Brief history: A 48-year-old lady, Ms. Sonam from Ghaziabad, presented to the OPD surgery with an ulcer in her right ankle for the past 3 months. She is working in a factory that demands a prolonged standing posture throughout the day. She is also giving a history of dilated and tortuous superficial veins in her right leg for the past 5 years for which she didn't take any treatment even though it was showing symptoms like aching and skin discoloration. She is a mother of three without any other significant medical history or comorbidities.

How to evaluate this patient further?

The patient was examined in a standing posture.

Tortuous and dilated veins noted in the greater saphenous vein territory along the medial side, up to above the knee level was seen.

A 4x3x1 cm ulcer was noted in the greater area (above medial malleolus) of the right ankle (Fig.1). Ulcer having sloping edges with healthy tissue on the floor with no purulent material noted. The base is made of connective tissue only. Surrounding skin shows bluish-black discoloration associated with skin thickness, non-viable tissue in the superior margin, and itching. All the peripheral pulses are palpable normally bilaterally. The contralateral leg appears normal. A systemic and per abdominal examination was normal.

The patient was further assessed with a bilateral Doppler ultrasound and showed right greater saphenous system varicosities with saphenofemoral junction (Fig.2) and below knee perforator incompetence. The deep venous system is normal.

Routine blood evaluations including hemogram and blood sugar levels revealed a normal study.

Diagnosis of this patient: right great saphenous territory varicose veins with SFJ and perforator incompetence with an active venous ulcer (C6) with no signs of infection.

Before any intervention to the varicose veins, it is advised to manage an active venous ulcer first and after the healing of the ulcer, we can tackle the varicose veins in this patient.

A multimodal approach was initiated in this patient.

The patient was advised leg elevation and simple leg exercises including daily walking and flexion exercises.

Wound cleaned and moist saline dressings were applied over the wound. As there is no high-quality evidence, we didn't use povidone-iodine in this patient. Mild necrotic tissues were debrided in the superior aspect. There were no clinical signs of infection and hence no antibiotic therapy was initiated at this point and also a wound culture was deemed unnecessary.

Four-layer bandaging was done over the wound dressing (Fig.3) for the next 4-6 weeks for faster healing of the ulcer with inspection and re-applying bandage on a weekly basis. The layers were orthopaedic wool, a crepe bandage, an elastic bandage, and an outer layer made of an elastic cohesive bandage.

The graduated compression hosiery was applied with high pressure of 40mmHg.

The patient was also given oral medical management like MPFF (veno-active combination-Daflon), on-demand NSAIDs for analgesia initially

After 2 weeks of conservative wound care, the ulcer showed signs of healing and it almost healed after 6 weeks.

The patient was planned for the definitive management of varicose veins to avoid recurrence of complications after 1 month with options to choose from like endothermal ablation, radiofrequency ablation and traditional Trendelenburg stripping surgery with perforator ligation. Though the newer modalities are the gold standard, definitive treatment can be selected considering availability and other practical considerations from a health system-based angle.

Hence this case report demonstrates the successful management of an active venous ulcer, initially with conservative ulcer care followed by a definitive varicose vein treatment.

Dr. Ranjish AT is an MBBS, MS ( General Surgery), DNB ( General Surgery). Apart from his DNB (General Surgery), he has also completed a fellowship in Vascular Surgery. Dr. Ranjish is currently working as a Consultant in Vascular Surgeon at Meitra Hospital, Calicut, and PVS Hospital, Calicut.

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