PAGE 36, JOURNAL OF VASCULAR NURSING. JUNE 2015 wen Joascnursiner Chronic venous disease and venous leg ulcers An evidence-based update ‘Teresa J. Kelechi, PhD, RN, CWCN, FAAN, Jan J. Johnson, MSN, RN, ANP-BC, CWOCN, RN, ANP-BC, CWOCN and Stephanie Yates, M: Chronic venous disease (CVD) is a complex chronic vascular condition with multifaceted primary and secondary et ologies leading to structural and functional changes in veins and valves and blood flow of the lower legs. As a conse: quence, a spectrum of clinical manifestations arise, ranging from symptoms of mild leg heaviness and achiness to debilitating pain, and signs of shin changes, such as eczema and hemosiderosis, to nonhealing, heavily draining venous leg ulcers (VLUs). Triggers such as trauma tothe skin are responsible for a large majority of VLU recurrences, Diagnostic testing for venous refx includes ultrasound imaging: unfortunately, there are wo diagnostic tests to predict VLUs. The hallmark of treatment of both CVD and VLUIsi compression, Leg elevation, exereise, and wound management with dres- ings and advanced healing technologies that provide an environment conducive to healing should focus on reducing pain, necrotic debris, drainage, and odor, as well as preventing infection. VLUs that become chronic without evidence of healing ‘over ad-week period respond best to multdisciplinary wound experts within a framework of patient-centered care, Nurser ‘are in key positions to provide early recognition ofthe signs and symptoms as well a initiate prompt diagnostic and pro ‘mote early treatment to offse! the progression of the disease and improve quality of life. (I Vase Nuss 2015;33:36-46) ‘Chronic venous disease (CVD) is a vascular condition char- acterized by a myriad of symptoms ranging from lower leg swelling and skin redness to venous leg ulcers (VLUs). The ‘ease can become chronic and progressively debilitating, Com- plaints of leg achiness, pain, and heaviness are common. ‘Affecting millions of individuals worldwide, CVD remains ‘underdiagnosed, misunderstood, and disregarded as posing sig- nificant health threats.’ The purpote of this evidence-based auticle isto increase awareness of the signs and symptoms, diag- nostic tests, and classification criteria of CVD, as well as VLU treatment, including primary and secondary prevention strate- gies, Barly recognition and prompt ueatment can alleviate and/ ‘r prevent the physical, functional, and psychological complica tions of this chronic vascular disorder. SIGNIFICANCE Decades of investigation into CVD etiology and risk factors and teatments for VLUs"’ have resulted in numerous From the College of Nursing, Medical University of South Carolina, Charleston, South Carolina; Wound Management Center, Duke University Medical Center, Durham, North Carolina; Duke Cancer Center Duke University Medical Center, Durham, North Carolina Corresponding author: Teresa J. Kelechi, PhD, RN, CWCN, FAAN, College of Nursing, Medical University of South Carolina, {99 Jonathan Lucas Sireet, MSC 160. Charleston, SC 29425-1600. Tel +1 843-792-4602, 843-810-3157(cell): fax: +1 843-792. 2104. E-mail: kelecij@muscedy) 1062-0305/836.00 Copyright © 2015 by the Society for Vascular Nursing, Inc up ffa: doi. org/10.1016)}vm.2015.01.003 consensus statements and evidence-based guidelines"; however, the overall management remains suboptimal.° Unfortu: nately, individuals with CVD and VLUs experience negative func- tional and psychological consequences, which lead to low physical activity, increased risk for other comorbid conditions (such as obesity,’ ansiety and depression,’ social isolation”) and poor quality of life." The economic burden is enormous. In 2008, the National Institute of General Medicine Sciences re- ported that between $20 and $25 billion was spent for ulcer cate, not accounting for costs associated with lost wages snd hu- ‘man sulfering. Asthe population ages, the incidence of new VLLUs isexpectedtofar surpass the 600,000 VLUs that develop each year inthe United States.” Similarly, the prevalence rate for VLUs that affect 6.5 million individuals is expected to increase requiring ‘more intensive screening and weatment to prevent ulceration! PATHOPHYSIOLOGY ‘The most common etiologic factors associated with CVD include hypertension of the venous system of the lower legs, incompetent perforator veins that connect the deep and superti- cial veins, weak valves leading to reflux ot retrograde blood flow, and failure of the calf muscle pump to move deoxygenated blood from the venous system.” Veins can be injured as a result of inflammation, trauma, venous thromboembolism, surgery. and comorbid conditions, such as obesity. These factors lead to vein damage, venous insufficiency, and/or CVD." VLUs are the most common type of lower extremity ulcer, ac- counting for >70% of all types of ulcers, including those with an arterial or neuropathi/diabetic etiology, or a combination of et- logies."” Approximately 50% of VLUs are chronic, filing to proceed through an orderly reparative process fr timely healing of the anatomic or functional injury.” Chronic VLUs are open for 4-6 weeks or more,” and have a tendency to become infected, ‘malodorous, and painful. Several theories have been establishedol, XXXMI No, 2 JOURNAL OF VASCULAR NURSING PAGE 37 wren Joasenursinet ahout the causes of VLUs including the development of fibrin cuffs, leukocyte entrapment, and microangiopathy.” Also, recent studies of pathogenic associations in VLUs have demonstrated an overabundance of activated neutrophils secreting high levels of proteases,” such as metalloprotcinase9, that kill growth fac~ tors! These aberrancies contribute to a chronic inflammatory state that disturbs the microczculatory blood flow and inhibits healing Several risk factors for developing CVD and VLUs have been identified (Table). CLINICAL PRESENTATION ‘The initial presentation of CVD varies widely. Common syrnp- toms of CVD include heaviness or aching of the legs, especially at the end ofthe day: calf, thigh, orbuttocks pain; swelling around the lower pat of the legs: dry skin; a feeling of tightness inthe lower limb; skin ititation; and itching.” If pain is present itis typically reported as worsening with prolonged dependency, improving with levation, and may be severe enough to limit ambulation." ‘VLUs ae confined generally to the lower aspect ofthe leg at the gaiter region, located between the malleolus and calf muscle. ‘The ulcers tend to be large, have irregular borders, variable ‘exudate, pain, and odor, and may present with or without fibrin, ‘hich is a yellowish material embedded between small red gran- ulation buds of healing tissue.” Classification systems ‘When physical signs of CVD are present, the most commonly ‘used classification system is the CEAP classification: C (clinical presentation), E (etiologic factors), A (anatomical location). and (pathologic process; Table 2).""" Other venous classification systems such as the Chasting Cross Venous Ulcer Questionnaire and the Venous Clinical Severity Score, assess risk, quality of life, function, treatment outcomes, and severity ofthe disease."" ‘There is no classification system for VLUs or consensus on the best approach ta staging them (eg, full vs patil thickness) ASSESSMENT AND DIAGNOSTICS ‘The diagnosis of VLU is primarily made based on an assess- ‘ment of the patient's history and the clinical examination, The assessment should determine if there is a family history of CVD andlor past or present thromboembolic conditions, and calf muscle pump dysfunction, which cause inereased resistance to venous return and damage tothe valves.’ Ask the patient about a history of healed or current ulcerations, noting the location, character, duration, treatment, number of recurrences, and possible “wiggers.” Approximately 74% of VLUs begin with a specific tigger such as cellulitis, penetrating injury/trauma, con- tact dermatitis, rapid onset of leg edema, burs, dry skin with itching/seratching, and insect bites."” Factors identified with poor healing outcomes include having a longstanding ulcer, infection, longer topical and systemic antibiotic use, and poor adherence to compression therapy.”! Assessment and dacumen- tation of VLUs should include measurements of the size (length, ‘width, and depth), location on the leg, condition of the wound ‘edges (eg, rolled down in appearance), characteristics of the ‘wound bed (ie, slough, hypergranulation), presence of exudate, ‘odor, and pain, and the condition of the periwound skin,” RISK FACTORS Nonmodifiable Modifiable Older age Physical inactivity Diabetes Higher body mass index Hypertension Toint/skeletal disease of the legs (eg, rheumatoid arthritis) History of superficial and deep venous thromboembolism Family history of venous leg ulcers Deep or perforator vein reflux, deep vein obstruction, or combination of both CLINICAL CLASSIFICATION OF CHRONIC LOWER EXTREMITY VENOUS DISEASE* Class Clinical signs ° No visible or palpable signs of venous disease 1 Teleangiectases, reticular veins, malleolar flare 2 Varicose veins, distinguished from reticular veins by a diameter of =3 mm 3 Edema without skin changes 4 Skin changes ascribed to venous disease 4a — hyperpigmentation 4b — venous eczema 4c — lipodermatosclerosis 4d — atrophie blanche 5 Skin changes (as defined in class 4) in conjunction with healed ulceration 6 Skin changes (as defined in class 4) in conjunction with active ulceration "Auapled wid permission om Wound, Osiomy and Continence [Nutees Society, 2015, Because patients with CVD may have concomitant arterial disease, hand-held Doppler ultrasonography verifies the presence of an audible signal when edema makes palpation of the pulse difficult, Assessment in the clinical setting should include anPAGE 38, JOURNAL OF VASCULAR NURSING. JUNE 2015 wen Joascnursinet ankle-brachial index (ABI) as @ measure of perfusion status of the lower extremity.” ABI rules out coexisting arterial disease and determines the appropriate level of compression to be used for eatment.” Peripheral sensory neuropathy is often present in patients with CVD and the patient's evaluation should include monofilament testing.” Decisions regarding which tests ae indicated are made after considering whether the patient is interested in vascular interven- tion and whether they are a suitable candidate. Vascular studies are als helpful when the clinical presentation is unclear or typ- ical, Color flow duplex is the most reliable and first-line diag- noslic tes’ Ultrasound is used to identify vessels, elucidate the presence and direction of blood flow, detect Venous reflux ‘or venous obstruction, and identify its anatomic location, This in- formation confirms the diagnosis of venous insufficiency and can ‘be used to plan for vein ablation of other interventions. Other noninvasive tests used to assess the presence and severity of ‘enous reflux include air plthysmography and photoplethys- mography (PPG); however, they do not have a primary ole in clinical prectie as diagnostic tests.” PPG is relatively quick to perform and provides information about the overall venous refill time (normal is > 20 seconds). Handheld PPG devices have been shown to provide valid results and may be used in selected set- tings asa screening test for suspected venous insufficiency.” CLINICAL MANAGEMENT Compression therapy ‘Compression is well-established as an effective treatment for ambulatory Venous hypertension and considered the gold stan- dard of care for managing CVD and VLUs."* Compression re- duces the distention of supericial veins and assists the calf ‘muscle pump by preventing retograde flow of blood, resulting i reduced edema.” ‘Compression therapy is contraindicated in severe arterial insf- ficieney, acute o uncompensated heart failure, and acute unteated cellulitis." However, compression can be safely used in selected patients with mixed arterial and venous disease, if the level of ‘compression is modified." For an ABI between 0.60 and 090 mmllg, reducing ankle compression to 20-25 mmallg is recommended: for ABIs of <0.50 mmHg or an absolute ankle pressure of <70 mm, compression is contraindicated, and the patient shouldbe evaluated forevasculsization, In cass of acute cellulitis, the patient is treated initially with elevation and systemic anxibioes, and when the inflammation and pan subside, compres- sion can be implemented.” ‘Compression can be provided by multiple modalities, including wraps (bandage is the more commonly used term in European literature," leggings stockings, hose, garments and devices (Lable 3), The most common and best known wrap, the Unna's boot, was developed in 1883 by German dermatologist Dr Paul Gerson Unna (1850-1929)"" and remains the most pop- ‘ular type of layered compression wrap in the United States: the 4-layer wrap is more widely used in the United Kingdom.” Types of compression. There are 2 major types of compres- sion—slatic and dynamic—used in the teatment of VLUs and the management of CVD. Static compression is characterized by a constant pressure gradient from distal to proximal in the lower extremity and includes compression wraps/bandages, gar ments, and leggings. Compression wraps can be composed of elastic oF inelastic materials, oF a combination of both, as with multicomponent wraps."° Compression bandage materials are often classified as elastic (long stretch) or inelastic (short stretch, Extensibility i the term used to describe the degree to which the bandage can be stetched when pulled. In general, the elastic! Jong sietch bandage has a maximal extensibility of >100%, Whereas the inelastic/short stretch bandage has <100% maximal extensibility.” Inelastic compression wrap systems have high working pres- sures when the patient is ambulating and low resting pressures ‘when patient is at rest. This type of system cannot accommodate changes in the leg's volume, such as an increase in size with edema, or reduction of edema and size ofthe leg with elevation, ‘Wraps with an elastic component are effective whether the pa- tient is resting or active.” ‘An international expert consensus group recommends that classification of compression systems (ie, wraps or bandages) ‘make a distinction between layers and components of bandaging systems.“ Previously, compression wraps were described as sin- ale layer, layer, 3 layer, or 4 layer, when even single layers have Cverlap. The components inthe bandages should be described as orthopedic wool, crepe, paste, or self-adherent, rather than count- ing the layers. Thus, itis recommended that wraps be docu- mented as either single-component or multicomponent versus layers” with one exception for the Charing Cross 4-layer bandage (4LB), 4LB is term that continues to be used because itis an internationally recognized bandage system."” There are humerous advantages of this new classification metiod; it pro- motes consistent use of the terminology, provides guidance among healthcare providers regarding the likely effect of the bandage on patients’ legs, and fosters comparisons among different devices if used in research.” The method provides sup- port for manufacturers who want to ereate products with spectie compression levels and outlines specifications for health author- ities and insurance companies for reimbursement. Compression hosiery is another type of static compression and includes hose, stockings and other garments such as leg- sings. Inthe United States, stockings are the mainstay in main- tenance therapy for patients with CVD, and available in 5 pressure gradients (<20, 20-30, 30-40, 40-50, and >50 mmHg)" To be effective, the stockings should exert 20-30 momPlg of pressure at the ankle. A variety of lengths are available, including knee high, thigh high, chaps (unilateral waist high), and pantyhose; knee length is considered suffi- cient for most patients and is usually well-olerated.”* Low-pressure stockings in the 8-10 mmllg (support) and 15-17 mmHg (anti-embolism) range are considered inadequate for treatment of CVD or VLUs.* Application of compression stockings can be difficult for patients who are obese, have back problems, or have limited hand strength or dexterity, ‘There are several devices such as stocking doffing and donning applicators, zippered stockings, stocking liners, and leggings with Velcro fasteners to assist patients who are unable to re- move and/or apply their stockings. Stockings are suboptimal for the treatment of VLU. ‘The second type of compression is dynamic compression, which is delivered by a device such as an intermittent pneumaticVol. XXXII No, 2 JOURNAL OF VASCULAR NURSING ‘wren oasenursinet PAGE 39 (COMPRESSION THERAPIES* Type of compression Examples Performance characteristics and mmHg pressure High elastic compression: 3 oF 4 ‘component Light compression, support Light support Cohesive bandage Multicomponent, high compression Inelastic compression Elastic compression: Stockings Hosiery Leggings Dynamic compression: Intermittent ‘compression pumps Setopress (MoInlycke), Surepress ‘(Convatec) Elastocrepe (Smith & Nephew; BSN Medical), Tubigrip (Molnlycke), Medigrip (Medline) Crepe, rolled gauze Coban (3M), Co-Flex (Andover), ‘Medi-Rip (Hartmann), Sensi-wrap (Dynarex) Profore (Smith & Nephew), DYNA- FLEX (Systagenix), FourPress (Hartmann) Short stretch: Comprilan (BSN Medical), Coban 2 (3M) Farrow Wrap (Farrow Medical) Unna’s boot paste: Tenderwrap Kendall (Covidien), Unna-Flex ‘(Convatec), Gelocast (BSN Medical), Duke boot-modified Unna’s boot" CirePlus Cireaid (medi) Jobst (BSN-Jobst USA), Juxte-Lite adjustable Circaid (medi), Juz0 (Guzo USA), Sigvaris (Sigvaris USA), TheraPress Duo (Hartmann Conco) ‘Lympha Press (Lympha Press USA). Flexitouch (Tactile Systems Technologies), Mobility (DermaScience) “Aaapied with ponnistion fom Wound, Oxomy and Continence Noreh Society, 2015, Sustained compression, wash and reuse, 25-35 mmHg Low pressure, light support, 14-17 mmHg Secures dressings Self-adherent, compression well-sustained ‘Maintains 35-40 mmHg at ankle 23-40 mmHg 20-30 mmHg light: 30-40 mmHg regular Zinc oxide impregnated bandage often ‘with calamine (plus cohesive bandage with Duke boot) Static compression Delivers: 20-30 mmHg 30-40 mmHg 40-50 mmHg >50 mmHg Inelastic, intermittent inflation compression (IPC) pump that provides continuous changes inthe intensity of the pressure and does not require any bandaging Pumps consist of a plastic bladder-ike sleeve that encases the leg and invlaes to a preset pressure and then deflates over many repetitive eycles for a prescribed amount of time. This type of compression is useful for immobile patents or those needing higher pressures than cannot be obtained or tolerated ‘with static compression wraps or stockings. Evidence suggests that IPC facilitates wound healing when compared with no compression; however, thete is limited evidence as to whether IPC provides a greater benefit for healing when itis used in addi- tion to compression wraps.” A benefit of TPC is thatthe pumping action enhances Venous zetura without impairing arterial blood ow, making it safe for patents with coexisting arterial disease." Benefits of compression. Despite the fact that long-term compression therapy bas been demonstrated in numerous ran- domized clinical trials to be beneficial in the management of CVD and VLUs, there are no internationally accepted perfor- mance standards." However, based on the evidence as reported, in recent systematic reviews."""" it is concluded that: ‘© Compression compared with no compression increases ulcer healing rates ‘* Multicomponent systems are more effective than single-component systems; ‘* Multicomponent systems containing an elastic bandage seem to be more effective than those composed mainly of inelastic components”;PAGE 4 JOURNAL OF VASCULAR NURSING. JUNE 2015 wen Joascnursnet ‘© Two-component bandage systems seem to perform as well as the 4LB; «© Patients receiving the 4LB compared with short stretch bandages heal faster; and ‘© Further research is required before the difference between high-compression stockings and the 4LB can be estab- lished on patient outcomes such as reduction of edema and prevention of VLUs. Elevation Limb elevation is simple way to decrease edema associated with CVD and improve microcizculation. Although the dizectef- fect of elevation on healing VLUs is unclear, its positive effect on enhancing the microcirculation inthe capillaries, venules, and ar terioles is well-documented.” Approximately 60% of blood vol- ‘ume isin the veins and, when the legs are clevated above the heart, the larger veins empty passively by gravity while the microcirculatory system responds by opening up, enhancing blood flow: when legs are in a dependent position, the opposite ‘occurs. The large veins fill with blood and there is a decreased microcirculatory flow as a result of the physiologic venoarterio- lar eesponse.”” Leg elevation is especially important inthe daily routine of patients who are unable or unwilling to adhere to a compression therapy regimen." However, leg elevation alone is usually inadequate forthe management of patients with severe ‘CWD (tage C5) and is more effective when combined with ‘compression therapy.”* Most guidelines recommend three or four 30-minute sessions of leg elevation per day, or 1-2 hours twice daily.” TOPICAL THERAPY FOR VLUS Dressings ‘Wound dtessings are a critical component of VLU care. Fac- tors to consider inthe selection of dressings include the uleer's characteristics, the patients needs such as confor, availabilty, cost, ease of application, and avoidance of allergens.”” Dressings ‘an be effective in decreasing the rate of infection, promoting & ‘moist environment that enbances autolytic debridement, and facilitating growth of granulation tissue, as well as controlling ‘odor and pain, Options for dressings to manage VLUs include ‘occlusive, semipermeable adhesive films, simple nonadherent Jressings, composites, transparent films, collagens, acellular bu- ‘man skin equivalents, biologicals or cellars, antimicrobials Cie, caldexomer iodine, silver), impregnated gauzes, paraffin gauze, hydrogels, hydrocolloids, alginates, and foams. Occlusive dressings stimulate collagen synthesis, speed ree- pihlislization, and create an environment that encourages angiogenesis” Occlusive hydrocolloid dressings have been found to reduce pain and are often preferred by patients because ofthis effect, the ease of application, and lower cost”? Other types of dressings, such a low adherent dressings, ae inexpen- sive but require freqvent changes and they control odor and rainage poorly. Hycrofibers and alginales ae highly absorbent and well-suited for management of the heavily draining VLU. A patil list of dressings is provided in Table 4 Investigators of numerous studies of dressings for VLUR, such as hydrocolloids, alginates, foam, and hydrogels, concluded there was no evidence that any of these dressings were more effective to promote healing than another.’ For example, a review of 5 tials comparing alginate dressings with other alginates, hydrocolloids, and plain nonadherent dressings found there were no significant differences in the healing of VLUs."! It should he noted that these studies were found to be of low or unclear methodological quality. Twelve randomized contol iri- als compared foam dressings with other dzessings and there was no evidence that foam dressings were any more effective than other wound dressing treatments; however, the evidence was found to be of low quality.” ANTIBIOTICS AND ANTISEPTICS ‘When VLUs become infected, healing is delayed, Systemic antibiotics can be taken by mouth, injection, intravenously, or topically to treat wound infection. Without clinical or laboratory evidence of infection, there are no data to support routine use of systemic antibiotics to promote wound healing." There is some evidence to support using caldexomer iodine, a topical prepara- tion thought to have cleansing and antibacterial effects" There is limited current evidence to support the topical use of honey or silver-based products (o aid healing or to teat infection” ‘There is 1 exception: manuka honey. which has been shown pre- viously to be bactericidal, and may reduce the motility of Pseu- domonas aeruginosa by exerting an antiseptic effect and limiting its virulence.” Rigorous research is needed before conclusions can be drawn about the effectiveness of oral antibiotics and topical agents in healing VLUs Silver-containing dressings are popular for the management of VLUs. In a review of trials evaluating these antimicrobial dressings, the studies were found to be of low quality. Silver dressings reduced wound size, but there were no differences in the rate of wound healing with silver dressings compared with other types of wound dressings.” Tn other tials using silver containing dressings, odor and drainage were seduced signifi cantly, but size was not affected.” Therefore, tere is insufficient evidence that silver-containing dressings are more effective for eating VLUs than other dressings.”” Rigorous research is needed before conclusions can be drawn about the effectiveness of orl antibiotics, topical agents, and dressings in healing VLUs. ADJUNCTIVE TREATMENTS FOR VLUS Negative pressure wound therapy [Negative pressure wound therapy was introduced first in 1997 and is used to teat acute or chronic wounds. The continous or Intermittent pumping action ofthe device removes fuid and other exudative materials, Its role in healing of VLUs is uncertain; few studies have been conducted to establish the effectiveness of negative pressure wound therapy compared with standard of care on wound bed management, absorption of drainage, redue- tion of odor and pain, and maintenance of a moist healing environment.” Other adjunctive weatments for VLUs, hyperbaric oxygen therapy,” electromagnetic therapy,”” and therapeutic ultrasone- graphy,”” are considered to be ineffective owing to a lack ofVol. XXXII No, 2 JOURNAL OF VASCULAR NURSING PAGE 41 wren oasenursinet DRESSINGS Product wi examples Characteristics Indications Alginatelhydcofiber Agisite (Smith & Nephew) Restore, Caleicare (Hollister Aquacel (ConvaTec) Foam Biatain (Coloplast) Ura (Milken) Allevya (Smith & Nephew) Optifoam (Medline) Hydrocolloids DuoDerm CGF (ConvaTec) Replicare (Smith & Nephew) Exuderm (Medline) Hydrogel Aquasite (DermaSciences) Curasol (Healthpoint) Normigel (Molalycke) Elasto-Gel (Southwest Technologies) Contact layer Merpitel (Motolycke) ‘Adaptic, Adaptic Touch (Systagenix) Demanet (DeRoyal) ‘Antimicrobial dressings Silver impregnated: Actisorb (Gobnson & Johnson) Manuka honey: Medihoney (ermaSciences) Todine containing: Iodasorb (Smith & Nephew) Polybexamethylene biguanide (PHMB): Kendall AMD (Covidien) Gauze Kerlix (Covidien) Many others Highly absorbent, nonwoven, converts to viscous hydrophilic gel when wet Requires a secondary dressing ‘Made of hydrophilic open cell polyurethane Available in many forms ‘With and without adhesive borders Composed of gelatin, pectin or carboxymethyleellulose Available in various shapes and forms Adhesive and occlusive Absorbs light to moderate exudate and forms gelatinous contact with wound base Formulation of water, polymers and ‘other ingredients in various forms Absorbs very litle ‘Maintains a clean, moist wound base Many require secondary dressing Porous dressing used to line wound base to prevent adherence Requires a secondary dressing Dressings of various makeup that are impregnated with antimicrobials ‘Most require a secondary dressing Dry, woven or nonwoven sponges made of cotton, polyester, rayon May be sterile or nonsterile Partial to full-thickness wounds with moderate to heavy exudate Partial to full-thickness wounds with moderate to heavy exudate Avoid using adhesive border under compression wrap Partial or full-thickness wounds with ‘minimal depth and mininval to moderate exudate Use with caution for infected wounds Promotes autolysis, Reduces pain and protects Partial or full-thickness wounds with dry base or minimal exudate Assists with autolytic debridement Rehydrates wound base ‘Watch for maceration of periwound skin Partial ot full-thickness wounds ‘May be used over skin graft sites, infected wounds, and donor sites Partial or full-thickness wounds where colonization or biofilms are suspected ‘May be used for odorous wounds Should not be used alone to treat an infected wound ‘Used forall types of wounds as either a primary or secondary dressing Absorbs but does not wick away drainage (Continued)PAGE 4 JOURNAL OF VASCULAR NURSING. JUNE 2015 wen Joascmursiner CONTINUED Product with examples Characteristics Indications Collagen dressings Promogran (Systagenix) Biostep (Smith & Nephew) Endoform (Hollister) fibers fibroblasts Many formulations derived from bovine, porcine, or avian sources ‘May enhance deposition of collagen Chemoattractant to granulocytes and Requites a secondary dressing Full-thickness wounds with minimal to moderate drainage Consider with slow or stalled healing high-quality, comparative effectiveness trials. Medications and supplements have received increased attention over the past decade, There is sufficient evidence to suppor the use of pentox- ifylline to aid in blood flow, with or without compression.” ‘There is a category of biotechnology products that specifically target nonhealing foot and leg ulcers. These tissue-engineered skin biological or cellular skin substitutes or equivalents include ‘exyopreserved fibroblast derived dermal. substitutes, platelet-derived growth factors, autologous keratinocytes in @ fibrin sealant, and allogenic, bilayered living human skin equiva- Tents. There ae inconsistent data to support whether they are su- perior 0 standard dressings on shortening treatment times, ‘decreasing complications, or reducing hospitalization." A recent study of platelet-derived growth factors showed no beneficial f= fects on healing times for VLUs.”” These products are more ‘expensive than standard dressings; thus, the cost benefit needs to bbe considered as pat of the total cost of care. “ Of note: all prod- ucts and dressings should be used in conjunction with compres- sion therapy; they are not intended as standalone treatments human NEW AND INVESTIGATIONAL TREATMENT: Unfortunately, there is no cure for CVD and VLUs, which continues to fuel the quest for new and innovative discoveries, Some recent advances to promote the healing of VLUs include membranes (eg, poly-W-aeetyl glucosamine)” newer collagen matrices.” statin therapy.” topical agents. including zinc,” hemoglobin spray,” aloe vera," sulodexide,”* and chemokine- ‘based stem cell therapies."° SURGICAL MANAGEMENT ‘Although superficial vein surgery has been shown to decrease the rate of recurrent VLUs, evidence demonstrates, although itis Limited, hat it may also improve healing rates of VLUs recalei- trant to conservative measures."* Anecdotally, many surgeons and insurance providers are requiring a 3- to 6-month trial of standard and/or advanced wound healing technologies before ‘considering surgical options ‘The minimally invasive techniques used to treat great saphe- ‘nous varicose Veins include ultrasound-guided foam sclerother- apy, radiofrequency ablation, and endavenous laser therapy.” ‘When these techniques are compared with fush saphenofemoral ligation with stripping (also referred to as open surgery) or high ligation and stripping, there are fewer complication lost from work, improved quality of life scores, less need for gen- eral anesthesia, and similar recurrence rates of VLUs."" Evidence from current clinical trials suggests that ultrasound-guided foam sclerotherapy, endovenous laser therapy, and radiofrequency ablation are at least as effective as surgery in treating great saphenous veins."” Furthermore, the current evidence does not support conclusively the advantage of endovascular surgical in- terventions compared with compression alone for healing.”* Although superficial endovenous thermal ablation is gaining in popularity, there are no randomized, controlled trials about its ef fects on healing VLUs, quality of life, or its cost effectiveness." “The evidence lacks robustness owing to large incompatibilities between the trials and different methods used to measure out- comes; therefore, more research is needed PRIMARY PREVENTION FOR VLUS Prompt identification of CVD (CEAP levels C1-C3) allows for eauliet teatment, which is diected toward reducing 5 toms and preventing progression to ulceration. Patients with known risk factors or early signs of venous insuficiency (eg, edema) should be instructed to use compression stockings ox ‘wraps immediately and consistenly during waking hours to prevent venous edema and ulceration In addition to compression, there are 3 additional categories of preventive strategies, including weight management for obesity, execiselphysical activity to improve the efficiency of the calf muscle pump, and teatment of varicosities. Efforts should be undertaken to attain and maintain a healthy weight, Including diet, exercise, counseling, drug therapy, and weight loss surgery. Because an impaired calf muscle pump plays a crite ical role in the pathophysiology of CVD, exercise programs aimed at improving the function ofthe calf muscle have shown to be helpful fr patents with both CVD and VLUs.”? Physical therapy may improve range of motion andor gat Interventional treatment of varicosities, suchas endovenaus laser ablation, radiofrequency ablation, and other approaches to repair veins and valves, have been shown to prevent the progression of CVD to ulceration.”Vol. XXXII No, 2 JOURNAL OF VASCULAR NURSING PAGE 43 ‘wren Joasenursinet (COMPRESSION STOCKING CLASSIFICATION®: UNITED STATES US class Descriptor __Ankle pressure (mmHg) IndicationCEAP Light support 20-30 ‘Treatment of varicose veins; CEAP class C, to Cy 2 Medium support 30-40 ‘Treatment of mote severe varicosities and prevention of leg ulcers; CEAP class C, to Cs 3 Strong support 40-50 ‘Treatment of severe chronic hypertension and severe varicose veins, and (o prevent VLU recurrence; CEAP class Ce 4 Very strong support 50-60 ‘Treatment of VLUs; CEAP class Cy ‘CEAP = clinical, cuologc, anatomical and puholopiealclaviieation: VL “Reprinted with permision from the Wound, Ostomy and Continenee Nunes Society, 2015 nous lg ulcer SECONDARY PI RECURRENCE, v1 ‘TION: PRE G VLU Patients must understand that compression therapy will be a lifelong commitment. After a VLU bas healed, a compression garment providing the appropriate strength of compression rust be wom daily. The prescription for elastic compression stockings must include both the length (i, knee, eal, thigh, or waist) and the amount of tension or compression. Knee-length ‘compression is the common length used because it promotes increased adherence as long as symptom relief is adequate.” Based on clinical severity, the amount of compression for pa- tients varies according to the CEAP classifications, The amount ‘of compression for patients with CEAP class C2-C3 should be 20-30 mmHg, those with CEAP classes C34 and C3 should use 30-40 mmHg, and patients with recurrent ulcers should use 40-50 mmllg. Active ulcers CEAP class C6 requires high compression (50.60 mmHg). There are various compression classification aystems; the one used most commonly in the United States i shown in Table 5 If the patient is unable to don or doff the stockings indepen- ently, and does not have available assistance, 2 referal to ‘occupational therapy may be needed or a different type of ‘compression used. Other types include tubular elastic bandages or inelastic compression leggings with Velero straps. The goal is to provide the level of compression that is most appropriate for the patient's disease status," and with which they will comply. SurgicaVintrventional correction of varicosities and valve dysfunction can also contiibate to secondary prevention."° Adherence to lifelong exercise programs, weight contol, and protection against skin injury is critical CARE DELIVERY MOD} Health service pathways that offer patient-centered care mo- dalities are gaining popularity as methods to provide immediate and real-time consultation for patients with VLUs, For example, telemedicine is one health care delivery modality that could augment and/or potentially replacement in-office visits for ‘wound healing evaluation. Although wound telemedicine (eg, advice is provided by teams of wound care experts to home health nurses) holds promise for improved healing of chronic ‘wounds compared with conventional care,”’ there is conflicting evidence as to whether telemedicine consultation is as effective as traditional in-office follow-up.” “There is growing evidence to suggest that using a multidisei- plinary approach and care that is guided by clinical wound ex- petts, and/or delivered in specialized wound centers, improves patient outcomes and results in fewer hospitalizations and surgi- cal procedures.”” As technological advancements, interactive systems, and hand-held, self-monitoring devices (eg, infrared thermometers), and self-management therapies (¢g, cooling in- flamed skin)" become popular in the prevention of VLUs, patients will play more active roles in comprehensive, patient centered models of wound care.” NURSING IMPLICATIONS It is recommended that patients with chronic VLUs of >4 weeks’ duration without healing be referred to specialty wound. cate providers or centers. They are better equipped to employ tueatment decision-based algorithms and advanced wound heal- ing treatment modalities, and provide supportive care to patients and cazegivers."° When selecting any type of CVD or VLU man- agement approach, it is imperative to consider the underlying pathophysiologic deficit, disease stage, characteristics of the ul- cer, functional abilities, and quality of life ofthe patient and care- giver, as well as costs. Unfortunately, CVD is associated with ‘multiple comorbid conditions that can hamper the effectiveness of treatments and healing of VLUs. Although treatment takes place in multiple clinical settings and is provided by numerous isciplines, it is important to provide care that is guided by evidence-based, clinical practice guidelines, and is well coordinated, In conclusion, CVD and VLUs affect millions of individuals and are associated with significant physical, functional and emotional disabilities and high costs of care. 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