Management of leg ulcers in patients with rheumatoid arthritis or systemic sclerosis: The importance of concomitant arterial and venous disease

Hafner, Jürg; Schneider, Ernst; Burg, Günter; Cassina, Paolo C.

doi:10.1067/mva.2000.106942

Cited by 81 publications

(52 citation statements)

References 17 publications

(20 reference statements)

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“…Arterial and venous disease may also contribute to healing delay in scleroderma and can be seen in as many as 50% of patients. Therefore, vascular evaluation is recommended in all patients (23). …”

Section: Scleroderma and Mixed Connective Tissue Disease Associated Umentioning

confidence: 99%

Vasculitic and autoimmune wounds

Shanmugam

Angra

Rahimi

et al. 2017

Journal of Vascular Surgery: Venous and Lymphatic Disorders

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Chronic wounds are a major cause of morbidity and mortality. Approximately 20–23% of non-healing wounds that are refractory to vascular intervention have other etiologies including vasculitis, pyoderma gangrenosum and other autoimmune diseases. The purpose of this article is to review the autoimmune and coagulopathic diseases that are commonly associated with leg ulceration. OBJECTIVES To review the literature across medical and surgical specialties with regards to refractory chronic wounds associated with vasculitis and autoimmune diseases and to delineate clinical outcomes of these wounds in response to vascular and other interventions. METHODS An electronic search encompassing MEDLINE®, PubMed®, Cochrane Library and Scopus ® was completed using the following search terms: rheumatoid arthritis; systemic sclerosis; systemic lupus erythematosus; ANCA associated vasculitis; mixed connective tissue disease; antiphospholipid syndrome; pyoderma gangrenosum; thromboangiitis obliterans; cryoglobulinemia; hydroxyurea; sickle-cell; atrophie blanche; livedoid vasculitis; cholesterol emboli; calciphylaxis; antiphospholipid antibodies; prothrombotic; combined with the terms: chronic wound and leg ulcer. Full text articles published in English up to March 1, 2016 that investigated the clinical outcomes of chronic wounds associated with autoimmune diseases were included. Review articles and evaluations of management of chronic wounds were also reviewed. Primary outcomes included in the review were amputation, ulcer healing, reduction in wound size, overall survival and freedom from reintervention. Owing to the heterogeneity of data reporting among articles, qualitative analysis is also reported. CONCLUSIONS Autoimmune and vasculitic etiologies should be considered in patients with chronic wounds who do not respond to appropriate vascular intervention and standard local wound care. A multidisciplinary approach with the involvement of rheumatology allows investigation for underlying systemic disease and improves clinical outcomes for many of these challenging patients.

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Section: Scleroderma and Mixed Connective Tissue Disease Associated Umentioning

confidence: 99%

Vasculitic and autoimmune wounds

Shanmugam

Angra

Rahimi

et al. 2017

Journal of Vascular Surgery: Venous and Lymphatic Disorders

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“…In fact, several cases of peripheral vascular disease causing chronic leg ulcers in rheumatoid patients have been reported, in some cases even leading to limb amputation. [14][15][16] Our findings suggest that impairment of peripheral arterial function in rheumatoid arthritis may be more common than previously suspected.…”

Section: Discussionmentioning

confidence: 50%

“…Indeed, cases of severe peripheral vascular disease affecting rheumatoid patients have been described. [14][15][16] However, the frequency and extent of impaired peripheral arterial function in rheumatoid arthritis are not well established. This information is important for an understanding of atherosclerosis and cardiovascular disease in general, and of how such disorders affect patients with rheumatoid arthritis.…”

mentioning

confidence: 99%

Lower limb arterial incompressibility and obstruction in rheumatoid arthritis

Rincón

Haas

Pogosian

et al. 2004

Annals of the Rheumatic Diseases

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Background: Despite increased cardiovascular morbidity and mortality in rheumatoid arthritis, the peripheral arteries remain understudied. Objective: To examine the lower limb arteries in age and sex matched, non-smoking subjects with and without rheumatoid arthritis. Methods: The ankle-brachial index (ABI) was measured at the posterior tibial and dorsal pedal arteries. Arteries were classified as obstructed with ABI (0.9, normal with ABI .0.9 but (1.3, and incompressible with ABI .1.3. Multinomial logistic regression was used to estimate differences in ABI between patients and controls, adjusting for cardiovascular risk factors, rheumatoid arthritis manifestations, inflammation markers, and glucocorticoid dose. Results: 234 patients with rheumatoid arthritis and 102 controls were studied. Among the rheumatoid patients, 66 of 931 arteries (7%) were incompressible and 30 (3%) were obstructed. Among the controls, three of 408 arteries (0.7%) were incompressible (p = 0.002) and four (1%) were obstructed (p = 0.06). At the person level, one or more abnormal arteries occurred among 45 rheumatoid patients (19%), v five controls (5%, p = 0.001). The greater frequency of arterial incompressibility and obstruction in rheumatoid arthritis was independent of age, sex, and cardiovascular risk factors. Adjustment for inflammation markers, joint damage, rheumatoid factor, and glucocorticoid use reduced rheumatoid arthritis v control differences. Most arterial impairments occurred in rheumatoid patients with 20 or more deformed joints. This subgroup had more incompressible (15%, p(0.001) and obstructed arteries (6%, p = 0.005) than the controls, independent of covariates. Conclusions: Peripheral arterial incompressibility and obstruction are increased in rheumatoid arthritis. Their propensity for patients with advanced joint damage suggests shared pathogenic mechanisms.

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“…Coexistent prothrombotic states contribute to ulceration in scleroderma and evaluation for antiphospholipid antibodies and genetic prothrombotic states is recommended. Furthermore, arterial and venous disease can be seen in as many as 50% of scleroderma associated ulcers, therefore, vascular evaluation is recommended in all patients (21). While vascular interventions play a role in the management of distal ischemia in scleroderma, the long-term effectiveness of bypass surgery is limited due to small vessel vasculopathy and studies show high rates of graft failure and limb loss (22).…”

Section: Overview Of Vasculitic Woundsmentioning

confidence: 99%

Vasculitic Diseases and Prothrombotic States Contributing to Delayed Healing in Chronic Wounds

Shanmugam

2016

Curr Derm Rep

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PURPOSE Autoimmune diseases are a common cause of delayed wound healing and should be considered in patients with chronic wounds who do not respond to local wound care or who fail skin grafting in the absence of infection. RECENT FINDINGS Epidemiologic studies have shown that, of patients with chronic wounds evaluated in specialized wound healing clinics, 20–23% have autoimmune etiologies for their wounds including vasculitis, rheumatoid arthritis, systemic lupus erythematosus, scleroderma, pyoderma gangrenosum and other autoimmune diseases. SUMMARY In this article autoimmune diseases known to be associated with chronic wounds and delayed wound healing are reviewed and the importance of a multidisciplinary approach for patients with chronic wounds, with involvement of rheumatology and dermatology is highlighted. This approach allows for investigation of underlying systemic disease and improves clinical outcomes for many of these challenging patients.

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Management of leg ulcers in patients with rheumatoid arthritis or systemic sclerosis: The importance of concomitant arterial and venous disease

Cited by 81 publications

References 17 publications

Vasculitic and autoimmune wounds

Vasculitic and autoimmune wounds

Lower limb arterial incompressibility and obstruction in rheumatoid arthritis

Vasculitic Diseases and Prothrombotic States Contributing to Delayed Healing in Chronic Wounds

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