[Medical compression therapy]

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.

Kompressionstherapie in der Schwangerschaft: Fluch oder Segen?

Hintergrund: In der Schwangerschaft kommt es bedingt durch verschiedene Faktoren zur Ausbildung peripherer Ödeme im Bereich der unteren Extremität. Des Weiteren stellt die Schwangerschaft einen Risikofaktor für die Entstehung einer Varikose sowie thrombembolischer Ereignisse dar. Eine prophylaktische Versorgung schwangerer Frauen mit Kompressionsstrümpfen erfolgt häufig nur in Risikosituationen, jedoch noch nicht flächendeckend. Ziel der Studie war es, den Effekt einer optimal angepassten Kompressionstherapie im Hinblick auf die Ödemreduktion und subjektive Beschwerdesymptomatik in der Schwangerschaft zu untersuchen.

Patienten und Methoden: In einer randomisierten, prospektiven Studie wurden 21 schwangere Frauen (33,4 Jahre (SD 4,4 Jahre)) in den klinischen Stadien C0 (3), C1 (11), C2 (6) und C3 (1) untersucht. 13 Frauen erhielten eine Kompressionsstrumpfhose, 8 Frauen keine Kompression. In 4-wöchigen Abständen wurden die Patientinnen bezüglich des Beinumfanges und der Beinvolumina mittels Wasserplethysmographie und berührungsloser Image 3D untersucht. Parallel dazu wurde die Lebensqualität und subjektive Beschwerdesymptomatik mittels Patientenfragebögen evaluiert. Die digitale Photoplethysmographie, doppler- und duplexsonographische Untersuchungen der Beinvenen wurden zu Beginn, kurz vor Geburt sowie 3 Mona-te postpartal vorgenommen.

Ergebnisse: In beiden Gruppen kam es im Verlauf der Schwangerschaft zu einer linear zum Körpergewicht ansteigenden Beinvolumenzunahme. Allerdings zeigte sich in der Wasserplethysmographie ein deutlich geringerer Anstieg des Unterschenkelvolumens in der Patientengruppe mit Kompressionsstrümpfen (p<0,05). Die Lebensqualität sowie die subjektive Beschwerdesymptomatik waren bereits bei Untersuchungsbeginn in der Gruppe mit Kompressionsstrümpfen schlechter bewertet, als in der Gruppe ohne Kompressionsstrümpfe. Es zeigte sich aber im Verlauf der Schwangerschaft keine Verschlechterung, sondern eher eine Verbesserung. Dabei wurden die negativen Trageeigenschaften der Kompressionsstrümpfe als sehr gering eingestuft, was sich auch in der hohen Compliance bezüglich der Tragedauer der Strümpfe widerspiegelte.

Schlussfolgerung: Die Kompressionstherapie bei Schwangeren wird gut toleriert und wirkt einer schwangerschaftsbedingten Unterschenkelvolumenzunahme entgegen und sollte daher in die generelle Empfehlung zur Gesundheitsvorsorge bei Schwangeren aufgenommen werden.

Compression therapy of leg ulcers with PAOD

Objectives: To assess the clinical safety of a new short-stretch 2-layer compression system (3Mtm Cobantm 2 Lite) in patients with peripheral arterial occlusive disease (PAOD). This system combines a low resting pressure with a high working pressure.

Methods: A pilot study was performed in 15 subjects with moderate PAOD, i.e. an ABPI of 0.5-0.8. Co-existing chronic venous insufficiency or leg ulcer was not mandatory. All subjects received the compression system which was reapplied at each study visit (days 1, 2, 3, 4, 7, 10, 14). The safety parameters were: sub-bandage pressure immediately after application, pressure-related skin damage, hypoxia-related pain, and adverse events. A product comfort questionnaire was completed at the last visit.

Results: The average sub-bandage pressure of 30 mmHg defined by the protocol was achieved. No pressure-related skin damage or hypoxia-related pain was found. The reported adverse device effects were as expected for compression therapies, including dry skin and pruritus. The product comfort questionnaire completed by the subjects showed a good tolerability profile.

Conclusion: The short-stretch 2-layer compression system (3Mtm Cobantm 2 Lite) was safe and well tolerated in subjects with moderate PAOD.