ABSTRACT: Lower extremity ulceration is disabling and can be secondary to arterial or venous insufficiency. Although chronic venous disease is the etiology in the majority of cases, venous ulceration is often initially mistaken for arterial disease. We present a case of concomitant arterial and venous disease with ulceration receiving multiple stages of arterial interventions before receiving definitive therapy for venous insufficiency and complete resolution of symptoms.
VASCULAR DISEASE MANAGEMENT 2012:9(7):E121-E124
An 80-year-old female with history of chronic renal insufficiency, ischemic cardiomyopathy, and peripheral arterial disease presented initially with lifestyle-limiting claudication of the left lower extremity. Physical examination revealed non-palpable pulses except for Doppler signal of the left dorsalis pedis artery. Ankle-brachial index of the extremity was 0.43 suggestive of occlusive femoral disease.
Angiogram of the left common femoral artery with runoff revealed distal left superficial femoral artery occlusion (Figure 1A) with reconstitution of the distal popliteal artery and 2-vessel runoff into the left foot via the anterior tibial and peroneal arteries (Figure 1B). Revascularization of the occlusion was performed using balloon angioplasty and stent placement (Figure 2A) with good angiographic result and runoff (Figure 2B). She had complete resolution of her claudication symptoms, but returned 1 year later with ulceration of the medial aspect of her left foot above the medial malleolus. Repeat angiogram revealed restenosis of the stent (Figure 3A) and re-occlusive disease of the distal popliteal artery stent extending into the anterior tibial artery (Figure 3B) requiring atherectomy and balloon angioplasty for successful revascularization (Figure 4). However, her ulceration progressed despite revascularization, prompting further evaluation of the etiology of her ulcer (Figure 5). A venous Doppler study of the left lower extremity revealed severe reflux of the left greater saphenous vein (Figure 6) with flow above baseline in the proximal, mid, and distal portions of up to 1.7 seconds. An incompetent perforating vein was also noted in the left calf 23 cm from the ankle and measured at 0.33 cm in diameter (Figure 7). She subsequently underwent radiofrequency ablation of the left greater saphenous vein followed by the left calf perforator with complete occlusion by ultrasound (Figure 8).
Patient returned for follow-up at 3 months with complete healing of the ulceration and no residual symptoms.
Lower extremity ulceration is debilitating with significant economic impact.1 The prevalence of lower extremity ulceration is 0.18% to 2%, with majority (up to 72%) being caused by chronic venous disease (CVD).2 The burden of treating CVD in the United States is enormous with an estimated annual cost of over 1 billion dollars per year.3
Various types of lower extremity ulcers exist including venous, arterial, neuropathic, lymphatic, malignant, infectious, medication-induced, and inflammatory.1 Therefore, clinical history and physical examination are necessary to distinguish them. Venous ulcers, although more common, are often mistaken for arterial ulcers which range from 10% to 30% of all lower extremity ulcerations.4 Arterial ulcers are typically more painful affecting the toes, heel, malleoli, or anterior shin4 and are caused by arterial insufficiency. The main mechanisms of venous ulcers are reflux, venous outflow obstruction, or a combination of both,5 and are predominantly found within the gaiter area above the medial malleolus.2 However, in some subsets of patients, both arterial and venous disease coexist, developing ulceration from mixed etiologies.2 In these cases, the dominant disease process must be teased out and treated first.
Clinical history and physical examination are critical in diagnosis including comorbid conditions, history of arterial or venous disease, prothrombotic states, quality of symptoms, and location of ulcer. Noninvasive diagnostic tests of choice include ankle-brachial index for diagnosis of peripheral arterial occlusive disease4 and duplex ultrasound for venous reflux or thrombosis.6
The mainstay of treatment for arterial insufficiency is revascularization via endovascular techniques or surgical bypass,7 while that of CVD includes compression stockings, endovenous ablation, ambulatory phlebectomy, or surgical stripping.8 Endovenous ablation via laser or radiofrequency causes direct thermal injury to the vein wall, resulting in destruction of the endothelium, collagen denaturation of the media, and fibrotic and thrombotic occlusion of the vein,8 and has become the most popular invasive approach for treatment of chronic venous insufficiency.
We present, herein, a case of refractory lower extremity ulceration that persisted beyond arterial revascularization, and found to be secondary to chronic venous insufficiency that only resolved after endovenous ablation of the greater saphenous vein.
- Spentzouris G, Labropoulos N. The evaluation of lower-extremity ulcers. Semin Intervent Radiol. 2009;26(4):286-295.
- Adam DJ, Naik J, Hartshorne T, Bello M, London NJ. The diagnosis and management of 689 chronic leg ulcers in a single-visit assessment clinic. Eur J Vasc Endovasc Surg. 2003;25(5):462-468.
- Lawrence PF, Gazak CE. Epidemiology of chronic venous insufficiency. In: Gloviczki P, Bergan J, eds. Atlas of Endoscopic Perforator Vein Surgery. London: Springer-Verlag;1998;31-44.
- Lazarides MK, Giannoukas AD. The role of hemodynamic measurements in the management of venous and ischemic ulcers. Int J Low Extrem Wounds. 2007;6(4):254-261.
- Nicolaides AN, Allegra C, Bergan J, et al. Management of chronic venous disorders of the lower limbs: guidelines according to scientific evidence. Int Angiol. 2008;27(1):1-59.
- Androulakis AE, Giannoukas AD, Labropoulos N, Katsamouris A, Nicolaides AN. The impact of duplex scanning on vascular practice. Int Angiol. 1996;15(4):283-290.
- Norgren L, Hiatt WR, Dormandy JA, et al; for the TASC II Working Group. Inter-society consensus for the management of peripheral arterial disease. Int Angiol. 2007;26(2):81-157.
- Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011;53(5 Suppl):2S-48S.
From the Division of Interventional Cardiology and Endovascular Medicine, Deborah Heart and Lung Center, Browns Mills, New Jersey.
Disclosure: The author has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. George reports consultancy for Covidien.
Manuscript submitted May 9, 2012, final version accepted June 4, 2012.
Address for correspondence: Jon C. George, MD, Director of Clinical Research, Division of Cardiovascular Medicine, Deborah Heart and Lung Center, 200 Trenton Road, Browns Mills, NJ, 08015, USA. Email: firstname.lastname@example.org