Mixed Venous Arterial Disease Right Lower Extremity Chronic Ulcer Treated With An Innovative Dehydrated Human Umbilical Cord Expandable (dHUC EX) Allograft

Introduction: Venous leg ulcers (VLUs), although common, are often mismanaged due to errors of not correctly diagnosing the arterial insufficiency component. In fact, mixed arterial venous disease is estimated to affect approximately 26% of the patients with lower extremity (LE) ulcerations (Hedayati et al, 2015). Yet, there is no consensus on the ideal treatment approach, whether conservative or operative. Clinical hints that help to recognize arterial insufficiency ulcers include the ulcers are typically painful and tend to affect the toes, heel, malleoli, or anterior shin.

Method: Retrospectively reviewed the patient’s clinical treatment course over 249 days. Results: The patient was an 83 y/o nondiabetic male with chronic LE edema who experienced a ground level fall in January resulting in a nondisplaced metatarsal/cuneiform fracture along with a right LE (RLE) wound involving the dorsum of the right foot. In April, a vascular surgery consult was requested to evaluate his persisting RLE ulcer that had developed an eschar covering and associated pain at rest. The vascular work-up revealed severe arterial disease requiring stenting. He was referred to an outpatient wound clinic on 5/5. The ulcer measured 135 sq cm. By 5/26 the ulcer demonstrated minimal size reduction with standard care, measuring 134.6 sq cm. In an attempt to improve the trajectory toward closure, negative pressure wound therapy (NPWT) was initiated on 5/27. By 7/27 the ulcer measured 75.7 sq cm. NPWT was then discontinued and a purified native cross-linked extracellular matrix plus polyhexamethylene biguanide (PCMP) was applied to the wound bed. After 4 applications of PCMP, the ulcer remained open with an observed increase in nonviable tissue. On 8/24 a dHUC EX allograft was applied. By 11/30, after six applications of dHUC EX, the ulcer had reduced to 3.1 sq cm. By 12/21 the ulcer closed.

Conclusion: This case demonstrated a unique approach to lower extremity limb salvage in a patient with mixed arterial venous disease using an innovative dHUC EX allograft. The expandability of dHUC EX allowed for greater versatility related to surface area coverage options. The case also hints to dHUC EX’s potential to favorable support of the healing cascade.