Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 280-282

Non healing venous ulcer: An interesting presentation


1 Department of Vascular Surgery, Christian Medical College and Hospital, Ludhiana, Punjab, India
2 Department of Surgery, Christian Medical College and Hospital, Ludhiana, Punjab, India

Date of Submission17-Aug-2020
Date of Decision28-Sep-2020
Date of Acceptance19-Oct-2020
Date of Web Publication6-Jul-2021

Correspondence Address:
Pranay Pawar
Department of Vascular Surgery, Christian Medical College and Hospital, Ludhiana, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_120_20

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  Abstract 


Chronic leg ulceration affects 1–2% of the population and is associated with poor healing, frequent ulcer recurrence, and significant morbidity. Venous reflux can be identified in more than 70% of ulcerated legs. Coexistent arterial disease may be a factor in up to 20% of patients, but the clinical significance is poorly understood. We describe a patient who presented with a lower-limb ulcer, which was treated as a misdiagnosed case of venous ulcer for 12 years, following femoral pseudoaneurysm ligation.

Keywords: Bypass, compression bandage, pseudoaneurysm ligation, venous ulcer Introduction


How to cite this article:
Pawar P, Pradeep KS, Mahahan A, Luther A. Non healing venous ulcer: An interesting presentation. Indian J Vasc Endovasc Surg 2021;8:280-2

How to cite this URL:
Pawar P, Pradeep KS, Mahahan A, Luther A. Non healing venous ulcer: An interesting presentation. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Jul 26];8:280-2. Available from: https://www.indjvascsurg.org/text.asp?2021/8/3/280/320616




  Introduction Top


Venous ulcers of the lower limbs, identified as stasis ulcers, or stasis dermatitis, or venous leg ulcer or varicose ulcers, are the most severe and devastating form of chronic venous insufficiency/disease and account for nearly 80% of lower extremity ulcerations. Coexistent arterial disease may be a factor in up to 20% of patients, but the clinical significance is poorly understood. Elevated venous pressures, reflux, or insufficient venous return are the proposed etiologies for venous ulcer.[1],[2] We report an interesting case of a patient who developed a lower-limb ulcer after femoral artery pseudoaneurysm ligation, which was being treated as a venous ulcer for 12 years. We describe the points that need to be kept in mind while encountering similar patients.


  Case Report Top


A 43-year-old gentleman was admitted with chief complaints of a non-healing ulcer over the medial malleolus of the left foot for the past 12 years. On examination, there was a 10 cm × 12 cm ulcer over the medial malleolus which was exudative and mildly tender on examination. His peripheral pulses were absent with an Ankle Brachial Pressure Index (ABPI) of 0.5, and he had varicosities present on the left leg, thigh, suprapubic region, and lower abdominal wall. He had a curvilinear scar over the left groin region. His past history revealed that the patient was a drug abuser who underwent emergency exploration of the left groin with ligation of external iliac artery and vein and common femoral artery and vein due to a ruptured pseudoaneurysm of the left common femoral artery in 2008. The patient also gave a history of left great saphenous vein radiofrequency ablation in 2018 for varicose veins of the left lower limb which worsened the ulcer over the left leg.

His computed tomography peripheral angiography showed nonvisualization of left external iliac artery and vein, left common femoral artery and vein, and left saphenofemoral junction. There were multiple tortuous varicosities on the lower abdominal wall and left lower limb with reformation of the proximal superficial femoral artery in the proximal third of the thigh [Figure 1].
Figure 1: Computed tomography angiogram showing nonvisualization of the left EIA with reformation of proximal SFA

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A working diagnosis of a mixed arterial and venous ulcer was made, and he was taken up for a transperitoneal left common iliac artery to left mid-superficial femoral artery bypass with a 6 mm × 60 cm ringed polytetrafluoroethylene graft [Figure 2]. Postprocedure, he had a palpable dorsalis pedis with an ABPI of 1 and he was started on Ecosprin 75 mg once daily and flavonoid 500 mg twice daily. For the venous component of the ulcer, he was put on 4 layer venous ulcer dressings for 6 weeks, following which his ulcer completely healed.
Figure 2: Proximal and distal anastomosis

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This case is interesting because for 12 years, the gentleman was being treated as a venous ulcer, which was in fact a mixed ulcer with both arterial and venous components. His arterial inflow was improved, and once his ABPI was 1.0, he underwent four-layer compression for his venous ulcer, which healed after 6 weeks. He has been on regular monthly follow-up since the healing of the ulcer and is doing well [Figure 3].
Figure 3: Sequence of images over 6 weeks with four-layer bandaging postoperative

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  Discussion Top


Venous ulcers are an extremely common etiology of lower extremity ulceration, which affects approximately 1% population in most of the countries, and the incidence rate increases with age and female gender. Proper assessment and diagnosis of both the patient and ulcer are inevitable in order to differentiate venous ulcers from other lower extremity ulceration and to frame an adequate and individualized management plan. Venous reflux can be identified in more than 70% of ulcerated legs with multiple etiologies. Coexistent arterial disease may be a factor in up to 20% of patients, but the clinical significance is poorly understood.[2],[3] Causes of lower-limb ulcerations such as arterial insufficiency, diabetic neuropathy, and systemic illnesses such as rheumatoid arthritis, vasculitis, osteomyelitis, and skin malignancy also have a similar presentation and therefore require appropriate diagnosis and management.[4]

Arterial disease should be ruled out by taking a history of intermittent claudication, cardiovascular disease and stroke, palpation of pedal pulses, and ABPI. Further examinations such as ankle-brachial index, color duplex ultrasonography, plethysmography, angiography, and venography may be helpful in doubtful cases.[5] Ulcers of venous etiology are best managed using multilayer graduated compression bandaging, applying up to 40 mmHg at the ankle. Compression may not be appropriate for ulcerated legs with coexistent arterial compromise, as critical ischemia and limb loss may occur.[6]

An aggressive revascularization policy has been advocated previously for legs with significant coexistent arterial disease and a conservative approach with modified compression bandaging and selective revascularization for limbs with moderate arterial disease.[7]

In our patient, since his ABPI was 0.5 and his femoral, popliteal, and tibial pulses were not palpable, we made a plan of arterial revascularization by a bypass followed by compression bandaging. The fact that the patient was misdiagnosed for many years and treated as a venous ulcer should lend gravity that a thorough vascular evaluation and workup should be done in all ulcers.


  Conclusion Top


While venous ulcers are common, there can be co-existent arterial disease in 20% of patients. Proper examination of the arterial component and individualized therapy in these patients should be done for the best results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Collins LG, Seraj S. Diagnosis and treatment of venous ulcers. Am Fam Phys 2010;81:989-96.  Back to cited text no. 1
    
2.
Callam MJ, Harper DR, Dale JJ, Ruckley CV. Arterial disease in chronic leg ulceration: An underestimated hazard? Lothian and forth valley leg ulcer study. Br Med J (Clin Res Ed) 1987;294:929-31.  Back to cited text no. 2
    
3.
Jindal R, Dekiwadia DB, Krishna PR, Khanna AK, Patel MD, Padaria S, et al. Evidence-based clinical practice points for the management of venous ulcers. Indian J Surg 2018;80:171-82.  Back to cited text no. 3
    
4.
Prakash S, Tiwary SK, Mishra M, Khanna AK. Venous ulcer. Surg Sci 2013;4:144-50.  Back to cited text no. 4
    
5.
Humphreys ML, Stewart AH, Gohel MS, Taylor M, Whyman MR, Poskitt KR. Management of mixed arterial and venous leg ulcers. Br J Surg 2007;94:1104-7.  Back to cited text no. 5
    
6.
Callam MJ, Ruckley CV, Dale JJ, Harper DR. Hazards of compression treatment of the leg: An estimate from Scottish surgeons. Br Med J (Clin Res Ed). 1987;295:1382.  Back to cited text no. 6
    
7.
Ghauri AS, Nyamekye I, Grabs AJ, Farndon JR, Poskitt KR. The diagnosis and management of mixed arterial/venous leg ulcers in community-based clinics. Eur J Vasc Endovasc Surg 1998;16:350-5.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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