A Guide To Compression Dressings For Venous Ulcers

Author(s): 
Nancy Slone-Rivera, MS, ANP-C, CWON, CFCN, and Stephanie C. Wu, DPM, MSc

Given the relatively common incidence of venous insufficiency and the high likelihood of recurrence with venous leg ulcers, these authors offer a thorough review of the literature and share their insights on compression modalities ranging from inelastic (short stretch) bandages to intermittent pneumatic compression therapy.

Venous insufficiency affects approximately 30 percent of the population and venous leg ulcers (VLUs) comprise the majority of leg ulcers. Venous leg ulcers have a high recurrence rate and many clinicians consider compression therapy to be the gold standard in the management of venous ulcerations.

   While there are a myriad of compression alternatives available on the market, there is not a one-size-fits-all answer when choosing the type of product to use. The wrong compression product can lead to complications from skin necrosis to severe ischemia.1,2 Inappropriate application and lack of consideration for the individual needs of the patient can lead to ineffective therapy and diminished quality of life. A good working knowledge of compression therapy options is essential to achieve the best outcomes.

   While the exact mechanism of venous ulcer formation is still unclear, it is well recognized that the underlying pathology is related to venous insufficiency secondary to longstanding venous hypertension.3 Pathology can occur in the deep, superficial, perforator or all three venous systems.4 Causes may be structural, functional or both as in the case of a patient who develops complicating deep vein thrombosis after undergoing an ankle arthrodesis procedure.5

   Researchers have shown that calf pump dysfunction and decreased ankle range of motion are significant factors in the development of venous ulceration.6-9 Ultimately, chronic tissue damage occurs, leading to development of the characteristic manifestations of chronic venous insufficiency (CVI), including edema, skin changes and ulceration.5 Healed ulcerations can have a five-year recurrence rate as high as 40 percent.10

   When patients are in a supine position, pressure in the veins normally approximates 10 mmHg. When patients are standing, the pressure increases up to 80 to 100 mmHg.5 The mean hydrostatic pressure decreases to 22 mmHg during ambulation because of actions from the calf and foot pump.5 In people with chronic venous insufficiency, however, ambulatory pressures consistently exceed that of 40 mmHg. Nicolaides and co-workers noted that almost all patients with CVI who had exercising venous pressures in excess of 90 mmHg developed ulceration.11

   Graduated compression therapy can reduce the vessel diameters and redirect blood centrally, reduce edema, and may also improve arterial circulation.12 Additionally, there is evidence that compression can reduce levels of destructive proteases and inflammatory cytokines that may contribute to ulcer formation and chronicity.13 A Cochrane Review by Cullum and colleagues reported that treatment of venous ulcers with compression is better than no compression, higher compression is more effective than low compression, and multi-layer bandage systems are more effective than single-layer systems.14 Despite surgical advances, compression therapy continues to be the most common conservative treatment for venous ulceration and chronic venous insufficiency.5

Comments

As a disclosure, I am VP of Farrow Medical, which manufactures short stretch garments. This is a long comment.

I would like to clarify a point with regard to the definitions herein of inelastic versus short stretch, which I believe, as stated, allow for confusion, even historically, predating 2006.

I don't believe inelastic products are historically considered to be products with 30 to 70% stretch. In fact, Foldi specifically distinguishes between short stretch and inelastic.

Why would they be separated in textbooks and yet be referred to by others as the same or similar?

If a product with less than 15% stretch, as an example, is applied, there are several issues.
1. You are not really sure how much compression is being applied because the amount of compression is directly related to how hard the provider is pulling. Does the provider know how hard he is he is pulling? Does the next person applying know how hard he or she is pulling?
2. Products with this amount of stretch don't work terribly well over joints, such as the anterior ankle, and this can cause ulcerations.
3. True inelastic products are generally reserved in wound centers for patients with a low AB index, and they are applied with very little tension, meaning they are applying little if any significant resting compression. They depend upon a higher working compression to reduce/control edema.
4. If the leg decreases significantly in circumference as a result of higher working compression levels generated, the garment can slide down and the higher working compression advantage would be lost until readjusted.

"Short stretch" products are applied with some stretch and hence, inherent in that stretch is some tension, which translates into ~some~ compression. As the authors appropriately state, this compression level can fall of rather abruptly with time. Short stretch bandages, traditionally, are manufactured of 100% cotton and depend a good degree on the weave of the product to produce the tension and hence compression. So if a product which has some stretch but little sustained elastic compression of its own is applied near its maximal stretch, it would essentially function as inelastic, although if the leg reduced in size, it "might" shrink along with the leg, but also provide a lower working compression level.

If, however, a product with short (limited or low) stretch AND elastic fibers was used, the compression would not fall off as quickly and the performance would be hybridized with other elastic compression garments. By hybridized, I mean provide a steady lower resting compression (like a stocking) AND a higher working compression (more like inelastic).

Why is this important?

In my opinion, with elastic short stretch products ...
1. The short stretch can better cue you in to the amount of tension being applied by feeling the abruptness of the short stretch and hence the tension level.
2. The stretch allows for better functionality over joints.
3. The short stretch generally allows for more consistent low resting compression and higher working compression levels (working like a pump when the patient ambulates when properly applied). (It is sometimes referred to as a poor man's pump.)
4. The product can shrink some if the leg decreases in size, limiting slippage and the need for adjustments.

As a clinical example, in a chair-bound nursing home resident, a truly inelastic product that is properly applied might apply very little resting compression (or if too tight could be a tourniquet). A short stretch product with elastic fibers would apply some sustained resting compression with the potential for higher working compression when properly applied. Long stretch wraps have the potential to produce highest sustained resting compressions, which can be a little more hazardous if not professionally applied, and lower working compressions unless applied with a significant (potentially more dangerous) amount of tension.

Conversely, if a patient had poor arterial circulation, the provider may opt to apply a product that is "inelastic" with very little tension applied because a lower resting compression has a lower potential to block arterial circulation, but still has the potential to provide a higher working compression to help reduce/control edema. Note that this would work best if the calf muscle pump was functional.

One last point. A product that is inelastic applied and just barely snug would apply a low resting compression when vertical, but very little, if any, when lying down. Short stretch would apply more resting compression than inelastic when lying down. Long stretch would generally provide the most compression when lying down (and the least potential for high working compression when vertical). So patients with impaired arterial circulation are generally safer with inelastic, then short stretch products, when they lie down, as opposed to long stretch, IF compression is safe be applied at all depending on the situation.

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