Servier – Phlebolymphology

IX. Compression treatment solutions in
vein and lymphatic diseases

Current indications and guidelines for medical compression st
Eberhard Rabe (Germany)
A review article was published in Phlebology in 2017 concerning the “indications for medical compression stockings in venous and lymphatic disorders” based on a systematic research from Pubmed, including randomized control trials, observational human studies, and reports of use of compression stockings. The recommendation was grade 1b for use of medical compression stockings to alleviate venous symptoms in chronic venous disease, to improve quality of life and venous severity in chronic venous disease, to prevent leg swelling in chronic venous disease and in healthy individuals at risk of leg swelling and to reduce swelling, whereas, the recommendation was grade 1C for improvement in skin changes. For the improvement in venous leg ulcer healing, the recommendation was grade 1A. For the reduction in pain and swelling in patients with acute deep vein thrombosis, the recommendation was grade 1B, but, for the patients with superficial vein thrombosis, the recommendation was just grade 1C due to study limitations. According to the 2019 German guidelines on compression therapy, which is now available at http://www.awmf.org,

The indications for medical compression stockings are summarized as follows with a recommendation of grade 2B:
– Chronic venous disease (for prevention and improvement in venous signs and symptoms, improvement in quality of life, functional venous disease [in obesity or sitting/standing profession])
– Thromboembolic diseases of the extremities (deep vein thrombosis, superficial vein thrombosis)
– Postthrombotic syndrome
– Edema of the extremities

The contraindications for medical compression stockings are as follows:
– Severe peripheral arterial occlusive disease (ankle brachial pressure index <0.5, ankle pressure <60 mm Hg, toe pressure <30 mm Hg or TcP0₂ <20 mm Hg foot level). If inelastic material is used, ankle pressure of 50 to 60 mm Hg can be acceptable. - Decompensated cardiac insufficiency (NYHA (III) + IV) - Septic phlebitis - Phlegmasia coerulea dolens Elastic and non-elastic compression: how strong should it be to reach the therapeutic goals? Giovanni Mosti Intravenous pressure in a standing position is about 70 to 80 mm Hg and physiologically decreases to about 30 mm Hg in normal subjects during movement due to normal muscle-venous valve function. In patients with venous disease, intravenous pressure does not decrease due to valve incompetence and can increase in case of venous obstruction leading to ambulatory venous hypertension (venous reflux, reduced pumping function, etc). Only inelastic multilayer, multicomponent bandages can provide effectiveness and comfort at the same time because they exert a very strong standing pressure and pressure peaks effective in counteracting the arteriovenous hypertension starting from a much lower and comfortable supine pressure. It is not easy to respond to the question “how strong should it be to reach the therapeutic goals?” because there are no specifications in the guidelines, such as the Society of Vascular Surgery/American Venous Forum, International Union of Phlebology, or in Cochrane reviews published in 2009. There are few studies where compression pressure was measured. In addition, it is not easy to apply inelastic compression effectively and to monitor. In one study, ulcer patients were divided into three groups: (i) tubular elastic device (36 mm Hg) were applied; (ii) tubular elastic device (36 mm Hg) plus 1 elastic bandage (54 mm Hg) were applied; or (iv) tubular elastic device (36 mm Hg) plus 2 elastic bandages (74 mm Hg) were applied. There was better healing rate with higher pressure, but the compliance was poor. In another study, using compression greater than 40 mm Hg was effective in achieving faster ulcer healing. In another study, compression pressure >50 mm Hg was effective for ulcer healing. From different studies, the healing rates with elastic kits or stockings in small and recent ulcers were 47% to 96%, with an average of 64%.

In conclusion, compression therapy is very effective in treating venous ulcers. Inelastic bandages or adjustable compression wraps applied with strong pressure are the most effective compression modality. A supine pressure consistently maintained at >40 mm Hg seems to be the most effective for achieving the best healing rate. Due to their pressure loss, inelastic bandages should be applied with an initial pressure >60 mm Hg. Compression devices maintaining the initial pressure (elastic kits and adjustable compression wraps) may be applied with a pressure >40 mm Hg. The pressure must be reduced when moderate arterial disease coexists: the compression pressure at application should not be more than 40 mm Hg. Sustained pressure must be avoided in case of severe arterial disease.