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38 Epidemiology of Venous Ulcers
HEALING AND SURVIVAL
The healing prognosis for patients in the community is rather poor, with
expected 12 weeks healing results often lower than 40%. In Scotland, a nation-
wide randomized study
26
failed to detect any benefi t from a nurse-training
program. The 12 weeks of healing remained virtually unchanged. Only around
28% of patients healed their ulcers during a follow-up of 21 months.
As a part of the Skaraborg study, we made a 5-year follow-up of all
patients to assess healing and survival.
6
Venous ulcers had a bad outcome:
Only 54% had healed, 44% without recurrence and 10% with a recurrence,
during the period. At that time most venous ulcers were treated with con-
servative compression bandaging usually by district nurses in the commu-
nity. Patients with deep vein incompetence had a signifi cantly worse
outcome compared with patients with superfi cial venous incompetence
alone. Regarding patient survival, we found that the patients with venous
ulcers had a 5-year survival equal to an age- and sex-matched control
population (Figure 3-4).
FUTURE TRENDS
A more holistic approach in Skaraborg, Sweden, with a multidisciplinary
approach including interventions such as intense use of varicose vein
FIGURE 3-4 Life table of the 5-year survival for patients with leg ulcers of various
origin. Wicoxon (Gehan) test *** p * .014 0.001, n.s. p = 0.53.
6
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Epidemiology of Venous Ulcers 39
surgery and arterial reconstruction, has resulted in lowered point preva-
lence both for venous and arterial ulcers and has created a marked shift
of the etiologic spectrum, according to preliminary data.
12,27
These data
were the result of a repeat of a cross-sectional study in 2002 comparing the
data with a similar study performed in the area in 1988,
1,2,3
showing a 46%
reduction in patients with venous ulcers.
27
The point prevalence for venous
ulcers has been reduced from 0.16% down to 0.09%. Preliminary data
from a repeat large size (10,000 participants) study validated a population
questionnaire study also pointing strongly in the same positive direction.
It appears that men now, to a greater extent, are seeking professional help
and that varicose ulcers now outnumber ulcers with deep vein incompe-
tence, leaving room for further use of surgical treatment. There still appears
to be room for further reductions of venous ulcer prevalence, at least within
the Swedish population. It appears that a radical change in management
strategy does result in improved healing and a lowered rate of recurrent
ulcers, especially when venous and arterial ulcers are concerned. Changing
the course of ulcers of multifactorial or other origins seems, however, to
be more diffi cult.
Leg ulcers are common in most populations, and the prevalence rises
with age. Due to the expected increasing proportion of elderly in most
populations, an increased prevalence of chronic venous leg ulcers is
expected, unless radical changes of management are undertaken. If we
continue to treat the majority conservatively with compression regimes,
few, if any, will be cured, and the majority will experience recurrent ulcer-
ation over time and some will never heal. We have strong evidence that
superfi cial venous surgery reduces the risk of recurrence of venous ulcers
signifi cantly within 1 year.
28
Surgically untreated superfi cial venous and
incompetence has been shown to be a risk factor for venous ulcer recur-
rence,
29
which is in line with our experience in Skaraborg. So, by increased
use of leg ulcer diagnosis and tailored treatment, including superfi cial and
perforator surgery, for each individual it is likely that the scenario can be
substantially improved, and the prevalence of leg ulcers can actually be
lowered worldwide, not only in Sweden.
REFERENCES
1. Nelzén O, Bergqvist D, Hallböök T, Lindhagen A. Chronic leg ulcers: An underesti-
mated problem in primary health care among elderly patients. J Epidemiol Community
Health. 1991;45:184 –187.
2. Nelzén O, Bergqvist D, Lindhagen A. Leg ulcer etiology—A cross-sectional population
study. J Vasc Surg. 1991;14:557–564.
3. Nelzén O, Bergqvist D, Lindhagen A. Venous and non-venous leg ulcers: Clinical history
and appearance in a population study. Br J Surg. 1994;81:182–187.
4. Nelzén O, Bergqvist D, Lindhagen A. The prevalence of chronic lower-limb ulceration
has been underestimated: Results of a validated population questionnaire. Br J Surg.
1996;83:255–258.
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40 Epidemiology of Venous Ulcers
5. Nelzén O, Bergqvist D, Fransson I, Lindhagen A. Prevalence and aetiology of leg ulcers
in a defi ned population of industrial workers. Phlebology. 1996;11:50–54.
6. Nelzén O, Bergqvist D, Lindhagen A. Long term prognosis for patients with chronic leg
ulcers: A prospective cohort study. Eur J Vasc Endovasc Surg. 1997;13:500–508.
7. Nelzén O. Patients with chronic leg ulcers: Aspects of epidemiology, aetiology, clinical
history, prognosis and choice of treatment. Comprehensive Summaries of Uppsala dis-
sertations from the Faculty of Medicine 664. Uppsala: Acta Universitatis Upsaliensis,
1997;1:1–88.
8. Graham ID, Harrison MB, Nelson EA, Lorimer K, Fisher A. Prevalence of lower-limb
ulceration: A systematic review of prevalence studies. Advances in Skin & Wound Care.
2003;16:305–316.
9. Baker SR, Stacey MC, Jopp-McKay AG, Hoskin SE, Thompson PJ. Epidemiology of
chronic venous ulcers. Br J Surg. 1991;78:864–867.
10. Cornwall JV, Dore CJ, Lewis JD. Leg ulcers: Epidemiology and aetiology. Br J Surg.
1986;73:693–696.
11. Moffatt CJ, Franks PJ, Doherty DC, Martin R, Blewett R, Ross F. Prevalence of leg
ulceration in a London population. Q J Med. 2004;97:431–437.
12. Jakobsson A, Nelzén O, Fransson I. (Abstract) Dramatic changes in the aetiological
spectrum of leg ulcers: Results from a cross-sectional based study. Int Angiol.
2005;24(Suppl. 1):92.
13. Bobek K, Cajzl L, Cepelak V, Slaisova V, Opatzny K, Barcal R. Étude de la frequénce
des maladies phlebologiques et de l’infl uence de quelques facteurs étiologiques. Phle-
bologie. 1966;19:227–230.
14. Widmer LK. Peripheral Venous Disorders. Basle Study III. Bern: Hans Huber, 1978.
15. Fischer H. Venenleiden: Eine Repräsentative Untersuschung in der Bevölkerung der
Bundesrepublik Deutschland (Tübinger-studie). München: Urban Schwartsenberg,
1981.
16. Heit JA, Rooke TW, Silverstein MD, et al. Trends in the incidence of venous stasis syn-
drome and venous ulcer: A 25-year population-based study. J Vasc Surg. 2001;33:
1022–1027.
17. Walker N, Rodgers A, Birchall N, Norton R, MacMahon S. The occurrence of leg ulcers
in Auckland: Results of a population-based study. New Zealand Med J. 2002;
1151:159–162.
18. Evans CJ, Fowkes FGR, Ruckley CV, Lee AJ. Prevalence of varicose veins and chronic
venous insuffi ciency in men and women in the general population: Edinburgh Vein
Study. J Epidemiol Community Health. 1999;53:149–153.
19. Rabe E, Pannier-Fischer F, Bromen K, et al. Bonner Venenstudie der Deutschen Gesell-
schaft für Phlebologie. Phlebologie. 2003;32:1–14.
20. Criqui MH, Jamosmos M, Fronek A, et al. Chronic venous disease in an ethnically
diverse population: The San Diego Population Study. Am J Epidemiol. 2003;158:
448–456.
21. Walsh JC, Bergan JJ, Beeman S, Comer TP. Femoral venous refl ux abolished by greater
saphenous vein stripping. Ann Vasc Surg. 1994;8:566 –570.
22. Magnusson M, Nelzén O, Volkmann R. Leg ulcer recurrence and its risk factors: A
duplex ultrasound study before and after vein surgery. Eur J Vasc Endovasc Surg.
2006;32:453–461.
23. Skene AI, Smith JM, Dore CJ, Charlett A, Lewis JD. Venous leg ulcers: A prognostic
index to predict time to healing. Br Med J. 1992;305:1119–1121.
24. Milne AA, Ruckley CV. The clinical course of patients following extensive deep venous
thrombosis. Eur J Vasc Surg. 1994;8:56–59.
25. Saarinen J, Sisto T, Laurikka J, Salenius J-P, Tarkka M. Late sequelae of acute deep
venous thrombosis: Evaluation fi ve and ten years after. Phlebology. 1995;10:106–109.
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Epidemiology of Venous Ulcers 41
26. Scottish Leg Ulcer Trial Participants. Effect of a National Community Intervention
Programme on Healing Rates of Chronic Leg Ulcer: Randomized Controlled Trial.
Phlebology. 2002;17:47–53.
27. Jakobsson A, Nelzén O, Fransson I. (Abstract) Leg ulcer point prevalence in a defi ned
geographical population: A repeat cross-sectional study. Int Angiol. 2005;24(Suppl. 1):
91–92.
28. Barwell JR, Davies CE, Deacon J, et al. Comparison of surgery and compression with
compression alone in chronic venous ulceration (ESCHAR study): Randomised con-
trolled trial. Lancet. 2004;363:1854–1859.
29. Gohel MS, Taylor M, Earnshaw JJ, Heather BP, Poskitt KR, Whyman MR. Risk factors
for delayed healing and recurrence of chronic venous leg ulcers. An analysis of 1,324
legs. Eur J Vasc Endovasc Surg. 2005;29:74–77.
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43
4
Lower Extremity
Ultrasound Evaluation
and Mapping for
Evaluation of Chronic
Venous Disease
Stylianos K. Tsintzilonis and Nicos
Labropoulos
Duplex ultrasound scanning is considered the test of choice among dif-
ferent diagnostic tools for detailed evaluation of chronic venous insuffi -
ciency. It combines color fl ow imaging with B-mode and pulsed Doppler.
It is very well documented that duplex ultrasound scanning is the most
reliable, cost-effective, quick, and noninvasive method to identify venous
refl ux. This type of scanning is also able to detect venous obstruction and
assess recurrence of both refl ux and thrombosis.
Most recent studies have shown that the superfi cial and perforating
veins are involved in the majority of patients.
1
However, several reports
document that the type and duration of treatment and the rate of recur-
rence of venous ulcers are signifi cantly different when the deep venous
system is involved.
2,3
Therefore, knowledge of the venous anatomy, pathol-
ogy, and their variations is an important prerequisite for the person who
performs the duplex ultrasound in order to identify precisely the etiology
and the anatomic distribution of the venous malfunction in each patient.
REQUIREMENTS AND SETTINGS
The test starts by having the patient stand with support of his/her
bodyweight on the contralateral limb. The limb under examination
Venous Ulcers
Copyright © 2007 by Academic Press, Inc.
All rights of reproduction in any form reserved.
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44 Lower Extremity Ultrasound Evaluation and Mapping for Evaluation
should be relaxed with the knee slightly fl exed. It has been shown that this
is the best position for testing refl ux, and the supine position is no longer
recommended.
4
If the patient cannot stand, the sitting position is
preferred.
Superfi cial veins can be imaged with different transducers based on the
depth of their location, especially in patients with obese and edematous
limbs. Superfi cial veins within 1 cm in the subcutaneous fat can be evalu-
ated with a 10-MHz transducer. A 3-MHz transducer is used for evaluation
of veins deeper than 6 cm. The veins to be examined are identifi ed with
B-mode imaging. Many of the modern ultrasound machines have transduc-
ers with a range of frequencies that can adjust according to the depth, so
it is not necessary to change the transducer often.
Manual compression is used to demonstrate refl ux by rapidly squeezing
and suddenly releasing different muscle beds above and below the vein in
question. At the groin, Valsalva maneuver can also be used. In obese
patients or in patients with edema, dorsi/plantar fl exion may be used if the
compression is insuffi cient to augment the fl ow. However, when precise
measurements are needed regarding fl ow or duration of refl ux, then auto-
matic rapid infl ation-defl ation cuffs should be used.
All main veins should always be imaged along their entire length. Non-
saphenous, accessory veins and major tributaries when incompetent should
be followed, and their course and connections should be noted. It is impor-
tant, for the study to be reliable and accurate, that the examiner is aware
of the venous anatomy and the different variations such as duplications,
hypoplasia, and segmental aplasia (Figure 4-1). Duplication is usually seen
in the popliteal vein in up to 40% of limbs and in 25% to 30% in the
femoral vein. Pathologic fi ndings may be detected in one of the two veins.
Duplications of the GSV and SSV are found in <3%, while hypoplasia and
aplasia are frequently seen.
Throughout the exam, color fl ow imaging is used on top of the B-mode
ultrasound. Initially, the artery is identifi ed by a red color on the monitor.
Then and while applying compression, the adjacent veins are identifi ed by
a blue color. Blue color indicates that fl ow is in the opposite direction than
the fl ow in the artery. If no color is noticed in the vein after the release of
the compression, then no refl ux is present, implying that the valves are
competent. The appearance of red color in the vein indicates the presence
of refl ux. The Doppler waveform will document the presence of refl ux.
Retrograde fl ow with short duration is seen behind competent valves, and
it is normal.
4,5,6
This is explained as a result of reverse fl ow just before valve
closure, and this should not last more than 0.5 second. Reverse fl ow greater
than 0.5 second in the vein under investigation is considered abnormal.
4
Several studies were done to defi ne signifi cant refl ux on different veins.
The results of the most recent and complete study defi ned refl ux as a ret-
rograde fl ow lasting >1,000 ms in the common femoral, femoral, and pop-
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Lower Extremity Ultrasound Evaluation and Mapping for Evaluation 45
A
B
FIGURE 4-1 Anatomic variations in the superfi cial veins. A. Dilated accessory saphen-
ous vein and normal GSV in the upper thigh. The accessory vein extended to the midcalf
and had prolonged refl ux. B. Hypoplasia of the GSV in the lower thigh that measured only
0.7 mm. A dilated accessory vein starting at midthigh had replaced the GSV to the calf
where they rejoined.
liteal veins; >500 ms in the superfi cial veins, deep femoral veins, and deep
calf veins; and >350 ms in the perforating veins (Figure 4-2).
4
Refl ux also can be distinguished into segmental when it is confi ned to
a single venous segment and multisegmental when it is confi ned to more
than one venous segment.
7
The location of refl ux and etiology are described
with the CEAP classifi cation.
8
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46 Lower Extremity Ultrasound Evaluation and Mapping for Evaluation
SUPERFICIAL VEINS
Imaging of the GSV starts at the groin where the saphenofemoral junc-
tion (SFJ) is identifi ed medial to the common femoral artery. The terminal
valve in the GSV is located 1–2 mm distal to the SFJ; the preterminal valve
is located 2 cm more distally. Between those two valves, there are tributar-
ies that join the GSV, which are often associated with pathology. They can
have refl ux together with GSV or be independent to it. In cases of deep
C
D
FIGURE 4-1 Continued
C. Aplasia of the GSV at the knee. An incompetent dilated accessory vein is seen outside
the saphenous canal where the GSV is absent. D. Duplication of the SSV from the upper
calf to midcalf. Both veins are seen inside the saphenous canal.
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Lower Extremity Ultrasound Evaluation and Mapping for Evaluation 47
vein obstruction, they are dilated and act as collateral pathways. For
example, refl ux in the accessory saphenous vein without the involvement
of GSV occurs in about 9% of patients. This is important because only the
accessory vein should be treated, and the GSV can be spared.
9
In the thigh,
GSV is always identifi ed in the “saphenous eye,” which the fascial sheets
create.
10,11
The upper echogenic layer seen in a transverse scan is the super-
A
B
FIGURE 4-2 Refl ux in different veins in the lower extremity. A. The GSV in the thigh
is dilated, has old thrombosis, is partially recanalized, and has refl ux. B. The anterior acces-
sory saphenous vein is dilated and has refl ux lasting about 3 seconds.
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