Identifying the source of superficial reflux in venous leg ulcers using duplex ultrasound

Mapping of venous reflux routes associated with medially or laterally located venous leg ulcers and their source of origin.

This prospective report presents the results of duplex investigations performed in consecutive leg ulcer patients, all with venous reflux, in a time period over 2 years. A total of 169 patients (183 legs), with chronic venous leg ulcers (CEAP: C6) were examined in a private practice. The data collection integrated an examination that included medical history and clinical diagnoses and incorporated measurements such as body mass index, oscillometric index, and range of motion of the ankle joint. Venous function was assessed with duplex ultrasound, and the cases were described using the advanced CEAP classification. Additionally, a "sourcing" technique was performed with duplex ultrasound investigation of the ulcer bed and the venous system under manual compression and release of the ulcer. The principle of "sourcing" is to follow venous reflux from the ulcer area to its proximal origin. The detected reflux routes were classified either as "axial" or "crossover" type.

A total of 20% of the ulcer patients showed no clinically visible varicose veins. One hundred three patients had medial ulcers, 54 lateral ulcers, 21 medial and lateral, and five had gaiter ulcers. Sixty-four (35%) of the medially located ulcers had reflux in the great saphenous vein (GSV), 28 (15%) showed reflux in the medial perforating veins (axial types), and 11 (6%) had reflux in the small saphenous vein (SSV; crossover type). From 54 patients presenting with lateral ulcers, 25 (14%) showed GSV incompetence (crossover type) and only 13 (7%) SSV incompetence (axial type). Sixteen patients showed refluxes penetrating from deep into lateral perforating veins.

Crossover reflux routes were detected in 25 of 54 (46%) legs with lateral and in 11 of 103 (11%) legs with medial ulceration (χ2 44.34; P<.001). In venous ulcer patients, an extended examination (CEAP classification) and a special duplex technique ("sourcing") are recommended to identify the specific route responsible for the venous reflux. This seems essential for planning a rational treatment of venous reflux ulcers.