01 · The Patient
An 83-year-old woman with chronic lymphocytic leukemia came to our attention with a progressively worsening ulcer on the left lower limb, in the malleolar region. The lesion had been present for approximately two years and had already led to a recommendation for amputation.
The patient’s clinical history was complex. She was an active smoker, hypertensive, and had a history of lower limb ulcers and bilateral saphenectomy. Pharmacological therapy included furosemide, spironolactone, transdermal nitroglycerin and valsartan.
A previous vascular evaluation had identified occlusion of the superficial femoral artery with distal collateral flow, but the lesion had been interpreted as a venous stasis ulcer. At our center, however, reevaluation revealed severe peripheral arterial occlusive disease, with no possibility of revascularization.
Given the lack of surgical options and the high risk of limb loss, treatment with mononuclear cells was proposed as a conservative limb-salvage attempt.
02 · The Wound
At presentation in May 2023, the ulcer was located on the left lower limb, in the malleolar area. It measured 24.77 cm² and was associated with severe pain, with an NRS score of 8.
The lesion was clinically consistent with a complex mixed ulcer, dominated by severe ischemic impairment. The patient’s systemic condition further complicated the case: chronic lymphocytic leukemia increased the risk of infection and reduced the margin for aggressive surgical approaches.
The wound was therefore not simply a local skin defect, but the visible expression of a severe vascular and systemic imbalance. Without the possibility of restoring blood flow through revascularization, the expected clinical trajectory was poor.
03 · Prior treatment history
Before PBMNC therapy, the patient had already been evaluated in another setting, where amputation had been recommended.
On 27 July 2023, she underwent a procedure involving PRP and platelet gel injection. The procedure was uneventful, but because pain control remained unsatisfactory, the patient left the center and sought care elsewhere.
When she returned to our center on 30 November 2023, the wound area had reduced to 19.46 cm², but pain had worsened, reaching NRS 9. The wound bed had slightly improved, but exudate control remained inadequate. Pain management was therefore intensified, including intravenous prostanoid therapy, while local treatment with silver-based antiseptics was used because of the combined infectious risk linked to peripheral arterial disease and leukemia.
Despite these measures, the clinical course remained unstable.
04 · Decision and protocol
By early 2024, the lesion had begun to worsen again. On 12 January 2024, the wound area had increased to 24.48 cm², with a Wound Bed Preparation Score of D3, although pain was partially controlled.
On 29 March 2024, the lesion had enlarged dramatically to 44.76 cm², with worsening wound bed conditions and declining oxygen saturation, with TcPO₂ measured at 11. Given the absence of revascularization options, a course of PRP treatment was proposed.
Three monthly PRP injections were administered on 27 April, 14 June and 5 July 2024. No complications were observed.
The first treatment cycle produced a clinically meaningful response, with a reduction in lesion area from 44.76 cm² to 30.32 cm². Between August and October 2024, the lesion reduced further to 21.77 cm².
The most relevant improvement, however, was not only the reduction in wound size. Oxygen saturation increased from 11 to 68, while pain disappeared completely.
05 · Clinical response
The patient remained under follow-up, and the oxygenation values remained stable. In February 2025, the lesion experienced an episode of critical colonization, with slight enlargement to 21.55 cm² and a Wound Bed Preparation Score of C3.
Despite this infectious episode, the lesion maintained an acceptable regression curve until the summer of 2025.
On 11 July 2025, the wound had significantly reduced to 10.25 cm² and pain was well controlled, with an NRS score of 2. However, given the long treatment period and the slowing of the healing process, a second treatment series was proposed.
This second course was performed using E-PRP produced with the High Q Cell® Liquid procedural kit. Applications were administered on 24 July, 28 August and 2 October 2025, without complications.
06 · Outcome and follow-up
On 28 October 2025, the lesion had improved dramatically. The wound bed progressed to WPS A1, the best possible score in that classification, and oxygen saturation reached 71, remaining stable thereafter.
The lesion area decreased to 9.17 cm², corresponding to an almost 55% reduction over four months, while pain remained completely controlled at NRS 0.
On 20 February 2026, the wound was clearly progressing toward healing, with an area of only 4.15 cm² and no pain. This clinical improvement allowed the patient to resume her normal quality of life.
Over the full follow-up period, the treatment supported limb salvage, maintained infection control, improved oxygenation beyond expectations and proved repeatable even in a patient with significant surgical risk.
07 · Discussion
This case illustrates the potential value of PBMNC therapy in a particularly complex mixed ulceration associated with severe peripheral arterial occlusive disease and chronic lymphocytic leukemia.
The case was extreme because the patient had no viable revascularization option and was considered at high risk for amputation. The coexistence of leukemia further increased the complexity, both because of immune vulnerability and because it limited aggressive therapeutic alternatives.
The first PRP cycle appeared to support a progressive reduction in lesion area and, most importantly, a marked improvement in oxygenation and pain control. The subsequent E-PRP cycle produced a further acceleration in wound bed improvement, leading to WPS A1, stable oxygenation and a significant reduction in wound area.
The clinical value of this result is not limited to wound size reduction. In this patient, the main outcome was limb salvage in a context where amputation had previously been proposed.
This treatment did not replace vascular assessment or standard wound care. Rather, it offered a regenerative and minimally invasive option in a patient who could not benefit from standard revascularization and who presented a high surgical risk.