Chronic Venous Ulcers: A Case Study of Successful Management

Chronic venous ulcers are a debilitating condition that can affect not only the patient but also their family, causing significant physical, emotional, and financial strain. These ulcers are often persistent, resistant to treatment, and recurrent, despite attempts with various medical interventions. This article delves into a detailed case study of a 62-year-old male with a large chronic venous ulcer on his right leg, highlighting the treatment approach that ultimately led to successful healing and a better quality of life.

Introduction to Chronic Venous Ulcers

Chronic venous ulcers are long-lasting wounds typically found on the lower legs, resulting from venous insufficiency. When the valves in the veins do not function properly, blood pools in the legs, increasing pressure within the veins. This pressure damages the skin, leading to ulceration. These wounds can be difficult to heal, and even after treatment, they tend to recur if the underlying venous problem is not addressed. For patients and their families, the journey of managing such ulcers is often filled with frustration, discomfort, and emotional distress.

The following case study presents the challenges and eventual successful management of a large chronic venous ulcer.

Case Presentation

A 62-year-old male presented with a large venous ulcer covering the lower two-thirds of his right leg, encompassing 80% of the leg's circumference. The ulcer was deep with an irregular base, slough, and unhealthy tissue. The patient's history revealed previous surgeries for varicose veins, as well as two skin grafting procedures, all of which had been performed at a medical facility in Nadiad. Unfortunately, despite these efforts, the ulcer had not healed and had continued to worsen.

# Clinical Findings and Diagnosis

Upon examination, the patient's ulcer presented as deep and irregular, with unhealthy tissue and a foul-smelling discharge. These characteristics are common in venous ulcers, which often exhibit slow healing, leading to an increased risk of infection and deterioration of the surrounding tissue. The patient had a history of varicose veins, which had likely contributed to the formation and persistence of the ulcer.

A Doppler ultrasound was performed to evaluate the venous system in the affected leg. The findings indicated significant venous reflux in the great saphenous vein (GSF), as well as reflux in three perforator veins in the leg. Venous reflux is a common cause of chronic venous insufficiency, where the veins do not allow blood to flow back toward the heart, resulting in pooling in the legs. This reflux was the primary factor driving the persistence of the patient's ulcer. 

Treatment Plan

The management of chronic venous ulcers requires a multifaceted approach, addressing both the wound itself and the underlying venous insufficiency. In this case, a comprehensive treatment plan was initiated to promote healing of the ulcer and prevent recurrence.

# 1. Compression Therapy

The first step in treatment was the application of a four-layer compression bandage. Compression therapy is a cornerstone in the management of venous ulcers, as it helps improve venous return, reduce swelling, and promote healing. The compression bandage exerts graduated pressure, with the highest pressure applied at the ankle and gradually decreasing upward. This promotes the upward movement of blood in the veins, helping to reduce pooling and venous pressure.

The patient’s ulcer showed significant improvement after two months of consistent compression therapy. The size of the ulcer reduced, and the unhealthy tissue began to heal, indicating that the underlying venous hypertension was being effectively managed.

# 2. Laser Ablation of Varicose Veins

While compression therapy was essential in promoting wound healing, it was not sufficient to address the underlying venous reflux. To prevent recurrence of the ulcer, a more definitive treatment was required to correct the dysfunctional veins. The patient underwent a laser ablation procedure to treat the great saphenous vein reflux. Endovenous laser ablation (EVLA) is a minimally invasive procedure that uses laser energy to heat and close off the affected vein. This prevents blood from pooling in the vein, redirecting it to healthier veins with properly functioning valves.

In addition to laser ablation, the patient also underwent stab avulsions of the three perforator veins that had been identified as incompetent. Stab avulsion is a procedure where small incisions are made over the vein, and the incompetent portion of the vein is removed. This further reduced the venous hypertension and improved blood flow in the leg.

# 3. Skin Grafting for Ulcer

After addressing the underlying venous insufficiency, the patient’s ulcer was treated with a split-thickness skin graft (STG). Skin grafting is often used in cases where ulcers are large or have not healed with conservative measures alone. A healthy portion of skin is harvested from another part of the body and applied to the ulcer. The graft helps cover the wound and promotes the growth of new tissue.

In this case, the patient had undergone two previous skin grafting procedures, but they had failed due to the persistence of venous reflux. However, with the venous insufficiency now corrected, the new graft successfully took hold, and the ulcer showed good signs of healing.

Outcome and Follow-Up

Following the treatment, the patient achieved excellent healing of the venous ulcer. The patient was advised to wear below-knee compression stockings for long-term management to prevent the recurrence of venous insufficiency and ulceration.

Compression stockings are an essential part of post-treatment care, as they help maintain proper venous pressure in the legs. The patient was instructed to wear them regularly, particularly during long periods of standing or sitting, to prevent the reoccurrence of venous reflux.

Discussion

This case underscores the importance of addressing both the wound and the underlying cause in the management of chronic venous ulcers. While traditional wound care methods such as dressings, debridement, and skin grafts are important, they may fail to provide lasting results if venous reflux is not corrected. Chronic venous ulcers are notorious for recurring after apparently successful treatment if the root cause of venous hypertension is not addressed.

The use of compression therapy, laser ablation, and surgical correction of perforator veins provided a comprehensive approach to managing this patient’s condition. Laser ablation has emerged as a highly effective, minimally invasive technique for treating venous insufficiency. When combined with proper wound care, it can lead to significant improvements in healing and prevent recurrence.

Conclusion

Chronic venous ulcers are a significant burden for both patients and their families, often causing prolonged suffering and frustration due to persistent non-healing wounds. In this case, a thorough treatment plan that addressed both the venous insufficiency and the ulcer itself led to successful healing and prevention of recurrence. This case highlights the need for a holistic approach in managing venous ulcers, focusing not only on wound care but also on correcting the underlying venous pathology to achieve lasting results.