Abstract 18820: Persistent Lower Extremity Ulcers: Not Just Skin Deep
A healthy 66-year-old woman presented for evaluation of non-healing lower extremity ulcers. Several years prior, she developed a small ulcer above her left lateral malleolus. Biopsy showed only chronic inflammation, and the ulcer gradually increased in size despite intensive wound care. Over subsequent years, she also suffered a provoked femoral DVT in the affected limb and developed progressive edema. She underwent endovenous laser therapy (EVLT) for presumed venous insufficiency but developed additional ulcers following the procedure. She was diagnosed with livedoid vasculopathy and was empirically treated with aspirin and pentoxifylline. Due to persistent symptoms, she was then referred to vascular medicine clinic.
On exam, her left leg exhibited multiple signs of venous disease including varicose veins, edema, brawny skin changes, and corona phlebectatica. Her lower leg revealed several open ulcers on the medial and lateral surfaces as well as a healed venous ulcer, or atrophie blanche. Using a sphygmomanometer and handheld Doppler, venous pressure in the limb was elevated at 60mmHg while supine. Venous duplex showed chronic proximal DVT as well as severe superficial and deep venous reflux. It was felt that her DVT likely caused post-thrombotic syndrome and venous reflux, and EVLT worsened her ulcers because it destroyed an anatomic pathway for relieving her venous hypertension.
She was prescribed aggressive compression therapy but suffered persistent and worsening ulcers. CT venogram was obtained to evaluate for proximal venous obstruction and revealed May-Thurner Syndrome. This anatomic finding led to venous hypertension and reflux causing her initial ulcer development. Invasive venography confirmed occlusion of the left external iliac vein. She underwent stenting of this segment, and her ulcers nearly completely healed several weeks later with ongoing compression therapy.
The stigmata of venous disease are often overlooked. In this case, a careful physical exam revealed several signs of venous insufficiency and hypertension that led to the diagnosis of venous ulcer. A lack of response to compression subsequently led to an anatomic study which revealed proximal obstruction and facilitated a successful therapeutic intervention.
Author Disclosures: A.W. Aday: None. M.D. Gerhard-Herman: None. P. Sobieszczyk: None. M.P. Bonaca: None.
- © 2016 by American Heart Association, Inc.