Q: My mother has varicose veins for the past 10 years and has got it operated twice. Presently, for the past 6 months she is having ulcers mostly on the left leg because of the varicose veins and her feet colour has become black. She is having terrible pain and cannot sleep properly. We have consulted many leading specialists - they have advised her to keep her leg in an elevated position and apply bandage/regular medicines, etc, and even inject some medicine in the veins quarterly but the problem still persists.

A:This problem (chronic venous insufficiency) is far too often treated inappropriately or inadequately. The painful ulcerations are the most distressing form of the disease of CVI (Chronic Venous Insufficiency). It seems that the lady in question has not had thorough assessment of the condition. This is needed to evaluate the condition for precise treatment. The plan of management that we can do now, at this late stage is as follows: First she should have Duplex scan of the legs done for both arterial and venous side. This should give us arterial status, that is if the arterial circulation is normal and that these ulcers are purely venous and not combination of artertial and venous disease. From the information given in the query, I can assume that the ulcers are only venous. The venous doppler will tell us which system is contributing towards the persistence of ulcers. More so as the lady has been operated on a few times then clinical examination will be fallacious. The possibilities are that it is one of the following conditions responsible for the ongoing problem; 1) That she has no deep venous problem and that the ulcer is only persisting because of the perforators in the vicinity of the ulcers. 2) That the original operations have not dealt with the Spheno-femoral junction adequately and there are some tributaries left or over the years neo-vascularity has developed which is feeding the ulcers. 3) That there is deep venous incompetence which is keeping the ulcers going. 4) This looks less likely but has to be kept in mind that the ulcer has gone into neoplastic change, like Marjolin's ulcer. The plan of management would be first to do the edge biopsy of the ulcers and assuming this is negative then get the ulcers healed by 3 layered/ 4 layered bandage not just crepe bandage. This treatment will definitely heal the ulcers if the bandages are applied properly and if there is any infection, it should be treated effectively. Once the ulcers are healed then a definitive surgical procedure is to be done which will depend on the Venous Duplex scan result. This might be perforator ligation, re-exploration of the Spheno-femoral junction or in some cases ligation of the Spheno-Popliteal junction. If the deep veins are incompetent then the only safe treatment after the ulcers are healed perhaps would be to keep the Graduated Compression stockings on for an indefinite period. These stockings are custom made, now available in India made by NORMA DND and are cotton based to suite the Indian climate.