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3. Multi-layer Varistretch
w
elastic compression bandage; e.g., Proguide
w
4. Elastic compression hosiery
Application Methods
The methods used should be in conjunction with the manufacturers instructions for use and
alongside supervized practical instruction. All patients should receive careful explanation
of the procedure. If written information is given, this must be documented.
Multi-Layer Elastic Compression Bandages (9)
Measure the patient’s ankle circumference. Most kits are only suitable for ankles that are
18–25 centimeters in circumference. Narrower ankles will need more padding, and wider
ankles will need bandages with more power to provide enough compression.
The patient and nurse should be comfortably positioned so that the patient’s foot is at
right angles to the leg throughout, and the nurse can reach around the leg without having to
lift it or bend his/her back. The padding layer should be applied in a spiral. The first turn
starting at the base of the toes, the next turn cupping the heel, returning over the top of the
instep, down under the foot and then continuing up the leg to just below the knee. If the leg
is thin, then more padding may be required to protect any bony prominences. Extra
padding will also be required if the leg needs reshaping. The leg should then be twice as
wide under the knee as it is at the ankle (Fig. 1).
The next layer is a crepe bandage used to smooth out the padding layer. It is
applied in a similar fashion to the first layer. Cut off any excess and secure with tape
under the knee. The third layer is a light compression bandage. This is applied around
the foot in the same way as the first two layers, using only enough stretch to take up the
slack and make it fit snugly over the crepe layer. Overstretching at this point will be
very uncomfortable for the patient and can lead to tissue damage. Once the ankle is
covered, then the bandage should be stretched by 50% and applied in a figure-of-eight
technique with 50% overlap. Once the knee is reached, cut off the excess and secure
with tape.
The final layer is a cohesive compression bandage. It is applied over the foot as
before, just taking up the slack; then at the ankle stretching by 50% and continuing in
a spiral with 50% overlap. Cut off the excess. Make sure the patient can move the ankle
joint (Fig. 4).
Short Stretch Inelastic Bandages
These bandages cannot accommodate any change in the limb circumference. They work as
the pressure beneath the bandage increases as the calf muscle is activated. The bandage
reinforces the action of the calf muscle pump. Because they rely on this calf muscle action
and have low resting pressures, they are unsuitable for immobile patients or those who
have fixed ankles due to arthritis. A recent randomized trial has suggested that they are less
effective in ulcer healing than four-layer bandaging (10).
The method of application depends upon the size and shape of the limb. The width of
bandage is also dependent upon the circumference of the limb. An easy way to gauge this
is to choose a bandage with a similar width to the diameter of the widest part of the leg.
Padding should be used over any bony prominences and to fill any concave areas such as
behind the malleoli.
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Starting at the toes the bandage should be applied at full stretch with one anchoring
turn around the foot. The next turn should go around the heel, mostly above the heel. The
next goes over the instep and back around the heel, mostly below it. The bandage can
then be wound around the leg at full stretch to just below the knee. It must not be cut, as
it would fray. Instead it can be brought back down the leg and secured with tape. If a
second bandage is required to treat a large limb, it should be applied in the opposite
direction to the first. Pieces of tape around the toes and heel can prevent the bandage
rolling or slipping. As these bandages have no elastic they may not stay in place on
some patients.
If this happens then use the “knee lock” method. The bandage is applied on the foot
as before. It is then taken at a steep angle up to the knee where an anchoring turn is made
around the knee. The bandage is then wound down the leg to be secured at the ankle
with tape.
Multi-Layer Varistretch
w
Bandages
These elastic bandages employ new technology, which reduces the margin for error in
applying the correct amount of compression. There are three sizes of kit so it is important
to measure the ankle and choose the correct one. The first layer is padding, which is
applied toe to knee. This is to protect bony prominences and absorb exudate. Extra
padding may be used to reshape the limb as with the other multi-layer bandages.
The other layer has a guide printed on it to enable the nurse to tell if the bandage has
been extended by the correct amount. The bandage should be applied around the foot as in
the other methods, without any extension. At the ankle the bandage should be stretched
until the oval guide printed on it becomes circular. Continue using this degree of stretch in
a spiral method at 50% overlap until the knee is reached. Cut off the excess and secure
with tape.
Although there is a printed guide, there is no need to worry too much about using an
exact amount of stretch, as the bandage itself has been developed to deliver 35–40 mmHg
compression at the ankle, even if it has not been stretched quite enough or a little
too much.
Figure 4 Standard four-layer compression: 1) cotton wool padding, 2) crepe, 3) light compression
bandage, and 4) cohesive bandage.
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All compression bandaging techniques will reduce edema in the limb if correctly
applied. It is important, therefore, to reassess the limb circumference in the initial stages of
treatment to ensure the patient has the correct bandage system. Once the edema is
controlled, the bandages should stay in place for up to one week.
Elastic Compression Hosiery
Compression hosiery can be used to prevent recurrence of venous leg ulcers once they
have healed. In some circumstances, such as patient preference and when there is only
a small ulcer, they can be used to provide a treatment for venous ulcer disease.
Treating ulcers and controlling venous edema requires a similar amount
of compression to an elastic compression bandage; i.e., up to 35 mmHg at the ankle. A
continental class 2 stocking will provide this, or a U.K. class 3 stocking (the classifications
are different). If the patient cannot tolerate this, then a lower compression class can be used
but will not be as effective. Below-knee stockings are adequate in most cases.
Correct measurement is important. This should be done with the patient barefoot and
standing on a flat surface. Measurements should be taken in three places: at the ankle just
above the level of the malleolus, around the widest part of the calf, and the length from the
top of the stocking under the knee to the ground. The correctly sized stocking can then be
fitted. Some patients find stockings very difficult to apply, particularly if they have arthritis
or cannot reach their feet. Application aids are available. Stockings should be replaced
every 3–6 months; and continued compression may prevent recurrence (11). It is advisable
to ensure that the patient has not developed any arterial disease in the interim before
supplying new stockings.
Choice of Compression Method
In light of the multitude of compression therapies available, several trials have been
conducted to study the efficacy of each method. Table 1 summarizes some of these trials.
Most authors therefore believe that four-layer compression therapy achieves the best
results. There are however other factors that might cause delayed or failed healing with
compression. These factors include an ulcer size greater than 10 cm and a duration of more
than 12 months (16,17).
Table 1 Trials of Types of Compression
Compression used
Study
Type (No. of
patients)
Four-
layer
Short-
stretch
Two-
layer Other Conclusion
Nelson
et al. (10)
Randomized
(387)
X X Healing is quicker with four-
layer compression
Franks
et al. (12)
Randomized
(156)
X X Healing speed similar
between both
Ukat
et al. (13)
Randomized
(89)
X X Healing is quicker with four-
layer compression
O’Brien
et al. (14)
Randomized
(200)
X X Four-layer is most effective
treatment
Moffat et al.
(15)
Randomized
(112)
X X Four-layer is better tolerated,
and less expensive
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KEY POINTS
† Most venous ulcers can be effectively treated using compression therapy.
† Patients with leg ulcers should have a full assessment by an experienced
practitioner.
† Arterial insufficiency should be excluded by clinical assessment and measure-
ment of the ankle: brachial pressure index (ABPI).
† The dressing should be simple, non-adherent and not padded or bulky.
† Compression bandages should be carefully applied to ensure graduated
compression from ankle upward.
† Compression hosiery can be used to prevent recurrence of venous leg ulcers once
they have healed.
REFERENCES
1. Royal College of Nursing Clinical Practice Guidelines. The Management of Patients with
Venous Leg Ulcers. RCN Institute, 1998.
2. Moneta GL, Nicoloff AD, Porter JM. Compression treatment of chronic venous ulceration:
a review. Phlebology 2000; 15:162–168.
3. Cullum N, Nelson EA, Fletcher AW, Sheldon TA. Compression for venous leg ulcers Cochrane
Database Syst Rev 2001; (2):CD000265. Update of: Cochrane Database Syst Rev 2000;
(3):CD000265.
4. Partsch H. Compression therapy in venous leg ulcers. How does it work. J Phlebol 2002;
2:129–136.
5. Marston W, Vowden KR. Compression therapy: a guide to safe practice. In: Understanding
Compression Therapy (EWMA position document). MEP, 2003.
6. Morrison M, Moffatt C. A Colour Guide to the Assessment and Management of Leg Ulcers.
2nd ed. London: Mosby, 1994.
7. Stubbings NJ, Bailey P, Poole M. Protocol for the accurate assessment of ABPI in patients with
leg ulcers. J Wound Care 1997; 6:417–418.
8. Scottish Intercollegiate Guideline Network. The Care of Patients with Chronic Leg Ulcers.
SIGN secretariat, 1998.
9. Ruckley CV, Dale JJ, Gibson B, Brown D, Lee AJ, Prescott RJ. Multi-layer compression:
comparison of four different four-layer bandage systems applied to the leg. Phlebology 2003;
18:123–129.
10. Nelson EA, Iglesias CP, et al. Randomized clinical trial of four-layer and short-stretch
compression bandages for venous leg ulcers (VenUS I). Br J Surg 2004; 91:1292–1299.
11. Nelson EA, Bell-Syer SE, Cullum NA. Compression for preventing recurrence of venous
ulcers. Cochrane Database Syst Rev 2000; (4):CD002303.
12. Franks PJ, Moody M, et al. Randomized trial of cohesive short-stretch versus four-layer
bandaging in the management of venous ulceration. Wound Repair Regen 2004; 12:157–162.
13. Ukat A, Konig M, et al. Short-stretch versus multilayer compression for venous leg ulcers:
a comparison of healing rates. J Wound Care 2003; 12:139–143.
14. O’Brien JF, Grace PA, et al. Randomized clinical trial and economic analysis of four-layer
compression bandaging for venous ulcers. Br J Surg 2003; 90:794–798.
15. Moffatt CJ, McCullagh L, et al. Randomized trial of four-layer and two-layer bandage systems
in the management of chronic venous ulceration. Wound Repair Regen 2003; 11:166–171.
16. Meaume S, Couilliet D, et al. Prognostic factors for venous ulcer healing in a non-selected
population of ambulatory patients. J Wound Care 2005; 14:31–34.
17. Margolis DJ, Allen-Taylor L, et al. The accuracy of venous leg ulcer prognostic models in
a wound care system. Wound Repair Regen 2004; 12:163–168.
Compression Therapy and Nursing Care for Venous Leg Ulcers 381
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29
Surgical Therapies for Chronic Venous
Disease: Superficial Venous Surgery
Frank C. T. Smith
Bristol Royal Infirmary, Bristol, U.K.
INTRODUCTION
The term chronic venous insufficiency embraces a variety of disorders of the lower limb
veins, ranging from simple varicose veins to skin changes and venous ulceration. The
broad condition is characterized by long-term failure of venous return due to reflux in the
superficial, perforating or deep veins, or to combinations of these, failure of the calf
muscle pump, or due to venous outflow obstruction. These conditions lead to ambulatory
or dependent venous hypertension and sequelae of pain, discomfort, swelling, varicose
eczema, lipodermatosclerosis or ulceration.
The condition is widespread and has enormous economic impact. Between 2–9% of
the adult population are affected (1). The prevalence of active ulceration in the United
Kingdom is approximately 1.9 per 1000 in adults over the age of 45 years, with an annual
incidence of 3.5 per 1000 in the same age group, a figure that increases with age (2). Open
venous ulcers occur in approximately 0.3% of the population and a history of open or
healed ulceration, exists in around 1% (3). In the United Kingdom, the cost of chronic
venous insufficiency to the National Health Service is estimated to be between £230–600
million per annum (4). In the United States 4.6 million workdays are lost each year due to
chronic venous disease. Up to 5% of affected patients may suffer job losses (5).
Appropriate surgical treatment for chronic venous disease should be directed at the
underlying causes of venous hypertension. This is dependent on accurate diagnosis of
predisposing factors. This chapter deals specifically with superficial venous surgery.
THE ROLE OF SUPERFICIAL INCOMPETENCE
IN CHRONIC VENOUS INSUFFICIENCY
The CEAP classification of venous disease outlines three aetiologies for chronic venous
insufficiency: congenital, primary and secondary (6,7).
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Although the stigmata of chronic venous insufficiency have traditionally been
associated with a post-phlebitic picture, it is now evident that these may also occur due to
isolated primary deep or superficial reflux, with or without perforator incompetence, or as
a result of multisystem incompetence involving at least two of these three systems.
Primary valvular incompetence accounts for approximately 70% of cases of advanced
chronic venous insufficiency and can be diagnosed in the absence of history of previous
deep venous thrombosis (DVT), and where duplex ultrasound or venography fails to
demonstrate signs suggestive of previous DVT (5).
Secondary incompetence usually affects the deep or perforating veins and most
frequently arises as a result of deep venous thrombosis. Incompetence rather than venous
obstruction is the more common cause of chronic venous insufficiency in the latter
group. Symptoms of persisting deep venous obstruction include leg swelling and
venous claudication.
Various studies have identified the extent of involvement of isolated and mixed
incompetence in patients with chronic venous insufficiency although published evidence
has been conflicting.
In a duplex study of patients with venous ulceration, Hanrahan et al. demonstrated
isolated superficial venous incompetence in only 17% of 91 limbs (8). Lees and Lambert,
also using duplex, found isolated superficial reflux in 57% of limbs. In patients with more
than one site of reflux, 77% had involvement of the superficial system, with the deep
system implicated in 39% of cases (9). Darke and Penfold employed ascending and
descending venography, detecting superficial reflux in 39% and deep reflux in 57% of 213
legs (10). In an overview of 12 studies involving 1084 limbs with chronic venous disease,
examined with a variety of techniques, Kalra and Gloviczki noted that isolated superficial
incompetence occurred in 10%, the superficial system was affected as part of multisystem
disease in a further 73% of cases and that isolated deep venous incompetence occurred in
only 11% of cases (5). The role of superficial venous incompetence in chronic venous
insufficiency, particularly in the absence of previous DVT, has therefore clearly
been established.
Key techniques used for pre-operative assessment of the extent and nature of reflux
include duplex Doppler imaging, venography, plethysmography and ambulatory venous
pressure measurements. These have been discussed in detail elsewhere in this book.
SURGERY FOR SUPERFICIAL VENOUS REFLUX
Aims of Surgical Treatment
The aims of superficial venous surgery are to alleviate the component of chronic venous
insufficiency which is due to superficial reflux and to promote ulcer healing, or to prevent
further skin changes or symptoms such as swelling and pain, by reducing venous
ambulatory hypertension. The ESCHAR study suggested that while surgery confers no
benefit over multilayer elastic compression, in terms of healing of venous ulcers, it does
lead to reduction of ulcer recurrence in patients with isolated superficial venous
reflux (11). Haemodynamic benefits from superficial surgery, in patients with coexisting
segmental deep venous reflux, have been clearly demonstrated in other studies (12,13).
These results are reflected by improvement in quality of life, as assessed by both disease-
specific and generic questionnaires (14–16).
In each case, surgery will be tailored to the individual patient on the basis offindings
from clinical examination and the results of non-invasive or invasive investigations.
In the case of superficial incompetence this may be achieved by attenuation of reflux
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in the long or short saphenous systems, and by removal of incompetent varicose veins,
(phlebectomies).
Various interventional techniques have been employed to ablate superficial venous
reflux. These include surgery, radio-frequency ablation, laser ablation of the saphenous
vein and ultrasound-guided foam sclerotherapy. Subfascial endoscopic perforator surgery
(SEPS) has been used to deal with incompetent perforators. This chapter deals with
superficial surgery alone and the other therapeutic modalities are addressed elsewhere in
this book.
Medico-Legal Aspects of Venous Surgery
Venous surgery is the most common source of medico-legal claims arising from vascular
surgery. In 424 vascular claims notified to the National Health Service Litigation
Authority and Medical Defence Union from 1990–1999, 244 arose from varicose vein
surgery (nerve damage 76; incorrect or unsatisfactory surgery 35; damage to femoral vein
16, or artery 13) (17). Prior to undertaking superficial venous surgery, the operating
surgeon must therefore explain the proposed procedure to the patient in detail, outlining
specific risks. These include haematoma formation, wound infection, recurrence and the
possibility that not all varicosities affecting the patient will be excised or ameliorated.
Flare veins may occasionally be exacerbated. Risks of injury to the saphenous nerve
during stripping of the long saphenous vein with resultant anesthesia, paraesthesia or
neuralgia should be explained. Where short sapheno-popliteal surgery is proposed, the
risks of associated sural or peroneal nerve injury should also be outlined. Discussion of
these risks should be documented. Best practice dictates that the patient should be
provided with a comprehensive information leaflet, but this alone will not provide a
defence against litigation.
Factors increasing thrombotic tendency, particularly the oral contraceptive pill and
hormone replacement therapy, should be considered with the patient. These medications
should either be stopped for an adequate period before elective surgery, or, if patient and
surgeon elect to continue with treatment, the deliberation and rationale for this course of
management and potential treatment with other anti-thrombotic measures should also be
carefully documented.
Day-Case or In-Patient Surgery?
The majority of patients undergoing long or short saphenous vein surgery can be treated as
day cases. Patient fitness is usually assessed by the clinician in the out-patient department.
Routine pre-operative evaluation can be undertaken by a nurse specialist. If day-case
surgery is carried out, then adequate time must be taken to explain the consequences of
surgery to the patient and to ensure that questions are answered. It is important to ensure
that adequate post-operative analgesia is prescribed and that the patient is fully conversant
with treatment protocols detailing dressing removal, use of compression hosiery, bathing,
exercise, driving and resumption of employment.
Factors militating against successful day-case surgery include long procedures
entailing prolonged anesthesia, obesity and co-morbidity. Age, fitness, and the availability
of a care-giver in the early post-operative period should also be considered. Some day-case
units will not undertake bilateral procedures or revision surgery and in these cases,
admission to a short-stay unit (!24 hr) may be a viable option. The patient’s wishes
should also be considered.
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Factors contributing to a successful outcome of day-case surgery include adequate
local anesthetic infiltration of wounds, judicious use of non steroidal anti-inflammatory
drugs and avoidance of opiates, which may help to reduce post-operative nausea (18).
Early telephone follow-up by a specialist nurse or medical practitioner, together with
printed contact details of who to contact in case of post-operative problems, may help to
allay any residual patient fears.
Skin Marking
The operating surgeons should carry out preoperative marking of varicosities to their
own satisfaction. Where revision surgery is being undertaken, when perforators play a
significant part in the pattern of incompetence, as an aid to marking the variable level of
the sapheno-popliteal junction, or where any doubt exists as to the source of incompetence,
pre-operative duplex scanning and mapping provides an invaluable aid to surgery. Each
surgeon adopts their own approach to marking of varicosities, but a common theme will be
to avoid placing markings where cuts or stab incisions might predispose to skin tattooing.
It is worth noting that alcohol-based skin preparations may prove a frustrating solvent for
many proprietary skin markers, resulting in the outline of carefully mapped varicosities
disappearing before the surgeon’s eyes! On completion of marking, the patient should
always be asked whether any varicosities of concern to them have been missed.
Anesthesia
The majority of superficial venous surgery performed in the United Kingdom is
undertaken under general anesthesia. This is not necessarily the case in other parts of the
world, for instance in areas of Europe, where regional and local anesthesia are sometimes
prevalent alternatives. The latter techniques may have particular merit when dealing with
high-risk, elderly or pregnant patients. A femoral nerve block can be used when stripping
the long saphenous vein, but prolonged effects may prevent early postoperative discharge
from the hospital. Many surgeons opt to infiltrate the path of the long saphenous vein with
a solution of dilute local anesthesia and adrenaline, which promotes vasoconstriction,
reducing bleeding and haematoma formation. Flush ligation and division of the sapheno-
femoral junction, with localised distal ligation/division of the long saphenous vein can
be performed under local anesthetic infiltration and may be a valuable adjunct to ulcer
healing, particularly in elderly or frail patients. When employing extensive infiltration
with local anesthetics, it is important that compliance with maximal dosage is adhered to,
in order to avoid potential problems with overdose toxicity.
Positioning
The patient is placed supine for long saphenous surgery, but ideally, is turned prone for
short saphenous surgery and popliteal explorations. The anaesthetist may entreat the
surgeon to undertake the latter surgery with the patient in a lateral position, the affected leg
lying uppermost, or from underneath with the knee flexed, but this allows the veins to
retreat from the skin surface into the depths of the popliteal fossa and provides sub-optimal
access. When the patient is placed prone for surgery under general anesthesia, adequate
chest support and use of a cuffed endotracheal tube, to protect the airway, will be
necessary. The patient should be warned about the possibility of a postoperative “sore
throat” before surgery. A head-down position reduces venous pressure and bleeding.
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Sapheno-Femoral Ligation and Stripping of the Long Saphenous Vein
Flush ligation of the long saphenous vein at the sapheno-femoral junction, with division of
the vein and stripping to the level of the knee, reduces risk of recurrence (19,20) and
remains the preferred surgical procedure for treatment of sapheno-femoral incompetence.
A 2 cm oblique incision is placed in, or just above, the groin skin crease, medial to
the femoral pulse. In obese patients, access should not be hampered by a diminutive
incision. The skin may be lifted with a small self-retaining retractor allowing the
adventitial tissue and fat to be swept away distally from the saphenous opening in the
fascia lata, exposing the long saphenous vein and tributaries. All tributaries are dissected
to facilitate division and ligation distant to the saphenous vein. (So named long saphenous
vein tributaries in the femoral triangle include the superficial epigastric, the superficial
external pudendal, the superficial circumflex iliac veins and the lateral and medial femoral
branches). If these vessels are not divided at some distance from the long saphenous vein,
then persistent branches may form a residual network of veins, a common source of
recurrence. When approaching the sapheno-femoral junction care should be taken to
prevent bleeding from the external pudendal artery which usually passes from lateral to
medial in the angle between the long saphenous vein and femoral vein.
The most important part of the groin dissection is clear visualization of the sapheno-
femoral junction with demonstration of the descending portion of the femoral vein.
Inadvertent ligation or stripping of the femoral vein (or even the artery) is well recognized
as a cause for successful litigation, and demonstration of the junction will help the surgeon
avoid this potentially disastrous pitfall.
Ligation of the sapheno-femoral junction should be undertaken flush with the
femoral vein, avoiding creation of a stenosis. Techniques of ligation are a matter of
surgeon preference, as are suture materials, but ligation in continuity reduces the risk of
bleeding from the femoral vein defect if a securing vascular clip slips and some authors
have argued that employment of a non-absorbable polypropylene transfixion suture
reduces risk of recurrence due to neovascularisation.
Traction on the divided proximal end of the long saphenous vein and retraction on
the lower border of the skin incision should enable access to and ligation of, the postero-
medial and anterior thigh veins, further potential sources of recurrence.
Stripping of the long saphenous vein reduces risk of recurrence compared to high
ligation alone. Historically, stripping of the full length of vein to the ankle was associated
with a significant incidence of saphenous nerve injury (10%) and disabling saphenous
nerve neuralgia in approximately 1% of cases. Current recommendations suggest stripping
of the long saphenous vein to just below the level of the knee. This ablates the major effect
of truncal incompetence, allows disruption of the thigh perforators and confers some
protection to the saphenous nerve which joins the long saphenous vein at a variable
distance below the knee. Proponents advocate stripping from groin to knee but there is no
good prospective evidence to support the hypothesis that this results in fewer nerve
injuries. However, risk of inadvertent passage of the stripper into the deep veins is less
likely using this technique. The technique of PIN-stripping, with inversion of the vein,
allows retrieval of the long saphenous vein through a small distal incision at the knee and
may result in less local damage to the vein tract than passage of a stripper with a terminal
“olive.”
The presence of dense scar tissue may hamper exploration of the groin during
revision varicose vein surgery. A persistent sapheno–femoral junction can be approached
from laterally, having dissected down to the femoral artery and then having identified the
femoral vein medially. A clean plane of dissection on the surface of the femoral vein can
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