Doctors Lounge: Managing Mixed Arterial-Venous Leg Ulcers

Case Presentation

Panelists worked through a 56-year-old smoker with diabetes, a prior DVT, and a
non-healing leg ulcer with absent pedal pulses. The group agreed on toe pressure or ABI
screening before venous duplex, generally treating compression as safe above an ABI of
0.7 and unsafe below 0.5, with judgment needed in between, especially in diabetics where
calcification can falsely elevate readings.

Sequencing Arterial and Venous Treatment

With a toe pressure of 35 and SFA occlusion, most panelists favored addressing arterial
disease first, though several noted a large, reflux-driven saphenous vein could still be
ablated without compromising a future bypass conduit. As arterial disease became milder
across the case variations, panelists shifted toward treating venous disease first,
ablating the saphenous vein promptly while deferring arterial workup.

When to Look Further

An absent common femoral vein waveform prompted cross-sectional imaging for
suprainguinal outflow obstruction, which panelists said should be considered in large or
long-standing ulcers, especially with a history of DVT. The group agreed on culturing
large, chronic wounds for resistant organisms and treating perforator veins around the
ulcer bed regardless of the underlying cause.