Dogmas and controversies in compression therapy: report of an International Compression Club (ICC) meeting, Brussels, May 2011

[Classification and nomenclature of current materials for compression therapy]

Compression therapy has been an essential part of conservative therapy for people with chronic wounds and edema of the lower extremities for hundreds of years. The initiated therapy can be divided into the decongestion phase, maintenance phase, and prevention. The choice of the respective compression materials is based, among other factors, on these phases, the clinical stage and symptoms, the needs of the affected person and their physical abilities. Today, a wide range of different materials and methods are available for compression therapy. Thus, it is increasingly difficult to keep an overview of these treatment options, especially since the nomenclature used by the manufacturers is often inconsistent. Thus, the materials and methods for compression therapy currently available in German-speaking countries and their clinical indications are described in this review article. In addition, a uniform nomenclature is proposed, on the basis of which an appropriate exchange between all those involved in the care of people with compression therapy is guaranteed.

Mechanomodulation of Burn Scarring Via Pressure Therapy

Significance: The physical and psychological sequalae of burn injuries account for 10 million disability-adjusted life years lost annually. Hypertrophic scarring (HSc) after burn injury results in reduced mobility, contracture, pain, itching, and aesthetic changes for burn survivors. Despite the prevalence of scarring and the number of scar therapies available, none are highly effective at preventing HSc after burn injury. Recent Advances: Recent studies modulating the mechanical environment surrounding incisional and excisional wounds have shown off-loading of tension to be a powerful strategy to prevent scar formation. Preclinical studies applying force perpendicular to the surface of the skin or using a combination of pressure both circumferentially and perpendicularly have shown substantial reductions in scar thickness and contraction after burn injury. Critical Issues: Though pressure therapy is highly effective in preclinical studies, outcomes in clinical studies have been variable and may be a result of differing therapy protocols and garment material fatigue. A recent adult clinical study reported a significant reduction in pressure after 1 month of use and significant reduction between 1 and 2 months of use, resulting in below therapeutic doses of pressure applied after only 1 month of use. Future Directions: To enhance efficacy of pressure garments, new low-fatigue materials must be developed for use in standard garments or garments must be redesigned to allow for adjustment to compensate for the loss of pressure with time. Additionally, measurements of applied pressure should be performed routinely during clinic visits to ensure that therapeutic doses of pressure are being delivered.

The effects of gravity and compression on interstitial fluid transport in the lower limb

Edema in the limbs can arise from pathologies such as elevated capillary pressures due to failure of venous valves, elevated capillary permeability from local inflammation, and insufficient fluid clearance by the lymphatic system. The most common treatments include elevation of the limb, compression wraps and manual lymphatic drainage therapy. To better understand these clinical situations, we have developed a comprehensive model of the solid and fluid mechanics of a lower limb that includes the effects of gravity. The local fluid balance in the interstitial space includes a source from the capillaries, a sink due to lymphatic clearance, and movement through the interstitial space due to both gravity and gradients in interstitial fluid pressure (IFP). From dimensional analysis and numerical solutions of the governing equations we have identified several parameter groups that determine the essential length and time scales involved. We find that gravity can have dramatic effects on the fluid balance in the limb with the possibility that a positive feedback loop can develop that facilitates chronic edema. This process involves localized tissue swelling which increases the hydraulic conductivity, thus allowing the movement of interstitial fluid vertically throughout the limb due to gravity and causing further swelling. The presence of a compression wrap can interrupt this feedback loop. We find that only by modeling the complex interplay between the solid and fluid mechanics can we adequately investigate edema development and treatment in a gravity dependent limb.

Evidence-Based Practice Guideline for the Management of Lymphedema Proposed by the Japanese Lymphedema Society

Background: Secondary lymphedema mostly occurs as an aftereffect of cancer treatment, and it is estimated that 100,000-150,000 patients are affected in Japan. An estimated 3500 patients, develop lymphedema of the lower and upper extremities each year secondary to uterine and breast cancer treatment. Medical reimbursement was first instituted in April 2008 by the Ministry of Health, Labour and Welfare in Japan. Since 2008, we have developed guidelines regarding treatment options for patients with lymphedema based on scientific evidence. This is the third edition of the guidelines established by the Japanese Lymphedema Society (JLES), published in 2018. The JLES Practice Guideline-Making Committee (PGMC) developed 21 clinical questions (CQs). Methods and Results: A review of these 15 CQs was performed in accordance with the methodology for establishing clinical guidelines. The 15 recommendations for each of these CQs were developed and discussed until consensus by the PGMC was reached. Moreover, outside members who had no involvement in these guidelines evaluated the contents using the Appraisal of Guidelines for Research and Evaluation (AGREE) II reporting checklist. Conclusion: These guidelines have been produced for the adequate management of lymphedema by doctors and other medical staff on the lymphedema management team of medical institutes, including nurses, physical technicians, and occupational therapists.

Venous Leg Ulcers: A Review of Published Assessment and Treatment Algorithms

Significance: Chronic venous disease (CVD) is prevalent in the aging population and leads to venous leg ulcers (VLUs). These wounds can last and recur for years, significantly impacting quality of life. A large body of literature exists on CVD and VLU diagnosis and treatment. Multiple algorithms, guidelines, and consensus documents have been published on this topic, highlighting the importance of this issue in clinical practice. However, these documents are not fully aligned with each other. Recent Advances: The latest update of the internationally used classification system for CVD was recently published. Our review aims to summarize the existing information to provide an educational tool for clinicians new to this topic, and to highlight the commonalities between the published recommendations. Critical issues: VLUs need to be treated with consideration for the extent of venous disease present in the patient. This requires a good understanding of the various components involved and the possible additional concomitant conditions by the first-line clinician who encounters the patient. A multidisciplinary team is necessary for a successful overall treatment plan, and this plan should be tailored to each patient's specific needs and lifestyle. Future Directions: Compression is still the mainstay of treatment for CVD and VLUs. Compression is needed long term, but it does not suffice by itself to prevent recurrences without interventional correction. Venous intervention should be offered early to prevent or slow disease progression and reduce recurrence.

Electrical stimulation for pain reduction in hard-to-heal wound healing

OBJECTIVE

Despite treatment advances over the past 30 years, the societal impact of hard-to-heal wounds is increasingly burdensome. An unresolved issue is wound pain, which can make many treatments, such as compression in venous leg ulcers, intolerable. The aim of this review is to present the evidence and stimulate thinking on the use of electrical stimulation devices as a treatment technology with the potential to reduce pain, improve adherence and thus hard-to-heal wound outcomes.

METHOD

A literature search was conducted for clinical studies up to August 2020 reporting the effects of electrical stimulation devices on wound pain. Devices evoking neuromuscular contraction or direct spinal cord stimulation were excluded.

RESULTS

A total of seven publications (three non-comparative and four randomised trials) were identified with four studies reporting a rapid (within 14 days) reduction in hard-to-heal wound pain. Electrical stimulation is more widely known for accelerated healing and is one of the most evidence-based technologies in wound management, supported by numerous in vitro molecular studies, five meta-analyses, six systematic reviews and 30 randomised controlled trials (RCTs). Despite this wealth of supportive evidence, electrical stimulation has not yet been adopted into everyday practice. Some features of electrical stimulation devices may have hampered adoption in the past.

CONCLUSION

As new, pocket-sized, portable devices allowing convenient patient treatment and better patient adherence become more widely available and studied in larger RCTs, the evidence to date suggests that electrical stimulation should be considered part of the treatment options to address the challenges of managing and treating painful hard-to-heal wounds.

Inability of Laplace's law to estimate sub-bandage pressures after applying a compressive bandage: a clinical study

OBJECTIVE

The aim of the current study was to compare pressures exerted on the lower limb by a high compression bandage as recorded by sub-bandage sensors and those estimated by Laplace's law. The correlation between pressures obtained in each anatomical zone and the corresponding limb perimeters were explored.

METHOD

For the measurement of sub-bandage pressures, four anatomical zones in the lower right limb were determined. Pressures were recorded by nine pneumatic sensors and a PicoPress transducer. A two-layer compression bandage system (UrgoK2, Urgo Group, France) was used for the dressing. Pressures were registered in supine position. Sensor pressures were compared with those estimated by a modified Laplace's equation.

RESULTS

A total of 47 female volunteers were recruited (mean age: 21.9±2.3 years) to the study. In the four anatomical segments studied, pressures obtained by the sensors were lower than would be expected by applying Laplace's law (p<0.05). The biggest difference between the two methods was found at the supramalleolar level (42.1% lower by sensors compared with Laplace's equation). The correlation coefficient between pressure recorded by the sensors and that calculated at the perimeters was very weak, ranging from 0.5233 to 0.9634.

CONCLUSION

Laplace's law, used to predict the sub-bandage pressure after applying a compressive bandage in the lower limb, was not useful, providing significantly higher pressures than those obtained by pneumatic sensors. Laplace's law underestimates the variable musculoskeletal components at the different segments of lower limb that act as compression damping forces.

Acute effects of graduated and progressive compression stockings on leg vein cross-sectional area and viscoelasticity in patients with chronic venous disease

OBJECTIVE

To determine the effects of graduated and progressive elastic compression stockings (ECS) on postural diameter changes and viscoelasticity of leg veins in healthy controls and in limbs with chronic venous disease (CVD).

METHODS

In 57 patients whose legs presented with C_1S, C₃, or C₅ CEAP classes of CVD and treated primarily with compression, and 54 healthy controls matched for age and body mass index, we recorded interface pressures at 9 reference leg levels. Cross-sectional areas of the small saphenous vein (SSV) and a deep calf vein (DCV) were measured with B-mode ultrasound with subjects supine and standing, recording the force (PF) applied on the ultrasound probe to collapse each vein with progressive ECS, and with and without graduated 15‒20 mmHg and 20‒36 mmHg elastic stockings. We chose these veins because they were free of detectable lesion and could be investigated at the same level (mid-height of the calf), while their compression by the ultrasound probe was not hampered by bone structures.

RESULTS

Interface pressures decreased from ankle to knee with graduated 15‒20 and 20‒36 mmHg, but increased with progressive ECS, and were 8.4‒13.8 mmHg lower for C_1s than for control or C₃ and C₅ limbs. Without ECS, SSV median [lower‒upper quartile] cross-sectional area was 4.9[3.6‒7.1] and 7.1[3.0‒9.9]mm² in C₃ and C₅ limbs vs. 2.9[1.8‒5.2] and 3.8[2.1‒5.4]mm² in controls (p<.01), respectively while supine and standing. It remained greater in C₃ and C₅ than in C_1S and control limbs wearing any ESC. Wearing compression, especially with progressive ECS, decreased SSV and DCV cross-sectional area only with subjects supine, thus lowering postural changes which remained highly diverse between individuals. The SSV cross-sectional area vs. PF function traced a hysteresis loop of which the area, related to viscosity, was greater in C₃ and C₅ limbs than controls, even with graduated 15‒20 or 20‒36 mmHg ECS. Progressive ECS lowered vein viscosity in the supine position whereas 20‒36 mm Hg and progressive ECS increased distensibility in the standing position.

CONCLUSION

Elastic compression stockings reduce cross-sectional area of superficial and deep calf veins with patients supine but not upright. C_1s limbs show distinctive features, especially regarding interface pressures. Graduated 20‒36 mm Hg and progressive stockings lower viscosity and increase distensibility of the small saphenous vein.

Update in the management of lipedema

Lipedema is a chronic feminine disease that causes abnormal fat deposition in lower limbs and occasionally upper limbs. Easy bruising and pain are common. Lipedema patients suffer from both physical and psychological disability. Despite the relatively high prevalence and the impact on the quality of life, little is known about the disease. The majority of patients are misdiagnosed as lymphedema or obesity. The objective was to perform a non-systematic review on lipedema literature, related to diagnosis and therapy. Regarding pathophysiology, alterations are not exclusively confined to adipose tissue. Lymphatic dysfunction, cardiovascular variations, blood capillary fragility and increased permeability are common. Patients often present with neurological alterations and hormonal malfunction. Elevated cutaneous sodium has been documented. Due to the absence of a defined etiology, evidence-based research is difficult in the management of lipedema. The setting of realistic expectations is important for both patient and medical care provider. The major aims of the management are multimodal for improvements in the quality of life; reduction in heaviness and pain, reshaping the affected limbs, weight control, improvements in mobility. Compression garments, physical therapy, exercise regimens, diet and psychological counseling are necessities. For selected patients, surgical treatment is an added option.

Compression stockings to prevent postthrombotic syndrome: Literature overview and presentation of the CELEST trial

Postthrombotic syndrome (PTS) is a burdensome and costly complication of deep vein thrombosis (DVT) that develops in 20%-40% of patients within 2 years after proximal DVT. In the absence of effective curative treatment, management of PTS relies on its prevention after DVT. The effectiveness of elastic compression stockings (ECS) to prevent PTS is uncertain. We present an overview of published studies assessing the efficacy of ECS to prevent PTS and present the protocol for the CELEST clinical trial. While previous open-label randomized trials have reported a 50% risk reduction in PTS in patients treated with >30 mm Hg ankle pressure ECS, a large double-blind trial reported no effect of ECS. We discuss the main potential limitations of these trials, including a placebo effect and suboptimal compliance to ECS. We present the protocol of the CELEST double-blind randomized trial comparing 2 years of high strength (ankle pressure 35 mm Hg) versus lower strength (ankle pressure 25 mm Hg) ECS in the prevention of PTS after a first acute symptomatic, unilateral, proximal DVT. The use of lower-strength ECS than that used in previous studies should favor compliance. CELEST may provide important evidence about the efficacy of ECS in the prevention of PTS after DVT. The results will be interpreted in the light of results from recent clinical trials assessing ECS for PTS prevention that reported that the duration of ECS use should be tailored to the individual, if ECS are efficacious in the prevention of PTS.

Hyperelastic Properties of Platinum Cured Silicones and its Applications in Active Compression

This paper presents the fundamental research of design, development, and evaluation of an active compression system consisting of silicone based inflatable mini-bladders, which could be used in applying radial pressure for the treatment of venous disease. The use of mini-bladders will nullify the effect of radius of curvature and provide a higher resolution to the pressure distribution. They are designed with two elastomeric layers and inflation is limited only to one side. The mini-bladders apply a radial force onto the treated surface when inflated, and the pressure inside mini-bladders could be measured using the concept of back pressure, which provides the flexibility to inflate mini-bladders to a predefined pressure. The 3-D deformation profile of the mini-bladders was analysed using finite element method (FEM) and FEM simulations were validated with experimental data, which showed good agreement within pressure region required for the treatment of venous disease. Finally, the pressure transmission characteristics of mini-bladders were evaluated on a biofidellic lower leg surrogate and the results have shown that the mini-bladders could apply a uniform pressure irrespective of the location on the leg with a 60%–70% of inlet pressure successfully transmitted onto the leg surface, while 40%–50% was available after the fat layers.

[Compression bandages with and without padding : Observational controlled survey of pressure and comfort]

BACKGROUND

In the context of compression therapy, padded bandages are designed to prevent skin damage, increase adherence and support the success of therapy. Routine use is discussed, because comparative studies are lacking.

OBJECTIVES

This study examines effectiveness, comfort, and impact of short-stretch bandages without padding compared to underpadded bandages.

PARTICIPANTS AND METHODS

In all, 61 healthy participants wore padded bandages foam or synthetic cotton wool on one leg and nonpadded bandages on the other. On both sides, a resting pressure of 50 mm Hg was generated. After 60 min resting pressure, skin condition, comfort, pain, and fitting of the bandages were assessed.

RESULTS

All bandages showed pressure losses after 1 h; 82.0% of nonpadded bandages had a pressure drop of 9 mm Hg or more. The following were observed in unpadded bandages: constrictions (100.0%), severe redness (77.0%) and bruises (42.6%). Comfort was rated as pleasant by 3.3% without padding, by 83.9% with foam padding, and by 73.3% with synthetic cotton wool padding. Nonpadded compression bandages caused in 62.3% pain from 1-3 (numerical rating scale 0-10).

CONCLUSIONS

Padded compression bandages maintain the therapy-relevant pressure better, provide more comfort, and cause less pain and skin problems than nonpadded compression bandages. These aspects are crucial for adherence, and therapeutic success. After 1 h of use on the healthy leg, there were obvious differences. Significantly more side effects may appear after several hours of use on previously damaged skin. Therefore, compression bandages should always be padded.

Reduced incidence of vein occlusion and postthrombotic syndrome after immediate compression for deep vein thrombosis

Thus far, the association between residual vein occlusion and immediate compression therapy and postthrombotic syndrome is undetermined. Therefore, we investigated whether compression therapy immediately after diagnosis of deep vein thrombosis affects the occurrence of residual vein obstruction (RVO), and whether the presence of RVO is associated with postthrombotic syndrome and recurrent venous thromboembolism. In a prespecified substudy within the IDEAL (individualized duration of elastic compression therapy against long-term duration of therapy for prevention of postthrombotic syndrome) deep vein thrombosis (DVT) study, 592 adult patients from 10 academic and nonacademic centers across The Netherlands, with objectively confirmed proximal DVT of the leg, received no compression or acute compression within 24 hours of diagnosis of DVT with either multilayer bandaging or compression hosiery (pressure, 35 mm Hg). Presence of RVO and recurrent venous thromboembolism was confirmed with compression ultrasonography and incidence of postthrombotic syndrome as a Villalta score of at least 5 at 6 and 24 months. The average time from diagnosis until assessment of RVO was 5.3 (standard deviation, 1.9) months. A significantly lower percentage of patients who did receive compression therapy immediately after DVT had RVO (46.3% vs 66.7%; odds ratio, 0.46; 95% confidence interval, 0.27-0.80; P = .005). Postthrombotic syndrome was less prevalent in patients without RVO (46.0% vs 54.0%; odds ratio, 0.65; 95% confidence interval, 0.46-0.92; P = .013). Recurrent venous thrombosis showed no significant association with RVO. Immediate compression should therefore be offered to all patients with acute DVT of the leg, irrespective of severity of complaints. This study was registered at ClinicalTrials.gov (NCT01429714) and the Dutch Trial registry in November 2010 (NTR2597).

Report of the Society for Vascular Surgery and the American Venous Forum on the July 20, 2016 meeting of the Medicare Evidence Development and Coverage Advisory Committee panel on lower extremity chronic venous disease

On July 20, 2016, a Medicare Evidence Development and Coverage Advisory Committee panel assessed the benefits and risks of currently used lower extremity chronic venous disease (CVD) treatments and their effects on health outcome of the American adult population. The main purpose of the meeting was to advise the Centers for Medicare & Medicaid Services on coverage determination for interventions used for treatment of CVD. A systematic review of the Agency for Healthcare Research and Quality was presented, followed by lectures of invited experts and a public hearing of representatives of professional societies and the industry. After discussing critical issues, the panel voted for key questions. This report summarizes the presented evidence to support recommendations of the Society for Vascular Surgery/American Venous Forum coalition and the presentations on selected discussion topics. These included important venous disease evidence gaps that have not been sufficiently addressed, venous disease treatment disparities and how they may affect the health outcomes of Medicare beneficiaries, and mechanisms that might be supported by the Centers for Medicare & Medicaid Services to improve the evidence base to optimize the care of patients with lower extremity CVD.

Clinical and economic impact of compression in the acute phase of deep vein thrombosis

Essentials The value of compression therapy in acute phase of deep vein thrombosis is still unclear. Patients with deep vein thrombosis received acute compression hosiery, bandaging, or none. Acute compression reduces irreversible skin signs related to post thrombotic syndrome. Compression hosiery may be the preferred choice for the acute phase SUMMARY: Background The effectiveness of compression therapy in the acute phase of deep vein thrombosis (DVT) is not yet determined. Objectives To investigate the impact of compression therapy in the acute phase of DVT on determinants of the Villalta score, health-related quality of life (HRQOL), and costs. Patients/Methods Eight hundred and sixty-five patients with proximal DVT (substudy of the IDEAL DVT study) received, immediately after DVT diagnosis, either no compression, multilayer bandaging, or hosiery. In the acute phase and 3 months after diagnosis, HRQOL was determined by use of the EQ-5D, SF6D, and VEINES-QoL intrinsic method (VEINES-QoLint ). At 3 months, signs and symptoms were assessed for the total and separate items of the Villalta score, and healthcare costs were calculated. Results The compression groups had lower overall objective Villalta scores than the no-compression group (1.47 [standard deviation (SD) 1.570] and 1.59 [SD 1.64] versus 2.21 [SD 2.15]). The differences were mainly attributable to irreversible skin signs (induration, hyperpigmentation, and venectasia) and pain on calf compression. Subjective and total Villalta scores were similar across groups. Differences in HRQOL were only observed at 1 month; HRQOL was better for hosiery (EQ-5D 0.86 [SD 0.18]; VEINES-QoLint  0.66 [SD 0.18]) than for multilayer compression bandaging (EQ-5D 0.81 [SD 0.23; VEINES-QoLint  0.62 [SD 0.19]). Mean healthcare costs per patient were €417.08 (€354.10 to €489.30) for bandaging, €114.25 (€92.50 to €198.43) for hosiery, and €105.86 (€34.63 to €199.30) for no compression. Conclusions Initial compression reduces irreversible skin signs, edema, and pain on calf compression. Multilayer bandaging is slightly more effective than hosiery, but has substantially higher costs, without a gain in HRQOL. From a patient and economic perspective, compression hosiery would be preferred when initial compression is applied.

TRIAL REGISTRATION

IDEAL DVT study ClinicalTrials.gov number, NCT01429714.

Prevention and treatment of the post-thrombotic syndrome

Post thrombotic syndrome (PTS) is a common chronic complication of deep vein thrombosis of the leg (DVT). Treatment options are limited therefore emphasis is placed on its prevention. Several risk factors have been recognized, but were so far not used for risk stratification or translation into prediction models. Early interventions did not yet result in more successful preventive treatment strategies; for the acute phase of DVT there is equipoise on the value of elastic compression, as well as on catheter directed thrombolysis. There are no drugs specifically targeted at PTS prevention. The use of anticoagulant medication such as direct oral anticoagulants (DOACs) might decrease PTS incidence, but this needs to be corroborated. Both research into more effective treatment options as well as future PTS management may benefit from a uniform diagnostic strategy and the use of prediction rules to better allocate treatment and thereby increase treatment efficacy.

Compression therapy in patients with venous leg ulcers

Wund-D.A.CH. is the umbrella organization of the various wound care societies in German-speaking countries. The present consensus paper on practical aspects pertinent to compression therapy in patients with venous leg ulcers was developed by experts from Germany, Austria, and Switzerland. In Europe, venous leg ulcers rank among the most common causes of chronic wounds. Apart from conservative and interventional wound and vein treatment, compression therapy represents the basis of all other therapeutic strategies. To that end, there are currently a wide variety of materials and systems available. While especially short-stretch bandages or multicomponent systems should be used in the initial decongestion phase, ulcer stocking systems are recommended for the subsequent maintenance phase. Another - to date, far less common - alternative are adaptive Velcro bandage systems. Medical compression stockings have proven particularly beneficial in the prevention of ulcer recurrence. The large number of treatment options currently available enables therapists to develop therapeutic concepts geared towards their patients' individual needs and abilities, thus resulting in good acceptance and adherence. Compression therapy plays a crucial role in the treatment of patients with venous leg ulcers. In recent years, a number of different treatment options have become available, their use and application differing among German-speaking countries. The present expert consensus is therefore meant to outline concrete recommendations for routine implementation of compression therapy in patients with venous leg ulcers.

Film compression bandage

Purpose: Textile compression stockings or bandages are limited in comfort; they do not allow uninterrupted wearing. A novel elastic film bandage was evaluated regarding practicability, patient comfort and effect on vein regression. Main endpoint was the frequency of symptomatic inflammatory reactions.

Methods: In a comparative pilot study, a compression film bandage (CFB, investigational) comprising an elastic, self-adhesive breathable polymer film of d <20 µm was continuously worn for 14 d after foam sclero-therapy. Inclusion: 62 patients (26–68 y.) frequently doing sports and taking daily showers, 90 legs with superficial varicosities, 5–12 mm ø (MW: 7.3 mm), randomized to A) CFB + medical compression stocking (MCS), B) MCS alone, C) CFB alone. Follow-up examinations including ultrasound and photography were performed after 2, 4 and 8 weeks.

Results: Continuous wearing time of 14 days was completed in 57/60 cases with CFB (95.0 %, A+C), while 3/60 (5.0 %) finished wearing after 8–10 d. There were no adverse skin reactions except minor irritations at the upper edge (n = 2). Vein diameters were reduced within 14 days by 29–54 % (mean: 43.5 %) in group A, 16–44% (mean: 39.1 %) in group B, and 24–50 % (mean: 37.3 %) in group C. Symptomatic inflammation, indu-ration or discolouration was observed within 28 days in 5/60 cases (8.3 %) when using CFB (A, C) versus 19/30 (63.3%) related to stocking compression (B). Comfort was rated by the patients 6.6 (A), 4.3 (B) and 9.2 (C) on a 10 degree scale. This difference was statistically highly significant (p <0.01).

Conclusions: The film bandage is an effective and safe compression modality. For superficial varicosities the adhesive bond to the skin seems to be relevant additional to the elastic properties. The device significantly improves vein regression of foam-treated superficial varicosities when combined with compression stockings or even as stand-alone modality. Continuous wearing for two weeks is well tolerated. The bandage may also offer an alternative for patients not tolerating textile compression media, or during summer.

Eccentric compression of large varicose veins after foam sclerotherapy using a novel silicone gel pad

Ziel: Wir evaluierten eine neuartige exzentrische Kompression, die ultraschalltransparentes Silikon-Gel zwischen selbstklebenden Fo-lien als individuelles Druckpolster verwendet.

Methodik: Es wurden 120 Patienten mit 148 oberflächlichen Varizen (Ø 5,1–13,7 mm; MW: 7,6) nach Schaumverödung einbezogen: A) segmental randomisiert mit fokaler Kompression durch Silikon-Gel-Polster (Venartis® SGP) für 14 Tage plus Kompressionsstrumpf KKl. 2 (KS) tagsüber für 28 Tage, oder B) nur KS. Das SGP-System besteht aus einer selbstklebenden Basisfolie, auf die Silikon dem Venenverlauf folgend aufgetragen wird. Eine zweite Folie bedeckt Gel und Basisfolie. Den Patienten war Duschen erlaubt. Ermittelt wurden Querschnittsreduktion (QR, Ultra-schallscans) sowie klinische Parameter nach 2, 4 und 8 Wochen.

Ergebnisse: Segmente mit SGP zeigten gegenüber KS eine höhere QR, im Mittel 52,5 vs. 23,1 % (2 Wo), 48,4 vs. 28,9 % (4 Wo) und 66,7 vs. 39,2 % (8 Wo). Entzündungsreaktionen waren unter SGP mit 12,4 vs. 39,9 % signifikant seltener, ebenso Verfärbungen mit 10,8 vs. 35,1 %. Minithrombektomien (8,1 vs. 29,7 %) und orale Analgetika (6,8 vs. 19,6 %) wurden seltener benötigt. Unerwünschte Wirkungen: Diskrete Hautirritationen (10,1 %).

Schlussfolgerung: Indikationsspezifische Silikonhärten, Dosierungen, Tragezeiten und die Höhe externer Drücke bedürfen weiterer Untersuchungen, wobei die Ultraschalltransparenz neue Wege eröffnet.

Foam sclerotherapy of segments of the saphenous vein with adjuvant hyaluronan compression

Background: Thermal, mechano-chemical and chemical methods of vein closure are increasingly less effective in saphenous veins with diameters above 10 mm. Furthermore, increasing vein size is associated with unpleasant inflammatory reactions, in particular in locations close to sensitive structures like the skin. External compression media are not able to prevent these unwanted sequela in a tolerable way. As a possible solution, perivenous hyaluronan compression was evaluated combined with microfoam sclero-therapy.

Methods: 34 patients (25 f, 9 m, 43–71 yr/o) with saphenous insufficiency (GSV), dia -meters 10.1–23.1 mm (M: 14.1 mm), distance to skin: >10 mm, received a vein lumen compression oft thigh- or calf segments by perivenous injection of a NASHA gel mediated by a coaxial paravenous catheter prior to catheter-applied microfoam sclerotherapy (aethoxysklerol 1 %). Injection of both, hyaluronan and microfoam, were performed during catheter withdrawal. The aim of hyaluronan compression was a 2/3 reduction oft the native vein cross section. For comparison, adjacent segments were compressed with common tumescent fluid. Segments for both modalities had similar diameter and were randomized. Due to department rules, the junction segment was closed with endovenous lasers to warrant elimination of reflux. No textile compression media were applied. Clinical controls including ultrasound were performed after 2, 8, 26 and 54 weeks.

Results: All treated vein segments showed total occlusion after 2 weeks (first visit). The lumen reduction was 54–81 % (M: 68.4 %) in segments with hyaluronan compression and 8–29 % (M: 19.2 %) in segments with tumes-cent fluid. Time needed for hyaluronan compression was 1.1–3.5 min (M: 2.2 min) and for tumescence 0.8–2.7 min (M: 1.8 min) per 10 cm-segment. Clinical investigations up to 8 weeks did not reveal any symptoms, visible inflammations or stainings in segments covered with hyaluronan, while tumescent-compressed segments had such findings in 20/34 cases (58.8 %). Perivenous hyaluronan did not induce any discomfort or side effects during follow-up.

Conclusions: Even large saphenous veins can be effectively and safely treated by microfoam sclerotherapy without any postinterventional symptoms when the vein lumen is reduced by perivenous injection of hyaluronan gel. However, it takes additional interventional effort to achieve this goal. Future applications could also include combinations with thermal or gluing device or support novel foams like Varithena or biomatrix sclerofoam when treating very large veins or venous aneurysms, and furthermore serve in vein shaping fort the purpose of establishing laminar flow or modifying pressure relations (venoplasty).

[Indications and contraindications for modern compression therapy]

Compression therapy is a physical therapy with few side effects, which is used especially in patients with edema of the lower extremities. The indication for compression therapy is given here for edema of very different origins such as, for example, venous or lymphatic disease symptoms as well as renal insufficiency, obesity or inflammation. However, different contraindications must be considered in these patients. Of particular importance are the advanced peripheral arterial occlusive disease and the polyneuropathy, which need special attention.Due to the large number of different compression materials and systems available today, in spite of these contraindications, compression therapy can be carried out with a large proportion of patients with edema of the lower extremities. The therapy should be adapted to the comorbidities and individual needs as well as personal abilities in the context of a patient-oriented care.

Progressive compression versus graduated compression for the management of venous insufficiency

Venous leg ulceration (VLU) is a chronic condition associated with chronic venous insufficiency (CVI), where the most frequent complication is recurrence of ulceration after healing. Traditionally, graduated compression therapy has been shown to increase healing rates and also to reduce recurrence of VLU. Graduated compression occurs because the circumference of the limb is narrower at the ankle, thereby producing a higher pressure than at the calf, which is wider, creating a lower pressure. This phenomenon is explained by the principle known as Laplace's Law. Recently, the view that compression therapy must provide a graduated pressure gradient has been challenged. However, few studies so far have focused on the potential benefits of progressive compression where the pressure profile is inverted. This article will examine the contemporary concept that progressive compression may be as effective as traditional graduated compression therapy for the management of CVI.

An investigation of the ability to produce a defined 'target pressure' using the PressCise compression bandage

Compression therapy is the cornerstone in the prevention and treatment of leg ulcers related to chronic venous insufficiency. The application of optimal high pressure is essential for a successful outcome, but the literature has reported difficulty applying the intended pressure, even among highly skilled nurses. The PressCise bandage has a novel design, with both longitudinal and horizontal reference points for correct application. In the current experimental study, the results for the general linear model, where the data set is treated optimally, showed that all 95% confidence intervals of the expected values for pressure were, at most, 5 mmHg from the target value of 50 mmHg, independent of the position on the leg and the state of activity. Moreover, even nurses with limited experience were consistently able to reach the targeted pressure goal. Future studies are needed to determine how well the bandage works on legs of different shapes, the optimal way of using the bandage (day only or both day and night) and whether the bandage should be combined with an outer bandage layer. In addition, special attention should be paid to subjective patient experiences in relation to the treatment as pain, discomfort and bulk are factors that can compromise patients' willingness to adhere to the treatment protocol and thereby prolong the healing process.

Effect of three-size too large strong stocking on venous hemodynamics in normal subjects

OBJECTIVES

To study the differences in impact on venous hemodynamics between larger size strong graduated elastic compression stockings (GECS) and appropriate size strong/moderate GECS.

METHOD

In healthy legs fitted for a small (Group S; n = 8) and large (Group L; n = 8) GECS, air plethysmography was performed without GECS, with an appropriate size strong GECS (GECS1), with a three-size too large strong GECS (GECS2), and with an appropriate size moderate GECS (GECS3) in this order.

RESULTS

In Group S, interface pressure with GECS2 was equal to or higher than that with GECS3. Decreased venous volume, unchanged ejection volume, and decreased residual volume were achieved by GECS, but differences in these parameters among GECS were not observed. Although insignificant, a similar tendency was found in Group L.

CONCLUSIONS

A larger size strong GECS seemed to have equivalent interface pressure and impact on venous hemodynamics compared to an appropriate size moderate or strong GECS.

Relationship between medical compression and intramuscular pressure as an explanation of a compression paradox

Background

Using standing magnetic resonance imaging (MRI), we recently showed that medical compression, providing an interface pressure (IP) of 22 mmHg, significantly compressed the deep veins of the leg but not, paradoxically, superficial varicose veins.

Objective

To provide an explanation for this compression paradox by studying the correlation between the IP exerted by medical compression and intramuscular pressure (IMP).

Material and methods

In 10 legs of five healthy subjects, we studied the effects of different IPs on the IMP of the medial gastrocnemius muscle. The IP produced by a cuff manometer was verified by a Picopress® device. The IMP was measured with a 21G needle connected to a manometer. Pressure data were recorded in the prone and standing positions with cuff manometer pressures from 0 to 50 mmHg.

Results

In the prone position, an IP of less than 20 did not significantly change the IMP. On the contrary, a perfect linear correlation with the IMP ( r = 0.99) was observed with an IP from 20 to 50 mmHg. We found the same correlation in the standing position.

Conclusion

We found that an IP of 22 mmHg produced a significant IMP increase from 32 to 54 mmHg, in the standing position. At the same time, the subcutaneous pressure is only provided by the compression device, on healthy subjects. In other words, the subcutaneous pressure plus the IP is only a little higher than 22 mmHg—a pressure which is too low to reduce the caliber of the superficial veins. This is in accordance with our standing MRI 3D anatomical study which showed that, paradoxically, when applying low pressures (IP), the deep veins are compressed while the superficial veins are not.

Compression therapy: clinical and experimental evidence

AIM

A review is given on the different tools of compression therapy and their mode of action.

METHODS

Interface pressure and stiffness of compression devices, alone or in combination can be measured in vivo. Hemodynamic effects have been demonstrated by measuring venous volume and flow velocity using MRI, Duplex and radioisotopes, venous reflux and venous pumping function using plethysmography and phlebodynamometry. Oedema reduction can be measured by limb volumetry.

RESULTS

Compression stockings exerting a pressure of ~20 mmHg on the distal leg are able to increase venous blood flow velocity in the supine position and to prevent leg swelling after prolonged sitting and standing. In the upright position, an interface pressure of more than 50 mmHg is needed for intermittent occlusion of incompetent veins and for a reduction of ambulatory venous hypertension during walking. Such high intermittent interface pressure peaks exerting a "massaging effect" may rather be achieved by short stretch multilayer bandages than by elastic stockings.

CONCLUSION

Compression is a cornerstone in the management of venous and lymphatic insufficiency. However, this treatment modality is still underestimated and deserves better understanding and improved educational programs, both for patients and medical staff.