By Pradeep K. Nair, MD, FACC, FSCAI; Angel Thao Duplantis, RDMS, RVT; Ashley Guidry, CCMA; Kristy Poiencot, LPN; Trunetta Diggs, LPN; Craig M. Walker, MD

JB was Cajun to his core, having grown up in the Bayou Region of Southern Louisiana. He loved to fish, hunt, eat crawfish, and watch the Saints play football on Sundays. His true passion though was simply being outdoors, enjoying what nature had to offer. He never had the ambition to attend college, so he began work as a deckhand on an offshore oil platform after high school. This was a very labor-intensive job that required him to be on his feet 18 hours a day for three months straight. When he turned 19-years-old, he began to first notice his legs swell and feel heavy after a shift.

After a year, he saw dark patches of skin on both of his shins which he thought came from working in the blazing sun. He learned to live with these changes. He would rest in his cabin at the end of his shifts with his feet elevated on a few pillows. This seemed to ease the discomfort in his legs and reduce the swelling.

The daily onslaught of physical labor this job entailed eventually had him eyeing a new career. At the age of 21, he got married to his long-time girlfriend. Soon they had a son, and he felt this was an ideal time to find a new job that didn't require him to be away from them for three-fourths of the year. He ultimately landed a job as a Garbage Collector for a local Parish. This wasn’t the most thrilling job for him, but it was an opportunity to be closer to his wife and child. Most importantly, however, the job provided excellent benefits, including health insurance for himself and his family. Prior to this job, he was uninsured.

Fast forward five years to when JB was 26 years old. He remained in the same job, which required him to be on his feet for at least 10 hours a day. The swelling, discomfort, and darkening of the skin in his legs continued to worsen. He was now frequently getting dry, cracked skin on the shins and ankles of both legs. Several bouts of skin tears and cellulitis developed in the legs after wading through the marshes of the Bayou during outdoor excursions with his son. He used a homemade ointment (which we believe was honey-based) to treat many of these superficial wounds because of a strong aversion he had at the time to doctors and hospitals. As a result of the progressive changes to his legs, he started to cut back on the outdoor activities he loved. Nevertheless, despite the constant pain, he pushed forth with his job for the betterment of his family.

His life forever changed on May 5, 2013, when he was 27 years old. His partner accidentally dropped a heavy trash can on his left leg during a routine garbage pick-up. He was in excruciating pain but somehow managed to get through the day. By the time he got home, he was walking very gingerly. So, he opted to take a few days of sick leave. He treated the pain with ibuprofen, ice packs, and elevation. A few days after the injury, his left leg became severely swollen, and the pain became unbearable. His wife essentially forced him to go to a local emergency room, where an ultrasound (US) of the leg was performed. He was found to have an occlusive deep vein thrombosis (DVT) in the left common femoral vein to the popliteal vein. Coincidentally, given that the right leg also had some swelling, an US was performed on that leg as well and revealed occlusive DVT in the mid-right femoral vein extending into the popliteal vein. A CT Angiogram of the chest also revealed subsegmental bilateral pulmonary embolism, but fortunately, he was not complaining of symptoms of shortness of breath or pleuritic chest pain, and there was no evidence of right ventricular strain or hemodynamic compromise. To his displeasure, he was transferred to the nearest tertiary care center several hours away, given these findings. The treating physicians opted to place an Inferior Vena Cava (IVC) filter given the clot burden and initiate anticoagulation with heparin followed by warfarin. They also ruled out a hypercoagulable state with a battery of laboratory tests given his age and finding of thrombus in the uninjured leg. He was sent home on anticoagulation yet did not follow up with the treating physicians after discharge based primarily on the distance he would have to travel and his aversion to hospitals. He established with a local primary care clinic where he was continued on warfarin to a goal of INR 2-3. A few weeks after his venous thromboembolism (VTE) diagnosis, he returned to work.

Over the ensuing year, his swelling became persistent throughout the day. The skin changes on his left ankle became progressively worse, and ultimately, he developed an ulcer that exposed the fat layer. He was referred to a local wound care clinic, where he received treatment. Unfortunately, the wound would never completely healed, and he suffered from several bouts of infection requiring antibiotics over the next few years. The pain he was experiencing with the simple task of walking short distances led him to apply for and receive a full-time disability. Once a vibrant and energetic young man, JB was now unable to work a meaningful job given his suffering. He completely gave up his favorite past times of fishing and hunting and found it challenging to even play with his son. He was falling into depression and began antidepressant medications. He was also frequently taking narcotics prescribed to him to make it through the days marred by pain.

Given the futility of his wound care treatments over the next three years, one of his wound care nurses finally convinced him to visit a vascular specialist for a second opinion. He was referred to the closest vascular specialist, who assessed him with an arterial and venous duplex ultrasound of his left leg. The arterial duplex US revealed wide patency to the arteries in the left leg. However, the venous duplex US demonstrated occlusive thrombus of the left popliteal to the common femoral vein. The US study also revealed four seconds of reflux to his left greater saphenous vein (GSV) throughout its course. Based on the presence of a left medial malleolus ulcer with reflux along the segment of the GSV, a radiofrequency ablation of this vessel from the upper calf to the sapheno-femoral vein junction was successfully performed. To the patient's delight, with ongoing wound care, this led to complete healing of the ulcer roughly four months later. He was very optimistic to see these results because he had been living with an ulcer now for almost four years. He chose not to follow up with the vascular specialist because he thought he was cured. Unfortunately, roughly eight months later, the ulcer re-opened with a vengeance. When he called to schedule an appointment with his previous vascular specialist, he discovered his doctor had retired. At this point, he performed his internet search for vascular specialists and discovered our clinic at the Cardiovascular Institute of the South in Houma, Louisiana.

When we first met JB, we noticed he was limping down the hallway with his wife and son by his side and appeared to be suffering from intense pain. The odor from his wound flooded the hallway. The ulcer was 7.7cm long, 3.7cm wide, and 0.2cm deep, with adipose tissue exposed and active drainage of malodorous pus. While it is not uncommon for us to see patients in this level of distress, JB was different in that he was younger than most of the patients who presented with venous ulcers. We were disheartened to see a man suffering from these issues for this long at such a young age. It brought a sense of determination to our team to help JB battle through his condition. As with all wounds, however, we recognize that the road to recovery truly requires a multidisciplinary, team approach between the patient, vascular specialty team, wound care, and primary care. We realized that, given his distance from our clinic, we could face an uphill battle. As with all patients, we started with a comprehensive history and physical examination. The first pertinent historical fact that caught our attention was the leg swelling and skin changes he first developed while working offshore. Immediately, we could surmise that he had a long history of suffering from superficial venous reflux disease, as evidenced by his symptoms progressively worsening over the ensuing years with characteristic changes, including edema and skin discoloration. He learned to live with this condition by elevating the legs, which seemed to lessen the symptoms as many patients with venous reflux experience. If we could guide him during that time, one of the first recommendations would have been for him to initiate knee-high compression socks with at least 20mmHg to 30mmHg pressure.

The second salient historical fact relates to his bout of VTE. He was suffering from a severe form of post-thrombotic syndrome with a Villalta score calculated at 28 (≥ 15 severe). In the office, we concluded from our venous ultrasound that he indeed had a chronic, occlusive thrombus throughout his left femoral vein. Chronic, more organized thrombus by ultrasound has a characteristic hyperechogenic appearance compared to the hypoechogenic appearance of acute thrombus. It was also noted that his GSV was occluded from his previously radio-frequency ablation to the upper calf. While superficial venous ablation can be a powerful tool to aid in wound healing, the fact that he had a recurrence of his ulcer indicated that the occlusive disease within his deep venous system was likely yielding substantial venous hypertension. In these situations, when proximal DVT transitions from acute to chronic, it is not uncommon for patients to have more central occlusive disease typically involving the iliac veins or IVC ^1,2. While initial reduction of reflux via the superficial veins may yield temporary relief and assist with wound healing, what can ensue is a vicious cycle of venous hypertension as a result of poor drainage through diseased or occlusive deep veins. In the contemporary era with the plethora of catheter-based technologies available, our typical strategy when patients present with extensive, acute proximal DVT is to pursue invasive thrombectomy to help alleviate symptoms and the subsequent development of post-thrombotic syndrome.

In JB’s situation, however, his thrombus was now chronic which occurs from the transformation of soft, red blood cell rich thrombus into a characteristic fibrin rich, highly collagenous matrix of scar tissue.

JB was sent from our office directly to the hospital for initiation of intravenous antibiotics for treatment of his wound infection. After discharge a week later, we scheduled him for a repeat duplex venous US where we focused our attention to the burden of his chronic thrombus and for any reflux within perforators and specifically within the more proximal common femoral veins. This ultrasound clearly demonstrated 8.5 seconds of reflux within the left common femoral vein with Valsalva maneuver, a technique commonly employed in our clinic to unmask any potential concerns for central vein obstruction (Figure 4). While the negative predictive value for this technique helps to exclude central vein obstruction, a positive test is not always diagnostic, but often necessitates further investigation with either non-invasive imaging such as CT or MRI of the central veins or invasive venography ^3,4. Our US technologist commented that the evaluation of the superficial veins below the knee was technically challenging given the presence of open wounds and patient discomfort with scanning. At this juncture, we felt that enough information was present to make a clinical decision. Given the presence of chronic, occlusive proximal DVT with common femoral vein reflux, we strongly suspected iliac vein compression or thrombotic/fibrotic occlusive disease. The timeframe from his original VTE episode was roughly five years ago, so thrombectomy was not contemplated as a viable option at this point. We anticipated these chronic changes would more likely necessitate angioplasty and/ or stenting. After review of his hospital records during the time of his original DVT episode, it was clear that the intention was for the IVC filter to be removed after three months. Unfortunately, this was never performed given lack of follow-up. Thus, there was also some concern for the potential of occlusion within or near his filter.

JB was scheduled for a peripheral venogram where bilateral US guided popliteal vein access was obtained while he was in a prone position. After placement of two 8-French sheaths, the initial venogram revealed severe occlusive disease of the left femoral vein with extensive collateralization feeding the common femoral vein.

The right femoral vein was widely patent. The bilateral iliac veins and IVC including the filter appeared widely patent on venography. First, we were able to traverse the occluded left femoral vein using a 0.035-inch Glidewire (Terumo) and QuickCross (Philips). The lesion was not easily crossed indicating the chronicity of the thrombus. Next, intravascular ultrasound (IVUS) was performed to assess luminal size, thrombus chronicity, and for any segments of iliac vein compression that can be easily missed with venography alone. IVUS confirmed severe compression within the bilateral iliac veins (left > right) with apparent fibrotic changes as noted by its hyperechogenic appearance scattered throughout the venous system. We then proceeded with intervention to his deep veins after upsizing his sheaths to 10-French. An 8mmx150mm Mustang Balloon (Boston Scientific) was used to dilate the left femoral vein with a four-minute inflation time to lessen the chance of vessel recoil. A 16mmx40mm Atlas Gold balloon (BARD) was used to pre-dilate the left followed by right iliac vein. Severe residual vessel recoil was noted, so the left iliac vein was stented with two overlapping 16mmx90mm Wallstents (Boston Scientific), followed by a 16mmx90mm Wallstent to the right common iliac vein. The stents were then post-dilated with the same Atlas Gold balloon. Follow-up IVUS revealed excellent stent apposition and expansion with a widely patent left femoral vein with dominant flow.

After stent implantation in the iliac veins and angioplasty of his left femoral vein, he noticed an almost immediate improvement in his pain symptoms and swelling. Over the next month, he continued with wound care and noticed the ulcer was granulating. Yet, while the symptoms improved, over the next three months of observation, wound debridement’s and dressings, the ulcer still did not fully heal beyond the granulation stage. Our next step was to identify any potential targets for superficial venous ablation around the ulcer, but we recalled the challenges for US imaging our sonographers faced. We were fortunate at that time to have a new research tool at our disposal, Point of Care Thermography (POCT), for detecting superficial venous reflux. This tool was first introduced to our clinic investigationally by Ariel Soffer, MD, the co-founder of USA Therm (Aventura, Florida) around the same time that JB walked through our doors. Thermographic imaging is a rapid test that detects areas of increased heat relative to areas of adjacent skin temperature that usually represents has been shown to highly correlate with incompetent superficial veins. The refluxing venous blood is substantially hotter than the skin (by roughly 30 Celsius) as it arrives from the deeper, heated venous pool. These thermal changes typically stand out clearly as irregular linear areas representing incompetent superficial veins. With modern thermal cameras, changes as low as 0.10 Celsius can be detected. While there was an initial learning curve for performing and interpreting thermal images, over time, we have found it to be a highly valuable tool to aid our sonographers in identifying potential targets for venous ablation. Specifically, in many patients with complex venous anatomy, we find that the results from the traditional Gold Standard of duplex US can be highly variable among sonographers. With the use of thermography, our experience has been a more consistent and reliable evaluation of superficial venous reflux as our sonographers have an additional aid to help guide them in identifying incompetent veins during US scans. Fortunately, through the use of Thermography guided duplex US, we were able to identify several incompetent varicosities and large perforator branches that were directly feeding into JB’s ulcer.

We felt ablation of these remaining veins would provide JB’s best chance for complete wound healing. Our strategy was to perform endovenous laser therapy (EVLT) [VenaCure PVAK, Angiodynamics] to the large perforator branches followed by injection of 1% polidocanol foam (Varithena) [Boston Scientific] into the refluxing varicosities (Figure 9a and 9b). By performing EVLT first to the perforators followed by Varithena injection we have been successful in preventing the foam from entering the deeper tibial veins which can be vital outflow conduits. We accomplish EVLT by accessing the perforator with a 21-Guage needle followed by placement of the small 400 Micron laser fiber through the needle. Care is taken to keep the fiber at least 1cm from the deep vein. Next, tumescent anesthesia is injected around the fiber followed by ablation with an energy of 60 joules/ cm for every 2mm the fiber is pulled back in the vessel. Varithena injections are often done by placement of a micropuncture sheath into the varicosity or at times injected directly through a 21G needle. In JB’s case we were able to successfully treat four perforators around his ulcer with EVLT and a large network of varicosities in the same area with Varithena.

Over the next month, JB experienced for the second time, an ulcer that completely healed. As compared to the last time, however, he chose to continue with his follow-up routinely every four months. Despite the devastation that came with the COVID pandemic, one silver lining that emerged was the value of virtual visits that allowed many of our patients who live far away to remain connected to our clinic without ever having to leave their homes. Over the years, we have periodically monitored JB with thermography to assess for any newly developing incompetent superficial veins, and duplex US scans to ensure ongoing patency within his deep venous system. At three years since his last ablation, now at the age of 36 years old, he has managed to sustain complete wound healing without the need for further procedures. He is now able to wear his graded compression socks without significant skin irritation and no longer suffers from the constant daily pain. This has been a life-changing event for JB who spent roughly one-third of his life battling a highly disabling condition. He has weaned himself completely off the narcotics and takes ibuprofen very sparingly. During his last visit, he stated that he is now mentally and physically ready to get back into the workforce, albeit doing a less labor-intensive job. He then intimated that the greatest joy he has after all these years is being able to take his son fishing again. JB was asked to play a more prominent role in sharing his story for this publication. Not surprisingly, he declined, but rather, opted to share his story with us in anonymity, hoping that it can be helpful to others suffering from venous disease.

Over the years, we have periodically monitored JB with thermography to assess for any newly developing incompetent superficial veins, and duplex US scans to ensure ongoing patency within his deep venous system. At three years since his last ablation, now at the age of 36 years old, he has managed to sustain

If there is one lesson to be learned from JB, it is that early detection, diagnosis and treatment of venous disease can make a tremendous impact on one’s life. For every JB, there are countless others around the globe with different, yet similar stories who are suffering from the consequences of venous disease. Our hope is that JB’s story, through our lens, can hopefully provide a positive impact to others.

References

1. Chung JW, Yoon CJ, Jung SI, et al. Acute iliofemoral deep vein thrombosis: evaluation of underlying anatomic abnormalities by spiral CT J Vasc Interv Radiol 2004;15:249-56.
2. Radaideh Q, Patel NM, Shammas Iliac vein compression: epidemiology, diagnosis and treatment. Vasc Health Risk Manag. 2019;15:115-122.
3. Eberhardt RT, Raffetto Chronic Venous Insufficiency. Circulation. 2014;130:333-346.
4. Ricci S, Moro L, Minotti GC, et Valsalva maneuver in phlebologic practice. Phlebology. 2018;33(2):75-83.
5. Soffer AD, Caine M, Hardigan PC, et al. Sensitivity and Specificity of Thermal Imaging When Used to Detect Superficial Venous Reflux as Compared to Duplex Vascular Disease Management. 2021;18(3):E45-E49.