Compression And Venous Stasis Ulcers: What You Should Know

Podiatrists commonly encounter venous stasis ulcers in wound care centers. Approximately 6 million patients experience these ulcers annually in the United States and treatment costs are approaching $2.5 billion with 2 million lost workdays annually.¹

The treatment for these ulcers has historically consisted of compression therapy. Over the past two decades, invasive endovenous procedures (saphenous ablation, iliac vein stenting) have emerged as safe and effective, and more permanent alternatives.² (This study is a must-read for any practitioner who encounters venous stasis ulcers.) Compression therapy works by controlling edema, which decreases capillary filtration and enhances lymph flow, eliminates local reflux, arguably improves local oxygenation and flow, and may downregulate inflammatory cytokine mechanisms.

However, there is controversy as to the efficacy of compression therapy. Some emerging evidence suggests that graduated compression (higher at the ankle and less compression above) is not necessary to promote forward blood flow.² Higher pressures in the calf than in the ankle may enhance blood flow as the venous reservoir is much larger in the calf region in comparison to the ankle. Compression may actually constrict deep veins more than superficial veins. 

In most wound care centers, venous stasis ulcers receive standard care with the application of multilayer compression wraps. What’s interesting is that while many of us probably debride these venous ulcers weekly, evidence exists that we should avoid debridement as the dermal layer is the source of reepithelialization during healing.³ In venous wounds, epithelial growth occurs from the center as well as the periphery of the wound in contrast to diabetic or ischemic ulcers, in which epithelialization occurs only from the periphery of the wound. Could we be delaying the healing of venous leg ulcers by debriding weekly?

Once venous ulcers heal, the standard of care is to place these patents into compression stockings. Do they really work? Most of us will probably say absolutely. In fact, prior to reading the article by Raju and colleagues, I was frustrated that Medicare will not cover the use of compression stockings for the prevention of venous leg ulcers once they are healed.² Medicare does cover the use of compression stockings when an active ulcer is present, despite the fact that the standard of care doesn’t indicate the use of compression stockings over open venous wounds.

As Raju and colleagues note, the literature does not provide evidence that compression stockings have any prophylactic value in the treatment of chronic venous disease.² While this may sound surprising, the lack of evidence may stem from the inability to account for the non-adherence in the use of compression stockings. I’m sure many of you reading this will attest to the fact that it is difficult to get patients to wear their compression stockings consistently. In fact, many of mine can’t even get the stockings on.

Compression can and does heal venous ulcers in my clinical experience, but we need to think beyond compression when wounds aren’t healing and consider vascular intervention. A 10-year follow-up on conservative versus surgical intervention demonstrates that with the addition of surgical treatment of incompetent superficial, deep and perforating veins, there is a significantly higher chance of patients being ulcer-free in comparison to the use of compression therapy alone.¹

I think it’s important to consider a vascular consult when one encounters a difficult to heal venous ulcer or for cases of recurrent ulcerations that don’t always respond to prophylactic compression. 

References

1. Van Gent WB, Catarinella FS, Lam YL, Nieman FH, Toonder IM, van der Ham AC, Wittens CH. Conservative versus surgical treatment of venous leg ulcers: 10-year follow up of a randomized, multicenter trial. Phlebology. 2015;30(1 Suppl):35-41.

2. Raju S, Lurie F, O'Donnell TF Jr. Compression use in the era of endogenous interventions and wound care centers. J Vasc Surg Venous Lymphat Disord. 2016 Jul;4(3):346-54.

3. Raju S, Kirk OK, Jones TL. Endovenous management of venous leg ulcers. J Vasc Surg Venous Lymphat Disord. 2013;1(2):165-72.