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Usually compression therapy is considered dangerous or contraindicated in patients with leg oedema and arterial occlusive disease. In my primary care office, I use a Doppler instrument to diagnose arterial occlusive disease by measuring the systolic ankle pressure. Ankle pressure divided by the systolic arm pressure is called the Ankle Brachial Pressure Index (ABPI). This non-invasive test can indicate (ABPI): (1.0-1.4)→No narrowing or blockage of the leg-arteries; (0.9-1.0) → Acceptable state of arteries in legs; (0.80.9) → Some arterial disease; (0.6-0.8) → Moderate arterial disease; (less than 0.5) → Severe arterial disease, critical ischemia. Guidelines recommend referring the patient to a vascular specialist when this index is less than 0.8. According to guidelines, compression is strongly contraindicated in severe peripheral arterial disease, when the Ankle Brachial Pressure Index (ABPI), measured by Doppler ultrasound is less than 0.6.1 What happens when the patient has venous and arterial insufficiency? (Figure 1A and B). Can we use compression therapy in a patient with arterial occlusive disease? The following case reports show that compression may be very effective even in such patients, even improving arterial flow, but a careful follow up during the first days/weeks is necessary.2 It is possible to reduce edema and heal ulcers in a patient with occlusive arterial disease, using a simple technique of compression therapy, which we call Double focal compression bandaging. The first bandage is used for the focal compression of the wound bed and another bandage covers the first, to achieve a gradual external compression from the toes to the knee., each turn of the band covers the preceding tour by 50-70%. The area of the ulcer receives the pressure of 3 layers (that of the pressure over the wound bed, and the double effect of the external gradual compression). To apply this technique safely in primary care, it is necessary to follow three simple steps: i) To establish a differential diagnosis; ii) To establish a clinical diagnosis; iii) Measurement of the Ankle Brachial Index to exclude severe arterial disease: A/ Hand held Doppler ultrasound device. B/ 5.07 Monofilament and 128 Hz tuning fork. C/ Scales. D/ The Edinburgh claudication questionnaire. E/ Camera: We take photos of the wound bed at the beginning of treatment, and whenever the bandage is removed, this way, we can observe the clinical course of the ulcer until its healing. i) We use gauzes to make a padding of a thickness of 1 cm, with a size like that of the ulcer, surpassing its edges. This is what we call focal compression. ii) Adhesive bandage for fixing the padding to the wound bed. iii) Strong inelastic compression bandaging (10x12 cm) for making the gradual external compression. iv) Physiological saline solution for cleaning the wound bed. v) Adhesive tape for fixing the bandages and scissors to trim the gauze used as focal compression. Measuring local pressure by Picopress® we found sub-bandage pressure peaks (1 cm padding) over the wound bed, of up to 95 mmHg during walking (inelastic bandaging has better physiological effects on calf muscle pump).3 Three clinical cases with severe occlusive arterial disease, who were treated by this technique are presented.

Compression to reduce leg edema in patients with arterial occlusive disease - double focal compression bandaging