Compression stockings for the initial treatment of varicose veins in patients without venous ulceration

Comparative evaluation of the effectiveness of phlebotonic gels

Introduction. Varicose veins are a common disease with a chronic course and a high risk of complications and cosmetic defects. Venotonic drugs are widely used in conservative treatment of varicose veins.

Aim. To study the comparative efficacy of venotonic drugs for local application in experimental conditions.

Materials and Methods. Varicose veins were modeled in Wistar rats by partial stricture of the deep femoral vein. The studied drugs were applied in the course of 14 days from the operation. The assessed parameters were the change of local blood flow velocity in the skin in the dynamics and the degree of vascular permeability. The rate of local blood flow was assessed by Doppler ultrasound. Changes in vascular permeability were studied by the degree of extravasation of Evans blue dye in the Miles test. The results were processed using the methods of variation statistics.

Results. The study showed that under the conditions of experimental chronic venous insufficiency, a course of application of all the analyzed drugs resulted in an increase in the rate of local blood flow in the skin and a decrease in the degree of vascular permeability. It was noted that application of the investigated gel based on escin, heparin and essential phospholipids to the skin of animals resulted in reliably (p < 0,05) lower indices of vascular permeability in comparison with the rats which received a course therapy with the heparin-containing gel; combined cosmetic agent as well as the gel based on troxerutin, heparin and dexpanthenol.

Discussion. The results obtained testify that application of external dosage forms of combined venotonic drugs promotes the regression of chronic venous insufficiency manifestations. Maximum evident effect was registered while applying the studied drug, that can be related to its complex composition including essential phospholipids, heparin and aescin. It is known that aescin is a phlebotonic with a high degree of percutaneous absorption, the effect of which is significantly potentiated by the phospholipid component.

Conclusions. The application of the combined product based on heparin, aescin and essential phospholipids provided an optimum rate of onset of pharmacological effect compared to the other analysed compositions.

Understanding Chronic Venous Disease: A Critical Overview of Its Pathophysiology and Medical Management

Chronic venous disease (CVD) is a multifactorial condition affecting an important percentage of the global population. It ranges from mild clinical signs, such as telangiectasias or reticular veins, to severe manifestations, such as venous ulcerations. However, varicose veins (VVs) are the most common manifestation of CVD. The explicit mechanisms of the disease are not well-understood. It seems that genetics and a plethora of environmental agents play an important role in the development and progression of CVD. The exposure to these factors leads to altered hemodynamics of the venous system, described as ambulatory venous hypertension, therefore promoting microcirculatory changes, inflammatory responses, hypoxia, venous wall remodeling, and epigenetic variations, even with important systemic implications. Thus, a proper clinical management of patients with CVD is essential to prevent potential harms of the disease, which also entails a significant loss of the quality of life in these individuals. Hence, the aim of the present review is to collect the current knowledge of CVD, including its epidemiology, etiology, and risk factors, but emphasizing the pathophysiology and medical care of these patients, including clinical manifestations, diagnosis, and treatments. Furthermore, future directions will also be covered in this work in order to provide potential fields to explore in the context of CVD.

Graduated compression stockings for the initial treatment of varicose veins in people without venous ulceration

BACKGROUND

Compression hosiery or stockings are often the first line of treatment for varicose veins in people without either healed or active venous ulceration. Evidence is required to determine whether the use of compression stockings can effectively manage and treat varicose veins in the early stages. This is the second update of a review first published in 2011.

OBJECTIVES

To assess the effectiveness of compression stockings for the only and initial treatment of varicose veins in people without healed or active venous ulceration.

SEARCH METHODS

For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and AMED databases and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 12 May 2020. We also checked references of studies identified from the literature searches.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) involving people diagnosed with primary trunk varicose veins without healed or active venous ulceration (Clinical, Etiology, Anatomy, Pathophysiology (CEAP) classification C2 to C4). Included trials assessed compression stockings versus no treatment or placebo stockings, or compression stockings plus drug intervention versus drug intervention alone. We also included trials comparing different lengths and pressures of stockings. We excluded trials involving other types of treatment for varicose veins (either as a comparator to stockings or as an initial non-randomised treatment), including sclerotherapy and surgery.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology. Two review authors independently assessed trials for inclusion, extracted data, assessed risk of bias and assessed the certainty of the evidence using GRADE. Outcomes of interest were change in symptoms; physiological measures; complications; compliance; comfort, tolerance and acceptability of wearing stockings; and quality of life.

MAIN RESULTS

We included 13 studies with 1021 participants with varicose veins without healed or active venous ulceration. One study included pregnant women while other studies included participants who had sought medical intervention for their varicose veins by being on surgical waiting lists, or attending vascular surgery or dermatology clinics or outpatient departments. The stockings used in the studies exerted different levels of pressure, ranging from 10 mmHg to 50 mmHg. Five studies assessed compression stockings versus no compression stockings or placebo stockings. Three of these studies used knee-length stockings, one used full-length stockings and one used full tights. Eight studies compared different types or pressures of knee-length stockings. The risk of bias of many included trials was unclear, mainly because of inadequate reporting. We were unable to pool studies as they did not report the same outcomes or used different ways to assess them. Many studies were small and there were differences in the populations studied. The certainty of the evidence was therefore low to very low. Compression stockings compared with no treatment or placebo stockings All four studies that reported change in symptoms found a subjective improvement by the end of the study. However, change in symptoms was not always analysed by comparing the randomised arms of the studies and was therefore subject to bias. Two studies assessed physiological measures using either ankle circumference or duplex sonography to measure oedema. Ankle circumference showed no clear difference between baseline and follow-up while oedema was reduced in the stocking group compared with the placebo stocking group. Three studies reported complications or side effects with itching and irritation the main side effects reported. None of the trials reported severe side effects. Reports of compliance varied between studies. One study reported a high dropout rate with low levels of compliance due to discomfort, application and appearance; two studies reported generally good levels of compliance in the stocking group compared to placebo/no treatment. Two studies reported comfort, tolerance and acceptability with outcomes affected by the study population. Compression tights were increasingly rejected by pregnant women as their pregnancy progressed, while in one study of non-pregnant women, the stockings group showed no more hindrance of normal activities and daytime discomfort when compared with placebo stockings. One study reported quality of life showing no clear differences between the stocking and placebo stocking groups. Compression stockings compared with different compression stockings All five studies that reported change in symptoms found a subjective improvement in symptoms by the end of the study. Change in symptoms was not always analysed comparing the randomised arms of the trials and was therefore subject to bias. Five studies reported a variety of physiological measures such as foot volumetry, volume reduction and change in diameter. Generally, there were no clear differences between study arms. Four studies reported complications or side effects, including sweating, itching, skin dryness, and constriction and tightness. None of the trials reported severe side effects. Two studies reported compliance showing no difference in compliance rates between stockings groups, although one study reported high initial levels of dropout due to discomfort, appearance, non-effectiveness and irritation. Four studies reported comfort, tolerance and acceptability. Two studies reported similar levels of tolerance and discomfort between groups. Discomfort was the main reason for indicating a preference for one type of stocking over another. None of the studies assessed quality of life. No conclusions regarding the optimum length or pressure of compression stockings could be made as there were no conclusive results from the included studies.

AUTHORS' CONCLUSIONS

There is insufficient high-certainty evidence to determine whether or not compression stockings are effective as the sole and initial treatment of varicose veins in people without healed or active venous ulceration, or whether any type of stocking is superior to any other type. Future research should consist of large RCTs of participants with trunk varices either wearing or not wearing compression stockings to assess the efficacy of this intervention. If compression stockings are found to be beneficial, further studies assessing which length and pressure is the most efficacious could then take place.

Advances in Engineering Venous Valves: The Pursuit of a Definite Solution for Chronic Venous Disease

Native venous valves enable proper return of blood to the heart. Under pathological conditions (e.g., chronic venous insufficiency), venous valves malfunction and fail to prevent backward flow. Clinically, this can result in painful swelling, varicose veins, edema, and skin ulcerations leading to a chronic wound situation. Surgical correction of venous valves has proven to drastically reduce these symptoms. However, the absence of intact leaflets in many patients limits the applicability of this strategy. In this context, the development of venous valve replacements represents an appealing approach. Despite acceptable results in animal models, no venous valve has succeeded in clinical trials, and so far no single prosthetic venous valve is commercially available. This calls for advanced materials and fabrication approaches to develop clinically relevant venous valves able to restore natural flow conditions in the venous circulation. In this study, we critically discuss the approaches attempted in the last years, and we highlight the potential of tissue engineering to offer new avenues for valve fabrication. Impact statement Venous valves prosthesis offer the potential to restore normal venous flow, and to improve the prospect of patients that suffer from chronic venous disease. Current venous valve replacements are associated with poor outcomes. A deeper understanding of the approaches attempted so far is essential to establish the next steps toward valve development, and importantly, tissue engineering constitutes a unique toolbox to advance in this quest.

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

BACKGROUND

Many home-dwelling elderly use medical compression stockings to prevent venous insufficiency, deep venous thrombosis, painful legs and leg ulcers. Assisting users with applying and removing compression stockings demands resources from the home based health services, but the effects are uncertain. This systematic review aims to summarize the effects of preventive use of medical compression stockings for patients with chronic venous insufficiency and swollen legs.

METHODS

We conducted a search in six databases (Epistemonikos, Cochrane Database of Systematic Reviews, MEDLINE, Embase, CENTRAL and CINAHL) in March 2018. Randomized controlled trials evaluating the preventive effects of European standard compression stockings class 3 or 2 for elderly with chronic venous insufficiency and swollen legs were included. Primary outcomes were thrombosis, leg ulcers and mobility. Secondary outcomes were other health related outcomes, e.g. pain, compliance. We assessed risk of bias in the included studies and used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool for evaluating the overall quality of evidence.

RESULTS

Five randomized controlled trials met the inclusion criteria. Comparing compression stockings class 2 to class 1, meta-analysis showed a reduction in leg ulcer recurrence at 12 months (RR 0.52; 95% CI 0.30 to 0.88). The quality of evidence was assessed as moderate by GRADE. One study (100 participants) did not detect a difference between compression stockings class 3 versus class 2 on ulcer recurrence after six months (RR 0.64; 95% CI 0.20 to 2.03). In another study, patients wearing class 3 compression stockings had lower recurrence risk compared with patients without stockings (RR 0.46; 95% CI 0.27 to 0.76) at six months and (RR 0.43; 95% CI 0.27 to 0.69) at 12 months. We found no difference between class 2 and class 1 stockings on subjective symptoms of chronic venous insufficiency or outcomes of vein thrombosis or mobility.

CONCLUSION

Compression stockings class 2 probably reduce the risk of leg ulcer recurrence compared to compression stockings class 1. It is uncertain whether the use of stockings with higher compression grades is associated with a further risk reduction. More randomized controlled trials on vein thrombosis and mobility are needed.

[Compression therapy in leg ulcers]

Compression therapy is well-tried treatment with only few side effects for most patients with leg ulcers and/or edema. Despite the very long tradition in German-speaking countries and good evidence for compression therapy in different indications, recent scientific findings indicate that the current situation in Germany is unsatisfactory. Today, compression therapy can be performed with very different materials and systems. In addition to the traditional bandaging with Unna Boot, short-stretch, long-stretch, or multicomponent bandage systems, medical compression ulcer stockings are available. Other very effective but far less common alternatives are velcro wrap systems. When planning compression therapy, it is also important to consider donning devices with the patient. In addition to compression therapy, intermittent pneumatic compression therapy can be used. Through these various treatment options, it is now possible to develop an individually accepted, geared to the needs of the patients, and functional therapy strategy for nearly all patients with leg ulcers.

Interventions for varicose veins and leg oedema in pregnancy

BACKGROUND

Pregnancy is presumed to be a major contributory factor in the increased incidence of varicose veins in women, which can in turn lead to venous insufficiency and leg oedema. The most common symptom of varicose veins and oedema is the substantial pain experienced, as well as night cramps, numbness, tingling, the legs may feel heavy, achy, and possibly be unsightly. Treatments for varicose veins are usually divided into three main groups: surgery, pharmacological and non-pharmacological treatments. Treatments of leg oedema comprise mostly symptom reduction rather than cure and use of pharmacological and non-pharmacological approaches.

OBJECTIVES

To assess any form of intervention used to relieve the symptoms associated with varicose veins and leg oedema in pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised trials of treatments for varicose veins or leg oedema, or both, in pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

We included seven trials (involving 326 women). The trials were largely unclear for selection bias and high risk for performance and detection bias.Two studies were placebo-controlled trials. The first one compared a phlebotonic (rutoside) with placebo for the reduction in symptoms of varicose veins; the second study evaluated the efficacy of troxerutin in comparison to placebo among 30 pregnant women in their second trimester with symptomatic vulvar varicosities and venous insufficiency in their lower extremities. Data from this study were not in useable format, so were not included in the analysis. Two trials compared either compression stockings with resting in left lateral position or reflexology with rest for 15 minutes for the reduction of leg oedema. One trial compared standing water immersion for 20 minutes with sitting upright in a chair with legs elevated for 20 minutes. Women standing in water were allowed to stand or walk in place. One trial compared 20 minutes of daily foot massage for five consecutive days and usual prenatal care versus usual prenatal care. The final trial compared three treatment groups for treating leg oedema in pregnancy. The first group was assigned to lateral supine bed rest at room temperature, women in the second group were asked to sit in a bathtub of waist-deep water at 32 ± 0.5 C with their legs horizontal and the third group included the women who were randomised to sitting immersed in shoulder-deep water at 32 ± 0.5 C with legs extended downward. We did not include this study in the analysis as outcomes reported in the paper were not pre-specified outcomes of this review.We planned to use GRADE methods to assess outcomes for two different comparisons and assign a quality rating. However, only two out of three outcomes for one comparison were reported and could be assessed. Evidence from one trial (rutoside versus placebo) for the outcomes of reduction in symptoms and incidence of complications associated with varicose veins and oedema was assessed as of moderate quality. Rutoside versus placeboOne trial involving 69 women, reported that rutoside significantly reduced the symptoms associated with varicose veins (risk ratio (RR) 1.89, 95% confidence interval (CI) 1.11 to 3.22; moderate quality evidence). The incidence of complications (deep vein thrombosis) did not differ significantly between the two groups (risk ratio (RR) 0.17, 95% CI 0.01 to 3.49; moderate quality evidence). There were no significant differences in side-effects (RR 1.30, 95% CI 0.23 to 7.28). Women's perception of pain was not reported in this trial. External pneumatic intermittent compression versus restOne trial, involving 35 women, reported no significant difference in lower leg volume when compression stockings were compared against rest (mean difference (MD) -258.80, 95% CI -566.91 to 49.31). Reflexology versus restingAnother trial, involving 55 women, compared reflexology with rest. Reflexology significantly reduced the symptoms associated with oedema (reduction in symptoms: RR 9.09, 95% CI 1.41 to 58.54). The same study showed a trend towards satisfaction and acceptability with the intervention (RR 6.00, 95% CI 0.92 to 39.11). Water immersion versus leg elevationThere was evidence from one trial, involving 32 women, to suggest that water immersion for 20 minutes in a swimming pool reduces leg volume (RR 0.43, 95% CI 0.22 to 0.83). Foot massage versus routine careOne trial, involving 80 women reported no significant difference in lower leg circumference when foot massage was compared against routine care (MD -0.11, 95% CI -1.02 to 0.80).No other primary or secondary outcomes were reported in the trials.

AUTHORS' CONCLUSIONS

There is moderate quality evidence to suggest that rutosides appear to help relieve the symptoms of varicose veins in late pregnancy. However, this finding is based on one study (69 women) and there are not enough data presented in the study to assess its safety in pregnancy. Reflexology or water immersion appears to help improve symptoms for women with leg oedema, but again this is based on two small studies (43 and 32 women, respectively).