Key Insights On Treating Chronic Venous Ulcers

Clinical Editor: Lawrence Karlock, DPM

A: Dr. Katz prefers the multi-layer compression products, which he changes on a weekly basis. He says patients tolerate these products well and they provide both dynamic and static compression. He reemphasizes that one must check patients for good arterial flow and the absence of DVT. Once patients have healed, Dr. Katz likes using sequential compression pumps. Although compliance is a problem with prescription stockings, he will use them for some patients.
   One of Dr. Suzuki’s choices is prescription graduated compression hose if the patients can comply and wear them daily. He says the compression strength has to be at minimum above “20 to 30 mmHg (Class I)” at the ankle level. On the other hand, he notes that low compression “anti-embolism” hose (such as over-the-counter TED hose) are not considered therapeutic for venous reflux diseases.
   However, if that is not an option, Dr. Suzuki uses various multi-layer compression bandage kits. These include Profore (Smith & Nephew), Dynaflex (Johnson and Johnson), or the Coban two-layer system (3M), which patients can leave on for a week. He also uses the “do it yourself” approach by combining a foam dressing, cast padding, Ace wrap (long stretch bandage) and Coban/Coflex (short stretch bandage), although he says the aforementioned compression bandage kits are very convenient.
   Dr. Mulder uses paste bandages (Unna boot) with four-layered or occasionally two-layered wraps. He bases his choice on patient tolerance, skin evaluation and patient preference.
   “There is really no data to show that one approved multi-layer system is significantly better than another as far as outcomes are concerned,” points out Dr. Mulder.

Q: Is there any evidence that skin graft substitutes are effective in these wounds?

A: Dr. Katz notes there is a lack of vibrant cells and growth factors in chronic wounds so skin graft substitutes can “absolutely” be effective in these wounds. He says Apligraf (Organogenesis) has provided the best results and has utilized the modality for patients who cannot have compression. In his experience, Dr. Katz has found better success with Apligraf in comparison to other skin graft substitutes, and cites the amount of actual live material in the graft.
   “Although we do not have sufficient clinical evidence yet, I believe other skin substitutes can be very helpful in wound closure, given adequate wound bed preparation and strict edema control,” says Dr. Suzuki.
   However, Drs. Mulder and Suzuki note that studies support the use of Apligraf. Dr. Mulder says studies have shown that Apligraf has shown a statistically significant difference versus controls in treating patients with venous ulcers. Dr. Suzuki concurs, noting that Apligraf has AHA level 1 clinical evidence to show more effective complete wound closure over conventional moist compression dressing in 24 weeks (57 percent vs. 40 percent).2
   When physicians ensure appropriate patient selection, Dr. Mulder says “(tissue substitutes) can assist with expediting healing.” He does note that tissue substitutes are expensive and that “the majority of patients still do well with the more conservative treatments.”

Q: What vascular surgery procedures are currently in vogue?

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