Solutions can range from simple to complex
The trick: Selecting right therapy
In describing the popularity of compression therapy, John Macdonald, MD, FACS, puts it succinctly: It is the gold standard for treatment of venous stasis ulcers. Squeezing the leg to reduce swelling has been done for decades, and though it's not always successful, it's still your best bet.
"External compression has been the mainstay of treating patients with venous disease since early in the 1900s," says Macdonald, medical director of the Wound Healing and Lymphedema Center in Ft. Lauderdale, FL. When applied in a timely and proper manner - before wounds grow too large or deep - compression therapy will result in the healing of 85% to 90% of venous ulcers.
Clinicians have a number of options from which to choose, simple and complex, for applying gradient pressure to the lower leg. (For a list of products and manufacturers, see box, below.) They range from simple elastic wraps, multilayer bandage systems, and soft casts that cost relatively little, to compression pumps costing thousands of dollars.
Wounds that don't respond to compression therapy over dressings may require more aggressive measures, such as skin grafting or skin substitutes, according to Macdonald. There are also several surgical options that are usually reserved for younger, active people.
Macdonald adds that venous ulcers can be prevented if the underlying edema is controlled in time. "Patients who have edema and venous disease should have some form of compression all the time," he says. "It's the edema that comes from the venous disease that leads to ulceration. If patients wear compression hose, they will effectively stop the complications of venous hypertension." He notes that compression of any form will not eliminate the underlying venous disease.
Though its full physiological effects are not fully understood, graded compression has been shown to increase the blood's velocity in the deep veins; reduce edema and therefore reduce the pressure differential between the capillaries and the tissues; reduce distention of the superficial vein and reverse venous hypertension; and improve the healing rate of chronic venous ulcers.1 It is widely held that to reverse the effects of venous hypertension in the legs, compression needs to reach 40 mm Hg at the ankle.
Treatment choices for most venous stasis ulcers, then, do not revolve so much around what to do, but rather how to go about doing it, and selecting the specific compression alternative to reach the goal of reduced leg swelling.
The Thera-Boot, produced by CircAid Medical Products in San Diego, is a non-elastic boot-like device that cinches with Velcro fasteners. Its intended effect is the same as that of compression bandages or stockings, but the Velcro closures ostensibly allow the system to be easily adjusted as swelling diminishes, thus maintaining adequate pressure on the venous system as edema abates and limb circumference decreases.
This same feature allows easy removal and replacement by patients or caregivers, says Warner Bundens, MD, a CircAid consultant, and the non-elasticity ensures that pressure is maintained. In addition, the Thera-boot, which costs about $95, is reusable and can be taken off and set aside before activities such as bathing or dressing changes. Reimbursement for the device varies by state and private plan criteria. CircAid makes several similar compression devices for use on various parts of the body.
Macdonald calls the Thera-Boot "outstanding for certain patients." He tells Wound Care that he sometimes uses the device in Haiti to treat patients suffering from elephantiasis. Macdonald also notes that the Thera-Boot is not used for initial therapy for patients with venous ulcers, but as maintenance to prevent long-term recurrence of edema and ulceration.
While the Thera-Boot is relatively easy to adjust, patients can't know how much compression they're getting when they put on the device, cautions Morris Kerstein, MD, professor of surgery at Allegheny University of the Health Sciences in Philadelphia. "They may be making it too tight or too loose," he says.
1. Moffatt CJ, Dickson D. The Charing Cross high compression four-layer bandage system. J Wound Care 1993; 2:91-94.