
Ulcers 105
Brian D. Lewis and Jonathan B. Towne
10
Deep Vein Thrombosis and Prevention of Post-
Thrombotic Syndrome 113
Joseph A. Caprini
SECTION III
Theraputic Procedures for Chronic
Venous Insuffi ciency
11
Results Comparing Compression Alone Versus
Compression and Surgery in Treating Venous
Ulceration 135
Manjit S. Gohel, Jamie R. Barwell, Mark R. Whyman,
and Keith R. Poskitt
12
Superfi cial Surgery and Perforator
Interruption in the Treatment of Venous Leg
Ulcers 149
William Marston
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viii Table of Con ten ts
13
Endovascular Techniques for Superfi cial Vein
Ablation in Treatment of Venous Ulcers 173
Michael J. Stirling and Cynthia K. Shortell
14
Treatment of Chronic Venous Insuffi ciency with
Foam Sclerotherapy 185
Alessandro Frullini
15
Foam Treatment of Venous Leg Ulcers: The
Initial Experience 199
Juan Cabrera and Pedro Redondo
16
Foam Treatment of Venous Leg Ulcers:
A Continuing Experience 215
Van L. Cheng, Cynthia K. Shortell, and John J. Bergan
17
Ultrasound Guidance for Endovenous
Treatment 227
Luigi Pascarella, Lisa Mekenas, and John J. Bergan
18
Repair of Venous Valves in Severe Chronic
Venous Insuffi ciency 243
Michel R. Perrin
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Table of Contents ix
SECTION IV
Special Topics
19
Treatment of Recalcitrant Venous Ulcers with
Free Tissue Transfer for Limb Salvage 261
Stephen J. Kovach and L. Scott Levin
20
The Diagnosis and Treatment of Major Venous
Obstruction in Chronic Venous
Insuffi ciency 275
Francisco José Osse and Patricia Ellen Thorpe
21
The Venous Ulcer and Arterial
Insuffi ciency 299
Robert B. McLafferty and Colleen M. Johnson
22
Topical Negative Pressure Techniques in
Chronic Leg Ulcers 307
Jeroen D. D. Vuerstaek, Tryfon Vainas, and Martino H. A.
Neumann
Epilogue 327
John J. Bergan
Index 329
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