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.

S.T.R.I.D.E. Professional Guide to Compression Garment Selection for the Lower Extremity

The following supplement is a rare example of a paper that combines clinical experience and theoretical knowledge on textiles used in compression therapy. The authors' intention is to propose a decision support system for choosing specific compression devices, which can be adjusted to counteract the individual signs and symptoms in an optimally adopted way. The document concentrates on compression devices which can be self-applied by the patients—compression stockings and adjustable wraps. The acronym ‘S.T.R.I.D.E.’, incorporating both textile characteristics and clinical presentation, stands for: Shape, Texture, Refill, Issues, Dosage and Etiology. The intent of the mnemotechnical value is to highlight that successful compression includes more than dosage alone. In addition to dosage, etiology and patient presentation need to be incorporated, including a patient's physical ability to use compression effectively as part of the daily routine, thereby promoting adherence.

The suggested algorithms provide a valuable guide to stride across the important, but still underestimated field of medical compression therapy and will help to put the prescription of a specific product on a more rational basis. Enjoy reading!

Hugo Partsch Emeritus Professor Medical University of Vienna, Austria

Effect of gaiters on muscle pump activity in healthy volunteers

OBJECTIVES

Exercise of the leg with external limb compression has been reported to be useful for preventing and reducing leg oedema. The aim of this study was to investigate the effects of leg gaiters on calf muscle pump activity.

METHODS

Continuous measurements of the interface pressure at the leg during exercise and determination of the femoral venous velocity at the groin during exercise were carried out in healthy volunteers with elastic stockings alone, leg gaiters alone and gaiters over the elastic stockings.

RESULTS

The greatest pressure difference between muscle contraction and relaxation during exercise was observed when gaiters were applied over the elastic stockings at the calf. Gaiters alone without elastic stockings led to a significantly greater pressure difference between muscle contraction and relaxation during exercise than elastic stockings alone (P < 0.01). A significantly higher value of the peak flow velocity of the femoral vein was observed with the combined use of gaiters and elastic stockings than the single use of elastic stockings.

CONCLUSIONS

Leg gaiters have a beneficial effect of augmenting venous femoral blood flow during calf muscle pump activity in volunteers with a normal valve function of leg veins.

Correlation between the static and dynamic stiffness indices of medical elastic compression stockings

BACKGROUND

Compression therapy with medical elastic compression stockings (MECS) has been used effectively for treating patients with chronic venous insufficiency for many years.

OBJECTIVE

To study the correlation between static stiffness and the dynamic stiffness index of 18 different brands of MECS.

METHODS

In all, 18 different brands of MECS were divided into 5 categories (class II round-knit, class II flat-knit, class III round-knit, class III flat-knit, and class IV flat-knit) and tested. The tension of the textile of the MECS at the B1 level was measured according to the Institut de Textile France method to calculate the static stiffness index. The dynamic pressure pulsations were measured with a newly developed dynamic pressure-determining device to calculate the dynamic stiffness index.

RESULTS

The results showed that there was a positive correlation between the static stiffness index and the dynamic stiffness index. The dynamic stiffness indices were higher than the static stiffness indices.

CONCLUSION

Although the stiffness of MECS is a further refinement to the current classification, which classifies MECS according to the pressure they exert at the B level, the dynamic stiffness index does not have any additional value over the static stiffness index as far as the classification of MECS is concerned. Either or both of these characteristics should be used to select the most suitable MECS for the patient.

Variation in the dynamic stiffness index of different types of medical elastic compression stockings

OBJECTIVES

To calculate the dynamic stiffness index (DSI) of 18 different brands of medical elastic compression stockings (MECS).

METHODS

In all, 18 different brands of MECS that were divided into five categories (class II round-knitted, class II flat-knitted, class III round-knitted, class III flat-knitted and class IV flat-knitted MECS) were tested. The static pressure and dynamic pressure pulsations at the B1 level were measured with a newly developed dynamic pressure-determining device. The DSI was calculated.

RESULTS

The DSI of all 18 brands of MECS showed higher values compared with the static stiffness. A wide range of dynamic stiffness indices was observed not only between all brands of MECS, but also within the five categories.

CONCLUSIONS

The DSI of MECS is independent of the compression class and the type of knit. The variation in the DSIs between MECS is not because of any measurement error and would indicate that different therapeutic effectiveness may be expected within one compression class. Therefore, a refinement in the current classification system for MECS with other characteristics such as the DSI is warranted.