Cath Lab Digest

V enous insufficiency ulcers in the lower extremities arise as a late manifestation of venous system incompetence. These ulcers are the most common vascular disorder and account for 80% to 90% of all lower extremity ulcers.¹ Often, patients also have edema of the lower legs that further compromises oxygen and nutrition to the skin. The patient commonly presents with a long history of recurring problems such as lower leg edema, heaviness, blister formation, and slower healing from minor injuries that become worse with each episode. Traditional treatment has centered on reducing edema with limb elevation, compression wraps, stockings, or Unna boots. Understanding the nature of venous ulcers and the way in which wounds heal has enabled clinicians to tailor treatment specifically to each patient rather than to take a cookie-cutter approach. Most often, treatment now involves both compression and local wound care designed to reduce inflammation, resolve infection, and heal the ulcer.²

Compression is essential and can be accomplished in various ways as stated above. Staff at our center prefer to utilize three- or four-layer compression wraps such as Profore and Profore Lite (Smith & Nephew, Largo, Fla.). The decision to use three or four layers of compression is dependent upon the ankle/brachial index (ABI). The three-layer wrap is utilized if the ABI is 0.5 to 0.8 and the four-layer wrap is utilized if the ABI is 0.8 to 1.0. Consideration is also taken if the patient has diabetes and small vessel disease. Other compression products include Surepress and Setopress (ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ). Unna boots (Gelocast, BSN-Jobst, Charlotte, NC) are used at some centers; however, they have been found to be less effective than layered compression wraps.

Patients with venous ulcers are generally seen one to two times weekly at our clinic. Wound assessment, sharp debridement, and tissue cultures are routinely performed. Local wound care depends upon wound presentation. If positive cultures are obtained, the patient is placed on appropriate topical, and/or oral/IV antibiotics. Topical antibiotics most often used include Silvadene (Medline Industries, Inc., Mundelein, Ill.) and Bactroban (SmithKline Beecham Pharmaceuticals, Philadelphia, Pa.). A silver-coated dressing such as Acticoat, Acticoat 7 (Smith & Nephew) or Silvasorb (Medline Industries) may be applied to the wound bed to reduce bacterial load. Elidel (Novartis Pharmaceuticals Corp., East Hanover, NJ) is often applied to intact periwound tissue to reduce inflammation before compression wraps are placed.