A Cross-sectional Evaluation of the Association Between Lower Extremity Venous Ulceration and Predictive Risk Factors

  • Wed, 11/11/09 - 11:21am
  • 0 Comments
  • 3982 reads
Login to Download
PDF version
Author(s): 
Paul Y. Takahashi, MD; Lester Kiemele, MD; Stephen S. Cha, MS; Anupam Chandra, MD

Abstract: Objective. This study sought to identify the association between a history of venous ulceration and demographic, vascular, and nonvascular risk factors in a healthy cohort of older adults. Patients. All patients older than 60 years impanelled within a primary care practice residing in Olmsted County, Minnesota on January 1, 2005 were enrolled. Methods. This was a cross-sectional study utilizing administrative data from an outpatient practice. The primary outcome was a previous history of venous ulceration. The predictor risk variables included demographic risk factors and comorbid health conditions. Data analysis involved univariable comparison between venous ulceration and the risk variables. The significant variables were placed in a final multivariable model. Results. The authors reviewed the records of 12,650 patients and identified 581 (4.6%) who had a history of venous ulceration. Venous insufficiency had the highest association with venous ulceration with an odds ratio of more than 900. Decubitus ulceration also had a high association with an odds ratio of 2.66 [95% CI: 1.74–4.07]. Older age, female gender, previous hospitalization, diabetes, renal insufficiency, peripheral vascular disease, congestive heart failure, depression, degenerative arthritis, peripheral neuropathy, hypothyroidism, and falls were associated with venous ulceration. Marital status, hyperlipidemia, hip fracture, chronic obstructive pulmonary disease, cancer, and dementia were not associated with venous ulceration. Conclusion. The relationship between venous insufficiency and venous ulceration appears to be very strong, as expected, given the etiology of disease. Conditions such as vascular disease and vascular risk factors were also highly associated with ulceration. Interestingly, decubitus ulceration as a risk was a novel finding.



Address correspondence to:
Paul Takahashi, MD
Mayo Clinic, Department of Internal Medicine
200 First St. SW
Rochester, MN 55905
Phone: 507-284-2511
Email: takahashi.paul@mayo.edu





     Healthcare providers commonly encounter and treat venous ulcers in clinical practice. About 1% of the US population (estimated at 3 million people) experience venous ulceration, which results in pain and disability from both the wound and ongoing wound care.1,2 Providers strongly emphasize edema control as the primary method of treatment for venous ulcers.3 Effective local wound management involves controlling excessive exudate, which is common in venous ulcers.4 Providers have effective treatment for venous ulcers; however, most clinicians and patients would prefer prevention over treatment. Venous disease experts have developed consensus statements for the prevention of venous ulcers.5 For successful preventative strategy implementation, providers often try to identify the patients who are at the highest risk for ulcer development. Among the older population, a stratified approach appeals to both patients and providers because of the challenges of edema treatment in frail, older adults. However, scientists in clinical research have not found these risk factors within an older population; thus, one can only draw from previous work experiences with younger populations.

     While evidence of risk factors in the older population is lacking, there are many identifiable risk factors for venous ulcers in younger cohorts.

References: 

1. Ruckley CV. Socioeconomic impact of chronic venous insufficiency and leg ulcers. Angiology. 1997;48(1):67–69.
2. Valencia IC, Falabella A, Kirsner RS, Eaglstein WH. Chronic venous insufficiency and venous leg ulceration. J Am Acad Dermatol. 2001;44(3):401–421.
3. Cullum N, Nelson EA, Fletcher AW, Sheldon TA. Compression for venous leg ulcers. Cochrane Database Syst Rev. 2009;(1):CD000265.
4. Takahashi PY, Kiemele LJ, Jones JP, Jr. Wound care for elderly patients: advances and clinical applications for practicing physicians. Mayo Clin Proc. 2004;79(2):260–267.
5. Nicolaides AN; Cardiovascular Disease Educational and Research Trust, European Society of Vascular Surgery, The International Angiology Scientific Activity Congress Organization, International Union of Angiology, Union Internationale de Phlebologie at the Abbaye des Vaux de Cernay. Investigation of chronic venous insufficiency: a consensus statement. Circulation. 2000;102(20):E126–E163.
6. Magnusson MB, Nelzèn 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(4):453–461.
7. Kulkarni SR, Gohel MS, Wakely C, Minor J, Poskitt KR, Whyman MR. The Ulcerated Leg Severity Assessment score for prediction of venous leg ulcer healing. Br J Surg. 2007;94(2):189–193.
8. Callam MJ, Ruckley CV, Harper DR, Dale JJ. Chronic ulceration of the leg: extent of the problem and provision of care. Br Med J (Clin Res Ed). 1985;290(6485):1855–1856.
9. Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects. World Medical Association 18th General Assembly; 1964; Helsinki, Finland; 1964.
10. Bonham PA. Assessment and management of patients with venous, arterial, and diabetic/neuropathic lower extremity wounds. AACN Clin Issues. 2003;14(4):442–456.
11. Nelzén O, Bergqvist D, Lindhagen A. Leg ulcer etiology—a cross sectional population study. J Vasc Surg. 1991;14(4):557–564.
12. Forssgren A, Fransson I, Nelzén O. Leg ulcer point prevalence can be decreased by broad-scale intervention: a follow-up cross-sectional study of a defined geographical population. Acta Dermatol Venereol. 2008;88(3):252–256.
13. Heit JA, Rooke TW, Silverstein MD, et al. Trends in the incidence of venous stasis syndrome and venous ulcer: a 25-year population-based study. J Vasc Surg. 2001;33(5):1022–1027.
14. Baker SR, Stacey MC, Jopp-McKay AG, Hoskin SE, Thompson PJ. Epidemiology of chronic venous ulcers. Br J Surg. 1991;78(7):864–867.
15. Fu X, Sheng Z, Cherry GW, Li Q. Epidemiological study of chronic dermal ulcers in China. Wound Repair Regen. 1998;6(1):21–27.
16. Maida V, Corbo M, Dolzhykov M, Ennis M, Irani S, Trozzolo L. Wounds in advanced illness: a prevalence and incidence study based on a prospective case series. Int Wound J. 2008;5(2):305–314.
17. Kumar RN, Gupchup GV, Dodd MA, et al. Direct health care costs of 4 common skin ulcers in New Mexico Medicaid fee-for-service patients. Adv Skin Wound Care. 2004;17(3):143–149.
18. Boccalon H, Janbon C, Saumet JL, Tafani A, Roux T, Vilain C. Characteristics of chronic venous insufficiency in 895 patients followed in general practice. Int Angiol. 1997;16(4):226–234.
19. Wipke-Tevis DD, Rantz MJ, Mehr DR, et al. Prevalence, incidence, management, and predictors of venous ulcers in the long-term-care population using the MDS. Adv Skin Wound Care. 2000;13(5):218-224.
20. Etufugh CN, Phillips TJ. Venous ulcers. Clin Dermatol. 2007;25(1):121-130.
21. Falanga V, Eaglstein WH. The "trap" hypothesis of venous ulceration. Lancet. 1993;341(8851):1006–1008.
22. Laing T, Hanson R, Chan F, Bouchier-Hayes D. The role of endothelial dysfunction in the pathogenesis of impaired diabetic wound healing: a novel therapeutic target? Med Hypotheses. 2007;69(5):1029-1031.
23. Chen J, Kasper M, Heck T, et al. Tissue factor as a link between wounding and tissue repair. Diabetes. 2005;54(7):2143–2154.
24. Schramm JC, Dinh T, Veves A. Microvascular changes in the diabetic foot. Int J Low Extrem Wounds. 2006;5(3):149–159.
25. Mehta JS, Nicolaou N, Kiryluk S, Fordyce MJ. Venous leg ulcers after hip replacement. A clinical evaluation at 5 to 12 years. J Bone Joint Surg Br. 2003;85(7):960–962.
26. Baker SR, Stacey MC, Singh G, Hoskin SE, Thompson PJ. Aetiology of chronic leg ulcers. Eur J Vasc Surg. 1992;6(3):245–251.
27. Sellier E, Labarere J, Sevestre MA, et al. Risk factors for deep vein thrombosis in older patients: a multicenter study with systematic compression ultrasonography in postacute care facilities in France. J Am Geriatr Soc. 2008;56(2):224–230.
28. Snyder RJ. Controversies regarding vascular disease in the patient with diabetes: a review of the literature. Ostomy Wound Manage. 2007;53(11):40–48.
29. Barron GS, Jacob SE, Kirsner RS. Dermatologic complications of chronic venous disease: medical management and beyond. Ann Vasc Surg. 2007;21(5):652–662.
30. Jones J, Barr W, Robinson J, Carlisle C. Depression in patients with chronic venous ulceration. Br J Nurs. 2006;21;15(11):S17–S23.
31. Leibson CL, Needleman J, Buerhaus P, et al. Identifying in-hospital venous thromboembolism (VTE): a comparison of claims-based approaches with the Rochester Epidemiology Project VTE cohort. Med Care. 2008;46(2):127–132.
32. Melton LJ, 3rd. History of the Rochester Epidemiology Project. Mayo Clin Proc. 1996;71(3):266–274.
33. United States Census Bureau. US Census 2000. Available at: http://www.census.gov/main/www/cen2000.html. Accessed: December 2008.































image description image description