Active venous ulcer with superficial-plus-segmental-deep reflux — stratum, timing, and staying healed

Candidate tasks and model management

Stratify her deep reflux before promising anything. She sits in the segmental-deep stratum — not isolated superficial, not total deep — so quote the stratum-specific dividend: at 3 years recurrence runs 52 versus 24% with added surgery (P=0.04), matching the isolated-superficial dividend (51 vs 27% at 4 years), while total deep reflux dissolves it (46 vs 32% ns).^[10] Confirm the pattern on duplex of the ulcerated leg — ESCHAR imaged 500 consecutive legs this way — and note surgery abolished segmental deep reflux in 10 of 22 such legs.^[9][11]

Reconcile healing with recurrence honestly. Tell her surgery does not hasten healing — 24-week healing tied 65 versus 65%, 3-year tied 89 versus 93% — but halves 12-month recurrence (12 vs 28%) and buys ulcer-free time (78 vs 71% at 3 years).^[9][10] Then offer speed through early ablation: within 2 weeks of randomisation, healing hazard 1.38 with median 56 against 82 days and 24-week healing 85.6 against 76.3%.^[12]

Plan tributaries and compression in the same sitting. Treat tributaries concomitantly — 6 randomised trials, reintervention cut to one-third with no safety penalty — and set expectations with the Marston arc: 57/74/78% healed at 3/6/12 months with recurrence at 9/20/29% across 1–3 years, worsened by deep insufficiency and skipped phlebectomy.^[26][32] Bandage to heal by tolerance — 21 trials show no system heals meaningfully faster, with four-layer-or-hosiery cost-effective — then convert the healed leg to stockings: European class-3 halves reulceration against none and class-3 beats class-2.^[35][34] Cover high-thrombosis-risk legs with 1–2 weeks of low-molecular-weight heparin by consensus rather than a single dose.^[37]