Treatment of severe venous leg ulcerusing unique bacteria-binding dressing

Kazu Suzuki, DPM CWS

Cutimed® Sorbact®

physical attraction Hands-on Case Report 10

Introduction

Venous leg ulcers are one of the most common legwounds seen in the United States today, as theyare also the most common symptoms of Deep VeinThrombosis (DVT). Currently there are 600,000 casesof DVT annually in the United States, or 1 in 1,000persons per year.1

DVT causes a chronic vein disease, known as“Post-Thrombotic Syndrome.” This injury to thevenous valves creates chronic venous insufficiencythat causes painful varicosities, leg edema, as wellas venous ulcers and associated skin changes. In astudy of patients two years after developing deepvenous thrombosis, post-thrombotic syndrome wasthe major factor impairing quality of life.2

KAZU SUZUKI, DPM CWSTOWER WOUND CARE CENTER, CEDARS-SINAI MEDICAL TOWERS, LOS ANGELES, CA, U.S.A.DEPARTMENT OF SURGERY, CEDARS-SINAI MEDICAL CENTER, LOS ANGELES, CA, U.S.A.

Treatment of severe venous leg ulcer usingunique bacteria-binding dressing with afatty acid contact layer, combined with a multi-layer compression dressing

Example 1

Severe varicosities (varicose veins)

Example 2

Skin changes (hemosiderin stain) with venous leg ulcer

Example 3

Severe venous leg ulcer with overlapping lymphedema

Examples of post-thrombotic syndrome and venous leg ulcers seen in our wound care center

2

3

Clinical evidence and treatment

In addition to appropriate wound debridement andwound dressings, it is widely accepted that com-pression therapy for venous leg ulcers is key topromoting swift wound closure.

Based on a systemic review of 39 randomized con-trolled trials, it was concluded that “Compressionincreases ulcer healing rates compared with nocompression. Multi-component systems are moreeffective than single-component systems. Multi-component systems containing an elastic band-age appear more effective than those com-posed mainly of inelastic constituents.”3

This systematic review demonstates that inelasticbandages (e.g. “Unna boots”) are less effective thanmulti-layer compression dressings (e.g., JOBST®

Comprifore system) for treating venous leg ulcers.

Case Presentation

Presented here is a severe venous ulcer case in amorbidly obese patient with history of DVT. Thiswound was successfully treated on an outpatientbasis during weekly local wound care visits, using acombination of Cutimed® Sorbact® WCL (WoundContact Layer) and Comprifore multi-layer com-pression wraps.

Cutimed® Sorbact® WCL is a unique bacteria-bind-ing dressing coated with DACC (Dialkyl carbamoylchloride), a fatty acid derivative that is highly hydro-phobic. When the outer membranes and cell wallsof pathogenic microbes, which are also hydropho-bic, come in contact with DACC, the microbesbecome physically bound to the dressing, unable to reproduce, and are removed with each dressing change, which helps reduces the risk of woundinfection. As DACC is a fatty acid derivative, it isnot an anti-septic, antibiotic, or silver-containingproduct, and has not been linked to any develop-ment of resistant bacteria strain or allergic reactionto a particular chemical or metal.

The Comprifore multi-layer compression system isa 4-component dressing kit that provides sustainedgraduated compression of 40 mmHg up to 7 days,indicated for the treatment of venous leg ulcers.

Patient history

71 year old male with a long-standing history of DVT,post-thrombotic syndrome and varicose veins, pre-sented with a large venous leg ulcer that has beennon-healing for 2 years, despite multiple courses oforal antibiotic treatment and Unna Boot application.

Other co-morbidities include hypertension andbilateral leg edema. The patient is currently onWarfarin (Coumadin®) 15 mg daily for the treatmentof chronic DVT and recently diagnosed protein Sdeficiency.

Physical exam and Doppler exam:

Well-developed, morbidly obese male. He was notshowing signs of acute distress, but clearly in painfrom the large leg ulceration. Vascular exam showed+2-3 pitting edema of bilateral lower extremities,non-palpable pulses on both legs due to severeedema, but biphasic Dopplerable posterior tibialand dorsalis pedis arteries, bilaterally.

ABI (Ankle Brachial Index) was 1.12 Resting and1.04 Post-Exercise on left leg, and tibial waveformsare within normal limits. Skin Perfusion Pressureswere 88 mmHg at right foot and 96 mmHg at leftfoot, with SPP values over 40 mmHg indicatinggood wound healing potential.

A venous duplex exam showed DVT in the femoraland popliteal veins on both limbs, with chronic andrecanalized thrombus, as well as greater saphenousvein insufficiency in both the thigh and knee on bothlegs. The patient was previously seen by a vascularsurgeon, who recommended medical therapy withwarfarin, as opposed to surgical intervention.

2012 CPT code for compression dressings

According to the American Medical AssociationCPT(r) 2012 book, Category 1 CPT code "29581"has been assigned as "Application of multi-layercompression system; leg (below knee), includingankle and foot."

If one is applying these multi-layer compressionbandages on both legs, this "CPT 29581" codeshould be modified with a -50 modifier to indi-cate bilateral leg applications.

4

Day 3

The patient returned for the review of wound cul-ture results. It was MRSA (Methichillin ResistantStaph. Aureus) sensitive to Doxycycline. The patientwas instructed to continue with Doxycycline untilthe prescription was finished. The wound was debrided, irrigated and dressedwith Cutimed® Sorbact® WCL and Compriforedressing. The patient was instructed to return tothe clinic 2-3 times per week, as the wounddrainage was fairly copious.

Day 8 and 10

The wound size diminished, and the leg edemawas much improved. The wound odor was resolvedby Day 8 and the patient also reported a gradualreduction in wound pain and drainage. The woundwas sharply debrided with a #15 scalpel, followedby 35 kHz ultrasound saline irrigation treatments.The wound dressing consisted of the same regi-men of Cutimed® Sorbact® WCL, an ABD pad,and Comprifore multi-layer compression wrap.

Day 1 (initial visit)

The patient presented with large venous leg ulcer, with copious sero-sanguinous exudate with slight odor.The wound was debrided, and the wound base was also sharply debrided with #10 scalpel, followed bysaline irrigation using 35 kHz ultrasound device (Quostic system by Arobella Medical) for 5 minutes.

After debridement, the wound base was covered mostly with moist red granular tissue with some yellowfibrotic tissues. This wound was a full skin thickness ulcer. The peri-wound skin was red and inflamed,with brawny skin texture, and mild cellulitis. The wound was cultured, and the patient was given empiricantibiotics, Oral Doxycycline 100 mg BID for 2 weeks. The wound dressing at this visit consisted ofCutimed® Sorbact® WCL, followed by an ABD pad and Comprifore multi-layer compression wraps foredema reduction.

Treatment history

1a 1b

3a 3b

8 10

Treatment history cont.

5

300

Day 20, 31 and 39

The wound size and leg edema improved steadilyat each visit. The wound was again debridedsharply and treated with 35 kHz ultrasound salineirrigation. The same dressing regimen was continuedusing Cutimed® Sorbact® WCL and Comprifore.

20 31

39

300 Day 63

Due to the patient’s travel schedule out-of-state,there was a 3-week hiatus of the wound carecenter visits. The wound treatment was resumedon Day 63, using sharp debridement, followed by35 kHz ultrasound saline irrigation, as well aswound dressing using Cutimed® Sorbact® WCLand Comprifore.

63

Day 74, 85, 98 and 106

Gradual reduction of wound size and depth wasnoted with the same wound treatment regimen. The patient reported much reduced wounddrainage.

74 85

10698

7055

0-00

543-

00

1

2/20

11

6

Discussion

This case study illustrates that the combination ofCutimed® Sorbact® WCL and Comprifore multi-layercompression wraps can be very effective in success-fully treating some severe venous leg wounds, evenwhen Unna Boot therapy had previously failed.

300 Day 114

The wound was completely healed on Day 114,just over 9 weeks after the initial visit. At thispoint, the patient was prescribed prescriptioncompression stockings of 20-30 mmHg and wasgiven education regarding the lifetime use ofcompression stockings.

114

300 Day 128

The patient was seen 2 weeks later for a follow-up visit, and the leg wound had maintained skinintegrity with minimal scar.

128a

References

1. The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism. 2008.

2. Kahn SR, Shbaklo H, Lamping DL et al. Determinants of health-related quality of life during the 2 years following deep vein throm-bosis. J Thromb Haemost. 2008;6(7):1105.

3. O'Meara S, Cullum NA, Nelson EA. Compression for venous leg ulcers. Cochrane Database of Systematic Reviews. 2009.

128b

Author

Kazu Suzuki, DPM CWS

Tower Wound Care Center, 8635 West 3rd Street,Cedars-Sinai Medical Towers, Suite #1085W,Los Angeles, CA 90048, U.S.A.

Department of Surgery, Cedars-Sinai MedicalCenter, Los Angeles, CA 90048, U.S.A.

E-mail: Kazu.Suzuki@cshs.org

Treatment history cont.