A Guide To Compression Dressings For Venous Ulcers
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