From the Editor: Part 2 of The Compression Continuum

  Just when you think you have seen it all, a patient walks in with something incredible. This week I saw a patient with a venous stasis ulcer of the hand. He has had lymphedema of the arm ever since a deep venous thrombosis of the subclavian vein 10 years ago, but his edema suddenly began to worsen a few months ago. He developed hemosiderin staining of the hand and then weeping ulcerations of the edematous fingers just exactly as we often see on the lower extremity. As I write this he is being worked up for an arteriovenous fistula using (of course) venograms and arteriograms. But what if we wanted to study his lymphatic system? What if we wanted “real-time,” quantifiable information about the lymphatic transport of the arm, or anatomical information about the lymphatic channels and whether they were blocked or still moving a normal lymphatic load? What if we wanted something equivalent to an “angiogram” of the lymphatics? Current nuclear scintigraphy tests of the lymphatics cannot provide real-time or anatomical information. For the past 4 years I have been working on one of the most exciting projects of my career in association with Dr. Eva Sevick, who has identified a method of lymphatic imaging using indocyanne green dye attached to a “glow in the dark” (flourophore) molecule. The camera utilizes the same technology as military “night vision goggles.” The first time we injected ourselves with microdoses of this dye just under the skin (now almost 4 years ago), we turned out the lights and watched in amazement as the camera focused right through the skin on the glowing green dye pulsating through the lymphatic channels towards the nearest lymph node. (Use the link to the TWC website to see the movie of lymphatic function. You will be among the first people in the country to actually see pulsating lymphatics!) For the first time we could determine whether the lymphatics of both arms or both legs pulsated in sync and whether they were timed with the cardiac cycle. What do the lymphatics look like when they try to regrow after surgery? What do they look like in primary lymphedema? These basic questions have remained unanswered in the 21st century, and thanks to Dr. Sevick’s work, supported by the NIH, the Department of Defense, and many other organizations, we can begin to answer them.

  I give you this shameless plug for Dr. Sevick’s article in this issue of TWC, because the day will come when this test (or one like it) will be THE diagnostic test for lymphatic function. It has given us the chance to study the effectiveness of pneumatic compression devices (PCDs) in lymphedema and more recently, the effect of PCDs on venous stasis ulcers (a trial just now underway at our clinic at Memorial Hermann Medical Center and the University of Texas, Houston). Eventually, it will be the way we evaluate the effectiveness of most treatments for lymphedema or venous disease. So, hopefully, with this test we will soon be able to tell you more about the fascinating man with the upper extremity lymphedema and venous stasis ulcers of the hand. He would seem a great candidate for pneumatic compression to control the edema of his fingers and arm and perhaps heal these unusual wounds.

  Laura Jacob provides an insightful article about the mechanism of action of PCD and their relation to vascular wounds. I have known Laura for 15 years. She was one of the first real lymphedema experts I met when I got into the field and I was awed by her engineering knowledge. Her perspective of lymphedema as an “engineering problem” and her analytical approach to research and treatment made an enormous impression on me. She postulates that pneumatic medicine represents a new paradigm for the management of patients with wounds and edema. What you don’t know from reading her article is her personal involvement with the patients she treats with PCD or how approachable she is for advice. Of course PCD cannot be used in the absence of appropriate compression. In her article on “Compression Pitfalls,” Val Sullivan reviews the most common reasons why patients fail to adhere to compression and some practical ways to deal with these challenges. I appreciate her “from the trenches” advice because we struggle with these obstacles every day. I confess to a bias about this subject because I published a paper entitled, “Why is it so hard to do the right thing in wound care?” in which we looked at the frequency with which venous ulcer patients received adequate compression.* I was shocked to discover that among patients with venous ulcers, adequate compression was prescribed in only 17% of visits to hospital based outpatient wound centers! Even at wound centers, venous ulcer patients are most frequently “treated” with advice to “elevate their legs.” Not only is elevation impractical, but inactivity increases the likelihood of weight gain and reduces the activity of the calf muscle pump. What we need to treat venous ulcers are ACTIVE, AMBULATORY patients wearing ADEQUATE COMPRESSION. Maybe Val’s article will help get that implemented.

  And that takes me to the second installment of what I like to think of as our TWC “consumer report” on compression garments. For nearly a quarter of a century I have been prescribing garments for venous disease and more recently, primary and secondary lymphedema. However, I STILL feel that I don’t know enough about them. For anyone who has ever worn compression stockings even for a day (or bought the wrong size pantyhose –ladies you know what I mean), the right fit is everything. It is no wonder that our patients have problems adhering to our recommendations when we are not sure what to order for them in the first place. A lot of engineering goes into the manufacturing of a garment. Different weaves, construction, sizing and materials can significantly affect their function and patient acceptance. I think you will find this article very helpful in prescribing garments to your patients.

  We are often equally oblivious as to whether a product we are ordering for a patient is likely to be covered by their payor. I will be ordering a PCD device for the man with the venous ulcer of his hand, but I will probably be better off explaining to his insurer that he has lymphedema of the arm rather than venous stasis of the upper extremity. I am certain to have paperwork to fill out on his behalf and a lot of specific questions to answer which relate to the coverage policy for this device. Kathleen Schaum reviews coverage policy in her usual thorough way in the “In Business Column.” There is no point prescribing devices for patients if we don’t understand both the rules which control whether they will have access to them, and our documentation obligations to help them get what they need.

  In this issue we have tried to make compression less complex by providing trouble shooting techniques for bandaging and garments as well as information on pneumatic medicine. We have tried to make it easier to prescribe these things by giving you an easy reference tool, and we have tried to keep you informed on coverage policy. So, whether you are seeing a run of the mill venous stasis ulcer or one of those patients who surprises you just when you think you have seen it all, we hope this issue of TWC will give you the tools you need. And from all of us at TWC, we wish you a happy and healthy holiday season.

*Fife CE, Carter MJ, Walker D. Why Is it So Hard to Do the Right Thing in Wound Care?" Wound Rep Reg (2010) 18 154–158.