venous leg ulcersmanagement and prevention of venous leg ulcers: a literature- guided approach

7/28/2019 Venous Leg UlcersManagement and Prevention of Venous Leg Ulcers: A Literature- Guided Approach

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ABSTRACT

Managing venous leg ulcers involves management techniques

that are indicated both in the treatment of all chronic leg ulcers

and those that are specific to venous leg ulcers. The first step in

managing venous leg ulcers is performing a holistic assessment

of the patient. Once this is complete, any systemic or local fac-

tors that may affect wound healing should be addressed. This

approach to managing the whole patient is critically important

because if significant general wound healing factors are not

treated, other specific attempts at healing the venous ulcer will

be fruitless. This paper reviews nutritional supplementation,

wound bed preparation, antimicrobial therapy, venous insuffi-

ciency, compression therapy, different bandage systems, thera-

peutic adjuncts to compression therapy, and recent advances in

vascular surgery. Recurrence prevention also is discussed.

Ostomy/Wound Management 2001;47(6):3649

Because the population is aging and venous leg

ulcers are common in the elderly,1wound care

providers must have the skills to diagnose and

manage venous leg ulcers. Wound healing in generalmust first be optimized both in terms of the whole

patient and in terms of the wound itself. Only after such

issues are identified and treated can specific therapy be

directed at venous disease.

In preparing the patient for successful healing, several

aspects of holistic care must be considered. All too

often, these important issues are ignored, as caregivers

tend to focus only on treating the ulcer. For example, sys-

temic factors that may inhibit wound healing must be

corrected or the ulcer will not heal. Additionally, the

milieu of the wound bed must be optimized and debride-

ment may be necessary. If the bacterial load is thought to

be a significant problem, antibiotic therapy may be

required. Furthermore, the principle of moist wound

healing must be applied in the selection of ulcer dress-

ings. This paper reviews the above as well as the princi-

ples of medical and surgical management of venous dis-

ease and adjunctive medical and surgical therapy.

General Managementof Venous Leg Ulcers

Treating the whole patient.After careful holistic

assessment, all patients with suspected malnourishment

should be assessed by a nutritionist or dietitian. Protein

and vitamin deficiencies are not uncommon, particularly

in the elderly. Identifying and treating protein malnutri-

tion is the most important aspect of nutritional therapy.

Managing these deficiencies may make the differencebetween a healing and a nonhealing wound even in the

presence of best ulcer care.

Protein replacement, when deficiency exists, has been

shown to be beneficial. In the animal model, in the pres-

ence of protein malnutrition, parenteral nutrition has

36 OstomyWoundManagement

Management and

Prevention of Venous LegUlcers: A Literature-Guided Approach

Brian T. Kunimoto, MD

Dr. Kunimoto is Clinical Assistant Professor, Division of Dermatology, Department of Medicine, The University of British Columbia,Vancouver, British Columbia. Address correspondence to: Brian T. Kunimoto, MD, Division of Dermatology, Department ofMedicine, The University of British Columbia, 835 West 10th Avenue, Vancouver, British Columbia, V5Z 4E8, Canada.


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been demonstrated to improve fibroblast activity.2

Similarly, in malnourished humans, collagen synthesis

has been shown to be improved by enteral nutrition in

the immediate postoperative period.3 It also restores mal-

nutrition-induced impairment of immune responses.4

Vitamin A.Although, in one study, vitamin A supple-mentation in nondeficient animals and humans was

found to be beneficial,5 its use should be confined to

patients who are deficient. Theoretically, vitamin A may

benefit patients who are taking large doses of glucocorti-

costeroids6; however, high doses of vitamin A may be

required, which may be unsafe. In this situation, the

deleterious effects of high doses of glucocorticosteroids

may be reversed by the vitamin A supplementation. More

clinical study is needed before the use of vitamin A for

this particular indication can be recommended. Vitamin

A should be administered with caution because highdoses (more than 50,000 IU/day) can be associated with

hypervitaminosis A syndrome. Routine use of vitamin A

supplementation in the management of venous ulcera-

tion is not recommended. It should be used only in

patients who are vitamin A deficient.

Vitamin C. In the presence of vitamin C deficiency,

wound healing is significantly impaired in terms of speed

and tensile strength.7,8 In patients suffering from vitamin

C deficiency, supplementation is reasonable. The recom-

mended daily allowance for ascorbic acid is 60 mg.9 In

major burn injuries, up to 2 g per day may be required torestore adequate tissue levels.10 There is no evidence that

even higher doses of vitamin C may be toxic making sup-

plementation relatively safe.11

Few studies have examined vitamin C supplementa-

tion in nondeficiency states. No evidence shows that

large doses of vitamin C benefits human wound healing

unless a deficiency exists.12 One randomized double-blind

trial examined 88 patients with pressure ulcers and found

no significant benefit for healing when vitamin C was

given as an adjunct compared to placebo.13 On the other

hand, in severe acute wounds, such as large burns, body

stores of vitamin C may be rapidly depleted, making rou-

tine supplementation with large doses appropriate.12 The

routine use of vitamin C supplementation in the man-

agement of venous ulceration is not supported by the lit-

erature. Its use should be restricted to patients who are

deficient.

Vitamin E. The use of vitamin E in wound healing is

controversial. Animal studies have shown some benefit in

the healing of rat gingiva14 and myocardium in dogs.15

One uncontrolled human study showed that vitamin E

appeared to accelerate healing in venous leg ulceration.16

A recent literature review of the possible uses of topical

and systemic tocopherols in dermatology revealed only

weak and conflicting evidence that vitamin E is of valuein the management of leg ulcers and wound healing in

general.17 Little or no evidence supports the use of vita-

min E in chronic wounds despite its popularity in the lay

community. Controlled studies are needed.

Zinc. Traditionally, zinc supplementation has been

considered to be a useful adjunct to wound management.

Although zinc deficiency, which is quite uncommon, is

associated with delayed wound healing18 and reduced ten-

sile strength,19 no study has shown that zinc supplemen-

tation in nondeficiency states benefits wound healing.20A

more recent review of the literature as of 1998 could notidentify a clinical trial that showed a statistically signifi-

cant benefit of zinc sulfate for healing venous or arterial

leg ulcers.21 Zinc supplementation is indicated when defi-

ciency exists.

Arterial insufficiency. If the leg affected by the

venous leg ulcer is complicated by significant arterial

insufficiency, consultation with a vascular surgeon is rec-

ommended. Any wound, acute or chronic, affected by

ischemia as a result of severe arterial insufficiency, will

not heal no matter what local measures are employed. If

the arterial disease is considered uncorrectable or if thepatients general health precludes surgery, management

becomes palliative and expectations of healing should be

abandoned.

Wound bed preparation.Wound bed preparation

requires management in three areas: debridement (if sig-

nificant wound debris, including slough, eschar, and

crust, is present); antimicrobial therapy (if bacteria in the

June 2001 Vol. 47 Issue 6 37

KEY POINTS

t In this second of two review articles (see

Ostomy/Wound Management, 2001;47(5):3853, the

author reviews the research base of all commonly

used ulcer management and prevention strategies.

t In addition to providing a succinct guideline for care,

the author identifies several areas in need of addi-

tional research, including guidelines for wound cul-

tures and antibiotic treatment and the comparative

efficacy of different types of compression bandages.

Ostomy/Wound Management 2001;47(6):3649


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ulcer base exists); and dressings (to achieve the optimum

moist wound healing environment).

Debridement.When slough and wound debris obscurethe base of the ulcer, debridement becomes essential.2224

Necrotic tissue left in the ulcer contributes to reduced host

resistance to infection because it acts like a foreign body.

Dead cells also release substances that inhibit healing.

However, debridement is contraindicated in ulcers when

healing is complicated by severe arterial insufficiency.

The many ways to debride a wound (see Table 1) are

well covered in an excellent recent review article.25

Venous leg ulcers often have fibrin in the base, which

appears as a dark yellow to brown gel and is easily dis-

lodged by gentle swabbing with a cotton tip applicator.Alternatively, autolytic debridement easily and painlessly

can clear this fibrinous material. In general, ulcers com-

plicated by significant arterial ischemia have slough and,

sometimes, dry eschar in the base as opposed to typical

venous leg ulcers.

Antimicrobial therapy. If the bacterial load in the

ulcer is suspected of being sufficient to impair wound

healing, antimicrobial therapy must be considered.

Bacteria can potentially become successful competitors for

the natural resources for wound healing. If a sufficiently

large population of a pathogenic species of bacteria ismultiplying in the living tissue of the ulcer, healing will

be severely impaired. However, bacterial quantitation may

not tell the whole story. Bacterial virulence that varies

among different bacterial species in the wound also will

impair healing. Lastly, if host resistance is deficient, bacte-

ria will thrive and markedly impair the healing process.

Host resistance comprises systemic and local factors.

Systemic factors include immune defenses and wound

vascularity. Many systemic conditions such as diabetes

and malnutrition contribute to reduced immune respons-

es. Some examples of local factors include necrotic debrisand foreign bodies that may be present at the wound sur-

face. The combination of these three factors determines

the risk of significant bacterial influence on healing. If

this bacterial influence is considered sufficient to abolish

good healing, antimicrobial intervention is necessary.

The decision to use antibiotics for clinically infected

ulcers is an easy one. The patient who develops periulcer

erythema, swelling, cellulitis, purulence, tenderness and

38 OstomyWoundManagement

TABLE 1ADVANTAGES AND DISADVANTAGES OF DEBRIDEMENT25

Method Advantages Disadvantages

Easy to use Utilizes moist occlusion

Painless

Effective when minimal debris

present

Easy to apply

Painless

May be combined with surgical

debridement

Easy to perform

Immediate results

Can be used with local

anesthesia

Any debris may be debrided

Very selective

Slow method (may require weeks)

May irritate surrounding skin

May be slow if slough or eschar is thick

May be expensive

Requires equipment (hydrotherapy, irrigation)

May remove viable tissue especially with

wet-to-dry dressings Painful

Requires training

May be painful and may need anesthesia

Maggots must be cultured and ordered

Autolytic (Moistocclusive dressings)

Chemical (Enzymatic)

Mechanical

(Hydrotherapy, wet-

to-dry dressings,

irrigation,dextra-

nomer)

Surgical (Sharp

debridement)

Biological (Maggots)


4/1240 OstomyWoundManagement

pain, and sometimes fever and toxicity, is a good candi-

date for systemic antibiotic therapy. In this situation, tak-

ing a culture swab of the wound base after cleansing and

debriding taking care not to sample the normal flora of

the wound edge is justified. Although the patient will

likely be started on an antibiotic before results are avail-able, changes can be made later if sensitivity results are

not favorable and the wound is not responding. Careful

interpretation of culture results is necessary because mul-

tiple organisms frequently are identified. Determining

which of the bacteria is the pathogen is difficult.26Also,

caution must be exercised in interpreting laboratory

attempts to quantify the results. Further research is need-

ed to correlate swab techniques and quantitative results

with healing rates. Large studies have not been published

to verify correlation between swab sampling and quanti-

tative biopsy.26

Infection is only one cause of periulcer inflammation;

therefore, cellulitis must be differentiated from these

other causes. Venous dermatitis (stasis dermatitis is a mis-

nomer) occurs much more frequently than wound infec-

tion and is also more common in the summer months.

This form of eczema presents with erythema, scaling,

erosion, and excoriation. Deep swelling characteristic of

cellulitis is not seen. Another noninfective cause of peri-

ulcer eczema is the irritant dermatitis that occurs under

the wound dressing if excessive moisture is draining from

the ulcer. Wound fluid contains many proteolyticenzymes that can be very irritating to the surrounding

skin. Again, deep swelling is absent. One other cause of

peri-ulcer eczema is allergic contact dermatitis.

Once a venous leg ulcer is considered clinically infect-

ed, systemic antibiotic therapy is indicated. In most cases

oral antibiotic therapy is adequate. The use of topical

antibiotics in this situation is not established as standard

therapy,26 and although common in practice, remains to

be clarified by clinical study. In cases where the infection

is thought to have resulted in septicemia, intravenous

therapy is necessary.

The choice of antibiotic is most often empirical and

occurs before the bacterial species is identified. In the

case of venous leg ulcers, Gram-negative organisms are

common colonizers, although, in general, chronic ulcers

of less than 1-month duration are usually colonized by

Gram-positive organisms.27 Staphylococcus aureusand

Group A Streptococcus are important to consider. In

these settings, cephalexin would be an ideal choice,

although cloxacillin is often used as well. If moist, occlu-

sive wound dressings are used, the bacterial flora gradual-

ly changes to favor Gram-negative and anaerobic organ-

isms.28After 1 month of therapy, the empirical choice of

antibiotic therapy must accommodate these changes. For

milder infections, clindamycin and cotrimoxazole wouldbe a good combination.26 More severe, potentially life-

threatening infections may require intravenous clin-

damycin and a third-generation cephalosporin agent such

as cefotaxime.26

Distinguishing the rapidly healing wound from the

clinically infected one is not difficult. However, between

these two extremes lies a gray area where the wound

stops healing because of significant bacterial numbers,

but as yet shows no obvious signs of inflammation. In

these cases, despite optimal management of venous insuf-

ficiency, using appropriate dressings, and debridement,the wound will show no improvement for several weeks.

Furthermore, wound deterioration may be noted as

healthy-looking granulation tissue turns into dusky, dark

red, friable tissue or is replaced by yellow necrotic slough.

In both of these situations, the signs and symptoms of

infection may be absent. The existence of this gray area

between noninfection and clinical infection needs to be

clarified, possibly by developing diagnostic criteria. In

this situation, considering an empirical trial of oral

antibiotics is justified in the authors opinion. However,

prospective studies are needed to confirm this approach.The role of nonantibiotic antimicrobials such as cadex-

omer iodine and silver-coated membranes in this situa-

tion also remains to be defined.

Wound bacterial culturing. The routine use of wound

bacterial culturing should be discouraged. Sampling of

the wound for bacteria should be reserved for instances

when nonhealing or deterioration of the wound is con-

sidered to be due to bacterial influence.

The only reason to take a swab of a wound for bacte-

ria is to obtain information to make the antibiotic deci-

sion-making process more accurate. Patients often are

managed with antibiotics as adjunctive therapy even

though significant infection is not suspected. In many

cases, antibiotics are prescribed on the basis of a positive

culture swab result. However, the literature does not sup-

port this approach. One randomized, controlled trial

compared the use of elastic support bandages to the same

treatment plus systemic antibiotics.29 No significant dif-

ferences were noted in terms of healing rates or changes


5/12June 2001 Vol. 47 Issue 6 41

in bacterial flora. The routine use of systemic antibiotics

is ineffective, costly, and will only facilitate the emer-

gence of yet more drug-resistant bacteria.

Topical antibiotics. The use of topical antibiotics as

routine adjuncts to venous ulcer therapy should be dis-

couraged.26,30 Further research is needed to conclusively

define the use of topical antibiotics in wound healing.

Evidence is lacking that shows that topical antibiotics are

capable of eliminating bacterial colonization.Concentrating on proper wound bed preparation to

reduce bacterial burden and improve host resistance

would be far more effective.

Topical agents.Avoiding the use of potentially aller-

genic materials is important. Contact eczema is always a

risk when patients or caregivers use a multitude of topical

agents in chronic wound healing. Evidence demonstrates

that, on the legs, patients with venous insufficiency are

more susceptible to allergic contact dermatitis from topi-

cal agents.3133 One study30 showed that 50% of leg ulcer

patients demonstrated allergic contact sensitization in the

absence of concomitant or past history of eczema. For

these reasons, topical agents containing such substances

as neomycin and related antibiotics, fragrance, lanolin,

and preservatives such as benzalkonium chloride and

parabens32 should be avoided.

Dressings. Chronic ulcer management requires the

use of wound dressings that provide the optimal moist

environment for healing. Moist occlusive dressings

should be utilized when-

ever possible.

Moist wound healing.

In 1958, Odland demon-

strated that blister

wounds healed faster ifleft intact.34 Then in the

early 1960s, a study

reported that occluded

porcine wounds healed

faster than dry ones.35At

that time, the concept of

moist wound healing

originated. Over the last

20 years, an explosion in

the number of new dress-

ings that incorporate theadvantages of moist occlu-

sion has occurred.

Moisture is required for the survival of cells involved in

healing and preserves the activity of growth factors and

enzymes important in the wound healing process. Many

of these enzymes are proteolytic and are important in the

process of autolytic debridement. Occlusive dressings also

provide a physical barrier to invasion by bacteria from

the surrounding skin. This is likely the reason infection

rates are lower for occlusive dressings when compared to

nonocclusive dry dressings.36 In fact, the use of hydrocol-loid dressings is associated with the lowest infection rates

of 1.3% compared to 7.6% for dry dressings.35 In addi-

tion, re-epithelialization rates are also increased by 30%

to 50% under moist occlusion.35An exhaustive review of

wound dressings is covered in three excellent current

reviews3739 (see Table 2).

With respect to venous leg ulcers, specific issues must

be addressed. For example, an edematous leg ulcer will

produce a great deal of drainage, which can be copious

for the first few weeks of treatment. This means that the

initial wound dressing should have considerable

absorbency. Also, during this early stage of ulcer manage-

ment, the absorbent dressing may have to be changed

frequently to avoid the development of irritant dermatitis

of the surrounding skin. This also reduces the annoying

odor that accompanies treatment, particularly with

hydrocolloid dressings. Appropriate dressing types for

this situation include absorbent foam dressings and calci-

um alginates.

TABLE 2CLASSIFICATION OF WOUND DRESSINGS

Dressing Type Main Uses Contraindications

Epithelialization

Granulation tissue formation

Absorption of exudate

Infected wounds

Absorption of exudate

Hemostasis

Infected wounds

Hydration of dry wounds

Donor sites (grafts)

Epithelialization

Difficult cases

Draining wounds Infected ulcers

Poorly granulated ulcers

Infected wounds

Excessively draining ulcers

Superficial wounds

Epithelializing wounds

Superficial wounds

Epithelializing wounds

Infected wounds

Excessively draining ulcers

Infected ulcers

Plastic films

Hydrocolloid dressings

Absorbent dressings

Calcium alginates

Hydrogels

Biological dressings



Once the initial edema is under

control, switching to a hydrocolloid

dressing that still retains some

absorbency is often useful. This

dressing can potentially be left on for

up to 1 week and may be combinedwith compression bandaging.

After the granulation tissue has filled the defect, facili-

tating re-epithelialization is important. At this time,

dressing changes should be kept to a minimum, as ker-

atinocytes beginning to migrate across the wound do not

anchor to the wound bed until it is covered. Too frequent

dressing changes at this point tend to tear off the neoep-

ithelium before it has a chance to establish itself.

Fenestrated, nonadherent plastic film dressings may be

best at this stage of healing.

One interesting recent advance in managing venous legulcers has been the development of biological skin equiva-

lents. In 1997, a cultured, allogeneic, bilayered human

skin equivalent, Apligraf (Organogenesis, Canton, Mass.;

Novartis Pharmaceuticals Canada Inc., Dorval, Quebec,

Canada), was first released in Canada. This has made

treating nonhealing venous and other difficult-to-treat

ulcers possible.40 By 1999, considerable Canadian experi-

ence had accumulated resulting in a consensus paper,39

which recommended that healthcare providers consider

using the human skin equivalent if the venous ulcer does

not show significant healing after 1 month of optimaltherapy. The pivotal study that confirmed the efficacy of

the human skin equivalent, Apligraf, was a randomized,

multicentered, prospective study involving 275 patients

with venous leg ulcers.41 The researchers found that treat-

ment with human skin equivalent was more effective than

compression therapy alone in the percentage of patients

healed at 6 months (63% vs 49%). Also, the median time

to complete wound closure was 61 days for the human

skin equivalent group compared to 181 days for those

receiving compression therapy alone. Both results were

considered statistically significant. Although this dressing

is expensive and must be delivered by courier for use

within a short time, human skin equivalent may provide

an alternative treatment for nonhealing wounds.

In the past decade, a great deal of research also has

been conducted in the field of growth factors. However,

the use of growth factors has been more successful in

treating diabetic and pressure ulcers than in the treat-

ment of venous leg ulcers.

Regarding venous leg ulcers and dressings, the author

believes that a wound covered by new epidermis should be

protected for about 2 months because the new skin cover-

ing the wound is fragile. In fact, the process of matrix-

remodeling continues for several months after the ulcer has

grown skin cover. Any protective dressing may be used for

this purpose. Thin hydrocolloid dressings are a good

choice because they can be applied under elastic stockings.

Specific Venous Ulcer ManagementCompression therapy. The cornerstone of managing

venous leg ulcers is treating the underlying disease:

Venous insufficiency. In the vast majority of patients, this

involves some form of compression therapy.

Venous hypertension underlies the development of

venous ulceration. In a way, the venous leg ulcer is sim-

ply a complication of this underlying disease. The final

insult to the skin before the development of the ulcer is

cutaneous ischemia as a result of the venous disease.

Without correction of the underlying disease, this

ischemia persists, resulting in a chronic wound that will

not respond to general measures. Compression therapywith a number of different bandaging systems corrects

this problem, giving the ulcer a chance to heal using the

proper techniques of wound bed preparation.

All ambulatory patients with venous leg ulcers require

compression therapy. A recent systematic review of the

literature was conducted restricting the search to ran-

domized controlled trials.42 The authors concluded that

compression systems improve the healing of venous leg

ulcers and should be used routinely in uncomplicated

venous ulcers. Many caregivers are unaware of this fact

and rely on topical treatments such as creams and the lat-

est wound dressings.43 Part of the reason for this may be

that only over the past decade has the mechanism of how

external compression works been elucidated. Many care-

givers are faced with a confusing array of different com-

pression bandage systems, making treatment decisions

unnecessarily difficult.

Compression pressures. Compression pressures of at least

30 mm Hg to 40 mm Hg at the ankle should be utilized

Compression = N (number of bandage layers) x T (bandage tension)

R (radius of the leg)

Figure 1Law of Laplace (modified).



in the management of venous leg ulcers. All compression

bandage systems must create a pressure gradient from

ankle to knee. According to the Law of Laplace (see

Figure 1), which mathematically relates bandage tension,

compression pressure, and limb girth, the shape of the leg

will create this gradient. Thus, if the bandage tension isconstant as the healthcare provider winds the bandage up

the leg, a compression gradient will naturally develop

because the smallest limb radius is found at the level of

the gaiter area, just proximal to the ankle joint. As the

bandage is wrapped up the leg, progressively larger radii

are encountered, resulting in lesser degrees of compression

given the constant bandage tension. This pressure gradi-

ent provides support against venous hypertension, which

is greatest at the ankles when the patient is standing.

Correcting venous hypertension requires that the com-

pression system be capable of exerting at least 30 mm Hgof pressure at the level of the ankle.4446 One study44

demonstrated that after 15 minutes of motionless stand-

ing, the transcutaneous oxygen tension around the ankle

drops to very low values. After examining the effects of

different degrees of compression using a pneumatic pump

device, the researchers found that 30 mm Hg to 40 mm

Hg at the ankle area abolished this response.

The occasional venous ulcer patient is nonambulatory

or absolutely cannot or will not tolerate compression

therapy. Most experts recommend these patients utilize

leg elevation (at least 2 hours per day) as an alternative.This requires positioning the ankle at the level of the

heart. Sometimes this can be achieved by placing 6-inch

wooden blocks under the foot of the bed. Asking the

patient to keep a legs-up chart can benefit compliance.

Compression systems may be classified into three

groups: short-stretch bandages (SSB), long-stretch ban-

dages (LSB), and stockings. If the limb affected by the

ulcer is edematous, most experts recommend using an

SSB system.45,47,48 Because SSB, by definition, provides lit-

tle or no elasticity against the contracting calf muscle, the

highest working pressures are attained. This working

pressure drives blood in the deep femoral vein upward.

For the same reason, when the calf muscle relaxes, the

bandage does not continue to exert pressure. This low

resting pressure facilitates deep venous filling.45

Short-stretch bandage systems require patients to be

ambulatory. Without a calf muscle capable of contract-

ing, the inelastic bandage becomes ineffective. Thus,

patients who tend to shuffle around need to be trained to

walk properly, making sure they push off with their toes.

Similarly, those patients with ankle joints stiffened by

arthritis or old injury may not be good candidates for

SSB systems.

Despite expert opinion that supports the use of SSB

while managing edema, only a few studies compare themto LSB and the results have been far from conclusive.

One recent controlled, nonrandomized study found that

inelastic compression was better than elastic compression

for reducing deep venous reflux.49Another study, which

looked at venous pressure in the dorsal vein of the foot

during treadmill walking, found that only the short-

stretch system was able to reduce the elevated venous

pressure seen in venous insufficiency.50 One recent

prospective, randomized, observer-blind, parallel group

study compared both systems in 32 patients with 39

ulcers. After 15 weeks, using complete healing as theendpoint, the study found no statistically significant dif-

ference.51A prospective, randomized trial comparing the

four-layer bandage system with an inelastic bandage in

53 patients revealed no significant differences in healing

after 12 weeks.52 Other comparison trials are currently

under way.

Long-stretch bandages are more commonly used than

SSB systems in North America and the United Kingdom.

The four-layer bandage is popular because it is capable of

maintaining high compression for several days and up to

a week. This reduces the frequency of dressing changes, agreat advantage for home healthcare nursing. The four-

layer bandage must be applied by trained personnel.

Because of elasticity, the four-layer bandage and other

LSBs continue to exert compression even when the leg is

elevated. This can be a problem if the patient has signifi-

cant arterial insufficiency. Therefore, the four-layer ban-

dage should not be used in patients with an ankle-

brachial index (ABI) of less than 0.8.

Other LSB systems are capable of lower levels of com-

pression. These systems are relatively safe in the presence

of moderate arterial insufficiency. They may be used if

the ABI is greater than 0.5 and require only a minor

degree of training. Like the four-layer bandage, they may

be left on for 1 week at a time. In the presence of severe

arterial disease (ABI less than 0.5), even these lower com-

pression systems are contraindicated.

Surgery. In some cases, the wound stubbornly refuses

to heal even after systemic factors have been managed,

the wound bed has been optimized, and compression


8/12June 2001 Vol. 47 Issue 6 45

therapy has been instituted. In this situation, venous vas-

cular surgery should be considered.

Venous incompetence in the deep system cannot be

corrected surgically. On the other hand, perforator

incompetence and disease of the superficial venous sys-

tem can be managed using new surgical techniques thatare associated with only mild morbidity. Significant per-

forator incompetence may cause localized venous hyper-

tension that may not be adequately managed by the use

of a compression bandage system.

Chronic venous insufficiency is caused by vascular dis-

ease affecting the deep, perforator, or superficial veins.

Historically, the first theories on venous insufficiency

postulated that the primary problem with the post-

thrombotic leg was that of deep-vein obstruction.

Obstruction of the deep veins was thought to cause

venous hypertension. Later, a small minority of patientswas found to have isolated venous outflow obstruction,

and in 90% to 95% of cases, valvular incompetence is

the cause of venous hypertension.53 Deep vein valvular

incompetence is believed to be of greatest importance in

pathogenesis. Despite Hippocrates observation correlat-

ing leg ulceration with the presence of varicose veins,

superficial venous disease has been considered to be

much less significant. Recently, duplex ultrasound scan-

ning has improved the measurement of reflux in deep,

superficial, and perforator veins. Of interest is the finding

that a lesser but significant proportion of venous ulcerpatients has competent deep veins and isolated superficial

venous reflux.54 Many of these patients have isolated

incompetence of great or lesser saphenous veins and may

benefit from saphenectomy.

In patients with combined deep and superficial dis-

ease, the removal of varicose superficial veins has been

feared to eliminate an important venous outflow tract for

occluded or hypertensive deep veins. This may not be

true in the majority of cases. One study found that less

than 10% of patients with deep vein obstruction had sig-

nificant reduction of venous outflow when the superficial

veins were occluded.55A recent study demonstrated that

in patients with combined disease, ablation of superficial

and perforator veins reduced deep venous reflux.56

Another study showed that preoperative femoral vein

reflux could be abolished by greater saphenous vein strip-

ping in 27 of 29 limbs.57Although more research is need-

ed, lesser saphenous vein reflux might be a significant

contributor to venous ulceration. One recent study

showed that incompetence of the lesser saphenous vein

may contribute to venous insufficiency and ulcers of the

lateral aspect of the leg.58 However, a significant propor-

tion of these patients have associated deep venous incom-

petence, making lesser saphenous vein ablation ineffec-

tive in improving long-term outcome.53

The role of perforator vein incompetence in chronic

venous insufficiency requires more study as well.

Perforator vein incompetence is accepted as important in

the development of venous ulcers. In 1949, Linton

described a technique for dissecting incompetent perfora-

tors using a long paratibial incision.59 This procedure

causes significant morbidity and prolonged hospitaliza-

tion. Since the mid-1990s, subfascial endoscopic perfora-

tor surgery (SEPS) has been studied.60 Its major advan-

tage over the Linton procedure is the greatly reduced

postoperative morbidity. One study examined the use ofSEPS in 19 patients with venous ulcers.61 The ulcers had

been present an average of 4.4 years. After treatment, all

ulcers healed within 90 days. A more recent study from

the Mayo Clinic reported an ulcer recurrence rate of

12% after SEPS compared to their population average of

28%.62 Contrasting these good results, another study

reported failure of healing or ulcer recurrence after SEPS

ranging from 2.5% to 22%.63 This study stated that one

limitation of SEPS is that perimalleolar perforators are

difficult to access.

Currently, surgical ablation of incompetent superficialveins and SEPS cannot be recommended as routine pro-

cedures. Certainly, if an ulcer shows no sign of healing

after 3 months using best practices, vascular surgery

should be considered. However, more research is needed

over the next few years to establish the role of vein

surgery in the treatment of nonhealing venous leg ulcers.

Adjunctive TherapyPhysical therapy for the ankle joint.A physical ther-

apist should be consulted for patients who possess little

ankle mobility if any potential for improvement of joint

flexion and extension exists. The ankle joint is equivalent

to the hinge component of the calf muscle pump. A

mobile ankle joint is essential for the pump to function.

If the joint in a patient with chronic venous insufficiency

is ankylosed, venous congestion is exacerbated. Patients

with this problem tend to shuffle around, barely lifting

their feet off the floor. Furthermore, the ability of com-

pression bandages such as the SSB system to enhance



venous return is compromised in the presence of the

frozen ankle. Chronic venous insufficiency itself may

contribute to ankle immobility through the deposition of

fibrotic tissue.

If ankle joint mobility is present, and an SSB system is

being used, the patient should be encouraged to raiseboth heels off the ground while in a standing position.

The shuffling gait that is so common among the elderly

should be discouraged.

If joint mobility is reduced, yet potential for improve-

ment exists, a physical therapist may be able to loosen

soft-tissue contractures through the use of physiotherapy.

Intermittent pneumatic compression. One means of

intermittently increasing compression to relieve edema is

to use the intermittent pneumatic compression (IPC)

device. Because some patients require higher levels of

compression than is tolerated, noncompliance with thebandage system becomes an issue. The IPC device can be

used as an adjunct to compression bandaging. It also may

be used as an alternative to compression bandaging in

patients who are relatively immobile and, therefore,

unable to activate the calf muscle pump.

The IPC device comprises a series of balloons that are

inflated by a pump. The timing of balloon inflation in

sequence moves edema fluid toward the inguinal region.

This device may be used to quickly reduce the volume of

the leg before compression bandages or graduated com-

pression stockings are applied. The device is also useful asan alternative to compression bandages in patients who

lack good mobility and cannot walk around to activate

the calf muscle pump and in those with lymphedema.

IPC therapy is contraindicated in the presence of signifi-

cant arterial insufficiency, and edema due to congestive

heart failure.

One randomized, controlled study compared healing

rates for 24 patients using moist occlusive dressings and

graduated compression stockings (30 mm Hg to 40 mm

Hg) with 21 patients using the same treatment plus IPC

for a total of 4 hours per day. The treatment period last-

ed 3 months. Only one patient in the control group

completely healed compared to 10 of the 21 in the IPC

group (P= 0.009, Fischers exact probability test).64

Another randomized, prospective controlled study exam-

ined 22 patients. Both groups received local wound care

and Unnas boot. The experimental group used IPC twice

weekly for 1 hour each session and achieved statistically

significant better healing rates.65

Intermittent pneumatic compression may be a useful

adjunct that complements compression bandage or stock-

ing therapy in the treatment of venous leg ulcers and

may be used in difficult cases.66

Medication therapy: Edema-preventive drugs.

Lymphedema may result in patients who have long-standing venous edema. This type of edema may respond

to coumarin drugs, which may be recommended as

adjunct therapy. The benzopyrones (coumarin) have been

shown to be efficacious in the management of chronic

lymphedema.67 Long-standing venous hypertension often

develops into chronic lymphatic insufficiency, especially

in obese patients.

Diuretics should not be used in the management of

edema caused by venous insufficiency. The edema associ-

ated with venous disease is caused by pump failure,

which causes venous hypertension and leakage of fluidfrom the intravascular compartment into the interstitial

space. None of this can be corrected with diuretics.

However, diuretics may be required during edema man-

agement using compression bandaging in patients who

suffer from congestive left-sided heart failure. Here, sig-

nificant increases in effective arterial blood volume may

be evident; these are caused by the improvement in calf

muscle pump function afforded by bandaging. This sud-

den shift of fluid from the interstitial space into the

blood may exacerbate left ventricular function, resulting

in the appearance of pulmonary edema. This should be aconsideration in the elderly with fragile cardiac function.

Hemorheologic agents. The routine use of hemorhe-

ologic agents, such as pentoxifylline, in the treatment of

venous leg ulcers is not recommended at this time.

Pentoxifylline increases the deformability of red blood

cells, improving blood supply to ischemic tissues. It also

has been found to reduce white blood cell trapping, mak-

ing it an attractive therapeutic agent in venous ulcer

management.68A review of the literature does not

unequivocally endorse the use of pentoxifylline.

One of the original studies was a prospective, random-

ized, double-blind, placebo-controlled trial involving 80

consecutive venous leg ulcer patients for 6 months.69

Complete healing was seen in the pentoxifylline group in

23 of 38 patients, compared to 12 of 42 patients in the

placebo group. This was found to be statistically signifi-

cant. A more recent double blind, placebo-controlled trial

involved only 12 patients.70 Drug or placebo was adminis-

tered for 60 days. In the active drug group, complete


10/12June 2001 Vol. 47 Issue 6 47

healing was seen in 4 of 6 patients compared to 1 of 6 in

the placebo group. This was considered statistically sig-

nificant; however, the study size was small. The most

recent randomized double blind, placebo-controlled trial

involved 200 patients.71 Complete healing was seen in 65

of 101 (64%) patients receiving active drug compared to52 of 99 (53%) patients on placebo drug. This result did

not reach statistical significance.

Management of obesity. In many patients with

venous ulceration, morbid obesity is a problem that must

be managed concomitantly with specific venous ulcer

therapy. Morbid obesity directly causes deep venous

insufficiency. If obesity is not managed, it is the authors

opinion that compression therapy will be difficult if not

impossible. Morbidly obese patients usually do not toler-

ate compression therapy.

Obesity is a risk factor for the development of venoushypertension. Patients who are severely obese may not be

able to lie down in bed at night as a result of restrictive

respiratory failure. However, sleeping in a chair can have

disastrous consequences on venous hypertension.

Lymphatic insufficiency is not unusual among these

patients and ulceration presents a major therapeutic chal-

lenge. After venous ulcer healing, continued morbid obe-

sity will predispose patients to ulcer recurrence. Obesity

management requires the skills of a dietitian or weight-

loss expert.

Prevention of Venous Leg UlcersGraduated compression stockings. Once the venous

leg ulcer has healed, prevention must be the main objec-

tive. In all ambulatory patients, graduated compression

stockings (GCS) should be recommended. Graduated

compression stockings are of proven value in the manage-

ment of venous hypertension.7274 The issue of ulcer pre-

vention was illustrated in a study that examined ulcer

recurrence rates both with and without the regular use of

GCS rated at 30 mm Hg to 40 mm Hg.75 Fifty-three

patients with venous leg ulcers were healed using GCS.

They were followed for the next 6 months and compli-

ance with stocking use was evaluated. Among the 25

patients who demonstrated good compliance, one ulcer

recurred. Of the 28 patients who were either poorly or

noncompliant, 22 had at least one ulcer recurrence. One

15-year retrospective study examined the efficacy of GCS

in the management of venous ulcers.76 Of 113 patients,

105 (93%) achieved 100% healing after an average of 5.3

months. One hundred two patients were compliant in

the use of GCS and 11 patients were not. Of those who

were compliant, 99 of 102 (97%) patients healed com-

pared to 6 of 11 (55%) patients who were not (P

venous leg ulcersmanagement and prevention of venous leg ulcers: a literature- guided approach

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