Clinical Problem: 62 yo male, history multiple strokes, left hemiparesis, LLE trauma wounds. Hx skin grafts X2 and ulcers healed, then recurrence 1 year later after trauma. Pt presented after LLE ulcers reopened for 14 months; necrotic tissue and tendon present. Comorbidities: DVT Left popliteal vein 1 month prior to admission, LLE ABI 0.41, arterial/venous insufficiency, high bacterial burden, smoking/pain management.

Past Management: Light compression, Iodosorb, ActiCoat, BiaFine, Dakins solution, or Silvadene, oral antibiotics, and failed smoking cessation.

Current Clinical Approach: Arginaid Extra BID, Two Cal/Vitamin-C 60 cc's TID, multivitamin daily. Baseline labs, Xrays, Vascular Studies. Initial care included accuzyme, kerlix, cotton tubular compression, monochromatic infrared therapy 3 X's/week, whirlpool for mechanical debridement prn, and pain management. Vascular studies determined ABI of 0.53 and 3-layer compression wrap was started with no stretch. Silver alginate used beneath multi-layer wrap to manage drainage and bioburden. 1 month after wound center admission, epi-vasc wound gel (nifedipene/pentoxiphyllin compound) was applied to wound 3X's/weekly under compression wraps. Social services and dietician consulted. Orthopedist consult 6 weeks after treatment for possible graft/flap surgical closure and a below the knee amputation was recommended.

Patient Outcomes: Initial visit pt had 5 open ulcers of LLE which varied in size from 1.0 cm by 1.0 cm to 13.7 cm X 11.0 cm X 0.4 cm. All ulcers had slough tissue, heavy drainage, and were odorous. 5 months after treatment began wounds no longer required mechanical debridement. The smallest ulcer healed at 5 months and the largest ulcer healed at 25 months. 18 mmHG compression hose applied to LLE.

Conclusions: A combination of nifedipine/pentoxiphyllin topical compound, monochromatic infrared therapy, and light compression can be successfully used to avoid amputation by healing lower extremity ulcers in a patient with mixed arterial/venous disease.