Extracorporeal Treatment with High Intensity Focused Ultrasound of an Incompetent Perforating Vein in a Patient with Active Venous Ulcers

INTRODUCTION: Endovenous techniques such as ultrasound guided foam sclerotherapy, thermal methods, or glues are generally recommended to occlude incompetent veins. However, these methods can be technically challenging and risky for patients with severe atrophic skin disorders like lipodermatosclerosis or atrophie blanche. High intensity focused ultrasound (HIFU), which has been shown to coagulate and occlude veins successfully, may offer an alternative method. This case report details ultrasound guided HIFU to occlude non-invasively a refluxing perforator vein causing active ulcers. REPORT: A 95 year old man presented to the Institute for Functional Phlebology (Melk, Austria) with painful recurrent ulcers in his left medial calf. His limb was scored C2,3,4a, b,6, Ep, Ap, Pr,18 according to the Clinical, Etiology, Anatomic, Pathophysiology (CEAP) classification. Lower limb ultrasound revealed a refluxing posterior tibial perforating vein, measuring 2.7 mm in diameter at the level of the fascia. Extracorporeal HIFU pulses were delivered to this vein with the Sonovein device (Theraclion, Malakoff, France). Sonication was applied for eight seconds at a mean acoustic power of 80 W. The patient was followed up for three months post-treatment and occlusion was evaluated by duplex ultrasound. There were no complications during treatment or follow up. Three months after the treatment, reflux was abolished and the two initially active ulcers had healed. DISCUSSION: Although this is an early report, this study shows that HIFU can be successful in ablation of incompetent perforator veins in the treatment of venous leg ulcers.