Cath Lab Digest

  It is a well-accepted fact that compression therapy is considered the standard of care for patients with chronic venous insufficiency (CVI). In the absence of significant lower extremity arterial disease, the use of different types of compression wraps and garments are often the single most effective component of CVI treatment. The external pressure of the compression wrap on the underlying venous system assists the calf muscle pump in the return of blood to the heart and lungs from the lower extremities, decreasing the venous hypertension that is the causative factor in many lower extremity ulcerations. Observing the effect of compression on patients with ulcers related to CVI can be an incredibly rewarding experience for the clinician because when appropriately applied, edema reduction is rapid and ulcer improvement is sure to follow. However, we are often faced with patients who are unable to maintain these wraps and dressings for the time period that they are supposed to be worn. It is a frequent occurrence to have patients return to the clinic with their compression wrap out of place or worse, having taken it off at home. Regardless of advanced dressing options and alternative treatments, CVI therapy without adequate compression usually results in further ulcer breakdown.

  Patients report difficulty tolerating their compression therapy for a multitude of reasons including:
    •A poorly fitting wrap or garment
    •Inability to apply garment
    •Pain
    •Discomfort related to heat and tightness of the wrap
    •Cost

  Other issues noted by practitioners are:
    •Drainage strike-through leading to a moist, soiled bandage
    •Patient lifestyle
    •Practitioner error in application

  Some issues are patient dependent, some are related to clinician ability and some issues with adherence to treatment are financially driven. Health care providers who render compression therapy need to be aware of common problems and errors related to the use of compression so that we may help our patients not only to increase their compliance level but also achieve goals and outcomes related to peripheral edema and wound management.

Appropriate Fit for the Patient

  Just as patients come in all shapes and sizes, so do their extremities. We are all familiar with the “bottle neck” deformity seen with CVI patient but often times, there are other tissue abnormalities seen that will affect the appropriate fit and feel of the compression wrap. Lymphedema and surgical changes can require more complex wrapping skill and forethought by the attending clinician.

  Extra foam or cotton padding may be required to apply uniform compression over surgical “shelf” deformities as well as soft tissue folds and hypertrophic areas. Boney and painful prominences will require extra care to prevent additional pain and pressure in susceptible limbs. The ability to maintain uniformity of compression over tissue abnormalities will improve patient satisfaction as well as wear time. Ultimately this also affects cost to the patient and/or the clinic, helping to assure the treatment is more efficient as well as cost effective.

  Extremity shape and contour aren’t just important considerations with compression wraps. Compression hose that aren’t appropriately sized for the patient may result in wrinkles in the garment, causing pressure areas or diminished blood flow circumferential.

  There are ready sized compression garments that may be appropriate for some patients and are often less expensive, however, custom fit hose will often result in a much better fit and greater adherence with treatment. Custom fit garments can be manufactured to allow for patient specific contours and can be sewn with zippers, allowing a patient to independently donn the stocking. Hosiery that is measured and fabricated to fit the individual patient is less likely to slip, slide and wrinkle.

Patient Ability to Apply Compression Hose

  Many of our patients that require the use of compression garments are elderly, obese, have musculoskeletal or neurological disorders and overall, diminished mobility. Donning compression garments requires lower extremity and spinal flexibility, upper extremity strength, hand and finger dexterity and usually, reasonably good eyesight.

  There are several products on the market designed to assist the less mobile patient with donning and doffing their compression garments. These include: Juzo® Slippie Gator (Juzo USA Inc, Cuyahoga Falls, OH), Mediven® Stocking Butler (Medi USA, Whitsett, NC), and the Jobst® Stocking Donner(Jobst BSN Medical, Charlotte, NC). In addition, patients may also get a better grip on the hose to pull them on and off by using regular household rubber gloves. If a greater grip is needed, there are ribbed gloves on the market specifically designed for compression hose application (Sigvaris, Peachtree City, GA). Appropriate moisturizing of the skin will also aid in less traumatic application. Specific donning apparatus may also require the use of either an open toe or close toe variation. This should be considered when prescribing the garment.