In a 48‑year‑old adult who underwent bilateral sclerotherapy for varicose veins and has a chronic lower‑leg ulcer that remains open despite wound care, is currently taking oral antibiotics, has stopped tramadol, codeine and ibuprofen, now experiences exertional dyspnoea on stairs and a sensation of heaviness and tightness in the lower one‑quarter of the left leg without redness, swelling, tenderness, fever or cough, with oxygen saturation 99 %, pulse 72 bpm, blood pressure 144/90 mmHg, normal cardiac and pulmonary examination, no pitting oedema, leg circumference 42.5 cm bilaterally, Wells score 1 (low probability for deep‑vein thrombosis) and a D‑dimer ordered, what are the appropriate pharmacologic and non‑pharmacologic management recommendations and follow‑up plan?

Management of Post-Sclerotherapy Patient with Exertional Dyspnea and Leg Heaviness

Immediate Assessment and DVT Risk Stratification

This patient requires urgent D-dimer testing and close clinical follow-up, but does not meet criteria for immediate duplex ultrasound based on the Wells score of 1. 1

The Wells score of 1 places this patient in the low-probability category for DVT, and current guidelines suggest D-dimer testing as the next step rather than proceeding directly to imaging. 1 However, several clinical features warrant heightened vigilance:

• Recent sclerotherapy (within weeks) represents a procedural risk factor for venous thromboembolism, with DVT occurring in approximately 0.3% of cases after endovenous procedures. 2
• New exertional dyspnea in the setting of recent venous intervention raises concern for pulmonary embolism (0.1% incidence post-procedure), though the absence of chest pain, cough, and normal oxygen saturation (99%) are reassuring. 2
• The sensation of "heaviness and tightness" in the lower quarter of the left leg for several months predates the sclerotherapy and likely represents residual venous insufficiency rather than acute thrombosis. 1

Critical pitfall: Equal bilateral leg circumference (42.5 cm) and absence of pitting edema argue strongly against acute DVT, as unilateral swelling with ≥3 cm difference would add 1 point to the Wells score. 1

Wound Management and Infection Prevention

Continue current antibiotic therapy for the open ulcer and maintain dry wound care as directed by the surgeon. 3

The presence of an open venous ulcer post-sclerotherapy requires:

• Aggressive infection control with systemic antibiotics when indicated for localized cellulitis or wounds with bacterial burden >1×10⁶ CFU. 4
• Maintenance of a moist wound environment while avoiding maceration, though the surgeon's instruction to "keep it dry" may reflect concern about specific wound characteristics or infection risk. 3
• Expected healing time of "a few months" is consistent with chronic venous ulceration, which can persist despite optimal therapy with recurrence rates as high as 70%. 5

The patient should be counseled that venous ulcers typically require 3-6 months to heal even with appropriate treatment. 3

Compression Therapy Optimization

Escalate to medical-grade gradient compression stockings delivering 30-40 mmHg pressure rather than standard 20-30 mmHg, given the presence of active ulceration (CEAP C6 disease). 3, 4

The current recommendation for "compression" must be made specific:

• For severe venous disease with active ulceration, 30-40 mmHg inelastic compression is superior to elastic bandaging and represents the minimum standard. 4
• Before escalating compression, verify that ankle-brachial index (ABI) >0.9, as approximately 16% of venous leg ulcer patients have unrecognized concomitant arterial disease. 3, 4
• If ABI is 0.6-0.9, reduce compression to 20-30 mmHg; if ABI <0.5, compression is contraindicated. 4
• Compression must be worn indefinitely after ulcer healing, as patient adherence is the single most critical determinant of recurrence rates. 3

Common pitfall: Compression pressures below 20 mmHg are ineffective; treatment failure is usually attributable to patient non-compliance rather than technical shortcomings of the device. 3

Cardiovascular Risk Modification

The recommendation for aspirin, ACE inhibitor, and atorvastatin is NOT supported by current venous disease guidelines and should be reconsidered based on standard cardiovascular risk assessment rather than venous pathology alone. 6

While recent epidemiological data demonstrate an increased risk of cardiovascular disease in patients with chronic venous insufficiency, there is only preliminary evidence that varicose vein therapy can lower this cardiovascular risk. 6 The blood pressure of 144/90 mmHg does warrant antihypertensive therapy per standard guidelines, but the specific recommendation for these medications should be based on:

• Presence of diabetes, chronic kidney disease, or established cardiovascular disease (not mentioned in this case).
• Standard cardiovascular risk calculators rather than venous disease alone.
• The statement that "beta blocker not needed as BP usually in low sides" is inconsistent with the documented BP of 144/90 mmHg.

Pain Management and Medication Reconciliation

The gradual discontinuation of ibuprofen as pain improves post-sclerotherapy is appropriate; continue to avoid tramadol and codeine given adequate pain control. 2

The patient's improved pain after sclerotherapy is expected, as:

• Sclerotherapy achieves 72-89% occlusion rates at 1 year for appropriately selected veins, resulting in symptom improvement including reduction in pain and heaviness. 2
• Common side effects include phlebitis, new telangiectasias, and residual pigmentation, but these typically do not require opioid analgesia. 2

Exercise and Lifestyle Modifications

Implement a supervised exercise program incorporating leg-strength training and aerobic activity for at least 6 months to improve calf-muscle pump function. 3, 4

The surgeon's advice for "a lot of walking" should be formalized into:

• Structured calf-pump-enhancing exercise that improves venous return and supports ulcer healing. 3
• Avoidance of prolonged standing or sitting to decrease hydrostatic pressure. 3
• Leg elevation above heart level while resting to reduce edema. 3
• Weight reduction if the patient is obese (BMI not provided in this case). 3

Follow-Up Plan and Red Flags

Schedule follow-up within 48-72 hours to review D-dimer results and reassess respiratory symptoms. 1

Return immediately or proceed to emergency department if:

• Dyspnea worsens or occurs at rest.
• Chest pain, hemoptysis, or syncope develops.
• Unilateral leg swelling, warmth, or erythema appears.
• Fever >38°C develops, suggesting wound infection.

If D-dimer is elevated, proceed to bilateral lower extremity duplex ultrasound to exclude DVT, as the Wells score of 1 combined with positive D-dimer would warrant imaging. 1

Adjunctive Pharmacotherapy for Ulcer Healing

Consider adding pentoxifylline 400 mg three times daily to compression therapy to improve venous tone and accelerate ulcer healing. 3, 4

Pentoxifylline combined with compression yields a relative risk of healing of 1.56 versus compression alone, though gastrointestinal side effects (nausea, indigestion, diarrhea) occur more frequently (RR 1.56 for adverse effects). 3, 4 This represents moderate-quality evidence for adjunctive therapy in chronic venous ulceration. 3

Long-Term Surveillance

If the ulcer fails to show ≥50% reduction in size after 4-6 weeks despite optimal compression and wound care, refer back to vascular surgery for consideration of advanced therapies. 4

Options include:

• Surgical debridement to convert the chronic wound to an acute healing wound. 4
• Split-thickness skin grafting or bioengineered cellular therapies for chronic ulcers persisting at 12 weeks. 4
• Repeat duplex ultrasound to assess for recanalization of treated veins or new reflux pathways (e.g., Giacomini vein). 3
• Evaluation for iliac vein stenosis if ulcer fails to heal despite superficial vein treatment, as stenting dramatically improves quality of life when stenosis >50% is present. 4

Recurrence of venous ulceration occurs in 20-28% of patients within 5 years despite successful initial treatment, underscoring the need for lifelong compression and surveillance. 3