Venous Leg Ulcers
A 67-year-old female with history of bilateral medial and lateral ankle ulcers presents to the wound center. She noticed the ulcers about 6 months ago and they have enlarged progressively. They currently measure more than 20 cm2 bilaterally. She denies any fever, cellulitis, or other constitutional symptoms. She was treated with systemic broad spectrum antibiotics twice within the last 6 months without any significant improvement in the size of the ulcers. She reports that cultures were not obtained at that time. She reports history of recurrent deep vein thrombosis (DVT), first diagnosed in the left lower extremity in 1992, attributed to ulcerative colitis. She underwent colectomy and ileostomy at that time. She then developed right lower extremity DVT in 1999 related to long-distance travel. On both occasions she was treated with anticoagulation for 6 months. She then developed a third DVT in the left lower extremity, which was considered idiopathic in 2000. She received an interior vena cava (IVC) filter and was placed on long-term anticoagulation with warfarin since then. Hypercoagulable testing at that time was negative. She does not have family history of venous thrombosis.
Wound exam demonstrates large ulcers around the ankle (Figure 1). The wounds are debrided to expose healthy underlying granulation tissue. Venous duplex testing for reflux demonstrates superficial venous reflux in the calf areas of the bilateral great saphenous veins. The sapheno-femoral junctions were competent. Deep venous reflux was noted in the bilateral femoral and popliteal veins. Four layered compression wraps are applied in the wound center every week for 6 weeks without any significant improvement.
Figure 1: Venous ulcerations
Which of the following is the best next step in the management of this patient?