Wound care physician Dr. Chris Leonard, D.O., discusses venous ulcers, their causes, and treatment options.
Disclaimer: This demonstration is performed by a trained wound care physician for educational purposes only and should not be tried at home.
How Venous Stasis Ulcers are Formed
Venous stasis ulcers are difficult to treat often because the underlying cause is not addressed. Various dressings can be used in primary care, but it’s very unlikely that they will heal unless the edema caused by the venous insufficiency itself is addressed. The deep venous system becomes incompetent and shunts blood to the superficial venous system. That causes visible varicosities.
Due to the hydrostatic pressure, particularly when the lower extremities are in the dependent position, the interstitial fluid increases. That increases the distance from the capillary bed to the skin surface, meaning that there’s a greater diffusion distance for nutrients and important cells that are involved in the healing process to get to the skin.
If a wound should form on the skin, it will hinder the healing process of venous ulcers. This is one of the many reasons to treat the underlying edema associated with venous stasis. After blood pools because of the hydrostatic pressure, hemosiderin deposits occur, and that’s where you get your discoloration and ultimately your brawny edema.
Using Multi-Compression Wraps
The idea of using multiple levels of compression rather than single-layer bandages is to get the right level of pressure. The initial layer is for protection of the skin and, to some degree, comfort. The second layer is generally a high stretch fiber that provides a constant yet gradient of pressure, which is high at the proximal end and continuously gets lower towards the knee. This creates a conduit and augmentation to venous return proximally. The third layer is generally a short stretch fiber that dynamically augments the pump action of the calf muscles for the blood back proximally towards the heart. It does not create a tourniquet effect, and, at rest, it does not create undue pressures. Yet, during ambulation or physiologic muscles movement, it augments that pumping action to produce increased blood flow via the venous system back towards the heart.
It’s been shown that single-layer compression wraps or compression bandages are much less effective than single-layer graded compression wraps. Multilayer compression wraps or multilayer compression bandage systems are more efficacious than single layer thus, they must be multilayer and graded.
What I mean by graded is that you want to have the highest bandage pressure down here at the foot and ankle and the decreasing pressure as you come up, so you don’t create a tourniquet effect. In this case, we don’t have an underlying ulcer. If we did, we would clean it in the appropriate manner and apply our dressing here.
The next thing we would do, in the case we’re using a Curlex, basically a rolled gauze. There are some versions of this that are padded. But, this is largely to prevent shear forces from the edges of the second layer of wrap. It also holds the dressing in place and provides a little bit of absorption.
For the treatment of venous leg ulcers, you start at the toe. You want to start distally. If you start up here, and your other layers start up there as well, you have this distal portion that could potentially, because the pressure is different from here to here, you can create a tourniquet effect, and this portion can become even more swollen.
You need to be careful with the use of bandages for the treatment of venous leg ulcers and follow the correct procedure. You want to start down at the toes and basically wrap in such a way that you overlap slightly, so the edges don’t rub on the skin which is generally much more fragile than skin without venous stasis simply because it’s not being provided with the nutrients it needs.
We would normally use another dressing to go all the way up to just below the knee. The reason you want to do that is there’s collateral veins here. Therefore, you want the compression to go all the way up to those collateral veins so they’ll pick it up. Your perforators generally are affected all the way up to that point. You don’t want to stop here. I’m stopping here for the sake of this demonstration.
The next layer is basically the equivalent of an ace bandage. This particular one is a self-elastic bandage. An elastic bandage is a stretchable bandage used to create localized bandage pressure. Some have hooks, some have Velcro. This is what’s considered a high-stretch elastic bandage.
High-stretch meaning just what it says; it stretches a greater distance. The problem with a high-stretch elastic bandage is that you can easily create areas where the pressure gradient is higher than in others. Also, it does not adapt to the pump function and the circumference of the leg when a patient is either ambulatory or at rest. Therefore, it can easily create a tourniquet effect if it’s applied too tight.
You want to start at the same point that you started with the underlying protective dressing. You want to have this graded now. You want to have more pressure at the foot. Generally, it’s anywhere from 35 to 50 millimeters of mercury at the foot. Basically, experience dictates the feel of it but inexperienced practitioners may struggle. As you come up the leg, you’re going to do it in a graded fashion. You create less tension toward the top. So, you’re allowing blood flow to choose the path of least resistance and go in the proximal direction and that’s what we mean by graded compression. It’s much more important in this case because this is the first layer.
The third layer in this multilayer compression wrap is probably the most important. Many times, we see this done simply with this single layer. Sometimes that’s done for compliance reasons. But, if you add the third layer, it becomes much more efficacious. As opposed to the long stretch, this is considered a short stretch dressing.
Coban is the brand name, but this is basically a short-stretch dressing. Short-stretch means that at rest, there’s minimal pressure. The pressure is not going to be high enough to create a tourniquet effect at rest. However, when the surface increases because of ambulation or muscle contraction, this allows for that movement and basically augments the natural pump function of the leg. That is the purpose and the function, and the benefit of short stretch fiber.
You apply this in the same fashion and use as many as you need to get to just under the knee. You always want to be at that point and again, you do this in a graded fashion. You would obviously be tighter here and graded so that it’s decreased at the top. Generally, you don’t want to have gaps in the padding because these edges will rub against the skin and can cause further ulceration.
We’ve now finished our wrap. We have stopped short of the knee. In general, you want to go right up to just distal to the knee where you get access to the popliteal vein, the popliteal vein system. This is a grade compression, and it is three layers. This is Coban which sticks to itself and creates a uniform dressing.
Healing the Venous Stasis Ulcer
Underneath the grade compression, if you have a venous stasis ulcer, you’ll have the appropriate absorptive dressing, maybe a calcium alginate or whatever is appropriate. You can leave this on for up to a week but you must plan for systemic reviews. In general, meta-analysis in clinical trials has shown that the type of dressing applied beneath compression doesn’t affect ulcer healing, and a practitioner can choose the appropriate dressing based on the patient’s preferences.
Depending on the patient taking baths or how often you want to evaluate this wound, if it’s highly secretive or potentially erythematous because of cellulitis, then you simply cut this off and check it more frequently.
It is reasonable to leave these on for as long as a week, take them off, and check your progression. The other thing with this is that this alone doesn’t do the job as effectively unless you have the behavioral component, which is to keep these legs elevated as much as possible.
Having the lower extremities, even if they’re wrapped in a dependent position unnecessarily, i.e. sitting in a wheelchair all day long with the feet in a dependent position will not augment what we’re trying to benefit here. What we’d like to do is keep the legs elevated even when in bed and particularly when in a sitting position.
The use of multilayer bandage systems, specifically a three-layer compression wrap, is the mainstay of treatment for an underlying venous insufficiency. It’s definitely better than using single-layer bandages to expedite the treatment with the right bandage pressure.
Generally, the healing process of venous ulcers is 3 to 4 months with appropriate treatment. However, practitioners trained in compression therapy must only carry out the treatment. Inexperienced practitioners may not be familiar with the levels of compression, which is crucial to treating a chronic venous insufficiency.
For the full video demo, visit here: https://youtu.be/kMpswpqUwY4