A randomised controlled trial comparing compression therapy after stripping for primary great saphenous vein incompetence

Background

Venous insufficiency of the lower extremity affects up to 40–60% of general adult population in the Western population, of which around 25% has varicose veins mostly treated by ablation of the incompetent great saphenous vein. Although endovenous options are available, the majority is still treated with stripping of the great saphenous vein for which there is no consensus regarding postoperative compressive therapy. The objective of this prospective randomised controlled trial was to evaluate 4 h compared to 72 h of leg compression after great saphenous vein stripping.

Method

Patients in the Zuyderland Medical Centre with an indication for stripping of the great saphenous vein were eligible for inclusion in this study. Patients were randomised to 4 or 72 h of leg compression (standard elastic bandaging) after stripping of the great saphenous vein. Primary outcome was change in leg volume after 14 days. Secondary outcomes were post-operative pain scores, complications and time to full recovery.

Results

A total of 78 patients were randomised, 36 patients enrolled the intervention (4 h) group and 42 patients the control group (72 h). The intervention group (4 h) showed a 57 mL reduction in leg volume after 14 days, compared to 6 mL of the control group (72 h) ( p = 0.11). Post-operative pain, complications and time to full recovery did not statistically differ.

Conclusion

Wearing leg compression four hours after stripping is non-inferior in preventing leg oedema compared with 72 h compression therapy. No statistically significant difference in pain and time to full recovery was shown.

Compression with 23 mmHg or 35 mmHg stockings after saphenous catheter foam sclerotherapy and phlebectomy of varicose veins: A randomized controlled study

Objectives

To compare two different medical compression stockings after varicose vein treatment.

Patients and methods

A randomized single-blind controlled study on two compression regimes after saphenous catheter foam sclerotherapy + phlebectomy was performed. After pads and 5 mmHg contention sock, 23 mmHg (group A, Struva 23®) or 35 mmHg (group B, Struva 35®) medical compression stocking was applied 24 h/day for seven days; subsequently 21–23 mmHg medical compression stocking in daytime. Symptoms, compliance, skin findings, and bioimpedance spectroscopy parameters were assessed.

Results

A total of 94 patients (48 and 49 limbs in groups A and B, respectively) were enrolled. Three (T3) and seven (T7) days post-operatively, most symptoms were significantly milder in group B, especially pain and heaviness at T7 and at day 40 (T40). Ambulation, medical compression stocking stability/tolerability and skin healing were significantly better in group B, with p = 0.046, 0.021/0.060, and 0.010, respectively, at T7. Bioimpedance parameters increased at T7 and decreased at T40 in both groups; leg reactance and limb L-Dex improved in group B at T7 and T40, respectively (p = 0.039 and 0.012).

Conclusions

Compression with 23 and 35 mmHg medical compression stocking after catheter foam sclerotherapy + phlebectomy was effective and well tolerated at immediate/short term. Compression with 35 mmHg medical compression stocking provided less adverse post-operative symptoms and better tissue healing. Bioimpedance results confirmed a slightly better edema improvement with 35 mmHg medical compression stocking.

Indications for medical compression stockings in venous and lymphatic disorders: An evidence-based consensus statement

Objective Medical compression stockings are a standard, non-invasive treatment option for all venous and lymphatic diseases. The aim of this consensus document is to provide up-to-date recommendations and evidence grading on the indications for treatment, based on evidence accumulated during the past decade, under the auspices of the International Compression Club. Methods A systematic literature review was conducted and, using PRISMA guidelines, 51 relevant publications were selected for an evidence-based analysis of an initial 2407 unrefined results. Key search terms included: 'acute', CEAP', 'chronic', 'compression stockings', 'compression therapy', 'lymph', 'lymphatic disease', 'vein' and 'venous disease'. Evidence extracted from the publications was graded initially by the panel members individually and then refined at the consensus meeting. Results Based on the current evidence, 25 recommendations for chronic and acute venous disorders were made. Of these, 24 recommendations were graded as: Grade 1A (n = 4), 1B (n = 13), 1C (n = 2), 2B (n = 4) and 2C (n = 1). The panel members found moderately robust evidence for medical compression stockings in patients with venous symptoms and prevention and treatment of venous oedema. Robust evidence was found for prevention and treatment of venous leg ulcers. Recommendations for stocking-use after great saphenous vein interventions were limited to the first post-interventional week. No randomised clinical trials are available that document a prophylactic effect of medical compression stockings on the progression of chronic venous disease (CVD). In acute deep vein thrombosis, immediate compression is recommended to reduce pain and swelling. Despite conflicting results from a recent study to prevent post-thrombotic syndrome, medical compression stockings are still recommended. In thromboprophylaxis, the role of stockings in addition to anticoagulation is limited. For the maintenance phase of lymphoedema management, compression stockings are the most important intervention. Conclusion The beneficial value of applying compression stockings in the treatment of venous and lymphatic disease is supported by this document, with 19/25 recommendations rated as Grade 1 evidence. For recommendations rated with Grade 2 level of evidence, further studies are needed.

A Double-Blind Clinical Trial of the Efficacy and Tolerability of O-(β-Hydroxyethyl)-Rutosides and Compression Stockings in the Treatment of Leg Oedema and Symptoms following Surgery for Varicose Veins

Objective:

To study the efficacy and tolerability of O-(β-hydroxyethyl)-rutosides (HR) and compression stockings in the treatment of leg oedema and symptoms after varicose vein surgery.

Design:

A prospective double-blind, randomized, Parallel, placebo-controlled trial.

Setting:

Surgical department of a regional hospital.

Patients:

Forty patients undergoing venous surgery for varices associated with superficial insufficiency.

Interventions:

Saphenofemoral ligation, stripping of the entire long saphenous vein and removal of varicosities via 0.5 cm incisions. HR was given at 2 g/day (or Placebo) for 6 weeks starting on the first postoperative day. Twenty patients were randomized to each group.

Main outcome measures:

Leg volumes were measured by an automatic electronic-optic volumeter, prior to operation and again after 6 weeks and 3 months. Leg symptoms were recorded on days 1 and 10, weeks 3 and 6, and at 3 months.

Results:

There was no difference in leg volume between the two groups during the first 6 weeks when stockings Were worn, but the increase in oedema of the distal leg in the subsequent 6 weeks was significantly less in the HR group. Symptoms disappeared rapidly 3 weeks Postoperatively in both groups.

Conclusions:

Stockings are effective in controlling postoperative leg oedema and symptoms. The addition of HR can prevent subsequent oedema after removal of the stockings.

Systematic review of compression following treatment for varicose veins

Background

Consensus regarding compression following treatment of varicose veins has yet to be reached. This systematic review aims to establish the optimal compression regimen after venous treatment.

Methods

A systematic review of MEDLINE, Embase and CENTRAL was performed to identify randomized clinical trials (RCTs) investigating different compression strategies following treatment for superficial venous insufficiency.

Results

Seven RCTs comparing different durations and methods of compression fulfilled the inclusion criteria. The treatment modality was open surgery in three trials, foam sclerotherapy in two and endovenous laser ablation (EVLA) in two trials. The quality of the studies was variable, and significant sources of potential bias were present. Both the studies and compression regimens used were heterogeneous. Ten products were used in six general regimens for a duration of 0–42 days. One study suggested that 7 days rather than 2 days of stockings following EVLA was associated with superior quality of life and less pain at 1 week. Another study reported that, following surgery, application of a compression stocking after 3 days of bandaging was associated with a slightly longer recovery than no compression after 3 days. One study recorded compliance clearly, finding it to be only 40 per cent. The quality and heterogeneity of the studies precluded meta-analysis.

Conclusion

There is currently little quality evidence upon which to base any recommendations concerning compression following treatment for varicose veins.

Compression regimes after endovenous ablation for superficial venous insufficiency – A survey of members of the Vascular Society of Great Britain and Ireland

Introduction

The optimal compression regime following ultrasound guided foam sclerotherapy (UGFS), radiofrequency ablation (RFA) and endovenous laser ablation (EVLA) for varicose veins is not known. The aim of this study was to document current practice.

Methods

Postal questionnaire sent to 348 consultant members of the Vascular Society of Great Britain and Ireland.

Results

Valid replies were received from 41% ( n = 141) surgeons representing at least 68 (61%) vascular units. UGFS was used by 74% surgeons, RFA by 70% and EVLA by 32%, but fewer patients received UGFS (median 30) annually, than endothermal treatment (median 50) – P = 0.019. All surgeons prescribed compression: following UGFS for median seven days (range two days to three months) and after endothermal ablation for 10 days (range two days to six weeks) – P = 0.298. Seven different combinations of bandages, pads and compression stockings were reported following UGFS and four after endothermal ablation. Some surgeons advised changing from bandages to stockings from five days (range 1–14) after UGFS. Following endothermal ablation, 71% used bandages only, followed by compression stockings after two days (range 1–14). The majority of surgeons (87%) also treated varicose tributaries: 65% used phlebectomy, the majority (65%) synchronously with endothermal ablation. Concordance of compression regimes between surgeons within vascular units was uncommon. Only seven units using UGFS and six units using endothermal ablation had consistent compression regimes.

Conclusion

Compression regimes after treatments for varicose veins vary significantly: more evidence is needed to guide practice.

Post-treatment compression: duration and techniques

BACKGROUND

Compression treatments used the following intervention for varicose veins range from no compression, to elastic stockings and compression bandaging. There is no consensus on the strength or duration of compression which should be applied following a particular treatment. The author reviews the evidence that has led him to reach his own viewpoint on this subject.

SUMMARY

Compression stockings are often prescribed after treatment of varicose veins, but these in general exert a much lower pressure in the thigh compared with firm inelastic compression bandages. It has been shown by objective investigation that it takes a pressure of 10-15 mmHg in the supine position and 40-50 mmHg in the standing position to occlude a superficial vein in the thigh. The author has published a study in which three groups of patients were studied following varicose vein surgery. One group received a strong medical compression stocking, the second group an inelastic bandaging system which achieved 63 mmHg compression in the standing position and an eccentric compression system which achieved 98 mmHg in the standing position. Adverse events after surgery were most frequent in the stocking group with fewer in the inelastic compression bandage group and fewest in the eccentric compression group. A further study has been published by another author in which elastic compression has been compared with eccentric compression following endovenous laser ablation of the saphenous vein. Eccentric compression reduced postoperative pain. Unfortunately, very little data are available to indicate the period for which compression should be applied following varicose vein treatment.

CONCLUSIONS

In comparison to compression treatments following varicose vein surgery where the actual level of compression has been measured, higher levels of compression are more effective than lower levels in moderating postoperative pain and complications. Strong compression can be achieved by inelastic bandaging or by eccentric compression systems. Far fewer data are available to indicate the duration for which postoperative compression is required.

The optimal duration of compression therapy following varicose vein surgery: a meta-analysis of randomized controlled trials

OBJECTIVE

The optimal duration of compression therapy following varicose vein surgery of the great saphenous vein (GSV) remains controversial. Therefore, the aim of this study was to evaluate different durations of compression therapy after varicose vein surgery and their outcomes.

DESIGN

A systematic review and meta-analysis of randomized controlled trials (RCTs).

METHODS

Outcomes from short-duration (3-10 d) and long-duration (3-6 wk) compression therapy after GSV stripping and phlebectomies were evaluated. Pain was assessed post surgery using a visual analog scale. Secondary outcomes included leg volume, complications, and the duration of absenteeism from work.

RESULTS

We identified 4 RCTs published between 1991 and 2009 that evaluated 686 patients. We observed non-significant differences in postoperative pain scores between the long-duration and short-duration groups, with a weighted mean difference of -0.03 (95% confidence interval (CI): -0.53 to 0.47) at 4 weeks, and -0.01 (95% CI: -0.31 to 0.33) at 6 weeks, postoperatively. We also observed non-significant differences in the incidence of postoperative complications (risk ratio: 0.84, 95% CI: 0.60-1.18), and changes in leg volume, 4 weeks postoperatively (P = .18) between the groups.

CONCLUSION

Our study results indicate that there are no benefits to long-term compression therapy after varicose vein surgery of the GSV regarding postoperative pain, leg volume, incidence of complications, and duration of absenteeism from work.

Multicenter randomized trial comparing compression with elastic stocking versus bandage after surgery for varicose veins

OBJECTIVES

Postoperative limb compression is widely used after venous surgery to prevent thromboembolism and to reduce hemorrhage, edema, hematoma, and pain. Only limited studies have been published regarding the most adequate postoperative compression therapy after varicose vein surgery. This study evaluated the effectiveness of a new stocking kit used for postoperative limb compression.

METHODS

The study compared the clinical practicability, ease to use, effectiveness, and safety of a postoperative stocking system (23 to 32 mmHg at the ankle) with compression bandages (control group). This prospective, randomized, open-label clinical trial, was performed in three Italian centers specializing in venous surgery. Sixty consecutive patients (classification CEAP C₂,(S)) underwent unilateral varicose vein surgery at one of the three centers. After surgery, patients were randomized for postoperative compression therapy with a new stocking system (Sigvaris Postoperative Kit; Ganzoni Sigvaris Corp, Winterthur, Switzerland) or standard stretch bandages (30 patients per group). Primary end points were incidence of venous thromboembolism, hemorrhage, limb hematoma, or edema.

RESULTS

No episodes of venous thromboembolism were observed. The mean area of thigh hematoma on postoperative days 7 and 14 was 75.70 cm² and 2.93 cm², respectively, for the stocking group, and 92.97 cm² and 5.42 cm² for the bandage group (not significant). On postoperative day 7, edema was found in 50% of the patients wearing bandages and in 20% of the patients wearing the stocking kit, which was a significant reduction. No statistical difference was recorded for postoperative pain; however, better patient acceptance and quality of life after the operation were recorded in the stocking group.

CONCLUSION

Patients can be effectively treated with the Sigvaris Postoperative Kit. Patients treated with stockings have less edema compared with standard bandaging, and the application of the stocking kit improves patient quality of life and compliance with postoperative compression therapy.

To wear or not to wear compression stockings after varicose vein stripping: a randomised controlled trial

OBJECTIVES

To assess the need to wear compression stockings for 4 weeks after inversion stripping of the great saphenous vein (GSV) from the groin to the level of the knee.

DESIGN

Randomised controlled trial.

PATIENTS

A total of 104 consecutive patients with primary complete incompetence of the GSV treated by inversion stripping of the GSV.

METHODS

Postoperatively treated limbs underwent elastic bandaging for 3 days. Volunteers were randomised to wear a compression stocking for additional 4 weeks (intervention group) or no compression stocking (control group). The primary outcome was limb oedema as assessed by photoelectric leg volume measurement. Secondary outcome measures were pain scores, postoperative complications and return to full work.

RESULTS

The control leg volume was 3657ml (standard deviation, SD 687) preoperatively and 3640ml (SD 540) 4 weeks postoperatively (non significant, N.S.). The stocking leg volume was 3629ml (SD 540) preoperatively, falling to 3534ml (SD 543) (P<0.01) 4 weeks postoperatively. The difference in leg volume between both the groups was not statistically significant. Patients in the control group resumed work earlier (control 11 days, stocking 15 days, P=0.02, Mann-Whitney test). No difference was observed in the number and type of complication and in pain scores during the 4-week follow-up period.

CONCLUSIONS

Wearing an elastic compression stocking has no additional benefit following elastic bandaging for 3 days in postoperative care after stripping of the great saphenous vein as assessed by control of limb oedema, pain, complications and return to work.

Résultats d’une enquête sur les techniques compressives et contensives utilisées dans le traitement chirurgical des varices

OBJECTIVES

A survey on postoperative compression after varicose vein surgery was undertaken in 2001 among surgeons of the French-speaking Vascular Surgery Society as well as non-members with a heavy caseload in varicose vein surgery. The aims of the study were to 1) identify the various medical devices and protocols used postoperatively, 2) estimate the frequency and duration of use, and 3) identify the surgeon's rationale for prescribing postoperative compression. The first part of the inquiry was devoted to surgical procedures and has been previously published (J Mal Vasc 2003; 28: 277-86).

MATERIAL AND METHODS

A questionnaire with 11 items for postoperative treatments and a patient form was mailed to 675 surgeons.

RESULTS

The response rate was 41.5% (280 surgeons). Results were assessed by a scientific committee. Surgeons were classified into different groups according to their membership in the French-speaking Vascular Surgery Society or not, the type of practice (private, public hospital, mixed), and caseload. Compression was widely used (97.1%). It was the only postoperative treatment for 25.2% of the surgeons, was associated with anticoagulant treatment for 38.8% or non-steroidal antiinflammatory drugs for 11.2%. Prescription was evidence-based for only 11.6%. Compression therapy was mainly started postoperatively (93.2%). Elastic bandages (long stretch) were used by 87%. Duration of bandage therapy was variable (less than 8 days for 38.8%, 8-15 days for 24.5%). After bandage therapy, medical compression stockings (above knee 74.7%) or French class II (77.9%) were used. Compression stockings were prescribed for 8-15 days or 15-30 days by 12.7% and 84.6% of the surgeons respectively. Prolonged postoperative treatment was not common (28%) and was prescribed for patients with trophic changes.