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380 Compression therapy for venous ulceration
(a)
(b)
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(c)
Figure 31.1 Stages of venous ulcer healing with compres-
sion therapy:
(a) 1 month, (b) 2 months, (c) 3 months.
Figure 31.3 (a) Video microscopic image of a distorted,
torturous medial malleolar microvessel in a patient with
chronic venous disease. (b) Florescent video microscopy
demonstrating disruption of perimalleolar subcutaneous
lymphatics in a patient with venous disease.
Figure 31.2 (a) Lipodermatosclerosis. (b) Large venous ulcer in the medial malleolar region.
31.2 Mechanism 381
Transmitted venous hypertension
Ulceration
Altered lymphatics
Epidermis
Dermis
Subcutaneous
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Tissue hypoxia/
malnutrition
Fibrin deposition
and edema
Dilated capillaries
Arteriole
Venule
Figure 31.4 Abnormalities of capillary permeability are postulated to lead to leakage of plasma proteins, cytokines, and
white cells into the extravascular space. Perivascular fibrin cuff formation may contribute to poor wound healing by inhibiting the diffusion of nutrients and oxygen to the cells.
applied to an enclosed system of an incompressible uid is
evenly distributed.4 e rigidity of a compression dressing
promotes uid movement into the venous and lymphatic
systems due to the pressure gradient created between the
interstitial space and the intravascular space. e optimal
pressure required to achieve a therapeutic hemodynamic
eect is a matter of debate; however, the greater the pressure increase in the leg, the greater the force that pushes the
uid back towards the heart. Gravity governs intravenous
pressure, which changes depending on the body position,
and this must be counteracted. Physiologically, the pressure in a leg vein reects the weight of the blood column
between the site of measurement and the right atrium.5 In
the supine position, the venous pressure will be between 10
and 20 mmHg. Using a sphygmomanometer cu containing an ultrasound-permeable window (Echo Cu, VNUS
Medical Technologies, Sunnyvale, CA), it can be demonstrated that in this position, lower leg veins will be narrowed by an external pressure of 10–20 mmHg and totally
occluded by a pressure of 20–25 mmHg.6 Venous narrowing by such low external pressures may explain the eect
of thromboprophylactic stockings used in a recumbent
patient. ese stockings exert a pressure of between 15 and
20 mmHg and enhance venous blood ow velocity when the
patient is supine. During standing, the intravenous pressure
in the lower leg vein rises to around 60 mmHg, depending
on the individual’s height. An external pressure of around
35–40 mmHg has been shown to narrow the veins, but a
pressure of more than 60 mmHg is necessary to occlude the
veins totally.
6
From these experiments, it may be concluded that major
hemodynamic eects of compression in an upright subject
may only be expec ted when the interface pressure of the compression device is higher than 35–40 mmHg. A safe upper
limit of 60 mmHg for externally applied, sustained compression was proposed based on several microcirculatory
investigations.7 Intermittent pressure peaks ca n considerably
exceed this upper limit.
8
Compression improves venous pump function in
patients with CVI (CEAP classes C3–C6), depending on
the interface pressure.9 Inelastic bandages that do not give
way to changes of the leg circumference produce a more
pronounced reduction of venous reux as measured by air
plethysmography compared to elastic material applied with
the same resting pressure.10 Inelastic bandages applied with
a resting pressure of over 50 mmHg have been shown to
demonstrate signicant reductions in ambulatory venous
pressure (Figure 31.5) as measured in patients with severe
CVI walking on a treadmill.
11
is eect may be explained by an intermittent occlusion of the leg veins exerted by the pressure peaks of
80 mmHg produced by an inelastic bandage during walking. Such eects cannot be achieved with elastic stockings
that increase the interface pressure during walking to values
only 3–8 mmHg higher than the resting pressure.
12
A study regarding compression therapy use in ulcers
secondary to both venous insuciency as well as arterial
insuciency (Ankle Brachial Index [ABI] > 0.5, absolute
ankle pressure >60 mmHg) showed that inelastic compression of up to 40 mmHg increases the venous pumping
function to near normal without impedance of arterial perfusion. Investigations in this work included laser Doppler
ux close to the ulcer and at the great toe, transcutaneous
oxygen pressure on the dorsum of the foot, and toe pressures to assess arterial perfusion. e ejection fraction of
the venous pump system was obtained to assess ecacy
of compression on venous hemodynamics. Compression
of 31–40 mmHg on the venous pump increased the ejection fraction from 33.9% to 62.6%. e arterial perfusion
was not impeded and may have improved slightly given
the raised arteriovenous gradient with increased venous
13
return.
382 Compression therapy for venous ulceration
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resolution of edema by the movement of uid from the
interstitial space into the lymphatic circulation (Figure31.6)
and counteracting leakage of uid out of the capillary. e
observations correlate with the fact that elastic and nonelastic bandages reduce lower extremity edema in patients
with CVI and venous ulceration. With edema reduction,
the cutaneous and subcutaneous metabolism may improve
because of enhanced diusion of oxygen and other nutrients to the cellular elements of the skin and subcutaneous
tissues, thereby promoting ulcer healing.
A number of biochemical abnormalities have now been
implicated in the etiology and chronicity of venous ulceration. e eects of compression therapy on these alterations in biochemistry remain largely unknown. VEGF and
tumor necrosis factor-α appear to participate in the tissue
damage associated with chronic venous disease. Serum
levels of both of these cytokines diminish in patients with
venous ulcers treated with 4 weeks of compression therapy
with four-layered bandaging. Reductions have correlated
with ulcer healing as reected by reduced ulcer size.
16
Figure 31.5 Ambulatory venous pressures can be
measured with cannulation of a dorsal foot vein and a
standard pressure transducer as deep venous pressures
are transmitted directly to the dorsal veins of the foot.
ere are many possible local cutaneous mechanisms
explai ning the benet of compression therapy. Improvements
in skin and subcutaneous tissue microcirculatory hemodynamics are postulated. A direct and favorable eect on
subcutaneous pressures was also described.
14,1 5
Supine
perimalleolar subcutaneous pressure increases with elastic
compression. is should create a Starling gradient favoring
31.3 PATIENT EVALUATION
Compression, like many other medical interventions, works
best when patients understand their condition and the goals
of therapy. Prior to the initiation of compression therapy for
venous ulceration, patients must be educated about their
chronic disease and the need to comply with their treatment
plan in order to heal ulcers and prevent recurrence.
ere are several possible causes of chronic leg ulcers.
Onlyabout 70% of leg ulcers have a venous origin. A denitive diagnosis of ulceration secondary to venous insuciency must be made prior to undergoing treatment with
Figure 31.6 Needle with transducer used to study subcutaneous pressures exerted by external compression devices such
as elastic stockings.
Straight
clamp
Needle
C-ARM
Transducer
Micrometer
Figure 31.7 Duplex scanning to detect venous reflux in
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response to cuff deflation with the patient upright and
non-weight bearing is the standard in most vascular laboratories for the detection of venous reflux of the lower
extremity axial deep and superficial veins.
compression therapy. A detailed history should be obtained,
including medications and other medical issues that may promote lower extremity edema and ulceration. Before the start
of compressive therapy, venous insuciency and/or venous
obstruction should be documented in the noninvasive vascular laboratory (Figure 31.7) or, in selected cases, by venography.
Possible arterial insuciency should also be assessed by
physical examination or noninvasive studies prior to therapybeginning. Coexisting arterial insuciency, especially
if severe, is a recognized risk factor for the non-healing of
venous ulceration.17 Compression therapy can be counterproductive in the presence of arterial insuciency, given
that the already diminished skin perfusion pressure can be
further decreased, resulting in an overall pro-ulcerogenic
eect, as well as an increased risk of critical limb ischemia.18
Compression therapy must be used with extreme caution
in patients with arterial insuciency and is essentially
contraindicated in patients with an ankle brachial systolic
blood pressure ratio of <0.5.
Finally, systemic conditions that aect wound healing
and leg edema, such as diabetes mellitus, immunosuppression, and malnutrition, should be sought and improved as
much as possible before or during the course of compression
therapy. Strong compression applied to both lower extremities may shi a considerable amount of blood volume
towards the heart, and is therefore potentially contraindicated in patients with severe cardiac dysfunction.
31.4 FORMS OF COMPRESSION THERAPY
31.4.1 Elastic stockings
Compression therapy is most commonly delivered with
gradient elastic compression stockings. Gradient elastic
31.4 Forms of compression therapy 383
compression stockings, initially developed by Conrad Jobst
in the 1950s, were made to simulate the gradient hydrostatic
forces exerted by water in a swimming pool. Elastic
compression stock ings are available in v arious compositions,
strengths, and lengths, and can be customized for a particular patient.
e benets of elastic compression stocking therapy
for the treatment of CVI and healing of venous ulceration
have been well documented. In a retrospective review of
113 venous ulcer patients, the use of below-knee, 30–40mmHg elastic compression stockings, aer rst resolving
edema and cellulitis if present, resulted in 93% ulcer healing. Complete ulcer healing occurred in 99 of 102 (97%)
patients who were compliant with stocking use versus six of
11 patients (55%) who were non-compliant (P < 0.0001). e
mean time to ulcer healing was 5 months. Ulcer recurrence
was less frequent in patients who were compliant with their
compression therapy. By life table analysis, the rate of ulcer
recurrence was 29% at 5 years for compliant and 100% at
19
3 years for non-compliant patients.
In this cross-sectional
study of venous ulcer patients, mean age was 59years and
27% of ulcers were recurrent. Compliance with the use
of stockings as instructed was very good. Not all centers,
however, have had such favorable results with elastic compression stockings. Older, less compliant patients and
populations with a higher percentage of recurrent or longstanding ulcers will likely not do as well.
Data on 3144 new chronic venous disease patients treated
from 1998 to 2006 were reviewed to further characterize
compliance with compression stockings. A total of 37%
of patients reported either full or partial compliance; 63%
did not use the stockings or abandoned them aer a trial
period. A total of 30% of non-compliant participants could
not specify a reason for non-compliance; 25% did not have
a prescription; 14% did not feel that the stockings helped;
13% reported the eect of binding/“cutting o” circulation;
8% felt that the stockings were too hot to wear; 2% reported
limb soreness; 2% reported poor cosmetic appearance; 2%
stated that they were unable to apply the stockings; 2%
reported itching or contact dermatitis; and 2% were noncompliant due to cost.
20
In addition to promoting ulcer healing, elastic compression therapy can also improve quality of life in patients
with CVI. In a recent prospective study, 112 patients with
CVI documented by duplex ultrasound were administered
a questionnaire to quantify swelling, pain, skin discoloration, cosmesis, activity tolerance, depression, and sleep
alterations. Patients were treated with 30–40-mmHg elastic
compression stockings. Overall improvement in symptoms
severity scores was observed at 1 month aer initiation of
treatment. Further ameliorations were noted at 16 months.
21
Elastic stockings as a treatment for venous ulceration
have the advantage over bandages that their eects are operator independent. Once applied, their eects are related to
the strength of the stocking and independent of the patient.
Stockings are less bulky than other forms of compression
therapy and therefore perhaps more comfortable. ey can
384 Compression therapy for venous ulceration
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be worn with normal footwear and allow daily inspection of
wounds. However, the stockings must be used to be eective and they are easily removed or “forgotten” by the noncompliant patient.
Patient compliance with compression therapy is crucial
in treating venous leg ulcers. It begins with patient education, being reinforced at every visit to the oce and the
clinic. Many patients are initially intolerant of compression
in areas of hypersensitivity adjacent to an active ulcer or
at sites of previously healed ulcers. is can sometimes be
overcome by initially tting the patient with lower-strength
stockings followed by higher-strength stockings over a
period of several weeks. An obvious disadvantage is the
added expense of the “introductory” stocking.
Patients may also have diculty applying elastic stockings. Elderly, weak, or arthritic patients cannot easily apply
elastic stockings. In one study of elderly (mean age: 72 years)
and predominately female patients (69%), 15% of patients
were incapable of applying stockings and 26% could only
put them on with signicant diculty.22 Obese patients
frequently cannot reach their feet and are dependent on
family members for application of the stocking. Anumber
of aids have been developed to assist in the application of
elastic stockings. With open-toe stockings, an inner silk
sleeve can be placed over the patient’s forefoot to allow
the stocking to slide smoothly during application. e
sleeve is removed through the toe opening aer the stocking has been placed. Another device allows the patient to
load thestocking onto a wire frame. e patient then steps
into the stocking and pulls the device upward, applying the
stocking to the leg (Figure 31.8).
Recurrence of ulceration aer healing can be lessened
by the use of elastic stockings aer the ulcer has healed.
19,22
However, in this case, an additional problem can be the
unwillingness of insurers to provide coverage for elastic
stockings, in spite of evidence of the cost-eectiveness of
elastic stockings in preventing ulcer recurrence.
23
Another indication of compression stockings is the prevention of post-thrombotic syndrome (PTS) observed in
25%–50% of patients following deep venous thrombosis
(DVT). e clinical features are the same as those for CVI,
and include a spectrum of symptoms and signs ranging
from mild lower extremity swelling and discomfort to severe
pain, to irreversible skin changes, and eventually ulceration.
Interestingly, the SOX trial, a recent randomized, placebo-controlled trial, questioned the use of compression
stockings for the prevention of PTS in patients with a rsttime proximal DVT.24 e study was conducted from 2004 to
2010 and followed for 2 years 410 patients who were blinded
and randomly assigned to either compression stockings with
a pressure of 30–40 mmHg or placebo stockings with less
than 5 mmHg of pressure. e cumulative incidence of PTS
was 14.2% in patients with the active compression stockings
versus 12.7% in the placebo arm, indicating no advantage
of compression stockings for preventing PTS. is trial
was in opposition to two previous trials that did show substantial benet of compression in this indication; however,
those trials were open label, single center, and smaller.
25,26
erefore, while the utility of compression stockings for the
prevention of PTS remains unclear, once PTS has developed,
compression therapy remains a staple of treatment.
31.4.2 Paste boots
Figure 31.8 The so-called Butler device can be used to
aid in donning compression stockings. The patient loads
the stocking onto the wire frame and then steps into the
stocking and pulls the device upward, applying the stocking to the leg.
Another method of compression was invented by the
German dermatologist Paul Gerson Unna in 1896. Unna’s
boot has been used for many years to treat venous ulcers
and is available in many versions. Unna’s boot is basically a
form of compression bandages (see below). A typical Unna’s
boot-type dressing is a three- or four-layer dressing and
requires application by trained personnel. A rolled gauze
bandage impregnated with calamine, zinc oxide, glycerin, sorbitol, gelatin, and magnesium aluminum silicate
is rst applied with graded compression from the forefoot
to just below the knee. Additional layers consist of a continuous gauze dressing followed by an outer layer of elastic
wrap, also applied with graded compression. e bandage
becomes sti aer drying and the rigidity may aid in preventing edema formation. e resting pressure, measured
on the distal lower leg immediately aer application, may
be 50–60 mmHg in the supine position. Unna’s boot is
changed weekly or sooner if the patient experiences signicant drainage from the ulcer bed. Once applied, Unna’s
boot requires minimal patient involvement and provides
continuous compression and topical therapy. However, the
Unna’s boot has several disadvantages. It is uncomfortable
to wear for some patients because of its bulkiness. is may
aect patient compliance. In addition, the ulcer cannot be
31.4 Forms of compression therapy 385
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monitored and the technique is labor intensive, with the
degree of compression provided being operator dependent.
Patients may also occasionally develop contact dermatitis
to the components of Unna’s boot that may require discontinuation of therapy. In a 15-year review of 998 patients with
one or more venous ulcers treated with Unna’s dressings,
73% of ulcers healed in patients who returned for more than
one treatment. e median time to healing for individual
ulcers was 9 weeks.27 Unna’s dressing has been compared
with other forms of treatment. A randomized, prospective study comparing Unna’s boot to polyurethane foam
dressing in 36 patients with venous ulcers demonstrated
a superior healing rate over 12 months in patients treated
with Unna’s boot (94.7% vs. 41.2%).
28
31.4.3 Compressive bandages
e purported advantages of multilayered compressive
dressings include maintenance of compression for a longer period of time, more even distribution of compression,
and better absorption of wound exudates. e pressure
delivered by a compressive bandage depends upon the
radius of the limb to which it is applied, the number of layers applied, the elastic properties of the materials utilized
in the bandage, and the wrapping technique of the health
care personnel who apply the bandages. ere are a wide
variety of compression materials with dierent textures
available, resulting in bandages in which the elastic properties and applied pressure are quite variable. Pressure, layers,
components, and elastic properties (P-LA-C-E) are the
deciding features that have to be considered when compression bandages are applied.
on the elastic property of the material. “Strong” and “very
strong” bandages clearly produce higher interface pressure
values than those obtained by compression stockings.
31.4.5 Layers
Single-layer bandages will usually have an overlap of up to
50%. Multilayer bandages consist of several single layers.
31.4.6 Components
e components of a bandage are the dierent materials
used for one compression bandage application. Besides their
intended functions of padding, protection, or retention,
they exert varying eects on the interface pressure and on
the stiness of the nal bandage. Compression bandaging
systems consist of at least two dierent bandaging materials applied over each other for the whole length of the leg
(Figure 31.9).
31.4.7 Elastic properties
e usual dierentiation between elastic and inelastic
compression material is based on in vitro measurements
using dierent extensometer devices and assessing the relationship between the power exerted to distend the bandage
and the resulting stretch. Table 31.2 shows a classication
system for single-layer, single-component materials.
Several layers of elastic bandages will create a bandage
with increasingly inelastic properties. e same is true
29
31.4.4 Pressure
e pressure developed beneath a bandage is governed by
the tension in the fabric exerted by the bandager, the radius
of curvature of the limb, and the number of layers applied.
Several instruments are available to measure the interface pressure exerted by a compression device on an individual leg. In the supine position, pressure ranges in the
gaiter area can be classied according to proposals from
a recent consensus conference (Table 31.1).29 It must be
stressed that the interface pressures exerted during standing and walking will increase in a manner that depends
Table 31.1 Pressure ranges of compression bandages
measured in the supine position at the medial aspect of
the lower leg where the tendon changes into the
muscular part of the gastrocnemius muscle
Recommendation mmHg
Mild <20
Moderate 20–40
Strong 40–60
Very strong >60
Figure 31.9 Application of the initial layer of a multilayer
compressive wrap.
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Table 31.2 Inelastic and elastic bandage materials
Elastic
Inelastic
Extensibility
(%)
Examples Zinc paste Comprilan Ace bandage
Velcro-band
devices
rigid
0–10 10–100 >100
Rosidal K Surepress (CircAid)
Short
stretch Long stretch
when two stockings are used over each other or when several components of dierent materials are applied. is
is because of an increase in friction between the rough
surfaces of dierent layers opposing the expansion of the
elastic strain of the bers. Typical examples of bandages
with high friction are cohesive bandages that adhere to the
underlying layer and are adhesive to the skin bandages.
Elasticity of the materials used in a compressive bandage (or stocking) is determined by in vitro measurements
that quantify the power required to distend or stretch the
bandage and the resulting extension of the bandage: a socalled hysteresis curve.
29,30
In general, an attempt is made
to achieve a pressure of about 40 mmHg at the gaiter area.
“Strong” bandage material will need to be stretched less
than “weak” bandage material to achieve this goal.
Compressive bandages have varying degrees of stiness,
dened as the increase in pressure per centimeter increase
in leg circumference.30 A higher stiness indicates relative
inelasticity of the bandage. An inelastic bandage is dened
as having a pressure increase of >10 mmHg when moving
from a supine to standing position, whereas with an elastic bandage, the pressure increase is <10 mmHg. Relatively
high-stiness (inelastic) bandages include the Pütter bandage, which consists of two 5-m long short-stretch bandages
applied to the leg in opposite directions (e.g., Comprilan,
Rosidal K, and Pütter bandage). e inelastic kits are composed of padding, foam material, short-stretch bandages,
and a protecting hose layer (Rosidal sys bandage). e main
component of these bandages is cotton, which is permeable
to air, very well tolerated, and can be washed and reused
(Comprilan and Rosidal). Applying several elastic layers
over each other creates a bandage system with high stiness
(Four-layer bandage and Profore). e nal bandage, when
used according to the manufacturers’ instructions, will
exert an interface pressure of about 40 mmHg on the distal
lower leg in the resting position. e Coban2 layer kit consists of two layers with an adhesive surface. It is easy to apply
and creates a stable, non-bulky bandage with high stiness.
ere are two main disadvantages of inelastic bandages.
One is the loss of bandage pressure starting immediately
aer bandage application. e initial resting pressure will
decrease by about 25% within 1 hour of application, mainly
due to a decrease in the volume of the limb. e second
disadvantage is the fact that a good inelastic compression
bandage is not easy to apply. It requires skills that must
be learned with proper training. Bandages with inelastic
material should be applied with much higher initial tension
than elastic bandages because of the fast pressure drop. An
inadequate technique is the main reason for the poor clinical outcome described in several studies.
31
Examples of elastic bandages are Ace-bandage, Surepress,
and Perfekta. Proguide is a kit consisting of a padding layer
and a specially designed elastic bandage. Elongation of the
bandage material leads to only a small pressure increase.7
Such bandages may exert a relatively high resting pressure,
which will increase only minimally during walking (“low
working pressure”). e main advantage of these bandages
is that they are relatively easy to apply, whether by untrained
sta or by the patients themselves. e main disadvantage is
the high resting pressure and the uncomfortable feeling due
to the constricting force of the elastic bers. is high resting
pressure might be responsible for skin damage, particularly
in patients with arterial occlusive disease and overexposed
pressure sites, such as over the dorsal ankle tendon.
Several points should be considered when compressive
bandages are applied:
●
Elastic bandages are easier to handle than inelastic
bandages and may be applied by untrained sta or by
patients themselves.
●
Inelastic material should be applied with much higher
resting pressure, pressing the bandage roll towards
the leg as if molding clay. e patient is encouraged to
immediately walk for at least 30 minutes to decrease
edema and thereby decrease the pressure being exerted
under the bandage.
●
In patients with a small ankle circumference, bandages
should be applied with much less tension using ample
amounts of orthopedic wool padding to protect the
tendon.
●
e initial turn may start at the base of the toes or be
placed around the ankle or between the heel and the
dorsal tendon to x the bandage. e ankle joint is
always bandaged with maximal dorsal extension of the
foot and the protruding tendon is carefully protected
with cotton-wool.
●
Overlapping can be carried out in a spiral fashion or
with gures of eight.
●
e proximal end of a knee-high bandage should cover
the level of the bular head.
●
e bandage must be applied with no gaps so that each
turn overlaps the previous turn by about 50%.
●
Bandage materials must be non-allergenic to avoid the
development of dermatitis.
●
Pads can increase local pressure over ulcers or rm
lipodermatosclerotic areas.
●
Pain may indicate arterial ischemia. In such cases, the
bandage must be removed immediately.
●
Bandaging of the lower leg is sucient for the majority
of patients with chronic venous disorders.
●
Walking exercises are essential to optimize the eect of
compression therapy. However, compression is also able
to reduce edema in immobile patients or in those with
31.4 Forms of compression therapy 387
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severely restricted mobility. Inelastic xed bandages are
preferred for this indication because of the lower resting
pressure.
●
Aer some walking, the pressure will drop because of the
immediate removal of edema. In the edematous phase,
the bandage will loosen aer a few days, and it should be
renewed or over-wrapped with a short-stretch bandage.
e same is advisable when exudate from the ulcer penetrates the bandage. is may occur particularly during
the initial treatment phase, and the patient should be
informed to come back if this happens. Generally, the
bandage is changed every 7 days on average.
Stier, more inelastic bandages may have greater eects
on measurements of deep venous hemodynamics. A study
using air plethysmographic measurements of venous
volume and venous lling index in limbs with venous ulcers
treated with elastic long stretch versus inelastic shortstretch bandages found greater improvement in varicose
veins and the venous lling index with the short-stretch,
inelastic bandage.
10
A clinical study of a relatively sti bandaging system
(multilayer wrap of orthopedic wool, crepe bandages, and
Coban bandages) reported results in 148 ulcerated limbs
(126 patients) that were refractory to simple wraps. At 12
weeks, 74% of ulcers had healed and measurements of compression declined only 10% over 1 week.
32
A direct comparison between an elastic and inelastic
bandaging regimen has been performed. e authors randomized 112 venous ulcer patients to an elastic or inelastic
bandaging group (n = 57 and n = 55, respectively). Larger
ulcers took longer to heal with the elastic compression,
but complete healing at 26 weeks was no dierent: 58% for
the elastic bandage arm versus 62% in the inelastic system
arm.33 Another study comparing multilayer bandaging versus relatively inelastic short-stretch bandaging for
venous leg ulcers showed that ulcers treated with multilayer
bandaging healed more quickly.
34
Authors from Serbia reported dramatic results in healing very large venous ulcers with a heelless, open-toe,
elastic, multilayered compression device knitted into a
tubular conguration. A total of 138 patients with very
large venous ulcers (20–210 cm
2
) were randomized to treat-
ment with the multilayered tubular device (n = 72) versus
bandaging plus compression stockings (n = 66). Cumulative
healing was 93% in the group treated with the multilayered
tubular dressing and 51% in the other group.
35
Clearly, multilayer compressive bandages can be eective
for healing of venous ulcers. Stier, short-stretch bandages
may have greater eects on deep venous hemodynamics
and perhaps demonstrate faster healing than more elastic
bandages. Whether this provides overall increased clinical ecacy remains to be determined. Direct comparisons
between dierent multilayer bandaging systems and between
those systems and other methods of compression are needed.
e Venous Ulcer Study IV (VenUS IV) looked at the
clinical eectiveness and cost-eectiveness of compression
two-layer hosiery versus four-layer compression bandages.
is was a randomized controlled trial involving 453 participants from 34 centers in England and Northern Ireland.
Study participants were stratied by ulcer duration and
area, and then randomized to either hosiery or bandage
compression therapy. e primary endpoint was time to
ulcer healing, with a maximum follow-up of 12 months.
Median time to healing was 99 days (95% CI: 84–126) in
the hosiery group and 98 days (95% CI: 85–112) in the
bandage group, indicating that both treatment options
have essentially equivocal healing rates. e economic
analysis, however, revealed a signicant advantage to the
hosiery group.
36
31.4.8 Legging orthosis
CircAid is a legging orthosis consisting of multiple pliable, rigid, adjustable compression bands.29 ese bands
wrap around the leg from the ankle to the knee and are
held in place with Velcro (Figure 30.10). e device pro-
vides inelastic, rigid compression similar to an Unna boot
with increased ease of application. Because the bands are
adjustable, it can be tailored to the individual as limb edema
decreases. e orthosis appears eective at promoting resolution of edema and is especially useful in patients who, for
various reasons, are either unable or unwilling to wear compression stockings. is legging orthosis may be superior
to elastic stockings at preventing limb swelling in patients
with advanced venous insuciency.
Figure 31.10 Example of a CircAid compressive bandage.
Compression can be varied according to how tightly the
Velcro straps are pulled.
37
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31.4.9 Pneumatic compression devices
Pneumatic compression devices can serve as adjuncts in
the treatment of lower extremity lymphedema or venous
ulceration. ese devices may be particularly applicable to
patients who have severe edema or morbid obesity. Relative
contraindications are arterial insuciency and uncontrolled congestive heart failure.
Pneumatic compression devices that provide sequential
gradient intermittent pneumatic compression have received
the most attention. Results suggest improvement in ulcer
healing, but this might be facilitated by the fact that pump
patients elevate their legs for longer on a daily basis than
non-pump patients. e intermittent compression has not
gained widespread acceptance, despite the results of the few
studies in this area indicating that pneumatic compression
may be useful in the treatment of venous ulcers, especially
those refractory to previous treatment with ambulatory
compression alone.
38,39
31.5 STUDIES COMPARING SURGERY
VERSUS COMPRESSION
e current literature highlights the diculties of comparing
various forms of compression therapy for venous ulcer treatment with venous surgery. At least two major reviews have
concluded that insucient evidence exists to favor one form
of compression over another.
cient evidence to favor the use of adjunctive dressings, such
as hydrocolloid dressings (DuoDERM), in addition to compression therapy to heal venous ulcers.41 Comparisons are
hampered by a low number of randomized controlled studies,
dierent patient selection criteria, variable use of compression as an adjunct to surgical therapy, and potentially variable
compliance with post-operative compression therapy.
e ESCHAR study evaluated the hemodynamic eects
of added compression in patients with venous ulceration.
40,41
In addition, there is insuf-
Legs with open or recently healed venous ulcers were treated
with multilayer compression bandages or supercial venous
surgery plus compression (n = 112 legs vs. 102 legs, respectively). Venous relling time as measured by photoplethysmography was the primary hemodynamic outcome. e
ulcer healing rate was 64% at 24 weeks and nearly identical
in the two groups. Although there was no benet to surgery
regarding ulcer healing, the ulcer recurrence rate was halved
42,43
in those that underwent surgery.
e ESCHAR study
results can be applied to the use of endovenous techniques.
In a study from Italy, Zamboni et al.44 randomized 80
consecutive patients with 87 venous leg ulcers to treatment with compression or minimally invasive surgery.
Healing was remarkable in both groups: 100% at 31 days
in the surgical group compared with 96% at 63 days in the
compression group (P < 0.02). Follow-up was 3 years and
recurrence rates were 9% in the surgical group versus 38%
in the compression group (P < 0.05). Quality of life was also
better in the surgical group.
A British study randomized 76 patients with venous
ulcer to treatment with a four-layer bandaging system or
supercial venous surgery and a four-layer bandaging system. Healing occurred in 64% of the compression group
and 68% of the surgical group (P = 0.75), with no signicant
dierence in the time to ulcer healing and no dierences in
health-related quality of life.
45
Why do these studies give such disparate results? e trials were similar in design, the patients nearly the same age,
and the mean ulcer sizes no dierent, and yet the Italians
stated that supercial venous surgery works as an adjunct
to the treatment of venous ulcers, whereas the English
concluded that supercial surgery added nothing to compression therapy. Details of the two studies may explain
the dierent results. e Italians excluded ulcers >12 cm
and patients with secondary reux or deep venous reux.
e English patients had a mean of two previous episodes
of venous ulceration. e Italian study did not provide
Guidelines 4.3.0 of the American Venous Forum on compression therapy for venous ulceration
No. Guideline
4.3.1 We recommend compression therapy to heal venous ulcers. 1 A
4.3.2 We suggest compression therapy to decrease the risk of ulcer
recurrence.
4.3.3 We suggest the use of multicomponent compression bandage
over single-component bandages for the treatment of
venous leg ulcers.
4.3.4 We suggest enforcing compliance since it is integral to the
success of compression therapy.
4.3.5 We suggest use of intermittent pneumatic compression when
other compression options are not available, cannot be used,
or have failed to aid in venous leg ulcer healing after
prolonged compression therapy.
Grade of
recommendation
(1: strong;
2:weak)
2 B
2 B
2 A
2 C
Grade of evidence
(A: high quality;
B:moderate quality;
C:low or very low quality)
information on previous episodes of venous ulceration. At
https://t.me/med1917
this time, one is le to conclude that supercial venous surgery may improve the results of compression therapy for
venous ulceration in certain, more favorable subgroups of
patients with venous ulcers.
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●
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