An 86-year-old man presented with refractory bilateral leg edema and venous stasis pigmentation. His leg was painful, inhibited walking, and he suffered from an associated left shin skin ulcer. His history was significant for hypertension, obesity, and obstructive sleep apnea. An echocardiogram was normal, ruling out heart failure and pulmonary hypertension. His renal function and serum albumin were normal. A venous duplex ultrasound revealed incompetent superficial veins and significant reflux in the greater saphenous veins in both legs, but worse in the left. The patient was pleased to learn that his edema was associated with a treatable condition: chronic venous insufficiency due to his age, obesity, and obstructive sleep apnea.
He began an exercise and wellness program. He was not told to “sit and keep your legs elevated” as this merely causes deconditioning and impedes the improved venous return achieved through use of the calf muscle pump. He was offered well-fitting compression stockings. He was taught that the use of donning and doffing aids could help his compliance in using the stockings. He learned that comfortable extrinsic compression was mandatory and key to lifelong success in managing the condition. He was referred to a wound care clinic. After 4 months, the patient’s edema and pain were much improved, yet the ulcer had not fully healed. He opted to undergo radiofrequency venous ablation of the left greater saphenous vein. With additional follow-up, the left leg ulcer completely healed. The patient is aware that to avoid edema and ulcer recurrence sustained use of leg compression is required. At follow-up visits, his use of venous compression stockings is re-assessed to ensure long-term success.
Most leg edema is not caused by heart failure. Patients with venous ulceration may, however, have other co-morbid medical conditions (e.g., systolic or diastolic heart failure, pulmonary hypertension, sleep apnea, obesity, venous obstruction, or lymphedema) whose treatment is key to long-term success.1 Venous insufficiency, the most common primary etiology of leg edema, cannot be cured but can be successfully managed.1 Medical treatment --spanning use of compressive garments, 4-layer bandaging, or pneumatic compressive devices -- is core to all effective long-term care.2 For many, such care may be all that is required to control edema and pain and foster rapid ulcer healing. Yet, treatment of venous ulcers may require concomitant use of venous ablative techniques.3,4 When compared with surgical ligation and stripping, greater saphenous vein radiofrequency ablation may contribute, in select patients, to a higher rate of clinical success (complete ulcer healing at 95% vs. 31% for patients receiving ligation and stripping; p<0.001).5
A preventive, long-term approach creates cost-effective, quality outcomes and helps patients better manage the risks of peripheral arterial disease and other vascular conditions.Continue reading
Patient with severe claudication joins a supervised exercise and wellness program. After 3 months, he doubled the distance he could walk pain free.Continue reading