A rare case of leg ulceration after hybrid ablation (EVLA + UGFS) in the treatment of varicose veins: case report and literature review

Introduction

Skin and subcutaneous tissue necrosis is a rare complication of hybrid procedures using thermal techniques supplemented with intraoperative foam sclerotherapy, which has become a widely used method for treating varicose veins.

Case report

A 54-year-old, previously healthy, non-smoking patient with a normal body weight and good physical fitness, with a healed right leg ulcer, reported to the phlebology clinic for a scheduled hybrid ablation (EVLA + UGFS) of varicose veins in the right lower limb. Doppler ultrasound examination revealed an incompetent right great saphenous vein (RGSV) (from the saphenofemoral junction to the calf), which was supplied by the varicose plexuses on the calf and incompetent posterior tibial perforators: middle and upper, and paratibial proximal perforator (CEAP: R: C2,3,4b,5(s)). The procedure included laser ablation of the R-GSV and incompetent perforators of the right calf (listed above) using a NeoV 1940 nm laser, as well as UGFS of varicose veins in the calf and thigh. The R-GSV ablation was performed continuously, while the perforators were closed using precise spot ablation with a pulsed technique and an “INFINITY” fiber. The energy applied for ablation, measured as LEED (line endovenous energy density), was 38 J/cm.
Approximately 10 cm3 of 1.5% Aethoxysklerol foam produced by the Tessari method was used for sclerotherapy [1].
After the procedure, compression therapy with class II compression stockings was applied. The patient was discharged from the clinic in good condition approximately one hour after the procedure.
However, four days later, the patient reported to the clinic due to increasing pain and an inflammatory infiltrate in the treated calf. Rapidly progressing necrosis was observed on the anteromedial surface of the right calf (Figs. 1-3).
The patient subsequently underwent further outpatient treatment. A Doppler ultrasound examination was performed, revealing occlusion of the R-GSV and varicose veins of the right lower leg, with partial thrombosis, as well as preserved triphasic arterial flow in the anterior and posterior tibial arteries at the level of the ankle joint. The fibular artery was not visualized.
During therapy, multiple debridement procedures were performed. Initially Intrasite Gel + UrgoClean Ag was applied, followed by Granuflex Extra Thin as a secondary dressing (Figs. 4-7). The wound was irrigated with H₂O₂ and hypochlorite solutions (Microdacyn). Subsequently, MEPILEX and Mextra Superabsorbent dressings were used, promoting rapid granulation.
In the final stage of treatment, vacuum-assisted closure (VAC) therapy was implemented. Once the wound was filled with granulation tissue, an ENDOFORM dressing was applied, leading to rapid and complete ulcer healing (Figs. 8-11).
During treatment, low-molecular-weight heparin (LMWH) (Clexane 40 mg once daily, subcutaneously) was administered, and antibiotic therapy was conducted based on culture results.
The patient was taking Augmentin (amoxicillin with clavulanic acid) and Cipronex (ciprofloxacin). Strains of Staphylococcus aureus and Escherichia coli, sensitive to the above antibiotics, were cultured.

Discussion

The treatment of such an ulcer is now a practically standardized procedure, and in the absence of ischemic symptoms, it leads to rapid healing.
However, a crucial issue requiring analysis is the underlying cause of this complication and the extensive necrosis of the lower leg, especially considering that the procedure itself – hybrid varicose vein ablation (EVLA + UGFS) – is also a standard approach.
Foam sclerotherapy is a common method for treating varicose veins that can be performed on an outpatient basis and is well tolerated [2-6]. Systemic or localized complications [7] include anaphylactic/anaphylactoid reactions (very rare), deep vein thrombosis (1-3%), stroke (0.01%), superficial vein thrombosis (4.4%), tissue necrosis (0.2-1.2%) [8,9], edema (0.5%), and nerve damage (0.2%) [7,10]. Cosmetic complications include the dulling of telangiectasias (15-24%) and hyperpigmentation (10–30%) [7,11-14].
There are various etiological factors for ulcerations following sclerotherapy and laser ablation, including operator-dependent, patient-dependent, and medication-related factors [2,10,15-19]. Operator-dependent factors include inadvertent perivascular or arterial injection (microsclerotherapy) [20,21] and an overly rapid, high-pressure injection into superficial veins, which may cause retrograde flow of the obliterating agent into the arterial capillaries.
Additionally, laser ablation closure of arterial branches located in the vicinity of the occluded venous trunks and the Staubesand triad, as well as inadvertent cannulation and ablation of arteries along incompetent venous trunks qualified for ablation, may contribute to these complications.
One potential mechanism that may have contributed to the development of necrosis is the infiltration of Aethoxysklerol foam into the anterior tibial artery or one of its branches, or its laser ablation. Sclerotherapy, while commonly used and considered safe, is not free from the risk of complications, especially when the substance is used in high concentrations. Intra-arterial injection leads to more severe necrosis secondary to tissue ischemia. Foam treatment for telangiectasia has also been associated with skin damage, likely secondary to an increased risk of extravasation. Ultrasound-guided foam sclerotherapy is an effective adjunctive treatment for invisible subcutaneous varicose veins and perforating veins [18,22]. After injection, the skin may blanch or become red, and pain is typically characteristic. Dermal necrosis usually occurs more than 24 hours after the procedure. Therefore, to minimize the risk of necrosis, the lowest possible concentration and smallest volume of sclerosing agent necessary to achieve adequate closure of the target vein should be used.
Similarly, the exclusion of a segment of an artery through its thermal ablation may result in immediate acute ischemia of the tissue supplied by the occluded artery, leading to necrosis. Additionally, damage to all components of the Staubesand triad (especially the artery within it) may result in localized necrosis of the skin and subcutaneous tissue [23,24]. Although ablation is a minimally invasive procedure, the risk of damaging neighboring anatomical structures always exists and must not be overlooked [25-27].
In our study, this is the second case out of more than 7,000 hybrid ablations (EVLA + UGFS) performed.
The basis of treatment consists of appropriately selected dressings (Figs. 6-9), with regular clinical reviews. Wounds should be subjected to surgical debridement if necrotic tissue is present, especially if signs of infection are observed. A compression bandage can also be applied, similar to the treatment of uncomplicated venous ulcers. The ulcer may persist, healing for up to 6 months, often leaving residual scarring.
Another factor to consider is the potential damage to the cutaneous branch of the anterior tibial artery during the ablation of incompetent perforators in the lower leg [12]. Although ablation is a minimally invasive procedure, the risk of damaging adjacent anatomical structures always exists.
It is also important to emphasize the significance of careful monitoring of patients after such procedures and educating them about potential complications. Early diagnosis and intervention can significantly impact treatment outcomes and reduce the risk of long-term consequences.

Conclusions

In conclusion, this case provides important material for analysis and reflection for specialists involved in the treatment of venous diseases. Identifying potential causes of necrosis and taking appropriate actions in such situations can contribute to improving patient safety and the effectiveness of therapeutic procedures in the future.
Although skin necrosis is a rare complication of hybrid varicose vein ablations (EVLA + UGFS), it can be extremely disfiguring.
This possibility should be discussed with the patient before obtaining their consent for the procedure. The case presented here highlights the potential for extensive ulceration following hybrid varicose vein ablation – a potentially very safe procedure. Although this complication is rare, it does occur, and subsequent treatment involves aggressive wound care, cleaning, and possibly skin grafts. Unfortunately, this exposes the patient to unnecessary suffering and costs associated with prolonged treatment and the formation of disfiguring scars.

Disclosures

1. Institutional review board statement: Not applicable.
2. Financial support and sponsorship: None.
3. Conflicts of interest: None.

References