Leg ulcers affect 1% of the general population and 5% of patients over the age of 80 years (HAS 2006). They are most commonly caused by venous insufficiency but can also be caused by arterial problems due to lower limb arteriopathy, or are of mixed origin, combining venous insufficiency and lower limb arteriopathy. Venous ulcers may be the result of venous failure due to leaky valves (leading to varicose ulcers) or may occur after phlebitis, causing deep venous insufficiency triggering venous ulcers that are more difficult to heal.
Treating an ulcer will depend on its origin thus it is essential to determine the nature of the ulcer involved (Table 7). With any lower-limb ulcer, it is advisable to palpate the peripheral pulses, and their absence or reduction indicates a potential ulcer of arterial origin. Another central element is the measurement of the systolic pressure index (SPI). This measurement, calculated using a hand-held Doppler and a manual pressure cuff, is the ratio between ankle systolic pressure/arm systolic pressure. SPI normally ranges between 0.9 and 1.3. When this figure is above 1.3 and the leg arteries cannot be compressed, this is referred to as “mediacalcosis” (i.e. media calcification of arterial vessels). SPI below 0.9 indicates the presence of lower limb arteriopathy, which is considered to be a critical stage of ischaemia if the SPI is below0.5 .
If doctors do not have the appropriate equipment in their surgery, they can ask the radiologist to measure the SPI when performing the arterial Doppler ultrasound.
Table 7. Major differences between venous and arterial ulcers.
A vascular assessment is important as:
• in venous ulcers,treatment is based on venous compression ;
• in arterial ulcers, compression is contraindicated (Figure 12). An arterial Doppler ultrasound of the lower limbs should be performed and the patientreferred to a vascular surgeon.
Figure 12. Deep and necrotic arterial ulcers.
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