500 years later: Henry VIII, leg ulcers and the course of history

The King Henry VIII

Venous ulcers affect the quality of life of people. Chronic venous disease can be painful, irritating and may also change the psychology of a person.

In case of Henry VIII it was said so! Subsequent ulceration affected Henry's legs bilaterally below the knee and may have been due to venous disease. The wearing of a garter  and the references to the King's shapely calf make it unlikely that Henry had prominent primary varicose veins. However, he may have acquired venous hypertension as a result of deep vein thrombosis (DVT). History does not record how tightly the garter was bound around his upper calf and he had several injuries to his legs as a result of his sporting activities, both of which represent risk factors for DVT. The most severe injuries were sustained during the fall from his horse that rendered him unconscious and crushed his legs in 1536. Crush injury with or without associated fracture of one or more long bones with obesity and relative immobility would increase the risk of DVT, damage to the deep venous system and subsequent venous insufficiency. Severe venous hypertension may therefore have resulted in ulceration. An untreated compound fracture may also result in diffuse infection with cellulitis, osteomyelitis, deep abscess formation and a persistently discharging sinus. A compound fracture may well have rendered Henry unable to walk and such a suggestion is absent in the records of the time. It is therefore much more likely that Henry suffered an extensive DVT as a result of his injuries and subsequent immobility resulting in the classical pattern of venous ulceration. J R Soc Med. 2009 December 1; 102(12): 514–517.

• J R Soc Med. 2009 December 1; 102(12): 514–517. '500 years later: Henry VIII, leg ulcers and the course of history
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HIV Positive person presenting with Iliofemoral deep vein thrombosis.

Statistically Deep vein thrombosis in HIV/AIDS is approximately 10 times greater than in the general population. It is less often reported. Femoral and popliteal vein thrombosis is common. But ilio-femoral deep vein thrombosis as first presentation in the HIV positive people is uncommon. Hypercoagulability in HIV positive people can occur due to many reasons and in future we may be looking at different types of thromboprophylactic measures in addition to the aggressive anti retroviral therapies. Here we are reporting on a HIV positive person presenting as unprovoked, acute ilio-femoral deep vein thrombosis.

Psoriasis and subdermal venous dilatations

Psoriasis in association with dilated veins (sub dermal) the legs. It is some times difficult to differentiate which clinical condition is the cause for the symptoms of the person. This is possible when psoriasis is seen along with the varicose veins. These patients complain of symptoms such as pain, discomfort, heaviness and difficulty in walking with skin lesions (dry, scaly) and few dilated veins in the legs. We have noted in our clinic especially in women who were treated for the skin disease (assumed as skin allergy), significant importance was given to the dilated veins by their family physicians and dermatologists. They were referred to the vascular surgical clinic with view to consider varicose veins surgery. In such patients a detailed examination for arthritis is necessary as this may be part of psoriasis (10-20% of patients). Counseling of the patients and their families about the psoriasis (skin disease) is important before any surgical therapies can be considered. A Dermatologist who can consider “ Foam- Sclerotherapy” along with skin therapies may be ideally suited for treating for such vein disorders in association with the skin diseases. But in India, very dermatologists in our city are considering foam Sclerotherapy for varicose veins in their clinics. Probably in future more number of dermatologists may consider foam Sclerotherapy in their practices.

Psoriasis (pronounced /səˈraɪəsɪs/) is a non-contagious disorder which affects the skin and joints. It commonly causes red scaly patches to appear on the skin. The scaly patches caused by psoriasis, called psoriatic plaques, are areas of inflammation and excessive skin production. Skin rapidly accumulates at these sites and takes on a silvery-white appearance. Plaques frequently occur on the skin of the elbows and knees, but can affect any area including the scalp and genitals. In contrast to eczema, psoriasis is more likely to be found on the extensor aspect of the joint

By

Pinjala RK

Venous Ulcer in Chronic Venous insufficiency

Chronic venous disease is noted as large venous ulcers around the ankle. In India, it is not uncommon to see this type of advanced forms of chronic venous disease (see Fig.)
There are many reasons which make this type presentation a common feature in the govt general hospital out patient clinics. Some times the plastic surgeons attempt skin grafting for these ulcers after control of infection with regular dressing. But these ulcer recur due to the underlying venous insufficiency. Venous reflux in the superficial veins is addressed by Flush ligation of the SFJ, SPJ and perforators. But the deep venous insufficiency is left to subside or regress with the external compression therapies in the post operative period for few years. Very few hospitals are able to consider some form of therapy for the deep vein reflux across the globe and in India.

Phlebology 2007;22:219-222
Catheter directed foam Sclerotherapy
Kolbel T, Hinchliffe RJ, Lindblad B

ABSTRACT
The authors present results on chemical ablation of 50 great saphenous veins (GSVs) using 3% polidocanol foam delivered via a standard coaxial endovenous sheath. The sheath was steadily withdrawn with one hand, while injecting between 5 and 8cc of sclerosing foam out the endhole. The amount of sclerosant was a function of the length of the treated vein.

All 50 veins were occluded at the 1-week follow-up visit which included examination by color flow duplex imaging. One vein had a 10 cm long open segment in the middle of the thigh. One patient suffered a pulmonary embolus post-procedure. Most patients had advanced disease, 43 veins were in limbs with CEAP class 4-6. There was no mention of vein diameter in the study. The authors correctly point out that vasospasm in the GSV caused by catheterization may alter the flow of the foam and result in its unintended distribution. The authors also mention a newly launched catheter-assisted vein sclerotherapy device (KAVS, F care Systems NV, Aartselaar, Belgium) which comprises a balloon catheter capable of occluding the GSV without occluding the common femoral vein. They had no results or experience with the device.

How important venous surgery in poor people?

Varicose veins are generally benign and often subjected for corrective therapies with varying degrees of symptoms. These procedures are also some times performed with a view to give the cosmetic results for the legs. In case of a common man there is a possibility to look for less invasive, less expensive and probably less cosmetic therapies as an alternative to the expensive therapies.

Sclerotherapy for Asymptomatic varicose veins in the contralateral leg

Varicose veins are known to be bilateral. The varicose veins may be more prominent on one side and symptomatic and on the other side they may be asymptomatic. After surgery for the symptomatic varicose veins the patients would be getting rid of the asymptomatic varicose veins on the opposite side. In such cases it may be helpful to consider sclerotherapy to such varicose veins if they are suitable for it. Recently we have treated such patients sclerosants and the results are satisfactory with satisfaction from the patients. The proper dilution of the sclerosant is more important in such patients to get the best results in terms of obliteration of the varicose veins which are 3 to 5 mm in diameter. The veins disappeared immediately after the sclerotherapy and remained so in the follow up of 3 months.