Hrev_master Veins and Lymphatics 2016; volume 5:5986 [Veins and Lymphatics 2014; 3:5986] [page 13] Compression in mixed ulcers Giovanni Mosti Angiology Department, Barbantini Clinic, Lucca, Italy Peripheral arterial occlusive disease (PAOD) is reported in about 15-20% of patients with venous leg ulcers (VLU). In such cases compression therapy is considered a con- traindication when ankle-brachial pressure index (ABPI) is <0.8.1 Aim of this short paper is to briefly refer about the literature data and summarize our personal experience in applying compression therapy in patients with mixed ulcers and moderate PAOD. Despite the fact that arterial recanalization is often recommended as first therapeutical step in patients with leg ulcers and arterial impairment,2,3 there are some reports on clini- cal effectiveness of compression in favoring the healing of mixed ulcers with a not critical arterial disease. Ghauri4 applying compression in patients with mixed moderate arterial/venous ulcers achieved healing rates comparable with venous ulcers, although nurse-led surveillance was required. Humphreys5 managed patients with leg ulcers due to mixed moderate arterial/venous disease (ABPI above 0.5 up to 0.85) with supervised modified compression and considered for revascularization these patients only if their ulcer did not heal. He reported a 68% healing rate at 36 weeks in patients with mixed moder- ate arterial/venous disease and 87% in patients without arterial impairment. Georgopoulos6 treated patients with moderate PAOD (0.560 mm Hg. Similar data were published by Junger,11 who reported that, after application of an inelastic multicomponent compression system in subjects with moderate PAOD, laser Doppler fluxmetry indicated significant improvements of the microcirculation. Taking into consideration these data, we wanted to check the outcomes of patients with mixed ulcers with moderate PAOD treated by compression. We retrospectively analyzed the records of 180 outpatients (43 men and 137 females; mean age was 74±11.5 years; age ranged between 31-92 years) with recalcitrant venous leg ulcers (VLU with ulcer surface up to 100 cm2 showing no healing tendency after a 6 months therapy) who had been treated between January 2011 and July 2014. In this case series we compared the clinical outcome of patients with mixed leg ulcers (MLU) with that of patients affected by pure VLU (pVLU). PAOD in mixed ulcers was considered moder- ate when ABPI was <0.8 and >0.5 Patients with small ulcers lower that 15 cm2 or lasting less than 6 months, which cannot be defined as recalcitrant were excluded, as also patients affected by severe PAOD with ABPI <0.5 who need to be referred for arterial revas- cularization as first therapeutical step. Seventy-one out of 180 patients were affect- ed by MLU with moderate PAOD and 109 by pVLU. All patients received the same local dressing (debridement with saline or light antiseptic solution and foam absorbing dress- ing). When clinical signs of infection occurred Cadexomer® powder was added until signs of infection disappeared. In addition to the same local wound dressing, the patients received foam sclerotherapy (sodium tetradecyl sulfate 3%) of the superficial veins with reflux direct- ed to the ulcer area and inelastic compression therapy (CT). In patients with pVLU CT was applied with a strong pressure higher than 60 mm Hg and patients with MLU received short stretch bandages with a reduced pressure lower than ≤40 mm Hg. No patient was referred for arterial revascularization. The patients were followed until complete ulcer healing and healing rate was recorded. Patients with MLU and pVLU showed com- parable demographic characteristics in terms of sex, age, venous pathophysiology, ulcer sur- face, duration, wound-bed conditions and recurrence. Twenty-five patients were lost at follow-up and were excluded from final analy- sis. The outcomes were analyzed in the remaining 155 patients [93 patients with pVLU (85.4%) and 62 patients with MLU (87.4%)]. The maximal time for complete healing was 48 weeks in pVLU group and 52 weeks in MLU (P=0.009). The median healing time of patients with pVLU (23 weeks) was signifi- cantly shorter than that of patients with MLU (25.5 weeks) (P=0.03). Multiple linear regression analysis showed the factors which influenced the healing time: deep venous disease (P<0.001), ulcer surface (P<0.001), arterial disease (P=0.002), and ulcer duration (P<0.01). Pain ulcer-related rapidly disappeared. Pain cessation required an average of four weeks (in patients with VLU) and up to eight weeks in patients with mixed ulcers. Compression device-related pain or discomfort were mini- mal and tended to disappear when the patients got used to compression therapy. In conclusion patients with mixed ulcers and moderate arterial disease may be effec- tively and safely treated with reduced, modi- fied compression therapy characterized by short stretch material applied with reduced interface pressure (<40 mmHg) and close sur- veillance. The vein disease treatment may be completed by foam sclerotherapy of refluxing veins. This treatment protocol may heal the mixed ulcers even if in a longer time period compared to pure VLU. We suggest this conservative treatment pro- tocol to patients with mixed ulcers not compli- cated by severe arterial disease restricting arterial revascularization procedures mainly to cases with critical ischemia (ABPI <0.5). References 1. O’Meara S, Cullum NA, Nelson EA. Compression for venous leg ulcers. Cochrane Database Syst Rev 2009;1: CD000265. 2. Lantis JC, Boone D, Lee L, et al. The effect of percutaneous intervention on wound healing in patients with mixed arterial venous disease. Ann Vasc Surg 2011;25:79-86. Correspondence: Giovanni Mosti, Angiology Department, Barbantini Clinic, via del Calcio, 55100 Lucca, Italy. E-mail: giovanni.mosti10@gmail.com This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright G. Mosti, 2016 Licensee PAGEPress, Italy Veins and Lymphatics 2016; 5:5986 doi:10.4081/vl.2016.5986 No n c om me rci al us e o nly Conference presentation [page 14] [Veins and Lymphatics 2016; 5:5986] 3. Hafner J, Schaad I, Schneider E, et al. Leg ulcers in peripheral arterial disease (arte- rial leg ulcers): impaired wound healing above the threshold of chronic critical limb ischemia. J Am Acad Dermatol 2000;43: 1001-8. 4. Ghauri AS, Nyamekye I, Grabs AJ, et al. The diagnosis and management of mixed arterial/venous leg ulcers in community- based clinics. Eur J Vasc Endovasc Surg 1998;16:350-5. 5. Humphreys ML, Stewart AH, Gohel MS, et al. Management of mixed arterial and venous leg ulcers. Br J Surg 2007;94:1104-7. 6. Georgopoulos S, Kouvelos GN, Koutsoumpelis A, et al. The effect of revas- cularization procedures on healing of mixed arterial and venous leg ulcers. Int Angiol 2013;32:368-74. 7. Marston WA, Carlin RE, Passman MA, et al. Healing rates and cost efficacy of outpa- tient compression treatment for leg ulcers associated with venous insufficiency. J Vasc Surg 1999;30:491-8. 8. Marston WA, Davies SW, Armstrong B, et al. Natural history of limbs with arterial insufficiency and chronic ulceration treat- ed without revascularization. J Vasc Surg 2006;44:108-14. 9. Top S, Arveschoug AK, Fogh K. Do short- stretch bandages affect distal blood pres- sure in patients with mixed aetiology leg ulcers? J Wound Care 2009;18:439-42. 10. Mosti G, Iabichella ML, Partsch H. Compression therapy in mixed ulcers increases venous output and arterial per- fusion. JVS 2012;55:122-8. 11. Junger M, Haase H, Schwenke L, et al. Macro- and microperfusion during appli- cation of a new compression system, designed for patients with leg ulcer and concomitant peripheral arterial occlusive disease. Clin Hemorheol Microcirc 2013;53:281-93. No n c om me rci al us e o nly