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14 Therapeutic Alternatives forVenous Ulcer
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podiatrists Carrizosa and Antonio from Mexico
[42] described that in some patients an operation to elongate the gastrocnemius medially
alleviated the pain of venous ulcers.
We designed a study to corroborate these
observations and to look for their causes and
other variables. For this study, we selected
patients with venous ulcers and a positive test
for short gastrocnemius, as previously described,
and a positive result on the Silfverskiold test
[43, 44]; the patients underwent Doppler ultrasound and measurements were made of the
diameters and venous blood velocity in the great
saphenous, popliteal, and femoral veins before
and after gastrocnemius ultrasound morphology
was determined. Short gastrocnemius syndrome
was conrmed in all the patients and they were
prepared for surgery, in which release of the
medial tendon of the gastrocnemius was performed under local anesthesia, and a short cut
was made in the popliteal fossa skin. This surgery releases the tendon of the gastrocnemius
muscle, elongating it and recovering adequate
function, with which we are able to get the calf
muscle pump to work normally again, improving gait biomechanics. With this procedure the
musculoskeletal defect was corrected and subsequently the muscular pump worked again in
better conditions [45]. We obtained the approval
of the Ethics Committee and the patients’
informed consent for the procedure. The initial
results are very encouraging; the venous ulcers
closed within 1–4 weeks after the procedure,
and gait improved considerably, as did the dorsiexion angles of the foot, making the test for
short gastrocnemius negative. The diameter of
the great saphenous vein decreased and the
diameter of the gastrocnemius veins also
decreased. The study has not yet been completed. Some aspects of the study that deserve
attention are that the patients need to re- learn to
walk; we have seen that they are afraid to walk
“normally” and they lean forward to move the
foot. The gastrocnemius veins are usually tortuous or enlarged, and determination of this aspect
could be a way of diagnosing pump failure;
however, more details about the normal and
pathologic features of gastrocnemius veins will
be required [46]. The elongation of the internal
tendon gives the gastrocnemius muscle better
capacity to contract and consequently better
capacity to pump the venous blood, and the
venous hypertension is rapidly decreased simply by walking. In the light of this study, we can
ask ourselves some questions about venous
ulcers: Is venous hypertension and valvular
damage secondary to malfunction of the leg
muscles? And do all the venous problems have
their origin in alterations of the biomechanics
of walking? (Figs.14.1, 14.2, and 14.3).
Fig. 14.1 Before and after release of the medial gastrocnemius tendon in a patient with venous ulcer
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Fig. 14.2 Left, abnormal gastrocnemius vein in Venous Chronic Insufciency (VCI); right contralateral gastrocnemius
vein is normal (same patient)
F. VegaRasgado
Fig. 14.3 Left gastrocnemius vein postoperatively; right normal gastrocnemius vein in contralateral leg
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Conclusions
The treatments for venous ulcer are many and
varied; the main point in regard to treatment is
to obtain the correct diagnosis, as many ulcers
that are classied as venous do not meet the cri-
teria for this classication. In 354 leg ulcers,
Koerber found the prevalence of venous leg
ulcers to be 75.25%, of which 3.66% were arte-
rial leg ulcers, 14.66% were mixed ulcers
(venous and arterial), and 13.5% were vasculitic
ulcers [5]. There is a close relation of high rate
of arterial hypertension’s comorbidity (63.2%)
and leg ulcers and this with the prevalence of
ulcers with venous or mixed (arterial-venous)
etiology (about 80%). The cure rate varies from
41% for venous ulcers and decreases to 26% in
ulcers of mixed etiology [47]. For this reason,
drugs may be useful as general treatments in
ulcers of indeterminate etiology, but if only treat
ulcers from venous ethiology the treatment
needs to take into account other causes of
venous hypertension. With this in mind, the dis-
connection of reux points on the venous sys-
tem would be the most important treatment, but
as a venous ulcer is a delayed consequence of
chronic venous insufciency, compression also
plays an essential role in the treatment of dis-
ease, not only alone but as an adjunct with other
therapies. The three-layer system of bandaging
remains as the best method, while other thera-
pies such as drugs and exercise can be helpful.
The integral management of venous ulcers is
not a “magic procedure,” it is a logical matter
that requires common sense, a little science, and
a lot of patient care. To provide better treatment
for our patients, we also need to consider addi-
tional factors, such as gait biomechanics, mobil-
ity of the leg joints, muscle function, concomitant
diseases, and many other causes or complica-
tions of venous ulcers.
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Compression Therapy forVenous
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Ulcer
GiovanniMosti
15
15.1 Introduction
Leg ulcers have a venous pathophysiology in the
vast majority of cases [1–4]. Supercial or deep
venous insufciency and deep vein obstruction
produce ambulatory venous hypertension due to
venous reux and venous pumping function
impairment. The impaired venous hemodynamics
is the key pathophysiologic mechanism leading to
skin damage through several intermediate steps.
Fibrin cuff formation around the microvessels
leading to impaired gas (O2, CO2) exchange [5],
white cell entrapment [6] causing skin necrosis,
and growth factor inhibition [7] producing a stagnation of the healing process have been considered involved in ulcer onset and maintenance.
The treatment of venous leg ulcers (VLU)
must be based on the correction of the
hemodynamic impairment which can be achieved
conservatively by means of compression therapy,
walking, and leg elevation or by means of invasive procedures (open surgery, endovascular
procedures as endovenous laser ablation, radiofrequency, foam sclerotherapy, conservative
hemodynamic treatment).
G. Mosti
Angiology Department, MD Barbantini Clinic,
Lucca, Italy
Compression therapy is frequently considered
the rst treatment option, and it is the only therapeutical procedure which achieved the grade 1A
in most recent guidelines [8, 9]. The crucial point
is choosing the most effective compression
modality, which is still a matter of debate.
On one side there are clear evidences that
inelastic is more effective than elastic material
in counteracting the venous hemodynamic
impairment [10–14]. This should “ensure” a
superior effectiveness in promoting a higher
healing rate of VLU, which are due to venous
hemodynamic impairment. In addition we have
some evidences that the higher the compression
pressure, the higher the healing rate [9, 15, 16],
and this is clearly in favor of inelastic bandages
which exert a much higher pressure than elastic
materials.
On the other side, we have many papers claiming a greater effectiveness of elastic stockings or
elastic bandages compared with inelastic material [17–30].
Nevertheless studies comparing elastic and
inelastic devices have so many aws that their
conclusions are hard to trust [31].
In this chapter we will try to provide updated
information about compression therapy effects
on venous hemodynamic and the most effective
compression modality to achieve the best outcome in VLU treatment.
© Springer Nature Singapore Pte Ltd. 2018
A. K. Khanna, R. Jindal (eds.), Venous Disorders, https://doi.org/10.1007/978-981-13-1108-6_15
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G. Mosti
15.2 Impaired Venous
Hemodynamics
The venous pressure in the legs depends on body
position: it is very low in supine position, it
increases in the sitting position, and it is maximal
in standing position. Actually in the sitting and
standing position, the hydrostatic venous pressure results from the unbroken column of uid
that extends from the right heart to the foot which
can be easily measured by calculating the distance from the right heart and the ankle in these
different positions.
In the standing position, the venous pressure is
about 70–80 mmHg both in normal individuals
and in patients with venous disease. In the normal
subjects, this pressure decreases signicantly
during active movements (e.g., walking) down to
20–30 mmHg due to venous pumping function
and valvular function that fragment the blood
column and reduce the hydrostatic venous pressure [32]. In patients with venous insufciency,
valves’ failure causes the column of standing
blood in the vein to remain unbroken even during
ambulation, and a minimal hydrostatic pressure
decrease occurs. In some clinical situations (e.g.,
venous obstruction), the hydrostatic pressure can
even increase during and immediately after
ambulation: this is what we call ambulatory
venous hypertension (AVH) which causes venous
congestion.
15.3 Eectiveness
ofCompression Therapy
inCounteracting
Ambulatory Venous
Hypertension (AVH)
Compression therapy increases the transmural
pressure increasing the extravenous pressure so
narrowing or occluding the leg veins. This is the
prerequisite for the hemodynamic effectiveness
of compression therapy, but venous narrowing/
occlusion can be possible only by applying an
external pressure of the same magnitude or higher
than intravenous pressure. Actually, it has been
shown that due to different venous pressures in
different body positions, a low external pressure
in the range of 20 mmHg is able to narrow or
occlude the veins in the supine position, but the
compression pressure must rise to 50mmHg in
the sitting position and to close to 70–80mmHg
in the standing position [33] to exert the same
effect. These data were conrmed by studies with
magnetic resonance imaging (MRI) showing that
in the standing position, a pressure of 40mmHg
is not able to occlude the veins that are completely occluded with a pressure of 80 mmHg
[34] which was dened as very strong in a recent
consensus paper [35].
Such high external pressure approaching or
overcoming the intravenous pressure may produce
a vein occlusion at every step during physical
activity, so restoring a kind of valve mechanism. In
this way compression reduces the AVH [14] by
reducing the venous reux [10, 11] and increasing
the calf pumping function [12, 13].
15.4 Which Compression Material
Is Able toCounteract AVH
All compression devices are basically made up
with elastic or inelastic material. When wrapped
on the leg, they exert a compression pressure
which, according to the Laplace law, depends on
the stretch applied to the bandage, the number of
turns, and the radius of the leg segment [36].
The two materials have completely different
physical characteristics.
The elastic or long-stretch material (represented by elastic stockings or elastic bandages
with an extensibility higher than 100%) gives
way to the muscle expansion, which occurs during standing and physical activity, resulting in a
very low pressure difference between the resting
and standing or walking conditions. The static
stiffness index (SSI) which is the difference
between the standing and the supine pressure is
lower than 10mmHg that characterizes the elastic range [37, 38]. Also the difference between
diastolic and systolic pressure during muscular
activity, responsible of these called “massaging
effect” [39] of compression devices over the calf
muscle, is very low. These characteristics are
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consistently maintained independently on applied
pressure and material (if elastic stockings or elastic bandages). In conclusion elastic material
exerts a quite sustained pressure. In addition it
tends to regain its initial length when stretched,
and this “return force” is directly related to the
stretch applied to the bandage. The “squeezing
effect” of a too stretched elastic material can be
painful and not tolerated by the patients after a
short time from application. As a consequence,
when properly stretched, an elastic bandage will
exert a supine pressure of 30–40 mmHg. This
pressure will rise by 4–8 mmHg in a standing
position and will never approach the intravenous
pressure resulting unable to narrow or occlude
the veins and to exert a hemodynamic effect
(Figs.15.1, 15.2, and 15.3). When we want to use
elastic material to exert a very strong pressure in
standing position, necessary to occlude the leg
veins, elastic bandages must be applied with
strong stretch, or several elastic stockings must
be superimposed: in both these circumstances,
the “squeezing effect” of these materials will be
painful and poorly tolerated, as reported
(Fig.15.4).
An advantage of elastic materials is that they
are easy to apply, usually as a single component.
The inelastic material (short stretch or inextensible bandages, Velcro devices, hybrid pumps)
exerts its effect by resisting the increase of muscle volume during muscular contraction in standing position and during physical activity (the leg
will give way) so producing higher peak pressures when standing or walking compared with
elastic, long-stretch devices. Inelastic material
doesn’t have any elastic ber and doesn’t have
any return force: it doesn’t “squeeze” and can be
applied with full stretch.
The modern composite, multilayer and multicomponent, inelastic bandages, including a
padding layer with the inelastic material as a
last component, exert a relatively low and
Fig. 15.1 Compression pressure tracings of an elastic
stocking of the second class according to the RAL regulatory (mm 23–32 mmHg). Compression pressure increase
by dorsiexions, standing up, and walking is very small:
sustained pressure. DSI (dynamic stiffness index) is the dif-
ference between diastolic and systolic pressure performing
foot dorsiexions in supine position; SSI (static stiffness
index) is difference between standing and supine position.
WPA (walking pressure amplitude) is the difference
between systolic and diastolic pressure while walking
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G. Mosti
Fig. 15.2 Compression pressure tracings of an elastic kit
made up of two superimposed elastic stockings exerting
about 40mmHg in supine position. Compression pressure
increase by dorsiexions, standing up, and walking is very
small: sustained pressure despite of the resting pressure
increase
Fig. 15.3 Compression pressure tracings of an elastic bandage exerting about 40 mmHg in supine position. The
dynamic characteristic is the same as with elastic stockings or kits
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Fig. 15.4 Pressure curve of an elastic bandage applied
with high stretch to exert a very strong standing pressure.
It can be noticed that also the supine pressure must be
well- tolerated pressure at rest but a much higher
pressure often higher than 70 mmHg during
standing. The SSI is always >10 that characterizes the inelastic range. The intermittently
strong or very strong pressure peaks during
muscular exercise will overcome the intravenous pressure intermittently occluding the vein
and so restoring a kind of valvular mechanism
[14] (Figs.15.5 and 15.6).
In a few words, the inelastic material is able
to adapt to the body position by exerting a relatively low pressure in the resting position (comfortable) and a strong or very strong pressure in
the standing position and during muscle activity
(effective) coming close to an ideal compression
device [40].
Unfortunately the multilayer, multicomponent
inelastic bandages are difcult to apply and
require expert and well-educated personnel. In a
series of papers, it was demonstrated that only
from 10 to 60% (depending on the paper) of
health personnel treating venous ulcers were able
to apply the target pressure with different inelastic bandages [41–45].
very strong as the pressure increase by standing is very
small with elastic material. This strong and sustained
pressure can be painful
15.5 Hemodynamic Eects
ofCompression Materials
The different physical properties of elastic and
inelastic materials result in completely different
effects on venous hemodynamics.
Inelastic is signicantly more effective than
elastic material in:
• Reducing venous reux both in patient with
deep venous [10] and supercial venous
incompetence [11]
• Improving the venous pumping function
severely reduced in venous insufciency
[12, 13]
• Reducing AVH [14]
Inelastic material is able to reduce venous
reux and increase venous pumping function
even at a low/mild pressure range of 20–40mmHg
[46] which has an important implication when
inelastic compression necessary to improve
venous hemodynamics must be applied with
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G. Mosti
Fig. 15.5 Pressure curve of an inelastic bandage exerting
a supine pressure of 60 mmHg. Compression pressure
increase by dorsiexions, standing up, and walking is very
high: intermittent compression with high pressure peaks
that overcome the intravenous pressure (represented by
the red line) restoring a kind of valvular function
Fig. 15.6 Pressure curve exerted by a Velcro device
designed for ulcer treatment. Also with this device, compression pressure increase by dorsiexions, standing up,
and walking is high overcoming the intravenous pressure
and restoring a kind of valvular function
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