Anthony Tickner, DPM, FACCWS, FAPWCA, FAPWH
Venous leg ulcers (VLUs) can occur when incomplete valve closure induces an increase in venous hypertension and blood pooling. This increase in pressure stretches the vein walls, allowing proteins in the blood to leach into subcutaneous tissues, which, in turn, causes edema and eventual tissue breakdown. The fibrin cuff theory of ulcer formation states that fibrin leaks through the endothelial pore, creating a cuff that decreases oxygen transport to surrounding tissue that results in ulcer formation1; Coleridge Smith et al2 hypothesized that an increase in inflammatory mediators and mast cell stimulation traps white blood cells, with subsequent endothelium damage from free radicals and proteolytic enzymes that causes tissue breakdown, and leads to venous ulcer formation.
VLUs most commonly occur around the circumference of the lower leg known as the “gaiter area.” Peripheral edema usually is present, and although a large surface area may be affected, VLUs often are more shallow than other ulcers. The base of the wound may be granular, oozing venous blood when handled. The surrounding skin may exhibit hyperpigmentation, dermatitis, atrophie blanche (smooth, ivory-white plaques), and other signs of serious vascular inflammation. The patient may have an altered leg shape commonly known as “champagne bottle,” where edema is more common in the upper calf and tapers at the ankle.3
Venous ulceration affects approximately 1% of the population and 3% of people 80 years of age and older in westernized countries.4 Moreover, the global prevalence of VLUs is predicted to escalate dramatically as people live longer, often with multiple comorbidities.5
Compression therapy is the cornerstone treatment for VLUs. Compression of 30 mm Hg to 50 mm Hg at the ankle will reduce venous hypertension without causing discomfort or damage to the skin. Evidence has proven high compression (35 mm Hg to 40 mm Hg) is more effective than light compression (15 mm Hg to 20 mm Hg) in managing VLUs.6
Patients have reported difficulty in tolerating compression therapy due to poor fitting wraps, pain, discomfort related to itching, and interruption of lifestyle. Health care providers have reported difficulties in achieving patient adherence to compression protocols, drainage leading to moisture associated skin damage, and compression application errors.7
Concerns voiced both by patients and care providers led to the development of a compression system that could address the 3 Cs of compression therapy: Continuity, Consistency, and Comfort. Continuity is the ability to provide an effective therapeutic pressure level regardless of the patient’s activity level; whether the patient is walking or at rest, pressure needs to be sustained over a period of time. Not addressing continuity can impair quality of life and affect compliance, thus delaying healing. Consistency ensures accuracy and repeatable application at therapeutic pressure levels. Comfort addresses how well patients tolerate the system. Well-tolerated comfortable products allow for improved patient compliance.
Dual Compression or multicomponent systems are beneficial for patients in that they provide different elasticities that facilitate compression for the patient during different levels of activity and allow consideration of unique patient needs and ambulatory status. Elastic components are helpful in applying compression at rest; inelastic components are helpful in applying compression during ambulation. Evidence-based guidelines8 suggest that compression should be continuous to be effective and that multicomponent systems are more beneficial than those only containing inelastic components.
Dual Compression System. Graduated compression has been clinically proven to be the most important factor when managing chronic venous insufficiency because it aids drainage from the superficial veins. As such, pressure should be higher at the ankle than at the calf9 (Figure 1). A Dual Compression System (UrgoK2, Urgo Medical North America) was developed utilizing evidence-based research, and the system was studied as part of a landmark randomized controlled trial.9 The system comprises 2 separate bandage components: a composite bandage that combines viscose and polyester short-stretch or inelastic “wadding” with a polyamide and elastane knitted layer and a second layer of long-stretch bandage made of acrylic, polyamide, and elastane. Both layers are printed with pressure indicators designed to indicate when the bandages have been applied correctly (ie, have reached the therapeutic level recommended to treat VLUs — approximately 40 mm Hg)10 (Figure 2).
The Dual Compression system was designed to be continuous, consistently applied, and comfortable for the patient. The combination of elastic and inelastic components allows this Dual Compression System to efficiently deliver guideline recommendations in an intuitive, comprehensive system that has been proven more tolerable than its 4-layer counterparts.9 Junger et al11 demonstrated this ability to deliver continuous compression by taking pressure measurements while volunteers were standing, resting, and walking over a 7-day period. The results of this study showed that a dual compression system achieves continuous compression through its combination of short- and long-stretch components in a 2-layer system that is the first of its kind in North America.
This Dual Compression System was applied to 10 patients, all with venous stasis leg ulcers of at least 4 weeks’ duration that had previously been treated with some form of compression. All of the clinicians who applied the dressings were asked to document patient responses and their own observations regarding 7 compression wrap performance parameters (Table 1).
Exemplary cases
Case 1. An 81-year-old female patient with a history of hypertension, osteoporosis, and long-term prednisone use had a VLU of the right lateral ankle. Previous treatments included elastic compression, long-stretch wraps, and antiembolism socks. Her ankle-brachial index was 0.97. Figure 3 shows healing progress over 9 weeks using the dual compression system.
Case 2. A 77-year-old obese woman with osteopenia, venous insufficiency, and omychomycosis presented with ulcers of the right anterior foot and left medial ankle. Previous treatment included compression stockings and 2-layer short-stretch wraps. In 3 weeks, the right foot healed and the left showed progress and healed within the following week (Figure 4).
Patient evaluations. Patient responses were overwhelmingly positive (no one selected the difficult or very difficult/poor options), indicating that patients experienced improved comfort, better wear time with reduced slippage, and improved compliance in relation to previous systems they had used. Staff noted ease of application in addition to the efficacy of this procedure, decreased edema, improved periwound skin condition, perceived application accuracy, and an increased ability for patients to wear footwear due to the low profile of the 2-layer Dual Compression System.
Summary
A 10-patient case series showed that using this Dual Compression System resulted in improved periwound skin condition and decreased edema. In addition, the compression bandage elicited positive feedback from patients and staff. The product met the 3 Cs of compression therapy and because it was well accepted, it should improve patient adherence to compression protocols.
Affiliations
Pearls for Practice is made possible through the support of Urgo Medical, Fort Worth, TX (www.urgomedical.com). The opinions and statements of the clinicians providing Pearls for Practice are specific to the respective authors and not necessarily those of Urgo Medical, Wound Management & Prevention, or HMPGlobal. This article was not subject to the Wound Management & Prevention peer-review process.
Originally Published- Wound Management and Prevention June 2020
