External leg compression in the treatment of vascular disease

The Unilateral Swollen Lower Limb: Etiology, Investigation, and Management

The swollen lower limb, a common finding in routine clinical practice, is clinically challenging. The cause underlying this problem is often multifactorial, and its management may involve different specialties. It is important, though difficult, to avoid unnecessary and expensive investigations. The aim of this article is to provide an overview of the management of this problem by addressing the common causes, methods of assessment, diagnosis, and therapeutic options.

Compression bandaging: are practitioners achieving the ideal sub-bandage pressures?

Compression bandaging is the mainstay of conservative management of patients with venous ulceration. But debate is growing over what levels of pressure to apply and how to balance this with what patients can tolerate.

Circulator boot therapy alters the natural history of ischemic limb ulceration

Despite numerous advances in interventional radiology and vascular surgery, the clinician continues to be confronted with inoperable vascular disease. Previous studies have shown that ulceration associated with a transcutaneous oxygen pressure (tcPO2) of <20 mmHg is refractory to all attempts at healing. External pneumatic compression for the treatment of peripheral vascular disease has been available for several years, although there is a relative paucity of data regarding its role in clinical practice as well as its efficacy. The objective of this study was to examine the experience with circulator boot therapy in the treatment of ischemic ulcers in the absence of osteomyelitis, and specifically to determine whether such therapy can be of benefit in ischemic limb ulceration associated with a tcPO2 of <20 mmHg. A retrospective chart review was undertaken of ail patients with a lower limb ulcer who, in the absence of osteomyelitis, underwent circulator boot therapy at the Gonda Vascular Center. A total of 98 patients was identified. Two patients died within 1 month of commencing therapy and were not included in further analysis. The tcPO2 data were unavailable in five patients. Outcome in the patient population was classified as favorable if (1)healing was achieved, (2)the ulcer decreased in size, or (3) the affected limb improved sufficiently to allow successful revascularization. An unfavorable outcome was one where a major amputation was performed or where the ulcer increased in size. Out of a total of 29 patients with a tcPO2 <20 mmHg at the area of ulceration, 19 had a favorable outcome following circulator boot therapy. Of the remaining 62 patients with a tcPO2 >20 mmHg, 54 had a favorable outcome. Circulator boot therapy is associated with improved outcomes in limb ulceration due to peripheral vascular disease. Complete ulcer healing as well as preservation of the affected limb can be achieved in most cases.

Pulsatile venous insufficiency in severe tricuspid regurgitation: does pulsatility protect against complications of venous disease?

Prior observations showed that the consequences of venous hypertension depend not only on the magnitude of the venous pressure but also on the efficiency of compensatory mechanisms that protect against the effects of excessive pressures on the microcirculation. Pulsatile venous insufficiency (PVI) associated with severe tricuspid regurgitation (TR) provides the opportunity to investigate the effect of the pulsatile shear stress on the outcome of venous insufficiency. The authors conducted a study to assess the flow characteristics and clinical outcome of PVI associated with TR. Five patients were evaluated, presenting venous insufficiency associated with ectasia, varices, and visible systolic pulsations of the leg veins. Characteristics of the venous flow were assessed by duplex ultrasound. In two patients, flow in the distal calf veins was evaluated by power Doppler sonography, and the supine-to-sitting leukocyte trapping was calculated. Results of the latter measurements were compared with measurements in five control patients who presented chronic nonpulsatile venous insufficiency. A survey of complications of PVI was conducted. On follow-up for 6 to 15 years (average 9.4 years) none of the patients developed venous thrombosis, phlebitis, or cutaneous ulcer. Flow in the distal calf vessels was increased in PVI (12-20 vessels/field) as compared with nonpulsatile venous insufficiency (0-7 vessels/field). Leukocyte trapping in the upright position was diminished in PVI (0.8-3%) as compared with nonpulsatile venous insufficiency (7-22%). In conclusion, PVI is characterized by increased flow in the distal calf veins, diminished leukocyte trapping, and a benign clinical course. These data are in agreement with experimental studies showing that pulsatile shear stress enhances secretion of cytokines by venous endothelial cells and, consequently, counteracts a predisposition to platelet aggregation, hypercoagulability, and white cell adhesion and promotes healing of leg ulcers.