attraction Hands-on Case Report 10
Treatment of severe venous leg ulcer
using unique bacteria-binding dressing
Kazu Suzuki, DPM CWS
KAZU SUZUKI, DPM CWS
TOWER 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 using
unique bacteria-binding dressing with a
fatty acid contact layer, combined with
a multi-layer compression dressing
Venous leg ulcers are one of the most common leg DVT causes a chronic vein disease, known as
wounds seen in the United States today, as they “Post-Thrombotic Syndrome.” This injury to the
are also the most common symptoms of Deep Vein venous valves creates chronic venous insufficiency
Thrombosis (DVT). Currently there are 600,000 cases that causes painful varicosities, leg edema, as well
of DVT annually in the United States, or 1 in 1,000 as venous ulcers and associated skin changes. In a
persons per year.1 study of patients two years after developing deep
venous thrombosis, post-thrombotic syndrome was
the major factor impairing quality of life.2
Examples of post-thrombotic syndrome and venous leg ulcers seen in our wound care center
Example 1 Example 2
Severe varicosities (varicose veins) Skin changes (hemosiderin stain) with venous
Severe venous leg ulcer with overlapping
Clinical evidence and treatment Patient history
In addition to appropriate wound debridement and 71 year old male with a long-standing history of DVT,
wound dressings, it is widely accepted that com- post-thrombotic syndrome and varicose veins, pre-
pression therapy for venous leg ulcers is key to sented with a large venous leg ulcer that has been
promoting swift wound closure. non-healing for 2 years, despite multiple courses of
oral antibiotic treatment and Unna Boot application.
Based on a systemic review of 39 randomized con-
trolled trials, it was concluded that “Compression Other co-morbidities include hypertension and
increases ulcer healing rates compared with no bilateral leg edema. The patient is currently on
compression. Multi-component systems are more Warfarin (Coumadin®) 15 mg daily for the treatment
effective than single-component systems. Multi- of chronic DVT and recently diagnosed protein S
component systems containing an elastic band- deficiency.
age appear more effective than those com-
posed mainly of inelastic constituents.”3 Physical exam and Doppler exam:
Well-developed, morbidly obese male. He was not
This systematic review demonstates that inelastic showing signs of acute distress, but clearly in pain
bandages (e.g. “Unna boots”) are less effective than from the large leg ulceration. Vascular exam showed
multi-layer compression dressings (e.g., JOBST® +2-3 pitting edema of bilateral lower extremities,
Comprifore system) for treating venous leg ulcers. non-palpable pulses on both legs due to severe
edema, but biphasic Dopplerable posterior tibial
and dorsalis pedis arteries, bilaterally.
2012 CPT code for compression
ABI (Ankle Brachial Index) was 1.12 Resting and
According to the American Medical Association 1.04 Post-Exercise on left leg, and tibial waveforms
CPT(r) 2012 book, Category 1 CPT code "29581" are within normal limits. Skin Perfusion Pressures
has been assigned as "Application of multi-layer were 88 mmHg at right foot and 96 mmHg at left
compression system; leg (below knee), including foot, with SPP values over 40 mmHg indicating
ankle and foot." good wound healing potential.
If one is applying these multi-layer compression A venous duplex exam showed DVT in the femoral
bandages on both legs, this "CPT 29581" code and popliteal veins on both limbs, with chronic and
should be modified with a -50 modifier to indi- recanalized thrombus, as well as greater saphenous
cate bilateral leg applications. vein insufficiency in both the thigh and knee on both
legs. The patient was previously seen by a vascular
surgeon, who recommended medical therapy with
Case Presentation warfarin, as opposed to surgical intervention.
Presented here is a severe venous ulcer case in a
morbidly obese patient with history of DVT. This
wound was successfully treated on an outpatient
basis during weekly local wound care visits, using a
combination of Cutimed® Sorbact® WCL (Wound
Contact Layer) and Comprifore multi-layer com-
Cutimed® Sorbact® WCL is a unique bacteria-bind-
ing dressing coated with DACC (Dialkyl carbamoyl
chloride), a fatty acid derivative that is highly hydro-
phobic. When the outer membranes and cell walls
of pathogenic microbes, which are also hydropho-
bic, come in contact with DACC, the microbes
become physically bound to the dressing, unable
to reproduce, and are removed with each dressing
change, which helps reduces the risk of wound
infection. As DACC is a fatty acid derivative, it is
not an anti-septic, antibiotic, or silver-containing
product, and has not been linked to any develop-
ment of resistant bacteria strain or allergic reaction
to a particular chemical or metal.
The Comprifore multi-layer compression system is
a 4-component dressing kit that provides sustained
graduated compression of 40 mmHg up to 7 days,
indicated for the treatment of venous leg ulcers.
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 by
saline 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 yellow
fibrotic 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 empiric
antibiotics, Oral Doxycycline 100 mg BID for 2 weeks. The wound dressing at this visit consisted of
Cutimed® Sorbact® WCL, followed by an ABD pad and Comprifore multi-layer compression wraps for
3a 3b Day 3
The patient returned for the review of wound cul-
ture results. It was MRSA (Methichillin Resistant
Staph. Aureus) sensitive to Doxycycline. The patient
was instructed to continue with Doxycycline until
the prescription was finished.
The wound was debrided, irrigated and dressed
with Cutimed® Sorbact® WCL and Comprifore
dressing. The patient was instructed to return to
the clinic 2-3 times per week, as the wound
drainage was fairly copious.
8 10 Day 8 and 10
The wound size diminished, and the leg edema
was much improved. The wound odor was resolved
by Day 8 and the patient also reported a gradual
reduction in wound pain and drainage. The wound
was sharply debrided with a #15 scalpel, followed
by 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.
Treatment history cont.
Day 20, 31 and 39
The wound size and leg edema improved steadily
at each visit. The wound was again debrided
sharply and treated with 35 kHz ultrasound saline
irrigation. The same dressing regimen was continued
using Cutimed® Sorbact® WCL and Comprifore.
63 Day 63
Due to the patient’s travel schedule out-of-state,
there was a 3-week hiatus of the wound care
center visits. The wound treatment was resumed
on Day 63, using sharp debridement, followed by
35 kHz ultrasound saline irrigation, as well as
wound dressing using Cutimed® Sorbact® WCL
Day 74, 85, 98 and 106
Gradual reduction of wound size and depth was
noted with the same wound treatment regimen.
The patient reported much reduced wound
Treatment history cont.
114 Day 114
The wound was completely healed on Day 114,
just over 9 weeks after the initial visit. At this
point, the patient was prescribed prescription
compression stockings of 20-30 mmHg and was
given education regarding the lifetime use of
128a Day 128
The patient was seen 2 weeks later for a follow-
up visit, and the leg wound had maintained skin
integrity with minimal scar.
This case study illustrates that the combination of Kazu Suzuki, DPM CWS
Cutimed® Sorbact® WCL and Comprifore multi-layer
compression wraps can be very effective in success- Tower Wound Care Center, 8635 West 3rd Street,
fully treating some severe venous leg wounds, even Cedars-Sinai Medical Towers, Suite #1085W,
when Unna Boot therapy had previously failed. Los Angeles, CA 90048, U.S.A.
References Department of Surgery, Cedars-Sinai Medical
Center, Los Angeles, CA 90048, U.S.A.
1. The Surgeon General’s Call to Action to Prevent
Deep Vein Thrombosis and Pulmonary E-mail: Kazu.Suzuki@cshs.org
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.