- Email: [email protected]
Thrombophilia and Chronic Venous Ulceration
Eur J Vasc Endovasc Surg 24, 97±104 (2002) doi:10.1053/ejvs.2002.1683, available online at http://www.idealibrary.com on
REVIEW ARTICLE
Thrombophilia and Chronic Venous Ulceration A. W. Bradbury1, R. K. MacKenzie1 , P. Burns1 and C. Fegan2 1
University Department of Vascular Surgery and 2Department of Haematology at Heartlands and Solihull NHS Trust (Teaching)
It is known that thrombophilia (TP) is a risk factor for deep venous thrombosis (DVT), and that DVT predisposes to chronic venous ulceration (CVU). However, the relationship between TP and CVU has not been well studied. Review of the literature reveals that the prevalence of TP in CVU patients is high ± similar to the prevalence found in patients with a history of DVT. This is despite many patients with CVU having no clear history, or duplex evidence of previous DVT. TP may predispose to CVU by leading to macro- or micro-vascular thrombosis. This association raises several issues regarding the investigation, prevention and management of patients with venous disease.
Introduction Chronic venous ulceration (CVU) affects at least 1% of the adult population (life-time risk), is associated with a marked reduction in quality of life, is characterized by low healing and high recurrence rates regardless of treatment, and consumes 1±2% of health care spending in most developed countries.1±4 The pathogenesis of the condition, especially at the microvascular level, remains incompletely defined and controversial. However, at the macrovascular level, it is generally agreed that the skin changes of chronic venous insufficiency (CVI) are predominantly due to sustained ambulatory venous hypertension. This, in turn, is due to venous reflux in the superficial and/or deep venous systems and, to a lesser extent, deep venous obstruction. A significant proportion of ulcers follow a clinically apparent and clearly documented episode of deep venous thrombosis (DVT) (post-thrombotic syndrome). Almost certainly, a further significant proportion of CVU follows a sub-clinical, forgotten, undocumented or unrecognised DVT. As a result, the proportion of CVU that are deemed to be post-thrombotic varies considerably between series depending upon thoroughness with which previous DVT is sought. Please address all correspondence to: A. W. Bradbury, University Department of Vascular Surgery, Lincoln House (Research Institute), Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, B9 5SS, U.K.
Thrombophilia (TP) may be defined as an abnormality of the clotting and/or fibrinolytic cascade(s) that leads to a hypercoagulable state.3,5,6 TP can be acquired or inherited and may predispose to atypical and/or recurrent arterial and/or venous thrombosis at a relatively young age (Table 1). As DVT is clearly a major risk factor for CVU it is perhaps surprising that the possible link between TP and CVU has not received more attention. It seems reasonable to hypothesise that a DVT developing in the presence of TP is more likely to lead to the post-phlebitic syndrome and CVU because it may occur earlier in life,7 is more likely to be extensive, may be more resistant to endogenous fibrinolysis and recanalisation, may be less responsive to treatment and is more likely to recur. Furthermore, CVU is associated with microvascular thrombosis and the development of a peri-capillary fibrin cuff; both of which may reflect defective fibrinolytic capacity. The aim of this paper is to review what is known of the relationship between CVU and TP. Methods The Medline database was searched for articles using the terms: thrombophilia, venous ulceration, venous insufficiency, as well as the individual thrombophilias. All abstracts were reviewed, and full text of relevant articles retrieved. Reference lists of retrieved articles were also searched for pertinent publications.
1078±5884/02/020097 08 $35.00/0 # 2002 Elsevier Science Ltd. All rights reserved.
A. W. Bradbury et al.
98
Table 1. The prevalence of thrombophilia and the relative risk for venous thrombosis. Thrombophilia
Estimated prevalence in general ``Western'' population (%)
Estimated prevalence in unselected patients with a first DVT (%)
Estimated relative risk for DVT
Antithrombin III deficiency Protein C deficiency Protein S deficiency Activated protein C resistance Factor V Leiden Hyperhomocystinaemia Elevated factor VIII levels Elevated factor XI levels Prothrombin G202210A Lupus anticoagulant Anticardiolipin antibodies
0.2 0.2 1 510 5±10 5 10 10 2.5 5 5
1 3 3 21 20 11 25 20 6 15 15
5.0 6.5 2.5 6.5 5.0 2.5 5.0 2.0 3.0 3.0 3.0
Data are based on figures presented in several recent reviews.5,8±10,12,54,55
Thrombophilia Thrombophilia and its relationship with arterial and venous thrombosis has been extensively reviewed elsewhere.5,8±11 For that reason, only a short description of the common abnormalities to be discussed below in relation to CVU is given here.12 Antithrombin (AT) deficiency AT is synthesized by the liver and inhibits thrombin and the activated factors of the intrinsic cascade (Xa, IXa, XIa, XIIa) and kallikrein. Many (480) mutations of the AT gene have been reported. AT deficiency is usually inherited in an autosomal dominant manner. Type I deficiency is due to low levels of AT and type II is due to the presence of a variant AT protein. In either case, functional AT activity can be determined by its ability to inhibit Xa in a heparin cofactor assay. Other tests can be used to distinguish type I from type II deficiency, as well as different types of type II deficiency. However, the clinical significance of this is unclear and a functional test is recommended for screening. Acquired AT deficiency can occur in association with many conditions including major surgery and malignancy.5 Protein C (PC) deficiency Protein C (PC) is a vitamin K dependent glycoprotein that is synthesised in the liver. Protein C is activated by the thrombin-thrombomodulin (T-TM) complex on the surface of endothelial cells (EC). Activated PC (APC) inhibits membrane-bound Va and VIIIa. More than 160 mutations have been described leading to type I and type II deficiencies. Again, a functional Eur J Vasc Endovasc Surg Vol 24, August 2002
test is required for screening. This can be a synthetic chromogenic substrate assay or a coagulation-based assay founded on the ability of APC to prolong the activated partial thromboplastin time (APTT). Protein S (PS) deficiency Protein S (PS) is a vitamin K dependent glycoprotein that is synthesised in the liver. Approximately 60% is bound to complement (C4b) and 40% circulates as free protein. Only free PS acts as a non-enzymatic cofactor to enhance the actions of APC on Va and VIIIa. At least 70 mutations have been identified leading to type I and type II deficiencies, which are usually passed on in an autosomal dominant manner. Some patients have low functional PS activity but no identifiable mutation; either the relevant mutations is yet to be identified or another mechanism is responsible. This, so-called, type III deficiency is associated with normal total PS antigen but reduced free antigen and activity. Type I and type III deficiencies may coexist in the same kindred. There is overlap in free PS levels between PS deficient heterozygotes and the normal population. Also, PS levels vary with age, gender, a number of medical conditions, pregnancy and hormone usage. For all these reasons, the diagnosis of PS deficiency is more difficult than for AT or PC. Activated protein C resistance (APCR) and factor V leiden (FVL) Activated PC resistance (APCR) is caused in the great majority (90%) of cases by a single base (Leiden) mutation in the factor V gene (FVL).13 This mutation renders Va resistant to the action of APC. Other factor V mutations (Cambridge, Hong Kong) and
Thrombophilia and Chronic Venous Ulceration
secondary causes, such as antiphospholipid antibodies (APLA), account for the remaining cases of APCR. FVL is common in Europeans (5±10%), uncommon in people from North India and the Middle East and absent in the indigenous people of Asia, America and Australasia. FVL heterozygotes may have a survival advantage through a reduction in intra- and post-partum haemorrhage. The commonest test for APCR involves measuring the prolongation of the APTT following the addition of APC (APC ratio). However, there are a number of problems associated with using this test as a screening tool and most authorities also recommend a polymerase chain reaction (PCR)-based ``genetic'' test to specifically identify the FVL mutation.12 Hyperhomocystinaemia Hyperhomocystinaemia (HHcy) has been implicated in the development of arterial and venous thrombosis through a range of incompletely understood mechanisms.14±16 Homocysteine is a metabolic breakdown product of methionine, which is itself metabolised through remethylation (vitamin B12 dependent) or transulphuration (B6 dependent) pathways. HHcy, due to a heterozygous deficiency of one of several enzymes involved in these pathways, is present in approximately 1% of the population. More commonly, HHcy is due to a deficiency of B12, B6 and folate in the diet. Such HHcy is frequently defined as 415 mmol/l; this being the level found in about 5% of the population. Hcy can be measured in number of different ways; in our laboratory we use high-pressure liquid chromatography. Elevated factor VIII levels Elevated factor VIII (FVIII) levels (4150 IU/dl) are associated with an almost five fold increase in DVT risk and are present in just over 10% of the normal population. Affected patients are particularly prone to recurrent thrombosis.17 The reasons for high FVIII are unclear but there does appear to be a hereditary component, possibly linked to the X-chromosome.18 FVIII can also arise as part of an acute phase response and it is recommended that C-reactive protein (CRP) be measured at the same time. Elevated factor XI levels Factor XI (FXI) is a component of the intrinsic system with direct procoagulant and indirect antifibrinolytic
99
activity.19 Elevated FXI levels (490th centile) are associated with a doubling of thrombotic risk.20 As yet, it is unclear whether the elevated level is due to specific genetic mutations. Prothrombin G20210A variant Prothrombin is a vitamin-K dependent glycoprotein. A single base mutation (A to G at position 20210) of the prothrombin gene is found in approximately 1±3% of the general European population but is rare in people of African and Asian descent.21 The mutation is associated with increased prothrombin blood levels and activation, which presumably explains the increased thrombotic risk.22 This may be due to increased gene expression. The mutation can be readily detected by means of PCR. Antiphospholipid antibodies There are two distinct types of APA; lupus anticoagulant (LA) and anticardiolipin antibodies (ACLA).23 LAmay inhibit the T-TM complex dependent activation of PC upon the EC surface. ACLA are commoner than LA in the general population and may be IgM or IgG or, rarely, IgA molecules. IgG is generally held to be the most pathogenic. ACLA appear to promote thrombosis through a number of different, incompletely defined, mechanisms including stimulation of platelet aggregation, inhibition of APC and AT, and up-regulation of tissue factor. APLA are frequently detected transiently in patients with autoimmune and viral conditions and those on certain drugs. It is recommended, therefore, that patients positive for LA or ACLA should be retested after a period of at least three months. Other thrombophilias New information regarding various putative inherited and acquired risk factors for venous thrombosis is accruing rapidly. The multifactorial nature of thrombophilic risk and its management In an otherwise young and fit individual, heterozygosity for a single inherited TP does not usually confer a significant increase in the risk of primary or recurrent thrombosis24 or of pulmonary embolism.25 Eur J Vasc Endovasc Surg Vol 24, August 2002
A. W. Bradbury et al.
100
However, where one or more such abnormalities cosegregate and/or where they are accompanied by one or more acquired TP, then risk of DVT can increase dramatically.26 This is especially so in older individuals. For example, a FVL-positive women taking hormone replacement therapy undergoing venous surgery for a post-thrombotic CVU may present an exceptionally high risk for recurrent thrombosis.27,28 At the present time, there are insufficient data to provide a firm evidence base for the management of thrombophilic patients. However, it must be remembered that oral anticoagulation to a target INR of 2.5 is associated with one major and 0.25 fatal haemorrhages per 100 patient treatment years. The Prevalence of TP in CVU AT, PC and PS deficiency The first study to examine the relationship between TP and CVU was conducted by Falanga who found a reduction in PC activity/antigen, and/or PS antigen, in 5 of 19 patients with lipodermatosclerosis (LDS) and ulceration; two of which had a history of DVT.29 This led Falanga to propose PC deficiency as a possible risk factor for CVU. In subsequent correspondence Salmaska suggested that as PC (PS) activation requires the presence of TM, the decreased PC activity found by Falanga might be due to an endothelial cell defect related to venous hypertension rather than an actual deficiency of PC.30 Tsutsui described a patient with recurrent venous leg ulcers and a type II protein S deficiency who responded to warfarin.31 Phifer identified three siblings with chronic venous insufficiency, all of whom had AT III deficiency. A further sibling had died aged 20 years old of pulmonary embolism.32 More recently, however, Ribeaudeau found that none of 35 consecutive patients presenting with CVU (14 of which had a history of DVT) had a deficiency in PC (antigen or activity), PS (activity and free and total antigens) or AT antigen.33 APCR and FVL In 1995, Munkvad and Jorgensen reported on 46 patients with CVU.34 Using a functional assay based upon the activated partial thromboplastin time (APTT) in the presence and absence of APC, APCR was found in 12 (26%). Of these, 25% had a history of DVT compared with eight of 34 (26%) without APCR (non significant). Grossman reported on 29 consecutive patients with CVU.35 APCR was first determined Eur J Vasc Endovasc Surg Vol 24, August 2002
by a functional assay based upon the APTT and if this was positive the FVL genetic test was performed. Although APCR was found in 11 patients, only two (7.7% overall) were found to be heterozygous for FVL. Hafner and von Felten studied 20 consecutive patients presenting with CVU.36 APCR was present in four patients on the basis of the APTT test. Two of these patients had a history of DVT compared with four of 16 patients without APCR (non-significant). However, the importance of performing the FVL genetic test in all patients was quickly emphasised as it is possible to be heterozygous for FVL without an abnormality in the APTT APCR test, and not all cases of APCR are caused by FVL.37,38 Hachenjos described a 34-year-old man who had suffered recurrent CVU of both legs since childhood in association with APCR due to FVL and an intermittent factor XIII deficiency.39 Mitsis presented a similar report of a 25-year-old man with recurrent DVT and severe post-phlebitic syndrome. He was found to be homozygous for FVL, and heterozygous for f II 20210 G-A mutation.40 Maessen-Visch found that 21 of 92 patients with healed or open ulceration (54 of which had a history of DVT) were FVL positive (20 heterozygous and one homozygous) compared with four of 53 controls (7.5%) (odds ratio 3.6, 95% CI 1.2±11.2, p 0.03).41 Patients with FVL were more likely to have a history of DVT (91% vs 48%, p 0.002) and, specifically, recurrent DVT (38% vs 14%, p 0.03) and to have had more than nine episodes of ulceration (43% vs 16%, p 0.01). There was no relationship between FVL and age or the results of light reflection rheography. The authors concluded that the combination of DVT and FVL increased the risk of recurrent CVU. Ribeadeau also looked at the prevalence of FVL and APCR in 35 patients with CVU.33 APCR was present in only four of 33 patients tested, of whom one had a history of DVT. One patient with APCR, and a previous DVT, was FVL positive and also had IgG APLA. FVL was not detected in any patient without APCR. The high prevalence of FVL in CVU patients was confirmed by Gaber who studied 100 consecutive CVU patients.42 Of these, 53 were deemed to have a post-thrombotic ulcer, 19 of whom had FVL (36%); this compares with three of 47 CVU patients with no history of thrombosis, and 5% of healthy controls. Prothrombin 20210A To date, only one study has examined the prevalence of PT 20210A. Ribeadeau found no cases in a series of 35 patients with CVU.
Thrombophilia and Chronic Venous Ulceration
101
Table 2. Putative thrombophilic risk factors for venous thrombosis. Increased factor levels56 Hypercholesterolaemia, hypretriglyceridaemia57 (statin therapy may decrease the risk)58 Increased plasma glucosylceramide levels59 Elevated lipoprotein (a) (Lp[a])57,60
Fig. 1. Prevalence of specific thrombophilias in CVU patients in the Edinburgh-Birmingham study, in patients with a first DVT and in the normal population.
Antiphospholipid antibodies Three studies have examined the prevalence of APAs in patients with CVU. Grossman studied 29 patients presenting with CVU and found ACLA in six of 21 patients tested.35 In a series of 35 patients with CVU, Ribeadeau found that APLA of IgG class were present in three of 31 patients tested (one of whom had a previous DVT) compared with two of 23 controls.33 No patients had IgM class antibodies. IgG antibodies were associated with APCR in two patients, one of whom also had FVL. Alcaraz studied 27 CVU patients. Twelve CVU patients had APLA (five ACLA, four LA and three both), three of whom had a history of DVT.43 Unfortunately, none of the above studies performed confirmatory repeat tests, noted concomitant drug therapy or quantified the level of antibody titre. The Edinburgh and Birmingham Study This was a prospective study of 88 patients with CVU who underwent clinical assessment, duplex ultrasound and TP screen comprising antithrombin (AT), protein C (PC) and S (PS), activated protein C resistance (APCR), factor V Leiden (FVL), prothrombin G20210A (PT 20210A), lupus anticoagulant (LA) and anticardiolipin antibodies (ACA).44 There were 35 men of median age (IQR) 61 years (45±72), and 53 women of median age 76 years (69±82); and 36% of patients had either a history or duplex evidence suggestive of previous DVT. The following abnormalities were detected: 4 AT, 5 PC and 6 PS deficiencies, APCR 14, FVL 11, PT 20210A 3, LA 8 and ACLA 12. All abnormalities were confirmed on repeat testing
Gene polymorphisms affecting the level and/or activity of: Tissue factor pathway inhibitor (TFPI) mutations61 Thrombomodulin62 Thrombin-activatable fibrinolysis inhibitor (TAFI)63 Plasminogen activator inhibitor (PAI)26,64 Factor XIII65,66 Angiotensin converting enzyme inhibitor67 Fibrinogen68 Factor VI 69 b2-glycoprotein I 70
at three months. The presence of TP was not significantly related to previous DVT, deep reflux or disease severity (duration of disease, total area, number of episodes or level of pain). In this cohort, 41% of patients had at least one abnormality on TP screening. This is 2±30 times higher than the general population but similar to that reported for DVT patients. In a further study HHcy (415 mmol/l) was found in 23 (42%) of 55 patients with open CVU and four (25%) of 16 patients with healed CVU. This compares with 5% of the normal population (Fig. 1). There was no association between the presence, number or type of thrombophilic abnormalities and the severity of disease or the pattern or severity of reflux on duplex. Other Thrombophilias and CVU At the time of writing there are no published data regarding the prevalence of elevated coagulation factor levels, or the moieties listed in Table 2, and CVU. However, on-going work in our own department is addressing this area. Discussion The main conclusion to be drawn from the available literature is that patients with CVU appear have a prevalence of TP that is much higher than the general population but similar to post-DVT patients. This high prevalence is observed in ulcer patients with and without a documented history of DVT. It is well recognised that a patient-reported history of DVT is unreliable due to false positives and negatives. In other words, many DVTs are sub-clinical, others are misdiagnosed and patients may confuse DVT with other related conditions such as superficial Eur J Vasc Endovasc Surg Vol 24, August 2002
A. W. Bradbury et al.
102
thrombophlebitis. Duplex, as opposed to venography, is increasingly used to image patients with CVU; and duplex is much less sensitive at picking up minor post-thrombotic changes in the deep veins, particularly below the knee.45 It can be difficult, therefore, to determine whether DVR in a patient with CVU is post-thrombotic in aetiology or due to primary valvular insufficiency. The strong association between CVU and TP, regardless of whether there is clear clinical or duplex-based evidence of previous DVT, suggests that a considerably greater proportion of patients than previous thought may actually have a post-thrombotic ulcer. However, further work is required to determine if, indeed, this is the case. Many duplex-based studies have reported CVU in association with apparently isolated superficial venous reflux. But, it remains difficult to explain why certain patients with gross superficial reflux have pristine skin while others with lesser disease suffer the full gamut of venous hypertensive skin changes. There is the suspicion that some other, as yet unrecognised factor, must be at work in such patients. It is interesting to speculate that this additional factor is distal macrovascular and/or microvascular thrombosis; in many cases this may be associated with undiagnosed TP. It may well be that a significant proportion of patients with apparently isolated superficial disease actually have infrapopliteal post-thrombotic venous pathology that is below the limit of duplex detection. In this regard it is interesting to observe that DVT occurring in association with TP is more likely to be distal than proximal.46 Furthermore, it is clear that DVT is associated with the development of superficial reflux.47 This may be post-thrombotic due to direct LSV damage but other, as yet ill-defined, mechanisms may be involved. It is also suggested that varicose veins may be a risk factor for DVT, especially in older patients.48 At the level of the microcirculation, CVU patients are recognised to have a hypercoagulable diathesis characterised by depressed fibrinolytic activity, increased red cell aggregation, endothelial cell damage, expression of adhesion molecules and cytokine release. In this regard it is interesting to observe that long after the acute inflammatory phase of DVT has passed there is evidence of chronic thrombin and fibrin formation as manifest by PF12 and D-dimer; and that this may predict recurrent thrombotic events.47,49 Future Work TP is clearly an important risk factor for a large proportion, perhaps the great majority of CVU. Eur J Vasc Endovasc Surg Vol 24, August 2002
Cross-sectional and longitudinal studies are needed to answer several important clinical questions relating to the prevention and treatment of CVU. Is TP a risk factor for the progression of simple varicose veins to CVI and, eventually, ulceration? If so, would antithrombotic treatment in thrombophilic patients with uncomplicated varicose veins slow, even prevent, disease progression? Should patients with DVT in association with TP be offered more prolonged anti-thrombotic treatment, either with Warfarin50,51 or low molecular weight heparin,52 in order to prevent the development of CVU? Would long-term anti-thrombotic treatment of thrombophlic patients with CVU augment healing and reduce recurrence?53
References 1 Laing W. Chronic venous diseases of the leg. London. Office of Health Economics. 1992. 2 Bradbury AW, Evans CJ, Allan PL, Lee AJ, Ruckley CV, Fowkes FGR. What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey. Br Med J 1999; 318: 353±356. 3 Evans SM, Brittenden J, Adam DJ, Ludlam CA, Bradbury AW. The prevalence and clinical significance of thrombophilia in intermittent claudication. B J Surg 1999; 86: 82. 4 Allan PL, Bradbury AW, Evans CJ, Lee AJ, Ruckley CV, Fowkes FGR. Patterns of reflux and the severity of varicose veins in the general population. Edinburgh Vein Study. Euro J Vasc Endovasc Surg 2000; 20: 470±477. 5 Burns PJ, Mosquera DA, Bradbury AW. Prevalence and significance of thrombophilia in peripheral arterial disease. Euro J Vasc Endovasc Surg 22: 98±106. 6 Tripodi A, Mannucci PM. Laboratory investigation of thrombophilia, Clini Chem 2001; 471: 597±606. 7 Segel GB, Francis CA. Anticoagulant proteins in childhood venous and arterial thrombosis: a review. B Cell Mol Dis 2000; 26: 540±560. 8 Lane DA, Grant PJ. Role of hemostatic gene polymorphisms in venous and arterial thrombotic disease. [Review] [226 refs]. Blood 2000; 95: 1517±1532. 9 Lillicrap D. The genetics of venous and arterial thromboembolism. Curr Atheroscl Rep 2001; 3: 209±215. 10 Matei D, Brenner B, Marder VJ. Acquired Thrombophilic Syndromes. Blood Rev 2001; 15: 31±48. 11 Turton EP, Coughlin PA, Berridge DC, Mercer KG. A survey of deep venous thrombosis management by consultant vascular surgeons in the United Kingdom and Ireland. Euro J Vasc Endovasc Surg 2001; 21: 551±563. 12 Cumming Am, Shiach CR. The investigation and management of inherited thrombophilia. Clin Lab Haemat 1999; 21: 77±92. 13 Lee R. Factor V Leiden: a clinical review. Amer J Med Sci 2001; 322: 88±102. 14 Marcucci R, Brunelli T, Giusti B, Fedi S, Pepe G, Poli D, Prisco D, Abbate R, Gensini GF. The role of cysteine and homocysteine in venous and arterial thrombotic disease. Am J Clin Pathol 2001; 116: 56±60. 15 Sykes TCF, Morris AG, Bradbury AW, Mosquera DA. Apoptosis in vascular disease. Euro J Vasc Endovasc Surg 2001; 22: 389±395. 16 Conlan MG, Folsom AR, Finch A, Davies CE, Sorlie P, Marcucci G, Wu KK. Associations of factor VII and von Willebrand Factor with Age, Race, Sex, and Risk Factors for
Thrombophilia and Chronic Venous Ulceration
17
18
19 20 21 22
23 24
25 26
27
28
29 30 31 32 33
34
Atherosclerosis. The Atherosclerosis Risk in Communities (ARIC) Study. Thromb & Haemost 1993; 70: 380±385. Kyrle PA, Minar E, Hirschl M, Bialonczyk C, Stain M, Scneider B, Welterman A, Speiser W, Lechner K, Eichinger S. High plasma levels of factor VIII and the risk of recurrent venous thrombo-embolism. N Engl J Med 2000; 343: 457±462. Schambeck CM, Hinney K, Haubitz I, Mansouri Taleghani B, Wahler D, Keller F. Familial clustering of high factor VIIIs levels in patients with venous thromboembolism. Arterioscl, Thromb Vasc Biol 2001; 21: 289±292. Bouma BN, Meijers JCM. Role of blood coagulation factor XI in downregulation of fibrinolysis. Curr Opin in Hema 2000; 7: 266±272. Meijers JCM, Tekelenburg WLH, Bouma BN, Bertina RM, Rosendaal FR. High levels of coagulation factor XI as a risk factor for venous thrombosis. N Engl J of Med 2000; 342: 696±701. Nguyen A. Review and management of patients with the prothrombin G20210A polymorphism. Clin Appl Thromb Haemost 2000; 6: 94±99. Bauer KA, Humphries S, Smillie B, Li L, Cooper JA, Barzegar S, Rosenberg RD, Miller GJ. Prothrombin activation is increased among asymptomatic carriers of the prothrombin G20210A and factor V Arg506Gln mutations. Thromb Haemost 2000; 84: 396±400. Galli M. Which antiphospholipid antibodies should be measured in the antiphospholipid syndrome? Haemost 2000; 30: 257±262. De Stefano V, Martinelli I, Mannucci PM, Paciaroni K, Rossi E, Chiusolo P, Casorelli I, Leone G. The risk of recurrent venous thromboembolism among heterozygous carriers of the G20210A prothrombin gene mutation. Br J Haematol 2001; 113: 630±635. Kohlmeier RE, Cho CG, Bux RC, Guerra L, Rulon JJ, Selby DM, Gulley ML. Prothrombin gene mutation uncommon in pulmonary embolism. South Med J 2000; 93: 1073±1077. Aznar J, Vaya A, Estelles A, Mira Y, Segui R, Villa P, Ferrando F, Falco C, Corella D, Espana F. Risk of venous thrombosis in carriers of the prothrombin G20210A variant and factor V Leiden and their interaction with oral contraceptives. Haemat 2000; 85: 1271±1276. Hoibraaten E, Ovigstad E, Arnesen H, Larsen S, Wickstrom E, Sandset PM. Increased risk of recurrent venous thromboembolism during hormone replacement therapy±results of the randomized, double-blind, placebo-controlled estrogen in venous thromboembolism trial (EVTET). Thromb Haemost 2000; 84: 961±967. Lowe G, Woodward M, Vessey M, Rumley A, Gough P, Daly E. Thrombotic variables and risk of idiopathic venous thromboembolism in women aged 45±64 years. Relationships to hormone replacement therapy. Thromb Haemost 2000; 83: 530±535. Falanga V, Bontemo FA, Eaglstein WH. Protein C and protein S plasma levels in patients with lipodermatosclerosis and venous ulceration. A. Dermat 1990; 126: 1195±1197. Salmaska CP. Protein C, protein S levels in patients with lipodermatosclerosis and venous ulceration. A. Dermat 1991; 127: 908. Tsutsui K, Ishida W, Ohashi T, Takehara K. Hereditary type Iib protein S deficiency in a patient with recurrent venous ulcers. Dermatol 1997; 194: 198±199. Phifer TJ, Mills GM. Occult antithrombin III deficiency: a potentially lethal complication of the postphlebitic limb. J Vasc Surg 1990; 11: 586±590. Ribeaudeau F, Senet P, Cavuela JM, Fund X, Paul C, Robert C, Scrobohaci ML, Dubertret L. A prospective coagulation study including resistance to activated protein C and mutations in factors V and II in venous leg ulcers. Br J Dermat 1999; 141: 259±263. Munkvad S, Jorgensen M. Resistance to activated protein C: a common anticoagulant deficiency in patients with venous leg ulceration. Br J Dermat 1996; 134: 296±298.
103
35 Grossman D, Heald PW, Wang C, Rinder HM. Activated protein C resistance and anticardiolipin antibodies in patients with venous leg ulcers. J Am Acad Dermatol 1997; 37: 409±413. 36 Hafner J, Felten A. Resistance to activated protein C in patients with venous leg ulcers. Dermatol 1997; 195: 413±414. 37 Peus D, von Schmiedeberg S, Pier A, Scharf RE, Weheimer A, Ruzicka T, Krutman J. Coagulation factor V gene mutation associated with activated protein C resistance leading to recurrent thrombosis, leg ulcers, and lymphedema: successful treatment with intermittent compression. J Am Acad of Dermatol 1996; 35: 306±309. 38 Peus D. Resistance to activated protein C: a common anticoagulant deficiency in patients with venous leg ulceration. Br J Dermatol 1997; 137: 303±304. 39 Hachenjos K, Bek M, Schopf E, and Vansceidt W. Recurrent ulcerations on both legs since childhood due to a factor V gene mutation. Dermatol 1997; 194: 297±298. 40 Mitsis M, Ioannou H, Eleftheriou A, Nousias V, Basioukas C, Kakosimos G, Batsis C, Vartholomatos G. Combined genetic defect (homogeneity for factor V Leiden and heterogeneity for prothrombin G20210A allele), in a young patient, with recurrent deep vein thrombosis and serious postphlebitic syndrome±a case report. Acta Dermat Venereol 1991; 71: 55±57. 41 Maessen-Visch MB, Hamulyak K, Tazelaar DJ, Crombag NH, Neumann HA. The prevalence of Factor V Leiden mutation in patients with leg ulcers and venous insufficiency. A. of Dermatol 1999; 135: 41±44. 42 Gaber Y, Siemens HJ, Schmeller W. Resistance to activated protein C due to factor V Leiden mutation: high prevalence in patients with post-thrombotic leg ulcers. Br J of Dermatol 2001; 144: 546±548. 43 Alcaraz I, Levfevre I, Wiart T, Lafon C, Forzy G, Modiano P. Leg ulcers and antiphospholipid antibodies. Prospective study of 48 cases. Annal Dermatol et de Venereol 1999; 126: 313±316. 44 Mackenzie RK, Ludlum CA, Ruckley CV, Allan PL, Burns PJ, Bradbury AW. The prevalence of thrombophlia in patients with chronic venous leg ulceration. J Vasc Surg 2002. [In Press] 45 Bucek RA, Schober E, Zontsich T, Haumer M, Potzi C, Minar E. Ultrasound with Levovist in the diagnosis of suspected calf vein thrombosis. Ult Med Biol 2001; 274: 55±60. 46 Bjorgell O, Nilsson PE, Nilssson JA, Svensson PJ. Location and extent of deep vein thrombosis in patients with and without FV:R 506Q mutation. Thromb Haemost 2000; 83: 648±651. 47 Meissner MH, Caps MT, Zierler BK, Bergelin RO, Manzo RA, Strandness DE. Deep venous thrombosis and superficial venous reflux. J Vasc Surg 2000; 32: 48±56. 48 Heit JA, Silverstein MD, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ3. Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study. A. Int Med 2000; 160: 809±815. 49 Van Aken BE, den Heijer M, Bos GM, van Deventer SJ, Reitsma PH. Recurrent venous thrombosis and markers of inflammation. Thromb Haemost 2000; 83: 536±539. 50 Van den Belt AG, Hutten BA, Prins MH, Bossuy PM. Duration of oral anticoagulant treatment in patients with venous thromboembolism and a deficiency of antithrombin, protein C or protein S ± a decision analysis. Thromb Haemost 2000; 84: 758±763. 51 Pinede L, Ninet J, Duhaut P, Chabaud S, Emolombe-Rague S, Urieu L, Ony P, Aanson C, Boissel JP. Comparison of 3 and 6 months of oral anticoagulant therapy after a first episode of proximal deep vein thrombosis or pulmonary embolism and comparison of 6 and 12 weeks of therapy after isolated calf deep vein thrombosis. Circ 2001; 103: 2453±2460. 52 Van der Heijden JF, Hutten BA, Buller HR, Prins MH. Vitamin K antagonists or low-molecular-weight heparin for the long term treatment of symptomatic venous thromboembolism. Cochrane Database of Systematic Reviews CD002001.
Eur J Vasc Endovasc Surg Vol 24, August 2002
104
A. W. Bradbury et al.
53 Willems HP, den Heijer M, Bos GM. Homocysteine and venous thrombosis: outline of a vitamin intervention trial. Sem Thromb Haemost 2000; 26: 297±304. 54 Sykes TC, Fegan C, Mosquera DA. Thrombophilia, polymorphisms and Vascular Disease. Mol Pathol 2000; 53: 300±306. 55 Den Heijer M, Rosendaal FR, Blom HJ, Gerrits WBJ, Os GMJ. Hyperhomocysteinaemia and venous thrombosis ± a metanalysis. Thromb Haemost 1998; 80: 874±877. 56 Van Hylckama Vlieg A, van der Linden IK, Bertina RM, and Rosendaal FR. High levels of factor IX increase the risk of venous thrombosis. Blood 2000; 95: 3678±3682. 57 Mcoll MD, Sattar N, Ellison J, Tait RC, Walker ID, Packard CJ, Greer IA. Lipoprotein (a), cholesterol and triglycerides in women with venous thromboembolism. Bl Coag Fibrinol 2000; 11: 225±229. 58 Ray JG, Mamdani M, Tsutki RT, Anderson DR, Yeo EL, Laupacis A. Use of statins and the subsequent development of deep vein thrombosis. Arch. Int Med 2001; 161: 1405±1410. 59 Deguchi H, Fernandez JA, Pabinger I, Heit JA, Griffin JH. Plasma glucosylceramide deficiency as potential risk factor for venous thrombosis and modulator of anticoagulant protein C pathway. Blood 2001; 97: 1907±1914. 60 Von Depka M, Nowak-Gottl U, Eisart R, Dieterich C, Barthels M, Scharrer I, Ganser A, Ehrenforth S. Increased lipoprotein (a) levels as an independent risk factor for venous thromboembolism. Blood 2000; 96: 3368. 61 Amini-Nekoo A, Futers TS, Moia M, Mannucci PM, Grant PJ, Ariens RA. Analysis of the tissue factor pathway inhibitor gene and antigen levels in relation to venous thrombosis. Br J Haematology 2001; 113: 537±543. 62 Le Flem L, Mennen L, Aubry ML, Aiach M, Scarabin PY, Emmerich J, Alhenc-Gelas M. Thrombomodulin promoter mutations, venous thrombosis, and varicose veins. Arterioscl, Thromb Vasc Biol 2001; 21: 445±451. 63 Henry M, Aubert H, Morange PE, Nanni I, Alessi MC, Tiret L, Juhan-Vague I. Identification of polymorphisms in the promoter and the 30 region of the TAFI gene: evidence that
Eur J Vasc Endovasc Surg Vol 24, August 2002
64
65
66 67
68 69
70
plasma TAFI antigen levels are strongly genetically controlled. Blood 2001; 97: 2053±2058. Hopper WC, Lally C, Austin H, Renshaw M, Dilley A, Wenger NK, Phillips DJ, Whitsett C, Rawlins P, Evatt BL. The role of the t-PA I/D and PAI-1 4G/5G polymorphisms in African-American adults with a diagnosis of myocardial infarction or venous thromboembolism. Thromb Res 2000; 99: 223±230. Franco RF, Middledorp S, Meinardi JR, van Pampus EC, and Reitsma PH. Factor XIII Val34Leu and the risk of venous thromboembolism in factor V Leiden carriers. Br J Haematol 2000; 111: 118±121. Vanscheidt W, Hasler K, Wokalek H, Niedner R, Schopf E. Factor XIII-deficiency in the blood of venous leg ulcer patients. Acta Dermato-Venereol 1991; 71: 55±57. Gonzalez-Ordonez AJ, Fernandez-Carreira JM, MedinaRodriguez JM, Martin Sanchez L, Alvarez Diaz R, Alvarez Martinez MV, Coto Garcia E. Risk of venous thromboembolism associated with the insertion/deletion polymorphism in the angiotensin-converting enzyme gene. Bl Coag Fibrinol 2000; 11: 485±490. Carter AM, Catto AJ, Koher HP, Ariens RA, Stickland MH, Grant PJ. a-Fibrinogen Thr312Ala polymorphism and venous thromboembolism. Blood 2000; 96: 1177±1179. Austin H, Hooper WC, Lally C, Dilley A, Ellingsen D, Wideman C, Wenger NK, Rawlins P, Silva V, Evatt B. Venous thrombosis in relation to fibrinogen and factor VII genes among African-Americans. J Clin Epidemiol 2000; 53: 997±1001. Gushiken FC, Arnett FC, Thiagarajan P. Primary antiphospholipid antibody syndrome with mutations in the phospholipid binding domain of beta(2)-glycoprotein I. Am J Haematol 2000; 65: 160±165.
Accepted 21 April 2002
REVIEW ARTICLE
Thrombophilia and Chronic Venous Ulceration A. W. Bradbury1, R. K. MacKenzie1 , P. Burns1 and C. Fegan2 1
University Department of Vascular Surgery and 2Department of Haematology at Heartlands and Solihull NHS Trust (Teaching)
It is known that thrombophilia (TP) is a risk factor for deep venous thrombosis (DVT), and that DVT predisposes to chronic venous ulceration (CVU). However, the relationship between TP and CVU has not been well studied. Review of the literature reveals that the prevalence of TP in CVU patients is high ± similar to the prevalence found in patients with a history of DVT. This is despite many patients with CVU having no clear history, or duplex evidence of previous DVT. TP may predispose to CVU by leading to macro- or micro-vascular thrombosis. This association raises several issues regarding the investigation, prevention and management of patients with venous disease.
Introduction Chronic venous ulceration (CVU) affects at least 1% of the adult population (life-time risk), is associated with a marked reduction in quality of life, is characterized by low healing and high recurrence rates regardless of treatment, and consumes 1±2% of health care spending in most developed countries.1±4 The pathogenesis of the condition, especially at the microvascular level, remains incompletely defined and controversial. However, at the macrovascular level, it is generally agreed that the skin changes of chronic venous insufficiency (CVI) are predominantly due to sustained ambulatory venous hypertension. This, in turn, is due to venous reflux in the superficial and/or deep venous systems and, to a lesser extent, deep venous obstruction. A significant proportion of ulcers follow a clinically apparent and clearly documented episode of deep venous thrombosis (DVT) (post-thrombotic syndrome). Almost certainly, a further significant proportion of CVU follows a sub-clinical, forgotten, undocumented or unrecognised DVT. As a result, the proportion of CVU that are deemed to be post-thrombotic varies considerably between series depending upon thoroughness with which previous DVT is sought. Please address all correspondence to: A. W. Bradbury, University Department of Vascular Surgery, Lincoln House (Research Institute), Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, B9 5SS, U.K.
Thrombophilia (TP) may be defined as an abnormality of the clotting and/or fibrinolytic cascade(s) that leads to a hypercoagulable state.3,5,6 TP can be acquired or inherited and may predispose to atypical and/or recurrent arterial and/or venous thrombosis at a relatively young age (Table 1). As DVT is clearly a major risk factor for CVU it is perhaps surprising that the possible link between TP and CVU has not received more attention. It seems reasonable to hypothesise that a DVT developing in the presence of TP is more likely to lead to the post-phlebitic syndrome and CVU because it may occur earlier in life,7 is more likely to be extensive, may be more resistant to endogenous fibrinolysis and recanalisation, may be less responsive to treatment and is more likely to recur. Furthermore, CVU is associated with microvascular thrombosis and the development of a peri-capillary fibrin cuff; both of which may reflect defective fibrinolytic capacity. The aim of this paper is to review what is known of the relationship between CVU and TP. Methods The Medline database was searched for articles using the terms: thrombophilia, venous ulceration, venous insufficiency, as well as the individual thrombophilias. All abstracts were reviewed, and full text of relevant articles retrieved. Reference lists of retrieved articles were also searched for pertinent publications.
1078±5884/02/020097 08 $35.00/0 # 2002 Elsevier Science Ltd. All rights reserved.
A. W. Bradbury et al.
98
Table 1. The prevalence of thrombophilia and the relative risk for venous thrombosis. Thrombophilia
Estimated prevalence in general ``Western'' population (%)
Estimated prevalence in unselected patients with a first DVT (%)
Estimated relative risk for DVT
Antithrombin III deficiency Protein C deficiency Protein S deficiency Activated protein C resistance Factor V Leiden Hyperhomocystinaemia Elevated factor VIII levels Elevated factor XI levels Prothrombin G202210A Lupus anticoagulant Anticardiolipin antibodies
0.2 0.2 1 510 5±10 5 10 10 2.5 5 5
1 3 3 21 20 11 25 20 6 15 15
5.0 6.5 2.5 6.5 5.0 2.5 5.0 2.0 3.0 3.0 3.0
Data are based on figures presented in several recent reviews.5,8±10,12,54,55
Thrombophilia Thrombophilia and its relationship with arterial and venous thrombosis has been extensively reviewed elsewhere.5,8±11 For that reason, only a short description of the common abnormalities to be discussed below in relation to CVU is given here.12 Antithrombin (AT) deficiency AT is synthesized by the liver and inhibits thrombin and the activated factors of the intrinsic cascade (Xa, IXa, XIa, XIIa) and kallikrein. Many (480) mutations of the AT gene have been reported. AT deficiency is usually inherited in an autosomal dominant manner. Type I deficiency is due to low levels of AT and type II is due to the presence of a variant AT protein. In either case, functional AT activity can be determined by its ability to inhibit Xa in a heparin cofactor assay. Other tests can be used to distinguish type I from type II deficiency, as well as different types of type II deficiency. However, the clinical significance of this is unclear and a functional test is recommended for screening. Acquired AT deficiency can occur in association with many conditions including major surgery and malignancy.5 Protein C (PC) deficiency Protein C (PC) is a vitamin K dependent glycoprotein that is synthesised in the liver. Protein C is activated by the thrombin-thrombomodulin (T-TM) complex on the surface of endothelial cells (EC). Activated PC (APC) inhibits membrane-bound Va and VIIIa. More than 160 mutations have been described leading to type I and type II deficiencies. Again, a functional Eur J Vasc Endovasc Surg Vol 24, August 2002
test is required for screening. This can be a synthetic chromogenic substrate assay or a coagulation-based assay founded on the ability of APC to prolong the activated partial thromboplastin time (APTT). Protein S (PS) deficiency Protein S (PS) is a vitamin K dependent glycoprotein that is synthesised in the liver. Approximately 60% is bound to complement (C4b) and 40% circulates as free protein. Only free PS acts as a non-enzymatic cofactor to enhance the actions of APC on Va and VIIIa. At least 70 mutations have been identified leading to type I and type II deficiencies, which are usually passed on in an autosomal dominant manner. Some patients have low functional PS activity but no identifiable mutation; either the relevant mutations is yet to be identified or another mechanism is responsible. This, so-called, type III deficiency is associated with normal total PS antigen but reduced free antigen and activity. Type I and type III deficiencies may coexist in the same kindred. There is overlap in free PS levels between PS deficient heterozygotes and the normal population. Also, PS levels vary with age, gender, a number of medical conditions, pregnancy and hormone usage. For all these reasons, the diagnosis of PS deficiency is more difficult than for AT or PC. Activated protein C resistance (APCR) and factor V leiden (FVL) Activated PC resistance (APCR) is caused in the great majority (90%) of cases by a single base (Leiden) mutation in the factor V gene (FVL).13 This mutation renders Va resistant to the action of APC. Other factor V mutations (Cambridge, Hong Kong) and
Thrombophilia and Chronic Venous Ulceration
secondary causes, such as antiphospholipid antibodies (APLA), account for the remaining cases of APCR. FVL is common in Europeans (5±10%), uncommon in people from North India and the Middle East and absent in the indigenous people of Asia, America and Australasia. FVL heterozygotes may have a survival advantage through a reduction in intra- and post-partum haemorrhage. The commonest test for APCR involves measuring the prolongation of the APTT following the addition of APC (APC ratio). However, there are a number of problems associated with using this test as a screening tool and most authorities also recommend a polymerase chain reaction (PCR)-based ``genetic'' test to specifically identify the FVL mutation.12 Hyperhomocystinaemia Hyperhomocystinaemia (HHcy) has been implicated in the development of arterial and venous thrombosis through a range of incompletely understood mechanisms.14±16 Homocysteine is a metabolic breakdown product of methionine, which is itself metabolised through remethylation (vitamin B12 dependent) or transulphuration (B6 dependent) pathways. HHcy, due to a heterozygous deficiency of one of several enzymes involved in these pathways, is present in approximately 1% of the population. More commonly, HHcy is due to a deficiency of B12, B6 and folate in the diet. Such HHcy is frequently defined as 415 mmol/l; this being the level found in about 5% of the population. Hcy can be measured in number of different ways; in our laboratory we use high-pressure liquid chromatography. Elevated factor VIII levels Elevated factor VIII (FVIII) levels (4150 IU/dl) are associated with an almost five fold increase in DVT risk and are present in just over 10% of the normal population. Affected patients are particularly prone to recurrent thrombosis.17 The reasons for high FVIII are unclear but there does appear to be a hereditary component, possibly linked to the X-chromosome.18 FVIII can also arise as part of an acute phase response and it is recommended that C-reactive protein (CRP) be measured at the same time. Elevated factor XI levels Factor XI (FXI) is a component of the intrinsic system with direct procoagulant and indirect antifibrinolytic
99
activity.19 Elevated FXI levels (490th centile) are associated with a doubling of thrombotic risk.20 As yet, it is unclear whether the elevated level is due to specific genetic mutations. Prothrombin G20210A variant Prothrombin is a vitamin-K dependent glycoprotein. A single base mutation (A to G at position 20210) of the prothrombin gene is found in approximately 1±3% of the general European population but is rare in people of African and Asian descent.21 The mutation is associated with increased prothrombin blood levels and activation, which presumably explains the increased thrombotic risk.22 This may be due to increased gene expression. The mutation can be readily detected by means of PCR. Antiphospholipid antibodies There are two distinct types of APA; lupus anticoagulant (LA) and anticardiolipin antibodies (ACLA).23 LAmay inhibit the T-TM complex dependent activation of PC upon the EC surface. ACLA are commoner than LA in the general population and may be IgM or IgG or, rarely, IgA molecules. IgG is generally held to be the most pathogenic. ACLA appear to promote thrombosis through a number of different, incompletely defined, mechanisms including stimulation of platelet aggregation, inhibition of APC and AT, and up-regulation of tissue factor. APLA are frequently detected transiently in patients with autoimmune and viral conditions and those on certain drugs. It is recommended, therefore, that patients positive for LA or ACLA should be retested after a period of at least three months. Other thrombophilias New information regarding various putative inherited and acquired risk factors for venous thrombosis is accruing rapidly. The multifactorial nature of thrombophilic risk and its management In an otherwise young and fit individual, heterozygosity for a single inherited TP does not usually confer a significant increase in the risk of primary or recurrent thrombosis24 or of pulmonary embolism.25 Eur J Vasc Endovasc Surg Vol 24, August 2002
A. W. Bradbury et al.
100
However, where one or more such abnormalities cosegregate and/or where they are accompanied by one or more acquired TP, then risk of DVT can increase dramatically.26 This is especially so in older individuals. For example, a FVL-positive women taking hormone replacement therapy undergoing venous surgery for a post-thrombotic CVU may present an exceptionally high risk for recurrent thrombosis.27,28 At the present time, there are insufficient data to provide a firm evidence base for the management of thrombophilic patients. However, it must be remembered that oral anticoagulation to a target INR of 2.5 is associated with one major and 0.25 fatal haemorrhages per 100 patient treatment years. The Prevalence of TP in CVU AT, PC and PS deficiency The first study to examine the relationship between TP and CVU was conducted by Falanga who found a reduction in PC activity/antigen, and/or PS antigen, in 5 of 19 patients with lipodermatosclerosis (LDS) and ulceration; two of which had a history of DVT.29 This led Falanga to propose PC deficiency as a possible risk factor for CVU. In subsequent correspondence Salmaska suggested that as PC (PS) activation requires the presence of TM, the decreased PC activity found by Falanga might be due to an endothelial cell defect related to venous hypertension rather than an actual deficiency of PC.30 Tsutsui described a patient with recurrent venous leg ulcers and a type II protein S deficiency who responded to warfarin.31 Phifer identified three siblings with chronic venous insufficiency, all of whom had AT III deficiency. A further sibling had died aged 20 years old of pulmonary embolism.32 More recently, however, Ribeaudeau found that none of 35 consecutive patients presenting with CVU (14 of which had a history of DVT) had a deficiency in PC (antigen or activity), PS (activity and free and total antigens) or AT antigen.33 APCR and FVL In 1995, Munkvad and Jorgensen reported on 46 patients with CVU.34 Using a functional assay based upon the activated partial thromboplastin time (APTT) in the presence and absence of APC, APCR was found in 12 (26%). Of these, 25% had a history of DVT compared with eight of 34 (26%) without APCR (non significant). Grossman reported on 29 consecutive patients with CVU.35 APCR was first determined Eur J Vasc Endovasc Surg Vol 24, August 2002
by a functional assay based upon the APTT and if this was positive the FVL genetic test was performed. Although APCR was found in 11 patients, only two (7.7% overall) were found to be heterozygous for FVL. Hafner and von Felten studied 20 consecutive patients presenting with CVU.36 APCR was present in four patients on the basis of the APTT test. Two of these patients had a history of DVT compared with four of 16 patients without APCR (non-significant). However, the importance of performing the FVL genetic test in all patients was quickly emphasised as it is possible to be heterozygous for FVL without an abnormality in the APTT APCR test, and not all cases of APCR are caused by FVL.37,38 Hachenjos described a 34-year-old man who had suffered recurrent CVU of both legs since childhood in association with APCR due to FVL and an intermittent factor XIII deficiency.39 Mitsis presented a similar report of a 25-year-old man with recurrent DVT and severe post-phlebitic syndrome. He was found to be homozygous for FVL, and heterozygous for f II 20210 G-A mutation.40 Maessen-Visch found that 21 of 92 patients with healed or open ulceration (54 of which had a history of DVT) were FVL positive (20 heterozygous and one homozygous) compared with four of 53 controls (7.5%) (odds ratio 3.6, 95% CI 1.2±11.2, p 0.03).41 Patients with FVL were more likely to have a history of DVT (91% vs 48%, p 0.002) and, specifically, recurrent DVT (38% vs 14%, p 0.03) and to have had more than nine episodes of ulceration (43% vs 16%, p 0.01). There was no relationship between FVL and age or the results of light reflection rheography. The authors concluded that the combination of DVT and FVL increased the risk of recurrent CVU. Ribeadeau also looked at the prevalence of FVL and APCR in 35 patients with CVU.33 APCR was present in only four of 33 patients tested, of whom one had a history of DVT. One patient with APCR, and a previous DVT, was FVL positive and also had IgG APLA. FVL was not detected in any patient without APCR. The high prevalence of FVL in CVU patients was confirmed by Gaber who studied 100 consecutive CVU patients.42 Of these, 53 were deemed to have a post-thrombotic ulcer, 19 of whom had FVL (36%); this compares with three of 47 CVU patients with no history of thrombosis, and 5% of healthy controls. Prothrombin 20210A To date, only one study has examined the prevalence of PT 20210A. Ribeadeau found no cases in a series of 35 patients with CVU.
Thrombophilia and Chronic Venous Ulceration
101
Table 2. Putative thrombophilic risk factors for venous thrombosis. Increased factor levels56 Hypercholesterolaemia, hypretriglyceridaemia57 (statin therapy may decrease the risk)58 Increased plasma glucosylceramide levels59 Elevated lipoprotein (a) (Lp[a])57,60
Fig. 1. Prevalence of specific thrombophilias in CVU patients in the Edinburgh-Birmingham study, in patients with a first DVT and in the normal population.
Antiphospholipid antibodies Three studies have examined the prevalence of APAs in patients with CVU. Grossman studied 29 patients presenting with CVU and found ACLA in six of 21 patients tested.35 In a series of 35 patients with CVU, Ribeadeau found that APLA of IgG class were present in three of 31 patients tested (one of whom had a previous DVT) compared with two of 23 controls.33 No patients had IgM class antibodies. IgG antibodies were associated with APCR in two patients, one of whom also had FVL. Alcaraz studied 27 CVU patients. Twelve CVU patients had APLA (five ACLA, four LA and three both), three of whom had a history of DVT.43 Unfortunately, none of the above studies performed confirmatory repeat tests, noted concomitant drug therapy or quantified the level of antibody titre. The Edinburgh and Birmingham Study This was a prospective study of 88 patients with CVU who underwent clinical assessment, duplex ultrasound and TP screen comprising antithrombin (AT), protein C (PC) and S (PS), activated protein C resistance (APCR), factor V Leiden (FVL), prothrombin G20210A (PT 20210A), lupus anticoagulant (LA) and anticardiolipin antibodies (ACA).44 There were 35 men of median age (IQR) 61 years (45±72), and 53 women of median age 76 years (69±82); and 36% of patients had either a history or duplex evidence suggestive of previous DVT. The following abnormalities were detected: 4 AT, 5 PC and 6 PS deficiencies, APCR 14, FVL 11, PT 20210A 3, LA 8 and ACLA 12. All abnormalities were confirmed on repeat testing
Gene polymorphisms affecting the level and/or activity of: Tissue factor pathway inhibitor (TFPI) mutations61 Thrombomodulin62 Thrombin-activatable fibrinolysis inhibitor (TAFI)63 Plasminogen activator inhibitor (PAI)26,64 Factor XIII65,66 Angiotensin converting enzyme inhibitor67 Fibrinogen68 Factor VI 69 b2-glycoprotein I 70
at three months. The presence of TP was not significantly related to previous DVT, deep reflux or disease severity (duration of disease, total area, number of episodes or level of pain). In this cohort, 41% of patients had at least one abnormality on TP screening. This is 2±30 times higher than the general population but similar to that reported for DVT patients. In a further study HHcy (415 mmol/l) was found in 23 (42%) of 55 patients with open CVU and four (25%) of 16 patients with healed CVU. This compares with 5% of the normal population (Fig. 1). There was no association between the presence, number or type of thrombophilic abnormalities and the severity of disease or the pattern or severity of reflux on duplex. Other Thrombophilias and CVU At the time of writing there are no published data regarding the prevalence of elevated coagulation factor levels, or the moieties listed in Table 2, and CVU. However, on-going work in our own department is addressing this area. Discussion The main conclusion to be drawn from the available literature is that patients with CVU appear have a prevalence of TP that is much higher than the general population but similar to post-DVT patients. This high prevalence is observed in ulcer patients with and without a documented history of DVT. It is well recognised that a patient-reported history of DVT is unreliable due to false positives and negatives. In other words, many DVTs are sub-clinical, others are misdiagnosed and patients may confuse DVT with other related conditions such as superficial Eur J Vasc Endovasc Surg Vol 24, August 2002
A. W. Bradbury et al.
102
thrombophlebitis. Duplex, as opposed to venography, is increasingly used to image patients with CVU; and duplex is much less sensitive at picking up minor post-thrombotic changes in the deep veins, particularly below the knee.45 It can be difficult, therefore, to determine whether DVR in a patient with CVU is post-thrombotic in aetiology or due to primary valvular insufficiency. The strong association between CVU and TP, regardless of whether there is clear clinical or duplex-based evidence of previous DVT, suggests that a considerably greater proportion of patients than previous thought may actually have a post-thrombotic ulcer. However, further work is required to determine if, indeed, this is the case. Many duplex-based studies have reported CVU in association with apparently isolated superficial venous reflux. But, it remains difficult to explain why certain patients with gross superficial reflux have pristine skin while others with lesser disease suffer the full gamut of venous hypertensive skin changes. There is the suspicion that some other, as yet unrecognised factor, must be at work in such patients. It is interesting to speculate that this additional factor is distal macrovascular and/or microvascular thrombosis; in many cases this may be associated with undiagnosed TP. It may well be that a significant proportion of patients with apparently isolated superficial disease actually have infrapopliteal post-thrombotic venous pathology that is below the limit of duplex detection. In this regard it is interesting to observe that DVT occurring in association with TP is more likely to be distal than proximal.46 Furthermore, it is clear that DVT is associated with the development of superficial reflux.47 This may be post-thrombotic due to direct LSV damage but other, as yet ill-defined, mechanisms may be involved. It is also suggested that varicose veins may be a risk factor for DVT, especially in older patients.48 At the level of the microcirculation, CVU patients are recognised to have a hypercoagulable diathesis characterised by depressed fibrinolytic activity, increased red cell aggregation, endothelial cell damage, expression of adhesion molecules and cytokine release. In this regard it is interesting to observe that long after the acute inflammatory phase of DVT has passed there is evidence of chronic thrombin and fibrin formation as manifest by PF12 and D-dimer; and that this may predict recurrent thrombotic events.47,49 Future Work TP is clearly an important risk factor for a large proportion, perhaps the great majority of CVU. Eur J Vasc Endovasc Surg Vol 24, August 2002
Cross-sectional and longitudinal studies are needed to answer several important clinical questions relating to the prevention and treatment of CVU. Is TP a risk factor for the progression of simple varicose veins to CVI and, eventually, ulceration? If so, would antithrombotic treatment in thrombophilic patients with uncomplicated varicose veins slow, even prevent, disease progression? Should patients with DVT in association with TP be offered more prolonged anti-thrombotic treatment, either with Warfarin50,51 or low molecular weight heparin,52 in order to prevent the development of CVU? Would long-term anti-thrombotic treatment of thrombophlic patients with CVU augment healing and reduce recurrence?53
References 1 Laing W. Chronic venous diseases of the leg. London. Office of Health Economics. 1992. 2 Bradbury AW, Evans CJ, Allan PL, Lee AJ, Ruckley CV, Fowkes FGR. What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey. Br Med J 1999; 318: 353±356. 3 Evans SM, Brittenden J, Adam DJ, Ludlam CA, Bradbury AW. The prevalence and clinical significance of thrombophilia in intermittent claudication. B J Surg 1999; 86: 82. 4 Allan PL, Bradbury AW, Evans CJ, Lee AJ, Ruckley CV, Fowkes FGR. Patterns of reflux and the severity of varicose veins in the general population. Edinburgh Vein Study. Euro J Vasc Endovasc Surg 2000; 20: 470±477. 5 Burns PJ, Mosquera DA, Bradbury AW. Prevalence and significance of thrombophilia in peripheral arterial disease. Euro J Vasc Endovasc Surg 22: 98±106. 6 Tripodi A, Mannucci PM. Laboratory investigation of thrombophilia, Clini Chem 2001; 471: 597±606. 7 Segel GB, Francis CA. Anticoagulant proteins in childhood venous and arterial thrombosis: a review. B Cell Mol Dis 2000; 26: 540±560. 8 Lane DA, Grant PJ. Role of hemostatic gene polymorphisms in venous and arterial thrombotic disease. [Review] [226 refs]. Blood 2000; 95: 1517±1532. 9 Lillicrap D. The genetics of venous and arterial thromboembolism. Curr Atheroscl Rep 2001; 3: 209±215. 10 Matei D, Brenner B, Marder VJ. Acquired Thrombophilic Syndromes. Blood Rev 2001; 15: 31±48. 11 Turton EP, Coughlin PA, Berridge DC, Mercer KG. A survey of deep venous thrombosis management by consultant vascular surgeons in the United Kingdom and Ireland. Euro J Vasc Endovasc Surg 2001; 21: 551±563. 12 Cumming Am, Shiach CR. The investigation and management of inherited thrombophilia. Clin Lab Haemat 1999; 21: 77±92. 13 Lee R. Factor V Leiden: a clinical review. Amer J Med Sci 2001; 322: 88±102. 14 Marcucci R, Brunelli T, Giusti B, Fedi S, Pepe G, Poli D, Prisco D, Abbate R, Gensini GF. The role of cysteine and homocysteine in venous and arterial thrombotic disease. Am J Clin Pathol 2001; 116: 56±60. 15 Sykes TCF, Morris AG, Bradbury AW, Mosquera DA. Apoptosis in vascular disease. Euro J Vasc Endovasc Surg 2001; 22: 389±395. 16 Conlan MG, Folsom AR, Finch A, Davies CE, Sorlie P, Marcucci G, Wu KK. Associations of factor VII and von Willebrand Factor with Age, Race, Sex, and Risk Factors for
Thrombophilia and Chronic Venous Ulceration
17
18
19 20 21 22
23 24
25 26
27
28
29 30 31 32 33
34
Atherosclerosis. The Atherosclerosis Risk in Communities (ARIC) Study. Thromb & Haemost 1993; 70: 380±385. Kyrle PA, Minar E, Hirschl M, Bialonczyk C, Stain M, Scneider B, Welterman A, Speiser W, Lechner K, Eichinger S. High plasma levels of factor VIII and the risk of recurrent venous thrombo-embolism. N Engl J Med 2000; 343: 457±462. Schambeck CM, Hinney K, Haubitz I, Mansouri Taleghani B, Wahler D, Keller F. Familial clustering of high factor VIIIs levels in patients with venous thromboembolism. Arterioscl, Thromb Vasc Biol 2001; 21: 289±292. Bouma BN, Meijers JCM. Role of blood coagulation factor XI in downregulation of fibrinolysis. Curr Opin in Hema 2000; 7: 266±272. Meijers JCM, Tekelenburg WLH, Bouma BN, Bertina RM, Rosendaal FR. High levels of coagulation factor XI as a risk factor for venous thrombosis. N Engl J of Med 2000; 342: 696±701. Nguyen A. Review and management of patients with the prothrombin G20210A polymorphism. Clin Appl Thromb Haemost 2000; 6: 94±99. Bauer KA, Humphries S, Smillie B, Li L, Cooper JA, Barzegar S, Rosenberg RD, Miller GJ. Prothrombin activation is increased among asymptomatic carriers of the prothrombin G20210A and factor V Arg506Gln mutations. Thromb Haemost 2000; 84: 396±400. Galli M. Which antiphospholipid antibodies should be measured in the antiphospholipid syndrome? Haemost 2000; 30: 257±262. De Stefano V, Martinelli I, Mannucci PM, Paciaroni K, Rossi E, Chiusolo P, Casorelli I, Leone G. The risk of recurrent venous thromboembolism among heterozygous carriers of the G20210A prothrombin gene mutation. Br J Haematol 2001; 113: 630±635. Kohlmeier RE, Cho CG, Bux RC, Guerra L, Rulon JJ, Selby DM, Gulley ML. Prothrombin gene mutation uncommon in pulmonary embolism. South Med J 2000; 93: 1073±1077. Aznar J, Vaya A, Estelles A, Mira Y, Segui R, Villa P, Ferrando F, Falco C, Corella D, Espana F. Risk of venous thrombosis in carriers of the prothrombin G20210A variant and factor V Leiden and their interaction with oral contraceptives. Haemat 2000; 85: 1271±1276. Hoibraaten E, Ovigstad E, Arnesen H, Larsen S, Wickstrom E, Sandset PM. Increased risk of recurrent venous thromboembolism during hormone replacement therapy±results of the randomized, double-blind, placebo-controlled estrogen in venous thromboembolism trial (EVTET). Thromb Haemost 2000; 84: 961±967. Lowe G, Woodward M, Vessey M, Rumley A, Gough P, Daly E. Thrombotic variables and risk of idiopathic venous thromboembolism in women aged 45±64 years. Relationships to hormone replacement therapy. Thromb Haemost 2000; 83: 530±535. Falanga V, Bontemo FA, Eaglstein WH. Protein C and protein S plasma levels in patients with lipodermatosclerosis and venous ulceration. A. Dermat 1990; 126: 1195±1197. Salmaska CP. Protein C, protein S levels in patients with lipodermatosclerosis and venous ulceration. A. Dermat 1991; 127: 908. Tsutsui K, Ishida W, Ohashi T, Takehara K. Hereditary type Iib protein S deficiency in a patient with recurrent venous ulcers. Dermatol 1997; 194: 198±199. Phifer TJ, Mills GM. Occult antithrombin III deficiency: a potentially lethal complication of the postphlebitic limb. J Vasc Surg 1990; 11: 586±590. Ribeaudeau F, Senet P, Cavuela JM, Fund X, Paul C, Robert C, Scrobohaci ML, Dubertret L. A prospective coagulation study including resistance to activated protein C and mutations in factors V and II in venous leg ulcers. Br J Dermat 1999; 141: 259±263. Munkvad S, Jorgensen M. Resistance to activated protein C: a common anticoagulant deficiency in patients with venous leg ulceration. Br J Dermat 1996; 134: 296±298.
103
35 Grossman D, Heald PW, Wang C, Rinder HM. Activated protein C resistance and anticardiolipin antibodies in patients with venous leg ulcers. J Am Acad Dermatol 1997; 37: 409±413. 36 Hafner J, Felten A. Resistance to activated protein C in patients with venous leg ulcers. Dermatol 1997; 195: 413±414. 37 Peus D, von Schmiedeberg S, Pier A, Scharf RE, Weheimer A, Ruzicka T, Krutman J. Coagulation factor V gene mutation associated with activated protein C resistance leading to recurrent thrombosis, leg ulcers, and lymphedema: successful treatment with intermittent compression. J Am Acad of Dermatol 1996; 35: 306±309. 38 Peus D. Resistance to activated protein C: a common anticoagulant deficiency in patients with venous leg ulceration. Br J Dermatol 1997; 137: 303±304. 39 Hachenjos K, Bek M, Schopf E, and Vansceidt W. Recurrent ulcerations on both legs since childhood due to a factor V gene mutation. Dermatol 1997; 194: 297±298. 40 Mitsis M, Ioannou H, Eleftheriou A, Nousias V, Basioukas C, Kakosimos G, Batsis C, Vartholomatos G. Combined genetic defect (homogeneity for factor V Leiden and heterogeneity for prothrombin G20210A allele), in a young patient, with recurrent deep vein thrombosis and serious postphlebitic syndrome±a case report. Acta Dermat Venereol 1991; 71: 55±57. 41 Maessen-Visch MB, Hamulyak K, Tazelaar DJ, Crombag NH, Neumann HA. The prevalence of Factor V Leiden mutation in patients with leg ulcers and venous insufficiency. A. of Dermatol 1999; 135: 41±44. 42 Gaber Y, Siemens HJ, Schmeller W. Resistance to activated protein C due to factor V Leiden mutation: high prevalence in patients with post-thrombotic leg ulcers. Br J of Dermatol 2001; 144: 546±548. 43 Alcaraz I, Levfevre I, Wiart T, Lafon C, Forzy G, Modiano P. Leg ulcers and antiphospholipid antibodies. Prospective study of 48 cases. Annal Dermatol et de Venereol 1999; 126: 313±316. 44 Mackenzie RK, Ludlum CA, Ruckley CV, Allan PL, Burns PJ, Bradbury AW. The prevalence of thrombophlia in patients with chronic venous leg ulceration. J Vasc Surg 2002. [In Press] 45 Bucek RA, Schober E, Zontsich T, Haumer M, Potzi C, Minar E. Ultrasound with Levovist in the diagnosis of suspected calf vein thrombosis. Ult Med Biol 2001; 274: 55±60. 46 Bjorgell O, Nilsson PE, Nilssson JA, Svensson PJ. Location and extent of deep vein thrombosis in patients with and without FV:R 506Q mutation. Thromb Haemost 2000; 83: 648±651. 47 Meissner MH, Caps MT, Zierler BK, Bergelin RO, Manzo RA, Strandness DE. Deep venous thrombosis and superficial venous reflux. J Vasc Surg 2000; 32: 48±56. 48 Heit JA, Silverstein MD, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ3. Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study. A. Int Med 2000; 160: 809±815. 49 Van Aken BE, den Heijer M, Bos GM, van Deventer SJ, Reitsma PH. Recurrent venous thrombosis and markers of inflammation. Thromb Haemost 2000; 83: 536±539. 50 Van den Belt AG, Hutten BA, Prins MH, Bossuy PM. Duration of oral anticoagulant treatment in patients with venous thromboembolism and a deficiency of antithrombin, protein C or protein S ± a decision analysis. Thromb Haemost 2000; 84: 758±763. 51 Pinede L, Ninet J, Duhaut P, Chabaud S, Emolombe-Rague S, Urieu L, Ony P, Aanson C, Boissel JP. Comparison of 3 and 6 months of oral anticoagulant therapy after a first episode of proximal deep vein thrombosis or pulmonary embolism and comparison of 6 and 12 weeks of therapy after isolated calf deep vein thrombosis. Circ 2001; 103: 2453±2460. 52 Van der Heijden JF, Hutten BA, Buller HR, Prins MH. Vitamin K antagonists or low-molecular-weight heparin for the long term treatment of symptomatic venous thromboembolism. Cochrane Database of Systematic Reviews CD002001.
Eur J Vasc Endovasc Surg Vol 24, August 2002
104
A. W. Bradbury et al.
53 Willems HP, den Heijer M, Bos GM. Homocysteine and venous thrombosis: outline of a vitamin intervention trial. Sem Thromb Haemost 2000; 26: 297±304. 54 Sykes TC, Fegan C, Mosquera DA. Thrombophilia, polymorphisms and Vascular Disease. Mol Pathol 2000; 53: 300±306. 55 Den Heijer M, Rosendaal FR, Blom HJ, Gerrits WBJ, Os GMJ. Hyperhomocysteinaemia and venous thrombosis ± a metanalysis. Thromb Haemost 1998; 80: 874±877. 56 Van Hylckama Vlieg A, van der Linden IK, Bertina RM, and Rosendaal FR. High levels of factor IX increase the risk of venous thrombosis. Blood 2000; 95: 3678±3682. 57 Mcoll MD, Sattar N, Ellison J, Tait RC, Walker ID, Packard CJ, Greer IA. Lipoprotein (a), cholesterol and triglycerides in women with venous thromboembolism. Bl Coag Fibrinol 2000; 11: 225±229. 58 Ray JG, Mamdani M, Tsutki RT, Anderson DR, Yeo EL, Laupacis A. Use of statins and the subsequent development of deep vein thrombosis. Arch. Int Med 2001; 161: 1405±1410. 59 Deguchi H, Fernandez JA, Pabinger I, Heit JA, Griffin JH. Plasma glucosylceramide deficiency as potential risk factor for venous thrombosis and modulator of anticoagulant protein C pathway. Blood 2001; 97: 1907±1914. 60 Von Depka M, Nowak-Gottl U, Eisart R, Dieterich C, Barthels M, Scharrer I, Ganser A, Ehrenforth S. Increased lipoprotein (a) levels as an independent risk factor for venous thromboembolism. Blood 2000; 96: 3368. 61 Amini-Nekoo A, Futers TS, Moia M, Mannucci PM, Grant PJ, Ariens RA. Analysis of the tissue factor pathway inhibitor gene and antigen levels in relation to venous thrombosis. Br J Haematology 2001; 113: 537±543. 62 Le Flem L, Mennen L, Aubry ML, Aiach M, Scarabin PY, Emmerich J, Alhenc-Gelas M. Thrombomodulin promoter mutations, venous thrombosis, and varicose veins. Arterioscl, Thromb Vasc Biol 2001; 21: 445±451. 63 Henry M, Aubert H, Morange PE, Nanni I, Alessi MC, Tiret L, Juhan-Vague I. Identification of polymorphisms in the promoter and the 30 region of the TAFI gene: evidence that
Eur J Vasc Endovasc Surg Vol 24, August 2002
64
65
66 67
68 69
70
plasma TAFI antigen levels are strongly genetically controlled. Blood 2001; 97: 2053±2058. Hopper WC, Lally C, Austin H, Renshaw M, Dilley A, Wenger NK, Phillips DJ, Whitsett C, Rawlins P, Evatt BL. The role of the t-PA I/D and PAI-1 4G/5G polymorphisms in African-American adults with a diagnosis of myocardial infarction or venous thromboembolism. Thromb Res 2000; 99: 223±230. Franco RF, Middledorp S, Meinardi JR, van Pampus EC, and Reitsma PH. Factor XIII Val34Leu and the risk of venous thromboembolism in factor V Leiden carriers. Br J Haematol 2000; 111: 118±121. Vanscheidt W, Hasler K, Wokalek H, Niedner R, Schopf E. Factor XIII-deficiency in the blood of venous leg ulcer patients. Acta Dermato-Venereol 1991; 71: 55±57. Gonzalez-Ordonez AJ, Fernandez-Carreira JM, MedinaRodriguez JM, Martin Sanchez L, Alvarez Diaz R, Alvarez Martinez MV, Coto Garcia E. Risk of venous thromboembolism associated with the insertion/deletion polymorphism in the angiotensin-converting enzyme gene. Bl Coag Fibrinol 2000; 11: 485±490. Carter AM, Catto AJ, Koher HP, Ariens RA, Stickland MH, Grant PJ. a-Fibrinogen Thr312Ala polymorphism and venous thromboembolism. Blood 2000; 96: 1177±1179. Austin H, Hooper WC, Lally C, Dilley A, Ellingsen D, Wideman C, Wenger NK, Rawlins P, Silva V, Evatt B. Venous thrombosis in relation to fibrinogen and factor VII genes among African-Americans. J Clin Epidemiol 2000; 53: 997±1001. Gushiken FC, Arnett FC, Thiagarajan P. Primary antiphospholipid antibody syndrome with mutations in the phospholipid binding domain of beta(2)-glycoprotein I. Am J Haematol 2000; 65: 160±165.
Accepted 21 April 2002