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The aim of this report is to present a patient with a large venous ulcer and severe coagulopathy, who underwent endovenous ablation.
Report
A 54-year-old patient had venous ulceration due to great saphenous vein (GSV) incompetence. She also suffered from chronic alcoholic liver cirrhosis and severe coagulopathy, which precluded treatment by means of saphenous stripping. She was treated by radiofrequency ablation of the GSV, without major post-operative complication. The ulcer healed following this over a period of three months.
Discussion
Endovenous radiofrequency ablation may be used to treat severe chronic venous disease in patients in whom other medical conditions preclude sapheno-femoral ligation and stripping of the GSV.
Endovenous radiofrequency and laser treatment are well established minimally invasive alternatives to classical surgical saphenous treatments, such as saphenous stripping.
Most authors emphasise the advantages of these methods, since they offer reduced post-operative pain and shorter recovery than surgery. Endovenous ablation techniques can be performed using local anaesthesia. Severe side effects are rare, and endovenous techniques appear to be useful and reduce the cost of treatment.
Since the implementation of these new techniques is rapidly increasing worldwide, we consider that it is timely to start debating special indications for endovenous treatment, which may greatly benefit some patients.
The aim of this paper is to present a case of patient with venous ulceration who could not undergo stripping, but was successfully treated with radiofrequency ablation of the great saphenous vein (GSV).
Case Report
A 54-year-old woman presented with a 10 cm×3 cm diameter and 0.5 cm deep ulcer of the right leg. The patient reported that the ulcer started to appear a year and a half ago. Duplex scanning confirmed right-sided GSV reflux of the fourth grade.
The deep venous system was intact, as well as the other major superficial lower limbs veins. There were also no duplex detectable signs of perforating veins incompetence.
Microbiological analysis of the specimens from the ulceration revealed that the ulcer was colonised with pseudomonas aeruginosa. The patient had been treated intermittently with antibiotic therapy.
However, the patient also suffered chronic alcoholic liver cirrhosis, with severe coagulopathy as a consequence
: platelet count was 83,000 per mm3, and prothrombin time was 0.58 (normal values in our laboratory range from 0.7 up to 1.2). She consulted several surgeons experienced in saphenous stripping, but none of them was prepared to operate on her.
Since endovenous ablation can be performed using Seldinger percutaneous access, which is minimally invasive, we decided to treat the patient in this way. The vein was punctured under ultrasound control in the mid-calf region, 3 cm above the ulcerated area. A VNUS® Closure® catheter was passed along the vein, until its tip lay some 2 cm away from the sapheno-femoral junction. After infiltration of tumescent anaesthesia along the vein, RF power was applied to the catheter which was withdrawn according to the manufacturer's standard instructions. After removing the catheter, bleeding at the site of the venous puncture occurred but it was successfully stopped with manual compression and elastic bandage. After the procedure, the patient recovered immediately. Post-operative duplex ultrasound scanning confirmed occlusion of the great saphenous vein in the thigh and proximal calf.
The only adverse event following treatment was marked bruising along the vein, at sites where tumescent subcutaneous anaesthetic had been injected which became visible two days after treatment (Fig. 1). The patient remained fit and well, reporting no significant symptom from the treated limb.
Figure 1Multiple hematomas two days after the endovenous treatment at sites where tumescent anaesthesia was applied.
The patient was also referred to a plastic surgeon who advised the use of compression bandaging and local therapy with Granugel (a hydrocolloid gel which absorbs exudates, manufacturer: ConvaTec Wound Therapeutics, Brystol Myers Squibb, 345 Park Avenue New York, New York, USA), and Mepilex (absorbent, atraumatic dressing, manufacturer: Mölnlycke Health Care AB Gamlestadsvägen 3 C, Gothenburg, Sweden).
Clinical follow up after one, two, and three months period showed rapid healing of the ulceration, resulting in total disappearance of the ulcer (Fig. 2).
Figure 2Venous ulceration before endovenous treatment, and one, two, and three months afterwards.
The rapid recovery of an otherwise inoperable patient suggests a new aspect of minimally invasive vein ablation techniques in the management of patients with chronic venous disease. Patients with severe, but treatable forms of venous disease who also have a serious medical condition are often left untreated and wander from one practice to another, searching for a surgeon prepared to risk an operation. They are frequently provided only with symptomatic therapy. The outcome we obtained in our patient reveals that minimally invasive techniques for treatment of superficial venous reflux can be methods of choice in patients when classical saphenous stripping is contraindicated.
To conclude, high risk patients with coagulopathy, who are inoperable by means of classic venous surgery (stripping), could be candidates for minimally invasive venous treatment such as radiofrequency or laser ablation. The same is almost certainly true for many other patients who might benefit from saphenous surgery but who are considered unfit for treatment due to coexisting medical conditions.
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