White cell accumulation in dependent legs of patients with venous hypertension: a possible mechanism for trophic changes in the skin

Thomas, Philip; Nash, Gerard B.; Ja, Dormandy

doi:10.1136/bmj.296.6638.1693

Cited by 304 publications

(133 citation statements)

References 7 publications

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“…47 Leukocytes also aggregate in capillary beds with low shear stresses and may activate, releasing proteolytic enzymes, resulting in increased capillary permeability and local inflammatory changes. [49][50][51] …”

Section: Pathophysiologymentioning

confidence: 99%

Chronic Venous Insufficiency and Venous Ulceration

Alguire

Mathes

1997

J Gen Intern Med

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OBJECTIVE:To review and summarize the literature on the normal venous circulation of the leg, and the epidemiology, pathophysiology, and treatment of chronic venous insufficiency (CVI).DATA SOURCES: English-language articles identified through a MEDLINE search using the terms venous insufficiency or varicose ulcer and epidemiology, pathophysiology, diagnosis, and clinical trial (pt), and selected cross-references. STUDY SELECTION:Articles on epidemiology, pathophysiology, and treatment of CVI. Randomized, controlled studies were specifically sought for treatment efficacy. DATA EXTRACTION:Data were manually extracted from selected studies and reviews; emphasis was placed on information relevant to the general internist. pproximately 5 million people in the United States exhibit some evidence of chronic venous insufficiency (CVI) and between 400,000 and 500,000 of these individuals have or will develop a venous leg ulcer. 1-3 The signs of CVI include engorgement of the cutaneous veins and dependent edema in mildly affected patients to pigmentation, dermatitis, and ulceration in the more severe cases. Although most patients are asymptomatic, others have leg heaviness and aching or recurrent and recalcitrant leg ulcers punctuated by bouts of cellulitis. These more severe cases are associated with recurrent hospitalization, high health-care costs, and disability. 4,5 Venous insufficiency with trophic skin changes or ulceration is a frustrating problem, which many physicians approach with a sense of ennui. This may be due to the chronic and remitting nature of the problem, the need for lifestyle modification, inconvenient therapies, and contradictory information regarding medical and surgical management. Nevertheless, CVI, including ulceration, is a manageable problem. The purpose of this review is to present the normal anatomy and physiology of the venous circulation and to summarize the epidemiology, pathophysiology, and treatment of CVI. DATA SYNTHESIS: METHODSA MEDLINE search for relevant English-language articles published between 1966 and 1996 was completed using the following MeSH terms: venous insufficiency or varicose ulcer and epidemiology, pathophysiology, diagnosis, and clinical trial (pt). When selecting articles on treatment, randomized, controlled trials were reviewed whenever possible. Emphasis was placed on reviewing articles with clinical relevance for internal medicine physicians. ANATOMY AND NORMAL PHYSIOLOGYVenous blood from the skin and subcutaneous fat is collected in a system of superficial venules and veins that drain toward the deep venous system underneath the fascia via three major pathways: (1) through the long or short saphenous veins, which join the deep system at the saphenofemoral and saphenopopliteal junctions; (2) through the perforating veins originating from the long or short saphenous veins or their branches; or (3) directly into the deep venous system or bypass the deep system entirely and enter the pelvis. 6 Deep veins are categorized as either intramuscular or intermuscular; o...

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Section: Pathophysiologymentioning

confidence: 99%

Chronic Venous Insufficiency and Venous Ulceration

Alguire

Mathes

1997

J Gen Intern Med

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“…Initially, Homanns (10) reported a reduced blood flow to the limbs, a theory which was soon discarded since studies demonstrated a greater flow in the femoral arteries of patients with CVH (11)(12)(13) than in normal individuals. Recently, the most popular theory in the literature (14,15) has been that the leukocytes are sequestered at the level of capillaries of the lower extremities, occluding them and causing regional hypoflow leading to ischemia and tissue destruction.…”

Section: Introductionmentioning

confidence: 99%

Variations in white blood count, thromboxane B2 levels and hematocrit in chronic venous hypertension

et al. 1998

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Objective: To analyze variations in leukocyte count and thromboxane B 2 production in the femoral vein of patients with chronic venous hypertension (CVH). Design: Prospective clinical study, controlled, non randomized and open. Location: Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, referral center, university hospital. Participants: 15 patients with recurring stasis ulcer were analyzed, selected randomly from the venous diseases outpatient center, and 4 without lower limb venous alterations were also analyzed. Intervention: Blood samples from the femoral and brachial veins were drawn following supine and 45º reverse Trendelenburg. Main outcomes measures: Direct leukocyte count and analysis of the thomboxane B 2 with enzyme linked immunosorbent assay test. Results: After 30 minutes in reverse Trendelenburg, patients with CVH showed a leukocyte count reduced by ±27% (p=0.02) and thromboxane B 2 levels increased by ±158% (p=0.02). Conclusions: We suggest that future studies of medications for stasis ulcers include their effects on leukocyte entrapment and thromboxane B 2 production in the lower limb venous system.

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“…White blood cell plugging in the capillaries results in local ischemia and the release of certain mediators (including proteolytic enzymes such as collagenase and elastase, cytokines, and free radicals), which can cause tissue injury. [6][7][8][9][10][11] These mechanisms that can lead to cutaneous and nail changes in patients with CVI may facilitate the development of onychomycosis.…”

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confidence: 99%

Venous Insufficiency in Patients With Toenail Onychomycosis

Kulaç

Açar

Karaca

et al. 2005

Journal of Ultrasound in Medicine

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Objective. Onychomycosis is a common fungal infection of the toenails and can originate secondary to vascular abnormalities. The aim of this study was to evaluate the relationship between onychomycosis and venous insufficiency. Methods. Forty-two patients with onychomycosis and 39 healthy control subjects who had normal toenails were enrolled in the study. Doppler examinations were performed with a commercially available scanner and a 7.5-MHz linear probe. Major superficial and deep veins of the lower limb, including long and short saphenous, femoral, and popliteal veins, were examined. Venous insufficiency was assessed with the Valsalva test. With the Doppler examination, retrograde flow of more than 1 second was accepted as venous insufficiency. Results. Venous insufficiency was detected more frequently in patients with onychomycosis than in the control group (15 [35.7%] of 42 and 6 [15.4%] of 39, respectively; P = .037). Reflux was bilateral in 4 (26.7%) of 15 patients with onychomycosis, and in those 4 patients the onychomycosis was also bilateral. In 7 (46.7%) of 15 patients, onychomycosis and venous insufficiency were detected ipsilaterally, whereas there were no onychopathic features contralaterally. Although unilateral insufficiency was present in 4 (26.7%) of 15 patients, these patients had bilateral onychomycosis. Conclusions. We found a significant relationship between onychomycosis and venous insufficiency; therefore, we recommend a routine venous Doppler examination for patients with onychomycosis to diagnose or rule out venous insufficiency.

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White cell accumulation in dependent legs of patients with venous hypertension: a possible mechanism for trophic changes in the skin

Cited by 304 publications

References 7 publications

Chronic Venous Insufficiency and Venous Ulceration

Chronic Venous Insufficiency and Venous Ulceration

Variations in white blood count, thromboxane B2 levels and hematocrit in chronic venous hypertension

Venous Insufficiency in Patients With Toenail Onychomycosis

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