Effects of preventive use of compression stockings for elderly with chronic venous insufficiency and swollen legs: a systematic review and meta-analysis

Prevention strategies for the recurrence of venous leg ulcers: A scoping review

Venous leg ulcer (VLU) is the most severe manifestations of chronic venous disease, which has characterized by slow healing and high recurrence rates. This typically recalcitrant and recurring condition significantly impairs quality of life, prevention of VLU recurrence is essential for helping to reduce the huge burden of patients and health resources, the purpose of this scoping review is to analyse and determine the intervention measures for preventing recurrence of the current reported, to better inform healthcare professionals and patients. The PubMed, Embase, Web of Science, Cochrane Library databases, Chinese National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), Wan Fang Data and Chongqing VIP Information (CQVIP) were accessed up to June 17, 2023. This scoping review followed the five-steps framework described by Arksey and O'Malley and the PRISMA extension was used to report the review. Eleven articles were included with a total of 1503 patients, and adopted the four effective measures: compression therapy, physical activity, health education, and self-care. To conclude, the use of high pressure compression treatment for life, supplementary exercise therapy, and strengthen health education to promote self-care are recommended strategies of VLU prevention and recurrence. In addition, the importance of multi-disciplinary teams to participate in the care of VLU in crucial.

Black holes in compression therapy: A quest for data

OBJECTIVE

Although compression therapy (CT) is considered a crucial conservative treatment in chronic venous disease, strong evidence is missing for many clinical indications. This literature review aims to point out what strong evidence we have for CT and all the clinical scenarios where strong evidence still needs to be included.

METHODS

The research was conducted on MEDLINE with PubMed, Scopus and Web of Science. The time range was set between January 1980 and October 2022. Only articles in English were included.

RESULTS

The main problem with CT is the low scientific quality of many studies on compression. Consequently, we have robust data on the effectiveness of CT only for advanced venous insufficiency (C3-C6), deep vein thrombosis and lymphedema. We have data on the efficacy of compression for venous symptoms control and in sports recovery, but the low quality of studies cannot result in a strong recommendation. For compression in postvenous procedures, superficial venous thrombosis, thromboprophylaxis, post-thrombotic syndrome prevention and treatment, and sports performance, we have either no data or very debated data not allowing any recommendation.

CONCLUSIONS

We need high-level scientific studies to assess if CT can be effective or definitely ineffective in the clinical indications where we still have a paucity of or contrasting data.

The effectiveness of nursing interventions in adherence to self-care for preventing venous ulcer recurrence: A systematic literature review

Venous ulcers affect up to 3% of the global population, with a high impact on economies and quality of life. This is exacerbated by its recurrence rates, which reach 70% at 12 months after healing. The perpetuation of these cycles of healing and recurrence is not interrupted or even attenuated by the self-care activities recommended and directed toward their prevention. In this context, we sought to identify the effectiveness of interventions that promote adherence to self-care to prevent venous ulcer recurrence. In August 2022, we conducted a literature search via EBSCO in the following databases: CINAHL Complete, MEDLINE Complete, Cochrane Database of Systematic Reviews, Scopus, and Web of Science. The inclusion criteria were researched in the form of randomised controlled trials or systematic literature reviews, and 99 studies were identified. During the different times of selection, four studies met the defined inclusion criteria and were included. As the main conclusions, the emphasis goes to the importance of the use of compression and the greater effectiveness of higher compression classes for the prevention of recurrence. Different educational methodologies seem to be important to increase knowledge about prevention, specifically regarding the aetiology of recurrence and the implementation of prevention measures.

Brazilian guidelines on chronic venous disease of the Brazilian Society of Angiology and Vascular Surgery

The Brazilian Society of Angiology and Vascular Surgery has set up a committee to provide new evidence-based recommendations for patient care associated with chronic venous insufficiency. Topics were divided in five groups: 1. Classification, 2. Diagnosis, 3. Conservative or non-invasive treatment, 4. Invasive treatment and 5. Treatment of small vessels. This last series is closely related to the activities of Brazilian angiologists and vascular surgeons, who are heavily involved in the treatment of small superficial veins. These guidelines are intended to assist in clinical decision-making for attending physicians and health managers. The decision to follow a guideline recommendation should be made by the responsible physician on a case-by-case basis taking into account the patient's specific condition, as well as local resources, regulations, laws, and clinical practice recommendations.

Incidence of Acute Upper Gastrointestinal Bleeding and Related Risk Factors among Elderly Patients Undergoing Surgery for Major Limb Fractures: An Analytical Cohort Study

(1) Background: Upper gastrointestinal bleeding (UGIB), a major postoperative complication after surgical fixation of major limb fractures, can be fatal but is often neglected. This study determined the incidence rates of and related risk factors for perioperative UGIB among older patients with major upper limb fractures but without a history of peptic ulcer disease (PUD). (2) Methods: We collected the data of patients aged more than 65 years who underwent surgery for major limb fracture between 1 January 2001 and 31 December 2017, from Taiwan's National Health Insurance Research Database and excluded those with a history of UGIB and PUD before the date of surgery. The primary outcome was the incidence of UGIB requiring panendoscopy during hospitalization. A multiple logistic regression model was used to identify the independent predictors of UGIB, with adjustment for confounding factors. The final model included variables that were either statistically significant in univariate analyses or deemed clinically important. (3) Results: The incidence of UGIB was 2.8% among patients with major limb fractures. Male sex, older age, major lower limb fracture, and a history of chronic renal disease were significant risk factors for the increased incidence of perioperative UGIB. (4) Conclusions: Patients with major limb fractures who underwent surgery exhibited a higher rate of stress ulceration with UGIB, even when they had no history of PUD. Perioperative preventive protocols (e.g., protocols for the administration of proton-pump inhibitors) may be necessary for patients with these major risk factors.

A prospective study on the wound healing and quality of life outcomes of patients with venous leg ulcers in Singapore-Interim analysis at 6 month follow up

Venous leg ulceration results in significant morbidity. However, the majority of studies conducted are on Western populations. This study aims to evaluate the wound healing and quality of life for patients with venous leg ulcers (VLUs) in a Southeast Asian population. This is a multi-centre prospective cohort study from Nov 2019 to Nov 2021. All patients were started on 2- or 4-layer compression bandage and were reviewed weekly or fortnightly. Our outcomes were wound healing, factors predictive of wound healing and the EuroQol 5-dimensional 5-level (EQ-5D-5L) health states. Within our cohort, there were 255 patients with VLU. Mean age was 65.2 ± 11.6 years. Incidence of diabetes mellitus was 42.0%. Median duration of ulcer at baseline was 0.30 years (interquartile range 0.136-0.834). Overall, the median time to wound healing was 4.5 months (95% confidence interval [CI]: 3.77-5.43). The incidence of complete wound healing at 3- and 6-month was 47.0% and 60.9%, respectively. The duration of the wound at baseline was independently associated with worse wound healing (Hazard ratio 0.94, 95% CI: 0.89-0.99, P = .014). Patients with healed VLU had a significantly higher incidence of perfect EQ-5D-5L health states at 6 months (57.8% vs 13.8%, P < .001). We intend to present longer term results in subsequent publications.

Compression Stockings Improve Lower Legs Symptom in Patients with Pulmonary Artery Hypertension Treated by Pulmonary Vasodilators-A Pilot Study

Pulmonary vasodilators have improved pulmonary arterial hypertension (PAH) symptoms and prognosis; however, the drugs cause some side effects, including lower legs pain, which impair quality of life (QOL). The present study examined if compression stockings improved lower extremity symptoms and QOL caused by pulmonary vasodilators in PAH patients. We retrospectively enrolled consecutively ten patients with PAH treated by pulmonary vasodilators, who were regularly followed in Kurume University Hospital from January 2022 to June 2022. Oral questionnaire surveys, the Numeric Rating Scale for Pain (NRS) and the Pain Disability Assessment Scale (PDAS), were conducted regarding lower extremity symptoms before wearing elastic stockings and one month later, to evaluate how the lower extremity symptoms affected daily life. All ten patients were female, with a mean age of 50.2 ± 11.5 years, out of whom intravenous prostacyclin analogue (PGI₂) was administered in five patients. In no intravenous PGI₂ group, NRS score was significantly improved from 4.6 ± 2.3 to 2.8 ± 1.2 (p = 0.037), while from 9.4 ± 1.2 to 5.4 ± 1.6 (p = 0.002) in intravenous PGI₂ group. PDAS score was also significantly improved [no intravenous PGI₂ group; 18.0 (15.0-24.0) to 15.0 (10.0-19.0), intravenous PGI₂ group; 25.0 (17.0-37.0) to 17.0 (5.0-27.0)]. Lower extremity symptoms in patients using pulmonary vasodilators were improved by wearing compression stockings.

[Venous ulcus cruris-Surgical treatment]

Venous ulcus cruris is usually a chronic disease and an extreme burden for patients and their families. An analysis based on a random statutory health insurance sample of the AOK Hessen/KV Hessen estimated the number of affected people to be 400,000 in Germany. A venous ulcus cruris is always caused by an underlying chronic venous insufficiency (CVI). A spontaneous healing of this chronic disease without treatment is not to be expected. The conservative treatment includes an adequate compression treatment and exudate management. Surgical treatment is based on three pillars: an open surgical or endovenous approach to resolve the pathological venous reflux, uIcer surgery and in rare cases the various procedures of fascia surgery as well as defect coverage by a combination of negative pressure wound therapy and skin transplantation.

Compression stocking compliance does not impact reintervention or symptom change after iliac vein stenting in patients with moderate to severe lower extremity edema

BACKGROUND

Medical compression stocking (MCS) therapy remains a core treatment for chronic venous disease, particularly in patients with lower extremity edema. This study investigated the impact of postoperative MCS adherence in patients with moderate to severe edema who underwent iliac vein stenting.

METHODS

Patients at a large tertiary care center who underwent iliac vein stenting from August 2011 to June 2021 were analyzed. Symptoms were quantified using the venous clinical severity score (VCSS) and clinical assessment score (CAS). The criterium for inclusion was moderate or severe lower extremity edema at the time of iliac vein stenting. Patients were stratified into two cohorts: complete postoperative compression therapy compliance (MCS+) and no postoperative compression therapy use (MCS-).

RESULTS

Among 376 patients fitting our study criteria, we identified 168 MCS+ and 208 MCS- patients. Preoperatively, the VCSS composite score was higher for the MCS+ group (11.7 vs. 9.5, p < 0.001), but the VCSS edema score did not significantly differ between groups (p = 0.179). Postoperatively, the mean changes in VCSS edema at the first postoperative visit, the one-year follow-up, and the two-year follow-up were not significantly different between the MCS+ and MCS- cohorts (p = 0.123, 0.296, 0.534, respectively). Analysis of CAS for edema revealed that the MCS+ cohort had modestly better improvement in edema at the 90-day follow-up visit vs. the MCS- cohort (p = 0.018), but this difference was not observed in the 30-day (p = 0.834) or 6-month follow up visit (p = 0.755). Multivariate analysis revealed no difference in the need for major intervention (OR 0.93 [95% CI 0.44 - 1.50], p = 0.504). Kaplan Meier analysis via log-rank test revealed no difference in reintervention-free survival between groups (p = 0.77).

CONCLUSION

Many patients with moderate to severe lower extremity edema experience reduction in their edema after iliac vein stenting. In our study, compression stocking compliance after surgery had little impact on edema relief in this population.

Incidence of Recurrent Venous Ulcer in Patients Treated at an Outpatient Clinic: Historical Cohort

The recurrence of venous ulcers is the wound reopening after a period of completed epithelisation of a previous ulcer due to exposure to causal factors and lack of prevention. Venous ulcers have a high recurrence rate that may increase through the years. Epidemiological evidence on its incidence and risk factors is scarce due to the lack of patient follow-up in outpatient clinics and adherence to treatment after healing. The objective was to analyze the incidence of venous ulcers recurrency in outpatients and the risk factors for its occurrence. It is an observational historical cohort with retrospective data collection, performed through electronic medical records. Setting: private health insurance outpatient clinic. The participants were adult patients with healed venous ulcers. Incidence of venous ulcer recurrence was calculated within individuals with healed ulcers from 2014 and 2018 with a follow-up of at least one year. Bivariate analysis and logistic regression were used to explore risk factors considering demographic, clinical, and wound-related variables. As a result, sixty-five (65) of the 134 patients with healed venous ulcers had a recurrence, leading to an incidence of 48.5%, with a mean onset time of 230.1 (SD 267) days. Patients with recurrent venous ulcers were primarily women (39/48.1%), with a mean age of 64 (SD 15.5) years, 57 (50.8%) had some comorbidity, with systemic arterial hypertension as the most frequent (47/51%). Obesity (15/88.2%) increased the risk of venous ulcers recurrence by 8.7 (OR 95% CI 2.1-60.8; P = .009) times. In conclusion, venous ulcers recurrence incidence was 48.5%, with obesity as a risk factor. This study demonstrates that the clinical approach of people with venous ulcers should not finish when the wound is healed. For ulcer recurrence prevention interventions addressing systemic factors, besides topical management of the wound, are essential.

Using the Functional Resonance Analysis Method to explore how elastic compression therapy is organised and could be improved from a multistakeholder perspective

OBJECTIVES

Elastic compression stocking (ECS) therapy is an important treatment for patients with deep venous thrombosis (DVT) and chronic venous insufficiency (CVI). This study aimed to provide insight into the structure and variability of the ECS therapy process, its effects on outcomes, and to elicit improvement themes from a multiple stakeholder perspective.

DESIGN

Thirty semi-structured interviews with professionals and patients were performed. The essential functions for the process of ECS therapy were extracted to create two work-as-done models using the Functional Resonance Analysis Method (FRAM). These findings were used to guide discussion between stakeholders to identify improvement themes.

SETTING

Two regions in the Netherlands, region Limburg and region North-Holland, including an academic hospital and a general hospital and their catchment region.

PARTICIPANTS

The interviewees were purposely recruited and included 25 healthcare professionals (ie, general practitioners, internists, dermatologists, nurses, doctor's assistants, occupational therapists, home care nurses and medical stocking suppliers) and 5 patients with DVT or CVI.

RESULTS

Two FRAM models were created (one for each region). The variability of the functions and their effect on outcomes, as well as interdependencies between functions, were identified. These were presented in stakeholder meetings to identify the structure of the process and designated variable and uniform parts of the process and its outcomes. Ultimately, six improvement themes were identified: dissemination of knowledge of the entire process; optimising and standardising initial compression therapy; optimising timing to contact the medical stocking supplier (when oedema has disappeared); improving the implementation of assistive devices; harmonising follow-up duration for patients with CVI; personalising follow-up and treatment duration in patients with DVT.

CONCLUSIONS

This study provided a detailed understanding of how ECS therapy is delivered in daily practice by describing major functions and variability in performances and elicited six improvement themes from a multistakeholder perspective.

Palliative care aspects of wound healing in complex patients: a case report

DECLARATION OF INTEREST

The authors have no conflicts of interest to declare.

The effect of percutaneous drainage using tiny incisions on the inflammatory factors in chronic venous insufficiency combined with lipodermatosclerosis of the lower extremities

OBJECTIVE

To explore the efficacy of percutaneous drainage with tiny incisions in chronic venous insufficiency (CVI) combined with lipodystrophy syndrome (LDS) of the lower extremities and its effect on the inflammatory factors.

METHODS

Sixty patients with CVI and LDS hospitalized for surgical treatment in Jiading District Central Hospital were recruited as the study cohort and randomly divided into a control group and an experimental group. The control group (n = 30) underwent varicose vein stripping in the lower extremities, while the experimental group (n = 30) was additionally treated with percutaneous drainage with tiny incisions for LDS. The efficacy of the two treatments, the mRNA expressions of collagen type I alpha 1 chain 1 (COL1A1), the lower limb circumferences, the subcutaneous thicknesses, the transcutaneous partial pressure of oxygen (TcPO₂), the venous clinical severity scores (VCSS), the serum i TGF-β1, TNF-α, IL-2R, and IL-1β levels, the soluble intercellular adhesion molecule-1 (sICAM-1) levels, the soluble vascular cell adhesion molecule-1 (sVCAM-1) levels, and the quality of life scores (CIVIQ) were compared.

RESULTS

The total effective rate in the experimental group was 93.33% (28/30), which was higher than the rate of 73.33% (22/30) in the control group (P < 0.05). The experimental group exhibited shorter ankle circumferences and calf circumferences, smaller subcutaneous thicknesses, lower VCSS scores, lower sICAM-1, sVCAM-1, TGF-β1, TNF-α, IL-1β, IL-2R, and COL1A1 levels, and higher ABI and TcPO₂ levels, and higher CIVIQ scores than the control group at 6 months after the treatment (P < 0.05).

CONCLUSION

Percutaneous drainage with tiny incisions has a high efficacy for CVI with LDS, and it can relieve the condition, inhibit the expression of adhesion molecules as well as the inflammatory response, improve the microcirculation of the lower extremities, reduce COL1A1 expression, and improve the quality of life.

An Innovative National Programme for Comprehensive Chronic Wound Therapy and Its Impact on Treatment Outcomes

BACKGROUND

Although the lifetime prevalence of chronic ulcers tends to be approximately 2.2-10 per 1000 population, no systemic solutions for this problem have been implemented in many countries. It is still not fully agreed whether treatment of chronic wounds requires hospitalization, which incurs high costs, or whether the therapy can be carried out entirely in an outpatient setting. Therefore, the aim of this study was to evaluate the 5-year activity and effectiveness of a national programme for the comprehensive treatment of chronic wounds based on hybrid care for patients. Treatment of nonhealing chronic wounds begins in the hospital, where necessary diagnostic actions are carried out, followed by surgical cleansing of the wound and selection of appropriate dressings. Then, the treatment is continued in the outpatient setting with a continuous patient education. The programme is divided into four subsequent stages. In addition, the present study compared the effectiveness of chronic wound treatment with that in the period before implementation of the programme.

METHODS

From January 2015 to December 2019, 383 patients were treated at a centre for chronic wounds. We analysed the outcomes in 227 individuals with chronic venous ulceration or diabetic foot syndrome.

RESULTS

The mean wound area at the time of introduction of treatment was 36 cm2 (1-290; SD 34). After three stages of treatment, wounds were completely healed in 139 patients (61.2%), 78 patients with venous ulcers (55.3%) and 61 patients with diabetic foot (70.9%). In an additional 67 cases (29.5%), a significant reduction in wound area and depth was achieved, and the treatment was continued beyond the actual treatment programme. No significant effect was achieved in 21 patients (9.2%). In the group of patients treated without systematic application of the guidelines of the programme, wound healing occurred only in 19 cases (26.8%), reduction in the wound area occurred in 27 patients (38.0%), and lack of any healing progress or even worsening of the wound status was found in the remaining 25 cases (35.2%); these differences were statistically significant (p < 0.001).

CONCLUSION

Treatment of chronic wounds based on a systematic dedicated programme using an experienced multidisciplinary team of professionals allows to obtain better results in terms of reduction in wound area and might be an effective procedure. The combination of frequent, scheduled outpatient visits, access to inpatient treatment, and regular education of patients based on a standard form improves treatment outcomes.

Improving Adherence to Wearing Compression Stockings for Chronic Venous Insufficiency and Venous Leg Ulcers: A Scoping Review

PURPOSE

Patient adherence to wearing compression stockings in the management of chronic venous insufficiency (CVI) and venous leg ulcers (VLUs) is low. Poor adherence with compression stockings contributes to recurrence and impaired healing of VLUs. As such, the purpose of this review was to report on the scientific evidence related to adherence and explore modifiable factors which impact adherence with compression stockings.

METHODS

A systematic search was conducted from inception to 31 October 2019. Following the PRISMA-ScR Checklist, PubMed, Medline, CINAHL, Cochrane, Embase, OT Seeker and Web of Science were explored using search terms: compression/compression stocking/compression garment/compression sock/stockings/garments and adherence/compliance/concordance.

RESULTS

We identified 2613 papers of which 125 full text papers were assessed for eligibility and 69 met inclusion criteria. Papers were grouped and charted by concepts relevant to the research questions and narratively synthesized. Several dominant themes emerged, and a conceptual framework was developed incorporating modifiable variables, adherence itself, and outcomes related to adherence. Specifically considering interventions to improve adherence, only five of 14 randomized controlled trials were able to demonstrate improvements in adherence through unidimensional approaches. All nine of the case studies/series demonstrated a positive impact on adherence, eight of which described a personalized multidimensional approach. A lack of consensus around defining, measuring, and quantifying adherence with compression stockings was identified, resulting in wide variation in reported adherence rates.

CONCLUSION

Inconsistency in the definition and measurement of adherence limits meaningful interpretation of the literature. No individual intervention has consistently demonstrated improved adherence. Multidimensional interventions show promise but require further investigation with high-quality trials. Improving adherence appears to improve health outcomes in VLU /CVI populations but there is a lack of information directly linking improved adherence with cost outcomes.

TRIAL REGISTRATION

Open Science Framework: ACTRN12620000544976p.

Why Venous Leg Ulcers Have Difficulty Healing: Overview on Pathophysiology, Clinical Consequences, and Treatment

Venous leg ulcers (VLUs) are one of the most common ulcers of the lower extremity. VLU affects many individuals worldwide, could pose a significant socioeconomic burden to the healthcare system, and has major psychological and physical impacts on the affected individual. VLU often occurs in association with post-thrombotic syndrome, advanced chronic venous disease, varicose veins, and venous hypertension. Several demographic, genetic, and environmental factors could trigger chronic venous disease with venous dilation, incompetent valves, venous reflux, and venous hypertension. Endothelial cell injury and changes in the glycocalyx, venous shear-stress, and adhesion molecules could be initiating events in VLU. Increased endothelial cell permeability and leukocyte infiltration, and increases in inflammatory cytokines, matrix metalloproteinases (MMPs), reactive oxygen and nitrogen species, iron deposition, and tissue metabolites also contribute to the pathogenesis of VLU. Treatment of VLU includes compression therapy and endovenous ablation to occlude the axial reflux. Other interventional approaches such as subfascial endoscopic perforator surgery and iliac venous stent have shown mixed results. With good wound care and compression therapy, VLU usually heals within 6 months. VLU healing involves orchestrated processes including hemostasis, inflammation, proliferation, and remodeling and the contribution of different cells including leukocytes, platelets, fibroblasts, vascular smooth muscle cells, endothelial cells, and keratinocytes as well as the release of various biomolecules including transforming growth factor-β, cytokines, chemokines, MMPs, tissue inhibitors of MMPs (TIMPs), elastase, urokinase plasminogen activator, fibrin, collagen, and albumin. Alterations in any of these physiological wound closure processes could delay VLU healing. Also, these histological and soluble biomarkers can be used for VLU diagnosis and assessment of its progression, responsiveness to healing, and prognosis. If not treated adequately, VLU could progress to non-healed or granulating VLU, causing physical immobility, reduced quality of life, cellulitis, severe infections, osteomyelitis, and neoplastic transformation. Recalcitrant VLU shows prolonged healing time with advanced age, obesity, nutritional deficiencies, colder temperature, preexisting venous disease, deep venous thrombosis, and larger wound area. VLU also has a high, 50-70% recurrence rate, likely due to noncompliance with compression therapy, failure of surgical procedures, incorrect ulcer diagnosis, progression of venous disease, and poorly understood pathophysiology. Understanding the molecular pathways underlying VLU has led to new lines of therapy with significant promise including biologics such as bilayer living skin construct, fibroblast derivatives, and extracellular matrices and non-biologic products such as poly-N-acetyl glucosamine, human placental membranes amnion/chorion allografts, ACT1 peptide inhibitor of connexin 43, sulodexide, growth factors, silver dressings, MMP inhibitors, and modulators of reactive oxygen and nitrogen species, the immune response and tissue metabolites. Preventive measures including compression therapy and venotonics could also reduce the risk of progression to chronic venous insufficiency and VLU in susceptible individuals.

Intermittent sequential pneumatic compression does not enhance whole-body heat loss in elderly adults during extreme heat exposure

Lower-limb intermittent sequential pneumatic compression (ISPC) improves circulation and vascular function in elderly adults. We evaluated the hypothesis that ISPC would also augment whole-body heat loss (WBHL) in elderly adults (aged 69 ± 4 years) resting in extreme heat (40 °C). While ISPC increased mean arterial pressure (91 ± 9 mm Hg) relative to no-ISPC (83 ± 5 mm Hg; P = 0.013) at the end of the exposure, no influence on WBHL was observed (81 ± 7 and 86 ± 11 W for ISPC and no-ISPC, respectively, P = 0.310).

Novelty When assessed in elderly adults during an extreme heat exposure, intermittent sequential pneumatic compression augmented mean arterial pressure but did not enhance whole-body heat loss.