The Static Stiffness Index: an important parameter to characterise compression therapy in vivo

The compression pressure, which corresponds to the dosage of compression therapy, has been widely neglected up to now, not only concerning scientific literature, but also in clinical practice. It is evident that compression pressures in the upright position and during walking are clinically more relevant than just the resting pressure. The Static Stiffness Index (SSI), which is the difference between standing and resting pressure, is a valuable parameter characterising the efficacy of a specific compression product to narrow/occlude the venous lumen. This is a prerequisite for reducing venous reflux and exerting a massaging effect necessary to improve the venous pumping function during movement. This article provides an overview of the recent literature on the SSI, which supports the recommendations of the International Compression Club. In addition, it aims to provide an insight on the importance of the SSI in daily practice, as an educational tool as well as in defining the properties of applied compression therapy in clinical research.

Stationäre und ambulante Thromboembolieprophylaxe in der Chirurgie und der perioperativen Medizin

Präambel: Alle aufgeführten medizinischen Fachgesellschaften haben sich zusammengefunden, um die früheren verschiedenen Empfehlungen zur Thromboembolieprophylaxe zu aktualisieren und in einer gemeinsamen »Leitlinie zur stationären und ambulanten Thromboembolieprophylaxe in der perioperativen Medizin« zusammenzufassen. Dazu wurden in einem ersten Schritt durch eine Konsensuskonferenz mit nominalem Gruppenprozess die früheren Empfehlungen (Fassung vom Juni 2000) überarbeitet (S2-Leitlinie). Dies erschien notwendig, um neue Therapieprinzipien und neu zugelassene Medikamente zu berücksichtigen. Als nächster Schritt erfolgt die Weiterentwicklung der vorliegenden Leitlinie nach der Vorgaben der 3. Stufe der Leitlinienentwicklung der AWMF (S3-Leitlinie).

Leitlinie: Intermittierende pneumatische Kompression (IPK oder AIK)

Leitlinien sind systematisch erarbeitete Empfehlungen, um den Arzt in Klinik und Praxis bei Entscheidungen über eine angemessene Versorgung des Patienten im Rahmen spezifischer klinischer Umstände zu unterstützen. Leitlinien gelten für Standardsituationen und berücksichtigen die aktuellen, zu den entsprechenden Fragestellungen zur Verfügung stehenden wissenschaftlichen Erkenntnisse. Leitlinien bedürfen der ständigen Überprüfung und eventuell der Änderung auf dem Boden des wissenschaftlichen Erkenntnisstandes und der Praktikabilität in der täglichen Praxis. Durch die Leitlinien soll die Methodenfreiheit des Arztes nicht eingeschränkt werden. Ihre Beachtung garantiert nicht in jedem Fall den diagnostischen und therapeutischen Erfolg. Leitlinien erheben keinen Anspruch auf Vollständigkeit. Die Entscheidung über die Angemessenheit der zu ergreifenden Maßnahmen trifft der Arzt unter Berücksichtigung der individuellen Problematik.

Primary varicose veins

Background: Compression stockings are widely used in patients with varicose veins. Methods: Based on published literature three main points are discussed: 1. the rationale of compression therapy in primary varicose veins, 2. the prescription of compression stockings in daily practice, 3. studies required in the future. Results: The main objective of prescribing compression stockings for patients with varicose veins is to improve subjective leg complaints and to prevent swelling after sitting and standing. No convincing data are available concerning prevention of progression or of complications. In daily practice varicose veins are the most common indication to prescribe compression stockings. The compliance depends on the severity of the disorder and is rather poor in less severe stages. Long-term studies are needed to proof the cost-effectiveness of compression stockings concerning subjective symptoms and objective signs of varicose veins adjusted to their clinical severity. Conclusion: Compression stockings in primary varicose veins are able to improve leg complaints and to prevent swelling.

Duplex-Ultraschalluntersuchung der Venen der unteren Extremitäten bei chronischer Veneninsuffizienz

Hintergrund: Die Duplex-Ultraschalluntersuchung ist der Goldstandard zur Beurteilung von Morphologie und Hämodynamik der Venen der unteren Extremitäten. Das in der vorliegenden Arbeit beschriebene Projekt wurde auf Grund einer Initiative der UIP (Union Internationale de Phlébologie) ins Leben gerufen. Das Ziel war es, einen Konsens internationaler Experten zu erreichen, wie die Methodologie der bildlichen Darstellung mittels Ultraschall zur Untersuchung der Venen der unteren Extremitäten verwendet werden kann. Design: Konsensuskonferenz, die zu einem Konsensusdokument führte. Methoden: Die Autoren luden eine internationale Expertengruppe zur Teilnahme an diesem Projekt ein. Elektronische Eingaben der Autoren sowie der internationalen Experten waren allen Teilnehmern auf der UIP-Website zugänglich. Die Autoren bereiteten ein erstes Dokument vor, welches auf dem UIP-Kongress in San Diego 2003 diskutiert wurde. Das überarbeitete Manuskript wurde im Anschluss an alle Experten geschickt und die Kommentare trugen zu weiteren Revisionen des Dokuments bei. Die endgültige Version wurde von allen Teilnehmern akzeptiert. Ergebnisse: Die Experten sprachen detaillierte Empfehlungen für die Duplex-Untersuchung der Venen der unteren Extremitäten sowie über die Interpretation der Befunde und Messergebnisse aus. Dieses Dokument enthält eine detaillierte Methodologie für eine komplette Beurteilung der oberflächlichen Venen sowie der Perforantes der unteren Extremität mittels Duplex-Ultraschall. Weiters enthält es Empfehlungen bezüglich der Erstellung von Befunden sowie bezüglich des Trainings von Mitarbeitern, welche diese Untersuchungen durchführen. Schlussfolgerung: Die Autoren und eine große Expertengruppe einigten sich auf eine Methodologie zur Untersuchung der Venen der unteren Extremitäten mittels Duplex-Ultraschall.

Pathogenese und Therapie der Chronischen Venenerkrankung

Neue Einblicke in die Struktur und Funktion des menschlichen Blutgefäßsystems und die Interaktion der Gefäßintima mit dem Blut führen zu einem umfassenden Verständnis des Krankheitsbildes der Chronischen Venenerkrankung in den unteren Extremitäten, das sich auf dem Boden ungünstiger physikalischer Durchblutungsbedingungen im Zusammenwirken mit heute gut aufgeklärten zellphysiologischen Prozessen autokatalytisch immer stärker ausprägt. Eine zentrale Stellung nehmen dabei das hochspezialisierte Endothel der Venulen und die zugehörigen Perizyten in den engen nutritiven Mikrogefäß-netzen (Vasa venarum) der Venenwand ein. Bei Reflux und Stase kann es im Venenblut zur Freisetzung schon in kleinsten Konzentratio-nen hochwirksamer, in metabolischer Koope-ration zwischen Plättchen und Neutrophilen Granulozyten gebildeter Freisetzungsprodukte kommen, die in den spezialisierten Venulen der Gefäßwand zu einem raschen Zusammenbruch der Endothelschranke und zur lokalen Entste-hung entzündlicher Ödeme führen. Durch den ausschließlich auf den Perizyten vorliegenden Gewebefaktor werden rasch interstitielle Gerinnungsprozesse initiiert, die auch auf den In-travasalraum übergreifen können. In der Folge kommt es auch zu sich autokatalytisch verstärkenden und immer weiter ausbreitenden entzündlichen Prozessen. Übliche Therapieansätze müssen vor diesem Hintergrund neu überdacht werden.

Healing of an arterial leg ulcer by compression bandaging: a case report

This case report demonstrates that arterial ulcers may heal with compression therapy. The patient was a 72-year-old woman with elevated blood pressure and type II diabetes mellitus, who underwent angiography because of a painful, non-healing ulcer over the shin. The angiography showed multisegment arterial occlusive disease, not amenable to surgical revascularisation. After 4 months of wearing inelastic bandages, with increased pressure over the ulcer area and hypertension and diabetes under control, the patient was pain-free and the ulcer had healed. The ankle-brachial pressure index (ABPI) increased from 0.54 at the start of treatment to 0.70. In patients with arterial leg ulcers, properly applied compression therapy using increased pressure over the wound may lead to an improvement of the arterial flow and to complete healing.

[Compression therapy of venous leg ulcers in the decongestion phase]

Compression therapy is the basis for successful treatment in most patients with venous leg ulcers. Concerning compression therapy, the initial phase of decongestion and the following phase of maintenance should be differentiated. While in the maintenance phase (ulcer) stocking systems are now frequently recommended, in the decongestion phase compression bandages are mostly still used, which however are often inappropriately applied. In German-speaking countries, compression therapy with short-stretch bandages has a long tradition. However, their correct application requires good training and monitoring, which is often lacking in daily practice. Less error-prone treatment alternatives are multicomponent systems, some of which have an optical marker for the control of the correct subbandage pressure. In another new type of compression system, which is called adaptive or wrap bandages, the compression pressure can be adjusted using a Velcro fastener. Accompanying intermittent pneumatic compression therapy can also be used in the decongestion phase. Thus, there are now several different treatment options that can be used for the decongestion phase in patients with venous leg ulcers. Often bandages with short-stretch materials are very prone to errors and should in most cases be replaced by other compression systems today. The patient's preference, need, and capability should be considered when selecting the appropriate system for the individual patient.

Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs – UIP Consensus Document. Part II: Anatomy

Objectives: Duplex ultrasound investigation has become the reference standard in assessing the morphology and haemodynamics of the lower limb veins. The project described in this paper was an initiative of the Union Internationale de Phlébologie (UIP). The aim was to obtain a consensus of international experts on the methodology to be used for assessment of the anatomy of superficial and perforating veins in the lower limb by ultrasound imaging.

Design: Consensus conference leading to a consensus document.

Methods: The authors performed a systematic review of the published literature on duplex anatomy of the superficial and perforating veins of the lower limbs. Afterwards, they invited a group of experts from a wide range of countries to participate in this project. Electronic submissions from the authors and the experts (text and images) were made available to all participants via the UIP website. The authors prepared a draft document for discussion at the UIP Chapter meeting held in San Diego, USA, in August 2003. Following this meeting, a revised manuscript was circulated to all participants and further comments were received by the authors and included in subsequent versions of the manuscript. Eventually, all participants agreed on the final version of the paper.

Results: The experts have made detailed recommendations concerning the methods to be used for duplex ultrasound examination as well as the interpretation of images and measurements obtained. This document provides a detailed methodology for complete ultrasound assessment of the anatomy of the superficial and perforating veins in the lower limbs.

Conclusions: The authors and a large group of experts have agreed on a methodology for the investigation of the lower limbs venous system, by duplex ultrasonography, with specific reference to the anatomy of the main superficial veins and perforators of the lower limbs in healthy and varicose subjects.

Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs – UIP Consensus Document. Part I: Basic principles

Objectives: Duplex ultrasound investigation has become the reference standard in assessing the morphology and haemodynamics of the lower limb veins. The project described in this paper was an initiative of the Union Internationale de Phlébologie (UIP). The aim was to obtain a consensus of international experts on the methodology to be used for assessment of veins in the lower limb by ultrasound imaging.

Design: Consensus conference leading to a consensus document.

Methods: The authors invited a group of experts from a wide range of countries to participate in this project. Electronic submissions from the experts were made available to all participants via the UIP website. The authors prepared a draft document for discussion at a UIP Chapter meeting held in San Diego, USA, in August 2003. Following this meeting, a revised manuscript was circulated to all participants, and further comments were received by the authors and included in subsequent versions of the manuscript. Eventually, all participants agreed on a final version of the paper.

Results: The experts have made detailed recommendations concerning the methods to be used for duplex ultrasound examination, as well as the interpretation of images and measurements obtained. This document suggests a methodology for complete assessment of the superficial and perforating veins of the lower limbs, including recommendations on reporting results and training of personnel involved in these investigations.

Conclusions: The authors and a large group of experts have agreed a methodology for the investigation of the lower limbs venous system by duplex ultrasonography.

Treatment of Resistant Leg Ulcers by Retrograde Intravenous Pressure Infusions of Urokinase

Ten patients with large resistant leg ulcers were treated by retrograde local pressure infusions containing 100 000 IU of urokinase three times per week for a total of 3–11 weeks. The effects of this therapy were assessed clinically, by laser Doppler flowmetry and by measurement of transcutaneous oxygen at the ulcer borders. Both methods revealed highly pathological findings before therapy, demonstrating a severe disturbance of local microcirculation in every case.

The drug is dissolved in 150 ml saline and injected into an empty leg vein while the circulation was blocked by a pressure cuff on the distal thigh for 15 min (Bier's block).

Nine patients showed an impressive clinical improvement. An increase in local skin blood flow was demonstrated by laser Doppler flowmetry, which revealed an increase in the peak flow values after release of the occlusion cuff and a shortening of the peak time with repeated injections.

The increase of transcutaneous oxygen tension with time was not statistically significant.

The beneficial effects of this therapeutic regime may be explained either by the fibrinolytic action of urokinase on intra- and extra-capillary fibrin and on blood viscosity, or by the haemodynamic changes and alterations to endothelial function caused by repeated limb occlusions.

Do we still need compression bandages? Haemodynamic effects of compression stockings and bandages

Objective: To compare haemodynamic data obtained with elastic compression stockings and inelastic compression material applied with different pressure ranges on the lower extremities.

Methods: Haemodynamic effects of compression therapy were demonstrated by measuring venous flow velocity, venous volume, venous reflux and venous pumping function using radioisotopes, phlebography, water displacement volumetry, duplex, air plethysmography, foot volumetry and phlebodynamometry.

Results: Light-compression stockings are able to increase venous blood flow velocity in the supine position and to prevent leg swelling after prolonged sitting and standing. In the upright position an interface pressure of more than 50 mmHg is needed for an intermittent occlusion of incompetent veins and for a reduction of ambulatory venous hypertension during walking. Such high interface pressures may rather be achieved by short-stretch, multilayer bandages than by an elastic stocking.

Conclusion: Elastic compression stockings exerting interface pressures up to 40 mmHg are effective in preventing or reducing oedema. Multilayer compression bandages with a pressure over 40 mmHg additionally improve severely disturbed venous pumping function.

Improvement of Ambulatory Venous Hypertension by Narrowing of the Femoral Vein in Congenital Absence of Venous Valves

Objective:

To assess the effect of femoral vein compression in a patient with congenital avalvulae.

Design:

Single patient study.

Setting:

Department of Dermatology; Teaching Hospital, Vienna, Austria.

Patient:

A single patient with the rare condition of congenital absence of venous valves.

Interventions:

Compression of the thigh using a thigh

Main outcome measures:

Ambulatory venous pressure Measurement.

Results:

The ambulatory venous pressure was reduced when the thigh calf pressure was increased in excess of 70 mmHg.

Conclusion:

Thigh compression in a patient with congenital absence of venous valves resulted in a temporary valve mechanism permitting orthograde flow during muscle systole, but inhibiting venous reflux.

Adjustable Velcro Compression Devices are More Effective than Inelastic Bandages in Reducing Venous Edema in the Initial Treatment Phase: A Randomized Controlled Trial

OBJECTIVE/BACKGROUND

The objective of this study was to compare the efficacy and comfort of inelastic bandages (IBs) and adjustable Velcro compression devices (AVCDs) in reducing venous leg edema in the initial treatment phase.

METHODS

Forty legs from 36 patients with untreated venous edema (C3EpsAsdPr) were randomized to two groups. Patients in the first group received IBs (n = 20) and those in the second AVCDs (n = 20). Both compression devices were left on the leg day and night, and were renewed after 1 day. Patients in the AVCD group were asked to re-adjust the device as needed when it felt loose. Leg volume was calculated using the truncated cone formula at baseline (T0), after 1 day (T1) and after 7 days (T7). The interface pressure of the two compression devices was measured by an air filled probe, and the static stiffness index calculated after applying compression at T0 and T1, and just before removal of compression on T1 and T7. Patient comfort with regard to the two compression systems was assessed by grading signs and symptoms using a visual analog scale.

RESULTS

At T1, the median percent volume reduction was 13% for the IB group versus 19% for the AVCD group; at T7 it was 19% versus 26%, respectively (p < .001). The pressure of the IBs was significantly higher compared with the AVCDs at T0 (63 vs. 43 mmHg) but dropped by > 50% over time, while it remained unchanged with AVCDs owing to the periodic readjustment by the patient. Comfort was reported to be similar with the two compression devices.

CONCLUSION

Re-adjustable AVCDs with a resting pressure of around 40 mmHg are more effective in reducing chronic venous edema than IBs with a resting pressure of around 60 mmHg. AVCDs are effective and well tolerated, not only during maintenance therapy, but also in the initial decongestive treatment phase of patients with venous leg edema.

Sport socks do not enhance calf muscle pump function but inelastic wraps do

AIM

Aim of the study was to measure the effect of elastic and inelastic compression on calf muscle pump function in healthy male athletes.

METHODS

This was an experimental study which included 21 healthy male athletes. The ejection fraction (EF) of the venous calf pump was measured comparing the effects of a variety of compression materials: 1) sport compression stockings; 2) light zinc paste bandages; 3) sport compression stockings with additional Velcro® wraps over the calf. The influence of sport stocking and wraps on the venous calibre at the largest calf circumference in the lying and standing position was investigated using MRI.

RESULTS

Inelastic compression exerting a median pressure in the standing position of 37.5 mmHg (zinc paste) and 48 mmHg (loosely applied straps over a sport stocking) achieved a significant increase of EF up to 100%. Sport stockings alone with a standing pressure of 19-24 mmHg did not show a significant change of EF. MRI demonstrated some venous narrowing in the lying but not in the standing position. By wrapping inelastic straps over the stocking an emptying of the veins in the lying and a considerable narrowing in the standing position could be observed.

CONCLUSION

Venous calf pump function in athletes is not influenced by elastic sport stockings, but inelastic wraps either alone or applied over sport stockings lead to a significant enhancement.

Improvement of venous pumping function by double progressive compression stockings: higher pressure over the calf is more important than a graduated pressure profile

BACKGROUND

Previous studies have shown that so-called progressive elastic compression stockings (PECS) with a negative pressure gradient have a more pronounced effect on venous pump function than conventional, graduated stockings. The aim of this study was to investigate the effect of higher graduated and non-graduated pressures on the venous calf pump in patients with venous disease.

METHODS

The ejection fraction (EF) of the calf pump was measured by plethysmography under a standardized walking test in 20 patients suffering from chronic venous disease (CEAP C2-C5) without compression, (a) with one and (b) two PECS on top of each other, and (c) with one additional conventional stocking covering only the gaiter area to achieve a graduated high pressure profile. Interface pressure was measured in the gaiter area and on the calf.

RESULTS

A significant improvement of EF compared with baseline was found with all three compression modalities. The two superimposed PECS, providing median pressures of 33 mmHg in the gaiter area and 46 mmHg at calf level, increased EF significantly up into the normal range. Increasing the gaiter pressure to 56 mmHg without changing the calf pressure did not result in further improvement.

CONCLUSIONS

Two PECS applied on top of each other lead to a maximal improvement of the venous pump function, which cannot be further improved by increasing the pressure in the gaiter area thereby restoring a graduated pressure profile.

Diagnosis and treatment of primary lymphedema. Consensus document of the International Union of Phlebology (IUP)-2013

Primary lymphedema can be managed effectively as a form of chronic lymphedema by a sequenced and targeted treatment and management program based around a combination of Decongestive Lymphatic Therapy (DLT) with compression therapy, when the latter is desired as an adjunct to DLT. Treatment in the maintenance phase should include compression garments, self-management, including self-massage, meticulous personal hygiene and skin care, in addition to lymphtransport-promoting excercises and activities, and, if desired, pneumatic compression therapy applied in the home. When conservative treatment fails, or gives sub-optimal outcomes, the management of primary lymphedema can be improved, where appropriate, with the proper addition of surgical interventions, either reconstructive or ablative. These two surgical therapies can be more effective when fully integrated with manual lymphatic drainage (MLD)-based DLT postoperatively. Compliance with a long-term commitment to MLD/DLT and particularly compression postoperatively is a critical factor in determining the success of any new treatment strategy involving either reconstructive or palliative surgery. The future of management of primary lymphedema has never been brighter with the new prospect of gene-and perhaps stem-cell oriented management.

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.

Bandages or double stockings for the initial therapy of venous oedema? A randomized, controlled pilot study

OBJECTIVE/BACKGROUND

Treatment for leg oedema conventionally starts with compression bandaging followed by elastic stockings once swelling is reduced. The aim was to investigate if a kit consisting of a liner and outer stocking, each exerting 20 mmHg of pressure, would be equally effective in achieving and maintaining volume reduction compared with short-stretch bandaging (2 weeks) followed by a class II (23-33 mmHg) stocking (2 weeks).

METHODS

Forty legs (28 patients) with chronic venous oedema were randomised to either short-stretch bandages applied weekly for 2 weeks, followed by an elastic stocking for 2 weeks (group A) or a light stocking ("liner") for 1 week followed by superimposing a second stocking for 3 weeks (group B). Interface pressures and leg volumes were measured weekly.

RESULTS

Despite differences in the pressure (median ± interquartile range) applied (bandage: 67 mmHg [55.7-73.0] vs. liner 24.5 mmHg [21.2-26.5]) volume reduction after 1 week was equal (12.8% [8.7-16.5] and 13.0% [10.4-20.6]). After 2 weeks (group A: 17.8% [10.6-20.0] vs. group B 16.2% [13.0-25.4]) and 4 weeks (group A: 17.3% [9.6-22.8] vs. group B: 17.0% [13.1-24.1]) volume reductions remained identical.

CONCLUSIONS

The initial improvement in leg volume (1 week) was independent of the pressure applied and the reduction was maintained by superimposing a second stocking. This offers a simple alternative for managing leg oedema with reduced staffing costs.

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.

High compression pressure over the calf is more effective than graduated compression in enhancing venous pump function

BACKGROUND

Graduated compression is routinely employed as standard therapy for chronic venous insufficiency.

AIM

The study aims to compare the haemodynamic efficiency of a multi-component graduated compression bandage (GCB) versus a negative graduated compression bandage (NGCB) applied with higher pressure over the calf.

METHODS

In 20 patients, all affected by greater saphenous vein (GSV) incompetence and candidates for surgery (Clinical, etiologic, anatomic and pathophysiologic data, CEAP C2-C5), the ejection fraction of the venous calf pump was measured using a plethysmographic method during a standardised walking test without compression, with GCB and NGCB, all composed of the same short-stretch material. Sub-bandage pressures were measured simultaneously over the distal leg and over the calf.

RESULTS

NGCBs with median pressures higher at the calf (62 mmHg) than at the distal leg (50 mmHg) achieved a significantly higher increase of ejection fraction (median +157%) compared with GCB, (+115%) with a distal pressure of 54 mmHg and a calf pressure of 28 mmHg (P < 0.001).

CONCLUSIONS

Patients with severe venous incompetence have a greater haemodynamic benefit from NGCB, especially during standing and walking, than from GCB.

Dose finding for an optimal compression pressure to reduce chronic edema of the extremities

AIM

The optimal pressure to reduce chronic extremity swelling is still a matter of debate. The aim of this paper was to measure volume reduction of a swollen extremity depending on the amount of pressure exerted by compression stockings and inelastic bandages.

METHODS

Thirty-six patients with unilateral breast cancer related arm lymphedema were investigated in a lymph clinic in the Netherlands, 42 legs with chronic edema of the lower extremities were examined in a phlebological centre in Italy. The arm-patients were randomized to receive inelastic arm bandages with a pressure between 20-30 mmHg or 44-68 mmHg. The leg patients were either treated with compression stockings (23-32 mmHg) or with inelastic bandages (pressure 53-88 mmHg). Water-displacement volumetry and measurement of leg circumference was performed before and after compression.

RESULTS

In the arm-patients low pressure after 2 hours achieved a higher degree of volume reduction (-2.3%, 95% CI 1.0-3.6) than high pressure (-1.5%, 95% CI 0.2-2.8) (n.s.). In patients with leg edema compression stockings in the range between 20 and 40 mmHg showed a positive correlation between exerted pressure and volume reduction, bandages applied with an initial resting pressure of more than 60 mm Hg resulted in a decreasing volume reduction.

CONCLUSION

There is obviously an upper limit beyond which further increase of compression pressure seems counterproductive. For inelastic bandages this upper limit is around 30 Hg on the upper and around 50-60 mmHg on the lower extremity.

Compression stockings with moderate pressure are able to reduce chronic leg oedema

Aim

To compare the efficacy of compression stockings and inelastic, high-pressure bandages concerning leg volume reduction in patients with chronic leg oedema.

Material and methods

Forty-two legs of 30 patients with chronic leg oedema caused by venous stasis were randomized to receive a strong inelastic bandage (IB) or an elastic stocking (ES) exerting a pressure of 23–32 mmHg. Changes in leg oedema were assessed after two and seven days by water displacement volumetry, measurements of leg circumferences and of skin thickness by using Duplex ultrasound. Interface pressure was registered under the compression devices for seven days.

Results

There was no significant difference between stockings and bandages, which both produced a significant reduction in leg volume after two days (−9.6% [95% CI 7.5–11.8] by ES and −11.5% [95% CI 9.9–13.2%] by IB) and after seven days (−13.2% [95% CI 10.4–16.2] by ES and −15.6% [95% CI 12.8–18.4] by IB). Bandages showed a more pronounced reduction in leg circumference and in skin thickness in the calf region. The pressure of IB in the lying position fell from initially 63 to 22 mmHg after two days, but only from 33 to 26 mmHg under ES (median values). The optimal pressure range concerning oedema reduction was found between 40 and 60 mmHg, while higher pressures produced by bandages showed a negative correlation with volume reduction.

Conclusions

Compression stockings exerting a pressure of around 30 mmHg are nearly as effective as high-pressure bandages with an initial pressure over 60 mmHg in reducing chronic leg oedema.

Compression stockings with a negative pressure gradient have a more pronounced effect on venous pumping function than graduated elastic compression stockings

OBJECTIVES

To measure the effect on the venous pumping function of a stocking providing a negative pressure gradient with higher pressures over the calf in comparison to a conventional graduated elastic compression stocking (GECS) in patients with advanced venous insufficiency.

DESIGN

Experimental study.

MATERIAL

30 patients with severe superficial chronic venous insufficiency were enrolled. Two elastic stocking designs exerting a pressure at ankle between 15 and 25 mm Hg were compared; a conventional GECS and a stocking exerting a higher pressure over the calf than over the ankle producing a "progressive" increase in compression (PECS).

METHOD

the venous calf pumping function was assessed by measuring the ejection fraction (EF) from the lower leg by a plethysmographic method during a standardised exercise. Interface pressure of the 2 compression devices was simultaneously recorded both at B1 = 12 cm above ankle, C = just above widest part of calf.

RESULTS

The mean increase of EF produced by PECS was +75% (95 CI 48, 7-101,3) compared with +32% (95% CI 16, 8-48,6) with GECS (P < 0.001). There was a significant correlation between EF and the stocking pressure measured at calf level during standing and walking.

CONCLUSION

Stockings exerting a higher pressure on the calf than on the ankle show a greater efficacy in increasing the venous ejection fraction from the leg.

Clinical trials needed to evaluate compression therapy in breast cancer related lymphedema (BCRL). Proposals from an expert group

AIM

A mainstay of lymphedema management involves the use of compression therapy. Compression therapy application is variable at different levels of disease severity. Evidence is scant to direct clinicians in best practice regarding compression therapy use. Further, compression clinical trials are fragmented and poorly extrapolable to the greater population. An ideal construct for conducting clinical trials in regards to compression therapy will promote parallel global initiatives based on a standard research agenda. The purpose of this article is to review current evidence in practice regarding compression therapy for BCRL management and based on this evidence, offer an expert consensus recommendation for a research agenda and prescriptive trials. Recommendations herein focus solely on compression interventions.

METHODS

This document represents the proceedings of a session organized by the International Compression Club (ICC) in June 2009 in Ponzano (Veneto, Italy). The purpose of the meeting was to enable a group of experts to discuss the existing evidence for compression treatment in breast cancer related lymphedema (BCRL) concentrating on areas where randomized controlled trials (RCTs) are lacking.

RESULTS

The current body of research suggests efficacy of compression interventions in the treatment and management of lymphedema. However, studies to date have failed to adequately address various forms of compression therapy and their optimal application in BCRL. We offer recommendations for standardized compression research trials for prophylaxis of arm lymphedema and for the management of chronic BCRL. Suggestions are also made regarding; inclusion and exclusion criteria, measurement methodology and additional variables of interest for researchers to capture.

CONCLUSION

This document should inform future research trials in compression therapy and serve as a guide to clinical researchers, industry researchers and lymphologists regarding the strengths, weaknesses and shortcomings of the current literature. By providing this construct for research trials, the authors aim to support evidence-based therapy interventions, promote a cohesive, standardized and informative body of literature to enhance clinical outcomes, improve the quality of future research trials, inform industry innovation and guide policy related to BCRL.

Measuring venous pumping function by strain-gauge plethysmography

AIM

Hemodynamic effects of compression devices in patients with venous insufficiency are still under dispute. The aim of this paper was to describe a method which is able to give quantitative results concerning an improvement of the venous pumping function by using compression devices in patients with venous insufficiency.

METHODS

The ejection fraction (EF) of the calf pump can be measured using strain gauge plethysmography proximal to a compression device on the leg and the degree of improvement depending on the exerted pressure and the elastic property of the material can be assessed. Experiments were carried out in 15 normal volunteers and in a total of 68 patients with severe superficial venous incompetence and who were investigated without compression and with various compression devices measuring interface pressure in different body positions.

RESULTS

Examples demonstrating the usefulness of the plethysmographic method are given. The median values of EF were 64.6 (IQR 63.4-68.6) in normal subjects and about half in the venous patients. Statistically significant improvement was achieved using inelastic bandages, resulting in further improvements with increasing pressures between 20 and 60 mmHg. Elastic stockings led only to a moderate improvement of the deficient venous pumping function. Significant correlations were found between EF and standing and walking pressure.

CONCLUSION

The described plethysmographic method is very useful to assess haemodynamic effects of different compression devices in patients with venous insufficiency.

Narrowing of leg veins under compression demonstrated by magnetic resonance imaging (MRI)

AIM

The aim of this paper was to demonstrate the usefulness of magnetic resonance imaging (MRI) for detecting the ability of compression material in narrowing superficial and deep veins in the lower extremity.

METHODS

MRI of the legs was performed in one healthy volunteer and in 11 patients with CEAP C2-C4 without and with different kinds of compression devices. The cross section area of superficial and deep veins was measured by planimetry in mid-calf and mid-thigh slices. The interface pressure of compression was measured at the same level.

RESULTS

Examples are presented showing that the narrowing of veins does not only depend on the exerted pressure but also on the body position and the resulting distortion of the tissue. In the prone and the standing position deep veins may show a greater reduction of the cross section area than in superficial veins.

CONCLUSION

MRI is a powerful method to assess venous narrowing by external compression. Especially in the standing position new insights regarding the effects of different compression devices may be expected.