Leg ulceration in venous and arteriovenous insufficiency: assessment and management with compression therapy as part of a holistic wound‑healing strategy

IntroductionThis international consensus document presents the outcomes of an expert panel discussion, convened in October 2023. The discussion aimed to provide best-practice recommendations on the assessment and management of venous and arteriovenous leg ulcers. To this end, the panellists explored the accurate assessment of the venous and arterial aetiologies underlying leg ulceration, as well as the optimal safe and effective management of venous or arteriovenous ulceration using compression therapy as part of a holistic care plan. This consensus document is intended to complement existing published guidance on the management of venous ulceration and use of compression therapy,[1–4] primarily by filling gaps in earlier guidelines on the assessment and management of leg ulcers with a mixed aetiology caused by combined arterial and venous insufficiency (CAVI).This consensus document has been written for a multidisciplinary readership of generalist and specialist healthcare professionals (HCPs), including physicians, podiatrists, nurses and allied health professionals, such as physical and occupational therapists. It aims for an inclusive international relevance in all healthcare settings, with consideration for variations in practice; access to resources; and the way services are designed, provided and reimbursed in the medical systems throughout the world. It is hoped that the recommendations in this consensus document will provide clinicians with the skills and confidence to accurately assess chronic venous and/or arterial insufficiency and deliver compression therapy in a timely, safe and effective manner.BackgroundChronic venous insufficiency (CVI), CAVI and resulting leg ulceration have a significant negative impact on quality of life. The global cost of CVI with and without ulceration is in the billions of dollars.[5] The reported global prevalence of CVI varies from <1 to 17% in men and <1 to 40% in women, and 1–2% of the global adult population have a lower-extremity wound (leg ulcer), with the prevalence increasing to 3% for patients over 65 years old.[5] According to a 2023 meta-analysis, venous ulceration has an international pooled prevalence of 0.32% and incidence of 0.17%.[6]The above statistics may be an underestimate of the real world burden due to small sample sizes, misdiagnosis and underreporting, especially of people outside of care, patients who self-treat their wounds and those in less-developed nations.[6] In addition, prevalence and incidence studies do not always include wounds that are treated without adequate diagnosis.[6] Prevalence and incidence statistics may also be influenced by factors such as delays in detection and diagnosis, as identified by a 2022 study in primary care, where the median time after first appearance of a hard-to-heal wound was 8 days to first assessment but 41 days to diagnosis.[7] Real-world prevalence would be better understood with higher-quality population studies using consistent methods, such as database analysis and shared population data. For example, large samples of diagnosis, treatment and outcome data could be accessed through a deidentified, compliant commercial database, such as the Blue Health Intelligence research database of administrative claims.[8] A reliable outcome would require the database to be accurately compiled by skilled HCPs.StructureThis international consensus document begins by summarising the potential venous, arterial, arteriovenous and atypical aetiologies underlying leg ulceration. It then explains how these aetiologies can be assessed and diagnosed with a full holistic patient assessment. Recommendations are presented for how the results of the patient assessment should be used to indicate the safety and recommended application of compression therapy as part of a holistic treatment strategy. The document then describes the different types of compression systems with reference to the main functional characteristics of pressure, elasticity and stiffness. Guidance is offered on product selection, application technique and long-term maintenance for compression therapy. The last section surveys other aspects of the holistic management of patients receiving compression therapy in CVI or CAVI, including wound and skin care, exercise and supported self-management, as well as adjunctive therapies, revascularisation and patient and professional education.Where possible, the recommendations presented in this document are informed and supported by citations to the best available published evidence. A narrative review of the literature was conducted on the electronic databases PubMed, ScienceDirect and Google Scholar, using keywords based on the aetiologies, tools and interventions discussed. The cited literature includes level 1 (systematic reviews or meta-analyses) to level 4 (case-control or cohort studies) publications, alongside grey literature. Other recommendations that are based on the expert opinion, professional experience and clinical judgment of the consensus panel without reference to published literature have been presented under the label ‘consensus statement’. The label ‘consensus statement’ denotes expert opinion and has no bearing on significance compared with the rest of the document. The full text has been read, discussed, edited and agreed by the panel prior to publication of the document.