This study was performed to precisely define the underlying pathophysiology in patients with active venous ulcers.

A PubMed search was conducted from 1991 to 2013 to select papers reporting the anatomic and physiologic etiology of ulceration in CEAP Class 6 patients. Studies which did not decipher between active and healed ulcers, did not use clear definitions, or did not give detailed accounts on the distribution/extent of venous pathology were excluded. Using the PRISMA guidelines, 12 studies were selected for further analysis.

Primary insufficiency was reportedly the most common etiology of ulcers. Reflux most frequently occurred in the superficial system, either isolated or in conjunction with perforating and/or deep systems. Combined superficial and deep disease was observed in a median of 11.6% of limbs (range of 0–48%). Triple system disease was seen in a median of 31.6% of limbs (range of 22–52%). Isolated deep reflux was infrequently reported (2.1–28.4% of limbs). Previous deep venous thrombosis, reported in a median of 33% of patients, is likely underreported as it may resolve without detectable damage.

There is a lack of data in the literature regarding the etiology of chronic active venous ulcers. Insufficiency of the superficial venous system from the micro- to the macro-vasculature has been frequently implicated in the development of venous ulceration. A prospective randomized controlled study is required for more conclusive results.