February 25, 2023

Challenging Venous Ulcer Cases Across Europe: Expert Insights and Treatments

Certain venous ulcer cases are difficult to treat and they necessitate a more thorough differential diagnosis, multidisciplinary management approach and in particular the use of medical compression therapy as conservative treatment.

Furthermore, managing a specific patient population - such as obese patients with venous ulcers, requires the use of specialized techniques, beside other examples, the experts recommended ulcer treatment with maggots or enzymatic debridement.

Therefore, gaining insights into managing difficult venous ulcer cases all over Europe based on best practices and real-world clinical practices with examples provided of intermittent claudication (IC) and rest pain (RP) and the use of medical compression therapy is beneficial, since there is no unified consensus on how to adequately treat them.

The session, dedicated to the topic “Challenging Ulcer Cases from all over Europe”, explored the insights of highly qualified and experienced experts from Austria, Greece, Italy and Romania regarding the successful treatment of challenging venous leg ulcer cases. The speakers insights were completed by the significant input from the moderator team that represented the Egyptian and British expert’s point of view.

The speakers highlighted the importance of compression therapy in the treatment of vascular ulcers and made recommendations regarding the daily wearing time. Although the experts were not fully in agreement, there was alignment, that the stockings should be worn at least for six to eight hours per day, some recommended even up to 16 hours.

The benefits of compression therapy, particularly for mixed ulcers and vascular diseases in general was discussed, and there was a special focus on the positive effect that compression therapy has on inflammatory processes.

In two case studies presented, a vascular specialist discussed the advantages of using a system or complex bandage rather than a single-layer bandage. The first case involved a patient who had bilateral chronic venous disease with typical ulcer features and chronic superficial edema including pigmentation, which was treated with a compression wrap after ultrasound evaluation. The second case a patient had a mixed response to great saphenous vein incompetency and PAD occlusion showed no granulation tissue on an x-ray, but deep debridement was required to achieve healing and was healed one month later after a successful autologous skin graft.

Watch the full session


Best practices from Austria

The web seminar starts with Professor Gregor Holzer discussing "The Best Practice for Treating Venous Ulcers." Professor Gregor Holzer presented a case study of a patient with multiple comorbidities, who was diagnosed with livedoid vasculopathy, a rare and painful complication of venous ulcers, that is resistant to conservative treatment. After starting various anticoagulants and immunoglobulins, the ulcer completely healed after adding new modalities of treatment

Take-home messages

  • The author shares a difficult case of an 80 year old with very painful ulcer on both legs with many clinical take-home messages
  • Diagnosis is essential before management, up to skin biopsy as happened in this case
  • Pathology diagnosis is very important
  • Full clinical picture and full investigation is very important in ulcer management
  • Always keep you therapeutic plan reassessed during the period of treatment as this patient did not improve on the initial management but improved after adding immunoglobulin
  • Don’t loose your nerves in venous ulcer management


Gregor Holzer

Dr. Gregor Holzer, AT

Chief physician in Department of Dermatology at Klinikum Donaustadt; University lecturer and educatifor Dermatology and Venerology at Medical University Vienna.




Best practices from Greece and Slovakia 

Dr. Papastavrou Dimitrios discussed about "the importance of thermodynamics in the treatment of difficult-to-treat ulcerations and the use of various types of compression therapy to improve patient outcomes". The lively panel discussion, that followed the presentation, highlighted the importance to consider different approaches when treating venous ulcers, like combining sclerotherapy along with different compression device as example the Ulcer-Kit.

Take-home messages

  • The basics of ulcer management are still very important
  • Following recent guidelines of ulcer management is important
  • Compression therapy is still the main stay in treatment of venous ulcer
  • Mixed ulcer, venous and arterial, are difficult to manage
  • Leg ulcer needs a multidisciplinary team to manage well, especially vasculitis cases


Dr Dimitrios Papastavrou

Dr. Papastavrou Dimitrios, GR

Vascular surgeon endovascular phlebologist; private doctor practicing phlebology & vascular surgery as in Thessaloniki Greece & Bratislava Slovakia; speaker at the UIP and lecturer in medcial universities about prodeutic surgery and vacular surgery. 



Best practices from Italy

Dr. Luca Gazzabin discussed the topic "CEAP classification, venous ulcer pathophysiology, and the best flow chart for treating such a condition. With evidence-based conclusions". Dr. Luca presented a very complicated venous ulcer case at the pre amputation stage and how the inclusion of medical compression in the treatment strategy has contributed to save the patients limb. Dr Luca showed also a new modality to assess the extend of bacterial contamination in venous ulceration and explained why this has to be considered when deciding on the best treatment strategy.

Take-home messages

  • CEAP classification is important in patient management
  • Pathophysiology of venous ulcer and effect on vein wall is important
  • Assessment of patient with venous ulcer as a whole is very important
  • Accurate diagnosis again is very important
  • Preparing the floor of the ulcer before healing is important
  • In all cases of venous ulcer he has used compression therapy


Dr Luca Gazzabin

Dr. Luca Gazzabin, IT

Contract Professor appointment teaching "Diabetic Foot Surgery." University master's degree in "Vascular and Neurodystrophic Cutaneous Injuries of the Lower Limbs in the Diabetic Patient."



Best practices from Romania

The final presentation with the topic "Difficult venous ulcer cases in elderly and overweight patients and how they manage such cases with limited resources while achieving excellent results", was provided by the speakers Dr. Cristian Adrian Siloși and Cătălin Voiculescu. They talked about the prevalence of venous ulcers in Europe, the different treatments available and the importance of medical compression as part of the conservative treatment. The speakers recommended to consider using multiple treatment methods to maximize success, and reminded the participants that ulcers can be life-threatening if they are not treated correctly.

Take-home messages

  • Treating risk factors in venous ulcer is important
  • Pandemic can affect venous ulcer treatment
  • Always keep clinical assessment of venous ulcer cases, even remotely
  • There is a place of remote management of venous ulcer
  • Multidisciplinary management is important in venous ulcer cases
  • Again compression dressing is very important


Dr Cristian Silosi

Dr. Cristian Adrian Siloși, ROU

Medical Doctor specialized in general surgery and vascular surgery; Primary physician in general surgery and vascular surgery; Associate professor at University of Medicine and Pharmacy, Craiova



Catalin Voiculescu

Cătălin Voiculescu, ROU

Specialist medical assistant in vascular surgery at private hospital REGINA MARIA in Craiova

What is the most common cause of venous ulcers?

Poll question 1

Challenging ulcer cases question 1

What is the recommended duration for wearing compression stockings per day?

Poll question 2

Challenging ulcer cases question 1

Which of the following is a common symptom of venous ulcers?

Poll question 3 

Challenging ulcer cases question 1

What is the primary purpose of compression stockings?

Poll question 4

Challenging ulcer cases question 4


Tracy Green

Tracy Green, UK

Clinical Manager at SIGVARIS GROUP Britain


Omar Farouk

Dr. Mohamed Omar Elfarok, EGY

M.Sc, FRCSEng, FRCSEd, IME, Consultant Vascular and Endovascular Surgeon Royal College Of Surgeons Of England Examiner

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