“Compression is a chronic treatment”

Venous leg ulcers can usually be healed using physical decongestive therapy. But their trigger, chronic venous disease, requires lifelong compression. The patient’s self-management is also important, explains Erik Küppers, wound specialist, in this interview.

life: How significant is the socio-medical burden that is caused by venous leg ulcers?

Erik Küppers: e actually don’t have much information about that at the moment. We recently initiated a comprehensive study with eurocom¹ that is designed to examine the social burden of conditions in which compression treatment plays a role. One thing is certain: the overall economic costs beyond the subject of medical aids are significant. Vessels are patient but at some point, they will strike. When the skin suddenly bursts open with ulcers, the world of those affected changes from one day to the next.

Venous leg ulcers are caused by chronic venous disease. You have coined the term “chronic treatment.” What does that mean for you?

Erik Küppers: Many people ignore the condition for a long time. Initially, they only have spider veins, then varicose veins, later a small red area. If measures aren’t taken in a timely manner, the wound will open up. After in-depth diagnostics, a treatment plan and treatment goal have to be prepared. The wound can usually be encouraged to heal effectively, but we have to be aware that we’re only treating the symptoms of chronic venous disease. We can’t eliminate the cause of the problem. Chronic vascular disorders need chronic treatment even when the wound has healed. And that means regular treatment. Daily. For the next 100 years. That’s what I tell my patients, even the 85-year-olds. It sounds more positive than ‘for the rest of your life.’ We have to accompany our patients on a lengthy, demanding journey. And we need adherence for that. I therefore motivate all my patients to moisturize their legs every day and inspect them carefully. I can see the condition of my vessels when looking at my leg. 

“We have to accompany our patients on a lengthy,
demanding journey.”

Erik Küppers

How does edema development impact the condition, and what role does decongestion play?

Erik Küppers: Edema development and decongestion depend on each other. We have to remember that the cardiovascular system provides the tissue cells in the leg with important nutrients. For this, they diffuse (flow) via a defined route. Metabolic waste products are also removed via this same route from the cells to the vessels. Edema will make this diffusion route longer, which results in deposits and insufficient supply to the tissue cells, which, in turn, increases edema. Transport will be impaired, metabolites will accumulate, and the thighs will turn brown, which is a precursor to venous leg ulcers. If the edema is not removed, the cell will ‘burst’ at some point, resulting in ulcerations. During decongestion, the edema and therefore the diffusion route will be reduced.

What effect does compression have exactly, and what methods are available for this?

Erik Küppers: In the beginning, there will always be decongestive therapy, for example including lymphatic drainage or intermittent pneumatic compression (IPC) as well as compression bandages. This phase can take weeks or months. Medical compression stockings will not be used until the maintenance phase. They have to be measured on the decongested leg. In addition to decongestion, compression therapy has an additional biochemical effect. We know that people wearing compression products have to be active to accelerate blood flow, which increases the shear and friction forces at the vascular walls. These effects release many biochemical substances. The more active the patient is while wearing compression products, the better the effect. Decongestion and compression therefore don’t just help drain the edema but they also release biochemical substances that positively influence the blood’s flow properties. The different medical aids complement each other and can also be used in parallel. There is no standard for the perfect treatment. We have to look at each individual patient. 

What are the advantages of intermittent pneumatic compression?

Erik Küppers: It can be used both during the decongestion and the maintenance phase. In 95 of 100 cases, stockings and bandages will suffice, but in the other five cases, IPC is the final effective solution during treatment. This applies to immobile patients or in cases of impaired peripheral circulation and polyneuropathy. IPC accelerates healing in cases of venous leg ulcers, which means reduced time in pain, and that is a crucial criterion for the treatment goal. One particular advantage of IPC is that patients themselves can decide and adjust the pressure and time of treatment. It’s therefore an important element of self-management.  

What type of compression stockings do you recommend to your patients?

Erik Küppers: Each patient has different symptoms. We need the right product that suits the specific patient. The most important thing is: the product must be worn on the leg every day. We have to convey the importance of IPC or compression stockings to ensure they are used or worn every day. This is the only way to prevent recurring problems. But if medical aids are just left in a drawer, we will have a clinical and socioeconomic problem, which brings us back to the initial question.

Intermittent pneumatic compression

During intermittent pneumatic compression (IPC), treatment cuffs with air chambers are secured around the affected limbs. The IPC device inflates one air chamber after the other. The patient can set pressure and time in consultation with the physician. The physical decongestion effect occurs relatively quickly: after just about 30 minutes, patients usually have to pass water, and after around 45 minutes, they feel a pleasant tingling sensation – arterial blood flow is stimulated. Depending on the indication, experts recommend implementing IPC for about 45 minutes to several hours per day. 

^{1 European Manufacturers Federation for Compression Therapy and Orthopaedic Devices}

Images: Bauerfeind, Bösl Medizinzechnik, Erik Küppers, Michael Bause, AdobeStock.com/chatuphot