Relationship between medical compression and intramuscular pressure as an explanation of a compression paradox

Background

Using standing magnetic resonance imaging (MRI), we recently showed that medical compression, providing an interface pressure (IP) of 22 mmHg, significantly compressed the deep veins of the leg but not, paradoxically, superficial varicose veins.

Objective

To provide an explanation for this compression paradox by studying the correlation between the IP exerted by medical compression and intramuscular pressure (IMP).

Material and methods

In 10 legs of five healthy subjects, we studied the effects of different IPs on the IMP of the medial gastrocnemius muscle. The IP produced by a cuff manometer was verified by a Picopress® device. The IMP was measured with a 21G needle connected to a manometer. Pressure data were recorded in the prone and standing positions with cuff manometer pressures from 0 to 50 mmHg.

Results

In the prone position, an IP of less than 20 did not significantly change the IMP. On the contrary, a perfect linear correlation with the IMP ( r = 0.99) was observed with an IP from 20 to 50 mmHg. We found the same correlation in the standing position.

Conclusion

We found that an IP of 22 mmHg produced a significant IMP increase from 32 to 54 mmHg, in the standing position. At the same time, the subcutaneous pressure is only provided by the compression device, on healthy subjects. In other words, the subcutaneous pressure plus the IP is only a little higher than 22 mmHg—a pressure which is too low to reduce the caliber of the superficial veins. This is in accordance with our standing MRI 3D anatomical study which showed that, paradoxically, when applying low pressures (IP), the deep veins are compressed while the superficial veins are not.

Venous symptoms in C0 and C1 patients: UIP consensus document

This UIP document provides an update on venous symptoms in CO and C1 patients. The correlation between venous symptoms and the presence of telangiectases and/or reticular veins is one of the most controversial topics in chronic venous disorders. As symptoms may be non-specific of chronic venous disease, it is important to differentiate venous symptoms from symptoms of other causes. Some data from the Bonn Vein Study suggest that the risk to develop venous symptoms is increased in women, advanced age and obesity. Treatment is based on physical advice, elastic compression, venoactive drugs, sclerotherapy, correction of foot static disorders and reduction of body weight. Future research should be promoted on venous symptoms in epidemiological and follow-up studies, about the relationship between female hormone levels and symptomatic telangiectasias, and between venous pain and foot static disorders in C0s C1s patients.

Chronic edema of the lower extremities: international consensus recommendations for compression therapy clinical research trials

Chronic edema is a multifactorial condition affecting patients with various diseases. Although the pathophysiology of edema varies, compression therapy is a basic tenant of treatment, vital to reducing swelling. Clinical trials are disparate or lacking regarding specific protocols and application recommendations for compression materials and methodology to enable optimal efficacy. Compression therapy is a basic treatment modality for chronic leg edema; however, the evidence base for the optimal application, duration and intensity of compression therapy is lacking. The aim of this document was to present the proceedings of a day-long international expert consensus group meeting that examined the current state of the science for the use of compression therapy in chronic edema. An expert consensus group met in Brighton, UK, in March 2010 to examine the current state of the science for compression therapy in chronic edema of the lower extremities. Panel discussions and open space discussions examined the current literature, clinical practice patterns, common materials and emerging technologies for the management of chronic edema. This document outlines a proposed clinical research agenda focusing on compression therapy in chronic edema. Future trials comparing different compression devices, materials, pressures and parameters for application are needed to enhance the evidence base for optimal chronic oedema management. Important outcomes measures and methods of pressure and oedema quantification are outlined. Future trials are encouraged to optimize compression therapy in chronic edema of the lower extremities.

Guidelines for clinical studies with compression devices in patients with venous disorders of the lower limb

OBJECTIVES

The scientific quality of published clinical trials is generally poor in studies where compression devices have been assessed in the management of venous disease. The authors' aim was to establish a set of guidelines which could be used in the design of future clinical trials of compression treatments for venous diseases.

DESIGN

Consensus conference leading to a consensus statement.

METHODS

The authors form a expert consensus group known as the International Compression Club (ICC). This group obtained published medical literature in the field of compression treatment in venous disease by searching medical literature databases. The literature was studied by the group which attended a consensus meeting. A draft document was circulated to ICC members and revised until agreement between contributors was reached.

RESULTS

The authors have prepared a set of guidelines which should be given consideration when conducting studies to assess the efficacy of compression in venous disease.

CONCLUSIONS

The form of compression therapy including the comparators used in the clinical study must be clearly characterised. In future studies the characteristics of the material provided by the manufacturer should be described including in vivo data on pressure and stiffness of the final compression system. The pressure exerted on the distal lower leg should be stated in mmHg and the method of pressure determination must be quoted.

Pregnancy-induced changes in lower extremity superficial veins: an ultrasound scan study

OBJECTIVE

The purpose of this study was to follow changes in superficial veins of the lower extremities during pregnancy and the postpartum period in women with varicose veins.

METHODS

This was a prospective study with the use of duplex scanning during the first and third trimesters of pregnancy and postpartum period. Competent veins were defined as veins with an absence of reflux, and incompetent veins were defined as veins with reflux. The diameter of the competent or incompetent greater saphenous vein (GSV) and lesser saphenous vein (LSV) was measured. The diameter of the largest varicose dilatations was measured in all three networks: GSV and its tributaries, LSV and its tributaries, and nonsaphenous varicose veins.

RESULTS

Sixty-six women were studied prospectively (mean age, 32.2 +/- 4 years; 85 affected extremities). The diameter of competent and incompetent GSVs and competent LSVs increased between the first and third trimester (P <.001) and decreased between the third trimester and the postpartum period (P <.001). The diameter of the largest varicose dilatations of the GSV and its tributaries and nonsaphenous networks increased between the first and third trimester (P <.001) and decreased between the third trimester and the postpartum period (P <.001). No statistically significant variation of the diameter was demonstrated for any of these veins between the first trimester and the postpartum period.

CONCLUSION

The diameters of competent and incompetent superficial veins increased during pregnancy and decreased during the postpartum period to return to their baseline values.

Chronic venous disorders of the leg: epidemiology, outcomes, diagnosis and management. Summary of an evidence-based report of the VEINES task force. Venous Insufficiency Epidemiologic and Economic Studies

BACKGROUND

To critically review the classification, epidemiology, outcomes, diagnosis and treatment of chronic venous disorders of the leg (CVDL), to issue evidence-based recommendations, and to identify areas requiring further research.

METHODS

Articles identified by an extensive literature search were scored by members of an international task force. Only those articles with a moderate or strong rating for internal validity were retained.

RESULTS

A scoring system weighing CVDL severity according to the probability of ulcer occurrence is proposed. Epidemiological data on the frequency of CVDL and its risk factors are reviewed. The following items are evaluated: costs associated with treatment; clinical outcomes related to CVDL and its treatment; available generic and disease-specific measures of quality of life; diagnostic procedures used to detect venous reflux; and efficacy of available treatments.

CONCLUSIONS

CVDL is an important public health problem, based on its prevalence, cost and impact on quality of life. High-priority areas for research on CVDL are identified.

Sclerotherapy. Continuous wave Doppler-guided injections

BACKGROUND

The usual method of injection of sclerosing agents is based simply on clinical recognition and visualization of the varicose vein.

OBJECTIVE

The authors present an original technique for sclerosing injections, named Doppler sclerotherapy. The purpose is to allow more accurate sclerotherapy in situations where varicose veins (usually greater than 4-5 mm) are not palpable in the supine position, but palpable when standing.

METHODS

This technique consists of injecting the sclerosing agent using an uncomplicated continuous wave Doppler, a syringe, and a needle, according to a method consisting of four well-defined steps ensuring avoidance of arterial vessels and constant appreciation of the varicose vein to be treated, even during the injection. It requires no assistants and allows the treating physician's gaze to remain at the injection site while listening for very specific Doppler sounds of aspiration and injection.

RESULTS

In our multicenter study of 220 patients (approximately 1,400 injections) all but 18 injections were successful for intravascular localization. No serious complications were noted.

CONCLUSIONS

The principal indication is the treatment of varicose veins that are palpable while standing but impalpable in the supine position. In addition varicose veins in the groin region, lower third of the thigh, and along the axis of the small saphenous vein may be treated with this technique. In these situations it is a more accessible, faster, and economical technique, although it does not replace duplex ultrasound-guided injections.

Importance of the familial factor in varicose disease. Clinical study of 134 families

BACKGROUND

The role of heredity in the development of varicose veins of the lower limbs has been raised many times in the literature. When evaluating this role, most authors only question the patients, without examining their relatives. As shown in other papers, the subjectivity of this type of data throws doubt on the results.

OBJECTIVE

This problem was evaluated by means of a prospective study based on clinical examination of all immediate family members.

METHODS

In the case-control study, the female or male patients had to satisfy the following criteria: 1. Varicose veins in their legs. 2. Age between 30 and 40 years (meaning that, in most cases, their parents were still alive). 3. No history of deep vein thrombosis. To limit the influence of certain confusing factors (diet, life-style), the control group was composed of the patients' spouses, who were not suffering from varicose veins. The parents of the cases and the parents of the controls were also examined. For each case-control couple and for the four parents, we recorded the history of venous disease, the life-style, and the results of clinical examination, including the results of palpation and percussion of the various varicose vein territories.

RESULTS

One hundred and thirty-four families were examined: 67 patients and their parents and 67 controls and their parents. A total of 402 subjects were examined. The results demonstrated a prominent role of heredity in the development of varicose veins (P < .001). The risk of developing varicose veins for the children was 90% when both parents suffered from this disease, 25% for males and 62% for females when one parent was affected, and 20% when neither parent was affected.

[A swollen, febrile leg]

The authors report the case of a young man, of Algerian origin, with edema of the right lower limb accompanied by an inflammatory syndrome present for several months. This symptomatology, clinically suggestive of a deep venus thrombosis, but not confirmed by sonography, proved to be due in fact to pulmonary tuberculosis with septicemic spread to the muscle masses of the right calf. The diagnosis was made by direct paracentesis of the right calf. It is important to remember that pulmonary tuberculosis with septicemic spread to muscle masses but without bone lesions remains rare. The special interest of this case thus concerns its tuberculous etiology and clinical similarity to a deep venous thrombosis. Nevertheless, the diagnosis should have been eliminated earlier in view of the clinical course and worsening of systemic manifestations.

[Leg ulcers in the obese: data from the literature]

The authors survey 131 publications on the epidemiology of leg ulcers in the obese patient, by successively interrogating computer data banks. By analysing this information they aim to determine the frequency of obesity in a population of patients with stasic ulcers, to see whether the ulcer has particular clinical characteristics in the obese patient, and finally, to know whether obesity affects the speed with which the ulcer heals. The results are given and assessed.

[Leg ulcers of venous origin. Rate of basic healing. Practical consequences]

The formula necessary for this study includes seven points of which the most important is the measurement of the reduction of the surface area of each ulcer. 100 leg ulcers, venous in origin, and representing a total surface area of 2.052 cm2, healed at varying speeds, directly proportionate to their initial surface area. To each surface area of ulcer there corresponds a length of time of half the cicatrization, equalling or less than thirty days which makes it possible to establish a point of reference in the development of cicatrization, and therefore a basic short-term prognosis. Once this time has passed, the diagnosis and the treatment are again the issue, with all that involves.

[An extender... For better application of compression. Value. Use. Indications]

The author presents an original methode for the pose, without effort, of an elastic stocking on a superior or inferior limb without moving any existing dressing. The extensor permits, without any experience, the utilisation of predetermined compression, which can easely reach 60 mmHg.