Surgical approach

Critical importance of vascular assessment

Mixed disease is increasingly more common (estimated 10-30%)

Many similar risk factors:

Older age

Obesity

Inheritance

Physical inactivity

Smoking

Presence of a lower extremity wound mandates arterial assessment

Pulses, doppler

Non-invasive diagnostics
- ABI
- Duplex ultrasound for venous reflux vs thrombus

Referral to vascular surgeon

Testing for DVT/thrombus vs Venous Insufficiency/Valvular Incompetence

When ordering venous studies it is critical to designate whether goal is to identify a DVT or to evaluate for venous insufficiency. In the latter, the duplex is performed with manual compression to demonstrate back-flow through incompetent valves and the duration of reflux is measured.

The study on the right shows the crisp closure of a competent valve vs the prolonged reflux, ie, 2 way flow when the valve is not closing properly.

Heather L. Gornik. Circulation. Duplex Ultrasound in the Diagnosis of Lower-Extremity Deep Venous Thrombosis, Volume: 129, Issue: 8, Pages: 917-921

Necas M. Duplex ultrasound in the assessment of lower extremity venous insufficiency. Australas J Ultrasound Med. 2010 Nov;13(4):37-45.

Endovenous ablation

Deferred endovenous treatment with compression vs compression alone (1)
- Combined therapy improves time to complete ulcer healing.

Early venous ablation with compression vs compression alone (2).
- Improves healing rate, reduces recurrence and is cost effective.

Image on the right: 55 y/o female with severely painful medial malleolus ulcer, recalcitrant to topical therapy combined with compression. Endovenous ablation relieved pain and promoted healing within 8 weeks.

(1) Cai PL, Hitchman LH, Mohamed AH, Smith GE, Chetter I, Carradice D. Endovenous ablation for venous leg ulcers. Cochrane Database of Systematic Reviews 2023, Issue 7. Art. No.: CD009494.

(2) Zheng H, Magee GA, Tan T, Armstrong DG, Padula WV. Cost-effectiveness of Compression Therapy With Early Endovenous Ablation in Venous Ulceration for a Medicare Population. JAMA Netw Open. 2022;5(12):e2248152.