Venous ulcers associated with superficial venous insufficiency

A 59-year-old female secretary was referred for evaluation and treatment of a non-healing painful ulcer on the medial aspect of her right lower leg. The ulcer had been recurrent almost every year for the past 9 years, often healing during the winter season. She had since early childhood been overweight (currently 87 kg, 170 cm, body mass index 30) and had difficulty in using compression stocking. She was otherwise healthy. She had two children, the first child born when she was 32 year of age and her second child 2 years later. After the birth of her second child she began to notice varicose veins on the lower leg on both sides and she often felt tiredness and heaviness in the leg in the afternoon. There was no history of deep venous thrombosis. She had been on birth control pills for 10 years and was currently on hormone replacement therapy because of severe postmenopausal symptoms. She had been treated at a local dermatological clinic for the past 2 years and was now being evaluated by a vascular surgeon. Clinical evaluation showed that she had 5 × 5 cm well-granulated ulceration above the right median malleolus which was surrounded by brownish leathery skin. She had slight swelling of the right leg with large varicosities below the knee. The left leg had large varicosities below the knee but no swelling or skin changes. Doppler examination revealed clear reflux in the groin that could be followed over both great saphenous veins (GSV) down the thigh. A possible minimal reflux was also noted in the popliteal fossa on the right side, although it was difficult to confirm this when the Doppler examination was repeated. Foot arteries were palpable on the dorsum of the foot on both sides.