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Chronic Wound Management—A Continuing Challenge 5
However, for two major wound categories, venous leg ulcers and diabetic foot
ulcers, well established interventions have been established to treat wounds and
improve outcomes: compression therapy and off-loading, respectively. For example, compression therapy increases venous leg ulcer healing rates compared with no
compression (O’Meara et al. 2012).
In order to improve healing outcomes, a reliable diagnosis and comprehensive
assessment are imperative. Notwithstanding all the innovations and guidelines, it is
reported that up to 25% of people with chronic wounds and in particular low er leg
ulcers either do not have a recorded diagnosis or are mis-diagnosed/classified: the
latter can and should be addressed (Guest et al. 2020). Low-cost Doppler ultrasound
probes are widely available to assist by measuring ABI. Although international
guidelines for the management of venous leg ulcers vary on whether to recommend
the use of ABI, this index is a reliable, essential tool in the assessment process
(Weller et al. 2019; Mani et al. 2016).
Future Opportunities
The orderly though complex process of wound healing is dysregulated in chronic
wound management. Vascular supply, glycaemic control as well as intrinsic and
such ex trinsic factors as temperature, wound perfusion, pH can and should be
measured certainly in controlled environments as obtain in research studies. It is
also important to know about the presence systemic disease, medications, knowledge and skills of the health care provider, and available resources.
Current wound healing strategies for managing such complications as exudate,
odour and pain need to be configured into care plans to better the predictability of
wound closure from more comprehensively designed studies the outcomes of which
will be topics of systematic reviews and meta-analysis to come. There is also a need
for attitudinal changes: wound healing is slower with advancing age though a
patient’s dream to have ‘the wound in their leg’ completely covered is not.
This book covers the spect rum of chronic wounds including chapters on
Atypical Wounds with reviews on Medicinal plants and products, latest laboratory
models of pressure wounds to study dressing materials, scars, and chronic wound
pain management. Vascular and diabetic foot wounds have been examined from a
perspective of standardised care and adjuvants with promise to improve healing
rates. There is a chapter on Translation illustrated with a few cases to argue that
translation is not a myth: it is achievable with persistent and collaborative efforts.
This book comes as we wake to the diminishing effects of the Covid pandemic—
learning lessons from it will significantly influence the future.
6 G. Gethin and R. Mani
References
Apollonio A, et al. A large Italian observational multicentre study on vascular ulcers of the lower
limbs (Studio Ulcere Vascolari). Int Wound J. 2016;13(1):27–34.
Berenguer Perez M, et al. Epidemiology of venous leg ulcers in primary health care: incidence and
prevalence in a health centre-A time series study (2010–2014). Int Wound J. 2019;16(1):256–65.
Gethin G, et al. The profile of patients with venous leg ulcers: a systematic review and global
perspective. J Tissue Viability. 2020.
Gethin G, et al. The impact of patient health and lifestyle factors on wound healing, Part 1: Stress,
sleep, smoking, alcohol, common medications and ilicit drug use. J Wound Manag. 2022;23(1).
Goldrick M, Gethin G. Patients’ perception of, and acceptance toward, using wearable sensor
technology in wound care. J Wound Manag. 2021;22(1):13–26.
Guest JF, Fuller GW, Vowden P. Cohort study evaluating the burden of wounds to the UK’s
national health service in 2017/2018: update from 2012/2013. BMJ Open. 2020;10(12):
e045253.
Hopman WM, et al. Health-related quality of life at healing in individuals with chronic venous or
mixed-venous leg ulceration: a longitudinal assessment. J Adv Nurs. 2016;72(11):2869–78.
Jockenhofer F, et al. Aetiology, comorbidities and cofactors of chronic leg ulcers: retrospective
evaluation of 1 000 patients from 10 specialised dermatological wound care centers in
Germany. Int Wound J. 2016;13(5):821–8.
Kelly M, Gethin G. Prevalence of chronic illness and risk factors for chronic illness among patients
with venous leg ulceration: a cross-sectional study. Int J Low Extrem Wounds. 2019;18
(3):301–8.
Korber A, et al. Etiology of chronic leg ulcers in 31,619 patients in Germany analyzed by an expert
survey. J Dtsch Dermatol Ges. 2011;9(2):116–21.
Mani R, Margolis DJ, Shukla V, Akita S, Lazarides M, Piaggesi A, Falanga V, Teot L, Xie T,
Bing FX, Romanelli M, Attinger C, Han CM, Lu S, Meaume S, Xu Z, Viswanathan V.
Optimizing technology use for chronic lower-extremity wound healing: a consensus document.
Int J Low Extrem Wounds. 2016;15(2):102–19.
Martinengo L, et al. Prevalence of chronic wounds in the general population: systematic review
and meta-anlaysis of observational studies. Ann Epidemiol. 2019;29:8–15.
O’Loughlin A, et al. Review paper: basic concepts to novel therapies: a review of the diabetic foot.
Int J Low Extrem Wounds. 2010;9(2):90–102.
Olsson M, et al. The humanistic and economic burden of chronic wounds: a systematic review.
Wound Repair Regen. 2019;27(1):114–25.
O’Meara SM, et al. Compression for venous leg ulcers. Cochrane Database Syst Rev. 2012(11),
Article number: CD000265. https://doi.org/10.1002/14651858.CD000265.pub3
Sen CK. Human wounds and its burden: an updated compendium of estimates. Adv Wound Care
(new Rochelle). 2019;8(2):39–48.
Sorensen K, et al. Health literacy and public health: a systematic review and integration of
definitions and models. BMC Public Health. 2012;12:80.
Sorensen K, et al. Health literacy in Europe: comparative results of the European health literacy
survey (HLS-EU). Eur J Public Health. 2015;25(6):1053–8.
Walker J, et al. Identifying wound prevalence using the mobile wound care program. Int
Wound J. 2014;11(3):319–25.
Weller CD, et al. ABPI reporting and compression recommendations in global clinical practice
guidelines on venous leg ulcer management: a scoping review. Int Wound J. 2019;16(2):406–19.
The Role of Technology in Managing
Vascular Wounds
Bodo Erhardt Günther and Raj Mani
Abstract
In man, most chronic wounds present on the lower extremities including the feet
caused by vascular conditions and or diabetes mellitus. Venous leg ulcers,
mixed-arterio venous leg ulcers, ischemic leg ulcers result from venous and or
arterial pathologies. Painful digital ulcers may also occur due to Raynaud’s
phenomenon or scleroderma. The prevalence of lower extremity vascular ulcers
is increasing d ue to increasing longevity in many countries including Europe,
USA, and China as well as the increasing prevalence of peripheral arterial
disease and diabetes. The clinical management of such wounds has benefitted
from the use of technology for diagnosis as well as management. Innovative
technology has permitted the development as well as the advocacy of sustained
compression and offloading, as mainstays for treatment for venous leg ulcers and
neuropathic diabetic foot ulcers respectively. Practical experience has led to the
development of guidelines for standardized care. However, timely, sustained
wound healing remains a clinical challenge: age and associated generalized
inflammation, effects on the main cellular directors of healing have been
proposed as likely explanations. Are we applying innovative technology
appropriately?
B. E. Günther
Surgical Department Stord General Hospital, Western University of Norway, Head Consultant,
Helse Fonna, Bergen, Norway
e-mail: bodo.erhardt.gunther@helse-fonna.no
International Association of Diabetic Foot Surgeons (IADFS), CEO Wounds Norway and
Wounds Africa, Frederiksberg, Denmark
R. Mani (&)
Shanghai Jiao Tong University School of Medicine, Shanghai, China
e-mail: rajgopalmani47@gmail.com
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
R. Mani (ed.), Chronic Wound Management,
https://doi.org/10.1007/978-3-031-26110-7_2
7
8 B. E. Günther and R. Mani
Keywords
Lower extremity woundsCompressionOffloadingRevascularization
NPWT
Introduction
Background
The aim of this chapter is to examine technology used to diagnose and to manage
lower extremity vascular wounds, the benefits, shortcomings, and to view the way
ahead. In his monograph on Leg Ulcers, Anning, in 1954, presented a succinct
account of the incidence of this condition and the scope of management whilst
employed in the Leeds General Infirmary (Anning 1954): the condition was cared
for by Dermatologists. Some 30 years later, Terence Ryan described how leg ulcers
which comprised venous ulcers (hitherto referred to as varicose ulcers) and
ischemic leg ulcers were mostly observed in the elderly and managed by Dermatologists with nurse support (Ryan 1983). Based on sound clinical observations,
Ryan argued that varicose veins did not lead to venous leg ulcers, on the epidemiology and on methods of bandaging for leg ulcers. Ischemic or arterial ulcers
were mostly treated using inelastic bandaging often impregnated in zinc paste and
patients were advised bed rest. Ryan referred to leg ulcers being a Cinderella of
conditions managed by Dermatologists: this monograph was published about the
time objective guidance to treat this condition was first described. Indeed, it also
coincided with the growth of peripheral vascular surgery: in this ambience, research
proliferated which promoted a wider interest in the condition, the initiation of
learned societies and, following a poll of patients with leg ulcers, a consensus-based
acceptance of the word “wounds” to describe the condition was accepted. Importantly, technology was used, initially for diagnosis based on Doppler Ultrasound
and this was followed by technology used for management. This had a catalytic
effect on the development of a wi de variety of wound dressings, compression
garments, adjuvants to accelerate wound healing, methods of debridement and not
the least, evidence from studies. Such evidence led to the development of guidelines
management (Rooke et al. 2011; Tenders et al. 2011; Scottish Intercollegiate
Guidelines Network (SIGN) 2010).
Venous leg ulcers (VLU), mixed arterio-venous leg ulcers (MAVLU), ische mic
or arterial leg ulcers (ILU) together with diabetic foot ulcers (DFU) are chronic
wounds presenting on the lower extremity and foot. The evolution and management
of lower extremity wounds may be considered as a tripod–each of its legs representing an individual condition–peripheral arterial disease, diabetes and DFU and
chronic venous insufficiency (CVI) and hence all three need to be reckoned with in
considering lower extremity wounds. DFU has a reported prevalence of 6.3% (95%
The Role of Technology in Managing Vascular Wounds 9
CI 5.4–7.3%) in all diabetic subjects (Zhang et al. 2017). The risks associated with
DFU are male gender, being higher than the risks with fema le gender and the risk
with Type 2 diabetes mellitus higher than that with Type 1 diabetes. This review
also identified that the highest prevalence of DFU was reported in North America
(13% 95%CI 10–15.9%), the lowest in Oceana (3.0% 95CI 0.9–5.0%). A lesser
order of prevalence was found in Asia, Europe, and Africa in that order. A lifetime
incidence of DFU was found in 15–25% in diabetic subjects (Singh et al. 2005).
DFU result from repetitive stress in the presence of neuropathy as well as ischaemia
in peripheral arterial disease (PAD) (Armstrong et al. 2017). PAD leads to chronic,
significant, reduction blood flow and oxygen to the limbs ultimately leading to cell
death, and ILU.
In 2015, a global estimate of PAD suggested some 236.62 million people aged
twenty-five and over were living with this condition with 72.91% living in lower to
middle income countries. Overall, the risks increased with age. Again, in lower to
middle income countries, more females were affected than males in the age range
45–89 the identified major risk factors for PAD being smoking, diabetes, hypertension, and hypercholesterolemia (Song et al. 2019). A major significance of this
observation was that the lower to middle income groups were affected which in turn
would affect their ability to work when suffering with lower extremity wounds.
Soyoyo from hospital-based studies reported that PAD is two to seven times more
prevalent in subjects with diabetes mellitus than in those without it (Soyoyo et al.
2021). These increased risks would negatively impact the burden of chronic
wounds.
Venous Leg Ulcers (VLU)
VLU which are sequelae of chronic venous insufficiency (CVI), result from unrelieved ambulatory venous hypertension. CVI has been classified using CEAP
(Eklöf et al. 2004; Lurie et al. 2020) (Clinical, Etiological, Anatomical and
Pathophysiological), VLU is defined by C
symptoms of chronic venous disorders with no visible or palpable signs on
C
0
clinical examination.
C
telangiectasia or reticular veins.
1
C
varicose veins.
2
C
oedema.
3
C
skin changes (eczema and or lipodermatosclerosis).
4
C
healed VLU.
5
C
active VLU.
6
Salim using the CEAP system (Salim et al. 2021), reported the prevalence of C
19%, C126%, C219%, C318%, C45%, C51%, C60.42% from a systematic review
done on nineteen studies in four continents. The overall incidence of C
reported to be in the range 0.18–0.122% in the general population and 0.3–1.2% in
older adults. Age, female sex, and smoking were identified as risk factors which is
the others being:
5–6
5–C6
was
0
10 B. E. Günther and R. Mani
broadly in accord with other observations: Salim and colleagues showed awareness
of the likeliness of their data being skewed on account of higher number of women
included. Chronic venous disease (with or without ulcers) causes pain, impacts on
work, mental health, negatively on quality of life and is estimated to cost around £
2.3bn (UK NHS and £ 3bn (USA) which approximates to 2% of the annual
healthcare costs in Western societies.
VLU (C
) may present on the medial or lateral aspect of the skin around the
5–C6
ankles, affect women more than men with a greater preponderance for the lesion to
present on the left leg. VLU may also present bilaterally, even circumferentially and
occasionally extending from the malleolus to the just below the knee. VLU tend to
be shaped oval with sloping edges and a hard base, can be painful. VLU result from
unrelieved venous hypertension associated with deep and or chronic venous
incompetence. Deep venous incompetence is frequently associated with a history of
previous deep venous thrombosis and or superficial venous incompetence. Chronic
venous incompetence has also been associated with the presence of congenital
aplasia (Friedman et al. 1988).
In health, venous pressures are normalized by calf muscle pump activity aided
by competent valves that enable unidirectional flow towards the right heart. In the
superficial venous system, valves permit flow towards the deep veins, in the deep
veins valves permit flow towards the heart: within the calves, perforator veins also
direct flow from the superficial to the deep venous system. Venous valves are
bicuspid with valvelets or thin leaves of muscle tissue susceptible to damage from
thrombotic clots which may get trapped between a valvelet and vein wall rendering
that valve incompetent. This leads to retrograde or downward pressure within the
veins or incompetence and increased venous pressures in the foot and calf veins
(Xie et al. 2018 ).
In CVI or DVI, high, unrelieved, venous pressures are communicated through
the smaller veins and venules to the capillaries causing vessel dilatation and
increased permeability which in turn, lead to oedema formation. A swollen edematous limb may lead to dry, scaly, itchy skin. Haemosiderin leaks from haemoglobin to stain tissues which also turn hard and dry due to loss of moisture, and
shiny: this condition is termed lipodermatosclerosis which can also affect subcutaneous tissues causing fibrosis. This skin is easily susceptible to damage especially
around the ankle and may easily ulcerate following trauma (Ryan 1983). VLU
result from macro and microvascular dysfunction.
Oedema impedes perfusion and diffusion of oxygen by increasing inter-capillary
distances (Mani 1995 ). Working independently but around the same time, Philip
Coleridge Smith and Vincent Falanga suggested microvascular dysfunction
resulting from capillaries blocked by leaked leucocytes (Burnand et al. 1982)orby
pericapillary cuffs of fibrin leading to cell death and venous ulceration as the cause
of VLU (Browse and Burnand 1982). The fibrin cuff hypothesis, fi rst proposed by
Burnand based on histopathology of ankle skin, was attractive, it was never refuted
or accepted (Coleridge Smith et al. 1988; Donohue and Falanga 2003). Harding
suggested that VLU may refer to many similar though not identical entities (Grey
et al. 2006).
The Role of Technology in Managing Vascular Wounds 11
VLU used to be treated with wound cleaning followed by elasticated bandaging
sometimes coated with zinc paste. Once the Charing Cross four-layer bandaging
system was innovated for the purpose of delivering sustained compression, it was
popular (Moffatt and Dickson 1993). The Cochrane Collaboration fostered the
development of the Cochrane Wounds Group about the same time. The Cochrane
Wounds Group published its first paper, a systematic review and meta-analysis of
relevant literature and based on the results, argued that sustained compression was
better than no compression to treat VLU (Cullum et al. 2001). This paper was
widely cited, it focused the attention of trained caregivers on delivering compression using bandaging systems. Data driven guidance of this nature gained acceptance setting off new research into the wound size measurements, the development
of new and later high-tech dressings, methods of debridement including the use of
sterile maggots: innovations led to additions to the literature, formation of publications dedicated to wound science an d management and guidelines for management. Other systematic reviews and meta-analysis also followed on from the
Cochrane Wound Group (O’meara et al. 2012; Nelson and Bell-Syer 2012).
Guidelines emerged based on experience in Europe, Americas and Australia were
focused on patients within this geography: this notwithstanding, the concept of
standardized care for VLU was defined, compression being the mainstay of management. Besides compression, the clinical management of VLU includes surgery
for debridement, to reduce CVI, for covering wounds with grafts. Sympathec tomy,
done surgically or chemically to better manage venous pressures, was a treatment
offered to certain patients. How does compression wor k?
The Physics of Compression Delivered
by Hosiery/Bandaging Systems
Bandage pressures or sub bandage pressures/contact pressures perceived on the
bandaged limb, result from the tension or force applied by the bandage, and the
radius of the limb as enshrined in Laplace’s law (Partsch and Mani 2019). When
tension is constant, a limb with greater circumference will perceive less bandage
pressure: contrarywise a smaller limb will feel a greater pressure in these conditions. So, to vary bandage pressure, the size of a limb may be temporarily increased
using cotton wool or a foam pad. Sub bandage pressures may be measured using
flat sensors that are reliable and accurate (Partsch and Mani 2019). Bandage
pressure is affected by positional changes (in the supine position, venous pressure
equilibrates with that in the right atrium, on standing, venous pressure in foot vein
is the product of the vertical distance from the right atrium to the foot, the density of
blood, and the acceleration due to gravity). Partsch (Partsch and Mani 2019) further
defined static stiffness index (SSI) as the ratio of sub bandage pressure standing to
that in the supine position: a compression garment—wrap around or stocking— an
elastic system would have a higher SSI, an inelastic system wound have a lower
SSI: paste bandages would be inelastic, short stretch bandages mildly elasticated
12 B. E. Günther and R. Mani
and long stretch ones are 100% elastic reflecting the property to stretch to their full
length in response to positional changes. Partsch recommended that sub-bandage
pressures be measured at the mid-point or B2 point of the calf where it tends to be
most rounded or closest to being circular. SSI measurements permit bandaging
systems to be assessed in a dynamic sense.
Duplex ultrasound is used to locate and measure venous flow or reflux: reflux
lasting longer than 0.5 s is consistent with the presence of valve incompetence
except when the test is done in patients either postpartum or following surgery
when all the effects of anesthesia have not worn off: using this and occasionally
plethysmography to measure volume changes, it was reported that compression
reduces venous diameter while increasing venous flow and return: it also reduces
oedema and afterload. Barnes and Mani demonstrated that bed rest significantly
reduced leg circumference measured using a tape measure as well as leg volume
plethysmography, in patients with active VLU CEAP = C
(Barnes et al. 1992;
5
Mani et al. 1995). Four-layer compression was then applied with benefit to healing
in this group of patients. While Barnes and Mani found limb volume and calf
circumference were significantly reduced after four hours, recently Mosti found that
leg oedema is significantly reduced in two hours after sustained compression is
applied offering an important practical application in VLU management (Mosti and
Partsch 2010). Compression reduces venous reflux by reducing venous tone: it also
improves arterial flow in cases where light compression is used (Mosti and Partsch
2010; Partsch et al. 2010).
Healing Rates of VLU Treated with Compression Are Variable
Returning to compression delivered using wrap around bandage systems or garments to treat VLU, Cochrane Systematic Reviews of randomized controlled trials
argued in favour of the use of sustained compression over no compression to heal
VLU (Cullum et al. 2001) and to reduce rates of re-ulceration of VLU (Nelson and
Bell-Syer 2012). In their review, O’Meara et argued that there were no statistically
significant differences at five years, between recurrences rates between high compression and medium compression use (O’meara S, Cullum N, Nelson EA,
Dumville JC. 2012). Earlier reviews of 4 trials (N = 979 participants, n = 153
patients) showed using sustained compression significantly reduced ulcer recurrence at one year (RR 0.46, 95% CI 0.27–0.76) (Nelson and Bell-Syer 2012).
Healing rates of VLU are varied between centres within the UK likely due to
variations between techniques as well as commercially available products (Vowden
and Vowden 2002). Guest reported a healing rate of 43% for all chronic wounds
(Guest et al. 2020) treated by Community Health in the UK, the majority (%) were
VLU. The variability was attributed to bandaging technique, a good effort was
made to train those who bandage by the UK NHS. Nelson reported the compliance
with compression bandaging was poor though there was confidence that sustained
compression benefits VLU healing and that three- or two-layer bandaging worked
equally well (Nelson and Bell-Syer 2012). Compression is difficult to use in warmer
The Role of Technology in Managing Vascular Wounds 13
climates. Nair reported success using two-layer bandagin g systems of which one
was elasticated, to treat VLU routinely in Malaysia (Nair 2019) where the patient
groups are younger and often in full employment. Increased limb size or growths
often make compression very difficult to apply or keep in place difficult as excel-
lently reviewed by Flour (2019).
Other Devices to Deliver Compression
Intermittent Pneumatic Compression (IPC), Sequential Contraction Compression
devices (SCCD) and the Gecko
R
are among devices designed to improve venous
flow/reduce the effects of venous reflux (Richardson 2019). IPC was designed to
treat lymphoedema using a sausage-like bag that can envelop a limb. The SCCD
device sends, in sequence, pulses of low current to a set of four electrodes stuck on
the, for example, the calf of a leg. This causes calf contraction which improves
venous return and in a cohort of patient chronic VLU, reduces calf circumference.
The Gecko (Sky Medical, UK) is a fine innovation which selectively stimulates the
common peroneal nerve which in turn increases calf muscle pump contraction and
hence venous return. These devices are safe to use and attractive to clinicians
treating CVI (Richardson 2019). These devices work and offer means of managing
healed ulcers.
Elasticated compression improves venous flow, reduces oedema and calf circumference at least soon after bandages are applied: since most oedema appears to
be expelled in the first two hours this would reduce sub-bandage pressures.
Adjusting bandaging tension would seem appropriate and could be achieved using
modern bandages now commercially available. Short stretch bandages with maximum extensibility i.e. <100% of full length, are an elegant option especially for
independently mobile wearers. What other options exist? It is argued that the use of
combined therapy helps to treat lymphoedema: the success offered by the treatment
advocated by Narahari and Prasanna (2019) may have lessons for managing VLU.
Narahari argued in favour of treating complicated lymphoedema with compression,
massage (to improve lymph clearance) and yoga (to improve breathing). Narahari
observed that the limbs in this patient cohort have underlying layer of collagen
which may limit the effectiveness of compression: future research may inform us
whether this obtains in patients with in chronic venous disease which may be of
benefit.
Mixed Arterio-Venous Ulcers
Mixed AV ulcers are an entity of lower extremity chronic wounds where a frank
ulcer has underlying venous and arterial disease defined by ABI between >0.65 and
<0.85 descriptions of which are limited in the literature. Nag and colleagues
reported a prevalence of 11% AV ulcers after a cross sectional study of lower
14 B. E. Günther and R. Mani
extremity wounds (N = 100 patients) in a tertiary referral center in India (Nag et al.
2020). The latter reported a prevalence for VLU 34%, ILU 14%, with leprosy 10%,
diabetes 9%, primary infection 8% and traumatic 6%. The high prevalence for ILU
and mixed AV ulcers were attributed to the level of diabetes in this cohort where
open wounds were found in a comparatively younger age i.e. under 60. This cohort
is younger than commonly seen in US, Europe, and Australia. Nag also observed
the presence of perforating veins in the cohort with VLU which is broadly in accord
with previous observations.
Mosti proposed that the presence of diabetes did not contradict the use of
compression in VLU or mixed AV ulcers from study in which he studied VLU and
mixed AV ulcers in patients with and without diabetes treated with appropriately
distinct levels of compression (Mosti et al. 2020). In this study N = 180 patients
with/without diabetes with VLU (N = 107) and with mixed AV ulcers (N = 73)
were recruited after diagnosis of venous incompetence using Duplex ultrasound.
VLU patients (ABI > 0.9) received compression <60 mm Hg: mix ed AV ulcers
(ABI >0.65–<0.85) received 40 mm Hg and ultrasound guided foam sclerotherapy
to treat superficial vein incompetence directed to the ulcer bed. Wound healing
times recorded were for VLU median 25 weeks (non-diabetic group) 28 weeks
(Diabetic group) difference non-significant (p = 0.09). N = 25 patients were lost to
analysis. In the mixed AV ulcer patients, median healing times noted were
27 weeks (non-Diabetic group) 29 weeks (Diabetic group) the difference being
statistically non-significant (p = 0.019). These findings hold promise while raising
the need for further studies.
No adverse effects of the use of compression were noted in any groups permitting the inference that diabetic patients may receive compression support for
mixed arteriovenous ulcer group <40 mm Hg. The method of selection adopted in
this study was not clear which is limits the level of the evidence even though the
results permit the inferences that there were no adverse events noted and diabetic
groups may receive light compression. Lessons learnt from this study were to
diagnose using Doppler ultrasound to measure ABI, use Duplex ultrasound to
measure reflux, and screen for diabetes. The reported work of Nag and Mosti
emphasized the importance of a good diagnosis to identify VLU and mixed AV
ulcers which could be venous leg ulcers in a cohort with PAD (ABI >0.6–<0.85).
Surgical Treatments of Venous Insufficiency in Conjunction
with Venous Ulcers
While compression therapy is the mainstay/primary treatment for venous leg ulcers,
some patients will also need surgical treatment to address the venous insufficiency.
General practitioners may not always be aware of this and may not refer a patient
with a venous ulcer under the assumption that compression therapy alone is always
sufficient. The challenge is identifying the patient groups where surgical treatment
should be considered. Poor prognostic factors like duration of the ulcer >3 months,
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