Download PDF
Zentralbl Chir 2015; 140(05): 542-546
DOI: 10.1055/s-0034-1382898
Übersicht
Georg Thieme Verlag KG Stuttgart · New York

Ulcus hypertonicum Martorell

Martorell Hypertensive Ischaemic Leg Ulcer
S. Nobbe
Dermatologische Klinik, Universitätsspital Zürich, Schweiz
,
J. Hafner
Dermatologische Klinik, Universitätsspital Zürich, Schweiz
› Author Affiliations
Further Information

Publication History

Publication Date:
21 October 2014 (online)

Also available at
    Permissions and Reprints

Zusammenfassung

Das Ulcus hypertonicum Martorell (UHM) ist eine häufige Differenzialdiagnose bei schmerzhaften Unterschenkelulzera. Zugrunde liegend findet sich bei Patienten mit langjährig bestehender arterieller Hypertonie eine stenosierende Arteriolosklerose in der Subkutis, welche im Endstadium zum Hautinfarkt führt. Die histologischen Veränderungen sind beim UHM und dem Krankheitsbild der Kalziphylaxie sehr ähnlich. Daher liegt die Hypothese nahe, dass die beiden Entitäten Varianten derselben Erkrankung sind. Klinisch findet sich beim UHM ein mit invalidisierenden Schmerzen einhergehendes Ulkus am laterodorsalen Unterschenkel oder über der Achillessehne. Aufgrund seines typischerweise entzündlich-livid veränderten Wundrands und einer Tendenz zur Größenzunahme wird das klinische Bild nicht selten als Pyoderma gangraenosum oder nekrotisierende kutane Vaskulitis verkannt, immunsuppressiv behandelt und eine Biopsie und chirurgische Therapien vermieden. Dabei wäre beim UHM die Nekrosektomie mit anschließender Spalthauttransplantation die Behandlung der Wahl.

Abstract

Martorell hypertensive ischaemic leg ulcer (HYTILU) represents an important differential diagnosis of painful leg ulcerations. Stenotic subcutaneous arteriolosclerosis in patients with long-standing arterial hypertension finally leads to skin infarction. The typical histological changes are very similar in Martorell HYTILU and calciphylaxis. This raises the hypothesis that the two entities may have a common pathogenesis. Martorell HYTILU presents as an extremely painful ulcer that is regularly located at the laterodorsal lower leg or at the Achilles tendon. Because of its inflammatory and violaceous wound edges and its tendency to progression, clinicians unaware of the diagnosis Martorell HYTILU might misdiagnose pyoderma gangrenosum or necrotising cutaneous vasculitis start an immunosuppressive treatment and avoid surgical diagnostic and therapeutic procedures. Instead, necrosectomy and split skin grafting are the treatment of choice for Martorell HYTILU.

Schlüsselwörter

Ulcus hypertonicum Martorell - subkutane Arteriolosklerose - Pyoderma gangraenosum - Kalziphylaxie - Ulkuschirurgie - Spalthauttransplantation

Key words

Martorell hypertensive ischaemic leg ulcer - subcutaneous arteriolosclerosis - pyoderma gangrenosum - calciphylaxis - leg ulcer surgery - split-skin grafting
 

  • Literatur

  • 1 Lozano FS, Cabot X, Silva I et al. Fernando Martorell (1906–1984): centenary of a pioneer in angiology. Angiology 2008; 59: 98-99
    CrossrefPubMedGoogle Scholar
  • 2 Martorell F. Las ulceras supramaleolares por arteriolitis de las grandes hipertensas. Actas (Reun Cientif Cuerpo Facul) Inst Policlinico Barcelona 1945; 1: 6-9
    PubMedGoogle Scholar
  • 3 Hines jr EA, Farber EM. Ulcer of the leg due to arteriolosclerosis and ischemia, occurring in the presence of hypertensive disease (hypertensive-ischemic ulcers). Proc Staff Meet Mayo Clin 1946; 21: 337-346
    PubMedGoogle Scholar
  • 4 Farber EM, Hines jr EA, Montgomery H et al. The arterioles of the skin in essential hypertension. J Invest Dermatol 1947; 9: 285-298
    CrossrefPubMedGoogle Scholar
  • 5 Schnier BR, Sheps SG, Juergens JL. Hypertensive ischemic ulcer. A review of 40 cases. Am J Cardiol 1966; 17: 560-565
    CrossrefPubMedGoogle Scholar
  • 6 Lazareth I, Priollet P. Necrotic angiodermatitis: treatment by early cutaneous grafts. Ann Dermatol Venereol 1995; 122: 575-578
    PubMedGoogle Scholar
  • 7 Henderson CA, Highet AS, Lane SA et al. Arterial hypertension causing leg ulcers. Clin Exp Dermatol 1995; 20: 107-114
    CrossrefPubMedGoogle Scholar
  • 8 Vuerstaek JD, Reeder SW, Henquet CJ et al. Arteriolosclerotic ulcer of Martorell. J Eur Acad Dermatol Venereol 2010; 24: 867-874
    CrossrefPubMedGoogle Scholar
  • 9 Hafner J, Nobbe S, Partsch H et al. Martorell hypertensive ischemic leg ulcer: a model of ischemic subcutaneous arteriolosclerosis. Arch Dermatol 2010; 146: 961-968
    CrossrefPubMedGoogle Scholar
  • 10 Duncan HJ, Faris IB. Martorellʼs hypertensive ischemic leg ulcers are secondary to an increase in the local vascular resistance. J Vasc Surg 1985; 2: 581-584
    CrossrefPubMedGoogle Scholar
  • 11 Giot JP, Paris I, Levillain P et al. Involvement of IL-1 and oncostatin M in acanthosis associated with hypertensive leg ulcer. Am J Pathol 2013; 182: 806-818
    CrossrefPubMedGoogle Scholar
  • 12 Ramsey-Stewart G. Eutrophication: spontaneous progressive dermatoliponecrosis. A Fatal Complication of Gross Morbid Obesity. Obes Surg 1992; 2: 263-264
    CrossrefPubMedGoogle Scholar
  • 13 Kalajian AH, Malhotra PS, Callen JP et al. Calciphylaxis with normal renal and parathyroid function: not as rare as previously believed. Arch Dermatol 2009; 145: 451-458
    PubMedGoogle Scholar
  • 14 Nigwekar SU, Wolf M, Sterns RH et al. Calciphylaxis from nonuremic causes: a systematic review. Clin J Am Soc Nephrol 2008; 3: 1139-1143
    CrossrefPubMedGoogle Scholar
  • 15 Hafner J, Keusch G, Wahl C et al. Uremic small-artery disease with medial calcification and intimal hyperplasia (so-called calciphylaxis): a complication of chronic renal failure and benefit from parathyroidectomy. J Am Acad Dermatol 1995; 33: 954-962
    CrossrefPubMedGoogle Scholar
  • 16 Hafner J, Keusch G, Wahl C et al. Calciphylaxis: a syndrome of skin necrosis and acral gangrene in chronic renal failure. Vasa 1998; 27: 137-143
    PubMedGoogle Scholar
  • 17 Llach F. Calcific uremic arteriolopathy (calciphylaxis): an evolving entity?. Am J Kidney Dis 1998; 32: 514-518
    CrossrefPubMedGoogle Scholar
  • 18 Weenig RH, Sewell LD, Davis MD et al. Calciphylaxis: natural history, risk factor analysis, and outcome. J Am Acad Dermatol 2007; 56: 569-579
    CrossrefPubMedGoogle Scholar
  • 19 Leu HJ. Hypertensive ischemic leg ulcer (Martorellʼs ulcer): a specific disease entity?. Int Angiol 1992; 11: 132-136
    PubMedGoogle Scholar
  • 20 Senet P, Beneton N, Debure C et al. Hypertensive leg ulcers: epidemiological characteristics and prognostic factors for healing in a prospective cohort. Ann Dermatol Venereol 2012; 139: 346-349
    CrossrefPubMedGoogle Scholar
  • 21 Senet P, Vicaut E, Beneton N et al. Topical treatment of hypertensive leg ulcers with platelet-derived growth factor-BB: a randomized controlled trial. Arch Dermatol 2011; 147: 926-930
    CrossrefPubMedGoogle Scholar
  • 22 Vuerstaek JD, Vainas T, Wuite J et al. State-of-the-art treatment of chronic leg ulcers: A randomized controlled trial comparing vacuum-assisted closure (V.A.C.) with modern wound dressings. J Vasc Surg 2006; 44: 1029-1037 discussion 1038
    CrossrefPubMedGoogle Scholar
  • 23 Dagregorio G, Guillet G. A retrospective review of 20 hypertensive leg ulcers treated with mesh skin grafts. J Eur Acad Derm Venereol 2006; 20: 166-169
    CrossrefPubMedGoogle Scholar
  • 24 El Khatib K, Danino A, Rzin A et al. Necrotic angiodermatitis: evaluation of an early skin graft treatment. Ann Chir Plast Esthet 2009; 54: 567-570
    CrossrefPubMedGoogle Scholar
  • 25 Cicone JS, Petronis JB, Embert CD et al. Successful treatment of calciphylaxis with intravenous sodium thiosulfate. Am J Kidney Dis 2004; 43: 1104-1108
    CrossrefPubMedGoogle Scholar
  • 26 Hackett BC, McAleer MA, Sheehan G et al. Calciphylaxis in a patient with normal renal function: response to treatment with sodium thiosulfate. Clin Exp Dermatol 2009; 34: 39-42
    CrossrefPubMedGoogle Scholar