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Abstract: The patient had earthy protrusion of the left lower extremity for 30 years with calf ulceration for 3 years. He was diagnosed with varicose veins of the left lower extremity with chronic ulceration at a local hospital, and after treatment at the local hospital, the symptoms continued to recur with lower extremity edema. The symptoms worsened in the last six months, so he sought treatment at our hospital. After completing relevant examinations, she was diagnosed with iliac vein compression syndrome, saphenous varicose vein, and chronic ulcer with infection in the left lower leg, and was given surgery + medication.
Basic information】Female, 58 years old
Disease Type】Iliac vein compression syndrome, saphenous varicose vein, chronic ulcer with infection in the left calf
Hospital】Zhejiang Hospital of Traditional Chinese Medicine
Date of Consultation】February 2022
Treatment plan】Surgical treatment (left iliac vein endovenous angioplasty, saphenous vein endovenous radiofrequency ablation, free skin implantation) + injectable drugs (piperacillin sodium sulbactam sodium for injection)
Treatment period】Discharge from hospital for half a month, outpatient follow up
Treatment effect]: The varicose veins in the lower limbs disappeared, the swelling and itching in the lower limbs improved, and the ulcers in the lower limbs healed.
I. First interview
The patient, female, 58 years old, saw chronic ulcer of the left lower limb and was admitted to the hospital by surgical consultation.
Patient’s self-report: She had been seen by several hospitals and had undergone varicose vein ligation and stripping, ulcer debridement and skin grafting, and also sought folk topical herbs and antibiotic powder, but the ulcer was sometimes good and sometimes bad. In the last six months, the ulcer was enlarged, accompanied by swelling and itching of the lower extremities, and the dermatologist told to apply mucopolysaccharide polysulfate cream with poor results.
Physical examination: the patient was slightly obese, the left lower extremity was slightly earthworm-like and distorted, the skin above the inner ankle was pigmented, the size of the ulcer was about 5×4 cm, the left lower leg was swollen, the finger pressure was depressed, and the dorsal foot artery pulsation was normal. After admission, heart, lung, liver, kidney and other important organ diseases were excluded, and diabetes mellitus was ruled out. Ultrasound report: the left common iliac vein near the junction of inferior vena cava was significantly narrowed with a diameter of 0.12 cm, the distal common iliac vein was 0.57 cm, the main trunk of the left saphenous vein was dilated and refluxed, and a penetrating branch with a diameter of 0.46 cm was seen below the calf ulcer with continuous reflux. Venogram of the left lower extremity: the left iliac vein was significantly stenosed with open peripheral collateral branches, the inferior vena cava was patent, the left deep veins of the lower extremity were patent with valvular regurgitation, and the saphenous vein was dilated and tortuous with traffic branch regurgitation.
The final diagnosis was: iliac vein compression syndrome, saphenous varicose vein, and chronic ulcer with infection in the left lower leg, based on the results of physical examination, medical history, and relevant examinations.
II. Treatment process
The patient was given a treatment plan, and all important tests were completed before the operation, including lower extremity venous ultrasound, electrocardiogram, chest CT, blood sampling, etc. A venogram of the lower extremity was arranged, and the diagnosis of saphenous varicose vein combined with left iliac vein compression syndrome was clearly made. The cause of varicose veins is mainly caused by the obstruction of the iliac veins, which is also one of the reasons for recurrence of varicose veins after treatment. The treatment plan is as follows.
1, firstly, the ulcer area was cleared and dressing changed, the patient’s left calf ulcer size was about 5×4cm, a small amount of exudate on the trauma surface was cultured as Pseudomonas aeruginosa, and antibiotic injectable piperacillin sodium sulbactam sodium was used. After sharp debridement of the ulcer, silver ion dressing was changed every other day, elastic bandage pressure treatment and usual elevation of the affected limb. 5 dressing changes later the traumatic infection was controlled, granulation tissue grew and the traumatic edema subsided.
2. Secondly, endovenous angioplasty of the left iliac vein and endovenous radiofrequency ablation of the saphenous vein were performed. As the angiogram showed 80% stenosis of the left iliac vein with open peripheral side branches, balloon dilation, stent implantation, and closure by intracavitary radiofrequency ablation of the saphenous vein were performed after clarification of the left iliac vein compression syndrome.
3. After 5 dressing changes, the trabecular exudate was reduced, the trabecular bacterial culture was negative, and the trabecular bed preparation had met the requirements for trabecular repair, and free skin implantation was performed. Free skin pieces were taken from the patient’s right thigh, traumatic free skin grafting was performed, covered with petroleum jelly oil gauze, sutured and packed, and the elastic bandage pressure treatment was continued.
In summary, the patient was treated for half a month in total, and the disease gradually improved and was discharged from the hospital.
III. Treatment effect
The patient underwent wound debridement, iliac vein stenting, endovenous ablation of the saphenous vein, and wound repair implantation, and the three problems of lower limb ulcer, iliac vein obstruction, and varicose vein were treated simultaneously in half a month of hospitalization. At the time of discharge, the varicose veins of the lower limbs disappeared and the patient walked freely, the ulcer surface implant was viable and painless, and the previous soreness and swelling of the lower limbs in the afternoon had also improved, and the ulcer of the lower limbs was cured, and the treatment effect was good.
IV. Precautions
Varicose vein combined with iliac vein compression syndrome is a more serious condition, and we are glad that the patients are treated and their symptoms are all improved, but after the operation, patients need to pay attention to the following conditions.
1.Avoid prolonged standing and sitting, and wear varicose vein stockings when work reasons require prolonged standing to promote venous reflux in the lower limbs.
2, after surgery to strengthen exercise, such as walking, cycling, dancing, after long standing it is recommended to do squatting, leg kicking, toe pads and other exercises, after long sitting it is recommended to do hooked feet, get up and walk, ankle pump exercises every half hour, to facilitate blood return.
3.Postoperative patients should follow up in the 1st week, 2 weeks, 1 month, 3 months and 1 year after surgery according to the doctor’s prescription to check venous ultrasound, coagulation function, liver function, kidney function, etc., and iliac venogram 1 year after surgery to assess the stent condition.
V. Personal insight
Varicose veins combined with iliac vein compression syndrome, some experts suggest to deal with the venous obstruction lesion of iliac vein compression syndrome first, and then deal with the saphenous varicose vein, that is, the cause and effect first, to reduce the recurrence of varicose veins after surgery. Some doctors believe that iliac vein compression syndrome does not necessarily require stenting and treat saphenous varicose veins first, but saphenous varicose veins have a significantly higher recurrence rate. My opinion is to individualize the treatment, for example, in this case the patient had preoperative clinical evaluation and ultrasound assessment of varicose veins, CEAP grade 4 or higher, venography was performed to treat iliac vein stenosis first and then saphenous varicose veins, or saphenous varicose veins were treated at the same time. For patients with CEAP grade 4 or less, saphenous varicose veins should be treated first and iliac vein stenosis should be observed with conservative treatment, such as wearing varicose vein stockings and oral venous active drugs, such as diosmin tablets and horse chestnut seed extract tablets.