Venous Ulceration Secondary to Chronic Venous Insufficiency Mistaken for Arterial Insufficiency

VASCULAR DISEASE MANAGEMENT 2012:9(7):E121-E124

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.

Case Report

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.

Discussion

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.

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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: georgej@deborah.org