Interactive Quiz: Chronic Venous Ulcers
Welcome to Cardiology Consultant's latest interactive diagnostic quiz. Over the next few pages, we'll present a case and ask you to make the diagnostic steps and treat the patient. Along the way, we'll provide details about the case, and at the end, we'll share the patient's outcome.
First, let’s meet the patient…
A 79-year-old man with a history of type 2 diabetes mellitus and hypertension presented with a 5-month history of poorly healing venous ulcers on the anterior and medial aspect of the left calf, which had been recurring over 14 years.
The ulcers were limited to the patient’s left lower extremity and did not involve the contralateral limb, despite his having advanced venous stasis skin changes and swelling on both calves. He reported having leg heaviness and constant pain that is alleviated by elevation of his lower extremities. Additionally, he reported having debilitating venous claudication symptoms, which he described as left calf and thigh pain that radiates up to the flank and buttock upon walking 2 blocks.
The patient had previously been treated with compression stockings and Unna boots at a local wound-care center with minimal success; the ulcers had recurred, along with functionally debilitating symptoms consistent with venous hypertensive disease.
Physical examination revealed visually remarkable calf-size asymmetry, extensive hyperpigmentation, stasis dermatitis, indurated skin, and active open and healed ulcers on the left leg (Figure 1). The left lower extremity demonstrated +3 (of 4) pretibial and ankle pitting edema extending to the mid-thigh, compared with +2 pitting edema limited to below the knee in the right lower extremity. There were palpable anterior tibial (AT), posterior tibial (PT), and dorsalis pedis (DP) pulses bilaterally.
Answer: All of the above
Lower-extremity arterial Doppler ultrasonography ruled out the presence of peripheral arterial disease. Venous Doppler ultrasonography findings showed no reflux in the superficial and deep vein systems. There was neither acute nor chronic deep vein thrombosis. Given the patient’s cardiovascular risk factors and bilateral leg swelling, transthoracic echocardiography was performed to rule out a cardiac etiology by confirming normal biventricular function.
Before this visit, the patient had had several consultations and vascular Doppler studies at various vein centers; however, he had not undergone intravascular ultrasonography (IVUS) guided endovascular therapy for possible proximal deep vein compression.
The decision was made to proceed with iliocaval venography and subsequent examination using IVUS. Under US guidance, the left great saphenous vein (GSV) was accessed using a micropuncture needle and a 4F sheath and subsequent upgrade to an 11F sheath using a Bentson guidewire. The wire was then advanced proximally into the left common iliac vein (CIV) up to the inferior vena cava (IVC); injection of contrast dye showed no apparent venous stenosis (Figure 2).
However, on evaluation with IVUS, extrinsic compression of the CIV and external iliac vein (EIV), with approximately 70% reduction in diameter compared with the adjacent normal reference segment, was identified (Figures 3 and 4).
Answer: Balloon dilation with stent deployment
Balloon dilation with stent deployment was performed successfully. Subsequent IVUS showed a complete resolution of diffuse iliac vein compression by right common iliac artery (CIA) after iliac vein stent implantation (Figures 5 and 6).
In addition, clear post-procedural improvement to 0% luminal narrowing and wall apposition were demonstrated. Despite this remarkable improvement in luminal patency recorded by IVUS, the post-stent venogram showed no significant difference from the one prior to intervention, demonstrating the important role of IVUS (Figure 7) despite no identifiable change in luminogram by contrast fluoroscopy.
Answer: At 1, 3, and 6 months and yearly thereafter
Stent patency was confirmed by duplex ultrasonography at 1, 3, and 6 months and yearly thereafter. Iliac vein stenting resulted in rapid healing of this patient's ulcer as well as in significant improvement in limb pain and swelling; those outcomes have continued without further reports of recurrent open ulcers. With relief of orthostatic leg pain and achiness, the patient returned to baseline normal daily activities. His venous stasis hyperpigmentation improved, and his leg swelling was significantly reduced.
Tae An Choi, ANP-BC; Esad Vucic, MD, CBNC; Back Kim, MD; and Nay Htyte, MD, MSc, DASNC
Heart Vein NYC, New York, New York
Choi TA, Htyte N, Vucic E, Kim B. Chronic venous ulcer treated with iliac vein stenting for proximal deep vein compression [published online June 18, 2018]. Cardiology Consultant. https://www.consultant360.com/articles/chronic-venous-ulcer-treated-iliac-vein-stenting-proximal-deep-vein-compression.