MANAGING CHRONIC VENOUS DISEASE

Transcription

1 MANAGING CHRONIC VENOUS DISEASE IMPROVE PATIENT OUTCOMES WITH INTEGRATED THERAPY SOLUTIONS THERAPIES. HAND IN HAND. 1

2 A CHRONIC DISEASE, A CHRONIC BURDEN Chronic Venous Disease (CVD) is a common condition. In the CEAP-based epidemiological studies, classes C0 and C1 together are prevalent in more than 60% of the population. Varicose veins (C2) are prevalent in more than 20%, with a higher prevalence in women. Skin changes due to venous diseases, including venous ulcers, are present in less than 10% of the population with no significant gender differences. 1 Chronic Venous Disease includes any morphological or functional abnormality of the venous system (C0 C6). Chronic Venous Insufficiency (CVI) is a term reserved for advanced CVD (C3- C6) and those with advanced signs and / or symptoms such as chronic edema, skin changes, and venous ulcerations. 2 In severe cases of untreated CVD, it can lead not only to venous ulceration but also to formation of secondary lymphedema (phlebolymphedema). All of these can significantly impact an individual s mobility, daily activities, and quality of life. A POPULATION AT RISK Today s obesity and diabetes epidemics, sedentary lifestyles, and aging demographics put many individuals at risk for development of CVD. Certain physical characteristics, family history, and comorbidities can further increase risk, resulting in higher CVD-related costs for patients and healthcare systems worldwide. CVD - THE RISK FACTORS Over 50 years of age Female Tall Limited mobility Pregnancy Obesity Sitting/standing for long periods Medications that cause/increase edema. 3 Family history of varicose veins, venous ulcers, or deep vein thrombosis. 4 Multiple chronic comorbidities that damage the venous system such as cardiac failure, diabetes, phlebitis, venous thrombosis, and venous obstruction. 3 CVD imposes a serious burden on healthcare systems. 4 It is estimated that: Nearly 5% of the adult population in developed countries are affected by CVI % of the population are affected by varicose veins. 4 Annually, nearly 2% of total health care costs in the U.S. and Europe are attributed to the therapy of chronic wounds; venous leg ulcer care is estimated at $3 billion annually. 4,5,6 More than 50% of venous leg ulcers require therapy longer than a year to heal 4, and up to 70% of venous leg ulcers recur. 7 The cost of VLU treatment in the U.S.A. is $19,000 $24,000 per patient, per year. 8 2

3 ACHIEVING VENOUS HEALTH - VENOUS DISEASE SOLUTIONS AND HOW TO CHOOSE CVD is a chronic burden in the U.S. This reference piece reviews the anatomy and physiology behind CVD, details the CEAP classification system used in the diagnosis of venous disorders, and the role of compression therapy in effectively managing venous disease. BSN medical makes a wide range of clinical solutions to help manage CVD, reduce edema, heal venous ulcerations, and prevent recurrence. JOBST has a 60+ year history of excellence in compression. BSN medical makes a wide range of advanced wound care solutions as well as a full range of compression solutions, in order to provide the broadest and most advanced CVD therapies available. We do this to aid the clinician, with a mutual goal to give patients the quality of life they desire and deserve. SUPPORTING YOUR HEALTH CARE JOURNEY 3

4 THE VENOUS SYSTEM ANTERIOR Deep vein Superficial vein Subcutaneous tissue Muscle fascia Perforating vein Deep femoral vein Great saphenous vein Muscle POSTERIOR Perforator veins of the femoral canal Femoral vein Popliteal vein Medial Knee perforator vein Anterior tibial vein Paratibial perforator vein Posterior tibial vein PERIPHERAL VENOUS SYSTEM OF THE LEG Chronic venous disorders are directly related to the health of the peripheral venous system of the legs, which consists of deep veins (deep to the muscle fascia), superficial veins (close to the skin), and perforating veins (connecting the deep and superficial veins). Deoxygenated blood flows through the inferior vena cava and back to the heart. Perforator veins of the femoral canal Popliteal vein Gastrocnemius veins Medial Knee perforator vein Small saphenous vein Paratibial perforator veins Anterior tibial vein Paratibial perforator vein Upper posterior tibial perforator vein Peroneal veins Anterior ankle perforator vein Peroneal vein Middle posterior tibial perforator vein Lateral leg perforator veins Posterior tibial veins Lower posterior tibial perforator vein 4 Medial ankle perforator vein Medial plantar vein Lateral plantar vein

5 HOW CVD DEVELOPS CALF MUSCLES AND VENOUS VALVES During movement and exercise, the calf muscle contracts and relaxes. When the calf muscle contracts, it expands in size and this squeezes the veins to help pump blood through a series of one-way valves distally towards the inferior vena cava.4 These valves open when the calf muscle contracts, and close when it relaxes. Together, this ensures that deoxygenated blood flows in one direction back toward the heart, without any significant pooling or venous reflux. This is called the Calf Muscle Pump, and it is one of the main ways you get blood back up to the heart in ambulatory patients. Blood flow caused by muscle contraction Valves prevent backflow The calf muscle acts as a pump for the deep leg veins Valve open Valve closed [Calf muscle relaxed] [Calf muscle contracted] DAMAGED VENOUS VALVES - PATHOGENESIS The peripheral venous system normally has an overall low pressure. Venous valves can weaken for multiple reasons, such as a consequence of deep vein thrombosis or due to hormonal changes during pregnancy, which cause increased vein size and blood volume increases of 40-50%.9 When venous valves weaken or there are abnormalities in the venous walls, blood can flow backward, creating venous reflux. This reflux results in elevated pressure in the peripheral venous system, known as venous hypertension. If venous hypertension is sustained over time the vein walls stretch and the valve cusps no longer meet when the valve closes. This creates further reflux and results in even more venous hypertension, which can lead to swelling, discomfort, and varicose veins. If the increased blood pressure and symptoms are not addressed, chronic venous insufficiency can develop. Open valve: Blood can flow towards the heart Closed valve: Blood cannot flow back distally Healthy veins Deficient valve: Allows venous blood to reflux With compression: Allows muscle to assist valve to function correctly Insufficient veins 5

6 THE PATH TOWARDS THERAPY CEAP CLASSIFICATION SYSTEM The first step towards managing CVD is classifying your patient s symptoms. A well-established clinical classification system known as CEAP clinical manifestations, etiologic factors, anatomic distributions, pathophysiologic dysfunction was developed in 1994 by a consensus conference of the American Venous Forum to provide uniformity in reporting, diagnosis, and treating CVD. Improvements in diagnosis and treatment followed, and were updated in 2004 based on international consensus recommendations. The Clinical portion of the CEAP classification system focuses on clinical aspects of CVD, which ranges from C0, where there are no visible signs of CVD when looking at the leg, to C6, with venous leg ulcers (VLU) present. CLINICAL CLASSIFICATION C0 No visible or palpable signs of venous disease C1 Telangiectases or reticular veins C2 Varicose veins C3 Edema C4 a. Pigmentation and eczema b. Lipodermatosclerosis and atrophie blanche C5 Healed venous leg ulcer C6 Active venous leg ulcer ETIOLOGIC CLASSIFICATION Ec: Congenital Ep: Primary Es: Secondary (postthrombotic) ANATOMIC CLASSIFICATION s: Superficial veins p: Perforated veins d: Deep veins PATHOPHYSIOLOGIC CLASSIFICATION Pr: Reflux Po: Obstruction Pr, o: Reflux and obstruction Pn: No venous pathophysiology identifiable 6

7 THE DEVELOPMENT OF CVD CEAP C0 - OUT OF SIGHT BUT DEVELOPING This class is easily missed, because there are no visual or clinical indicators of the disease. Patients may complain of tired, heavy legs but attribute it to standing for long periods. At this stage, preventative care can have an excellent outcome. Patient Education Challenge: Because there are no visible signs in C0, patients can remain unaware of CVD, what the risk factors are or what symptoms may present themselves. If your patient has several risk factors, begin dialogue about the disease and the consequences of leaving it untreated. Emphasize early therapy to prevent disease progression to maximize their quality of life. In addition to compression, exercise should be encouraged to improve calf muscle function. 10,11 Additionally, limb elevation when patient is not ambulatory may improve their microcirculation. 12 Therapy Solution - C mmhg Support compression stockings to relieve tired, heavy legs mmhg compression stockings for tired, heavy legs with a tendency to swell Medical skin care to hydrate and relieve dry skin BSN medical Recommended Products - C0 Compression: All JOBST 8-15 mmhg SupportWear or mmhg medical compression stockings Medical Skin Care: 5% Urea cream or dimethicone intensive skin moisturizer. CEAP C1 - SIGNS ARE BEGINNING TO APPEAR As the venous system begins to experience valve failure and difficulty with circulation, the first visual indicator will be telangiectasias or reticular veins, more commonly known as spider veins. As with CEAP C0, patients may also complain of tired, heavy legs and could experience some minor swelling, which resolves with leg elevation or rest. Patient Education Challenge: Many patients view spider veins as simply part of aging, particularly for those over 50 years of age. Spider veins are often seen as a cosmetic issue and not related to venous health. In fact, women will often cover spider veins with makeup, with understanding the only solution needed. Out of sight, out of mind. Spider veins, however, are indicative of CVD that tends to progress over time if left untreated. Discussion about the risks of disease progression from C1 to C2 Therapy Solution - C1 Medical compression stockings mmhg or above to relieve tired, heavy legs with occasional swelling, and for patients with reticular veins Sclerotherapy, laser treatment Compression bandages as acute follow-up to sclerotherapy/ablation Medical skin care to hydrate and relieve dry and itchy skin Taller and/or overweight patients generally require more compression than shorter, lower weight patients with visible varicose veins could help motivate a patient to take action. BSN medical Recommended Products - C1 Compression: All JOBST medical compression stocking or mmhg JOBST Comprifore 4-layer bandage systems, Comprilan short stretch bandage, and JOBST FarrowWrap for patients who cannot wear compression stockings / elastic hosiery Medical Skin Care: 5-10% urea cream or dimethicone intensive skin moisturizer. Add OTC steroid cream optionally under moisturizer for additional relief 7

8 COMFORTABLE, EFFECTIVE COMPRESSION CEAP C2 - TIME TO GET SERIOUS: VARICOSE VEINS SHOW VENOUS VALVES ARE FAILING In this clinical stage, the most significant indicator of CVD is visual / palpable varicose veins. Venous valve failure is serious enough that venous reflux and pooling are causing vein walls to stretch beyond repair and it is increasingly difficult for the venous system to pump blood back to the heart. Other factors may also be contributing to this difficulty, such as lack of exercise or mobility issues. This results in weakened calf muscles, responsible for pumping the blood through the venous system. Even simple daily exercise, like walking, can help keep the calf muscles strong. Complaints of tired, heavy, painful legs are common and minor swelling may also be present. Patient Education Challenge: In this stage, a patient might visit a clinician to address unsightly or painful varicose veins out of concern for underlying causes. Like spider veins, varicose veins 8 are also often viewed as cosmetic and simply part of aging, especially if a family member also had them. It is critical patients understand that once CVD begins to transition to CEAP C3, delivery of nutrients and oxygen to the skin is being compromised and complications can easily develop. Compression therapy can help delay or prevent disease progression. Dialogue Therapy Solution - C2 Medical compression stockings mmhg for varicosis reduce risk of disease progression Sclerotherapy, vein litigation or stripping Compression bandages or stockings for follow-up to sclerotherapy, vein ligation, or stripping Medical skin care for dry, itchy skin at this stage should focus on compliance with compression therapy to reduce risk of disease progression. BSN medical Recommended Products - C2 CompressIon: All JOBST medical compression stockings mmhg JOBST Comprifore 4-layer bandage systems, Comprilan short stretch bandage or JOBST FarrowWrap for patients who cannot wear compression stockings / elastic hosiery Medical Skin Care: 5-10% urea cream or dimethicone intensive skin moisturizer. Add OTC steroid cream optionally under moisturizer for additional relief

9 CEAP C3 - PATIENT DISCOMFORT INCREASES AS VARICOSITIES AND EDEMA FORM In C3, the primary symptom is lower extremity edema, typically found around the ankle. It often worsens during the day and resolves with limb elevation. Venous hypertension develops, leading to increased capillary leak and fluid pooling in the interstitial spaces. The edema becomes firm and is often accompanied by a deep and dull aching sensation. At this stage, there are no trophic changes to the skin, but therapy is critical to counteract more severe symptoms of CVD such as skin ulceration and other chronic manifestations associated with progression to the later stages of CVD. Patient Education Challenge: Though compression therapy is needed to reduce symptoms, the pain of the edema may make therapy seem more uncomfortable than beneficial. Pain often resolves over time as edema is reduced by the therapy. Giving the patient an inside perspective about his or her condition may help improve compliance. Explain to your patients, using visual references if possible, how compression therapy stockings and bandages help support the calf muscle to pump blood and prevent venous pooling / reflux in superficial veins. In addition, both of these compression options help reduce capillary filtration and increase interstitial compression, which helps excess fluid be absorbed back into the venous and lymphatic system, reducing edema. For stage C3, a greater compression class would be beneficial to achieve desired outcomes. Therapy Solution - C3 Medical compression stockings mmhg or mmhg and compression bandages can be effective at improving circulation as well as reducing pain and swelling associated with edema Taller and/or obese patients generally require more compression than thin or lighter weight patients Stockings and bandages can be effective at improving circulation, as well as reducing pain and swelling associated with edema. Elevating legs can also help Medical skin care to protect dry, fragile skin from the stress of edema BSN medical Recommended Products - C3 CompressIon: All JOBST medical compression stockings mmhg or mmhg JOBST Compri2 2-layer bandage system, JOBST Comprifore 4-layer bandage system, Comprilan short stretch bandage and JOBST FarrowWrap Medical Skin Care: 10% urea cream or dimethicone intensive skin moisturizer Add steroid cream under moisturizer for additional relief 11

10 LIVING LIFE TO ITS FULLEST WITH PEACE OF MIND CEAP C4 - SKIN CHANGES INDICATE SERIOUS RISK OF DISEASE PROGRESSION In CEAP C4, patients are facing an urgent situation with significant risks to their quality of life going forward. Edema is present, accompanied by skin changes. In addition, hemosiderosis, atrophie blanche, lipodermatosderosis, and varicose eczema may develop. There is significant risk for the skin to thicken, fibrose, and harden, a process known as lipodermatosclerosis. Once lipodermatosclerosis occurs, the skin is irreversibly damaged and the goal of therapy becomes to prevent further progression to an open venous leg ulcer (CEAP C6). Patient Education Challenge: Just as with C3, the pain and swelling of edema can make compression therapy initially uncomfortable, although this usually subsides over time as the wearer grows accustomed to the sense of compression, edema reduces, and the patient enjoys the relief of symptoms it provides. Additionally, because the skin is now quite fragile, extra care must be taken not to cause trauma to the skin. Healthy blood flow is necessary for the skin to effectively heal on its own. With the venous system compromised and chronic inflammatory changes occuring, left untreated there is a high risk of disease progression to ulceration or infection. It is critical for patients to understand how vital it is to have treatment to prevent or delay disease progression, as well as have a clear perspective of what could lie ahead should the disease progress. Treatment can in many cases help reverse chronic inflammatory skin changes over time. Managing a patient s expectations about quality of life, any current limitations, and duration of therapy, will help to ensure compliance. Therapy Solution - C4 Medical compression stockings mmhg or mmhg for varicose veins and edema. Can be used to treat CVI with its sequelae e.g. skin changes or healed ulcers. Higher compression levels are generally more therapeutic if tolerated. Some patients may be more compliant with reduced compression levels Medical compression bandages or FarrowWrap if edema is present Medical skin care to relieve stasis dermatitis (severely dry, fragile, flaky skin) Patients with severe disease, as well as taller and/or obese patients, generally require more compression than thin or lighter weight patients BSN medical Recommended Products - C4 Compression: If little to no edema: JOBST medical compression stockings mmhg or mmhg if edema is present If significant edema is present: JOBST Compri2, 2-layer compression bandage system JOBST Comprifore, 4-layer bandage system Comprilan, short stretch bandage JOBST FarrowWrap Medical Skin Care: 10% urea cream or dimethicone intensive skin moisturizer Add steroid cream under moisturizer for additional relief 10

11 CEAP C5 & C6 - THE ROAD TO VENOUS LEG ULCER RECOVERY CEAP C5 is a healed venous leg ulcer (VLU) and C6 is an active venous leg ulcer. In C5 there is still underlying CVI and up to 70% chance of venous leg ulcer recurrence. VLUs can be complicated, requiring a lengthy healing process. VLUs place a great burden on health care budgets (both financial and time), and with a significantly high rate of recurrence, additional strain on those same budgets in the future is nearly guaranteed. This is of particular concern when risk of infection and high wound exudate are also taken into consideration. In the U.S. alone, the monthly cost to treat an active VLU can be as high as $4, The increase of baby boomers aging further magnifies the financial challenges ahead for treating CVD. Costs can be lowered by catching patients earlier in the disease cycle and educating them in order to increase their compliance with compression therapy, and slow disease progression. For C6 open ulcers, evidence supports combined therapy of absorbent or bacteria-binding wound dressings and multi-component compression systems (sustained hydrostatic pressure of 40 mmhg at the ankle and decreasing upward) to control chronic venous edema and effectively heal previously non-healing venous leg ulcers. 14 This can contribute greatly to help reduce health care costs associated with CVD and venous ulcers long-term. Patient Education Challenge: Treating a chronic VLU can mean managing high wound drainage levels, malodor, and increased infection risk. The result is that a chronic VLU can negatively impact a patient s mobility, morale, and general sense of well-being. In C5, educating your patient on keeping the skin healthy as part of an overall ulcer prevention plan is key. In C6, helping your patient understand the healing process and why it sometimes takes longer than expected, can help manage patient expectations. At the same time, it is important to also offer patients hope that chronic VLU s can be healed by carefully and diligently complying with combined wound care and compression therapy plans. Supporting all stages of wound healing and treatment options - C6 Necrosis Inflammation Granulation Epithelialization Tissue Remodelling Wound healing phase Exudate levels Cutimed Gel Cutimed Sorbact range Cutimed Epiona range Cutimed Siltec range Cuticell Contact Therapy Solution - C5 & C6 C5: Medical skin care; Compression mmhg therapy products to assist blood flow and help control any edema C6: Use absorbant and / or bacteria binding wound care products, to help prevent and fight infection and help reduce odor Combine wound care with mmhg stockings or bandages Skin protection is needed to protect the adjacent periwound area from maceration Use Medical Skin Care to treat excessively dry, fragile skin Select patients may be appropriate candidates for reduced compression levels of mmhg BSN medical Recommended Products - C5 & C6 Compression: All JOBST medical compression stockings mmhg for C5 JOBST UlcerCARE 2-part compression system (venous ulcer therapy) JOBST Compri2 2-layer compression bandage system (edema reduction) JOBST Comprifore, 4-layer bandage system Comprilan short stretch compression bandage JOBST FarrowWrap Wound Care: Cutimed Gel Cutimed Sorbact bacteria-binding dressing Cutimed Epiona Cutimed Siltec foam-dressing Cutimed Sorbion Sorbact Medical Skin Care: 10% urea cream or dimethicone intensive skin moisturizer Add steroid cream under moisturizer for additional relief 11

12 IMPROVING PATIENT OUTCOMES COMPREHENSIVE PATIENT ASSESSMENT FOR ACCURATE THERAPY DECISIONS Before any therapy decisions can be made, a complete patient medical history and thorough examination of the legs is performed to assess the etiology (venous, arterial or mixed) and severity of CVD. Elements of patient assessment: Case history Physical examination Patient medical history, noting any other chronic conditions that could complicate CVD management or limit therapy options. Collect additional patient data such as age, dexterity and any disabilities or mobility issues that could affect therapy options and patient compliance. Also note any possible allergic reactions to any compression or wound care materials.* Inspect skin for abnormalities and vulnerable areas, such as active or newly healed ulcers, irritation, dryness, and stasis dermatitis from edema. Determine if venous reflux is present and measure ankle brachial pressure index (ABI) with a hand-held Doppler ultrasound and blood pressure cuff. Exclude clinically significant arterial disease before applying compression. Consider referral to vein specialist if patient is open to surgical treatment of their CVD, or if the diagnosis is in doubt. * Vulnerable skin areas may require medical skin protection and care. To help prevent skin irritation, a cotton tubular bandage can be worn under compression bandages. 12

13 THERAPY OPTIONS FOR CVD The overall goal when managing CVD is to manage or reduce the symptoms at the current clinical stage, and help reduce risk of disease progression through compliance with compression therapy. Therapy elements are considered based on the severity of the disease and likelihood of a positive outcome. Compression stockings assist insufficient venous valves by compressing the limb. This reduces the diameter of the distended veins, bringing the valve cusps closer together. The end result of compression applied to the limb is that the calf muscle pump functions better, decreasing venous pooling and decreasing venous hypertension back closer to normal levels. Stockings that provide graduated compression are tightest at the ankles and gradually less constrictive proximally. Graduated compression assists the calf muscle, and results in a more normal and efficient pumping mechanism, which improves venous blood return to the heart. In order to reduce symptoms of CVD, it is important that patients be advised not only to wear their compression stockings as prescribed, but to walk and exercise regularly to build up the calf muscle. Therapy goals Therapy solutions Recomended Compression Level C0 No visible or palpable signs of venous disease Create awareness, alleviate symptoms by improving venous blood flow Compression stockings Medical skin care 8-15 or mmhg* C1 Telangiectases or reticular veins Increase venous blood flow to counter effects of obstruction, reflux or both Compression stockings or VELCRO compression wrap Sclerotherapy Laser/radio frequency ablation Compression bandages Medical skin care or mmhg* C2 Varicose veins Increase venous blood flow to counter effects of obstruction, reflux or both Counter effects of venous hypertension Compression stockings or VELCRO compression wrap Vein stripping Laser/radio frequency ablation Compression bandages Medical skin care mmhg* CVD - Cronic Venous Disease CVI - Cronic Venous Insufficiency C3 Edema C4 a. Pigmentation and/or eczema b. Lipodermatosclerosis and/or atrophie blanche C5 Healed Venous Leg Ulcer C6 Active venous leg ulcer Increase venous blood flow to counter effects of obstruction, reflux or both Edema and pain reduction Protect dry and fragile skin Increase venous blood flow to counter effects of obstruction, reflux or both Relieve stasis dermatitis and chronic inflammatory changes Edema and pain reduction Increase venous blood flow to counter effects of obstruction, reflux or both Prevent recurrence of venous leg ulcer Maintain skin integrity Increase venous blood flow to counter effects of obstruction, reflux or both Promote wound healing Prevent and fight infection Odor control and exudate management Protect periwound skin from maceration Compression stockings or VELCRO compression wrap Compression bandages Medical skin care Intermittent pneumatic compression pumps Compression stockings or VELCRO compression wrap Compression bandages Medical skin care Intermittent pneumatic compression pumps Compression stockings or VELCRO compression wrap Compression bandages Medical skin care Intermittent pneumatic compression pumps Compression stockings or VELCRO compression wrap Compression bandages Wound dressings (absorbing, bacteria-binding, atraumatic) Medical skin care Intermittent pneumatic compression if ulcer is not progressing with adequate medical therapy or mmhg* or mmhg* mmhg* mmhg* * The mean compression for an average ankle size.

14 JOBST COMPRESSION THERAPY SOLUTIONS A COMPLETE COMPRESSION PORTFOLIO THAT FITS THE NEEDS OF ALL YOUR PATIENTS Pioneered by Conrad Jobst, graduated compression is considered the gold standard for managing CVD mmhg* mmhg* mmhg* mmhg* JOBST READY-TO-WEAR MEDICAL LEGWEAR Compression Therapy High quality yarns, knitting processes and testing standards ensure consistant fit and efficacy Innovations like SoftFit technology, moisture-wicking yarns, and natural odor control with carbon impregnated fibers, help ensure patient compliance 15 REMOVE REBUILD PREVENT REDUCE JOBST ULCERCARE Two-Part Compression System A liner gently holds the wound dressing in place, while the outer stocking delivers therapeutic compression to manage a venous leg ulcer Available with optional zipper for ease of donning JOBST FARROWWRAP Short-Stretch Compression Garment Designed with Elastic Short-Stretch compression technology that provides low steady resting compression levels, and high working compression when patient is standing or active Duplicates the effects of bandaging but with easily adjustable VELCRO compression bands which patients can apply and remove by themselves Ideal for patients who are unable to don or doff stockings, or who have fluctuations in their edema REBUILD REMOVE REDUCE PREVENT REBUILD REMOVE REDUCE PREVENT REBUILD REMOVE REDUCE PREVENT REBUILD REMOVE REDUCE PREVENT It is recommended that patients are prescribed at least 2 pair of legwear: one to wear and one to wash. For optimal efficacy, replacing their JOBST Legwear every 6 months is also recommended. For more information on these products for the management of Venous Leg Ulcers, please contact your BSN representative for VLU Clinician brochure 62420, and VLU Patient brochure with easy-to-understand patient education. Cutimed Gel Cutimed Sorbact Cutimed Siltec Cutimed Sorbion Sorbact Cutimed Protect Cutimed Acute Cutimed Epiona 14 Wound Care Chronic Venous Disease

15 SUPPORTING THE HEALTHCARE PROFESSIONAL EVERY STEP OF THE WAY The compression garments discussed in this brochure pertain to CVD management. Anti-Embolism stockings or Thrombo Embolic Deterrent stockings are also compression stockings, though not designed for the management of CVD. Anti- Embolism stockings or Thrombo Embolic Deterrent stockings have 18 mmhg compression, and are specifically designed to reduce risk of deep vein thrombosis (DVT) in non-ambulatory patients (including hospitalized, post-operative, and bedridden patients). Even for DVT prevention, ambulatory patients need higher compression levels than 18 mmhg. Ambulatory patients at risk for DVT should use higher compression level garments of to mmhg, or higher, depending on comorbidities....antiembolism hose provide sub-therapeutic levels of compression [in ambulatory patients] and are not considered therapeutic compression. Acute & Chronic Wounds, Bryan, Ruth A, p285. References: 1. Rabe, E. Identifying and accessing patients with chronic venous disease: the large-scale VCP International Study. Chronic venous disease guidelines and daily clinical practice. Medicographia 2011; 108, 33(3), Bo Eklöf et al: Updated terminology of chronic venous disorders. The VEIN-TERM transatlantic interdisciplinary consensus document. JVC 2009; 49: Keeley V Drugs that may exacerbate and those to use to treat lymphedema.j Lymphedema 2008;3(1): Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation. 2014;130(4): Angiology Jan;48(1):67-9. Socioeconomic impact of chronic venous insufficiency and leg ulcers. Ruckley CV 6. Laing W. Chronic Venous Diseases of the Leg. London, UK: Office of Health Economics; 1992: Grey JE, Enoch S, Harding KG. Venous and arterial ulcers. BMJ 2006;332(7537): Kumar RN, Gupchup GV, Dodd MA, et al. Direct health care costs of 4 common skin ulcers in New Mexico Medicaid fee-for-service patients. Adv Skin Wound Care. 2004;17: Guyton and hall (2005). Textbook of Medical Physiology (11 ed.) Philadelphia: Saunders. pp. 103g. 10. Kan YM, Delis KT. Hemodynamic effects of supervised calf muscle exercise in patients with venous leg ulceration: a prospective controlled study. Arch Surg 2001;136(12): Jull A, Parag V, Walker N, Maddison R, Kerse N, Johns T. The prepare pilot RCT of home-based progressive resistance exercises for venous leg ulcers. J Wound Care 2009;18(12): Australian Wound Management Association (AWMA) (2011) Australian and New Zealand Clinical Practice Guidelines for Prevention and Management of Venous Leg Ulcers Meissner, Mark, H., Venous ulcer care: which dressings are cost effective?, Phlebology, May 2014, Vol. 29, No.1, supple Brambilla R et al, VERUM A European Approach for Successful Venous Leg Ulcer Healing: Implementation of a Comprehensive Therapy Concept (VERUM) in Daily Practice, EWMA J, (2):

16 INTEGRATED THERAPY SOLUTIONS FOR EVERY CLINICAL STAGE OF CVD No matter which clinical stage your patient is in when therapy begins, alleviating the current symptoms and improving patient quality of life are always the overarching goals. BSN offers you and your patients integrated therapy solutions to manage CVD at every stage of the disease. Our best-in-class products include compression, wound care therapies, and medical skin care. Our products have proven efficacy when combined, so your patient care can be patient focused, without any problems of product incompatibility. The more complex and severe the condition, the more valuable BSN medical s integrated therapy solutions become. C0 No visible or palpable signs of venous disease C1 Telangiectases or reticular veins C2 Varicose veins C3 Edema C4 a. Pigmentation and/or eczema b. Lipodermatosclerosis and /or atrophie blanche C5 Healed venous leg ulcer C6 Active venous leg ulcer JOBST UltraSheer JOBST formen JOBST Travel Socks JOBST Sport JOBST UltraSheer, JOBST Opaque Compression Stockings & Bandages JOBST sosoft JOBST ActiveWear JOBST formen Ambition, JOBST formen and JOBST formen Casual JOBST FarrowWrap Lite JOBST FarrowWrap JOBST Comprilan JOBST Comprifore lite JOBST Compri2 lite JOBST Comprifore JOBST Compri2 JOBST UlcerCARE Cutimed Gel Cutimed Sorbact Cutimed Wound Care Cutimed Siltec Cutimed Epiona Cutimed Skin Care Cutimed ACUTE Cutimed Sorbion Sorbact Cutimed PROTECT VELCRO is a registered trademark of Velcro Industries B.V. Please refer to the product label and / or package insert for full instructions on the safe use of these products. BSN medical Inc Carnegie Blvd. Charlotte, NC Tel. (+1) Fax (+1) To order toll-free: BSN medical (+1) R BSN medical Inc. REV 04/16