compression - Collegio Italiano di Flebologia

Transcript

COMPRESSION
CONSENSUS DOCUMENT
based on
SCIENTIFIC EVIDENCE AND
CLINICAL EXPERIENCES
COMPRESSION impa.indd 1
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COMPRESSION
CONSENSUS DOCUMENT
BASED ON
SCIENTIFIC EVIDENCE AND
CLINICAL EXPERIENCES
Editor
Fabrizio Mariani
International Board
Claudio Allegra, Hans Bernbach, Werner Blättler, Vladimir Blazek,
Albert Claude Benhamou, Jean Patrick Benigni, Monika Gniadecka, Horst Gerlach,
Sergio Mancini, Michel Perrin, Hugo Partsch
Task Force 2009
Teresa Lucia Aloi, Carlo Astara, Pier Antonio Bacci, Valerio Bianchi, Giuseppe Botta, Matteo Bucalossi,
Giuseppe Castagna, Edoardo Colombo, Vincenzo Coscia, Stefano De Franciscis,
Francesco Ferrara, Christian Gardon-Mollard, Vincenzo Gasbarro, Bertrand Lun,
Marcello Izzo, Alberto Macciò, Vincenzo Mattaliano, Sergio Mancini, Stefano Mancini,
Giovanni Mosti, Massimo Pisacreta
With the collaboration of:
Math for Tech-Vasaetech Centre
Ferrara University
EDIZIONI MINERVA MEDICA
TORINO 2009
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Authors
Editor
Fabrizio Mariani (Italy)
International Board
Claudio Allegra (Italy)
Hans Bernbach (Switzerland)
Werner Blättler (Switzerland)
Vladimir Blazek (Germany)
Albert Claude Benhamou (France)
Jean Patrick Benigni (France)
Monika Gniadecka (Denmark)
Horst Gerlach (Germany)
Sergio Mancini (Italy)
Michel Perrin (France)
Hugo Partsch (Austria)
Task Force 2009
Teresa Lucia Aloi, Pavia (Italy)
Carlo Astara, Cagliari (Italy)
Pier Antonio Bacci, Arezzo (Italy)
Valerio Bianchi, Florence (Italy)
Giuseppe Botta, Siena (Italy)
Matteo Bucalossi, Siena (Italy)
Giuseppe Castagna, Cagliari (Italy)
Edoardo Colombo, Como (Italy)
Vincenzo Coscia, Ferrara (Italy)
Stefano De Franciscis, Catanzaro (Italy)
Francesco Ferrara, Naples (Italy)
Christian Gardon-Mollard, Chamalieres (France)
Vincenzo Gasbarro, Ferrara (Italy)
Marcello Izzo, Nola (Italy)
Bertrand Lun, St. Etienne (France)
Alberto Macciò, Savona (Italy)
Sergio Mancini, Siena (Italy)
Stefano Mancini, Siena (Italy)
Vincenzo Mattaliano, Florence (Italy)
Giovanni Mosti, Lucca (Italy)
Battistino Paggi, Novara (Italy)
Massimo Pisacreta, Milan (Italy)
CTG - Scientific Committee
Teresa Lucia Aloi, Pavia (Italy)
Guido Arpaia, Milano (Italy)
Carlo Astara, Cagliari (Italy)
Biagio Innocenzo Bonfiglio, Messina (Italy)
Giuseppe Castagna, Cagliari (Italy)
Vincenzo Coscia, Ferrara (Italy)
Egidio De Gaudenzi, Domodossola (Italy)
Panfilo Di Gregorio, Pescara (Italy)
Rossella Di Stefano, Pisa (Italy)
Ciro Falasconi, Napoli (Italy)
Massimo Fonti, Ancona (Italy)
Vincenzo Gasbarro, Ferrara (Italy)
Massimo Gatti, Firenze (Italy)
Saverio Giliberti, Bari (Italy)
Egidio Imbalzano, Reggio Calabria (Italy)
Alberto Macciò, Savona (Italy)
Stefano Mancini, Siena (Italy)
Ettore Manconi, Cagliari (Italy)
Vincenzo Mattaliano, Firenze (Italy)
Giovanni Mosti, Lucca (Italy)
Marco Romanelli, Pisa (Italy)
Angelo Santoliquido, Roma (Italy)
The Compression Therapy study Group - CTG
www.terapiacompressiva.it
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Preface
Compression is one of the most ancient treatments employed by man and its role has been defined over the centuries
by a wealth of experience and a large number of studies. Compression therapy is of fundamental importance in the
treatment of lymphatic and venous diseases, which affect more than a quarter of the population, and it has also become
essential in the prophylaxis of venous thromboembolism; if performed well in the classes of patients at risk, it may be
life-saving.
The “Compression Therapy study Group” – CTG was founded in Italy in 2003. It is engaged in scientific research
and to promote the “culture” of compression therapy in phlebolymphology in Italy. There is no legislation in Italy
defining the quality of compression methods such as medical compression stockings and bandages whereas in other
European countries production standards have been in force for many years; compliance with these is essential if medical stockings are to be reimbursed by the national health services, which serves as public recognition of the efficacy of
such devices, if made using materials and methods that comply with legislation.
The second Consensus on compression therapy in phlebolymphology issued by the CTG was necessary in order to
update the previous one of 2006 and to link the daily clinical and scientific experience of many experts with evidencebased medicine, as summarised in the Guidelines of the major scientific associations and in the documents of the International Compression Club (ICC). The purpose of this is to provide the briefest possible and at the same time most
complete picture of compression materials and methods in phlebolymphology and recommend the procedures required
in the various clinical conditions.
Fabrizio Mariani
Scientific Director of the CTG
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Contents
Preface . ............................................................................................................................................................................................................................... VII
Contents . ............................................................................................................................................................................................................................ IX
The history of compression therapy ........................................................................................................................................... 1
But when did elastic stockings appear? ......................................................................................................................................................... 3
The birth of modern textile fibres ..................................................................................................................................................................... 4
Compression therapy: actions and methods .................................................................................................................. 6
Actions .................................................................................................................................................................................................................................... 6
The bandage ..................................................................................................................................................................................................................... 8
Characteristics of bandages . ................................................................................................................................................................................... 9
Poorly extensible or short-stretch bandages (extensibility ≤70% of the initial length) .............................................. 10
Medium- and long-stretch bandages . ......................................................................................................................................................... 10
Classification of elastic compression bandages ...................................................................................................................................... 12
Bandaging techniques ............................................................................................................................................................................................. 14
Bandaging with regular turns ......................................................................................................................................................................... 14
Figure of eight bandaging .................................................................................................................................................................................. 15
Figure of eight bandaging fixed at the ankle ......................................................................................................................................... 15
Spontaneously unrolled bandage ................................................................................................................................................................... 15
Multilayer bandaging ........................................................................................................................................................................................... 15
Technique of applying the bandage, defined as “short elastic” according to Sigg ........................................................... 16
Eccentric compression ............................................................................................................................................................................................ 12
Recommendations ..................................................................................................................................................................................................... 18
The elastic stocking . ......................................................................................................................................................................................... 19
Definitions. ................................................................................................................................................................................................................... 19
The characteristics of the medical compression stocking (MCS) ............................................................................................... 19
Quality marks ............................................................................................................................................................................................................ 21
Intermittent pneumatic compression .................................................................................................................................... 22
Techniques of measuring compression in vivo . ...................................................................................................... 23
Compression therapy and ceap classification ........................................................................................................... 25
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CEAP “0” ........................................................................................................................................................................................................................ 25
CEAP “1” ........................................................................................................................................................................................................................ 26
CEAP “2” ......................................................................................................................................................................................................................... 26
CEAP “3” ........................................................................................................................................................................................................................ 27
Oedema in the economic class syndrome (prolonged sitting position syndrome) ............................................................ 28
Occupational phlebopathy-oedema due to a prolonged standing position for occupational reasons ................. 28
Oedema due to a defect of muscle pump function ............................................................................................................................. 28
Post-traumatic oedema . ....................................................................................................................................................................................... 29
Oedema in angiodysplasia ................................................................................................................................................................................. 29
CEAP “4-6” ................................................................................................................................................................................................................... 29
Compression and CEAP 6 ................................................................................................................................................................................. 29
Compression therapy: guide to the treatment of venous ulcers ................................................................................................... 30
Compression therapy and deep venous thrombosis ........................................................................................ 33
Compression therapy and pregnancy ..................................................................................................................................... 34
Compression therapy and peripheral arterial disease ................................................................................... 37
What are the clinical indications depending on the C.E.A.P. classification? ................................................................... 38
Conclusions .................................................................................................................................................................................................................. 39
Compression therapy and vein surgery ............................................................................................................................... 40
Compression therapy and sclerotherapy ........................................................................................................................... 42
Compression therapy and lymphoedema ......................................................................................................................... 44
Compression therapy and prophylaxis of venous thromboembolism ................................... 47
Risk factor stratification ........................................................................................................................................................................................ 47
Effects of compression therapy in the prophylaxis of VTE ...................................................................................................... 49
The antithromboembolism stocking ............................................................................................................................................................. 49
Bandaging .................................................................................................................................................................................................................... 50
Intermittent pneumatic compression . ......................................................................................................................................................... 51
Compression therapy in the prophylaxis of VTE in patients at risk. .................................................................................. 51
General surgery . ........................................................................................................................................................................................................ 51
Oncological surgery . ............................................................................................................................................................................................... 53
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Contents
XI
Cardiac surgery ......................................................................................................................................................................................................... 53
Vascular surgery ........................................................................................................................................................................................................ 54
Gynaecological surgery . ........................................................................................................................................................................................ 55
Urological surgery .................................................................................................................................................................................................... 56
Laparoscopic surgery .............................................................................................................................................................................................. 56
Orthopaedic surgery ............................................................................................................................................................................................... 57
Knee arthroscopy .................................................................................................................................................................................................. 57
Elective THA surgery ....................................................................................................................................................................................... 57
Elective TKA surgery ........................................................................................................................................................................................ 57
Surgery for hip fracture ................................................................................................................................................................................... 57
Elective surgery of the spine ........................................................................................................................................................................ 58
Neurosurgery ............................................................................................................................................................................................................... 58
Trauma ........................................................................................................................................................................................................................... 58
Burns . .............................................................................................................................................................................................................................. 59
Pregnancy and puerperium ............................................................................................................................................................................... 59
General medicine ..................................................................................................................................................................................................... 61
Myocardial infarction ...................................................................................................................................................................................... 61
Ischaemic and haemorrhagic stroke ........................................................................................................................................................ 61
Cancer patients . ................................................................................................................................................................................................... 62
Patients in intensive therapy ........................................................................................................................................................................ 62
Management of compression therapy in the prophylaxis of VTE in surgery ..................................................................... 62
Conclusions .................................................................................................................................................................................................................... 62
Contraindications to compression therapy ................................................................................................................... 65
General recommendations on compression therapy. ...................................................................................... 66
Bandages ........................................................................................................................................................................................................................ 66
Medical compression stockings . ....................................................................................................................................................................... 66
Intermittent pneumatic compression . ......................................................................................................................................................... 68
References ........................................................................................................................................................................................................................ 69
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1
The history of compression therapy
The history of containment and compression is lost in
the mists of time until the first evidence is found in the
Neolithic period (5000-2500 BC) with the discoveries
in the Tassili caves in the Sahara, where paintings on the
rocks show warriors with bandaged legs in a sort of ritual
dance. We find further evidence among the Scythian warriors with their bandage leggings and the Egyptians (17th
dynasty, 1650-1552 BC), as reported in the Edwin Smith
papyrus (155 BC), where the earliest descriptions of curettage of skin ulcers are found; in the Ebers papyrus (XVIII
dynasty, 1400 BC) where the use of haemostatic bandages is mentioned in the eighth section dedicated to the
heart and blood vessels; in biblical evidence in the Old
Testament (prophetic books, Isaiah, I: 6; 8th century BC
“…they are not bound up nor dressed…”); in the descriptions of Hippocrates (450-350 BC); in the Indian medical text “Sushruta Samhita” (200 BC) in which the use of
linen bandages, among others, is mentioned, and finally,
among the Greeks, Hebrews and Romans. There are further references in the early Christian period in Celsus (in
his “De Medicina”, 25 AD), in Galen (130-200 AD) with
his bandages of wool and linen and with the description
of an adherent bandage intended to prevent blood from
flowing back and downwards and compresses soaked in
wine, the first examples of positive eccentric compression,
and in Oribasius (324 AD) with his treatise on the surgery of ulcers and what is probably the first description
of stripping.
After that time, reports of compression therapy disappear and re-emerge, though only sporadically, with the
Persian philosopher and physician Avicenna (980-1037)
and with Guglielmo of Saliceto (1210-1276) who was
among the first to isolate wounds from the air (the modern concept of occlusive dressings). Compression was
subsequently treated by Henry de Mondeville (1320),
Guy de Chauliac (1363) and Giovanni Michele Savonarola (1384-1468) in his treatise on venous diseases; he
taught at Padua and was the grandfather of the theologian Girolamo who was burned at the stake; he was summoned in 1440 to the d’Este court in Ferrara, where he
became physician to Niccolò III; Paracelsus (1493-1541),
physician and alchemist who publicly burned the writings of Galen and Avicenna, famously saying “Thus every
bad thing goes up in smoke”; Ambroise Parè (1510-1590
AD), Henry II of France’s personal surgeon, who described bandaging with a layer of lead. A historical moment in Italian phlebology is thus reached: prior to the
description in the famous work De Venarum Ostiolis by
Girolamo Fabrizio of Acquapendente (1537-1619) the
venous valves had been described by Giambattista Canano (1515-1579), who was already a lecturer in anatomy
at Ferrara while still a student and who was famous for his
description of muscles (Muscolorum Humani Corporis
Picturata Dissectio, 1541). He subsequently told Andrea
Vesalius (1514-1564), whose brother Francesco was with
Canano at Ferrara, of his discovery of venous valves in
the azygos vein system. In reality, Canano had already
observed venous valves in the horse in 1536 and he then
described them in the azygos veins in humans. In the
autumn of 1542 Vesalius showed Canano the plates of
his work De Humani Corporis Fabrica (first edition 1543,
second edition 1555) designed by Kalkar, a famous apprentice of Titian’s, and Canano halted publication of his
treatise on myology. Canano in fact destroyed the copies of the book that were already printed but fortunately
a few examples distributed to friends and relatives survived.
In the same years, around the time of the discovery of
the venous valves, another famous anatomist of the period (Charles Estienne or Carolus Stephanus, 1504-1564),
a contemporary of Vesalius and a pupil of the same master as Vesalius’s (Jacques Dubois known as Sylvius, 14781555), published his important anatomical work, De
Dissectione Partium Corporis Humani (1545), in which he
described the valves of the hepatic veins. This monumental work was started in 1530 but was only published in
1545 and Albrecht von Haller in 1751 called l’Estienne
“primus valvularum auctor”.
Girolamo Fabrizio of Acquapendente (1537-1619, a
successor to Savonarola as a teacher in Padua described
both venous valves (De Venarum Ostiolis) and laced calf
leather stockings (De Chirurgicis Operationibus). Guy de
Chauliac (1300-1386), a surgeon in Montpellier, in his
“Chirurgia Magna” marked a historical moment for compression as this work was referred to for the next four centuries. Michele Savonarola is regarded as the founder of
conservative treatment of varicose veins; in his “Pratica”,
he specifies that the bandage had to be applied from the
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foot to the top of the limb, an idea also supported by
Parè. In 1628, based on the observations of Fabrizio of
Acquapendente (De Venarum ostiolis), William Harvey
(1578-1657) described the circulation of the blood and
indicated the relationship between venous stasis and compression therapy.
Richard Wiseman (1622-1676), Charles II of England’s sergeant surgeon, described puerperal venous
thrombosis in his “Several chirurgical treatises” which he
treated with bandaging from the foot to the knee; he
recommended the use of a laced stocking made of dog
skin, and was probably the first to use the term “varicose
ulcer”. In the same years, the Parisian surgeon Pierre Dionis (1643-1718) described the use of elastic laces and
flannel bandages, while Johann Christian Anton Theden
(1714-1797), surgeon general to the court of Frederick
II of Prussia, in the first part of his work, which appeared in 1771 (“Neue Bemerkungen und Erfahrungen
zur Bereicherung der Wundarzneykunst und Arzneygelahrtheit” or “The great benefit of wrapping the extremities
in bandages”), illustrated bandaging techniques with the
detail of including the fingers or toes, stitching the turns
or wearing a sock to avoid displacement of the bandage.
In the same period, two other publications appeared in
England: the first by Else J on compression of ulcers
with lead plates (a method developed by Battiscomb, an
apothecary who jealously kept this technique secret from
everyone), and the second by Rowley in his monograph
on ambulatory treatment of leg ulcers. The importance
of compression in healing leg ulcers was confirmed in a
detailed manner by Bell B in 1778 by using tight bandages with the aim of approximating the ulcer margins to
promote healing. Compression with India rubber was
described by Wye in 1781 and soon afterwards there
were reports on the use of inflatable India rubber leggings (aerie pulse leggins) for ulcers or even compression
packs impregnated with turpentine wax and covered
with bandages of different types (leather, cardboard,
cork, celluloid).
Thomas Baynton represents a further stage in the history of compression therapy with his “New method of
treating old ulcers” of 1797, which, based on Bell’s observations, described a tight bandage (Baynton bandage) with
plasters of pitch resin cut in strips and positioned on the
limb like tiles, which was able to exert strong pressure to
approximate the margins of the ulcer. Other authors such
as Velpeau (1826) and Boyer (1831) confirmed Baynton’s
method while Sir Everard Home (1801) described the
role of elastic compression in reducing ulcer recurrence;
finally, Sir Astley Cooper (1824) affirmed that “elastic
compression is able to restore valvular continence”. Different historical testimonies prove the widespread use in
London hospitals towards the end of the 18th century of
elastic containment for treating leg ulcers, while its prophylactic therapeutic use appeared later in the 19th century, especially because of the importance attributed to
ulcerative pathology of the legs as a cause of absence from
work. In 1730, counsellor Eller TJ in Berlin complained
of the fact that very large numbers of persons affected by
ulcers of the limbs applied to the Charité hospital, where
more than 20% of those admitted around 1850 were suffering from ulcers of the lower limbs. In those years, the
often criticised poor skill of healthcare workers together
with superstition (the ulcer was regarded as a sort of common cloaca through which the negative humours were removed) caused a disproportionate increase in the carriers
of this disease as well as of hospital crowding. At the same
time, severe criticism was directed even at the university
because of poor medical education in this important area
of human pathology.
Finally, outpatient treatment with bandages that could
be removed and applied by the patient himself was introduced by Martin of Boston (1870), who suggested a rubber bandage, an example of a highly extensile bandage,
in direct contact with the skin and covered by a second
bandage. Victor von Bruns criticised the use of rubber for
strong compression and the risk of skin maceration, while
his son Paul, a surgeon in Tübingen, described it as “the
best method set up until now”.
Paul Unna, a dermatologist in Hamburg (1885),
marked another historic point with his rigid zinc oxide
bandage (Unna’s paste boot), like the “Klebrobinde” from
Teufel of Stuttgart at the end of the 19th century, the first
industrial example of adhesive bandages. In 1929 in association with Beiersdorf, N. Brann produced “Novoplast”
bandages, with adhesive on both sides. Numerous other
types of bandages were manufactured between the end of
the 1880s and the early 1900s. Heinrich Fischer (1910),
based on Unna’s observations, was the first to show the
fundamental ideas of graduated decreasing pressure and
the dual concept of compression and mobilisation in the
treatment of venous thrombosis.
Prophylaxis of venous thromboembolism was recommended as early as 1900 by Hagapoff at the international
medical conference in Paris, while Kappis practised it systematically from 1923 in Würzburg University surgical
clinic with excellent results.
Post-sclerotherapy compression appeared late because
there was a common conviction that sclerosis should be
followed by rest due to the risk of embolism and so there
was a “fear of bandaging”. Paul Linser (1871-1963) introduced sclerotherapy in Germany, employing outpatient
treatment, unlike his pupil Karl Linser (1895-1976) who
admitted all patients who were undermedical-lsing sclerotherapy. Another great supporter of outpatient treatment
was Gabor Nobl (1864-1938) at the Vienna polyclinic:
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“systematic use of elastic compression is the best treatment for
varicose nodules and ulcers”. Compression therapy with
bandages in surgical treatment came later, long after the
use of this therapy for leg ulcers and essentially after the
discovery and advent of surgical anaesthesia (William
Morton, dentist in Boston, gave the first real demonstration of surgical anaesthesia with nitrous oxide at Massachusetts General Hospital in 1846).
Karl Sigg (1912-1986), a supporter of compression therapy in sclerotherapy with his famous method,
together with the Dutch Van der Molen (Van der Molen’s “tuyautage” [piping]) and the French Robert Stemmer then established the scientific basis of compression
therapy. Karl Sigg was also the inventor of the graduated
compression elastic stocking produced by the Ganzoni
Sigvaris® company from 1958-1960.
The elastic bandage appeared in very remote periods,
certainly long before the elastic stocking, and was used for
the most varied reasons (ritual, ornamental and protective) especially because of its haemostatic effect (“Morelli’s
haemostatic laces”, 1674) and for the treatment of aneurysms (Moro, 1760 and Guattani, 1772). The Startin
bandage for treating varices (1851) is the precursor of Van
der Molen’s “tuyautage”, together with a more recent one
by Helferich (1937), who described a method with rubber laces for the treatment of oedema of the lower limbs
in which rubber laces were positioned on the leg at regular intervals. Examples of this, today known as “eccentric
positive compression”, were used in numerous schools beyond the Alps; thus, one type of garter, to which a compression patch of various materials was attached, was the
“Hoeftmann compression ball”, or Wolfram’s rigid plates
for compressing the femoral artery and thus reducing venous stasis.
History always conceals something that is then presented in a new guise today; for instance, the first devices
that were precursors of modern sequential pressure therapy
were invented by Hofmeister, who in 1902 presented his
metal cylinder filled with mercury for the treatment of
oedema of the upper limb; Hurtel in 1917 created the
first pneumatic chamber and Hammesfahr in 1929 the
first intermittent pneumatic chamber.
But when did elastic stockings appear?
A precursor of elastic stockings were gaiters (a sort of
stockings without feet and with anterior or lateral laces),
already described by Fabrizio of Acquapendente (15371619) and used for various reasons. They were made of
dog skin, string, rubber etc., but they were rapidly abandoned because they produced oedema of the foot and ankle. Between the end of the 18th and the start of the 19th
centuries, they were replaced by true stockings (elastic
leggings), which also included the foot.
3
Murphy created an elastic “leg corset”, Heermann a
made-to-measure shoe which continued into a gaiter,
and Stephan described a patented gaiter for varicose
veins. The first true elastic stockings (which replaced
unsuccessful attempts in natural or India rubber, which
were difficult to put on and poorly tolerated) appeared in
the 19th century, after the discovery of rubber vulcanisation by Charles Goodyear in 1839. In 1846, only seven
years after Goodyear vulcanisation, Brockedon W and
Thomas Hancock in England registered the first patent
for fine and quadrangular rubber thread, which rapidly
conquered the textile industry. The elastic stocking was
born on the 26th of October 1848 when William Brown
of Middlesex registered patent no. 12294 concerning the
elastic stocking in India rubber manufactured on hand
looms. Shortly afterwards, in 1851, Jonathan Sparks
introduced threads made of silk and cotton (patent no.
13787, 1851). In 1861, thanks to William Saville we
have the first example of surgical elastic stockings manufactured on hand looms and also to measure. Almost at
the same time, the Ganzoni elastic materials factory was
founded in Winterthur in Switzerland in 1864 (today
Ganzoni Sigvaris®), which then became the world leader
in the production of medical elastic stockings. In 1866
criticism of elastic stockings also began, little different
from that of today: Billroth complained of the excessively
high costs of rubber stockings and also of the fact that
they were difficult to wash.
Industrialisation thus commenced (especially in Middlesex and Nottingham and later in Louvain in Belgium
thanks to Anne Catherine Laury) and compression therapy
reached its peak with the founding by the engineer Julius
Römpler of the first factory manufacturing rubber elastic
bandages in Germany in 1861. In 1871 Römpler introduced elastic weaving, moving the factory to Zeulenroda
(a small town in Thuringia where there was great availability of labour). In 1930 the little town of Zeulenroda had
about 30 industries, thus rapidly becoming established as
the world centre for stockings for varicose veins. However,
rubber elastic stockings continued to be poorly regarded
by doctors and patients because they were thick and poorly transpiring, so that in 1907 N. Brann (of the Novoplast
bandages) wrote “...the elastic stockings are badly constructed
and have failed in their aim …”. But matters improved,
first with the “Viktoria“ company and its “smooth knit“,
then in 1904 when Oskar Huppelsberg produced the first
seamless stockings known as “Ohrs-Ohrsana”, and finally in
1920 when a new very fine rubber thread with a round
cross section was produced, which was used to manufacture double-elastic, circular knit and seamless stockings
(“lastic flor” stockings with a patent held by Römpler J,
subsequently produced at Apoda due to Böttgen W). Elastic stockings with fibres other than rubber appeared for
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COMPRESSION
the first time in 1917 and towards the end of the 1920s
they were produced by the Thalysia company, while modern elastic stockings with synthetic elastomers appeared in
the second half of the twentieth century.
The birth of modern textile fibres
The American “Viscose Company“ created the name
Rayon® in 1924 to replace “artificial silk”, which had
aroused such anger among producers of natural silk. This
name was comfortable because it was easy to use, sounded
nice and recalled the brightness of the fabric. With time,
new textile fibres were produced, derived from water, carbon and hydrocarbons, which can today be grouped into
two main categories: cellulose or natural fibres (animal,
vegetable or mineral) and chemical fibres (artificial or
synthetic).
Natural fibres
Chemical fibres
Animal: silk, wool, etc.
Vegetable: cotton, linen, hemp,
coconut, bamboo etc.
Mineral: asbestos wool
Artificial: viscose, cellulose
acetate, cupro, etc.
Synthetic: acrylic, polyester,
polypropylene ( nylon, spandex,
etc.), glass, etc.
The synthetic polymers (containing at least 85%
polyurethanes by mass) appeared on the market in both
monofilament and multifilament form (Lycra®, now a
registered trademark of Invista, or Dorlastan® from Bayer,
etc.); in general, the latter are used in stockings and the
former in bandages (DuPont patented Lycra® in 1959 and
Nylon® or polyamide in 1938). These extremely fine and
light threads (1500-3000 times finer than a hair; 1 g = 10
metres of yarn) are always used in various combinations
with other fibres such as cotton, nylon and silk and have
gradually provided us with ever finer elastic hose with
greater wearability.
1938 was the year of the first revolution in stocking
production because Nylon® was invented and patented
(1935) by Wallace H Carothers at the factory founded
by the French chemist Eleuthère Irènèe DuPont of Nemours, who had emigrated to the state of Delaware in
the USA. In those years, the advertising described it as
“…the first synthetic fibre as tough as steel and as delicate
as a cobweb…”. In 1939 sales began in a few shops in
Wilmington (the headquarters of DuPont of Nemours)
and from there they extended throughout America and
the world. DuPont presented the Nylon® stocking in 1939
at the international exhibition in Boston and in 1940 64
million pairs of Nylon® stockings were sold. While this
was happening, the chemist Otto Bayer (1902-1982) in
Europe started his studies of polyurethane and in 1939
Paul Schlack obtained the first elastic polymer capable of
sustaining great stretching.
The second revolution arrived in the 1960s, again under
the DuPont name, first with the patenting (1959) and
then with the marketing of Lycra®, which would become
the fibre of the 20th century.
In 1951, Brenschede W obtained the fibre known as
“Vulkollan“ and from 1962-64 production (Bayer-Germany and USA) of “compression stockings” began, under
the trademark Dorlastan® which was patented by Bayer.
Between the end of the 1970s and the start of the 1980s,
Lycra® (the elastomer synthetic fibres were called Elastam
or Spandex in the USA and Canada) became the new and
indisputable leader in the stocking industry. The modern
chemical textile industry in little over 50 years has made
such giant steps that in 1990 it has produced 20 million
tons of chemical fibres globally, much more than wool,
cotton, linen and silk. Numerous other fibres have followed in the last few decades, employed not only in the
textile industry but also in other sectors.
LACTRON: this is a biodegradable synthetic fibre
based on polylactic acid and obtained ecologically from
maize by fermentation of its amide. It is thus a synthetic
fibre of an ecological, biodegradable nature, not derived
from petroleum but from a plant and completely degradable to carbonic anhydride and water. It has physical
properties almost identical to those of nylon and polyester. It is used by Kanebo® for diverse uses such as civil
engineering, the paper industry, sutures, gauze, clothing
(corn fibre).
CALAFINE QD: this is a polyester, which has the advantage of being able to be dyed at atmospheric pressure
and not under pressure like other types of polyester. Toyobo® produces Calafine QD® (Quick Dry) which also has
the merit of great ease of maintenance (wash and wear).
NOMEX: a vast range of “engineering fibres” developed by DuPont, particularly resistant to heat and much
used in electrical insulation. In the form of fabrics particularly resistant to wear and tearing, used in fire-fighters’
clothing. “Delta K” NOMEX contains KEVLAR fibres, a
filtering agent for atmospheric pollution.
Fig. 1 – Classical polyester fibre.
20-05-2009 14:33:33
Fig. 2 – PTT fibre.
DYNEEMA: this is a flexible and particularly tough
polyethylene because of its special physical and mechani-
5
cal characteristics, much used in industry (naval, electrical insulation, bullet-proof jackets, skis, canoes, sails,
etc.).
Corterra fibres or PTT (polycondensation of PTA or
purified terephthalic acid) (Fig. 2): this is a special polyester obtained by chemical (Shell) or biochemical (DuPont)
polycondensation. It is a fibre with characteristics better
than those of nylon and polyester, capable of undermedical-lsing great deformation and returning readily to its
original form; it dries rapidly and is used in clothing, the
automobile sector, furnishings, etc.
About 10% of the current stocking market consists of
elastic stockings, with support and therapeutic stockings
each accounting for about 5%, and non-elastic (fashion)
stockings accounting for the other 90%.
20-05-2009 14:33:33
6
Compression therapy: actions and methods
It is not easy to give an exact definition of compression
therapy, but it can be understood as: pressure exerted on
a limb by materials of varying elasticity in order to prevent
and treat disease of the venolymphatic system (Diagnostic
and therapeutic guidelines for diseases of the veins and lymphatics of the Italian College of Phlebology CIF, revisions
2003-2004).
The terms containment and compression are often used
incorrectly as synonyms but in reality they indicate different concepts:
–– Containment: passive action (static) of a rigid compression system (nonelastic or with hardly any elasticity),
which is more or less inextensible and opposes systolic
muscle dilatation, developing a raised working pressure (reinforcement effect on the venous pump); the leg
is contained at rest but not compressed.
–– Compression: active action exercised at rest on a limb
by the more or less elastic characteristics of the system
with the development of high resting pressures; the leg
is compressed even at rest.
ACTIONS
The mechanisms of action and the clinical consequences of compression therapy in phlebolymphology
have been described in a large number of scientific studies
and can be summarised in brief as:
a) action on the superficial and deep venous system;
b) action on the blood volume;
c) action on the tissues;
d) action on the microvascular tissue compartment;
e) action on the venous thrombus.
Compression exerted on the lower limbs causes a reduction in the calibre of the veins, consequent better coaptation of healthy valve cusps and a reduction of pathological reflux (incompetent perforators) of up to 30-40%
(Fischer H. 1976; Stemmer R. et al. 1976; Emter M. et
al. 1991, Sarin S. et al. 1992, Mariani F. et al. 1991).
Compression both by bandages and by elastic stockings
reduces in a very obvious way the cross section of the calf
muscle veins; on the other hand, the reduction in the calibre of the popliteal vein is variable, as is that of the common femoral vein, whereas the volume of the superficial
varicose veins always appears reduced.
Many authors, using radionuclides, have also shown
an increase in lymphatic drainage in the course of compression therapy.
The bandage reduces the blood volume of the lower
limb by about 45% in lying position and 62% in the
standing position, with a significant increase in right ventricular filling. The local blood pool measured by Partsch
H et al. with labelled red blood cells diminishes by 30%
after application of a compression bandage of about 40
mmHg to the entire lower limb.
During walking, these effects, added to the reinforced
squeezing of the venous pump (foot and calf ) cause an increase in the rate of venous (up to 5-fold) and lymphatic
flow with a reduction in backflow and therefore of stasis
(Partsch H 1979). Some studies also demonstrate that to
obtain optimal efficacy of compression therapy it must be
combined with mobilisation and normal plantar support
(Brizzio EO et al. 1994).
Radioisotope studies have shown that the external pressure exerted by the bandage increases tissue pressure, promoting the reabsorption of fluids back into the veins in accordance with Starling’s law, thus producing a reduction of
oedema, together with the mechanisms referred to above.
Curri SB et al. (1989) have demonstrated that compression therapy with an elastic stocking produces a reduction
of veno-capillary ectasia, interstitial oedema and reactive
thickening of the arteriolar basal membrane in patients affected by Widmer stage II venous insufficiency. Allegra C
et al. (1995) in a microlymphographic study have shown
a reduction in endolymphatic and tissue pressure after 4
weeks of treatment with a bandage worn constantly. Compression promotes detachment of leucocytes from the endothelium and prevents them from adhering further (AbuOwn A et al. 1994). Capillary filtration is also reduced and
reabsorption is promoted due to the greater tissue pressure. The therapeutic elastic stocking is also able to reduce
oxidative stress in healthy subjects obliged to stand for
prolonged periods at work (Flore R et al. 2007).
The results of all the studies conducted show unanimously that compression causes a reduction of venous capacity, which will automatically diminish venous output
and speed up venous return with an increase in the flow
rate, which must be regarded as the main cause of the effects of compression therapy in the prophylaxis of VTE.
20-05-2009 14:33:33
Compression therapy: actions and methods
The compression bandage increases the adhesion of
any thrombus to the vein wall provided this does not extend beyond the upper border of the bandage (Fischer H,
Bassi G, Stemmer R); recent studies by Partsch H et al.
(1997, 2000, 2004), Gerlach HE and Blättler W (2002,
2003) show that in patients with DVT (provided they
are able to walk) there is a lower incidence of embolic
episodes if they are treated with bandaging, heparin and
mobilisation compared to heparin therapy alone.
Compression therapy has an effective action on various
coagulation factors: a few studies suggest a reinforcement
of fibrinolysis of the vein wall with the use of pneumatic
compression (Altenkamper H 1983; Comerota AJ et al.
1997) and also with an elastic bandage. Pneumatic compression also produces an increase in capillary perfusion
and tissue oxygenation, with an increase in the release of
nitric oxide. The treatment acts also by reducing blood viscosity, with suppression of procoagulant activity, but the
effect of this in the prophylaxis of DVT appears to lead
back to the increase in the venous flow rate demonstrated
by many authors. Besides the reinforcement of venous
emptying by means of the containment action on the muscle mass during walking and exercise, with muscle volume
increasing during the contraction phase, it must today be
regarded as one of the most effective mechanisms, just as
the dual concept of compression and mobilisation is regarded as indispensable for obtaining significant effects
from the clinical aspect (Bassi G and Stemmer R 1983).
Recently (International Angiology 2008) a group of experts (ICC-International Compression Club) review published literature concerning the use of compression treat-
7
ments in the management of venous and lymphatic diseases
and establish where reliable evidence exists to justify the use
of medical compression and where further research is required to address areas of uncertainty. The authors searched
medical literature databases and reviewed their own collections of papers, monographs and books for papers providing information about the effects of compression and
randomized clinical trials of compression devices. Papers
were classified in accordance with the recommendations
of the GRADE group (Guyatt G et al., CHEST 2006) to
categorize their scientific reliability. Further classification
was made according to the particular clinical problem that
was addressed in the papers. The review included papers on
compression stockings, bandages and intermittent pneumatic compression devices (Table 1). Low levels of compression 10-30 mmHg applied by stockings are effective
in the management of telangiectases after sclerotherapy,
varicose veins in pregnancy, the prevention of edema and
deep vein thrombosis (DVT). High levels of compression
produced by bandaging and strong compression stockings
(30-40 mmHg) are effective at healing leg ulcers and preventing progression of post-thrombotic syndrome as well
as in the management of lymphedema. In some areas no
reliable evidence was available to permit recommendations
of level of compression or duration of treatment. These included: management of varicose veins to prevent progression, following surgical treatment or sclerotherapy for varicose veins, and the level of compression required to treat
acute DVT. This review shows that whilst good evidence
for the use of compression is available in some clinical indications, there is much still to be discovered.
Table I – Evidence Based Medicine and Compression Therapy. Modified from: Partsch H., Flour M., Coleridge Smith P., Benigni J.P.,
Cornu-Thénard A., Delis K., Gniadecka M., Mariani F., Mosti G., Neumann H.A.M., Rabe E., Schuren J., Uhl J.F. Indications for compression
therapy in venous and lymphatic disease. Consensus based on experimental data and scientific evidence. Under the auspice of the IUP.
Int. Angiol. 2008;27,3,193-219.
INDICATIONS
VCI
C0s
C1s
C1 after sclero
C2 a,s
C2s pregnancy
C3 pregnancy
C3 therapy
C4b
C5
C6
After procedures
VTE
Prevention
Therapy
SPT
Prevention
Therapy
LYMPHEDEMA
Therapy
10-20 mmHg
1B
1B
1B
1B
?
MCS
20-30 mmHg
1B
2B
1B
2B
?
1B
2B
1A
30-40 mmHg
Bandage
CP
?
1B
1A
1A
1B
?
?
1A
1B
2B
1B
1B
1A
2B
?
?
?
1A
1B
1B
1B
20-05-2009 14:33:33
8
The bandage
The most important properties of bandages and elastic
supports are represented by their elasticity and extensibility or stretch. Elasticity defines the ability of the material
to return to its original length when the stretching force
ceases. The force required to obtain specific stretching
indicates the power: this parameter is a determinant in
defining the pressure exerted by the bandage at a fixed
extension.
Inextensible or short-stretch (<70%) bandages produce
high “working pressures” during ambulation because of the
containment effect on the contraction of the muscles of
the leg, whereas the “resting pressure” is reduced compared
with the working pressure. In contrast, elastic bandages
classified as medium- (between 70 and 140%) or longstretch (>140%) compared with their initial dimensions
are characterised by the fact that there is a gap between
the resting and working pressures that they exert which
is inversely proportional to their elasticity. They therefore
maintain continuous pressure on the superficial venous
system, relatively independent of muscle activity, as do
stockings made of long-stretch elastic fibres. Depending
on their extensibility, they thus have different actions during the static phase and movement, bearing in mind that
compression therapy must be combined with mobilisation of the patient to achieve maximum efficacy:
–– inextensible short-stretch bandages (<70%), like Unna’s zinc oxide boot or medicated adhesive bandages,
produce high working pressures and lower pressures
at rest, which can be maintained constantly over 24
hours; they reinforce the action of the calf muscle
pump, have a greater action on the deep venous system
and are tolerated at rest;
–– bandages that stretch over 70% and elastic stockings
instead produce lower working pressures and usually
have to be removed at bedtime because they are not
well tolerated.
The pressure exerted by a bandage depends essentially
on the tension T at which it is applied, the number of layers n and the radius of the limb R. The relation between
these quantities is expressed by Laplace’s law P = Tn/R,
which is modified to P = Tnt/Rw, where t is the thickness of the material employed and w is the width of the
bandage.
The tension is produced by the force applied to the
bandage when it is stretched but the ability of the bandage to maintain a specific tension and thus the pressure
exerted is derived from its elastomeric properties (hysteresis – stretching and retraction curves), which in turn are
dependent on the type of thread and the methods employed in making the fabric. As mentioned above, the
ability of a bandage to stretch if subjected to a pulling
force is called its extensibility, which describes the stretching ability of the elastic material, which in any case behaves differently in response to traction depending on its
hysteresis properties: the applied pressure increases in proportion to the tension up to a maximum, beyond which
the phenomenon of overstretching occurs, that is, the pressure stabilises. When the bandage is applied, numerous
factors determine its compression efficacy over time: wear
of the material, walking with repeated and continuous
stretching and retraction, any reduction of the oedema,
and the physical characteristics of the material utilised. It
is believed that the pressure falls by about 40% just a few
hours after application and these effects are greater the
more short-stretch the bandage, while highly elastic materials reduce such effects to the minimum. The patient’s
position also contributes to the change in pressure; it is
increased when the patient is standing as compared with
lying down.
The bandage must be applied keeping the tension of
the bandage constant and overlapping the turns regularly
so as to provide uniform pressure, since the pressure increases proportionally at each overlap in accordance with
Laplace’s law. Different techniques can be used (regular
turns, figure of eight, figure of eight fixed at the ankle,
spontaneous unrolling etc.) and they should be used depending on the case, always following a few fixed rules:
–– the bandage must extend as far as the base of the toes;
–– it must be done from the inside to the outside of the
limb, maintaining regularity and uniformity (the bandage must be unrolled at constant tension, overlapping
the turns by about 50% of their width), thus avoiding
areas of excessive pressure and local constriction.
It should be recalled that in practice the pressure exerted by the bandage and its efficacy when using that particular material depend closely on the tension to which the
bandage is subjected, the number of overlapping turns
20-05-2009 14:33:33
The bandage
and the technique employed: the figure of eight bandage
remains in place longer without changing and compresses
about 30-40% more compared with regular turns; the
spontaneously unrolled bandage compresses mainly the
calf and is therefore indicated for venous disorders in the
posterior part of the leg; the figure of eight bandage fixed
at the ankle compresses mainly the medial inside regions
of the leg and is therefore indicated for venous disorders
in that region, such as ulcers and hypodermitis (Partsch
H, Rabe E, Stemmer R 2000, Mariani F 2005).
The use of so-called eccentric compression with cotton
or rubber pads is based on the physical principle that every
change in the radius of the compressed surface produces
a change in the pressure exerted that is inversely proportional to the radius. Its practical usefulness is therefore the
possibility of varying the pressure according to the regions
to be compressed, for example, greater pressures are usually required in the region of the venous ulcer where the
effects of venous reflux are greater, or the creation of a
radius that can be compressed is required where the surface is flat (for example areas of indurated hypodermitis)
or even concave (retromalleolar fossae). This technique is
also found useful in levelling the radii that are to be compressed or protected (such as the tibial crest, the Achilles
tendon etc.) in all legs that have an irregular circumference. The pressure exerted beneath the pad, when nonelastic bandages are used, has special characteristics: the
resting pressures come very close to the working pressures
so that a local compression effect is obtained similar to
that of elastic bandages.
An interesting innovation in the bandage area is represented by the multilayer system kits (four layer bandages,
Profore® Smith & Nephew – Rosidal sys® Lohmann &
Rauscher, or bi layer bandage Coban 2® 3M) which consist
of application of four or two superimposed bandages of
different elasticity; the systems allow a high pressure (between 40 and 60 mmHg) to be maintained for more days
with optimal tolerability at rest and is indicated especially
in the reduction of “difficult” oedema, such as indurated
and lymphatic oedema, and in the treatment of venous
ulcers. The elastic material provides constant pressure and
the non-elastic material provides high working pressures
during walking.
The practical problems of bandage application and
therefore of their efficacy are substantially represented
by the skill of the healthcare professional and the choice
of suitable material. Manufacturers have sought to solve
some of these problems by providing visual guides to the
bandage (lines, circles, rectangles), which are modified
according to the tension exerted and which should therefore help the healthcare professional to apply appropriate and uniform pressures to the limb. The development
of manufacturing technologies may help to reduce the
9
variability in inter- and intra-bandage tension; one of the
most promising possibilities is fabrication of a vari-stretch
elastomer (Proguide®, Smith & Nephew) which is able to
exert relatively constant pressure independent of limited
variations in extension.
Characteristics of bandages
The art of bandage requires a more or less prolonged
apprenticeship and trained staff, the bandage is closely
dependent by the operators. Another aspect to consider
is the more or less limited duration of containment/compression therapy carried out with bandaging, because the
bandage loses about 40% of its original pressure after 120
min (Damstra RJ 2008). The principal reasons of this
loose of pressure are: the volume reduction of the bandaged limb and the deterioration of the bandaging components (Benigni JP et al. 2007).
Elasticity and hysteresis. Elasticity is the property of a
material to recover its original size and/or shape after the
removal of a deforming force. In order to evaluate this
property, it is subjected to a series of cycles of traction (application of the deforming force) and retraction (cancellation of the deforming force) with the aid of a dynamometer which records a load diagram of force/stretching and
the graph of these stresses over time. This is expressed as
the percentage change between the sample at the start and
the sample after it has undermedical-lsne the hysteresis
cycle. In general the hysteresis cyclef (Fig. 3) defines the
visco-elastic properties of a material. The term extensibility
is used as a synonym of elasticity: the meanings are completely different. Thus, extensibility indicates the degree
of stretching of a bandage under the action of a certain
tractional force, whereas elasticity is the capacity of that
particular bandage to resume its original dimensions after
the tractional force has ceased. Another parameter that
characterises compression materials is their stiffness (or
slope), defined as the increase in pressure per increase of one
centimetre in the circumference of the lower limb, expressed
Fig. 3 – Hysteresis (short-stretch band).
20-05-2009 14:33:34
10
COMPRESSION
in hectopascals or mmHg (CEN - European Committee
for Standardisation).
The working pressures are intermittent elevated pressures that coincide with muscle contractions, while the
resting pressures are usually lower. Based on these concepts,
bandages used for bandaging a limb are classified as rigid
or non-elastic (extremely low modulus of elasticity) or
elastic: short-stretch (<70% of the original length), medium-stretch (70-140%) and long-stretch (>140%) according to the type of elastomer utilised; the elastic stocking is
an example of long stretch
Poorly extensible or short-stretch bandages
(extensibility ≤70% of the initial length)
These are pure containment bandages where the action is exerted especially during muscle contraction
during ambulation and not during muscle relaxation;
they are bandages that produce a working pressure greater than the resting pressure and are well tolerated at rest.
They exert effective pressure on deep regions and are
able rapidly to reduce oedematogenic conditions of various origin. Although this type of bandage is included
among the short-stretch bandages (bandages with elasticity ≤70%) it is clear that in the strict sense of the
term, a bandage with a very low Young’s modulus of
elasticity (close to zero) is rigid or inextensible so that a
distinction should be made clinically between non-elastic or so-called rigid bandages (≤30%) and short-stretch
ones (>30%≤70%).
An example of a rigid or inextensible bandage still frequently utilised today is the zinc oxide bandage conceived
by the dermatologist Paul Gerson Unna in 1885; there are
also elastic versions of this today.
Other types of inextensible bandages are usually made
of cotton (or more rarely of linen, flannel etc.) with a variable polyamide percentage between 20-40%, for instance
Ideal bandages (Lohmann & Rauscher), still used today
in our operating theatres.
Some authors (Marmasse G) consider that the optimal
percentage elasticity of short-stretch bandages is 30-40%,
which is the optimal level for obtaining increased working pressure on the one hand and will also act on deep
regions, and on the other hand, does not at the same time
involve the disadvantages of a completely rigid bandage,
such as the marked difficulty of application and of keeping it in place over time.
The fundamental problem of bandaging with this type
of bandage is its execution and therefore its stability especially during ambulation; in fact, this bandaging is difficult in practice because it readily produces regions of
greater and less compression with a loss of the uniformity
and reduction of the pressure, or the bandage slips downwards or shifts, creating oedematous areas in a few criti-
cal regions such as the dorsum of the foot. It is certainly
easier to bandage a limb with a medium- or long-stretch
bandage (which will be poorly tolerated at rest by the patient) than with a rigid bandage (which is most tolerated
by the patient).
The inextensible bandage is used today basically in
ulcer disease, lipodermatosclerosis, erysipeloid dermatitis with or without lymphangitis, severe oedematogenic
conditions and the acute phase of DVT of the lower limb
prior to an elastic stocking.
Medium- and long-stretch bandages
A distinction is classically made between one-way or
two-way stretch bandages according to the direction of
stretch (length or length + width) and between:
–– medium-stretch bandages ( >70 ≤140 % of the initial
length);
–– long-stretch bandages (>140% of the initial length).
They are made with natural or synthetic elastic threads
of various types such as caoutchouc or natural rubber,
polyamide (Nylon®) and elastane (Lycra®) in combination
with materials such as cotton.
Natural rubber: in nature, rubber is present as a colloidal suspension in the latex obtained from some plants
(Hevea brasiliensis or rubber tree, originally from Amazonia but cultivated today in Malaysia, Indonesia, Sri
Lanka etc.) and raw rubber is extracted from the latex of
these plants. The vast majority of rubbers today are petroleum derivatives (synthetic rubbers), whereas natural
rubbers were used predominantly up to the middle of
the 20th century. According to international agreements
(Geneva Agreement of 20 March 1987) natural rubber is
today defined as a non-vulcanised elastomer in liquid or
solid form derived from Hevea brasiliensis or from other
similar plants (Tarassaco russo, Parthenium argentatum
etc.).
The physical and chemical properties of interest to
us are the thermal dependency of the mechanical elastic
characteristics (thermal instability) in that products made
of natural rubber become fragile and rigid in winter (between 0-10°C) and often become sticky in summer (elastic and supple above 20°C). The rubber is not affected
by weak acids and bases, and it dissolves in petroleum,
benzene and carbon disulphide; it is insoluble in water
and is oxidised slowly by atmospheric oxygen.
Polyamide or Nylon®: these are thermoplastic polymers,
and those used most often in the textile industry are polyamides 6 and 6.6 (PA 6 and PA 6.6) even if the market
today offers a wide choice up to Grilamid, an extremely
stable and tough polyamide 12 (of which there are different versions) with a density similar to that of water, which is
used in various sectors including the area of sports.
20-05-2009 14:33:34
The bandage
The main characteristics of this polymer are its high
resistance to traction, to solvents and to basic products,
while their main limitation is their marked sensitivity to
moisture and UV rays. A particular polyamide used in the
elastic stocking industry is microfibre.
Elastam, Elastane, Spandex (commercial names Lycra®
Invista or Dorlastan® Bayer): these are synthetic polymers
containing at least 85% polyurethane by mass; they are
on the market in both monofilament and multifilament
form, with the latter employed usually in the stocking
sector while the former are used in bandages.
Lycra® can be imagined as a segmented polymer structure in which elastic segments are linked to rigid segments
which keep distension in check, thus avoiding breakage.
These elastic threads can be stretched 7-fold and then return to their original size; in the 1960s, this represented
the second revolution in the elastic textile industry (elastic stockings with high wearability) after that of Nylon® in
the 1930s, both produced by Du Pont (Du Pont patented
Lycra® in 1959 and Nylon® or polyamide in 1938. These
extremely fine and light threads (1500-3000 times finer
than a hair; 1 g = 10 metres of thread) are always used in
various combinations with other fibres such as cotton, nylon and silk and have provided us with very sheer elastic
stockings of great wearability.
Elastic bandages sometimes contain a certain amount
of viscose (Rayon® Viscose), derived from cellulose, together with cotton and various types of elastic polymers.
As noted above, elastic bandages are classified as short-,
medium- and long-stretch. This classification of elastic bandages by the French school is probably the most
widespread worldwide. However, in this connection a few
considerations and precise definitions are needed:
1. the tension with which elastic bandaging is carried out
indicates the force dissipated on stretching the bandage when it is wrapped around a limb;
2. the pressure exerted by the elastic bandage on the tissues
depends on the structural characteristics of the bandage
(Young’s modulus, hysteresis), the tension to which the
bandage is subjected, the number of layers applied and
the curvature of the limb (which differs in the various
regions of the leg);
3. the ability of the bandage to maintain a certain tension
over time and, secondly, the pressure on the tissues depend on its elastic properties (type of elastomer used in
manufacture of the bandage);
4. the ability of an elastic bandage to stretch under traction is defined as extensibility, whereas the ability of a
bandage to return to the original length on cessation of
stretching is defined as elasticity;
5. locking represents the bandage’s point of maximum
stretch;
6. the locking point should be at 70% of extension for
11
short-stretch bandages, while this locking point should
exceed 140% of the original length in the case of longstretch bandages. For bandages belonging to the same
categories, for instance short-stretch, but containing
different elastomers, this locking can occur with the use
of different forces (different hysteresis curves). In other
words, if the force used to produce that particular extension, that is, the power = work over time, is not expressed, the definitions short-, medium- or long-stretch lose
their significance because they only express the physical
characteristics of the material employed. The concept of
power is the basis of that of tension, since the latter is a
parameter that is directly correlated with the force employed to produce that particular stretch;
7. the pressure exerted with a particular material and potency in application also depends on the bandaging
technique and the overlapping of the turns: figure of
eight bandaging, for instance, provides more compression than bandaging with regular turns; the pressure
also depends on the structure of the bandage, stretch
being equal: bandages with different fabric structures
exert different pressures, and heavier bandages with
the same maximum stretch compress more than others
under the same application conditions. For example,
the Dauerbinde® K bandage from Lohmann & Rauscher (stretch 180%), which is heavier, compresses
more than the F (stretch 180%), which is light.
The industry is examining new elastomers closely
(vari-stretch) that are able to produce constant pressures
so that variations within certain ranges of bandage extension can be eliminated so as to reduce intra-bandaging
(same operator) and inter-bandaging (different operators)
variability.
Adhesive and cohesive bandages
These are usually short- to medium-stretch bandages
which are able to stick to the skin and to themselves (adhesive bandages) or only to themselves (cohesive bandages)
by means of acrylic adhesive or zinc oxide glue. Cohesive
bandages are manufactured by atomisation of the surface
of both sides of the bandage with latex or acrylic microspheres diluted in water, which evaporates on heating to
50°C in suitable furnaces. The latex suspension is fixed
and covers the entire surface of the bandage and is able
to adhere only to itself. The acrylic or zinc oxide glues are
highly hypoallergenic and these bandages can be used relatively readily in direct contact with the skin. In this connection, the following precise definitions are required:
1. adhesive bandages can be manufactured with the presence of elastomers (natural rubber etc.) or be made
completely of cotton with a defined elastic weave (or
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12
COMPRESSION
the elasticity is not associated with elastomers but with
the particular weft of the weave);
2. a few bandages with zinc glue are made of cotton and
Rayon® and have soft and tough edges so as to reduce
the lacing effect at difficult points;
3. some adhesive elastic bandages are made of pure cotton
without elastomers and with a particular weft, producing elasticity in the bandage which is defined as “variable memory”. These bandages, which often require
shaving when they are placed in contact with the skin,
have the adhesive arranged in strips with a protective
film which is removed when they are used. If they are
stretch to up to 50% of their length (submaximal tension), they behave like normal elastic bandages and
can regain their original length but if this exceeds 50%
they lose their elastic capacity (maximum tension) and
are transformed into rigid bandages. These bandages
are used mainly in orthopaedics, sports medicine and
physiotherapy;
4. adhesive elastic bandages, like elastic bandages, can be
one-way stretch (stretch in the longitudinal direction)
or two-way stretch (stretching in both longitudinal
and transverse directions);
5. cohesive bandages are a further example of short- and
medium-stretch bandages and are described as strong,
medium, light or soft to indicate their compressive
power;
6. in general it is preferable to use a skin protector (polyurethane foam film with high porosity) beneath the
adhesive bandage even if this technique may reduce
the stability of the bandage (slipping). The use of elastic tubing beneath the bandage produces greater stability of the bandage itself with the addition of the pressure exerted by the tubing, which is about 10 mmHg
at the ankle.
The types of bandaging with adhesive and cohesive
bandages provide permanent bandages (fixed bandages
that the patient must not remove) which are more stable
over time and provide medium to high pressures on the
tissues. This type of bandage is indicated when a fixed
bandage has to be applied, which the patient must not
remove for a long period and must leave on both day and
night (venous ulcers, oedema, post-operative or post-sclerotherapy etc.).
Working and resting pressure of bandages
Working pressures (muscle contraction) and resting
pressures (muscle relaxation or rest) have been mentioned
several times with reference to bandage type. It was explained above that the non-elastic or rigid type of bandage in the strict sense is the zinc oxide bandage in its nonelastic form or the Ideal type of bandage, and that a rigid
bandage in general must have a Young’s modulus of elasticity close to zero, whereas we can have different types of
elastic bandages depending on the elastomer employed.
Non-elastic (rigid) bandages create peak pressures, and conversely, elastic bandages, especially long-stretch ones, absorb the volumetric changes of muscle contraction in the
limb and do not demonstrate peak pressure variations but
more constant pressures with minimal pressure changes
during walking. The more a bandage, when applied, is
able to give peak pressures (working pressures), the more
the action is transmitted deeply (deep venous system).
To further simplify this concept, we can say that passing
gradually from the rigid bandage to the elastic stocking
the net difference between the resting and working pressures is reduced more and more in favour of lower but
more constant pressures.
Within certain limits, we can transform a long-stretch
into a medium-stretch bandage and a medium- to a
short-stretch bandage by doubling the number of turns
of the bandage; the overlapping of the turns causes not
only an increase in the pressure exerted but also a shift of
the system towards rigidity (Von Gregory’s force-stretch
diagrams). This stratagem allows a greater variety of bandaging with fewer types of bandages.
Finally, a sort of general rule can be formulated “the
more severe the venous disease, the more the bandaging must
be short-stretch or completely non-elastic in combination
with movement, and in this way the best result will be obtained in correcting stasis”.
Classification of elastic compression
bandages
There are national standards that classify bandages; the
most important ones are German and English (Table II).
The German standard (RAL-GZ 387) classifies bandaging materials into:
–– material for protection, absorption and fixation (orthopaedic wool, light cohesive bandages, foam) and
material for eccentric compression;
–– non-elastic bandages (rigid zinc oxide bandages, CircAid®);
–– short-stretch bandages (40-70%);
–– medium-stretch bandages (70-140%);
–– long-stretch bandages (>140%).
Instead, the English standard (BS 7505:1995) divides
bandages into:
–– fixation bandages (orthopaedic wool, foam, light cohesive bandages);
–– short stretch bandages (zinc oxide bandages, shortstretch elastic bandages);
–– long stretch bandages (long-stretch elastic bandages (3A
- 3B - 3C - 3D).
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The bandage
As regards the long-stretch elastic bandages, the German and English standards divide the bandages into four
classes of different elastic strength and therefore different
resting pressure. This pressure is calculated at a known
ankle circumference (23 cm) with the bandaging overlapping 50%; it should be noted that the pressures relating
to the different classes differ considerably in the two classifications.
Table II – Classifications of bandages.
RAL-GZ 387
Germany
standard pressure mmHg
BS 7505
England
standard pressure mmHg
Class 1 18,4-21,2
3A up to 20
Class 2 25,1-32,1
3B 21-30
Class 3 36,4-46,5
3C 31-40
Class 4 >59
3D 41-60
Moreover, these classifications, as mentioned above,
consider the parameter of extensibility, which has no clinical relevance if other more important characteristics are
not described at the same time; these are:
1. Elasticity understood as the ability of the bandage to
regain its original form after extension; this is due to
the addition of elastic threads in the longitudinal direction of the bandage; the force employed to stretch
the bandage (deformation energy) indicates the elastic power or tension. The ability of the bandage to
maintain tension and therefore the pressure it exerts
depends on its elastomer properties (which depend in
turn on the thread and the method used to construct
the fabric);
2. Rigidity can be defined as the ability of the bandage to
oppose muscle expansion when it contracts. It depends
on the elastic recoil of the material used in its construction. The more compact the weft (and with a lower
presence of elastic fibres) the shorter the stretch of the
bandage and the more its rigidity increases. Today,
as mentioned above, the rigidity of a bandage can be
measured with simple, economical and reproducible
methods and can be expressed with various indices, the
most studied of which is the “static stiffness index” (SSI),
which is the difference between the pressure exerted in
vivo by the bandage on the surface of the leg (point
B1) standing and lying, and if this pressure difference
is greater than 10, the bandaging is of the rigid type
(Partsch H. 2005). Stiffness (CEN 1996-1998) signifies the increase in the pressure of the bandage (given
by the resistance offered by the bandage) with a 1 cm
increase in the circumference of the limb;
3. Extensibility is defined as the ability of the bandage to
elongate when subjected to stretching; this is measured
13
by the lengthening of the bandage when a force of 10
N is applied per cm of height and is expressed as a percentage of the length at rest. Once a given extension
has been reached, the physical structure of the bandage prevents further stretching; this condition is called
“locking”. According to Stemmer’s classification, shortstretch bandages should lock once a maximum of 70%
of extension has been reached (preferably between 30
and 40%) while long-stretch bandages should lock beyond 140%. However, extensibility cannot be translated into a clinical indication if the degree of elasticity
and rigidity of the bandage is not indicated at the same
time. In fact, there are bandages that can achieve similar extension when forces of very different intensity are
applied.
We therefore regard it as more appropriate to employ
the terms “elastic” and “non-elastic” to indicate bandages
with a highly elastic component (medium- and longstretch) and bandages with a reduced elastic component
(short- and medium-stretch). As can be observed in the
medium-stretch group of bandages (between 70% and
140%) we find bandages with a reduced elastic component
which should therefore be considered in the non-elastic
group, and bandages with a strong elastic component which
to all intents and purposes can be placed in the elastic
bandage categories.
The elastic bandage can therefore be classified as:
–– elastic bandage constructed with predominantly elastic
fibres in various combinations of weave, which when
extended exert pressure (at rest), which is proportional
to its elastic power (force utilised to extend it);
–– non-elastic bandage constructed with predominantly
non-elastic fibres in various combinations of weave,
which, by opposing muscle contraction during walking, cause an increase in (working) pressure, which is
proportional to its rigidity and indirectly proportional
to its extensibility.
Because of the invariability of the physical qualities
and because they are only partly subject to Laplace’s law, a
separate classification is warranted for the non-elastic inextensible bandage made with materials (e.g. zinc oxide bandages), which do not extend when subjected to stretching
(inextensibility) and do not have any tendency to regain
their original shape after being subjected to traction (nonelasticity). The differential between working pressure and
resting pressure (which is present especially if the bandage
is pulled) is very high. The resting pressure can be weak or
absent in the case of application without traction or high
if the bandage is applied exerting more or less firm traction; in the former case, this type of bandage is optimally
tolerated even in conditions of supine rest.
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14
COMPRESSION
In view of what has been stated, the bandage can be
classified in the following way:
–– Fixation bandages (cotton, foam, crepe, etc.);
–– Elastic bandages;
–– Rigid and inextensible (Zn oxide - Circ Aid®).
The elastic bandages in turn can be divided into:
–– bandages with elastic fibres:
•• medium-stretch;
•• long-stretch
both with light/medium/strong/extra strong elasticity;
–– bandages with a low elastic component:
•• medium-stretch;
•• short-stretch
classified on the basis of their stiffness (more or less
high).
A new classification of the bandages is named P-LA-CE (Pressure-Layers-Components-Elastic Properties) and
was proposed by a group of experts of the ICC (Partsch
H et al. 2008).
The non-elastic bandage exerts greater resting and
working pressures compared with elastic bandages and a
greater haemodynamic effect in terms of the reduction of
venous reflux, venous volume, venous calibre and venous
hypertension. In all of the venous diseases in the active
phase, characterised by severe haemodynamic damage,
the non-elastic bandage should be preferred to the elastic
bandage and applied in a manner that develops high resting and working pressures; since this has a marked effect
on the reduction of the oedema, it is removed more often
than recommended (1 week) in the initial treatment period, as the pressure exerted falls dramatically with the
reduction of the oedema. The elastic bandage or elastic
stocking is reserved for cases with mild haemodynamic
damage or following remission of the acute symptoms in
order to maintain the results and prevent recurrence.
Bandaging techniques
Elastic compression bandaging can be carried out with
different materials and different techniques, depending
on the disease, particular needs and the shape of the limb
or the site of the limb to be bandaged. The basic physical
characteristics that a bandage must have are graduation
and uniformity.
Elastic compression bandaging can be carried out using:
–– non-elastic and short-stretch bandages;
–– medium- and long-stretch bandages.
This is a fundamental distinction from the clinical aspect, as, depending on which group of bandages is used,
the bandage can be kept in place for several days (with
bandages of the first group) or the bandage has to be removed in the evening and replaced the following morning (bandages of the second group) because they are not
tolerated at rest.
As a general rule, the bandages of the first group are
used in more elderly patients, in more severe venous
insufficiency complicated by trophic disorders, and in
forms associated with obliterative peripheral arterial disease (mild or moderate). In each case, these are bandages
that are not easy to handle and they can be used only by
professionals with a degree of experience.
Conversely, the bandages of the second type are used
for less severe venous disease, to reduce oedema and for
compression of the superficial venous circulation.
As regards application of the bandage, this can be done
using different techniques, each with different indications. The bandage should be unrolled keeping the hand
close to the surface of the skin so as to avoid pulling it upwards or downwards and to avoid differences in tension,
which can cause areas of non-uniform pressure within the
same region.
The patient’s position, seated or lying, does not influence the placement of the bandage apart from the greater
or less comfort of application. The heel can be kept covered or uncovered according to whether it is desired to
allow the patient to walk correctly (maintenance of proprioceptive sensation on contact with the ground during a
step), or it may be necessary to reduce oedema involving
the retromalleolar fossae. In the case of bandaging as far
as the thigh, the knee joint must be kept free, except in
special cases. The most common techniques, of which numerous “personal” versions are possible, are:
–– Bandaging with regular turns;
–– Figure of eight bandaging;
–– Figure of eight bandaging fixed at the ankle;
–– Spontaneously unrolled bandage.
Described separately:
–– Multilayer bandaging.
Bandaging with regular turns (Fig. 4)
All of the techniques share the rule of unrolling the
bandage from inside to outside, that is, in the medialto-lateral direction. In practice, proceed anticlockwise for
bandaging the right limb and clockwise for the left limb.
Bandaging is started at the base of the toes and after
2-3 turns around the foot, it moves to the ankle and proceeds proximally ensuring that the turns overlap by 50%,
that is, the bandage is extended covering half of the turn
underneath.
When it has reached below the knee, the turn is finished and if there are a few leftover centimetres of band-
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The bandage
Fig. 4 – Hysteresis (short stretch bandage).
age, these are extended in a distal direction without exerting much traction.
Figure of eight bandaging (Fig. 5)
This is a version of the above: it starts at the base of the
toes in regular turns and proceeds proximally, crossing the
turns of the bandage from the dorsum of the foot or from
the ankle to below the knee in a figure of eight; the maximum pressure is obtained at the crossing points of the
turns; this type of bandage is more compressive than the
preceding one because it provides greater overlapping of
the turns of the bandage, and it is more stable over time.
When placing this bandage, it is important to ensure
that the crossing points of the bandage do not correspond
to the tibial crest as they could cause skin injury.
15
Fig. 6 – Figure of eight bandaging fixed at the ankle.
Spontaneously unrolled bandage (Fig. 7)
This bandage is indicated especially for diseases of the
calf as it exerts its maximum compression posteriorly;
starting at the base of the toes, a few turns are made and
the bandage moves to the lower border of the belly of the
calf muscle; at this point, it is rolled around the calf to
below the knee, then making a so-called fixation turn,
that is, a complete turn of the bandage below the knee. It
is then brought downwards again in regular turns so as to
cover the leg completely to above the ankle.
Fig. 7 – Spontaneously unrolled bandage.
Fig. 5 – Figure of eight bandaging.
Figure of eight bandaging
fixed at the ankle (Fig. 6)
In this case, starting at the ankle, one turn of the bandage is placed and it is continued distally on the foot, which
is covered as far as the base of the toes. It is then continued proximally again, back to the ankle; at this point, a
figure of eight turn is made and it is continued upwards
with regular turns. It is indicated especially in the treatment of venous ulcers exerting strong pressure just above
the ankle around the medial malleolus, where at least 5-6
turns of the bandage overlap in this case.
Multilayer bandaging
This is a system produced by Smith & Nephew (Profore®), comprising a kit of 4 bandages, produced for different ankle circumferences (18-25 cm and over 25 cm),
which are applied in a precise sequence, each one with a
different technique:
–– the first layer consists of a bandage of synthetic wadding (orthopaedic wool), which is applied in regular
turns overlapping 50% and covering the heel also;
–– the second layer consists of a non-stretch cotton crepe
bandage which fixes the first layer, and is applied in
regular turns with overlapping of 50%;
–– the third layer consists of a light long-stretch bandage,
which is placed using the figure of eight technique,
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16
COMPRESSION
stretching the bandage about 50% and following a
central yellow line which acts as a guide;
–– the fourth and last layer consists of a cohesive bandage, which is applied with regular turns with extension
of 50% and overlapping of 50%, which will produce
final compression at the ankle of 40-50 mmHg
This bandage, with its characteristics of optimal comfort and especially its exceptional ability to reduce marked
oedema, is particularly indicated in venous disease complicated by large ulcers, areas of hypodermitis resistant to other treatments and significant oedema and lymphoedema.
Multilayer bandages with different features are: Rosidal sys® (Lohmann & Rauscher) and Coban 2® (3 M).
“Handcrafted” multilayer bandages can be made,
provided that quality bandages are used and the general
bandaging rules are taken into account. The long-stretch
bandage must be placed above the rigid one if obtaining adequate pressures is desired. The cohesive bandage
is used to keep the bandage obtained thus in place better,
increase the pressure and provide uniformity to the compression system.
Technique of applying the bandage, defined
as “short elastic” according to Sigg (Fig. 8)
The bandaging of an entire limb must be carried out
with 3 short elastic bandages plus an underlayer of ETA
foam for the thigh. The short elastic bandages have a
length of 5 m under tension and come in different widths:
8 cm for the foot, 10 cm for the leg, and 10 or 12 cm
for the thigh. It is applied immediately after performing
sclerosis of any vein with the exception of telangiectasia,
where use of a therapeutic elastic stocking is permitted. It
is worn whenever the patient is standing in conjunction
with frequent walking, it is removed completely at night
and reapplied before rising from bed, even if this is for a
short time:
–– the foot is bandaged starting with an initial turn behind the base of the toes (these are bandaged only if
they are the site of oedema or ulcer). The tension must
be able to utilise all the elastic capacity of the fabric
so that after it is applied, it unrolls on its own if it is
not stopped; the pressure is correct when the fingers
take on a cyanotic hue which disappears after a dozen
footsteps. The foot is at a right angle relative to the leg
and this is at 90° to the thigh. This bandage wraps the
foot and ankle until it reaches the start of the calf, in
more overlapping turns until all of the bandage has
been used. In this way, every part of the foot is covered, in particular, with the bandage passing 4-8 times
around the ankle as otherwise this site would be compressed insufficiently.
–– from here the leg is bandaged as far as the popliteal
fossa with a second 10 cm bandage, unrolling it in
direct contact with the leg, thus creating the direction
of the bandage, and it is possible at each turn to pull
it with force. In this way, the edges of the bandage are
subject to identical tension and furrows are not created; the leg is covered following its anatomical shape,
with each part covered 4-5 times with figure of eight
turns. Particularly large legs require the use of a 12 cm
bandage.
Fig. 8 – Sigg bandage.
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The bandage
–– the thigh must be bandaged differently because of its
tapering shape. An ETA foam (foam rubber) bandage
12 or 15 cm wide is used, which adheres very well to
the skin though it is not adhesive. This is used to prevent the thigh bandage from slipping; it must be 3-4
mm thick as it tears if it is thinner. The foam rubber is
attached to the skin and ensures that the overlying 10
or 12 cm short elastic bandage remains in place even
if the shape of the thigh is very tapered. The bandage
starts immediately below the knee and continues to
the groin. The knee is enclosed by the bandage and
can move freely due to the foam rubber bandage without destabilising the efficacy of the compression in
this area. An adhesive bandage is required rarely, and
is intended only for phlebitic conditions necessitating further compression even in bed at night. In this
case, this bandage is cut at each turn and it is often
medical-lsod practice to place a protective “skin sparing” layer of foam because of the frequent reactions
with the adhesive. This bandage is usually employed
to keep hard-core pads in place following sclerosis of
the saphenofemoral junction, cutting it after a half
turn.
If the patient has been well instructed, he himself will
be able to apply it better than anyone else because he will
feel the compression force on his leg so that he will soon
be able to bandage like a healthcare professional. However, this bandage is inspected at every consultation to avoid
oedema, which is frequent at the foot, where the patient
is told to apply it with low tension. Any oedema present
is revealed and demonstrated to the patient, teaching him
how to detect pitting so that he will be better able to calibrate the tension of the bandage, and he is asked to reapply it several times a day when it loosens and slips, which
allows compressive grooves to form and thus oedema to
develop in the distal segment. If applied well, the bandage
is so adherent that it becomes troublesome and painful after 2-4 hours at night so it should be removed at bedtime
and reapplied in the morning. If this is not possible, the
bandage is applied a little more loosely, enabling it to be
worn at night also, until the patient is able to reapply it
correctly himself after a few days.
Eccentric compression
By modifying the radius of curvature of the part of
the limb to which it is applied, in the sense of an increase
(negative eccentric compression), or a reduction (positive eccentric compression), the aim is to reduce in the first case
or increase in the second the compression exerted by any
concentric compression (stocking or bandage).
Negative eccentric compression is generally used over
the dorsum of the foot, the Achilles tendon, the tibial
17
crest and tendons. It can be achieved with strips of foam
up to 4 mm thick or with cotton wool rolls (instep) and
prevents irritation of the skin and pain in subcutaneous
structures.
The aim of positive eccentric compression is to provide
a focal increase in compression; this can use various materials:
1. Gauze is used because of its breathable and anti-exudative capacity on areas of epidermis and eczema. Because of its low deformability, gauze is used by choice
when making circular compact pads 2-3 cm in diameter, which are placed over varicosities or reticular
veins and held in place for a day with hypoallergenic
adhesive plaster.
2. Another material is cotton wool in the form of pads
with a core:
•• soft, spherical pads 1 cm in diameter;
•• semirigid, cylindrical pads 1/5 cm in diameter
(dental), to be applied like a bridge between two
gauze pads;
•• rigid, the cotton wool covers a sheet of compacted
aluminium, rolled into various shapes, used for selective compression of escape points; they are held
in place for 7 days with half a turn of adhesive
bandage;
–– for perforating veins, hemispherical pads 2 cm
thick and circular in shape can be used over the
muscle perforators (calf muscle), or half-moon
over the retrotibial perforators;
–– cylindrical for the saphenofemoral junction, 4-5
cm in length but of various thickness:
•• thin, 2 cm, for the internal and external
saphenous in thin thighs;
•• medium, 3 cm, for the internal saphenous
and Hunter and Dodd perforators;
•• thick, 4 cm, for the internal saphenous of
large thighs.
The purpose of these pads is to reduce the radius of
curvature of the thigh and therefore make the compression more intensive, according to Laplace’s law.
3. Another important device for eccentric compression
consists of rubber or latex foam pads of various shapes. The physical characteristics of natural rubber described above make such wedges capable of increasing
even the resting pressure. In fact, with the increase in
limb volume that characterises muscle contraction, the
rubber, which cannot expand, is squeezed between the
skin and the rigid bandage and exerts a constant, elastic and soft pressure on the veins but increases the
compression force less than rigid pads. When the muscle relaxes, on the other hand, its re-expansion fills the
potential space between bandage and skin, preventing
blood stasis, in practice restoring force to the compres-
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18
COMPRESSION
sion of the bandage, which would otherwise be practically non-existent in this phase. This results in a direct
pumping effect on blood reflux.
Such devices are used widely in the treatment of all
stages of CVI, including venous ulcer, with the precaution of avoiding the rubber coming in direct contact with
affected skin, such as eczema, hypodermitis or white atrophy.
Recommendations
–– The bandaging should extend to the base of the toes, it
should be carried out from the inside to the outside of
the limb and maintain the characteristics of regularity and uniformity: the bandage should be applied at
constant tension, overlapping the turns by about 50%
of their width, thus avoiding areas of excess pressure
and local constriction.
–– Figure of eight bandaging fixed at the ankle
compresses the medial regions of the leg mainly and is
therefore indicated for venous disorders in that region
such as ulcers and hypodermitis.
–– The pressure exerted by the bandage and its efficacy, according to the material utilised, depend closely
on the tension to which the bandage is subjected, on
the number of overlapping turns and on the technique employed.
–– Multilayer bandaging is indicated particularly in
venous disorders complicated by large ulcers, areas of
hypodermitis resistant to other treatments, and significant oedema and lymphoedema, including indurated
oedema.
–– The static stiffness index (SSI) is the most important clinical index to choose the type of compression bandage.
–– Eccentric compression should be used when the radius to be compressed needs to be controlled, to protect
some areas from excessive pressure, to obtain effective
compression where the curvature of the skin surface
does not allow it or to increase the pressure where necessary.
–– Figure of eight bandaging remains in place longer
without altering and provides about 30-40% more
compression compared to one with regular turns.
–– The spontaneously unrolled bandage compresses
the calf mainly and is therefore indicated for venous
disorders in the posterior region of the leg.
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19
The elastic stocking
Definitions
boembolism stocking is a therapeutic elastic stocking tolerated at rest which guarantees a pressure of 18 mmHg
at the ankle (tolerance limits ± 3 mmHg); the pressure
profile along the lower limb must be graduated: in B1
80-100% of the pressure at the ankle (B), in C between
60-80% and in F or G between 40-70% (CEN 1998,
draft prEN 12719).
Therapeutic or medical compression stocking
(MCS) (Fig. 9). The therapeutic or medical compression
stocking (MCS) is a stocking made with materials and
methods according to the standards defined by the legislation in force (currently the German RAL-GZ 387, French
NFG 30-102B IFTH and English BS7505), which guarantees a defined and graduated pressure along the limb
between certain parameters, specified according to compression classes and available in different models and
sizes. The compression and compliance with the specified
manufacturing methods must be certified constantly by
independent national institutes. In clinical trials and in
world scientific literature the therapeutic elastic stocking
has demonstrated a certain efficacy in the prevention and
treatment of phlebolymphological disorders: it is a medical device in all its effects.
Elastic support stocking (Fig. 10). An elastic stocking that does not meet the standards, in whole or even in
part, but which can guarantee pressure in mmHg at the
ankle and/or other points of the lower limb, maintaining
a certain reduction in pressure from below to above is defined as an elastic support stocking.
Elastic stocking. All other types of stockings made
with elastic fibres, which state pressures in den (deniers)
or do not guarantee defined and graduated pressures are
defined simply as elastic stockings.
Antithromboembolism stocking. The antithrom-
The MCS must meet the manufacturing and quality
criteria defined by the German standard RAL-GZ 387
(Reichs Ausschuß für Lieferbedingungen, 23 April 1925;
Medical Compression Hosiery Quality Assurance, last revision September 2000), French NFG 30-102B (IFTH)
or English BS7505 adopted by European producers:
–– manufacture with circular looms (or linear for some
types of made-to-measure stockings);
–– production with materials of a quality and methods
defined in the standard;
–– graduated and uniform compression from below to
above;
–– declaration of the compression class in mmHg at the
ankle and along all the lower limb;
–– extensibility of the knit in both directions to facilitate
joint movement;
–– aerated fabric to allow evaporation and cutaneous
transpiration;
Fig. 9 – Medical compression stocking (MCS).
Fig. 10 – Support elastic stocking.
The characteristics of the medical
compression stocking (MCS)
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20
COMPRESSION
–– knitted heel to allow anatomical position of the ankle
and therefore the required compression in the specific
region of the leg;
–– perfect adaptability to the shape of the lower limb;
–– guarantee of the duration of compression for a period
of at least 4-6 months, depending on the type of threads used in manufacturing the stocking;
–– production and product expiry dates on the packaging
together with all the details needed for certifying traceability and the quality of the medical device;
–– inspection of the products with tests conducted constantly by independent authorised institutes.
The standards differ essentially only in the difference in
the compression range in the various therapeutic classes,
even if an attempt is being made to achieve uniformity
in Europe with compliance with the compression classes
specified by the CEN, which the RAL-GZ producers have
already adopted (Table III).
The stocking consists essentially of a transverse weft
thread which produces the compression. The weft thread
is made of natural rubber or elastane, a synonym of Spandex (Lycra®, Dorlastan®, Linel®), which is usually double
wrapped (guipage phase) with threads such as cotton,
polyamide (Nylon®) or microfibre polyamide so as to
fix the weft thread itself at a predetermined tension and
produce the physical and aesthetic characteristics of the
stocking. The knit through which the weft thread passes consists of elastic yarns, of lower strength compared
with the weft, usually woven with the method known as
crossed and locked knit.
In Italy there is still no standard in force, although
the UNI [Italian Standardisation Organisation] adopted
the experimental European standard (CEN/TC205 prEN12718-19) in January 2002, whereas in other European countries, therapeutic elastic supports are subject
to strict quality controls by the appointed organs (Forschungsinstitut Hohenstein in Germany, ITF in France,
EMPA in Switzerland, TNO in the Netherlands, Segar
Design in Great Britain) and are partially reimbursable by
the national health systems.
MCSs have different stiffness values depending on the
compression class and within the different classes according to the materials used for their manufacture (Wegen-
Franken K et al. 2006). The stiffness is a factor in the
compression characteristics of the stocking and also in the
duration of the compression. In brief, it can be stated that
a stocking with weft threads of natural rubber compresses
more and with higher working pressures than elastane
within the same therapeutic class, and it also maintains
this pressure better (the pressure falls at the end of the day
by about 7-8% compared with the morning, whereas the
decrease is about 15% for elastane).
The efficacy of “support” stockings, defined with the
incorrect term “preventive” (up to 18 mmHg), which do
not have the weft thread but are produced only with a
knit fabric (usually of Nylon® fibre), is controversial, like
that of support stockings that state the pressure in “deniers” (den). The denier is a unit of measurement of the
weight of synthetic threads and its specific value is 1 denier = weight in grams of 9 Km of thread.
The producers of MCS propose different compression classes to be prescribed according to the severity of
the phlebolymphological disease, together with the socalled “antithromboembolism” stocking (18 mmHg at
the ankle, 8 at the thigh), which is distinguished from the
other models because it should be worn at rest to prevent
thromboembolic episodes.
The use of the antithromboembolism stocking can be
extended to post-thrombophlebitic patients to provide
prophylactic compression at rest to prevent recurrence
and to patients who have had varicose vein surgery in
the days following the operation, in combination with an
elastic support to be worn during daytime activity.
A relatively recent use of elastic stockings as a replacement for the medicated adhesive bandage (non-stretch
or short-stretch) is the one described by Mariani F et al.
(Phlebologie 2008) in the treatment of venous ulcers of
small-medium dimensions; once the large oedema has reduced (if it is present), wearing a kit of stockings (Ulcer
X® Sigvaris®) constantly over a suitable medicated dressing
is indicated.
MCS is useful in prevention and in maintaining the
results obtained; the adhesive bandage (rigid or shortstretch) should be used in the “active” treatment of oedema and complications. The elastic bandage is certainly the
most suitable for reducing soft reversible oedema in the
absence of trophic skin changes, but has the disadvan-
Table III – Compression classes at the ankle point B (mmHg). European standards.
Class
RAL-GZ 387
AFNOR G 30.12
BS 6612:1985
1a
18-21
10-15
14-17
2a
23-32
15-20
18-24
3a
34-46
20-36
25-35
4a
>49
>36
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The elastic stocking
tage of having to be removed daily with all the subsequent
technically difficulties of reapplying it. The choice of medium- and long-stretch bandages is determined greatly
by whether the patient has ready access to staff skilled in
bandaging techniques.
Prescription of a therapeutic elastic stocking is of great
importance, both because of the choice of compression
classes and because of the size and type of support. In
general, the practical rules are as follows:
–– the compression class should be suitable for the disease
(see table at the end of this document);
–– the choice of stocking model (below-knee, thigh length, tights or single-leg tights) must take into account
the clinical needs (extent of the disease and site of any
therapeutic intervention) and patient compliance, bearing in mind that the effects of the compression will
be exercised substantially on the leg;
–– the circumferences of the limb should be taken accurately, bearing in mind that an elastic support of the
wrong size will exert pressures different from those
desired and not graduated, thus impugning the efficacy and tolerability of the compression therapy;
there should therefore be no hesitation to prescribe a
custom-made stocking if the dimensions of the limb
do not correspond to the available sizes; these are available today with the same methods of manufacture as
standard stockings.
Quality marks
The marks attached to the products have various
meanings and values. There are obligatory marks; in Europe, the only mark of this type is the
mark, which
indicates that the product meets the safety requirements
laid down by specific community directives.
The
mark is found on many categories of products
and is also present on medical stocking packaging; it is a
kind of passport that allows the medical-lsods to circulate
freely within the European Community. However, it has
a limitation, which is due to the lack of an external body
to certify it, in other words, it is self-certification by the
producer, supported by technical documentation, which
states that the product complies with the requirements. It
is therefore a basic guarantee, a safety mark, but it does
21
not assure the actual qualities of the specific product.
In some cases, the SQS mark, which refers to a specific
mark. Then
certifying body, is combined with the
there are voluntary marks, accredited by governments or
by a third organ recognised by the national government.
In this case, it is the producers who voluntarily ask external certification bodies to inspect their product and
declare that it complies with specific requirements. The
best known is ISO 9002. The international ISO 9000
standards define the quality standards associated with industrial production processes. This type of certification
guarantees the production system but is not a guarantee
of greater product quality.
As regards medical stockings, the most widespread
mark is the RAL-GZ 387 mark (Fig. 11), which is issued
by independent certifying bodies (Hohenstein in Germany); these guarantee the quality of the threads utilised
in addition to compliance of the declared pressure values
with the standard. This is necessary if the medical stocking is to be reimbursed by the national health systems of
these countries. The standards also specify that medical
stockings must carry the Öko-Tex standard 100 mark or
an equivalent (class II product in contact with the skin),
which certifies that the fabric does not contain substances
that are harmful or irritant to the skin. In Italy there are
no precise standards in force, so that when choosing a
medical device such as a therapeutic elastic stocking (according to the Universal Medical Device Nomenclature
System, UMDNS, medical stockings are identified with
the number 13-789) it is important to confirm the presence
of one of the cited quality marks (RAL-GZ 387, IFTH,
BS7505), to protect the medical prescription and the patients.
Fig. 11 – RAL-GZ mark.
20-05-2009 14:33:36
22
Intermittent pneumatic compression
Pneumatic compression (IPC) systems differ in the
number and superimposition of the segments constituting the boot and armlet and in the determination of
the inflation sequences. A distinction is made between
equipment that exerts intermittent compression, first
produced in the 1950s, consisting of a sleeve with a single chamber that inflates and deflates alternately; peristaltic (presence of more aligned chambers that deliver
compression one at a time); sequential (the chambers are
multiple, overlapping each other, inflated sequentially
and deflated at the same time); plantar pneumatic (PPC).
There is no definitive proof in the literature of the superiority of one or the other system but it is considered
that the action exerted should be as physiological as possible. According to this criterion, the best compression
therapy appears to be the sequential one as the squeezing
of the fluid takes place in the physiological distal-proximal direction without causing reflux as the chambers are
inflated sequentially one after the other, remaining inflated until they all decompress simultaneously; moreover, the cycle times are rapid (about 30 sec) so they allow
a greater number of cycles in the same period of time
(about 60 in 30 minutes with 20 effective minutes of
treatment). However, it is advisable not to exceed pressures of 40-60 mmHg and to intersperse the sessions
with application of a bandage when significant oedema
has to be reduced, changing then to an elastic support of
a suitable compression class in the maintenance phase.
A sequential compression device (SCD Response® TycoKendall) has been introduced recently in clinical use for
VTE prophylaxis; this allows personalised intermittent
compression cycles, obtained by an automatic analysis of
venous refilling of the plethysmographic type. The pressure exerted by the three-chamber and six-compartment
boot is 45 mmHg at the ankle, 40 mmHg at the calf and
30 at thigh level.
Pneumatic compression has a grade 1A recommendation level (grading of Guyatt G et al., CHEST 2006)
in the prophylaxis of venous thromboembolism and 1B
in the treatment of lymphoedema and the venous postthrombotic syndrome.
The contraindications are represented essentially by
cardiac failure, which can be markedly exacerbated in a
short time because of the rapid major movement of the
blood mass towards the right heart and the extrinsic compressions on veins. Obstructive arterial disease does not
appear to be an absolute contraindication to the treatment, since there are articles in the literature which even
demonstrate an improvement of peripheral perfusion after low pressure PC: the emptying of the veins induces a
reduction in the flow resistance (reduction in the arteryvein gradient), the increased shear stress produces vasodilator biological effects and the reduction in the oedema
improves capillary flow (Labropulos N et al. 2002).
20-05-2009 14:33:36
23
Techniques of measuring compression in vivo
Measurement in vivo of the pressure exerted by the
different compression methods has always been a subject
of great interest for all who study compression therapy
in phlebolymphology. It can be performed with various
systems, which have developed from those of the past,
such as Van Der Molen’s tonometer (1955), the Sigg
Tester (1964) or that of Haid (1970), to today’s devices,
which are accurate, reliable and repeatable (Table IV).
Measurement of the pressures defined as interface pressure
with numerous sensors and devices can provide a whole
range of information that is extremely useful for the study
of the compression effects of various materials, such as
the resting and working pressures, stiffness (static stiffness
index by Partsch H), and the pressure exerted according to
the stocking, bandage or bandaging technique utilised, so
that compression methods can be classified according to
their actual clinical activity. It can also be highly useful
for learning bandaging technique, measuring in real time
the pressure exerted at various points in the limb. Many
modern measurement systems are available and none has
been shown to be superior to the others. However, it is
advisable that they should meet a few basic principles if
they are to provide reliable and repeatable results:
–– the system should provide measurement continuously
during rest and movement;
–– calibration of the sensors in contact with the compressed surface should be simple and repeatable at each
measurement;
–– the sensor should have a maximum thickness of 0.5
mm (Ferguson-Pell model) and be flexible but not distensible and be readily adaptable to different surfaces;
–– the sensor should be insensitive to variations in temperature and humidity;
–– the response to variations in pressure should be linear;
–– the optimal sensitivity is <0.1 sec, <0.1 mmHg;
–– the sensor should be durable and made of materials
that can remain in contact with the skin even for long
periods without causing irritation.
The points for measuring pressures on the lower limb
should be standardised according to the following anatomically regions:
–– B, at the smallest circumference of the ankle;
–– B1, at the circumference where the Achilles tendon
meets the inferior tip of the calf muscle (about 10-15
cm proximal to the medial malleolus);
–– C, at the greatest circumference of the calf;
–– D, just below the tibial tuberosity;
–– F, halfway up the thigh, between the midpoint of the
inguinal crease and the tibial tuberosity;
–– G, at the maximum circumference of the thigh, about
5 cm below the inguinal crease.
Point B, as a reference for the manufacturers of elastic stockings, is the point of main choice in the measurements because there is usually no irregularity of the radius
and it is a reliable index of the pressure exerted, together
Table IV – Devices for measuring interface pressure.
Pneumatic, pneumatic electric or piezoelectric systems
Kikuhime (Meditrade-Denmark)
MST MKIII Salzmann (Salzmann Medico-Switzerland)
Juzo Tester (Elcat-Germany)
Oxford Pressure Monitor
Talley Pressure Evaluator (Talley Ltd.-UK)
PicoPress (Microlab, Italy)
SIGaT Tester (Blazek device-Ganzoni Sigvaris-Switzerland)
Piezoelectric systems
MCDM-I (Mammendorfer Inst. Physik, Munich-Germany)
Strain gauge systems, resistive
Diastron (Diastron Ltd.-UK)
Fontanometer (Gaeltec Ltd.-Scotland)
Fscan, Iscan (Tekscan-USA)
FSR, FSA (Vista Medical-Canada)
MCDM (Mammendorfer Inst. Physik, Munich-Germany)
Rincoe SFS (Rincoe and Associates-USA)
20-05-2009 14:33:36
24
COMPRESSION
with points C and D. Partsch H et al. (2006) also propose
point B1 as a reference parameter for the measurements
since the maximum increase in circumference during
movement and passage from the supine to the erect position occurs in this area.
The interface pressure can be recorded with the patient
lying and standing, during plantar and dorsiflexion,
during tip-toeing movement or walking (for example
the treadmill test). Recording of these data with digital
equipment (computers) is recommended, as is recording
of pressor profiles, which should be produced from multiple simultaneous measurements at different points on the
lower limb. Recording of the pressor data should include
at least the resting pressure lying and standing, the systolic
and diastolic working pressure, the circumference where
the pressure is measured and the measurement points,
the times of application of compression and recording,
and the ambient temperature. Calibration of the sensor
should be accurate and the measurement method should
be standardised.
20-05-2009 14:33:36
25
Compression therapy and ceap classification
CEAP “0”
Equivalent to the stage at which there are no visible or
palpable clinical signs of venous disease.
This stage comprises all the conditions where there are
symptoms compatible with functional or early venous insufficiency (Bassi G).
These are often borderline conditions that are difficult
to classify and are more often identified by the symptoms
than by a precise clinical sign. The most important of
these conditions is hypotonic phlebopathy, a term attributed to Andreozzi GM and his school. In practical terms,
this consists of typical varicose symptoms without varicose
veins: a feeling of heaviness in the upright position (68%),
a feeling of discomfort or actual paraesthesias in the upright position (12%), restless legs (8%), and mild evening
oedema (9%) which recedes fully with bed rest. As mentioned above, there is no evidence of varicose veins; the
most important measurable signs are relative insufficiency
of the venous muscle pump and an increase in the distensibility of the vein wall as assessed with plethysmography,
LRR (light reflex reography) and duplex ultrasound. In
essence, in hypotonic phlebopathy there is hypotonia of
the vein wall which translates into a reduction in the tonic
reaction of the wall to a pressure load and thus to reduced
efficiency of the normal orthodynamic decrease (vasomotor venous reflex).
This varied group of so-called constitutional disorders
also includes the panniculopathies and so-called occupational venule hypertension, which are associated only with
prolonged standing and which probably, in the majority
of cases, belong with hypotonic phlebopathy.
Is elastic compression indicated in these forms? When
the pathophysiology of the disorder is considered, elastic compression therapy certainly appears rational but
studies published hitherto have not provided definitive
results. Since these are functional, or more accurately, microcirculatory disorders, the use of so-called therapeutic
compression cannot be proposed readily. Usually, in clinical practice, support stockings are chosen, which are also
incorrectly called preventive; we use the former term as no
preventive action on the development of the venous insufficiency has been demonstrated but only on the onset
of the symptoms. These are light stockings very similar to
ordinary ones and relatively low in cost. The compression
is graduated in mmHg: 10-14 mmHg and 15-18 mmHg.
They guarantee compression, however limited, only at
ankle level which decreases rapidly as the limb circumference increases (Laplace’s law) and is therefore insufficient
to counterbalance the altered interstitial pressures. A further limitation is the availability of standard sizes only,
similar to those of fashion stockings, which adapt because
of their elasticity but which do not conform precisely to
the different dimensions of the patients.
The main indications for using these stockings are:
–– “tired” legs due to working for many hours while standing without an opportunity for adequate mobilisation;
–– moderate oedema which is found in the premenstrual
period or in the evening;
–– “restless legs” syndrome;
–– alternating for a few hours a day with treatment stockings, especially when the aesthetic appearance is particularly affected;
–– placed over MCS to improve their appearance and increase their efficacy, even if only minimally.
Since the majority of the above-listed indications are not
always of purely phlebopathic origin, we can say that these
stockings are symptomatic, that is, they allow an improvement or disappearance of some disorders so they have been
shown to have an action on the symptom but do not have a
preventive effect on the development of the phlebopathy.
According to Vayssairat M et al. (2000) compression
with stockings of 10-15 mmHg (1st class of compression
- French standard) at the ankle produces a significant
improvement of quality of life (reduction in subjective
symptoms) and a reduction of the orthostatic oedema;
the study by Benigni JP and Vin F (2003) confirmed the
efficacy of support stockings with compression of 10-15
mmHg on the typical symptoms of the early phases of
venous insufficiency. Accordingly, we would agree with
some Italian authors (Arpaia G, Mariani F) and with the
CIF guidelines (Italian College of Phlebology 2003-2004)
according to which the use of compression less than 18
mmHg has not been fully codified. It is probably reserved
for patients without varicose veins who have a family history of varicose veins and/or whose work involves pro-
20-05-2009 14:33:36
26
COMPRESSION
longed standing. However, even for these indications, it
is necessary, according to the literature, to prescribe compression at the ankle of at least 10-12 mmHg, always with
stocking of optimal manufacturing quality (CIF 2004
guidelines, grade B recommendation).
CEAP “1”
In this stage, apart from the symptoms of chronic venous insufficiency, there are telangiectasias and reticular
varicose veins. The telangiectasias are small distal veins
(maximum calibre about 1 mm) located in the superficial
dermis, which can appear in isolation, that is, without
obvious varicose veins, or in association with definite
varicose veins. These are very common alterations, especially in women, generally asymptomatic but possible accompanied by localised or diffuse pain in the involved
region they usually have a branching appearance, or else
have the form of a star, spider, reticulum, etc. Reticular
varicose veins are small-calibre veins that usually spread
out in a reticular pattern but which can give rise to complex branching; they have a blue or greenish tinge and
occur predominantly in women. They are usually superficial (between the skin and subcutaneous tissue), they
are fed by incompetent perforating veins, they increase
in number because they multiply at escape points, and
they are nearly always bilateral (Bassi G). They are often
associated with telangiectatic branching. It is well known
that the treatment of these two forms of varicose veins is
sclerotherapy.
Elastic compression is certainly indicated as the presence of clinically apparent ectatic veins necessitates an
increase in the levels of compression (Choucair M et al.
1998) in order to halt progression of these varicose veins,
though it should be accepted that compression is not able
to produce regression of these veins in any way.
However, it should be stated that telangiectasias, with
a calibre less than 1 mm, are not easily compressed by
either resting or working pressure; on the other hand,
reticular varicose veins are compressible only if they are
surrounded by elastic subcutaneous tissue, whereas this
is not easy if they are surrounded by indurated oedema
(Partsch H et al. 2004).
The elastic stockings recommended in this situation
are usually MCS 1st class (from 18 to 21 mmHg at the
ankle, German standard), which ensure adequate compression of the superficial veins; since the reticular veins
are present particularly in the thigh, tights are usually prescribed. For stage C1, 140 denier or even 70 denier stockings are frequently prescribed; as mentioned above, these
do not exert an effective compressive action, but they are
certainly better accepted by the patients, usually women
who are still young, who do not tolerate the idea of wear-
ing stockings with greater compression which are often
unpopular from the aesthetic aspect; it is the duty of the
specialist to explain the need to use a stocking with correct compression, choosing a design of attractive appearance where possible. In the study by Benigni JP and Vin
F (2003) referred to above, patients with C1-C3, S, Ep As
1-5 were subdivided into two groups; the first group wore
so-called support stockings and the second wore MCS 1st
class. On follow-up after 15 and 30 days, the second group
had an appreciable improvement in pain, heaviness and
paraesthesias. The conclusion, though based only on the
clinical result, was that compression of at least 18 mmHg
at the ankle with a MCS 1st class is clearly superior to support stockings. The purpose of the elastic compression in
this study was to minimise the symptoms of VCI in the
form of heaviness, evening oedema or, as will be stated by
others, to consolidate the results of sclerotherapy. In any
case, according to the CIF guidelines (Italian College of
Phlebology 2003-2004), it is not possible, based on the
results in the literature, to recommend chronic use of elastic compression for these manifestations of VCI (grade C
recommendation).
It can be concluded that treatment of stages C0-C1 is
practically identical.
CEAP “2”
This is the stage of large varicose veins. The truncal
varicose veins develop in the territory of the long saphenous vein, short saphenous vein or both; it is important
always to assess the saphenofemoral and saphenopopliteal
junctions; the location of the varicose veins is usually
along the course of the long saphenous vein with a variable extension from the saphenofemoral junction as far as
the medial malleolus. Varicose veins of the main collateral branches of the long saphenous and short saphenous
veins are also frequent.
Elastic compression is a fundamental element in the
treatment of these varicose veins.
We shall therefore consider the type of elastic compression that should be prescribed in stage C2. The aim of the
treatment is to oppose further dilatation of the superficial
veins and thus slow down the extension of the varicose
process. Elective treatment of superficial venous insufficiency is active in type (surgery and sclerotherapy); for
instance, the incompetent “cross” (saphenofemoral junction) is the most important reflux point, and eliminating
this is fundamental for the success of treatment; this is a
site that is difficult to compress because of the inguinal
crease; in any case, adequate compression of the dilated
saphenous vein as far as the thigh will be fundamental. In
asymptomatic (C2 A) varicose veins, compression therapy
is usually recommended to prevent complications, while
20-05-2009 14:33:37
with symptomatic varicose veins (C2 S) the aim of compression is to reduce the symptoms, that is, to improve
the quality of life of these patients. When the varicosities
are not extensive and there is no significant oedema, 1st
class (German standard) compression can be prescribed.
With particularly extensive varicose veins, insufficiency
of large trunks and major collaterals, often accompanied
by oedema, 2nd class is prescribed. However, it should
be borne in mind that from the haemodynamic aspect, the
legging is sufficient for obtaining the necessary treatment effects.
The problem of the type of compression to use and the
pressure that should be applied correlates with the pressure level that must be counterbalanced not only in the
leg but also in the thigh; this obviously determines the
type of elastic stocking that should be used. In fact, this
choice will correlate with the involved region (superficial,
deep, perforating) and level (ankle, middle third of the
leg, entire leg, thigh). Depending on the classical conception (Stemmer R, Bassi G et al.), early or post-thrombotic
venous insufficiency requires firmer compression, the
greater the venous hypertension and, on the clinical level,
the greater the tendency to oedema; in general, the MCS
should provide the greatest possible level of compression
if there is deep reflux, if the saphenous veins are dilated,
and if the medial perforators of the leg and thigh are incompetent; in obese patients who frequently have particular adiposity of the lower limbs, which aggravates the
venous insufficiency, the compression should be greater
compared with a patient with a normal or reduced subcutaneous fat layer. On the other hand, excessive compression, apart from absolute contraindications, can have
repercussions on the microcirculation, which does not
tolerate major pressure variations (Allegra C).
Returning to the so-called essential varicose veins, we
know that the ideal treatment is surgery and/ or sclerotherapy; the role of compression is to maintain the results
obtained with the other techniques and to prevent or
minimise the microcirculatory compromise that is always
associated with venous hypertension.
From what has been said, stage C2 usually requires 2nd
compression class; a change to 1st class should be linked to
precise clinical and instrumental assessment and patient
compliance.
In conclusion: elastic compression is recommended with
a level of compression at the ankle greater than 18 mmHg
(CIF 2004 guidelines, grade B recommendation).
CEAP “3”
The oedema in the C3 classification is defined as a
perceptible increase in the volume of fluid in the subcutaneous tissue identified by the formation of an imprint
27
on pressure; it is usually apparent in the perimalleolar region but can extend to the foot and leg. It is the result
of complex interactions involving the capillary wall and
the hydrostatic and oncotic pressure gradients between
the blood vessels and the surrounding tissue. This situation is produced by various causes of both vascular and
extravascular origin so there are numerous classifications
in the literature. Venous oedema is regarded as a symptom which is now generally accepted and supported as
an indication for elastic compression, both from the scientific aspect and especially from the practical aspect, as
confirmed frequently both subjectively and objectively.
The effect of compression therapy consists basically of a
reduction in the volume of the limb with a consequent
improvement of the patient’s symptoms and quality of
life (QoL), which, as is well known, represents a factor
of great importance in the assessment of any medical
treatment. Oedema is a very common complication of
chronic venous insufficiency from the early stages until it
characterises the clinical picture of the post-thrombotic
syndrome. According to what is suggested by Starling’s
equation, external application of compression produces
an increase in local tissue pressure, reducing the loss of
capillary fluid and in this way promoting the reabsorption
of the fluid into the veins and lymphatics.
Compression speeds the blood flow at the microcirculatory level and promotes the detachment of leukocytes
from the endothelium, preventing their further adhesion.
Capillary filtration is greatly reduced and reabsorption is
promoted due to the greater tissue pressure. It also has an
action on the mediators that take part in the local inflammatory response, in this way causing the immediate relief
of symptoms that is obtained with adequate elastic compression therapy. As regards the effect of elastic compression on lymphoedema, its efficacy should be explained by
the action of reducing the lymphatic fluid in the tissues
rather than by an improvement of lymph transport. According to Földi M, venous oedema is always so greatly
linked to coinvolvement of the lymphatic system that the
term venolymphatic oedema is used more and more often.
This concept is important in that, regardless of the different causes that may produce it, the pathophysiological
damage is the same, and in consequence, the therapeutic
approach should be uniform and directed at the disappearance or at least reduction of the fluid at interstitial
level. Apart from the more well-known causes of venolymphatic oedema of the lower limbs, we can consider various situations that do not have a direct vascular cause but
that undoubtedly involve the vascular system indirectly.
Consequently, it may be considered useful to classify as
C3 various conditions that cause oedema of the lower
limbs, ranging from the post-thrombotic syndrome to angiodysplasia, from chronic venous insufficiency to post-trau-
20-05-2009 14:33:37
28
COMPRESSION
matic oedema, and also include causes that are sometimes
overlooked, such as the oedema described in the so-called
economic class syndrome; the oedema present in occupational phlebopathy characterised by prolonged standing
for many hours during the day, often combined with high
environmental temperatures; the oedema present in all
situations of altered plantar loading because of congenital or acquired deformities of the plantar surface; oedema
due to defects of the muscle pump.
Oedema in the economic class syndrome
(prolonged sitting position syndrome)
The oedema that occurs in this situation is quite frequent and not necessarily linked with deep vein thrombosis. In fact, it would be better to speak of “jet flight leg”
to indicate oedema of the lower limbs due to low pressure
at high altitude. Acute postural venous stasis can be manifested on the occasion of long journeys by car or coach
in patients who already have venous disease or have predisposing risk factors such as age, obesity, and popliteal
cysts compressing the venous axis. A prolonged sitting
position in close spaces with compression of the popliteal
and femoral vein plays a fundamental part in the genesis of the venous stasis; further promoting environmental factors, especially associated with pressurised airplane
cabins, can cause a reduction in fibrinolytic activity and
significant activation of the coagulation cascade. Elastic
support stockings or MCS 1st class are usually sufficient in
the absence of concomitant venous disease.
Occupational phlebopathy-oedema
due to a prolonged standing position
for occupational reasons
Among the various risk factors for venous disease, prolonged standing is a fairly frequent condition, especially in
certain occupational categories. Nowadays, if the prolongation of working life due to postponement of retirement
age, the prolongation of the average lifespan and consequent ageing of the working population are taken into account, it is considered that such occupational pathology
will be found more and more. Early retirement, the costs
of diagnostic investigations and the costs associated with
medical and surgical treatment represent high economic
commitments because of the high incidence of disease and
temporary inability to work. In order to have a crucial influence on the improvement in the quality of life in the
workplace and to reduce the social costs, tight prevention
is important to eliminate occupational and general risk factors, with early diagnosis and targeted treatment including
the elastic compression type. In this regard, it should be
recalled that in the context of the CEAP classification, assessment is made using a suitable invalidity score, which is
subdivided into 4 classes: 0 asymptomatic, 1 symptomatic
but can lead a normal life without compression, 2 able to
work eight hours a day only with compression, 3 unable
to work even with compression. Elastic support stockings or
MCS 1st class, in the absence of venous insufficiency, are
adequate for preventing evening oedema.
Oedema due to a defect of
muscle pump function
In changing from a horizontal to a vertical position, the
main centrifugal factor that comes into action is the force
of gravity, against which the human body opposes walking
to facilitate the return of blood to the heart. In the dynamics of walking, the movement makes the structures close
to the veins act on the veins, behaving like true pumps.
These are called pushing and aspiration pumps. The components of the pumps are subdivided into venous, primary
and secondary. The venous components are those in direct
anatomical contact with the structure that compresses,
the primary are represented by muscle, tendon and joint
structures, and the secondary by bone structures.
The pumps are located at different points and are activated by both walking and respiration. The walking
pumps are the plantar, the peroneal hallux muscle, the tibiotalar articular pump, the calf muscles, the popliteal articular pump and the quadriceps muscle. The abdominal
pump is activated by respiration. The plantar pump consists of various components (venous muscular, tendon,
aponeurotic, osteo-articular). The venous plantar pump
consists of a superficial plantar system and a deep one, the
superficial and deep plantar veins. The alterations of function of the plantar pump are due to anatomical structural
alterations of the plantar veins, static alterations of the
plantar support and dynamic alterations that produce a
limping gait, and alterations of the functional ejectors of
the plantar pump. Alterations of the abdominal pump are
produced by extrinsic pathological compression at crural
level, at the level of the left iliac vein and at the level of the
caval ring. From all of this, it is clear that it is essential to
maintain the integrity of the complex system of pumps in
order to guarantee correct venous return to the heart and
exclude the insidious complication of peripheral venous
stasis. Compression therapy, as demonstrated by Brizzio
EO et al. (1994), has better effects if combined with correct plantar support.
An immobile sitting position, for example in a motorcycle sidecar, aggravates physiological venous stasis with
the development of soft bilateral oedema originating distally and involving all of the leg in the course of the day.
Compression therefore has a preventive function on the
development of the oedema. MCS of 1st - 2nd class are usually employed, depending on the severity of the condition
and the patient’s tolerance, recalling that in such patients
the assistance of mobilisation cannot be counted on.
20-05-2009 14:33:37
Post-traumatic oedema
Post-traumatic oedema is included among the indications for elastic compression therapy since phlebographic
investigations have demonstrated co-involvement of the
venous and lymphatic areas. These investigations confirmed that persistent oedema after fractures generally
follows a previous unobserved venous thrombosis. Lymphographic investigations have demonstrated that even
minor trauma such as tibiotarsal sprains can cause lymphatic stasis and consequent oedema. It should also be recalled that for therapeutic purposes, plaster casts or semimobile splints are often used, which cause further venous
stasis combined with poor mobilisation. The compression
to use in these cases is 1st-2nd class, once the oedema has
been reduced with bandages.
Oedema in angiodysplasia
Oedema in angiodysplasia involving the vein side requires obligatory use of elastic compression, especially
if arteriovenous fistulas with venous dysplasia and lymphangiodysplasia are considered. Elastic compression
slows the development of the disease, preventing trophic
disorders and improving lymphatic function. The compression classes to use, depending on the type and nature
of the disorder, are 2nd-3rd-4th.
Concluding this brief examination of venolymphatic
oedema, it is evident that elastic compression is indicated for various different conditions; the literature in
this regard is somewhat meagre; referring to the study by
Partsch H (VASA 2004), we can say that stage C3 can in
general be treated with 1st-2nd compression classes, preceded
by medium-stretch bandages, for the reduction of soft,
non-reversible oedema during rest or indurated oedema.
In this regard, it is well known that the medium-stretch
bandage is the most effective in reducing soft oedema,
especially when there are no trophic lesions of the skin;
the main disadvantage is the need for daily removal and
reapplication, which requires the presence of staff who are
experienced in bandaging. Elastic compression therapy of
oedema differs according to whether it is reversible or irreversible. In the irreversible form of oedema, as in advanced forms of varicosis or angiodysplasia, use of a shortstretch bandage and MCS 2nd or 3rd class is indicated.
CEAP “4-6”
Compression and CEAP 4 and 5
Review of the literature shows that there is no study of
the efficacy of bandaging in class 4a; there is only a grade
C recommendation based on expert agreement.
In class 4b there is one study of MCS of 3rd class compression vs. non-compression and one of non-elastic
29
compression, which show a reduction in the area of lipodermatosclerosis and in ulcer recurrence (grade 1B evidence).
In class 5 (healed ulcers) the MCS with at least 30
mmHg at the ankle is essential for maintaining the result and preventing recurrence (grade 1B evidence). The
greater the degree of compression, the lower the incidence
of recurrence so that the maximum elastic compression
that the patient can tolerate should be prescribed.
It is necessary to stress that there are no studies comparing elastic stockings with elastic or non-elastic bandages for the condition of acute lipodermatosclerosis for
which the latter appears superior to a stocking alone.
Compression and CEAP 6
Compression is better than no compression:
–– High compression is better than light compression
(great attention should be paid to arterial and mixed
ulcers with significant arterial compromise; the W.I.
must be >0.8; trained staff can also apply the bandage
with a W.I. between 0.55 and 0.8);
–– Multilayer systems are preferable to single-layer systems as they are able to exert greater pressure, confer
greater rigidity on the bandage, and absorb exudate
better with the protective layers (cotton or polyurethane foam);
–– The efficacy of the bandage in patients with venous
stasis ulcers has been conclusively demonstrated with a
grade 1a level of evidence;
–– There is no agreement on the efficacy of different types
of compression; the lack of randomised controlled
studies requires a pragmatic approach and the recommendations in this field are based on the opinion of
experts.
In short, the type of compression in CEAP class 6 remains controversial: the German school prefers the nonelastic bandage whereas the English school prefers the
elastic bandage.
There are also studies comparing the two types of
bandage which demonstrate substantially similar efficacy
of the two bandages or superiority of the elastic bandage.
These studies have some methodological defects:
–– the ulcers considered are very small (often <10 cm2);
–– the pathogenesis and severity of the venous insufficiency are not indicated;
–– known risk factors for healing are not indicated, such
as the size and age of the ulcers and the patient’s mobility;
–– the pressure with which the bandage is applied is not
known nor whether the selected staff was equally skilled
in applying the two types of bandage, if the bandaging
technique for the different bandage types was equally
20-05-2009 14:33:37
30
COMPRESSION
known and therefore whether the compression was always applied in an optimal manner.
Other common and universally accepted recommendations are that the bandage should guarantee maintenance
of effective pressure over time (at least 1 week), guarantee
similar pressure in all patients (reproducibility), be easy to
apply and lack side effects as far as possible.
Reusability should be considered in relation to economy of treatment; in this case, maintenance of bandage
quality after repeated washing should be guaranteed.
The MCS 2nd class in natural rubber can be used successfully in the treatment of venous ulcers of limited size
based on the most recent randomised studies (Mariani
F et al. 2008), with an improvement to grade 1A recommendation level (grading of Guyatt G et al. CHEST
2006). The cited study shows the efficacy of stockings for
ulcers up to 8 cm in diameter, provided a kit composed
by an understocking with at least 18 mmHg compression
at the ankle to wear day and night over the dressing of the
ulcer, and a MCS of 2nd class to put over during the day
(Ulcer X® - Sigvaris®).
Compression therapy: guide to the
treatment of venous ulcers
Despite the fact that compression therapy has always
been used successfully in the healing of venous ulcers, the
optimal procedure for carrying out this treatment is still
not available today. Compression plays a central role in
the treatment of venous ulcers. The factors to consider
prior to applying it are: accurate diagnosis (the pathogenesis of the ulcer is a determining factor in the choice of
treatment), the presence of contraindications (obstructive
arterial disease, severe cardiac failure etc.) and any complications (infection, hypodermitis etc.); the patient’s ability to walk; the anatomical shape of the limb (for reasons
explained above); the condition of the skin (fragile skin
or areas of white atrophy can be damaged by excessive
pressure). The majority of controlled randomised studies
show that compression on its own facilitates the healing
of venous ulcers (grade 1A recommendation, according
to the grading of Guyatt G et al., CHEST 2006), but
defining the best compression and the relative cost effectiveness is more complex.
Firm compression (35-45 mmHg at the ankle) seems
to be more effective than less intense compression (15-25
mmHg at the ankle) and multilayer bandages have proven more effective than single- or two-layer bandages. No
differences have been found between stockings, the Unna
boot and high-compression multilayer elastic and nonelastic bandages. Based on these data, the use of highintensity multilayer elastic and non-elastic compression
is recommended for the treatment of venous ulcers; in
non-ambulant patients or when the ankle is immobilised,
the use of multilayer elastic bandages is recommended
since the non-elastic bandages do not succeed in exerting
adequate levels of compression if the calf muscle pump
is weak or absent. Intermittent pneumatic compression
can be added if ulcer healing does not proceed normally
even though there is inadequate evidence in the literature
in this regard.
The available data show that the most effective treatment is also the most expensive; the studies by Franks
PJ and Posnett J (2003) show moreover that the cost effectiveness of firm multilayer compression is better than
that of conventional therapy. Despite the fact that the
initial cost of the first option is four times greater compared with the second, the weekly cost is lower due to
the lower frequency of bandage replacement and even if
the efficacy of the treatment were the same, the cost effectiveness would still be in favour of the first method.
In addition, the mean time for healing is considerably
lower with the application of highly compressive multilayer bandages.
The use of MCS can be extended to patients with a
venous ulcer of limited size in the active phase, according
to studies by Horakova H et al. (1994) and Mariani F et al.
(2008) (grade 1A recommendation). On this basis, various
so-called “advanced” compression systems are available to
the physician (Ulcer-Kit®, Tubulcus®, Tubi-press®, Mediven®
ulcer kit); these should be assessed from both the clinical
aspect (pressures exerted, tolerability and time for healing
the venous ulcers) and as regards their cost effectiveness,
comparing use of the bandage with use of MCS.
In brief, the therapeutic compression protocol involves
the following: in the acute phase of the venous ulcer, following any debridement of the base, a non-elastic bandage is used, applied with the figure of eight technique or
figure of eight fixed at the ankle, possibly with eccentric
compression in the region of the ulcer, to be replaced on
average every four days in the initial treatment period
and every seven days subsequently. We reserve four-layer
bandages (Profore® Smith & Nephew, Coban 2® 3M or
Rosidal sys® Lohmann & Rauscher) for patients who have
indurated or combined lymphatic oedema and venous ulcers resistant to conventional therapy, or to cases where
there is early deep venous insufficiency or that are secondary to DVT and in patients who are poorly ambulant.
In the majority of venous ulcers, a simple nonadherent
dressing offers sufficient protection beneath the bandage;
the dressing is chosen based on the characteristics of the
ulcer and the skin surrounding it, taking other factors
into consideration also, such as the presence of exudate
and symptoms. The use of a antiembolism stocking plus
MCS 2nd class or “advanced” compression system is limited to ulcers of medium size and in the final phases of the
20-05-2009 14:33:37
skin repair process. In these cases we use the new Ulcer-X®
Sigvaris® system, an understocking of about 18 mmHg at
the ankle worn constantly over the dressing, and a MCS
2nd class (23-32 mmHg at the ankle) during the day for
some reasons: firstly, the QoL of life is improved in patients, secondly, because the stocking can be worn by the
patient after healing with a reduction in the costs compared to purchasing specific compression systems for the
active ulcer period. Superimposing elastic stockings with
different elasticity results in effective compression (4050 mmHg at the ankle) with working pressures that are
higher compared with a single stocking and very effective
to heal venous ulcers.
The efficacy of the treatment should be monitored
constantly. The relationship between the degree of improvement of the ulcer after four weeks and healing has
been studied; if the lesion improves clinically and diminishes perceptibly, it is advisable to continue with the
initial treatment, whereas if this does not occur or the
patient’s health status alters, clinical diagnostic reassessment is needed, possibly taking a sample for bacterial culture and/or biopsy. Use of additional treatments (medical
and surgical, skin grafts etc.) is advisable for patients who
show only slight improvements in the first 3-4 weeks of
treatment or who do not heal, after the causes of the delay
in the healing process have been investigated. In our view,
use of active treatment, such as surgery, in combination
with compression therapy, should be considered early
even before healing of the ulcer is obtained, since removal
of the causes of the venous insufficiency, whenever possi-
31
ble, has the double effect of hastening re-epithelialisation
and reducing the incidence of recurrence.
Recurrence of venous ulcers is frequent in both the
short and long term, ranging from 20 to 75%. One of
the most effective treatments is the MCS, provided it
exerts compression of at least 35-45 mmHg at the ankle. Among the elastic supports, we prefer to prescribe
a natural rubber stocking in these cases (the below-knee
stocking is nearly always sufficient) because of the elastomeric characteristics of the fibres, which guarantee high
pressure throughout the day, unlike other fibres which
demonstrate a slow drop in pressure after a few hours of
use. The efficacy of the treatment depends closely on the
prescription (type and size of stocking) and regular renewal of the stockings.
The patient’s compliance with compression therapy
is another factor that determines the result. Instructions
on the importance and use of compression carried out or
prescribed must be detailed, including all the instructions
needed for optimal maintenance of the elastic stocking
(method of washing, duration etc.). Sometimes, despite
this, the patient does not succeed in wearing and tolerating the support; this is the case especially in elderly and
obese patients and those affected by osteoarthritic disease.
In these cases it may be useful to prescribe devices that facilitate application of the stocking (for example the Medi
Butler® or Easy Slide®) and a support of a lower compression class than required, which can be worn with less strain,
then putting a similar one over it, which will slide more
easily over the first, thus achieving optimal pressure.
Recommendations
–– A custom-made therapeutic elastic stocking should
always be prescribed when the limb circumference
is outside the standard measurements.
–– In the majority of cases, the below-knee model is
sufficient to obtain a therapeutic result.
–– Wearing two MCS of 1st class is recommended to
improve compliance when obtaining high pressures
is desirable in patients with limited ability to wear
therapeutic elastic stockings of a higher class (for
example 2n -3rd class).
–– CEAP 0: compression at the ankle with a support
stocking of at least 10-12 mmHg, and always of optimal manufacturing quality.
–– CEAP 1: the treatment of stages C0-C1 is practically identical; in some cases, a support stocking or
MCS 1st class can be recommended.
–– CEAP 2: MCS 1st class is recommended, and 2nd
class in the case of very extensive or recurrent varicose veins.
–– CEAP 3: MCS 2nd-3rd classes are recommended
except in oedema due to standing or prolonged sitting (for example, long journeys) in the absence of
concomitant venous disease, where 1A or 1st class is
usually sufficient; in angiodysplasia, depending on
the type and severity, 2nd- 3rd- 4th classes are recommended.
–– CEAP 4: in the case of superficial venous insufficiency use of a MCS 2nd class is recommended
whereas in the case of deep venous insufficiency use
of a 2nd -3rd classes are indicated, preferably made
with a natural rubber weft thread. In the case of
acute hypodermitis: non-elastic bandage worn
constantly, to be renewed at least every 6-7 days.
–– CEAP 5: in the case of superficial venous insufficiency MCS 2nd class; in the case of deep venous
insufficiency MCS 3rd class, preferably made of
natural rubber, for the reasons explained above.
However, it should be recalled that the greater the
20-05-2009 14:33:37
32
COMPRESSION
degree of compression by the stocking, the lower
the incidence of recurrence, so the highest possible
compression class relative to the patient’s compliance should be prescribed.
–– CEAP 6: in the initial phases of the treatment of venous ulcers, especially in the presence of oedema or
concomitant hypodermitis, use of multilayer bandaging is recommended; in the subsequent phases,
this can be replaced by non-elastic or short-stretch
bandages, or where feasible, by MCS class 2nd . In
the case of deep venous insufficiency with a postthrombotic ulcer, use of constant non-elastic multilayer bandaging of high stiffness is appropriate. The
MCS 2nd class with an understocking (antithromboembolism or another type, provided it exerts
graduated compression of at least 18 mmHg) to
be applied over the dressing is advised for all venous ulcers up to a diameter of 8 cm, including
in the case of oedema (provided it does not exceed
the dimensions of the prescribed size) or local complications, combined with topical medications to
absorb any exudate or adapted to the skin conditions surrounding the ulcer, according to Wound
Bed Preparation and TIME principles.
–– Prevention of venous ulcer recurrence:
1. Maintenance phase: MCS, preferably made of
natural rubber (2nd-3rd class).
2. Acute phase of the pre-ulcer pathology (hypodermitis etc.):
–– Short-stretch bandages (<100%);
–– “Heavy” bandages (more compressive with
the same extensibility);
–– Bandaging techniques that provide for overlapping of 3-4 turns of the bandage (figure of
eight, figure of eight fixed at the ankle…);
–– Multilayer bandaging;
–– Eccentric compression.
3. Eccentric compression is not recommended in
the case of areas of white atrophy because of the
possible progress of such “ischaemic” areas towards ulceration if they are subjected to excessively firm compression.
20-05-2009 14:33:37
33
Compression therapy and deep
venous thrombosis
The use of compression therapy in the course of deep
vein thrombosis (DVT) and for the prevention of the
post-thrombotic syndrome (PTS) is now routine. Application of an elastic stocking of a high compression class
(3rd class - compression of 34/46 mmHg at the ankle) 2-3
weeks after the acute event reduces the incidence of PTS
by 57% (Brandjes DPM et al. 1997), a result confirmed
by a randomised trial that involved a total of 180 patients
followed up for 5 years after the acute event who used
support stockings with compression of 30-40 mmHg
at the ankle (Prandoni P et al. 2004). The role of compression in the early phases of DVT is still controversial.
Partsch H et al. have demonstrated that application of
bandages combined with early ambulation in patients
with both proximal and distal DVT, treated with overlapping heparin therapy and oral anticoagulants, is safe and
does not cause an increase in the frequency of pulmonary embolism during the treatment period. The type of
compression chosen, i.e. bandaging, would appear to be
more indicated especially in the initial phases. Oedema
of the lower limb, often present acutely at diagnosis and
which usually resolves in the first days of pharmacological
therapy, involves a need to adapt the elastic containment
to the new limb measurements in order to maintain the
desired level of compression. However, bandages, which
adapt more to this need, must be applied by skilled staff
in order to avoid excessive or insufficient compression
or, worse, incorrect application with a “lacing effect”.
Domiciliary treatment of DVT and early hospital discharge make monitoring of correct bandaging difficult,
as this would have to be entrusted to the patient himself
or to his relatives. Partsch H and colleagues subsequently
demonstrated that application of a MCS 2nd class adapted progressively to the changes in volume of the limb,
Recommendations
–– Compression therapy in the course of DVT with a
rigid or short-stretch bandage is always indicated
in the oedema reduction phase and a MCS 2nd-3rd
class in the maintenance phase.
–– The antiembolism stocking is indicated in the
acute phase of DVT in patients confined to bed af-
if necessary, and fixed bandaging, which is also replaced
if it becomes insufficient, have almost equal efficacy in
producing resolution of the oedema and pain in a limb
affected by DVT; above all, they have a marked influence
on thrombosis evolution, understood as a reduction in
the length of the thrombus as measured by ultrasound,
which was obtained in 69% of those treated with bandaging and 89% of those treated with an elastic stocking
(Partsch H et al. 2000). However, early application of
compression, regardless of quality (bandage or stocking)
is able to reduce significantly the signs and symptoms of
PTS compared to pharmacological treatment combined
with bed rest (Partsch H et al. 2004).
Recent evidence has shown a greater incidence of recurrent thrombosis in patients in whom complete recanalisation of the involved veins was not achieved (Prandoni P et al. 2002) and when D-dimer was still elevated
when oral anticoagulant therapy was suspended. In the
absence of elastic compression, complete recanalisation
would be obtained with conventional pharmacological
therapy in 20 to 30% of cases after 4 months, about 50%
at 6-12 months, and 75% at 24 months (Caprini JA et
al. 1995). Measurement of the residual thickness of the
thrombus is obtained after compression at the inguinal
crease and popliteal fossa; a residual thickness ≥ 2 mm is
regarded as an index of normalisation (Prandoni P et al.
1993). Early application of elastic compression (MCS 2nd
class in the COM.PRE study, Arpaia G et al. 2007), from
the time of diagnosis of DVT, encourages faster and more
complete recanalisation of the thrombus and therefore a
lesser risk of recurrent thrombosis and late sequelae such
as PTS (Partsch H et al. 2000; Blättler W et al. 2003;
Arpaia G et al. 2003; Partsch H et al. 2004; Arpaia G et
al. 2005; Arpaia G et al. 2007).
ter reduction of the oedema. It can be used at night
during the maintenance phase and combined with
a MCS of a suitable class during daytime activity.
–– The MCS below-knee stocking of a high compression class (2nd-3rd class), applied early after the acute
event, encourages recanalisation and significantly
reduces the incidence of PTS.
20-05-2009 14:33:37
34
Compression therapy and pregnancy
Review of the international literature on the subject has
shown that graduated elastic compression in gynaecology
and obstetrics is still not widespread, mainly because of
the fact that the available studies are still too limited in
size to attain to solid scientific evidence or have structural gaps (sampling and choice of statistical validation
parameters) which preclude a correct assessment of their
real efficacy in preventing DVT and PE in the obstetric/
gynaecologic area.
The Guidelines of the Italian College of Phlebology
– CIF (Acta Flebologica 2003, International Angiology,
revised 2004) are also of this opinion.
Elastic compression in obstetrics, up to recently recognised and codified only in the case of acute DVT occurring during pregnancy, is now becoming part of clinical
practice for pregnant women with major oedema of the
lower limbs.
For the prevention of VTE in gynaecology, some consensus statements have been drawn up involving specialists in both the gynaecology and cardiovascular fields.
The majority of these publications were in the Englishspeaking area, like these:
–– Expert Consensus Document on management of cardiovascular diseases during pregnancy. Eur Heart J
2003 24; 176;
–– Venous thromboembolism during pregnancy. NEJM
1996 335 (2); 108;
–– Barbour LA, Pickard J. Controversies in thromboembolic disease during pregnancy: a critical review. Obstetrics and Gynecology 1995; 86:621;
–– Quinones JN, James DN, Stamilio DM, Cleary KL,
Macones GA. Thromboprophylaxis after cesarean
delivery: a decision analysis. Obstet Gynecol. 2005
Oct;106(4):733-40;
–– American College of Obstetricians and Gynecologists
(ACOG). Thromboembolism in pregnancy. Int J Gynaecol Obstet. 2001;75:203-212;
–– Shannon M. Bates and Jeffrey S. Ginsberg. How we
manage venous thromboembolism during pregnancy.
Blood, 15 November 2002, 100 (10); 3470;
–– Aburahma AF, Boland JP. Management of deep vein
thrombosis of the lower extremity in pregnancy: a
challenging dilemma. Am Surg, 1999; 65:164-167;
are marked for the prevention of VTE solely on a phar-
macological basis, using unfractionated heparin, low molecular weight heparin or warfarin.
Since warfarin passes the placental membrane, it is not
recommended in the first trimester of pregnancy because
of its embryotoxicity and in the third trimester because of
the risk of bleeding during delivery.
Unfractionated heparin (UFH) or low molecular
weight heparin (LMWH), which does not pass the placental membrane, has been shown to be the drug of first
choice in the management of pregnant women at thromboembolic risk.
In these articles and in the guidelines derived from
them, there is no mention of elastic compression as an
anti-thrombosis measure.
The Maternal and Neonatal Haemostasis Working Party
of the Haemostasis and Thrombosis Task Force, through the
British Society for Haematology (J Clin Pathol 1993; 46:
489-96), has published guidelines for the prevention and
management of thrombosis associated with pregnancy,
which do not mention elastic stockings as a preventive
measure for thrombosis in pregnancy.
In the Consensus Conference on the prevention of
DVT, issued by the Medical Academy of Malaysia in 1999,
elastic stockings are indicated as an anti-thrombotic device only for women with a previous episode of VTE or
women who are carriers of congenital thrombophilia (it is
not stated whether this is only homozygote or also heterozygote) in whom pharmacological anti-thrombotic treatment with warfarin or LMWH is contraindicated.
This preventive treatment, moreover, is suggested
only in the post-partum period and for a period of 6-12
weeks.
For a pregnant woman, whether a patient at risk of
thrombosis or with a previous episode of VTE, pharmacological prophylaxis only with warfarin or LMWH is
indicated.
Furthermore, the Consensus Conference on Thrombophilia and Pregnancy, published in 2003 by the Collège National des Gynécologues et Obstétriciens Français
in association with the Groupe d’Études en Hémostase et
Thrombose does not indicate elastic containment to prevent thrombotic disease in the guidelines drawn up at the
end of the Consensus.
The committee that was in charge of the work of the
20-05-2009 14:33:37
Compression therapy and pregnancy
Maternal Medicine Symposium in Glasmedical-lsw in
2005 was of the same opinion, suggesting that elastic
containment should be worn only by women who have
been delivered and who are carriers of congenital thrombophilia (here, too, it is not specified whether homozygote or heterozygote); however, the duration of this antithrombotic prophylaxis is not stated.
All the protocols examined, instead, state that a MCS
2nd class needs to be worn for at least two years after a
thrombotic episode occurring during pregnancy, in agreement with the universally accepted guidelines on DVT
recurrence.
One publication suggests the use of elastic stockings
for preventive purposes only in pregnant patients with
a previous episode of VTE. These recommendations are
graded as 2C and are included in one of the most important studies on the prevention of thrombotic disease,
organised by the American College of Chest Physicians at
its 2004 conference (Seventh ACCP Conference - Chest
2004 126; 627)
Recently (February 2007) the Green-Top Guidelines
of the Royal College of Obstetrics and Gynaecology
(RCOG) published a revision of the guidelines proposed
in the previous edition of January 2004. In this revision,
compression by means of elastic stockings is suggested as
a measure for preventing VTE in patients with constant
oedema of the lower limbs. The compression class indicated as most effective in preventing VTE is the 2nd class
therapeutic elastic stocking.
This revision signals the first important recognition of
elastic compression therapy as an effective measure against
venous thromboembolism in pregnancy.
Caesarean delivery is stated by most study groups to be
a condition that predisposes more to the risk of thrombotic disease.
In two studies, the first published in the Department
of Health, Report on Confidential Enquiries into Maternal Deaths in the United Kingdom (1991-1993) and the
second published by the Australasian Obstetric Medicine
Working Group in MJA (2001 175; 258), elastic compression therapy is indicated as a prophylactic measure for
VTE in women operated of caesarean section.
However, this recommendation is still codified in both
cases as an expert opinion.
In the recent Cochrane Review (2005) on the prevention of VTE in pregnancy and the puerperium eight trials
were reviewed which examined a total of 649 women.
None of these studies included graduated elastic compression stockings as prophylaxis; the studies considered
the use of heparin (non-fractionated and LMWH) and
aspirin.
From the research that has been conducted, it is apparent that the use of elastic stockings during pregnancy and
35
the post-partum period, as a preventive measure against
venous thrombosis, is regarded as an ineffective procedure.
Among the few dissenting voices, a few study groups
have shown that elastic compression during the months
of gestation confers a definite haemodynamic benefit: Br J
Obstet Gynaecol (1999 106(6):563); Rev Med Liege (1999
54(5):424).
The conclusions arrived at by these authors demonstrate that elastic compression produces significant
changes in venous return from the legs in pregnant and
puerperal women and that therefore elastic containment
during pregnancy can diminish the incidence of thrombotic episodes.
In the SISET (Italian Society for Studies on Haemostasis and Thrombosis) guidelines for obstetrics and
gynaecology (J Hematol 2002 87; suppl. 12) the use of
elastic compression for primary prevention is suggested
for women at low to moderate risk (identified according
to the criteria of the Royal College of Obstetrics and Gynaecology); in the same article, elastic compression is also
stated to be useful in primary prevention for women who
are thrombophilia carriers.
A study published by a Swiss group in Swiss Medical
Weekly 2001 (131 (45-46): 659-62) demonstrated that
MCS 1st or 2nd class during pregnancy does not prevent the
appearance of varicose veins but diminishes the incidence
of reflux in the long saphenous vein and saphenofemoral
junction and also improves the patients’ symptoms.
On the beneficial effects of elastic compression, we
have also found a review by the Cochrane group published
in the Cochrane Database Syst Rev 2000 (2: CD001066),
which showed how external pneumatic pressure (IPC) is
able to reduce ankle swelling during pregnancy.
Some authors have demonstrated that elastic compression in pregnancy significantly increases the afterload and
vascular resistance, thereby preventing compartmentalisation of the blood at the level of the lower limbs (Am J
Obstet Gynec 1996 (174 (6): 1734-40).
Compared with the paucity of randomised studies on
the use of elastic compression in pregnancy, more study
groups have shown that among pregnant women, the
highest risk period for DVT and pulmonary embolism
is the post-partum period; a recent study published by
the Mayo Clinic (Ann Int Med 2005, 143 (10): 697-706)
stresses that any prophylactic strategy should be directed
particularly at the post-partum period.
In agreement with what has been stated here and also
in a study published in Pathophysiol Haemost Thromb
2002, 35(5-6): 322-4 it was shown that the risk of DVT is
5 times greater in pregnant women than in non-pregnant
women of the same age and that DVT is more frequent
post-partum than ante-partum.
20-05-2009 14:33:38
36
The efficacy of elastic compression, when the oxidative stress in workers who stand for long periods during
their working shift is considered, was published in Occup
Environ Med. (2004; 61(6):548-50). This study showed
how compression can reduce the production of free oxygen radicals, which are responsible for the onset and exacerbation of venous insufficiency and probably for other
chronic degenerative diseases.
Recommendations
–– Pregnancy, because of the physiological changes in
coagulation and haemodynamics, is to all intents
and purposes a risk factor for thrombosis.
–– Pregnancy places the woman in CEAP clinical class
1, even if asymptomatic from the venous aspect.
The elastic stocking may be a support stocking,
provide compression of 18 mmHg at the ankle, or
a MCS 1st class and should be worn throughout the
gestation period.
–– Women who already have varicose veins should
wear MCS throughout pregnancy of a class appropriate for the severity of the disease.
–– Natural delivery requires antithrombotic prophylaxis with antithromboembolism stockings.
–– Caesarean delivery adds a further thrombosis risk
factor to the pre-existing situation and these women
should therefore be given the usual antithrombotic
prophylaxis for surgical procedures: antithromboembolism stockings and possibly pharmacological
antithrombotic therapy.
–– When assessing the thrombotic risk of a pregnant
woman, this should also include multiparity, age
over 40 years and excessive weight gain.
20-05-2009 14:33:38
37
Compression therapy and peripheral arterial
disease
Elastic compression is universally recognised because
of its efficacy in the treatment of numerous venous disorders of the lower limbs. A large proportion of the patients
who can benefit from compression treatment are elderly
and consequently affected by numerous other conditions.
Among the most frequent is obliterative arterial disease of
the lower limbs (PAD), which may be associated with diabetes. Elastic compression is often contraindicated in cases
of PAD, since external compression may conflict with arterial insufficiency and cause tissue damage that may even
lead to necrosis. It is therefore necessary to clarify the criteria for and limits to the use of elastic compression in
patients with arterial disease. Elastic compression, carried
out by means of bandages or stockings, acts especially at
the surface of the lower limb; the pressure applied diminishes from the superficial to the deep level. It is in the surface that the most important pathological alterations occur in patients with diabetes or arterial disease. In arterial
insufficiency, the trophic disorders start at the level of the
skin. In the early phases of the arterial disease, a reduction
in the hairs, atrophy of the hair roots and a slowing of epidermal turnover are noted. In the second phase, an alteration of the colour of the skin can be observed, caused by
an alteration of oxidative exchange and a reduction of the
superficial temperature. The last stage is that of gangrene,
which is present when the trophic changes are no longer
reversible. The damage to the deep structures is manifested
first with disorders of the neurological type (paraesthesia
and anaesthesia). The muscular structures are the last to
be involved; in fact, deep rest pain of the muscle type appears late. The pain associated with intermittent claudication, of muscle origin, is a dynamic phenomenon, which
appears in the early stages of obliterative arterial disease. It
is intermittent and reversible, and is an expression of the
increased need for oxygen during muscular exercise.
Elastic compression acts especially on the most superficial part of the tissues; consequently, the target organ (epidermis and dermis) is the same as that of peripheral arterial
disease, which may be associated with diabetes. Theoretically, elastic compression and arterial disease are therefore
incompatible. The effects of elastic compression are also
manifested deeply especially during the dynamic phase
represented by walking. Compression has positive effects
on venous return, on the one hand (reduction of stasis,
diminution of interstitial pressure, improvement of exchange, speeding of blood flow rate in the veins, etc.), but
on the other hand, pressure is exerted on the tissues that
opposes arterial pressure. The precapillary arterial pressure
is reduced in a patient with arterial disease. The precapillary pressure falls in the case of microangiopathy and the
pressure exerted by the elastic compression can be greater
than that of the capillary unit; this can cause an ischaemic
state in the arteriopathic patient. This phenomenon occurs especially when the patient is lying down. Conversely,
during walking and/or in the standing position, the hydrostatic pressure aids the peripheral arterial pressure. The
rhythmical muscle contraction of walking alters the effect
of the elastic compression, which becomes intermittent.
These two elements contribute in a broadly proven manner to an improvement of peripheral perfusion even in the
arteriopathic patient. Active elastic compression must be
distinguished from passive compression. Compression exerts a resting pressure, especially on superficial structures.
Consequently, it interferes with the superficial arterial
perfusion of arteriopathic patients. Conversely, correctly
applied containment exerts reduced resting pressures. Its
maximum effect takes place during walking and interferes
less with perfusion at rest, instead improving perfusion
during physical activity. It can therefore be stated that
elastic compression is tolerated only by the arteriopathic
patient who walks and maintains his physical activity,
whereas containment is more suitable for arterial disease in
general, including non-ambulant patients. There are numerous indications for elastic compression in arteriopathic
and/or diabetic patients (Table V) and they do not differ
much from those of the general population. Unfortunately, few studies have been dedicated to the effects of elastic
compression in patients with arterial disease, in view of the
fact that elastic compression is not commonly regarded as
indicated in these cases. In fact, experience is episodic and
fragmentary and the studies present only partial results.
Nevertheless, it should be stated that elastic compression
is not contraindicated in the arteriopathic patient. In fact,
the term arteriopathy is a broad and varied term that refers
to a very wide range of pathological conditions. Furthermore, the textile structure of the means of elastic compression is varied and its characteristics can be more or less
compatible with arteriopathy. Elastic compression of the
20-05-2009 14:33:38
38
COMPRESSION
Table V – Indications for compression therapy in arterial disease.
Mixed ulcers of the lower limbs
Essential varicose veins
Secondary varicose veins
Lymphovenous oedema
Prevention of vte
Distal femoral bypass post-operative period
Table VI – Factors that influence tolerance of compression
therapy in arterial disease.
Ankle-brachial index <0.55
Peripheral neuropathy
Diabetes
Trophic changes in the skin
Deformities of the lower limb
Ambulation
Cardiac disease
lower limbs should be utilised when useful and necessary
in the patient with arterial disease, observing the rules of
“good use of elastic compression”, and taking into account
the factors associated with arteriopathy, which often interact, exacerbating the consequences (Table VI).
These factors are:
1. Perfusion index: the ankle/brachial perfusion index is
an important element but may be a source of error.
It can be regarded as a guide but is not absolute. An
ankle/brachial index <0.55 needs to be regarded as the
risk limit but an index over 1.2 should also be regarded
with suspicion because it may indicate incompressibility of the arteries, as occurs in diabetic patients;
2. Neuropathy: the presence of any neuropathy needs to
be assessed clinically as this can alter the patient’s superficial sensation and expose him to trophic lesions
induced by the compression;
3. Diabetes: the diabetic patient should be assessed with
the greatest care. He is particularly susceptible to skin
infections and the consequences of neuropathy. Finally,
it must not be formedical-lstten that the rigidity of the
arterial wall that is typical of the arteriopathic patient
can alter the ankle/brachial index, as mentioned above;
4. Skin dystrophy: any increase in skin fragility must be
sought, since this may constitute a contraindication to
elastic compression therapy even when the indices of
distal perfusion are satisfactory;
5. Bony irregularities: the tibial and malleolar bony and
tendon prominences, when they are very pronounced,
can expose the skin to excessive compression because
of their small radii of curvature (Laplace’s law). In this
case, skin ulcers can develop;
6. Ambulation: the negative effects of elastic compression
are more significant in patients who move little or who
are confined to bed. Elastic compression is much more
effective in patients who move actively. The indication for elastic compression in patients with arterial
disease must take their ability to move and walk into
account;
7. Cardiopathy: heart disease, always in association with
peripheral arteriopathy, can produce oedema of the lower limb.
These criteria should be assessed before prescribing compression. If these criteria are heeded, positive and beneficial
results are obtained. There will be an increase of capillary
pressure and skin oxygenation and a reduction of the oedema.
The reduction of the oedema will promote arterial flow and
diminish tissue pressure.
From the clinical point of view, the patient will tolerate
the compression better and the tolerance will be increased
when he is standing and walking
What are the clinical indications
depending on the C.E.A.P. classification?
C2 patients affected by moderate peripheral arterial disease (stage IIA), which may be associated with diabetes, do
not have any contraindication to daytime elastic compression,
which can be applied with MCS 2nd class. Tolerance of
compression is good in these patients. C3 patients at the
same stage of arteriopathy can benefit from compression
with medium-stretch bandages to reduce oedema and can
then wear MCS 2nd class for maintenance.
In C4-5-6 patients with the same level of PAD, it is
preferable to employ passive containment achieved with
short-stretch bandages or ideally with a rigid bandage
that ensures more tolerable resting pressure. In extreme
cases such as mixed ulcers, healing is difficult when the
PAD is high-grade. In these cases, arterial revascularisation is necessary where possible, performing PTA or
femoro-distal bypass. Elastic compression by means of
a Fischer bandage can be applied after the procedure.
The purpose of the revascularisation is not only to improve the peripheral perfusion index but also and above
all to improve the efficacy of vasoactive and antibiotic
treatments, whose action is indispensable for healing
these particular ulcers. Antithromboembolism stockings
can be combined with administration of subcutaneous
heparin in patients with arteriopathy (stage IIA) in order
to prevent the risk of perioperative thrombosis and pulmonary embolism.
In the case of severe arteriopathy (stage IIB, III, IV), the
use of elastic compression is dangerous. It is contraindicated
except in exceptional situations. Nevertheless, the results
can be positive in patients at stage III in the presence
of postural peripheral oedema associated with stasis, on
condition that the patients are willing to walk despite
the pains caused by wearing rigid bandages that exert
low pressure at rest. Good results are also obtained with
intermittent pneumatic pressure devices (IPC). During
the postoperative period following a lower limb revas-
20-05-2009 14:33:38
Compression therapy and peripheral arterial disease
cularisation procedure, elastic compression may be particularly indicated. In fact, patients operated with these
procedures often develop lymphovenous oedema in the
postoperative period secondary to the increase in arterial
flow in a territory where autonomic regulation is compromised. Moreover, the oedema can be caused by deep
vein thrombosis or by extrinsic venous compression secondary to the surgery. In these cases, it is important to
apply passive containment at first, especially if the oedema is significant or there is a DVT. MCS 2nd class can be
applied subsequently for 2-3 weeks until the patient is
walking better.
In all cases, elastic compression should be utilised with
great caution in arterial disease and patient selection must
be strict. It is essential to confirm the flow indices at the
ankle. When the ankle/brachial index is <0.55, Doppler
ultrasound should be performed and possibly arteriography to see whether surgical revascularisation is necessary.
If this is not necessary, the patient’s condition should be
reviewed frequently both to assess his tolerance of the
compression and to monitor the condition of the skin.
This monitoring should be even closer in the case of arthropathy associated with diabetes and it is particularly
important to check the state of the skin; to avoid excessive friction from the stockings or bandages on the tibial
prominences, foam or cotton protection should be used.
These often complex precautions make it very difficult or
even impossible for the patient to put on the stockings. In
these cases, there should be no hesitation in abandoning
elastic compression in favour of fixed bandages applied by
highly skilled healthcare professionals. Once the bandage
has been applied, it should be checked after 24 hours at
the most to monitor the condition of the skin. Patients
with arterial disease for whom elastic compression is recommended should be well informed about the need to
rapidly remove the compression stocking or unbandage
Recommendations
–– The recognised limit beyond which compression
in the arteriopathic patient becomes dangerous
is a peripheral perfusion index, or W.I. (Winsor),
<0.55; it is advisable to record the index with a
stress test and confirm the compressibility of the
arteries with Doppler ultrasound. An index above
1.2 should also be investigated.
–– C2-3 patients with mild PAD (stage IIA), which
may be associated with diabetes, do not have a contraindication to daytime elastic compression which
can be applied with MCS 2nd class, often preceded
in C3 by bandages to reduce the oedema.
–– In C4-5-6 patients with mild PAD (stage IIA), it is
39
the limb in the case of peripheral pain, especially in the
toes, at the ankle or in the heel. In addition to these instructions, it is important to remind the patient that the
stocking should be worn only during the day. During
use of the bandages, the most frequent complication is
skin necrosis, which is very slow to heal and is at risk of
becoming infected. In many cases, the loss of substance
caused by bandages left in place for too long has been
followed by amputation. Peripheral ischaemia of the toes
and forefoot may be found. This begins with cyanosis of
the toes, pain and functional loss of power of the toes
and ankle. The ischaemia is due to excessive compression
by the bandage at rest. This should not occur when the
healthcare professional is skilled. The lesions can regress
after immediate removal of the bandage. We are not
aware of incidents with regard to the use of antithromboembolism stockings.
In the patient with arterial disease, monitoring must
always be very careful, which is easy in the case of a hospitalised patient under frequent medical surveillance.
Conclusions
There are no absolute contraindications to the use of
elastic compression in the arteriopathic patient. Careful
patient selection is necessary. The history should enquire
about previous disease, investigation of the patient’s suitability, knowledge of his disease and understanding of
compression systems and their risks, and finally assess the
possibility of motor activity. Clinical examination must
identify disorders of sensation and/or fragility of the skin
and any anatomical deformities of the lower limb. The
type of compression must be adapted to the patient’s
clinical condition and, depending on the case, should
employ compression with bandages or MCS. Compression may improve the arterial circulation in certain conditions (i.e. the use of ICP).
preferable to use passive containment with shortstretch bandages or better, with a fixed adhesive
bandage which will ensure a resting pressure as low
as possible.
–– Antithromboembolism stockings can be combined
with administration of subcutaneous heparin in patients with arterial disease (stage IIA), with the aim
of reducing as far as possible the risk of perioperative thrombosis and embolism.
–– In the case of severe arteriopathy (stage IIB, III,
IV), the use of elastic compression is dangerous: it
is contraindicated except in exceptional situations.
–– Intermittent pneumatic compression can be utilised to improve peripheral arterial perfusion in the
initial stages of arteriopathy.
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40
Compression therapy and vein surgery
The rationale for compression carried out with various
methods in conjunction with venous surgery is prevention
of thromboembolic episodes in patients at risk (this topic is
discussed below), prevention of superficial venous thrombosis and reduction of the side effects of surgery such as
pain and haematomas. Prolonged use of compression can
also have a positive effect on the later appearance of varicose recurrences. There is insufficient evidence in the literature for advising one type of compression compared with
another; the choice of compression depends on personal
preferences and economic considerations (Bond R et al.
1999). There are no significant differences between 1, 2
or 6 weeks of compression for controlling postoperative
complications; a minimum period of 1 week is therefore
advised (Rodrigus I et al. 1991; Raraty MGT et al. 1999).
Compression with a MCS 2nd class worn for 12 months
after the surgical procedure has been shown to be effective in reducing the incidence of recurrent varicose veins
(Travers JP, Makin GS 1994).
The elastic compression rationale varies depending on
whether the varicose disease is treated with traditional methods (stripping) or with endovascular or CHIVA techniques.
In the first two types of treatment, use of eccentric
compression is very widespread, at least for the first 24-48
hours, whereas concentric compression with a stocking is
utilised after CHIVA surgery.
The most widespread therapeutic approach, at least in
our country, appears to be short- to medium-stretch compression bandaging in the immediate postoperative period
in order to obtain the most effective pressure possible to
control haematomas, and for the patient to wear a therapeutic elastic stocking subsequently for a period that varies
greatly from surgeon to surgeon, bearing in main that the
patient’s compliance with compression therapy is often
very poor once he/she has recovered from the procedure.
A study by Bisacci R et al. (2005) in 112 centres in
Italy – 26792 procedures/year – showed that compression
in the preoperative period is regarded as:
–– indispensable by 49.1% (55 centres), but only 53 use
it systematically;
–– not indispensable by 50.89% (57 centres), but 15 use it
systematically which means that it is used systematically
in 60.71% (68 centres).
In the immediate post-operative period 17.43% utilise
elastic stockings of various types with a predominance
of MCS 2nd class, 82.57% use bandaging with a predominance of adhesive bandages (29.98%) and two-way
stretch elastic (28.53%).
The preferred compression after discharge is the elastic stocking (53.68%), 2nd class (21.36%) or 1st class
(21.05%) single-leg tights; the bandage is kept in 46.32%
of cases, with adhesive bandages predominating.
Compression therapy after venous surgery is indispensable, as shown by the data cited above on the treatment
of CVI, and should be routine in all centres. Compression
can be carried out with different methods, but it must be
effective, at least 20 mmHg at the ankle and in keeping with
the underlying venous pathology (CEAP class), and must have
the characteristics of graduated pressure and uniformity: the
MCS or, when necessary for VTE prevention, superimposition of two elastic stockings (antithromboembolism
round the clock and MCS 1st or 2nd class during the day) is
preferable if staff are not available who are sufficiently skilled
in bandaging practice. The use of stockings (Sigvaris® postoperative stocking) with greater compression in the thigh
compared with traditional ones (about 20 mmHg) is probably preferable if graduated pressure is guaranteed and can
replace the traditional bandage in the immediate postoperative period, especially in patients with objective anatomical difficulties (for instance a thigh of disproportionate dimensions) for keeping an effective bandage in place.
In a recent study, Biswas S et al. (EJVES 2007) assessed
some outcomes (resumption of work, duration of pain
and quantity of analgesics utilised, postoperative complications and patient satisfaction) after traditional surgery
(saphenofemoral ligation and stripping). All of the treated
patients had been bandaged for the first 3 days and had
subsequently worn an antithromboembolic stocking for a
period varying between 1 and 3 weeks. The results were not
significantly different if compression was carried out for
one or for three weeks. The choice of antithromboembolic
stocking, which should not be prescribed for therapeutic
purposes after a stripping procedure, seems debatable. This
serious methodological error does not allow conclusions to
be drawn on the clinical level and therefore we still have
no studies today conducted with methodological strictness
that would allow accurate assessments of the value of elastic compression after surgery, whatever its kind.
20-05-2009 14:33:38
Compression therapy and vein surgery
41
Recommendations
–– Compression after venous surgery is indispensable.
–– Compression with MCS 2nd class worn for at least
12 months after the surgical procedure reduces the
incidence of recurrent varicose veins.
–– There is insufficient evidence for advising one type
of compression compared to another: the choice of
compression method depends on personal preferences and on economic considerations.
–– Compression can be carried out with different
methods but it must be effective, at least 20 mmHg
at the ankle, and in keeping with the underlying venous pathology (CEAP class), and have the characteristics of graduated pressure and uniformity.
20-05-2009 14:33:38
42
Compression therapy and sclerotherapy
Compression therapy is the cornerstone of sclerotherapy. It involves the use of bandages during treatment in
order to obtain a reaction to the sclerosis therapy that is
confined to the vein walls and use of elastic stockings following convalescence with the aim of ensuring adequate
compression to consolidate the venous fibrosis.
There is broad agreement on important principles
in the various methods of state of the art sclerotherapy,
such as immediate ambulation, avoidance of air bubbles,
haemostatic lacing, wheals in telangiectasias, etc. The
comparison of elastic compression in the eternal diatribe
between the maximalists and minimalists, remains open,
i.e. those who maintain the need for it and those who do
not regard it as useful. European phlebology at the end of
the century has seen the experience of the former become
popular especially in Switzerland, the United Kingdom
and Germany, under the influence of Sigg K (removable
short-stretch bandage for 3 weeks) and Fegan G (fixed
bandage under a removable stocking for 6 weeks); the second has become widespread especially in France, Italy and
Spain, under the influence of Tournay R (adhesive bandage over visibly bulky varicosities or stocking, still routine
for local complications of intravaricose haematoma, phlebitic reaction) and Bassi G (adhesive bandage).
This variety of views found justification since the maximalists aimed at global treatment, including the saphenous ostia, whereas the others often employed sclerosis
to treat collateral and reticular veins exclusively or often
following previous surgery on the saphenous trunks.
However, the debate regarding reticular varicose veins
and telangiectasias remained open. To improve the results of sclerosis of varicosities and perforating veins, their
diameter and the degree of reflux must be reduced with
constant pressure during activity and rest so as to prevent
them from refilling with blood coming from the incompetent points and from below. Medium-stretch bandages combined with targeted compression and stockings
therefore exert a more suitable action because of their
physical characteristics. The problem is that this type of
compression is not usually tolerated in bed (even if, according to Cornu-Thénard A, the pressure does not exceed 30 mmHg, it can be maintained during rest) and
must therefore be removed at night. Since it is necessary
to exert constant pressure over the 24 hours on sclerosed
varices, rigid or short-stretch bandages worn constantly
are often employed, especially in the treatment of largecalibre varicose veins, combined with eccentric compression in order to increase the local pressure and pressure
at rest on the treated vein segments, then changing to an
elastic support appropriate to the pathology once the venous thrombus has consolidated following the action of
the sclerosing agent.
The indications for compression therapy in combination with sclerotherapy vary according to the pathophysiology, the calibre of the varicosities and their anatomical
position. It should always be carried out in the case of:
–– veins of large dimensions (over 2 mm), especially in
the lower leg;
–– haemodynamically significant incompetent perforators;
–– varicosities at risk of haemorrhage;
–– peri-ulcer varicosities or those in areas of skin dystrophy;
–– varicose veins of the foot;
–– post-thrombotic varicose veins;
–– periphlebitic complications;
–– lack of experience in sclerosing therapy.
The critical areas in the lower limbs, which do not allow optimal compression, are the inguinal region and the
thigh (especially if obese); various stratagems can be used
(bandages applied in a figure of eight, with vein rolls etc.)
but even with their aid, the anatomical shape often prevents effective pressure from being exerted. The retromalleolar fossae and the popliteal fossa present different difficulties due to their concavity; it is necessary to make them
convex by using suitable padding so that correct bandaging can be applied, which is useful, for instance, with sclerosis at the saphenopopliteal junction. The foot represents
another difficult area, for the opposite reason: the very
pronounced convexities alternate with just as obvious
concavities and furthermore, the plantar contact with the
ground during walking causes firm pressures through the
periplantar veins on those of the foot surface.
“Canyon” varicose veins in sclerotic hypodermitis and
indurated oedema, even though located in readily accessible regions, are not greatly influenced by compression
therapy, and neither are telangiectasias and reticular veins.
In these cases, it is useful only in controlling the CVI and
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Compression therapy and sclerotherapy
limiting inflammatory dermal complications due to overdosage of the sclerosing liquid.
The duration and methods of compression vary according to the specialists and sclerotherapy techniques,
as shown by Partsch H et al. in 1997. Some studies show
equal efficacy in the therapeutic outcome of bandages
maintained for a few hours to six weeks, as a significant
fall in the pressure exerted by the bandages 6-8 hours following application has been shown. Compression combined with mobilisation of the patient is, however, fully
justified after sclerosis of varicose veins, especially if they
are large in size and located in the lower leg. This cannot
be standardised but must be assessed from case to case.
In general, a rigid bandage with the aid of “eccentric”
compression is applied after sclerotherapy of medium to
large varicose veins, and this is replaced after about a week
by a MCS 1st or 2nd class. The recent Sigvaris® postoperative stocking (23-32 mmHg at the ankle), devised to exert
greater compression of the thigh (about 20 mmHg) compared with classical therapeutic elastic stockings, which
maintained sufficient graduation of the pressure exerted
along the lower limb, can be an effective means when
43
used in sclerosis of the saphenous vein and varicose veins
at the thigh.
Compression therapy in brief controls extension of the
thrombus resulting from the endothelial lesion produced
by the sclerosing agent, approximates the vein walls and
limits periphlebitic reactions, thus improving the final result. However, we are unable to define the appropriate
level of pressure that should be exerted or to standardise
the type of compression (CIF guidelines 2004).
The use of elastic stockings after sclerotherapy of reticular varices and telangiectasias is controversial since the
pressures necessary to exert an effective action on small
veins are too high (about 80 mmHg); it is advisable to
prescribe support of a compression class suitable for the
degree of venous insufficiency that is present. A recent
study by Kern P, Ramelet AA, Wutschert R, Hayoz D
(J.Vasc.Surg. 2007) shows the necessity of a MCS 2nd
class (Sigvaris® 702) worn for three weeks to improve the
results of sclerotherapy carried out with liquid drug in
100 cases with C1, Ep, As1, Pn. The table below (Table
VII) gives suggestions for application of compression during sclerotherapy.
Table VII – Compression therapy during sclerotherapy.
(*)
Varicose veins
Concentric compression
Duration
Eccentric compression
GSV
Collateral varicose veins
Non-elastic or short-stretch
bandages.
MCS(*) at least 2nd class or
Sigvaris® postoperative
7-21 days
Obligatory, better if
in non-compressible
material
Fixed or
removable
4-7 days
SSV
Collateral varicose veins
bandages.
MCS(*) at least 2nd class
7-21 days
Optional,
Obligatory for large
varicosities
Fixed or
removable
4-7 days
Non-saphenous varicose
veins
bandages.
MCS at least 1st class
7-21 days
Optional, not necessary
for veins with a diameter
<2 mm
-
Duration
It is possible to use two superimposed elastic stockings, removing one of them at night.
Recommendations
–– Compression therapy is indicated after sclerotherapy of every type of varicose veins, utilising at least a MCS 1st class for C1 cases and 2nd class for C2
cases.
–– Bandaging is indicated after sclerotherapy of vari-
cose veins, using elastic or short-stretch bandages
and eccentric compression for the larger varicosities
until organisation of the intravenous thrombus (710 days), and in the subsequent period, a MCS 1st
or 2nd class is indicated.
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44
Compression therapy and lymphoedema
In lymphoedema and in cases of lymphatic insufficiency in general, compression therapy in the broadest sense
of the term represents a universally recognised cornerstone
in the nonsurgical approach to this type of disease.
Compression therapy in the area of lymphology can be
subdivided into at least 4 subsections:
1. manual lymphatic drainage;
2. mechanical lymphatic drainage;
3. bandaging;
4. elastic compression devices (supports and stockings).
In international protocols such as the Consensus Document of the International Society of Lymphology (revised,
I.S.L. International Congress – Salvador Bahia, Brazil - September 2005) and the Guidelines – EBM of the Italian Society of Lymphangiology (Guidelines: S.I.L. Lymphology.
2004 Dec; 37(4):182-4), which inspire the present work
and with which it conforms, the above subdivision of compression therapy is not mentioned but, on the contrary, given the complementarity and necessity of the elements that
comprise it, it is considered as a single therapeutic entity
under the name of “Combined Physical Therapy - CPT”.
“This method generally consists of a programme of treatment in two phases: the first phase involves treatment of the
skin, manual lymphatic drainage, a series of gymnastic exercises and elastic compression normally applied with multilayer bandages. The second phase, which is started as soon as
phase 1 is finished, with the aim of maintaining and optimising the results obtained in phase 1, consists of (…) elastic
compression by means of a support (stocking or sleeve) with
a low degree of elasticity, (…) repeated sessions of manual
lymphatic drainage according to the individual case”.
“Essential conditions for the success of the combined physical therapy are the availability of medical staff (clinical lymphologists), nurses and physiotherapists appropriately trained
in this therapeutic method. If not applied appropriately,
elastic compression may be useless or even harmful. For longterm treatment, it is essential that supports are prescribed for
elastic compression”.
“Failure of CPT is confirmed only in the case of failure of
intensive nonsurgical treatment conducted in an institution
specialised in the treatment of peripheral lymphoedema under the direction of an expert clinical lymphologist”.
From Italian Society Of Lymphangiology “Guidelines – Ebm On The
Diagnosis And Treatment Of Lymphoedema
The elastic compression bandage used most often in the
area of lymphology is the multilayer bandage, which is
also used in the acute phases of the disease and in erysipeloid lymphangitis and which owes its efficacy to the
combination of the characteristics and qualities of various
materials. From the physical aspect, the material utilised
should have “short-stretch” characteristics, which allow
low resting pressures and high working pressures to be
obtained (greater patient compliance and greater efficacy
over time).
It should be applied only by expert staff; in the German school (Vodder-Foeldi) the patients themselves are
taught the rudiments of the technique so that they are
able to apply it “on demand”.
The description of the physical foundations, the materials and bandaging methods has already been illustrated
exhaustively in other sections of this treatise; therefore,
as regards lymphatic disease specifically, two peculiarities
that characterise this type of functional elastic vascular
bandage can be noted, distinguishing it from the others:
in the first place, the pressures and tensions applied by
the healthcare professional for elastic compression supports in the course of lymphoedema should be markedly
higher compared with the bandages used in venous and/
or arterial disease; secondly, given the extreme variability
and dissimilarity that can be encountered in limbs affected by chronic lymphatic stasis, it is often difficult to
describe accurate standardisation in applying the bandage, which is usually performed with flexible techniques
that can be easily adapted to the individual case. For this
purpose, special thicknesses (in latex or cotton) are often
employed, which make it possible to level anatomically
the treated surfaces.
In the acute phases of the disease (e.g. lymphangitis)
or in elephantiasic limbs, the bandage often represents
the only therapeutic device for effective maintenance, as
elastic compression with stockings and supports cannot
be employed.
For elastic compression supports (e.g. sleeves, stockings,
etc.) it is pointed out that the pressure parameters utilised
in lymphostasis are higher on average compared with
diseases in which the venous component predominates,
as was mentioned above for elastic functional bandages.
In fact, use of greater compression classes is advised in
20-05-2009 14:33:39
Compression therapy and lymphoedema
lymphoedema, such as 3rd class (34-46 mmHg) and 4th
class (>49 mmHg). Use of custom-made elastic supports
is often required where the limb does not fit the standard
parameters on the market.
Intermittent pneumatic compression IPC (often simplistically called “pressotherapy”) is subdivided into two categories depending on whether the equipment is able to
exert uniform pressure and/or peristaltic sequential pressure. For this type of method, more than for the others,
the synergy of the treatments is indispensable. Carrying
out mechanical lymphatic drainage not combined with
other therapeutic devices (manual lymphatic drainage,
tailored bandages and supports) or carried out incorrectly
(e.g. pressures too high) could also cause a worsening of
the clinical condition; conversely, well-considered and
synergistic use allows better results and greater therapeutic “flexibility”. Usually, the combined programme,
which includes mechanical therapy, consists of 3 phases:
manual treatment of the proximal lymph node regions of
the limb to prepare them and prevent them from becoming blocked or, ideally, complete manual lymphatic drainage; mechanical compression therapy at suitable pressures
depending on the clinical stage of the disease (better if
peristaltic/sequential); application of an elastic support
(stocking, sleeve) or multilayer bandaging appropriately
tailored. Mechanical lymphatic drainage can also be carried out at home in selected cases with the aid of suitable
dedicated equipment.
There are also other types of mechanical devices that
are useful in the treatment of lymphatic insufficiency.
However, specific elements and dedicated probes succeed
in imitating effects more proximal to those obtained with
manual lymphatic drainage rather than acting in a manner similar to equipment with uniform or peristaltic pressures.
Manual lymphatic drainage is carried out following the
classical methods of the German (Vodder-Foeldi) and
Belgian (Leduc) schools. Depending on the case, different techniques of manual lymphatic drainage can be combined. The manual manoeuvres should not be performed
excessively vimedical-lsrously in order to avoid possible
damage to lymphatic and lymph node structures.
The techniques of manual lymphatic drainage are quite
complex; their execution requires expert staff trained in
the subject (universities or accredited centres).
Finally, it is necessary to note again that both lymphatic drainage and elastic compression devices represent
complementary elements in a single therapeutic programme and it is only their synergy that can guarantee
a satisfactory and lasting result. It can therefore be stated
that strict therapeutic coordination of a team specialising
in lymphoangiology should always be employed with appropriate and measured use of the resources of CPT.
45
Gasbarro V et al. (2008) proposed the following therapeutical approach to lymphedema at the CEAP stages:
C1: pre-clinical stage (no clinical signs)
INTENSIVE THERAPY PHASE
2 sessions x week (2 times for a
MLD
month/year)
Compression
multilayer bandage after MLD session
month/year)
MAINTENANCE PHASE
Compression:
MCS 1st class
at home 2 times x week ( 20-40
IPC
mmHg.)
Vascular gimnastic
C2: oedema disappears at rest
IPC
month/year)
Compression
IPC
month/year)
MAINTENANCE PHASE
Compression:
MCS 2nd class
IPC
at home daily ( 30-60 mmHg.)
Vascular gimnastic
C3: stable oedema
MLD
month/year)
Compression
IPC
month/year)
MAINTENANCE PHASE
Compression:
MCS 3rd class
IPC
Vascular gimnastic
C4: fibrotic oedema
MLD
month/year)
Compression
IPC
month/year)
MAINTENANCE PHASE
Compression:
MCS 4th class
IPC
Vascular gimnastic
C5: elephantiasic lymphedema
Compression
multilayer bandage
MAINTENANCE PHASE
Compression:
MCS 4th class
Vascular gimnastic
MLD
20-05-2009 14:33:39
46
COMPRESSION
Recommendations
–– Compression therapy represents a cornerstone in the
treatment of diseases of the peripheral lymphatic system;
this consists of various elements: manual lymphatic
drainage, mechanical lymphatic drainage (IPC), functional elastic bandages and elastic compression devices
which, to obtain the best clinical results, should be appropriately combined to give what is defined internationally as “Combined Physical Therapy - CPT”.
–– In lymphostatic disorders, the initial treatment is
variable in duration depending on the individual
case, and this is followed by maintenance therapy;
in both, the approaches can usefully be combined
with the various “compression” approaches cited
above.
–– For long-term treatment it is essential to prescribe
supports for elastic compression (including custom-
made) and it is also possible to combine use of suitable home mechanical lymphatic drainage devices
(better if peristaltic/sequential in more sectors) in
selected cases with intensive periodic cycles in specialised institutions,.
–– Essential conditions for the success of combined
physical therapy (CPT) and therefore of compression therapy are the availability of medical staff
(clinical lymphologists), nurses and physiotherapists adequately trained and skilled in these therapeutic methods.
–– Therapeutic failure is confirmed only in the case of
failure of intensive nonsurgical treatment conducted in an institution specialised in the treatment of
peripheral lymphoedema under the direction of an
expert clinical lymphologist.
20-05-2009 14:33:39
47
Compression therapy and prophylaxis
of venous thromboembolism
Risk factor stratification
Knowledge of the specific risk factors in groups of patients or in individual patients is the basis of appropriate
use of prophylaxis (Tables VIII-IX). The clinical risk factors are as follows: age over 40 years, prolonged immobility, stroke or paralysis, previous VTE, neoplasia and
related treatments; major surgery (especially operations
on the abdomen, pelvis and lower limbs); trauma (especially fractures of the pelvis, hip or leg); obesity; varicose
veins; cardiac failure; indwelling central venous catheters; inflammatory bowel disease; nephrotic syndrome;
pregnancy or use of oestrogens, with a greater risk from
replacement therapy at menopause compared with the
contraceptive pill.
It has been demonstrated by Wells PS et al. (1997)
that even if the clinical diagnosis of DVT of the lower
limbs is itself unreliable, assessment of the clinical probability in the patient with suspected DVT is recommended after risk stratification for each patient according to standardised criteria (Table X), in order to classify
him to one of the three categories of risk that have a
different probability of actually having a DVT. Attribution to one of these categories allows different diagnostic
paths to be adopted depending on the degree of clinical
probability.
These risk factors are present, often in combination, in
Table VIII – Absolute risk of VTE in hospitalised patients (in the
absence of prophylaxis).
Patient group
Medical diseases
General surgery
Major gynaecological surgery
Major urological surgery
Neurosurgery
Stroke
Hip or knee arthroplasty, hip fracture
Major trauma
Acute spinal cord trauma
Intensive care
VTE prevalence
%
10-20
15-40
15-40
15-40
15-40
20-50
40-60
40-80
60-80
10-80
a high percentage of hospitalised patients. For operated
patients, the incidence of DVT depends on the listed preexisting factors and on factors connected with the surgery,
such as the site, technique and duration of the operation,
type of anaesthetic, presence of infection and time of
postoperative immobilisation. General anaesthesia induces marked vasodilatation and a major reduction in
the rate of venous outflow, which justifies the widespread
Table IX – Risk factors.
General risk factors
––
––
––
––
––
––
––
––
––
––
––
Age >40 Immobility >3 d
Obesity (BMI Body Mass Index ≥ 30 Kg/m2)
Family history of VTE
Previous VTE
Varicose Veins of The Lower Limbs
Thrombophilia
Contraceptive pill
Hormone replacement therapy
Sepsis or shock
Journeys >8 hours
Specific risk factors
–– Anaesthesia
•• General/spinal/epidural anaesthesia
–– Surgical procedure
•• Minor lasting >45 min.
•• Major or pelvic
•• Laparoscopy
–– Gynaecology-obstetrics
•• Pregnancy
•• Caesarean section
–– Orthopaedics
•• Contusions, sprains
•• Fracture of tibia, fibula
•• Femoral fracture
•• Hip fracture
•• Hip, knee replacement
–– Medical diseases
•• Stroke
•• Pneumonia
•• Nephrotic syndrome
•• Cardiac failure
•• Antiphospholipid syndrome
•• Behcet’s disease
•• Myeloproliferative diseases
•• Paraproteinaemia
•• Paroxysmal nocturnal haemoglobinuria
•• Inflammatory bowel disease
•• Leg paresis or amputation
–– Neoplastic diseases
–– Indwelling venous catheters
20-05-2009 14:33:39
48
COMPRESSION
Table X – Assessment of the clinical probability of a diagnosis
of DVT (pretest).
Clinical characteristics
Score
Malignant disease (on treatment currently or
in the previous 6 months)
1
Paralysis, paresis or recent immobilisation of
a lower limb
1
Recent confinement to bed >3days or major
surgery (within 4 weeks)
1
Localised tenderness along the course of the
deep venous system
1
Oedema of all of the lower limb
1
Swelling of the calf >3 cm more than the
contralateral calf
1
Increased pitting in a symptomatic limb
1
Superficial collateral venous circulation
1
Alternative diagnosis (probably at least as
great as DVT)
-2
Total score
FINAL ASSESSMENT:
High probability
Medium probability
Low probability
score ≥3
score 1-2
score 0/neg.
opinion that this in itself presents a risk of VTE greater
than that of other types of anaesthesia.
The role of congenital and acquired thrombophilic
abnormalities (hypercoagulation states) in increasing the
risk of VTE associated with clinical risk factors (especially hospitalisation and surgery) has yet to be clarified.
The thrombophilic abnormalities include: resistance to
activated protein C (factor V Leiden) present in 3-7%
of the general Caucasian population; the G20210A prothrombin mutation present in 2-5% of the general population; antiphospholipid antibodies (anticardiolipin antibody and lupus anticoagulant); deficiency or dysfunction
of antithrombin, protein C, protein S or heparin cofactor
II; dysfibrinogenaemia; a reduction in the levels of plasminogen and plasminogen activators; thrombocytopenia
induced by heparin; hyperhomocysteinaemia, frequently
associated with a mutation of methylene tetrahydrofolate
reductase (MTHFR) present in 8-10% of healthy controls; myeloproliferative conditions such as polycythaemia
vera and primary thrombocytosis. The clinical penetrance
of these thrombophilic conditions and the frequency with
which carriers incur thrombotic events, is variable, being
greatest (60-70%) for antithrombin III deficiency and
decreasing for the other conditions, down to 8-10% of
carriers of the factor V Leiden mutation.
In many patients, multiple risk factors may be present
Table XI – Levels of risk of thromboembolism in operated patients with prophylaxis. Modified from: “Prevention of Venous
Thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines” (8th Edition - CHEST 2008)
Approximate risk
of DVT without
thromboprophylaxis
Levels of risk
Suggested Thromboprophylaxis options
Low risk
Minor surgery* in patients without other risk factors**.
Medical patients who are fully mobile.
<10%
Moderate risk
Minor surgery* in patients with other risk factors; major
surgery*** in patients without other risk factor. Medical
patients, bed rest or sick.
10-40%
LMWH (at recommended doses), LDUH bid
or tid, fondaparinux, ATS o IPC
High risk
Major surgery*** in patients with other risk factor. Hip or
knee arthroplasty, hip fracture surgery. Major trauma, SCI
40-80%
LMWH (at recommended doses),
fondaparinux, oral vitamin K antagonist
ATS/IPC + LMWH
No specific thromboprophylaxis.
Early and “aggressive” ambulation, ATS
VTE risk plus bleeding risk
ATS - IPC
Abbreviations:
ATS antithromboembolism stocking; IPC intermittent pneumatic compression; LDUH low dose unfractionated heparin; LMWH low molecular
weight heparin; DVT deep vein thrombosis; VTE venous thromboembolism.
* Minor surgery: all operations lasting less than 45 minutes with the exception of abdominal surgery
** Additional risk factors: age, weight, varicose veins, previous DVT, neoplasm, thrombophilia, infectious diseases
* ** Major surgery: all operations lasting longer than 45 minutes or abdominal surgery
20-05-2009 14:33:39
Compression therapy and prophylaxis of venous thromboembolism
and the risks are cumulative. For instance, elderly patients
with hip fractures who undergone major orthopaedic surgery and remain immobile in bed after the operation are
the most exposed to fatal PE. Modules for assessing the
risk of DVT have been proposed but these are used rarely
in the medical and surgical departments of our country,
thus preventing clear risk stratification in patients and
consistent and coherent VTE prevention. Knowledge of
the clinical context in which the risk is present has been
defined by epidemiological studies and is equally important in the correct application of the recommendations on
prophylaxis (Table XI). For instance, patients at greater
risk of VTE are those who undergone major orthopaedic
surgery of the lower limbs and those who sustain major
trauma or spinal cord injury.
Effects of compression therapy
in the prophylaxis of VTE
The antithromboembolism stocking
The first studies of the efficacy of the antithromboembolism stocking (ATS) in preventing episodes of VTE
were published by Sigel B et al. in 1973 and 1975. These
defined the optimal pressure at the ankle as 18 mmHg
and the pressure exerted on the thigh as 8 mmHg in the
supine patient. These values have been confirmed as optimal in the prophylaxis of VTE by numerous subsequent
studies and nowadays represent the reference pressure for
all ATS products.
The main mechanism of action for the prophylactic
efficacy lies in the increase in the rate of venous flow at
rest: Partsch H et al. in 1983 and 1985 demonstrated
a significant increase in the venous flow rate with ATS
compared with control groups, using isotope phlebography to measure the average times for Tc microspheres to
pass from the femoroiliac tract and from the vena cava. A
study by Mariani F et al. (2006) shows that a below-knee
ATS (Kit Embol-stop sanaGens®) produces a significant increase in the rate of popliteal and femoral vein flow at rest
and that this rate is further increased by activation of the
muscle pump by dorsiflexion of the foot and by respiratory exercises.
The ATS is today produced with computerised circular looms using hypoallergenic polyamide (Nylon®) and
elastane (Lycra®) threads in different proportions depending on the manufacturing company (for example,
74% polyamide and 26% elastane by sanaGens®; 82%
polyamide and 18% elastane by Ganzoni Sigvaris®, 85%
polyamide and 15% elastane in the T.E.D.® stockings,
Tyco Healthcare Kendall®), has a knitted mesh structure
without seams and is white in colour with an opening
on the foot for inspection. The ATS can be washed and
49
sterilised at 95°C about 40 times. The contraindications
are represented by oedema, hypodermitis, dermatitis in
the acute stage, infective and exudative dermatosis, ulcers
in the florid phase, obstructive arterial disease of the lower
limbs with a peripheral perfusion index (W.I.) <0.55, uncompensated cardiac failure and lower limb dimensions
that do not match the available sizes.
The CEN standard on ATS (European Committee for
Standardisation, draft prEN 12719 “Medical Thrombosis Prophylaxis Stockings”, 1998), which corresponds in
broad outline to the standard for therapeutic elastic stockings (CEN prEN 12718, WG2-CEN TC 205, RAL-GZ
387, French standard NFG 30-102 B), also specifies that:
–– there is a single compression class;
–– the pressure exerted at the ankle is between 13 and 18
mmHg, with a margin of variation of ± 3 mmHg, in
order to have a prophylactic action and so that it can
be worn both day and night without compromising
peripheral arterial perfusion;
–– the graduated pressure profile must be as follows:
100% in B, 80-100% in B1, 60-80% in C, 40-70%
in F and G.
The margin of variation of the exerted pressure of ± 3
mmHg appears excessive objectively and moreover, ATS
produced by different manufacturers do not always comply with the specified pressure levels, as demonstrated by
a study by Thomas S (1992) of 10 different brands of
ATS, where it was found in some that the tolerance limit
even exceeded 20%, with pressures at the ankle between 8
and 27 mmHg, and by a more recent study by MacLellan
DG (2002) of 4 different brands, which found that only
one met the specified standards.
Future regulation will therefore have to reduce the tolerance limits on the one hand and on the other hand control
of production of so important a therapeutic device should be
very strict, as in the case of therapeutic elastic stockings.
Monitoring by the physician or paramedical staff is
therefore fundamental, both at the stage of measuring the
limb circumference and then prescribing the corresponding size (a determining factor in the efficacy of the prophylaxis) and in the choice of ATS brand that will provide
the necessary guarantees of quality.
Scientific publications on the action of ATS in the
prevention of VTE are numerous. The conclusions that
can be reached from an analysis of the literature are as
follows:
–– the ATS should be worn by patients at risk in the periand postoperative period throughout the 24 hours and
for at least four weeks or longer in the case of postoperative complications that prolong the recovery period,
during prolonged confinement to bed and whenever
prescribed and instructed by the physician;
20-05-2009 14:33:39
50
COMPRESSION
–– use of ATS significantly reduces the incidence of VTE
after low and medium risk surgery (grade B recommendation, Guidelines for the diagnosis and therapy of
diseases of the veins and lymphatic vessels - Italian College of Phlebology CIF);
–– the combination of ATS and heparin is more effect
than ATS alone in patients at medium and high risk
(grade B recommendation, Guidelines for the diagnosis
and therapy of diseases of the veins and lymphatic vessels Italian College of Phlebology CIF);
–– the efficacy of the ATS depends closely on the quality
and size prescribed on the basis of the measured circumference of the patient’s limb;
–– significant differences in efficacy have not been found
between different models so that except in particular
cases, use of the below-knee model is sufficient;
–– the ATS is sterilisable (about 40 times) and can be reused by more hospitalised patients;
–– the ATS exerts compression sufficient for VTE prophylaxis only in patients confined to bed and should
therefore by combined with a therapeutic elastic stocking during mobilisation of the patient according to the
following procedures:
a) A MCS 1st compression class should be worn over
the ATS during daily activity and ambulation (not
at rest!) by patients with a low and moderate risk
of VTE in the case of CVI of a mild degree (CEAP
classes 0-1);
b) A MCS 2nd compression class should be worn over
the ATS during daily activity and ambulation (not
at rest!) by patients with a high and very high risk
of VTE and in the presence of chronic and/or lymphatic venous insufficiency of the lower limbs of a
medium to high degree (CEAP classes 2-5);
c) At the physician’s discretion, treatment with MCS
1st-2nd class can be prolonged for treatment of the
CVI of the lower limbs even after suspension of the
antithromboembolism stocking.
Antithromboembolism stockings reduce the incidence of
DVT and increase the protection ensured by LDUH and
LMWH. Patients with malignant disease and other highrisk general surgery conditions have been assessed in sufficient numbers to allow secure conclusions regarding the
efficacy of the ATS in these clinical situations. In some
of the randomised studies, the high-risk patients were
excluded specifically. Other clinical studies are necessary
to assess the efficacy of ATS in these patients. Another
limitation lies in the fact that some patients cannot wear
the ATS effectively because of the dimensions or unusual
shape of their limbs.
Combining ATS and other prophylactic agents, it
appears that greater protection against VTE is obtained
compared with one or the other method applied singly.
The ATS combats venous stasis and increases venous return during abdominal insufflation for laparoscopic procedures. In a recent non-controlled study, a 2% risk of
DVT was demonstrated with duplex ultrasound in patients undergone laparoscopic cholecystectomy or minilaparotomy when LMWH, intraoperative IPC and ATS
were combined, which was significantly diminished compared with controls.
A meta-analysis of the studies published between 1966
and June 1992 identified 35 randomised trials among
122 articles, only 12 of which were considered suitable
for analysis. In 11 of these, the prophylaxis concerned
medium-risk surgery (abdominal, gynaecologic, neurosurgery); only one included high-risk orthopaedic surgery: use of the stockings resulted in a significant reduction of the risks.
The Consensus Conference, issued by the International Union of Phlebology in San Diego in August 2003 and
published in Vasa in 2004 under the title “Evidence based
compression therapy”, concludes that from an analysis of
the data in the literature, ATS are effective in reducing the
risk of VTE in hospitalised patients with a recommendation level of A-B. The main publication referred to is that
of Amarigiri SV and Lees TA (2003) which analyses the
results of 9 randomised controlled studies of the efficacy
of ATS alone and in combination with other methods
versus placebo.
However, the data should be assessed with caution since
patients at high risk were specifically excluded in some of
the randomised studies. Other clinical studies are necessary to assess the efficacy of antithromboembolism stockings in these patients. Combining the stockings with other prophylactic agents, it appears that greater protection
against VTE is obtained compared with one or the other
method applied singly: there is favourable evidence in randomised controlled studies for the combination of ATS
and PC combined with low-dose unfractionated heparin
(LDUH) or low molecular weight heparin (LMWH).
The ATS is intended for patients who are confined to
bed and does not exert effective pressure when the patient is sitting or standing or during movement; it must
therefore be combined with or replaced by a therapeutic
stocking of a suitable class at the time of mobilisation if
there are risk factors in addition to the surgical operation
such as thrombophilic conditions or varicose veins of the
lower limbs (Struckmann JR et al. 1986, Cooke EA et al.
1996, Partsch H et al. 2000).
Bandaging
There are no significant data in the literature on the
preventive efficacy of bandaging of the lower limbs in the
prevention of VTE, despite the frequency with which it
20-05-2009 14:33:39
is used. The effects of bandaging on the venous and microvascular tissue system and in the treatment of superficial (SVT) and deep (DVT) venous thrombosis are well
known, but we have insufficient data on VTE prevention
in patients at risk. Moreover, application of the bandages
is closely operator-dependent and up to now there are no
reliable and reproducible clinical methods for measuring
the exerted pressure in every patient and its uniformity
and graduation in the bandaged limb; to this is added
the deterioration of the applied material (greater than
that of the ATS) and the drop in pressures exerted a few
hours after application (Raj TB et al. 1980; Partsch H et
al. 2000).
Bandaging may therefore be indicated in the prevention
of VTE only if carried out by highly skilled staff.
Pneumatic compression (IPC) is one of the preventive
methods used most often in the USA. It produces a significant increase in the rate and volume of venous flow in all
segments; in particular it is significantly higher compared
with simple elevation of the lower limbs in the patient
who is confined to bed (Lurie F et al. 2003). It also causes
an increase in tissue tcPO2, stimulates microcirculatory
vasomotor activity and fibrinolytic activity, though to a
lesser degree compared with pharmacological therapy.
IPC is utilised in the prevention of DVT in patients at
risk in conjunction with surgery or prolonged confinement to bed. The significant reduction in the incidence of
thromboembolic phenomena has been well demonstrated
by numerous studies, among them those of Hull RD et al.
(1990) and Pidala MJ et al. (1992). Only a few compared
IPC with the ATS; the results did not demonstrate highly
significant differences although slight superiority of the
IPC was recorded in operated patients. The combination
of IPC and heparin improves the results compared with
use of the two methods singly. Ramos R et al. (1996) in
2551 patients undermedical-lsing cardiac surgery demonstrated a reduction in the incidence of pulmonary embolism of 62% between patients treated with heparin alone
and those who also had IPC (reduction in incidence from
4% to 1.5%).
Thrombosis prophylaxis in surgery is usually carried
out with the following parameters even though there are
no definitive data in the literature in this regard:
–– minimum pressure of 35 mmHg, maximum 60
mmHg;
–– chamber inflation time between 10 and 35 sec, more
often between 10 and 12 sec;
–– deflation time of about 60 sec.
The treatment is carried out from the time of entering the operating theatre until active mobilisation of the
51
patient and is repeated for at least two weeks in patients
who are confined to bed.
Apart from the actual contraindications to compression therapy, patients who require surgery on the lower
limbs cannot use IPC on the operated limb, although the
boot can be applied on the non-operated limb or only
as far as the knee, with the therapeutic action remaining
practically unchanged.
The principle of action of plantar pneumatic compression (PPC) is based on the action of a pneumatic plantar
pad that produces intermittent pressures that can empty
the plantar venous plexuses. The pad acts only on the sole
of the foot and the pressures are of the order of 100-160
mmHg; the duration of the cycle is very short, corresponding to the contact time of the sole of the foot with the
ground during walking, and is from 0.4 to a maximum of
2 seconds, with an overall time between insufflation and
deflation of about 20 seconds. Although the method is
rarely used on its own, it has demonstrated efficacy in increasing the rate of venous flow, reducing venous oedema
and in the prophylaxis of VTE but the studies that have
been conducted are too small to allow significant conclusions to be drawn.
Compression therapy in
the prophylaxis of VTE
in patients at risk
General surgery
The incidence of DVT in general surgery in the absence of prophylaxis varies between 15 and 30%, with
a rate of fatal PE between 0.2 and 0.9%. The actual risk
of VTE occurring is still not defined today because comparative studies with patients without prophylaxis are fortunately no longer conducted. The additional major risk
factors, apart from the different surgical procedures, are
represented by:
1. previous episode of VTE, obesity, varicose veins, use of
oestrogens, cancer;
2. advanced age (>60 years);
3. type of anaesthesia (< risk for spinal/epidural anaesthesia);
4. poor possibility for postoperative mobilisation, dehydration, need for transfusion.
Antithromboembolism stockings (ATS) reduce the
incidence of DVT and increase the definite protection
provided by heparin but the available data are too few
because it is not possible to fully assess the effect on proximal DVT and on PE. Patients with malignant disease and
other high-risk general surgery conditions have not been
20-05-2009 14:33:39
52
COMPRESSION
assessed in sufficient numbers to allow secure conclusions
regarding the efficacy of ATS in these clinical situations.
In some of the randomised studies, high-risk patients
were specifically excluded. Other clinical studies are necessary to assess the efficacy of ATS in these patients. Better
protection against VTE is obtained by combining ATS
with other prophylactic agents compared with one or the
other method applied singly. It has been shown that the
ATS interferes with venous stasis and increases venous
return during abdominal insufflation for laparoscopic
procedures.
Pneumatic compression (IPC) is an effective preventive method which should be regarded as first choice together with ATS when there is a risk of severe haemorrhagic complications. Various studies have demonstrated
that IPC is effective in reducing DVT in general surgery
patients with malignant disease. In studies in which IPC
was compared with LDUH, both agents produced similar reductions in the incidence of DVT. Plantar pneumatic compression (PPC), utilising the foot vein pump,
produces haemodynamic effects on the emptying of the
lower limbs similar to those of IPC and like it appears to
stimulate fibrinolytic activity. However, as far as we know
there are no studies of these methods in general surgery
patients.
A suitable prevention strategy in general surgery should
take into account the risk of VTE and the efficacy of various agents in reducing the risk as well as the ensuing costs
and the possible complications of each method.
In low-risk patients undergoing minor or relatively
short surgical procedures, aged <40 years and without
other risk factors, specific prophylaxis is not necessary
apart from early ambulation. Some large-scale studies
document a risk close to zero for the development of
clinically manifested VTE after minor surgery in low-risk
patients.
In patients at medium risk aged >40 years or undergoing major surgery but without other clinical risk factors, LDUH administered once a day (5000 IU every 12
hours) or LMWH (≤3,400 IU every 24 hours) or ATS
used correctly could be sufficient. IPC is a reasonable
alternative, even if it involves management problems and
the cost of the equipment, and it should be provided to
each patient at least throughout the hospitalisation period
and be combined with an elastic stocking on mobilisation.
For patients >60 years of age undergoing major surgery
who have other risk factors, various effective methods are
available for prophylaxis. LDUH administered every 8 or
12 hours and LMWH at doses above 3500 IU every 24
hours is effective. The addition of ATS or IPC to one of
these methods ensures further protection and is always
obligatory in patients at risk of haemorrhage, at least until
this risk is reduced and pharmacological prophylaxis can
also be used at the same time.
The “International Consensus Conference on Compression Therapy”, issued by the French Society of Phlebology
(2003), recommends the use of ATS in the prevention of
VTE in medium-risk general surgery patients (grade A).
In general surgery patients with multiple risk factors,
combination of the most effective pharmacological methods with IPC or ATS offers excellent protection. Higher
daily doses of LMWH (>3,400 IU), such as those often
used in orthopaedic surgery, would likewise be indicated.
The problem of the duration of prophylaxis after the
hospitalisation period has not yet been solved; some studies show that prolonged prophylaxis with LMWH for 3
weeks after discharge from hospital seems not to reduce
significantly the incidence of DVT. The question of the
duration of thrombosis prophylaxis in general surgery
should be reassessed at this point in view of the currently
ever shorter duration of hospitalisation. A study by White
RH et al. (2003), conducted on 1,653,275 procedures of
various types, shows that, as regards abdominal surgery,
the incidence of DVT after discharge from hospital is
from 0.9% for splenectomy to 0.1% for appendicectomy
or laparoscopic cholecystectomy, versus an overall incidence of 1.6% and 0.2% for the procedures, whereas in
the case of abdominal surgery because of cancer, the values range from 1.7% for surgery of the colon to 0.9%
for rectal surgery, versus 2.6% and 1.5% overall. The size
of the problem is thus not negligible: about 50% of cases
of VTE are found after discharge, and review of the duration of prophylaxis strategies is needed. The problem of
extending prophylaxis after discharge following major abdominal surgery was addressed in the “Enoxacan 2” study
in 2002. Patients were randomised after treatment with
enoxaparin for one week to receive enoxaparin or placebo
for a further 21 days. A statistically significant reduction
in DVT on phlebography was observed, from 12% in the
placebo group to 4.8% in those treated with LMWH. Finally, it can be stated that, based on the available evidence
and in the absence of an optimal prophylaxis regimen,
VTE prophylaxis should be started before the surgical
operation and continued for at least 4 weeks at least in
cancer patients. ATS are useful and may increase the efficacy of pharmacological prophylaxis in these patients and
together with IPC they are an alternative in patients with
active haemorrhage or at high risk of haemorrhage.
The majority of patients who have day surgery fall into
the low, moderate and high risk categories, with the first
two predominating so, since they benefit from early mobilisation, prevention of thromboembolic episodes with
physical methods (ATS, IPC, PPC) should be employed
frequently and systematically according to risk stratification, given the efficacy, ease of use and low cost (the ATS
20-05-2009 14:33:39
appears to meet these criteria the best). In patients at high
risk of bleeding, and also if they have a medium and high
risk of venous thromboembolism, early ambulation combined with use of ATS or IPC is recommended (grade
A recommendation according to the instructions in the
majority of current guidelines: ACCP 2001-2004-2008,
SIAPAV-SIDV-SISET-GIUV 2000, SISET 2002, CIF
2001-2003-2004).
Oncological surgery
There are numerous controversies in the area of oncological surgery.
Some studies demonstrate the efficacy of compression
therapy in combination with pharmacological therapy in
the prevention of VTE; others deny the efficacy of pharmacological therapy in favour of compression therapy
alone in the prevention of thromboembolic events in
these categories of patients, and other still support the use
of compression therapy only in patients in whom anticoagulant therapy is absolutely contraindicated.
The clinical evidence suggests the need for further and
more precise identification of the thrombotic risk in oncology. New staging is needed that involves thromboembolic risk categories adapted to the type and staging of the
patient’s malignancy.
At present, it is appropriate to regard the cancer patient undergoing surgical procedures as at least moderate
or high risk and to integrate this with the specific surgical
risk.
Cardiac surgery
Patients undergoing cardiac surgery in the form of
CABG (coronary artery by-pass graft) or valve replacement, have a very low incidence of symptomatic DVT
(0.7%). However, the incidence of asymptomatic thromboembolic events in cardiac surgery patients is surprisingly higher. The low incidence of symptomatic VTE
after CABG is somewhat understandable. Dyspnoea with
possible desaturation is often attributed to the precarious
physical condition, episodes of atelectasis and/or pre-existing left ventricular dysfunction. Undoubtedly, in the
majority of patients who suffer “sudden death” within the
first thirty days after the cardiac surgery, the death is due
to PE in the absence of premonitory clinical symptoms
or signs. The clinical diagnosis of DVT in these patients
is difficult as the oedema in the lower limbs is attributable to the surgical trauma of saphenectomy to provide
the aortocoronary bypass grafts; the muscle cramps reported by the patients are often due to the perioperative
immobility. Rarely, DVT is suspected in the contralateral lower limb from the saphenectomy. In a randomised
clinical trial conducted in 330 patients who underwent
CABG, DVT was diagnosed with diagnostic ultrasound
53
methods in 20% of cases (67 patients). In 56 of these patients (84 %) the thrombosis was distal and located at calf
level, whereas the thrombosis was proximal in 11 patients
(16 %). Only one patient developed a proximal symptomatic DVT. These data show that the majority of patients
develop an asymptomatic and distally located DVT after cardiac surgery with a ratio of 5 to 1. Moreover, the
symptomatic DVT found in 1% of operated patients
can be manifested directly as a fatal PE. In the United
States, about 500,000 CABG operations are performed;
approximately 100,000 patients develop a DVT, 84,000
of which are isolated in the calf and 16,000 at a proximal
level. Only 10,000 patients develop symptoms and clinical instrumental diagnosis is definitive. Between asymptomatic and symptomatic patients, the incidence of mortality due to thromboembolic complications is about 1%
and 2-4% respectively. Thus, about 1100-1300 patients
die postoperatively of PE each year in the United States.
These deaths are incorrectly attributed to episodes of arrhythmia or myocardial reinfarction.
The most greatly feared complication of pulmonary
embolism should also be recalled, namely, chronic disability due to pulmonary hypertension secondary to
thromboembolic phenomena. PE and DVT constitute
the fifth most common cause (about 6.3%) of readmission within the first thirty days postoperatively. It has
been seen that of 5451 patients with DVT confirmed
with ultrasound methods, only 42 % had received prophylaxis within the last thirty days prior to the diagnosis of
the thrombotic event. This indicates the importance of
early diagnosis of DVT for the purpose of rapid treatment and accurate stratification of the cardiovascular risk.
Clinical diagnosis of DVT is not specific or sensitive. In
view of the unreliability of the clinical signs of DVT, use
of instrumental diagnostic methods such as non-invasive
Doppler ultrasound is necessary to investigate the iliacfemoral, subpopliteal and superficial venous circulation.
Thromboembolic disease and its consequences have significant weight both in general terms of public health and
in social costs due, for example, to the post-thrombotic
venous syndrome. Correct prophylaxis of patients who
have undergone cardiac surgery should involve a reduction in health costs as well as a lower incidence of postthrombotic complications.
Various strategies can be utilised to prevent VTE episodes after CABG or valve surgery. Both mechanical and
pharmacological prophylaxis can be employed, or a combination of the two. Prophylaxis of the mechanical type
is provided by devices such as the ATS and IPC. The antithromboembolism stockings increase the rate of venous
flow and prevent venous stasis in the lower limbs. They
are inexpensive medical devices that are easy to use and
free from serious complications. Venous stasis can also be
20-05-2009 14:33:40
54
COMPRESSION
prevented by means of inflatable boots that induce intermittent pneumatic compression of both lower limbs. By
insufflation of air into cuffs in a centripetal direction, ICP
prevents peripheral venous stasis and causes stimulation
of local and systemic endogenous fibrinolysis, and is indicated particularly in patients transferred to the intensive
therapy unit.
What is the practical approach for preventing PE after
CABG or valve surgery? Both mechanical devices, ATS
and IPC, can be used immediately in the postoperative
period. The ATS reduces the frequency of venous thrombosis and should therefore be regarded as prophylaxis par
excellence against PE except for patients suffering from
critical peripheral vascular disease. There is level 1 evidence of the real efficacy of ATS but protection against
fatal PE events has not been adequately confirmed by
sufficiently large studies. This limitation also applies to
IPC. IPC is very useful in intensive care units where the
patient’s compliance can be monitored promptly. Pharmacological prophylaxis should be regarded as a routine
method of prevention after CABG. In fact, in current
clinical practice, VTE thromboprophylaxis consists of the
use of mechanical means (ATS, IPC) and early mobilisation, with pharmacological prophylaxis only in case of
clinical suspicion of thromboembolic risk. Acetylsalicylic
acid and clopidogrel are prescribed routinely after percutaneous angioplasty with coronary stenting, while the
majority of patients who underwent CABG take low-dose
aspirin for secondary prevention of cardiovascular disease.
Even though a meta-analysis has shown that aspirin on
its own is not effective for thromboembolic prophylaxis
if compared with other pharmacological therapies, conversely there are trials which have demonstrated the prophylactic benefit of using it after general and orthopaedic
surgery. After cardiac surgery, because of the existence of
probable “resistance” to simultaneous use of both drugs
(aspirin and clopidrogel), there is a need for them to be
adjusted therapeutically or for an alternative treatment.
Oral anticoagulant therapy (warfarin) in the immediately
postoperative period is recommended only in well selected
cases (mechanical valves, presence of large left ventricular
thrombus), where the benefits largely exceed any haemorrhagic risks following cardiac surgery. A preliminary multicentre study is underway to determine the efficacy of
LMWH used in the immediate postoperative period as a
bridge to warfarin therapy in patients undermedical-lsing
mechanical valve replacement.
Vascular surgery
The majority of surgical patients should receive perioperative prophylaxis according to the published recommendations and guidelines. It has been broadly demonstrated that intraoperative anticoagulant therapy with
intravenous heparin sodium provides adequate protection
against thromboembolic events. Systematic use of intraoperative heparin sodium during elective aortic reconstruction, besides reducing the risk of arterial thrombosis
in the prosthetic graft and especially of myocardial infarction in the postoperative period, also has a prophylactic
effect on VTE, resulting in a lower perioperative risk of
DVT when compared with other major intra-abdominal
general surgical procedures. Thromboprophylaxis of vascular surgery patients, despite all this, is still controversial for the simple reason that the incidence of DVT in
the lower limbs in the postoperative period is regarded as
low. A few studies have demonstrated a high incidence
of postoperative DVT (equal to 32 %) in patients undergoing vascular procedures of the aortic and/or peripheral type without adequate prophylaxis. The limitation
of these studies is the small population cohort examined
so that the results obtained preclude any generalised
recommendation. In fact, the results show that there is
an urgent need for further randomised clinical trials to
determine the correct therapeutic strategy for preventive
purposes. Patients who underwent vascular surgery are
at high risk of developing episodes of VTE. In vascular surgery, the potential risk factors are advanced age,
critical ischaemia of the lower limbs, excessive duration
of the surgical procedure and damage to the vein wall.
The incidence of DVT after aortoiliac or aortofemoral
surgery is similar to that observed with other abdominal or pelvic surgical procedures. Naturally, these studies
excluded patients with a previous history of DVT and/
or PE or who underwent non-elective surgery or carotid
vascular or varicose surgery. For thromboembolism risk
stratification in vascular patients, therefore, any disability
on walking due to disabling claudication with a walking
distance of 50 metres or less is fundamental, in addition
to age, sex, the presence of varicose veins, any history of
thrombophilia, use of antiplatelet or anticoagulant therapy. Libertiny G and Hands L in a study conducted in
patients with disabling peripheral vascular disease documented a preoperative DVT in 19.6% of the enrolled patients. The preoperative propensity of patients with critical peripheral ischaemia to develop DVT is due to high
levels of homocysteinaemia and a generalised state of hypercoagulability as well as the prolonged immobilisation
resulting from the vascular disability. It is now certain
that immobilisation involves a greater incidence of DVT
and this is why early revascularisation is recommended
in the case of critical ischaemia, not only for limb salvage
but also to reduce the risk of VTE to a minimum, while
improving the claudication and ambulatory disability in
the broad sense.
Even though the ideal prophylactic regime still
remains elusive, it is certain that patients given phar-
20-05-2009 14:33:40
macological prophylaxis with LDUH or LMWH and
possibly with mechanical prophylaxis have a lower risk
of developing thromboembolic events. Patients who
underwent major vascular surgery procedures and who
have additional risk factors should receive adequate
antithrombosis prophylaxis with LDUH or LMWH.
Even though the optimal time for starting anticoagulant prophylaxis has not yet been well established, the
majority of surgeons prefer to give the first dose after the
surgical procedure. As regards patients having infrainguinal vascular surgery (femoro-popliteal, femoro-tibial,
femoro-femoral, iliaco-femoral, axillo-femoral bypass,
reoperation because of bypass thrombosis and grafting
for popliteal aneurysm), in view of the low incidence of
DVT (2.8%) in the postoperative period, anticoagulant
prophylaxis is not recommended unless strictly required
for specific indications regardless of the risk of VTE. On
the other hand, it is recommended for patients undergoing major amputation. The incidence of DVT following
revascularisation procedures is in fact 9.1%, compared
with 14.3% in the case of ablative procedures such as
above-knee amputation. LMWH can play an effective
role. However, there is so far no definite evidence regarding the antithromboembolism therapeutic strategy for
patients undergoing endovascular treatment of abdominal aortic aneurysms.
Vascular surgery of the superficial and deep venous
system should, in contrast, always be preceded and followed by compression therapy. The incidence of symptomatic VTE after superficial venous surgery is difficult to
assess for the reasons described above for arterial surgery
but in general it can be stated that prophylaxis should
be carried out according to the criteria defined in general
surgery, bearing in mind that varicose veins are a known
additional risk factor. Optimising the prophylaxis of patients at higher risk should involve the use of unfractionated heparin -LDUH- or low molecular weight heparin
-LMWH- with ever broader recourse to the use of graduated compression elastic stockings.
Gynaecological surgery
VTE is an important and potentially avoidable complication after gynaecological surgery. The overall incidence of DVT is similar or slightly lower than that associated with general surgery. Using labelled fibrinogen
as a diagnostic test, the reported frequency of postoperative DVT in 19 studies involving 2,268 patients who
underwent gynaecological surgery without prophylaxis
was between 4 and 38%, with a mean of 16%. Fatal PE
was reported in 0.4% of a cumulative sample involving
>1,000 unprotected patients. The factors that appear to
increase the thromboembolic risk most after gynaecological surgery are similar to those for general surgery such as
55
advanced age, previous DVT/PE, malignant disease and
abdominal surgery (as opposed to vaginal). In particular,
patients with gynaecological malignancy have a substantially increased risk of DVT as many of these patients are
elderly; in some there may be compression of major veins
by a pelvic mass; they are exposed to injury of the venous
intima during the operation, especially when dissection of
the pelvic lymph nodes is performed; the operations are
often long; postoperative mobility is often compromised
and chemotherapy is itself thrombogenic. As in other
surgical patients, even if the thrombus generally begins
to form during or shortly after the operation, a marked
percentage of symptomatic events occurs after discharge
from hospital (1.1% after discharge compared with 2.3%
in total, according to the study by White RH cited above).
When the incidence of fatal PE in prospective studies of
7,000 gynaecological surgery patients is added up, a 75%
reduction in risk is obtained with the use of thromboprophylaxis (from 0.4 to 0.1%).
However, rational prophylaxis is always based on
knowledge of the risk factors: gynaecological surgery,
compared to other types, has a few peculiarities that make
the risk of VTE relevant: in the first place, hormonal
contraception or hormone replacement therapy, which
increases the risk about fourfold, and the operations are
performed in particular anatomical regions for diseases
that involve important venous drainage regions. The risk
stratification proposals can be summarised according to
the International Consensus Statement (Tab.XII) which is
the one most widely utilised. In it a distinction is made
between vaginal and abdominal surgery, oestrogen therapy in young women is regarded as an additional risk
factor and a high risk is found in the case of malignant
disease or previous DVT.
Studies on patients undergoing gynaecological surgery
for benign disease have shown that antithromboembolism stockings ensure greater protection against DVT
compared with the absence of prophylaxis. Randomised
studies assessed IPC in patients undergoing gynaecological surgery. The use of IPC on its own during the surgery
and in the first 24 hours after the operation was not effective, whereas continuing the prophylaxis with IPC for
at least five days after the operation was highly effective
compared with controls and ensures protection similar to
that of LDUH.
The risk classification and recommendations for
prophylaxis described in tables IX-XI are applicable in
gynaecological surgery. The risk of VTE in conjunction
with laparoscopy has not yet been well defined and therefore it is recommended that prophylaxis be carried out
after assessment of the patient’s individual risk; when risk
factors are present, the choice can be made indifferently
between LDUH, LMWH, ATS or IPC.
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56
COMPRESSION
Table XII – Risk of VTE in gynaecological surgery. Modified from: International Consensus Statement (1997).
Risk
Surgery*
Age
Risk factors
Low risk
Minor
Major
<60 years
<40 years
None
None
Medium risk
Minor
Minor
Major
Major
>60 years
<60 years
<40 years
40-60 years
None
Oestrogen therapy, cancer, previous VTE
Oestrogen therapy
None
Major
Major
Any type
<60 years
>60 years
Any age
Cancer, previous VTE
None
Thrombophilic state
High risk
*Minor surgery: vaginal access <45 min; mayor surgery: vagina access >45 min, abdominal access.
In brief, the following can be recommended:
–– low risk: no pharmacological treatment, early mobilisation and possibly elastic compression with ATS (especially in patients with difficulty in mobilisation, for
instance, elderly patients);
–– medium risk: LDUH 5000 IU every 12 hours (the first
injection 2 hours before the surgery) or LMWH 2000
to 3500 IU anti-Xa, depending on the product, once
a day (the first dose 2-4 hours before the surgery) and
IPC/ATS;
–– high risk: LDUH 5000 IU three times a day (the first
injection 2 hours before the surgery) or LMWH 3800
to 5000 IU anti-Xa, depending on the product, once
a day (the first dose 10-12 hours before the surgery)
and IPC/ATS.
In patients operated because of malignant disease,
prophylaxis with LMWH and elastic compression is recommended for at least one month, and continued during
any radiotherapy.
Urological surgery
Thromboembolic events are regarded as the most important non-surgical complication of major urological
surgery. A percentage ranging from 1 to 5% of patients
undergoing major urological surgery has a DVT and a
fatal PE is found occasionally (risk less than or equal to
1/500). The factors that increase the risk of DVT in these
patients are open surgery (compared with transurethral),
malignant disease, more advanced age, general anaesthesia (compared with regional) and the duration of the operation.
Only a few randomised studies with adequate methodological criteria have been published in the past decade:
Belcaro G and Nicolaides A (1994) demonstrated that
LDUH and IPC are effective prophylactic measures in
reducing the incidence of VTE (about 50%), confirming
the studies by Coe NP et al. in 1978 and Salzman EW et
al. in 1980; Soderdahl DW et al. (1997) and Donat R et
al. (2002) demonstrated the activity of antithromboembolism stockings and IPC without finding significant differences between one method and the other.
The use of ATS or IPC is effective in urological surgery
as in general abdominal and pelvic surgery, and likewise,
combining mechanical prophylaxis with pharmacological
will provide greater protection compared with one or the
other method on its own.
The risks of VTE are low in patients undergoing
transurethral prostatectomy and there may be a greater
risk of haemorrhage with the use of perioperative LDUH
or LMWH. Early postoperative mobilisation and the use
of ATS is probably the only intervention justified in these
and other patients undergoing low-risk urological surgery.
Routine prophylaxis is recommended for more extensive open surgery, such as radical prostatectomy, cystectomy or nephrectomy, especially in the presence of malignant disease. Until we have further data, the treatment of
patients at high risk should be based, as in general surgery,
on the use of LDUH, ATS, IPC, LMWH and a combination of mechanical and pharmacological methods.
Urological patients undergoing major open surgery
should be given pharmacological treatment with LDUH
every 8/12 hours; an acceptable alternative is the use of
ATS or IPC or LMWH. In patients with multiple risk
factors, combined use of ATS and/or IPC with LDUH or
LMWH is recommended, bearing in mind the fact that
in those at high risk of haemorrhage, mechanical prophylaxis should be regarded as obligatory, at least until the
risk of haemorrhage is reduced.
Laparoscopic surgery
Laparoscopic techniques are associated with moderate
activation of coagulation and fibrinolysis, and the use of
pneumoperitoneum and the patient’s intraoperative position increase venous stasis. The low availability of clinical,
epidemiological and prospective studies does not allow
definitive conclusions to be drawn on the incidence of
VTE and better prophylaxis but the Society of Ameri-
20-05-2009 14:33:40
can Gastrointestinal Endoscopic Surgery recommends
the same prophylaxis as that followed for surgical procedures while the European Association for Endoscopic
Surgery recommends the use of intraoperative IPC or
ATS throughout the procedure. In patients undergoing
laparoscopic surgery with additional risk factors, prophylaxis using a method chosen from LDUH, LMWH or
ATS/IPC is recommended.
Orthopaedic surgery
Based on the results of phlebography performed on
control patients or patients randomised to receive placebo, the total prevalence of DVT in the absence of prophylaxis 7-14 days after total hip arthroplasty (THA), total
knee arthroplasty (TKA) and hip fracture surgery is 4060%. The incidence of PE is less definable (3-28% in the
first two weeks), even if it has been greatly reduced since
routine use of prophylaxis became widespread (1.5-10%
in the first three postoperative months). The incidence
of proximal DVT is about 25%, 15-20% and 30% in
surgery for THA, TKA and hip fracture respectively. Although the operated leg is involved most commonly, the
other leg is affected in about 20% of THA patients and
about 14% of TKA patients. New DVT and PE after discharge from hospital are equally common. Phlebographic
studies indicate that without prophylaxis after discharge,
10-20% of patients have a new episode of DVT within
4-5 weeks of discharge from hospital and about 6% have
pulmonary scintigraphy with an intermediate or high
probability of PE
Knee arthroscopy
Diagnostic arthroscopy and arthroscopic surgery of
the knee are today among the most frequent orthopaedic
surgical procedures and are performed on young patients;
nevertheless, we have few data on the risk of VTE. In
the absence of prophylaxis, the incidence of DVT varies
between 2 and 18%, with a higher risk for therapeutic
arthroscopy. The duration of intraoperative torsion, together with the complexity of the surgery and possible
need for firm compression with a tourniquet to obtain
a bloodless surgical field, are risk factors that must be
taken into account in the overall assessment of the risk
of VTE. In cases where venous stasis is prolonged, use
of ATS during the operative and convalescent period is
advisable until complete mobilisation, even if there are so
far no randomised studies on the prophylactic efficacy of
ATS or IPC.
Elective THA surgery
Various non-pharmacological methods of prophylaxis
have been studied in TKA patients, among them ATS,
IPC and early ambulation. All of these methods offer a
57
certain benefit, ensuring reductions in the risk of DVT
from 20 to 70%, but with little effect on the levels of
proximal DVT. Some studies suggest that PPC may be
moderately effective in diminishing overall DVT. Nevertheless, since the available data on the use of PPC are
limited and the figures for proximal DVT incidence seem
to be higher compared with those found with current
prophylaxis using anticoagulants, this method cannot be
recommended for primary prophylaxis.
Elective TKA surgery
From the aspect of onset of VTE, knee arthroplasty
differs from THA in various important ways. Without
prophylaxis, the overall incidence of DVT is greater with
TKA compared with THA. Prophylactic measures employed successfully in THA have significantly lower efficacy in TKA patients. The results of some studies indicate
that IPC is effective prophylaxis in TKA patients. This
technique is most effective if it is applied during the operation or immediately afterwards and if the pneumatic
boots are worn continually at least until the patient has
resumed full ambulation. Use of IPC is limited by poor
patient compliance and patient intolerance, significant
costs and the impossibility of continuing the prophylaxis
following discharge from hospital. IPC can be useful as a
complementary hospital treatment in addition to prophylaxis regimes based on anticoagulants and ATS.
For patients with other risk factors for postoperative
VTE, obligatory combined prophylaxis should be considered: IPC and LMWH and use of ATS on suspension
of the IPC.
Surgery for hip fracture
The incidence of extensive or proximal DVT after a
hip fracture (HFS) is 50% and 27% respectively without prophylaxis, based on prospective studies in which
phlebography was performed routinely. These figures are
similar to those obtained in patients having hip and knee
arthroplasty. Fatal PE is more common in patients with
a hip fracture than after elective arthroplasty and ranges
from 1.4 to 7.5% within three months of the event. In an
autopsy study of 581 patients who died after a hip fracture from 1953 to 1992, PE was the fourth cause of death
in order of frequency, representing 14% of all deaths.
The factors that further increase the incidence of VTE in
patients with a hip fracture include age, trauma, delays
in admission to hospital or in performing surgery and
the use of general anaesthesia (compared with regional
procedures). The site of the fracture (subcapital or intertrochanteric) does not appear to be important. The risk
of death following a hip fracture is reduced significantly
in patients who are given pharmacological prophylaxis.
These data bear out the recommendation that routine
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58
COMPRESSION
VTE prophylaxis should be guaranteed in all patients in
whom surgery for hip fracture is performed.
In a clinical study, the incidence of VTE was significantly reduced in a group that had postoperative PC
compared with placebo. Moreover, studies comparing PC
with other prophylaxis regimes have not been conducted.
The evidence we have is insufficient to allow recommendation of the use of ATS or IPC in hip fracture, even if
these methods have been shown to reduce the incidence
of DVT.
Elective surgery of the spine
The incidence of thromboembolic complications after
elective surgery of the spine is not known. The majority
of available studies are retrospective, of limited size and
defective methodologically. Symptomatic VTE and fatal
PE are sometimes observed in these patients despite the
use of aggressive mobilisation and prophylaxis with IPC
and/or ATS.
Duplex ultrasound identified DVT in 3% of 554 patients in 6 prospective studies all of which used mechanical prophylaxis routinely. It is not known whether or not
mechanical prophylaxis has a protective effect on the incidence of DVT in this group of patients as none of the
studies was controlled. In one clinical study, symptomatic
thromboembolic events were not found in any of the 110
patients who had been randomised to receive prophylaxis
with ATS only, ATS + IPC or ATS + warfarin.
Since there are few data regarding thromboprophylaxis
after surgery on the spine, specific recommendations cannot be made. However, it appears reasonable to use ATS
alone, LDUH alone or both in combination in patients
with further risk factors; intraoperative and postoperative
IPC may also be effective. Certainly, in patients undergoing surgery of the spine with other thromboembolism
risk factors, prophylaxis with at least one of the above
methods is suggested.
Neurosurgery
Patients who undergoing elective neurosurgery have
a high risk of postoperative DVT and PE. Randomised
studies that include a broad range of neurosurgical patients showed that 22% of these patients had signs
of DVT on the labelled fibrinogen test and 5% had a
proximal DVT. The risk factors that appear to increase
the incidence of DVT in neurosurgical patients include
intracranial surgery (as compared with spinal), malignant
disease (compared with benign), the duration of the operation and advanced age. Patients with brain tumours
are at particularly high risk of VTE (31% in patients operated because of glioma), both during the operation and
in the subsequent follow-up.
Physical methods of prophylaxis are frequently recom-
mended in neurosurgery, both because intracranial or spinal haemorrhage can occur with the use of pharmacological prophylaxis and also because they have demonstrated
marked preventive efficacy. IPC and ATS appear to be
very effective in preventing DVT in these patients, with
a mean reduction in risk of 68% compared with controls
(incidence from 21 to 7% in randomised studies). One
study conducted in 2,643 neurosurgical patients who
had prophylaxis with ATS and IPC found DVT in 6%
of cases. Turpie AGG et al. found a similar incidence of
DVT in patients with ATS compared with those with
combined AST and IPC (both methods were more effective than no prophylaxis).
The two major studies on prophylaxis in neurosurgical patients compared use of ATS alone with combined
ATS and LMWH started after the operation. Both studies employed phlebography routinely for screening, and
both demonstrated a significant reduction in the risk
with combined prophylaxis compared with ATS alone.
In the study conducted by Nurmohamed MT et al. the
incidence of DVT and proximal DVT in patients with
ATS was 26% and 12%, whereas patients with ATS +
LMWH demonstrated rates of 19% and 7% respectively.
In a double-blind study conducted by Agnelli G et al. the
incidence of DVT and proximal DVT was 33% and 13%
for the group wearing ATS only compared with 17% and
5% in the group that received combined prophylaxis.
In brief, IPC and ATS can be recommended for DVT
prophylaxis in patients undergoing elective neurosurgery.
Other possibilities that may be equally acceptable include
postoperative LDUH and LMWH. The combination
of LMWH and ATS is more effective than ATS alone,
whereas the combination of LDUH with mechanical
prophylaxis may also be more effective than either method on its own.
Trauma
Patients with polytrauma or major trauma have a risk
of DVT that exceeds 50% in the absence of prophylaxis
and fatal PE is found in about 0.4-2.0%. PE is the third
most common cause of death in trauma patients who
survive beyond the first day. Among the types of trauma, the greatest incidence of DVT has been observed
in patients with fractures of the lower limbs (69%), of
the spine (62%) and in those with severe head injuries
(54%). A DVT incidence of 40% has also been documented in patients whose only major injury involved the
face, the chest or the abdomen. Patients with non-orthopaedic trauma involving only one organ have a smaller
risk of VTE compared with those with multiple injuries
or fractures of the lower limbs. The specific risk factors
that are associated independently with a greater incidence
of thromboembolism include injuries of the spinal cord,
20-05-2009 14:33:40
pelvic or lower limb fractures, the need for surgery (in
particular venous repair), advanced age, protracted immobility and prolonged hospitalisation. Although the risk
of DVT increases with age, a major DVT and fatal PE
can also occur in young trauma patients. Therefore, employment of prophylaxis should not be omitted in young
patients.
The mechanical methods of prophylaxis are used in
trauma patients because these patients nearly always have
a high risk of haemorrhage. We are not aware of any studies that have assessed ATS in the prophylaxis of patients
with trauma. A recent study in 149 patients with trauma
but without fracture of the lower limbs found a DVT in
6.5% of the group treated with IPC and in 21.0% of cases
in another group treated with PPC (p=0.009). Various
studies have shown that IPC provides protection equal to
or less than that of LDUH. The major problems that often prevent the use of IPC are represented by the impossibility of applying it in about one third of patients with
trauma (due to fractures of the lower limbs, plaster casts
or dressings), poor compliance regarding the appropriate
use of the devices by the patients and nursing staff and
by the relatively high cost. Even if ATS and IPC cannot
be recommended as routine prophylaxis in trauma (the
former because of the lack of studies in this regard), these
methods can be of benefit in patients with intracranial
haemorrhage and probably also as initial prophylaxis in
patients who are at high risk of haemorrhage at that time,
until anticoagulants can be given at a later stage.
In patients with contraindications to prophylaxis with
LMWH, ATS and IPC should be taken into consideration. In these cases, in our view, given the ease of application and low cost, ATS are preferable, though they have
not been studied in these patients, since they guarantee
a significant action on the venous stasis induced by immobility and other risk factors, thus eliminating one of
the causes of DVT and PE. After an initial period of mechanical prophylaxis, during which primary haemostasis
is established, a regime including LMWH can usually be
employed in these patients. Although the optimal duration of the prophylaxis is not known in the specific case, it
should usually be continued until discharge from hospital.
If hospitalisation (including rehabilitation) lasts beyond 2
weeks and there is an acute risk of thromboembolism, the
need for continuing the prophylaxis in hospital with oral
anticoagulants should be considered, on condition that
there is no longer a major risk of haemorrhage and further
surgical procedures are not planned.
As regards acute spinal injury, although no controlled
studies of DVT prophylaxis following severe acute spinal
injury have been published, the very high risk of DVT
and PE, together with the results of recently available
studies, supports the aggressive use of early prophylaxis in
59
all patients with acute spinal injury. The use of LMWH
is promising but further studies are needed. LDUH, IPC
and ATS do not ensure suitable protection if used on their
own. LMWH or a combination of LMWH or LDUH
with IPC or ATS appears to be the best option available
in the majority of cases.
Burns
Burn patients have a significant risk of VTE because
of the presence of a systemic state of hypercoagulation
and because of the fact that they have to remain confined
to bed for a prolonged period and often undergoing repeated surgery, and also because of the frequent occurrence of sepsis, frequent use of central venous catheters
and associated risk factors (age etc.). A certain number
of autopsy studies has demonstrated that burn patients
commonly have DVT and PE at the time of death, even
if fatal PE has been described in only 0.1-0.5% of cases.
Symptomatic VTE has been reported in only 0.4%-0.9%
of burn patients in large case study reviews, but in some
prospective studies the rates of DVT were between 12
and 53%.
As far as we know, there are no studies on thromboprophylaxis in these patients and at the moment there are
insufficient data to justify the routine use of thromboprophylaxis in burn patients. Nevertheless, it is reasonable
to employ prophylaxis in patients with other risk factors
such as concomitant trauma of the lower limbs, advanced
age, obesity, prolonged confinement to bed and concomitant surgical procedures. Prophylaxis should therefore be
employed using the same criteria that apply to high and
very high risk patients and systematic use of ATS, when
allowed by the location of the burns, seems to be the most
rational solution together with pharmacological therapy
in patients who do not have a haemorrhagic risk.
Pregnancy and puerperium
Pregnancy has a significant impact on Virchow’s triad,
especially on the coagulation factors and venous stasis, as
explained in the section devoted to that subject. Pregnant
women have a risk of VTE about ten times greater than
that of non-pregnant women of the same age, with the
risk increased 2.5 times in pregnancy and 20 times in the
puerperium. The incidence of DVT seems to be 0.13-0.5
per thousand in the ante-partum period and 0.61-1.5 per
thousand in the post-partum period. In 1996, Macklon
NS and Greer IA reported an incidence of DVT in pregnancy of 0.615 per thousand women aged less than 35
years and 1.216 in those aged over 35 years. A three-year
report (1991-1993) on maternal mortality in Great Britain recorded 30 deaths due to PE divided equally between
pregnancy and the post-partum period, with a homogeneous distribution during the trimesters of gestation. The
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Table XIII – Mode of delivery and risk of VTE. Modified from: SISET Guidelines in Obstetrics and Gynaecology, Haematologica 2002
Mode of delivery
VTE events/pregnancies
Risk per thousand pregnancies
125 / 556.040
0,22
Elective caesarean delivery
23 / 33.779
0,68
Emergency caesarean delivery
47 / 55.839
0,84
All caesarean deliveries
70 / 89.618
0,78
Vaginal delivery
greatest incidence of fatal events is found in the first two
weeks after delivery but 40% occur between day 15 and
day 42 of the puerperium, following discharge from hospital. The risk therefore increases in the post-partum period and even more after caesarean delivery: more than ¾
of deaths post-partum due to VTE occur after caesarean
delivery. Operative delivery represents an important risk
factor for developing VTE post-partum; overall, the risk
associated with caesarean section is about 3 times greater
than that associated with spontaneous delivery, even if the
absolute risk is low (Table XIII).
About 90% of DVT in pregnancy involves the left
lower limb, compared with 55% in non-pregnant women and this seems to be explicable by the course of the
ovarian arteries, which cross the internal iliac vein on the
left, especially as the majority of DVT is iliaco-femoral
rather than femoro-popliteal (72% vs. 9%). It is also
known that in pregnancy there is an increase in coagulation factors (von Willebrand factor, factor VIII, factor V
and fibrinogen), a reduction in protein S, acquired resistance to activated protein C and an increase in PAI-1 and
PAI-2 produced by the placenta. Venous stasis is already
apparent at the end of the first trimester and reaches its
maximum levels in the 36th week. The risk of recurrent
VTE during pregnancy in women with a previous history of DVT is between 4 and 15%. The Royal College of
Obstetricians and Gynaecologists has defined the following risk catemedical-lsries in women undermedical-lsing
caesarean section and they can also be utilised from the
general aspect:
–– Low risk:
•• age<35 years;
•• negative family and personal history;
•• elective caesarean section in an uncomplicated pregnancy in the absence of risk factors.
–– Moderate risk:
severe varicose veins
•• age>35 years;
•• obesity (>80 kg);
•• parity ≥4;
•• immobility pre-operatively (>4 days);
•• concomitant disease or infection;
•• pre-eclampsia;
•• emergency caesarean delivery.
–– High risk:
•• presence of 3 or more moderate risk factors;
•• major abdominal or pelvic surgery (e.g. caesarean
section+hysterectomy);
•• positive family history of DVT, PE or thrombophilia;
•• confirmed thrombophilia;
•• absolute immobility (e.g. paralysis of the lower
limbs).
The most frequent additional risk factors are obesity,
cigarette smoking, age >35 years, thrombophilic states,
threatened abortion with associated bed rest, caesarean
delivery (hypotension induced by spinal or epidural anaesthesia) and venous insufficiency of the lower limbs.
The recommendations for prophylaxis depending on
risk are summarised in table XIV and have already been
specified in the relevant section: prophylaxis with ATS
should be carried out in all parturient women, started immediately pre-partum and continued throughout the puerperium. In the case of venous insufficiency of the lower
limbs, the recommendations described in the section on
the therapeutic elastic stocking apply. In view of current
knowledge, primary prophylaxis should be in accordance
with the following scheme:
–– in women at low to moderate risk, it is useful to adopt
non-pharmacological measures (early mobilisation,
ATS);
–– in women at high risk, pharmacological prophylaxis is
necessary (LDUH 5000-7500 IU s.c. every 12 hours
or LMWH), combined in every case with use of ATS;
–– in women who are carriers of congenital thrombophilic
states, prophylaxis with heparin throughout the pregnancy and certainly in the puerperium is useful, and
should be combined with elastic compression and correction of any additional risk factors (smoking, obesity
etc.);
–– in women with (previous or intermittent) antiphospholipid antibody syndrome and a negative history of
abortion or thrombosis, no treatment is recommended
or else low-dose ASA (50-100 mg.), while in cases of
previous thrombosis (whether or not in pregnancy),
administration of LDUH or LMWH is recommended
throughout the pregnancy and up to 4-6 weeks after
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61
Table XIV – VTE prophylaxis in pregnancy and the puerperium.
Clinical condition
Recommendation
Prolonged confinement to bed
ATS for the entire period of confinement to bed
Caesarean delivery
ATS or LDUH or LMWH peri- and post-partum, early mobilisation
Presence of additional risk factors (CVI)
ATS + MCS 2nd class during and after pregnancy + LDUH or LMWH periand post-partum, early mobilisation
Thrombophilic states
LDUH or LMWH or OAT or ASA + ATS from the start of the pregnancy
Abbreviations: ATS antithromboembolism stocking; MCS medical compression stocking; LDUH low-dose unfractionated heparin; LMWH low molecular
weight heparin; OAT oral anticoagulant therapy; ASA acetylsalicylic acid.
delivery (oral anticoagulant can also be used in this
period) together with elastic compression therapy.
General medicine
Aspects of VTE prophylaxis in patients admitted to
general medical departments have been studied less deeply compared with surgical patients despite the fact that
50-70% of symptomatic VTE events and 70-80% of fatal
PE are found in the course of internal medical diseases.
Autopsy studies have shown that among patients who
died in hospital of pulmonary embolism 75% consisted
of patients confined to bed because of disease of a medical
nature (Sandler DA et al. 1989). These categories include
myocardial infarction, stroke, serious infections, heart
failure, respiratory insufficiency, cancer patients and those
confined to bed for long periods. The most frequent risk
factors (Table XV) are advanced age, previous episodes
of VTE, heart failure (NYHA grade III-IV), exacerbation
of chronic obstructive pulmonary disease (COPD), sepsis, malignancy and stroke. According to the “Medenox”
study (1999) the incidence of VTE in medical patients
considered to be high risk and not given prophylaxis is
about 14.9%, much lower than in high-risk surgery. Even
if clinical case series are generally limited in number, we
currently have sufficient data for making recommendations on prophylaxis for many groups of non-surgical
patients, as can be inferred from the ACCP guidelines
2001-2004, SIAPAV-SISET-SIDV-GIUV 2000, CIF
2001-2003-2004, SISET 2004. The only medical area for
VTE prophylaxis where the effect of compression was assessed in acute myocardial infarction (Kierkgaard A et al.
1993) and a significant advantage of treatment compared
with controls was observed.
In the absence of studies of the efficacy of mechanical
prophylaxis (IPC, ATS) in general medical patients, however, there are no reasons to believe that these methods are
less effective than in surgical patients.
Myocardial infarction
The overall incidence of DVT is about 24% in patients
with myocardial infarction (MI) not given antithrombotic treatment. Various randomised studies have demonstrated that full anticoagulation with heparin and oral
anticoagulation after acute MI leads to a reduction in the
incidence of DVT and PE diagnosed clinically compared
with absence of prophylaxis or low-dose anticoagulants.
In a study conducted by Kierkegaard A and Norgren L
about 80 patients with acute MI (IMA) wore an ATS on
one leg while the other leg acted as control. Eight control
limbs had DVT demonstrated with the labelled fibrinogen test compared with no abnormality for the legs wearing the ATS (p=0.003).
Based on the available data, LDUH and full anticoagulation reduce the incidence of VTE in patients with acute
MI. The mechanical prophylaxis methods (ATS, IPC)
are probably also useful in patients with IMA when antithrombotic agents are contraindicated. Nevertheless, current aggressive therapy of IMA with thrombolytic agents,
unfractionated heparin, LMWH, anti-platelet agents or a
combination of these drugs has rendered prevention of
DVT a secondary aim.
Ischaemic and haemorrhagic stroke
Patients with stroke have a high risk of DVT in the
paretic or paralysed lower limb with a cumulative DVT
incidence of 55%. About 5% of early deaths following
Table XV – Risk of VTE in medical patients SIAPAV-SISET-SIDV-GIUV 2000 guidelines, THRiFT II-Consensus Group 1998, IUA 1997.
Grade of risk
Low
Minor medical disease
Moderate
Major medical disease: cardiac or pulmonary disease, heart failure, malignancy, inflammatory bowel disease. Minor
medical disease combined with thrombophilia or history of VTE. Immobilised patient.
High
Major medical disease with thrombophilia or history of VTE. Paresis of the lower limbs (paraplegia, hemiplegic
stroke). Stroke. Age >70.
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COMPRESSION
stroke can be attributed to PE. In a prospective, nonrandomised study of 681 patients with ischaemic stroke,
combined prophylaxis with LDUH + ATS + IPC demonstrated less symptomatic DVT and PE compared with the
combination of LDUH + ATS. We are not aware of any
studies of thromboprophylaxis in patients with haemorrhagic stroke. However, use of ATS or IPC is recommended
for these patients.
Cancer patients
VTE is one of the most common complications encountered in patients affected by cancer and this may be
due to the state of hypercoagulability that characterises
malignant disease and/or the related treatment, which
involves surgery, chemotherapy, radiotherapy and the
insertion of central venous catheters. In cancer patients,
prevention of VTE is a greater priority compared with
patients who do not have a tumour as the diagnosis of
DVT and PE is often more difficult, the treatment has
lower chances of success and is associated with greater
haemorrhagic complications. Cancer patients undergoing surgery have an almost doubled risk of postoperative DVT and more than three times the risk of fatal PE
compared with non-cancer patients undergoing similar
operations.
Chemotherapy itself is closely linked with thromboembolic complications. The risk of thromboembolism
in women with stage II breast cancer given chemotherapy is 7-11% and it drops drastically at the end of the
treatment cycle. The anti-oestrogen tamoxifen increase
the thrombotic risk of chemotherapy two- to sixfold in
patients with breast cancer. In a randomised study of
tamoxifen as adjuvant in stage I breast cancer, the risk
of thromboembolism was six times greater in the group
treated with tamoxifen compared with patients who took
placebo. Tamoxifen used to prevent breast cancer is associated with an increase in the figures for DVT (relative
risk = 1.6) and PE (relative risk = 3.0).
Other forms of malignancy at the advanced stage which
are associated with an elevated risk of thromboembolism
include brain tumours and adenocarcinoma (colorectal,
pancreatic, pulmonary, renal and ovarian). In brief, cancer
patients who undergoing major surgery are at high risk of
VTE and should receive aggressive prophylaxis as was recommended in table XI and in the sections on general surgery,
gynaecology and urology.
Patients in intensive therapy
The majority of patients in intensive therapy have
one or more risk factors for VTE. Even though there
is a paucity of data on thromboembolism specific for
this situation, the data presented above for the groups
that constitute the majority of patients (in particular
general surgery, trauma and medical patients) are high
relevant. In a study using the labelled fibrinogen test,
DVT was found in 29% of 59 patients who did not receive any form of prophylaxis. In a recent double-blind
study, duplex ultrasound was used every 72 hours up to
discharge from the intensive care unit and found DVT
in 21% of 390 control patients. In another prospective study, phlebography identified DVT in 28% of 85
patients.
All patients should be assessed for the risk of thromboembolism and prophylaxis should be employed in the majority. In these patients it is important to make individual
decisions regarding the start of the prophylaxis and the
methods employed, based on each patient’s particular
clinical condition. In general, in patients with a high risk
of haemorrhage, mechanical prophylaxis with ATS, possibly combined with IPC, appears reasonable as a first
choice until the risk of haemorrhage is reduced. For the
others, the prophylaxis schemes described above are recommended for medical and surgical patients according to
risk stratification.
Management of compression therapy
in the prophylaxis of VTE in surgery
From an analysis of the most recent literature, there
is sufficient evidence for recommending routine use of
VTE prophylaxis by means of compression therapy for
many groups of patients with diseases susceptible to surgical treatment. Risk stratification based on the type of
surgery suggest use of compression therapy on its own in
patients at low risk while in other classes at higher risk, its
use is recommended in combination with current pharmacological protocols (Table XVI). In low-risk patients,
the duration of the prophylaxis should cover at least the
period of hospitalisation, in patients at high risk it should
cover a period of 7 to 10 days and in patients at very
high risk, a period of up to 30 days should be planned,
depending on the disease.
Conclusions
VTE is an important problem on the social and healthcare level, which results in mortality, morbidity and a significant expenditure of resources. We believe that there
is sufficient evidence for recommending the routine use
of thromboprophylaxis with mechanical means (IPC and
ATS) for many groups of patients. These groups include
patients undergoing major procedures in general surgery,
gynaecology and urology, arthroplasty of the lower limbs
and hip fracture surgery, neurosurgery, patients admitted with major trauma or acute spinal cord injury and
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63
Table XVI – Management of compression therapy in the prevention of VTE in surgery. Modified from: Kaboli PJ, Brenner A, Dunn AS.
Prevention of venous thromboembolism in medical and surgical patients. Cleveland Clinic Journal of Medicine 2005; 72(S1):7-13.
Surgery
Risk
Compression therapy
Pharmacological
therapy
General surgery
Low risk
Medium risk
High risk
Very high risk
Gynaecological surgery
Low risk
Medium risk
High risk
Urological surgery
Low risk
Medium risk
High risk
Orthopaedic surgery
Pelvic fracture
Hip arthroplasty
Knee
arthroplasty
Neurosurgery
Indicated + early mobilisation
Indicated in combination with pharmacological therapy
LDUH o LMWH
LDUH o LMWH
LDUH o LMWH
LDUH o LMWH
LDUH o LMWH
LDUH o LMWH
LDUH o LMWH
LDUH o LMWH + OAT
LDUH o LMW H+ OAT
LDUH o LMWH + OAT
LDUH o LMWH+ OAT
LMWH
Trauma
Abbreviations: LDUH unfractionated heparin; LMWH low molecular weight heparin; OAT oral anticoagulant therapy.
medical patients with risk factors for thromboembolism.
Implementing suitably planned and evidence-based strategies for prophylaxis ensures benefit for the patients and
will also support medical and nursing staff and the hospitals in their responsibilities before the law. The use of
suitable protocols should be promoted in every clinical
institution: the first essential act is to identify patients
at greater risk of thromboembolic complications. Implementation of prophylaxis in a routine manner for all patients belonging to each target group should consistently
follow risk stratification. A prospective study in 1994
documented an almost two-fold growth (from 29% to
52%) in prevention carried out in hospitalised patients
at risk due to the use of educational strategies intended
to increase awareness of the problem of VTE. The use of
prophylaxis was significantly greater in hospitals where
physicians took part in refresher courses on the subject,
and where specific data were available for each hospital
which demonstrated the potential benefits of the strategies employed. Use of mechanical methods in the prevention of VTE now finds a precise rationale because of the
demonstrated efficacy and the ease of application combined
with the low cost (especially as regards antithromboem-
bolism stockings) and should be promoted more and more
through deepened knowledge of compression therapy, not
only in phlebolymphology but also in all the medical disciplines involved in the prevention and treatment of VTE. The
overall recommendation grade in evidence based medicine
is 1A according to the scoring criteria of the International
Grade Group (Guyatt G et al. Grading strength of recommendations and quality of evidence in clinical guidelines.
Report from an American College of Chest Physicians
Task Force. CHEST 2006).
On the other hand, new studies on large numbers of
patients should be conducted to provide a more accurate
assessment of the efficacy of compression in patients at
risk in specialties where it has been little assessed, such
as urology, gynaecology, obstetrics and general medicine.
Moreover, the optimal level of compression applicable at
rest to obtain the greatest venous flow rate, that is, the
primary efficacy end-point of mechanical therapy in the
prophylaxis of VTE, should also be better defined. In
addition, the role of compression methods in classes at
greater risk, in combination with classical medical treatments such as oral anticoagulants and LMWH, should
also be better defined.
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Recommendations
–– Patients should be stratified to identify the preoperative thromboembolic risk.
–– Before the operation, the healthcare staff (doctors,
nurses, etc.) should inform the patient, both verbally and in writing, of the risks of VTE and the
efficacy of prophylaxis; of the symptoms and signs
of DVT and PE, of the correct use of prophylaxis
at home and of the implications of not carrying it
out correctly.
–– On admission, surgical patients at risk should be
provided with ATS, which they should wear in the
perioperative period and throughout the period of
confinement to bed and according to the indications, and they should wear therapeutic stockings
until complete resumption of ambulation (excluding patients with critical ischaemia or diabetic neuropathy of the lower limbs).
–– Patients wearing ATS should be observed to ensure
correct use and their use should be monitored by
specialist staff after adequate training to avoid the
consequences of incorrect use (lacing effect, removal
of the ATS at night, etc.).
–– Intermittent pneumatic and pneumatic plantar
compression are devices that can be used as an alternative or in addition to the ATS until the patient is discharged.
–– In the postoperative period, the healthcare staff
should encourage the patient towards early mobilisation and patients confined to bed with disability
should be provided with adequate physical rehabilitation of the lower limbs.
–– Regional anaesthesia reduces the risk of VTE
compared with general anaesthesia. In the case of
regional anaesthesia, the start of the pharmacological prophylaxis should be well calculated in
order to reduce the risk of haematoma to a minimum.
–– Ensure that the patient does not become dehydrated in the postoperative period; the patient’s fluid
balance is therefore important in order to reduce
the risk of thromboembolism.
–– Patients should be informed that prolonged immobilisation for more than 3 hours in the case of
travel in the four weeks preceding or following the
surgery can increase the risk of VTE.
–– The healthcare staff should advise preventive suspension of the oral contraceptive pill four weeks
before an elective surgical procedure.
–– A caval filter should be utilised limitedly in surgical
patients with a recent episode of VTE (less than one
––
––
––
––
––
––
––
––
––
––
––
––
month) in whom anticoagulant therapy is contraindicated.
It is recommended that every hospital should draw
up a formal strategy with the object of risk stratification of patients and prevention of thromboembolic complications. This strategy should be presented as a written programme for risk stratification
and thrombosis prophylaxis; the clinical file should
contain the instructions needed for risk stratification and any prophylaxis to be carried out.
In patients at high haemorrhagic risk use of mechanical prophylaxis with ATS or IPC is always
recommended.
The use of ATS or IPC significantly reduces the incidence of VTE after low and medium risk surgery.
The combination of ATS and heparin is more effective than ATS alone in patients at medium and
high risk.
In general medical patients, in the absence of studies of the efficacy of mechanical prophylaxis, there
are no reasons why such methods should be less effective than in surgical patients. Use of prophylaxis
with ATS and IPC is recommended in all patients
confined to bed for more than 3 days.
The efficacy of the ATS depends closely on the prescribed quality and size based on the circumference
of the patient’s limb.
Significant differences in efficacy have not been
found between different versions of ATS, so that
except in particular cases it is sufficient to use a
below-knee model.
The ATS should be worn by patients at risk in the
peri- and postoperative period throughout the 24
hours and for at least four weeks or longer in the
case of postoperative complications that prolong the
recovery period, during prolonged confinement to
bed and always according to the doctor’s prescription and instructions.
The ATS is sterilisable (about 40 times) and can be
reused for more hospitalised patients.
The ATS exerts sufficient compression for VTE
prophylaxis only in the patient who is confined to
bed and therefore should be combined with a suitable MCS during patient mobilisation.
It is recommended that mechanical prophylaxis
(ATS or IPC) be utilised appropriately under the
supervision of medical and paramedical staff ensuring that the patient uses it correctly.
Bandaging is indicated in the prophylaxis of VTE
only if carried out by highly skilled staff.
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65
Contraindications to compression therapy
The absolute contraindications to compression can be
summarised as follows:
–– Obstructive arterial disease with a Winsor pressure index equal to or less than 0.55 (however, it is advisable
to assess this after a stress test);
–– Major neuropathy, since the absence or great reduction
in skin sensation increases the risk of damage produced
by the pressure exerted by the bandage;
–– Extrinsic compression on veins (Baker’s cyst in the popliteal fossa, lymphadenopathy ...);
–– Decompensated heart failure (depletion of the peripheral venous pool towards the heart);
–– Rheumatic fibromyalgia (marked intolerance of any
pressure on the skin surface).
The most frequently observed relative contraindications, apart from osteoarticular disorders, are represented
by acrocyanotic syndromes and Raynaud’s phenomenon
since intolerance of elastic stockings, even light ones, is
often observed in these cases.
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66
General recommendations on
compression therapy
Bandages
–– The non-elastic or short-stretch bandage has a more
effective action on the superficial and deep venous system compared with medium- and long-stretch; the
resting pressures are not low, as was believed, but the
difference between the resting and working pressures
is high.
–– The pressure exerted by the bandage also depends on
the structural characteristics of the bandage: every
bandage has a specific hysteresis curve, which identifies
the compressive power at the respective lengthening
and compressed circumference; the maximum extensibility (short, medium and long stretch) is not a
reliable index for identifying the compression ability
of the bandages but only indicates a general difference between the working and resting pressures: lower
stretch = greater difference in pressures.
–– The difference between the working and resting pressures measured in vivo is an index of activity: high
working pressures produce a greater effect deep down.
–– Based on the considerations presented here, research
and study of the indices of compression activity of the
different bandages is advised in order to define better
indications for their use.
–– The bandage is indicated, in its various versions, in the
treatment of phlebolymphological disorders in the
acute phase, in the reduction of persistent oedema
and in the complications.
–– The bandage must be used with the greatest care in the
event of arteriopathy, after accurately quantifying the
peripheral arterial perfusion at rest and during exercise.
–– The bandage should always be applied by skilled staff:
the institution of training courses in bandaging is recommended for all involved healthcare professionals,
with measurement in vivo of the pressures exerted.
Medical compression stockings
–– The therapeutic or medical compression stocking
MCS is a stocking made with materials and methods
according to standards defined by the legislation in
force (currently the German RAL-GZ 387, the French
NFG 30-102B IFTH and English BS7505), which
––
––
––
––
––
––
––
guarantees defined and graduated pressure along the
limb within certain parameters, laid down according
to the compression class, available in various models
and sizes. The compression and compliance with the
construction methods must be constantly certified
by independent national institutes. Only the MCS
has demonstrated certain efficacy in the prevention
and treatment of phlebolymphological conditions in
clinical trials and in the scientific literature: it is to
all intents and purposes a medical device (Universal
Medical Device Nomenclature System; medical stockings are identified with number 13-789).
Elastic stockings that do not comply with the standards in whole or only in part but which can guarantee
a pressure in mmHg at the ankle and/or in other parts
of the lower limb, maintaining a certain graduation
in pressure from below upwards are defined as elastic
support stockings.
All other types of stockings made with elastic fibres,
which do not state the pressures in mmHg (for example stating denier or den) or which do not guarantee
defined and graduated pressures should be defined
simply as elastic stockings.
The antithromboembolism stocking is a therapeutic
elastic stocking made with partly different methods to
make it tolerable at rest, which guarantees a pressure of
18 mmHg at the ankle (tolerance limits ± 3 mmHg),
and the pressor profile along the lower limb should be
graduated: 80-100% of the pressure at the ankle (B) at
B1, between 60-80% at C and between 40-70% at F
or G (CEN 1998, draft prEN 12719).
The efficacy of the therapeutic or elastic stocking depends closely on the quality and the size prescribed on
the basis of the circumference of the patient’s limb.
It is recommended that doctors and healthcare staff
prescribe the therapeutic elastic stocking accurately
and instruct the patient in detail on its use.
Compliance with treatment with a therapeutic elastic
stocking is improved by correct prescription and accurate instruction of the patient.
Compliance with the medical prescription by the
authorised retailer is obligatory (binding codes for
pharmacists and orthopaedic technicians), as for other
medical and pharmacological devices.
20-05-2009 14:33:41
General recommendations on compression therapy
67
Tab. XVII – General indications for compression therapy. Summary
Indications
Bandage
CEAP
C0-C1
MCS
Support
stocking
1 Class
•
•
C2
st
2 Class
nd
3 Class
rd
•
•
•
•
•
4th Class
ATS
C3
elastic
C4
short stretch
eccentric compr.
•
•
• at rest in
combination
with MCS
C5
short stretch
multilayer
•
•
• in PTS at rest
in combination
with MCS
C6
short stretch
multilayer
•
•
• in combination
with MCS
Surgery of VCI
elastic/short
stretch
eccentric compr.
Sclerotherapy of
telangiectasias
Sclerotherapy of
varicose veins
•
elastic/short
stretch
eccentric compr.
• in combination
with MCS
•
•
•
•
•
•
•
Acute DVT
short stretch
•
•
PTS
short stretch
•
•
Pregnancy,
delivery
•
Pregnancy,
delivery with VCI
•
•
VTE prophylaxis
short stretch
•
Lymphoedema
short stretch
multilayer
•
Angiodysplasia
VCI+PAD
short stretch
•
• at rest in
combination
with MCS
•
•
•
•
•
• in combination
with MCS
(if it is necessary)
•
•
•
•
•
•
•
•
Abbreviations: MCS medical compression stocking; ATS antithromboembolism stocking; VCI venous chronic insufficiency; DVT deep venous thrombosis;
PTS post-thrombotic syndrome; VTE venous thromboembolism; PAD arteriopathy
–– It is also recommended that the manufacturers establish a certified quality route from production to sale
to the patient, by setting up professional qualification
stages for intermediaries (advertising and sales staff)
and authorised retailers (pharmacists, orthopaedic
technicians etc.), with periodic confirmation of the
level of company quality, as happens in other European countries.
–– The therapeutic elastic stocking is indicated in the control of symptoms due to venolymphatic insufficiency,
for support of active treatments, in the maintenance
of the results obtained and in prevention, and there-
20-05-2009 14:33:41
68
COMPRESSION
fore not in the acute phases except for particular types
of venous ulcers.
–– The therapeutic action and duration of compression
also depend on the materials used in manufacture; it is
recommended that the manufacturers should provide
more instructions on the activity of their products in
the different diseases by providing a definition of the
physical characteristics of the various materials and not
only of the compression classes.
–– It is recommended that appointed Italian institutions
(UNI, Ministry of Health etc.) make medical-lsod
the lack of an Italian standard on therapeutic elastic
stockings, in order to make Italy equal to other European countries (Austria, France, Germany, Great Britain), in the interest of the patient’s health, by defining
and inspecting production quality.
–– It is recommended that physicians, while awaiting
the necessary standard, should prescribe only MCS
and, when indicated, support stockings, confirming
the presence of specified quality marks, in order to
safeguard the patient’s health and the dignity of the
medical prescription.
–– It is recommended that mechanical compression always be carried out after an accurate diagnosis and under medical control because of the potential danger in
the case of heart failure or current or previous venous
or arterial thrombosis.
–– Use of sequential devices is recommended whenever
the squeezing of fluids is in the distal-proximal direction without producing reflux since the chambers are
inflated sequentially one after the other, remaining inflated until all are deflated simultaneously.
–– The cycle times must be rapid (about 30 sec) to allow
a greater number of cycles in the same period of time
(about 60 in 30 minutes with 20 effective minutes of
treatment).
–– However, it is recommended that pressures of 40-60
mmHg should not be exceeded (except in particular
situations) in order to avoid damage to the lymphatic system and to alternate the sessions with bandage
application when significant oedema has to be reduced,
then switching to an elastic support of a suitable compression class in the maintenance phase.
20-05-2009 14:33:41
69
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PRINTED BY
EDIZIONI MINERVA MEDICA
JUNE 2009
SALUZZO (ITALY)
CORSO IV NOVEMBRE, 29-31
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20-05-2009 14:33:43

compression - Collegio Italiano di Flebologia

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