From the Guidelines
The most appropriate next step in managing this patient is to perform a venous duplex ultrasound to confirm the diagnosis of chronic venous insufficiency and assess the severity of venous reflux and obstruction. This patient presents with classic signs of venous insufficiency, including a non-healing ulcer on the medial aspect of the left leg, bilateral dilated veins, and hyperpigmentation of both lower legs. The presence of easily palpable dorsalis pedis and posterior tibial pulses indicates adequate arterial supply, ruling out arterial insufficiency as the cause 1.
Key Considerations
- The patient's symptoms and physical examination findings are consistent with chronic venous insufficiency, which is a common cause of non-healing ulcers and skin changes in the lower extremities.
- Venous duplex ultrasound is a non-invasive and readily available modality that can assess the anatomy and physiology of the lower extremity venous system, helping to determine the severity of venous reflux and obstruction 1.
- The results of the venous duplex ultrasound will guide further management, which may include compression therapy, sclerotherapy, or other interventions to reduce venous reflux and promote healing of the ulcer.
Rationale for Recommendation
The recommendation to perform a venous duplex ultrasound is based on the patient's clinical presentation and the need to confirm the diagnosis of chronic venous insufficiency. The test is non-invasive, widely available, and provides valuable information about the severity of venous reflux and obstruction. While other tests, such as ABI or venography, may be useful in certain situations, they are not the primary tests needed in this case, given the patient's intact arterial pulses and classic signs of venous insufficiency 1.
Management Options
Once the diagnosis of chronic venous insufficiency is confirmed, management options may include:
- Compression therapy to reduce venous reflux and promote healing of the ulcer
- Sclerotherapy or other interventions to reduce venous reflux and promote healing of the ulcer
- Lifestyle modifications, such as elevation of the affected leg and avoidance of prolonged standing, to reduce symptoms and promote healing.
From the Research
Patient Assessment
The patient presents with a non-healing ulcer on the medial aspect of the left leg, bilateral (B/L) lower extremity varicose veins, hyperpigmentation, and easily palpable dorsalis pedis and posterior tibial pulses. To determine the next step in managing this patient, it is essential to assess the patient's arterial and venous insufficiency.
Arterial Insufficiency Assessment
- The ankle-brachial index (ABI) is a widely used test to detect peripheral arterial disease (PAD) 2.
- However, in patients with diabetes, the ABI is notoriously unreliable due to medial calcinosis and the distribution of atherosclerotic lesions in below-the-knee (BTK) arteries 3.
- The ABI may underestimate angiographic atherosclerotic disease in patients with PAD causing tissue loss 3.
Venous Insufficiency Assessment
- Open venous ulcers in patients with combined arterial and venous insufficiency are notoriously hard to treat 4.
- Patients with an ABI of 0.5-0.8 have been shown to heal poorly, and adequate compression therapy is contraindicated in patients with an ABI of <0.7 4.
Next Steps
- Consider performing an ankle-brachial index (ABI) measurement to assess the patient's arterial insufficiency, despite its limitations in patients with diabetes or medial calcinosis 5, 6.
- If the ABI is <0.7, consider percutaneous revascularization before ambulatory compression therapy, as this approach has been shown to improve wound healing in patients with mixed arterial and venous insufficiency 4.
- Duplex ultrasonography or angiography may be necessary to confirm the diagnosis and guide treatment 5, 2.