46 yrs old male patient with no past medical history, presented to your clinic with left leg ulcer that is 8 months old and it is resistant to healing using standard dressing (as shown in the picture). No previous history of DVT or any surgery to the leg.
Q1: How will you approach this patient ?
Q2: if you organized a venous doppler scan and showed incompetent SFJ and GSV with competent deep system, what intervention options will you offer the patient?
Q3: if the patient is refusing any intervention, will the alternative management options heal the ulcer? Please justify your answer.
Q4: How can you support your answer in Q2 and Q3 with evidence?
I would like thank all who added comment, as Dr Tamer highlighted the aim of this discussion is to encourge all of you to get engaged and to use your own words that will reflect your understanding.
Regarding this patient, compression therapy alone will heal the ulcer but with the presence of superficial reflux, duration of healing will be prolonged and ulcer recurrent will comnent soon after you give up the compression.
The main aim of superficial ablation is to reduce the time needed for healing and to avoid ulcer recurrence as supported by EVRA trial (Level 1 evidence)
Q1: history taking focusing on lifestyle and work (standing longtime everyday)
clinical examination and venous DUS
Q2: option one will be endo-venous ablation of GSV +/- avulsion followed by compression to accelerate the healing process of the ulcer, and risk factor modification if present, exercise, encourage lifting leg up
Q3: compression therapy and risk factor modification, but will take much longer time with a higher possibility of failure
Q4: EVRA trial which recommended early endo-venous ablation to accelerate venous ulcer healing
Very good , thanks
full and examination include past medical , drugs, surgery, smoking, work, trauma,BMI.
Examination of varicosities ex assessment of edema presence of thrill or not.
Peripheral pulsation
Ulcer character
Duplex
Thermal and non thermal ablation vs surgery with compression as soon as possible
Ucer care compression and veno active drugs
For patients with symptomatic chronic venous disease, who are not undergoing interventional treatment, are awaiting intervention, or have persisting symptoms and/or oedema after intervention, medical treatment with drugs should be considered to reduce venous symptoms and oedema, based on the available evidence for each individual drug
Class IIa A
For patients with superficial venous incompetence, presenting with skin changes as a result of chronic venous disease (CEAP clinical class C4 e C6), interventional treatment of venous incompetence is recommended class 1 c
For patients with great saphenous vein incompetence requiring treatment, endovenous thermal ablation is recommended as first choice treatment, in preference to high ligation/stripping and ultrasoundguided foam sclerotherapy. Class I A
Good answer, I would appreciate having your own words rather than copying paragraphs from other source
Q1 full hx and examination include past medical hx, drugs, surgery, smoking, work, trauma,BMI.
Examination of varicosities trendelberge ex assessment of edema presence of thrill or not.
Peripheral pulsation
Ulcer character
Duplex
Q2.Thermal and non thermal ablation vs surgery with compression as soon as possible
Q3. Ucer care compression and venoactive drugs
For patients with symptomatic chronic venous disease, who are not undergoing interventional treatment, are awaiting intervention, or have persisting symptoms and/or oedema after intervention, medical treatment with venoactive drugs should be considered to reduce venous symptoms and oedema, based on the available evidence for each individual drug
Class IIa A
Q4. For patients with superficial venous incompetence, presenting with skin changes as a result of chronic venous disease (CEAP clinical class C4 e C6), interventional treatment of venous incompetence is recommended class 1 c
For patients with great saphenous vein incompetence requiring treatment, endovenous thermal ablation is recommended as first choice treatment, in preference to high ligation/stripping and ultrasound guided foam sclerotherapy. Class I A
Good
Multilayer compression could be one of the alternative treatments for active venous ulcer
1 full examination vascular pulsation thrill on pulse ing ln ulcer
Full lab swab ulcer
Duplex
2 evla rf open
3 dressing elastic stocking
May heal ulcer
Short but good answer, I believe rather than using stocking, multi-layer compression dressing for active ulcer should be better