Considerations For Compression

The ability for the circulatory system to deliver oxygen-rich blood throughout our body is as important as the return of deoxygenated blood back to the heart. Blood must return to the heart in order for the heart to pump oxygenated blood out to the periphery. Understanding the mechanism of action on how this important balance is achieved along with hemodynamic abnormalities and appropriate treatment can help prevent the progression of lower-extremity ulcerations. 

Lower-extremity blood return is contingent on a few factors working effectively, such as venous valve competency, having no obstructions, such as blood clots, and an effective calf pump mechanism. As we age, problems with the venous system increases proportionally due to risk factors such as limited mobility, obesity, venous disease, and others. When blood pools in our lower extremities instead of being returned to the heart, it increases excessive prolonged pressure, which the veins are not able to withstand, leading to symptoms such as swelling, pain, tenderness, and skin changes. 

More than 30 million Americans suffer from venous disease,^1-4 but only 1.9 million seek treatment each year. Venous disease, which impacts the delivery of blood return to the heart, can lead to venous hypertension and chronic venous insufficiency (CVI). Left improperly treated, CVI can lead to complications such as ulcerations and phlebolymphedema.

CVI also contributes to as many as 80% of lower-extremity wounds treated in outpatient clinics, and its prevalence is reported to range between 25–40% in women and 10–20% in men. It is reported that CVI occurs frequently in people over the age of 50.⁵

When veins become diseased and/or the calf muscle pump becomes ineffective, compression therapy remains the standard of treatment for CVI and venous ulcerations. External compression aids in venous return and decreasing capillary filtration, which leads to edema control. Additionally, one must also consider the lymphatic system when addressing CVI. As noted with the revised Startling Principle, lymphatic involvement occurs to help with fluid management, which can lead to lymphatic dysfunction if left untreated. Complete decongestive therapy (CDT), a multicomponent treatment that includes skin care, manual lymphatic drainage, compression, and exercise, is considered the gold-standard treatment when dealing with lymphatic failure.

This column will discuss a few key considerations that clinicians must account for before applying compression to an edematous lower extremity. Through a series of photos, this column will also present the case of a patient’s lower extremity that progressed from a venous complication with lymphatic involvement to lymphatic failure (phlebolymphedema) when a compression/exercise regimen was not appropriately followed.

Considerations Before Applying Appropriate Compression

• Diagnosis
  • Clinical history
  • Physical examination—looking for signs of venous disease, ulcers, skin changes
  • Ruling out systemic edematous conditions, such as renal disease, liver failure, and cardiac disease, etc.
• Does patient have adequate perfusion?
  • Obtaining non-invasive large and small vessel objective results, such as an ankle brachial index (ABI), toe brachial index, and transcutaneous oxygen (TCOM) or Skin Perfusion Pressure (SPP) can provide information for determining the proper amount of compression. If any of these test results are abnormal, vascular referral and further testing is indicated with the urgency based on results.
  • Does patient have a history of intermittent claudication?
  • Presence of pedal pulses should not be the determinant factor for applying compression.
• Poor prognostic factors:^6,7
  • Venous wounds > 1 year in duration
  • Large wounds (>10 cm²)
  • Fibrin in > 50% of wound surface
  • Inadequate arterial perfusion
  • History of venous stripping/ligation
• Indicators for slow healing⁸
  • Body mass index > 35
  • Short walking distance during the day (< 200 meters)
• Patient buy-in
  • Key phrase is that compression is for life.
  • Patient education is a must.
  • Is the recommended compression option available to the patient?
  • Does patient need assistance with donning/doffing compression?
• Sub-bandage pressure
  • Laplace’s law determines that bandage pressure is directly proportional to the bandage tension, but inversely proportional to the radius of curvature of the limb to which it is applied. Basically, increased bandage tension leads to increased pressure while increasing leg girth leads to a decrease in pressure.
  • When applying compression to a normal-shaped leg, if bandage tension is kept at a 50% stretch, one will find a graduate compression gradient from the ankle up to the calf muscle area, translating from approximately 40 mmHg to 17 mmHg, respectively.
  • If the lower extremity has an abnormal shape, such as the “inverted wine bottle,” the clinician may have to apply extra padding to build up the shape of the leg.
    • Additional considerations:
      • Bandage width must be considered. Smaller width translates to increased pressure.
      • Number of layers. Increased layers translate to increased pressure.
• Read the product manufacturer’s package insert recommendations
  • Included are indications, contraindications, usage, and pertinent information.
  • Most products do not recommend compressing based on abnormal ABIs and/or if ankle circumference is < 18 cm.
• Clinical skill and competency
  • Proper training?
  • Clinician competency?
  • Follow facility policies on compression.
• Type of compression:
  • Tubular bandages
  • Short stretch
  • Long stretch
  • Multilayer
  • Alternative Velcro device
  • Intermittent pneumatic compression
  • Garment/stocking
    • Varying degrees of compression measured in mmHg.
  • Unna’s boot
  • Duke boot
• Thrombo-embolic deterrent (TED) hose
  • Used for patients who are laying in bed, especially after a procedure, to reduce the risk of a blood clot developing
  • TEDs are for beds; not effective for ambulatory patients
• If lymphatic involvement is noted, certified lymphedema therapy referral for CDT
• Assess and treat thigh involvement accordingly 
  • Rule out May Thurner syndrome.

Ineffective lower-extremity compression treatment when thigh swelling is also present but not addressed

Initial presentation – Venous insufficiency. Compression initiated and treatment of choice.

More than 7 years later, without compression adherence, patient’s condition progressed from CVI to phlebolymphedema. CDT is now treatment of choiceAfter adherence to treatment.

Conclusion
Compression is still considered the cornerstone treatment choice for CVI. The rate for venous ulcer recurrence has been reported as high as 70%.⁹ Patients living with venous and/or lymphatic disease must be taught that compression is required for life to prevent disease progression. Appropriate selection of compression method and application is necessary to provide patients with a favorable healing outcome. The absence of compression and/or ineffective compression leads to disease progression that includes lower-extremity shape changes and skin changes, such as venous stasis, hemosiderin staining, lipodermatosclerosis, infections, ulcerations, and papillomas.

References

1. Criqui MH, Aboyans V. Epidemiology of peripheral artery disease. Circ Res. 2015;116:1509–1526. doi: 10.1161/CIRCRESAHA.116.303849. 

2. Dhaliwal G, Mukherjee D. Peripheral arterial disease: Epidemiology, natural history, diagnosis and treatment. Int J Angiol. 2007;16:36–44. doi: 10.1055/s-0031-1278244

3. Evans CJ, Fowkes FG, Ruckley CV, Lee A.\J. Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study. J Epidemiol Community Health. 1999;53:149–153. doi: 10.1136/jech.53.3.149

4. Heit JA, Silverstein MD, Mohr DN, Petterson TM, Lohse CM, O’Fallon WM, Melton LJ 3^rd. The epidemiology of venous thromboembolism in the community. Thromb Haemost. 2001;86:452–463. 

5. Cleveland Clinic. Chronic venous insufficiency (CVI). https://my.clevelandclinic.org/health/diseases/16872-chronic-venous-insufficiency-cvi

6. Ruckley CV. Socioeconomic impact of chronic venous insufficiency and leg ulcers. Angiology. 1997;48:67–9

7. Margolis DJ, Berlin JA, Strom BL. Risk factors associated with the failure of a venous leg ulcer to heal. Arch Dermatol. 1999;135:920–6. 

8.  Milic D, Zivic S, Bogdanovic D, Karanovic N, Golubovic Z. Risk factors related to the failure of venous leg ulcers to heal with compression treatment. J Vasc Surg.  2009;49:1242-1247.

9. Finlayson K, Edwards H, Courtney M. Relationships between preventive activities, psychosocial factors and recurrence of venous leg ulcers: a prospective study. J Adv Nurs. 2011;67(10):2180-2190.