Different applications of compression in chronic venous disorder

In the first MOH Connect, Dr Tobias Hirsch presented how different types of compression therapy can be used for chronic venous disorder and provided an insights into evidence-based international guidelines. Additionally, he presented cases from his daily work and provided insights into the preliminary results of the AKROE study.

Mark Whiteley

There is a long history of compression, even monks suffering from lymphedema were treated with bandages in older days. Today, bandages are still used, unfortunately sometimes provoking more damage than benefit to the patient as it requires very skilled persons doing it (bandaging is kind of a handcraft). Only a small number of bandages are still working throughout the whole day.

Compression therapy can be performed in different ways:

Compression bandages

+ Suitable for all types of edema, and very cost effective* 
- Health care professional required to put on, self-management difficult, they slip during the day

*Dr Mendoza adds that according to a calculation comparing double layer bandage with wraps for a 2-week period, it’s more cost-effective to use wraps from the first moment.

Medical compression stockings**

+ Standardized compression, optimal fit provides variety (stockings, shorts, capris, circular, flat)

- Only useful after decongestive therapy, costs for flat knit at its price

**With round knit and flat knit most patients can be equipped. (Round knit used for CVD, varicose veins, venous ulcer; flat knit used for lymphedema, lipedema and special calibres)

Adaptive compression devices (wraps)***

+ Easy self-management, suitable for all types of edema, standardized compression

- Not a lot of disadvantages here. Reimbursement depends on countries.

***Adaptive compression is a real revolution, but not yet as common as it should be.


Compression classes used for different indications

In general, CCL I (18–21 mmHg) is used with CVD, varicose veins and is sufficient in 80% of cases. CCL II (23–32 mmHg) is used with PTS, lipedema, lymphedema and in the first months of DVT. CCL III (34– 46 mmHg) is used for severe lymphedema. Note that there is pressure of 70–80 mmHg in an insufficient vein in the ankle. This makes a compression of CCL III very relative.

Indications for medical compression stockings in venous and lymphatic disorders (Rabe et al., 2018)

The authors conclude 14 recommendations for CVD, 2 for prevention of PTS: Improvement of venous symptoms, prevention and improvement of venous edema, improvement of skin changes, improvement of ulcer healing, prevention of venous ulcer recurrence, improvement of early side effects after venous interventions, prevention and improvement of PTS.

Compression treatment guidelines ESVS 2022 (Maeseneer et al., 2022)

There is a class I recommendation for venous symptoms in the guidelines (≥15 mmHg), 20–40 mmHg are recommended for edema, for LDS / atrophy blanche elastic compression with 20-40 mmHg is recommended. For patients with active venous leg ulceration, compression therapy is recommended to improve ulcer healing (recommendation 69, “I A”). For patients with active venous leg ulceration, multilayer or inelastic bandages or adjustable compression garments exerting a target pressure of at least 40 mmHg at the ankle are recommended to improve ulcer healing (recommendation 70, “I A“). Dr Hirsch criticizes that we spend a lot of money on wound dressing, but often we observe that there is no compression on these patients. So we cannot be successful.


Risks and contraindications of medical compression
treatment (Rabe et al., 2020)

The are very few contraindications. They include severe PAOD (severe means that we have a pressure below 70 mmHg), compression of epifascial arterial bypasses, severe cardiac insufficiency (means NYHA III and IV) and true allergy to compression material.
Note: Contraindications do not depend on the device uses. The effect of a well applied bandage, stocking or wrap is the same. If your patient suffers from heart insufficiency, you cannot use high degrees of compression neither with bandage nor with wrap.


Practical approach

Compression treatment for lymphedema following surgery

Alf, a road-worker, works hard. Suffers from arterial obstructive disease. Received an iliaco-femoral-popliteal bypass, lymphedema following surgery on the right leg. ABI of 0.74, bad arterial signals on his right side. He is able to work and wants to. Therapy: deconges­tion of lymphedema, decrease of leg volume. CCL I stocking, flat knit. Why CCL I as for a lymphedema you usually treat with CCL II. Due to bypass of the patient, it was decided to treat with CCL I. As he suffered pain with knee high stockings, shorter ones were used. You have to vary to reach the best for your patient.

Robert, 52 year old man suffering from prostate cancer, edema after oncological surgery. Recommended treatment options are manual lymphatic drainage, compression bandages, flat knit garments, movement, skin care, taken together a real challenge.There is a need for self- management strategies.


Compression treatment for obesity patient with lipedema

Heidi, 58 year old woman with BMI 42 (obese), lipedema. Round knit does not work. Wraps were used for decongestion, in the end flat knit could be prescribed. Use the right compression tool!!


Intermittent pneumatic compression for maintenance phase in lymphedema

Dieter, 72 year old man, GSV reflux °III, severe reflux , venous ulcer for 1.5 yrs. Treatment plan: Decongestion using IPC and wraps, wound care, thermal treatment of GSV, SCL of ulcer bed. Manual lymph drainage can be replaced by intermittent pneumatic compression during maintenance therapy in lymphedema. Recommendation Mendoza and Amsler paper in Vasa (Mendoza & Amsler, 2023).


Coolflex wraps treatment for ulcer patient

After decongestion IPC, Dr. Hirsch uses Coolflex wraps. The tube-like wrap can be applied easily by his nurse in no longer than 1 minute. Patient themself can also apply the devices as it was shown in the AKROE study. The wrap has no velcro, but hooks. White seams indicate compression ranges (1 line indicates CCL I, 2 lines indicate CCL II).


Compression after varicose vein treatment: 2 weeks recommended

In a current trial with > 1000 patients the best effects for compression treatment were found when patients wore the stockings for 2 weeks after the ablation.


Compression treatment for patients without DVT or PTS?

There are many patients with varicose veins who never had a DVT or PTS, but if they work (standing) as hairdressers, teachers, etc., they will have complaints. For those patients, laser or radio frequency treatment is not required, but they benefit a lot from compression treatment. CCL I below knee will have a great effect.


Compression after DVT

Evidence shows that CCL II stockings are superior to CCL I. It is important to start as early as possible after the diagnosis. After 3 months of compression there is no additional effect to expect according to current literature. However, the length of the treatment should always depend on patient’s complaints. If there is edema, also in the evenings, or skin changes, treatment should be continued.


AKROE Study, preliminiary results with edema patients using Coolflex Standard Calf and Foot

The study was performed at 4 sites (Dr. Faerber, Prof. Kahle, Prof. Szuba, Dr. Hirsch). Over a period of 6 weeks it was investigated if there was a change in the independent handling of the wrap, patient satisfaction and discomfort relief, clinical edema reduction and volume reduction of the lower limb, healthcare cost savings (due to self-management versus not having to involve HCP). Included were patients with lymphedema (45%), phlebedema (27%), phlebo-lymphedema (28%), age 63.5 ±16.1, BMI 35.0±8.6, WhtR 0.67±0.13, gender (m:f) 63.5:36.5. Interviews were done for the assessment of clinical scores, volume was measured with the LegReader (enables diameters of leg contact less).

Results: the wraps were fitted correctly by 90.8% of patients (98.7% at wk 6), the patients put on the wrap independently after 6 wks: 84.6% always; 7.7% mostly; 3.9% sometimes with help; 3.9% always with help. Ease of putting on the wrap after 6 wks: 51.3% very easy; 39.7% fairly easy; 9% somewhat difficult. Patient satisfaction after 6 wks: 56.6% satisfied; 39.5% rather satisfied; 3.9% rather dissatisfied and dissatisfied. Wearing comfort after 6 wks: 46.1% comfortable; 44.7% rather comfortable; 9.2% rather uncomfortable and uncomfortable. Further use after 6 wks: 95% always or intermittent; 5% don’t know and no. Clear and significant decrease in all Lymph ICF scores (physical, mental, household, mobiliy, life domain/social). Decrease of leg volume for all types of edema that were included. There is a higher effect on volume reduction in patients that did not undergo compression treatment before compared to patients that were treated with compression before.


Take-home messages:

Compression is the basis for phlebological and lymphological therapy and there are very few absolute contraindications. Effect and patient compliance can be influenced by the selection of the compression medium as well as by the material and the compression class. Keep in mind that CCL I works very well. Donning aids should be considered to improve self-management. Wraps make life easier and give patients with chronic leg edema a high degree of independence. Patients are satisfied with wraps treatment and very compliant to it. Wraps are especially suitable for patients with edema related obesity, but also appropriate for a very large number of patients. Improving self-management by using wraps helps to cut down health care costs.

Compression is a great standalone therapy for all phlebologic patients and a perfect add-on therapy for patients who need other treatments like wound dressings, have DVT, or varicose veins.

Compression therapy fits always.

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