Venous ulcer treatment requires inelastic compression

Summary

Leg ulcers have a venous pathophysiology in the vast majority of cases (1–4). Superficial or deep venous insufficiency and deep vein obstruction produce ambulatory venous hypertension due to venous reflux and venous pumping function impairment. The impaired venous hemodynamics is the key pathophysiologic mechanism leading to skin damage through several intermediate steps. Fibrin cuff formation around the microvessels, impairing gases (O₂, CO₂) exchange (5), white cells entrapment (6) causing skin necrosis, growth factors inhibition (7) producing a stagnation of the healing process have been considered involved in ulcer onset and maintenance. The treatment of venous leg ulcers (VLU) must be based on the correction of the hemodynamic impairment which can be achieved conservatively by means of compression therapy, walking and leg elevation or by means of invasive procedures (open surgery, endovascular procedures as endovenous Laser ablation, radiofrequency, foam sclerotherapy, conservative hemodynamic treatment). Compression therapy is frequently considered the first treatment option and it is the only therapeutical procedure which achieved the grade 1A in most recent guidelines or consensus documents (8–10). The crucial point is choosing the most effective compression modality. There are clear evidences that inelastic is more effective than elastic material in counteracting the venous hemodynamic impairment (11–14) that should „ensure” a superior effectiveness in promoting a higher healing rate of VLU, which are due to venous hemodynamic impairment. When looking at evidences we have some data showing that the higher the compression pressure the higher the healing rate (9, 15–17) and this is clearly in favors of inelastic bandages which exert a much higher pressure that elastic materials. On the other side we have many papers claiming a greater effectiveness of elastic stockings or elastic bandaged compared with inelastic material (18–30). Nevertheless studies comparing elastic and inelastic devices have so many flaws that their conclusions are hard to trust (31). Aim of this work is providing updated information about compression therapy effects on venous hemodynamic and the most effective compression modality to achieve the best outcome in VLU treatment.

 

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Zusammenfassung

Beinulzera haben in der überwiegenden Mehrzahl der Fälle eine venöse Pathophysiologie (1–4). Eine oberflächliche oder tiefe venöse Insuffizienz und eine tiefe Venenobstruktion führen zu einer ambulanten venösen Hypertonie aufgrund einer venösen Reflux- und venösen Pumpfunktionsstörung. Die gestörte venöse Hämodynamik ist der wichtigste pathophysiologische Mechanismus, der durch mehrere Zwischenschritte zu Hautschäden führt. An der Ulkus-Entstehung und Ulkus- Unterhaltung scheinen beteiligt zu sein: Fibrin- Manschetten-Bildung um die Mikrogefäße, Beeinträchtigung des Gasaustauschs (O₂, CO₂) (5), Einklemmung weißer Zellen (6) (verursacht Hautnekrose), Hemmung der Wachstumsfaktoren (7), welche eine Stagnation des Heilungsprozesses verursacht. Die Behandlung von venösen Beinulzera (VLU) muss auf der Korrektur der hämodynamischen Beeinträchtigung beruhen, die konservativ mittels Kompressionstherapie, Gehen und Beinheben oder mittels invasiver Verfahren erreicht werden kann (offene Chirurgie, endovaskuläre Eingriffe als endovenöse Laserablation, Radiofrequenz-, Schaum-Sklerotherapie, konservative hämodynamische Behandlung). Die Kompressionstherapie wird häufig als erste Behandlungsoption angesehen und ist das einzige therapeutische Verfahren, das in neueren Leitlinien oder Konsensusdokumenten die Stufe 1A erreichte (8–10). Der entscheidende Punkt ist die Auswahl der effektivsten Kompressionsmodalität. Es gibt eindeutige Hinweise darauf, dass unelastisches Material wirksamer ist als elastisches Material, um der venösen hämodynamischen Beeinträchtigung entgegenzuwirken (11–14), die eine höhere Wirksamkeit bei der Förderung einer höheren Heilungsrate von VLU gewährleisten sollte, die auf eine venöse hämodynamische Beeinträchtigung zurückzuführen ist. Wenn wir uns die Evidenz anschauen, haben wir einige Daten, die zeigen, dass je höher der Kompressionsdruck ist, desto höher die Heilungsrate (9, 15–17). Dies spricht eindeutig für unelastisches Material, welches einen viel höheren Druck ausübt als elastische Materialien. Auf der anderen Seite overhaben wir viele Studien, die eine größere Wirksamkeit von elastischen Strümpfen oder elastischen Bandagen im Vergleich zu unelastischem Material (18–30) behaupten. Dennoch haben Studien, in denen elastisches und unelastisches Material verglichen werden, so viele Mängel, dass ihre Schlussfolgerungen schwer zu glauben sind (31). Ziel dieser Arbeit ist es, aktuelle Informationen über die Auswirkungen der Kompressionstherapie auf die venöse Hämodynamik und die effektivste Kompressionsmodalität bereitzustellen, um das beste Ergebnis bei der VLU-Behandlung zu erzielen.

 

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Keywords

Venous leg ulcers - ulcer healing rate - compression therapy - elastic compression - inelastic compression - venous reflux - venous pumping function - venous hemodynamic impairment

Schlüsselwörter

Ulcus cruris venosum - Heilungsrate von Ulzera - Kompressionstherapie - elastische Kompression - inelastische Kompression - venöser Reflux - venöse Pumpfunktion - venöse hämodynamische Beeinträchtigung

 

 

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Conflicts of interest

The author declares no conflict of interest.

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