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Box 1
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Historical introduction of sclerosing agents
1840 Absolute alcohol (Monteggio, Leroy D’Etiolles)
1851–1853 Ferric chloride (Pravaz)
1855 Iodo tannic liquer (Desgranges)
1880 ‘Chloral’ (Negretti)
1904 5% Phenol solution (Tavel)
1906 Potassium iodo-iodine (Tavel)
1910 ‘Sublime’ (Scharf)
1917 Hypertonic glucose/50–60% calorose (Kausch)
1919 30% Sodium salicylate (Sicard and Gaugier)
1919 Sodium bicarbonate (Sicard and Gaugier)
1920 1% Bichloride of mercury (Wolf)
1922 12% Quinine sulfate with 6% urethane (Genevrier)
1922 Bi-iodine of mercury (Lacroix, Bazelis)
1926 Hypertonic saline with procaine (Linser)
1927 50% Grape sugar (Doeriffel)
1929 Sodium citrate (Kern and Angel)
1929 20–30% Hypertonic saline (Kern and Angel)
1930 Sodium morrhuate (Higgins and Kittel)
1933 Chromated glycerin (Scleremo) (Jausion)
1937 Ethanolamine oleate (Biegeleisen)
1946 Sodium tetradecyl sulfate (Sotradecol) (Reiner)
1949 Phenolated mercury and ammonium (Tournay and
Wallois)
1959 Stabilized polyiodinated ions (Variglobin) (Imhoff
and Sigg)
1966 Polidocanol (Aethoxysklerol) (Henschel and
Eichenberg)
1969 Hypertonic saline/dextrose (Sclerodex)
Modified from Goldman MP, Bennett R: J Am Acad Dermatol 17:167, 1987.
synthetic sclerosing agents in 1946 firmly established sclerotherapy (primarily in Europe) as a viable form of treatment
for varicose veins. Still, many physicians perceived clinical
results of sclerotherapy treatment to be less optimal than
those obtained with surgical approaches.
Although the use of compression therapy for treatment of
venous disease is mentioned in the Old Testament and was
performed by Hippocrates in the fourth century
used in sclerosing treatment of varicose veins only within the
past 50 years.
by Brunstein
and Fegan
51
Postsclerosis compression, initially described
50
in the 1940s, Sigg52 and Orbach53 in the 1950s
54
in the 1960s, is perhaps the most important
BC, it has been
advance in sclerotherapy treatment of varicose veins since the
introduction of relatively safe synthetic sclerosing agents in
the 1940s. With the advent of ‘compression’ sclerotherapy,
clinical results equal to surgical procedures are now being
reported.
In Europe, sclerotherapy has been fully accepted by the
medical community since the 1960s and exists as a separate
specialty (phlebology and/or angiology).
55
Even today,
however, American physicians do not understand the technique or its indications, safety and efficacy. Eighty-two percent
of gynecologists surveyed did not have enough knowledge to
advise patients who requested information on the treatment
of varicose and telangiectatic leg veins. In fact, the gynecologists incorrectly perceived that sclerotherapy produced indiscriminate venous destruction; had a high risk of venous
thrombosis and allergic reactions; caused permanent pigmentation or scarring; necessitated prolonged, repetitive, painful
treatments; and had a low percentage of improvement.
56
Reasons for Treatment
Reasons for Treatment
reported his first series of cases in 1920 on the use of carbonate of soda but later found that salicylate of soda was best for
sclerosing varicose veins.
37
Genevrier, a military physician in 1918 who used intravenous quinine to treat malaria, often injected varicose veins in
the same patients, thereby treating both the malaria and the
varicosities.
38
The first pharmaceutically manufactured sclerosing solution was a mixture of saline and procaine. Thereafter, multiple
solutions were produced by the German pharmaceutical
industry. This stimulated research on both sides of the Atlantic
for an ideal sclerosing solution and many different compounds were tried (
grape sugar,
salicylate,
41,42
1% bichloride of mercury,
sugar with 5% saccharose),
6% urethane.
unacceptable levels of allergic reactions, necrosis, pain and
even fatalities.
Box 1). These included the following: 50%
39
mercury bi-iodide,40 20% and 30% sodium
sodium citrate,43 20–30% sodium chloride,43
45
These substances were used widely but caused
46–48
(A complete discussion of the development
44
50–60% calorose (75% invert
45
and 12% quinine sulfate with
and properties of modern sclerosing solutions is found in
Chapter 7.)
Tournay was instrumental in developing a school of sclerotherapy in France and refined the injection technique to
include drainage of intravascular thrombi. McAusland
49
popularized the technique in the United States in 1939 with his
report of the successful treatment of 10,000 patients. He promoted injection into empty veins to limit the degree of thrombosis, treatment of the incompetent saphenofemoral junction
before sclerosing distal varices, the use of postsclerotherapy
compression, and the use of minimal sclerosant concentrations (in the form of sodium morrhuate froth) for sclerosing
telangiectasia. Brunstein
50
further popularized injection into
empty veins and the use of postsclerotherapy compression to
produce cosmetic, painless, efficient sclerosis. The advent of
Patients seek therapy for telangiectasias or varicose veins principally because of their unsightly appearance. A survey has
shown that American women are more concerned with lower
extremity telangiectasia than with almost any other cosmetic
problem.
57
However, proper treatment is frequently difficult
to obtain because correct surgical intervention and sclerotherapy are not often taught in medical schools or residency
programs. Frequently, patients with telangiectasias of the legs
are told that they must live with the problem. Treatment
options, including sclerotherapy, are either mentioned disparagingly or not discussed at all. However, available evidence
indicates that safe, effective forms of treatment other than
surgery are possible and quite successful.
In addition to the cosmetic benefits of sclerotherapy,
studies have demonstrated that sclerotherapy treatment of
incompetent perforating veins increases the efficacy of the
calf muscle pump, resulting in an improved clearance of
extravascular fluid.
58
Lymphangiography of patients with
chronic venous insufficiency who are treated with sclerotherapy also demonstrates normalization of lymphatic drainage,
in addition to improvements in venous hemodynamics.
59,60
Also, a significant percentage of patients (28–85%) with
chronic venous insufficiency have superficial venous insufficiency alone or in combination with deep venous system
abnormalities.
61–63
These patients show greater improvement
with sclerotherapy or surgical treatment of the superficial
veins combined with compression therapy than with compression therapy alone.
heaviness and aching of the legs are often relieved by wearing
a graduated compression stocking,
64
In addition, while the symptoms of
65
patients prefer to be rid
of the veins altogether because wearing a compression stocking (which may be difficult to apply) is unsightly, and uncomfortable in warm, humid climates.
Hobbs,
3
Lofgren,66 and Beninson and Livingood67 have
pointed out that the treatment of varicosities per se may have
no effect on alleviating superficial venous pressure. It is the
xi
treatment of the underlying communicating or perforating
https://t.me/med1917
veins draining the gaiter area that is important.
vessels may be either surgically ligated
17,19,68,69
Only then can the retrograde flow under high pressure through
the calf muscle pump be diverted upstream and away from
the skin. This succeeds in lowering the cuticular venous pressure with decreased capillary permeability and edema, thus
increasing tissue oxygenation and nutrition. Wilson and
Browse
57
estimate that 40–50% of patients with venous ulcer-
Introduction
ation have nonthrombotic or perforating vein incompetence
that can be treated successfully with interruption of the abnormal veins, either through superficial ligation or sclerotherapy.
Present Day Treatment
A common misconception among physicians is that knowledge of or dexterity in venipuncture confers expertise in sclerotherapy. True expertise in sclerotherapy, like all specializations
in medicine and surgery, comes only after extensive postgraduate education, the observation of trained physicians
using meticulous technique, and subsequent (preferably
supervised) practice. Fortunately, physicians who specialize in
the treatment of venous disease (phlebologists, dermatologists and vascular surgeons) now can offer relatively simple
treatments for this widespread medical ailment.
Sclerotherapy, as practiced today, has been shown to be
better than placebo in the treatment of varicose and telangiectatic leg veins.
ble surgical procedures (ligation and stripping) in long-term
follow-up studies of most types of varicose veins, excluding
those with significant saphenofemoral incompetence.
As discussed in Chapter 9, new methods of sclerosing varicose veins with reflux at the saphenofemoral junction (SFJ
reflux) by using sclerosant foam under duplex control may
also increase the safety and efficacy of sclerotherapy in patients
with that particular condition, and is becoming as effective as
surgical and intravascular laser and radiofrequency (RF) treatment. The older recommendation of Wallois, who used a
liquid sclerosing solution in non-surgical patients,
these patients once or twice a year to maintain effective sclerosis of the varicose great saphenous vein (GSV). Although
this method (with non-foamed sclerosing solutions) does not
produce a cure, it maintains both cosmetic and symptomatic
improvement. Finally, as discussed further in Chapter 10, sclerotherapy can also complement surgical and/or intravascular
laser/RF treatment, especially for varicose or perforating veins,
and can prevent recurrences.
Modern sclerotherapy has been demonstrated to result in
a relief of symptoms in up to 85% of patients with both vari-
4
cose
and telangiectatic veins.77 In addition, sclerotherapy
treatment has been demonstrated to be a more physiologic
approach to eliminating abnormal varicose veins. One study
of dissected cadaver legs demonstrated that more than 50%
of the patients with significant varicose veins had a normal
great saphenous system, suggesting that vein stripping may be
an inappropriate procedure in a significant percentage of
patients.
GSV as a conduit for myocardial revascularization. Although
the internal mammary artery is a better conduit for coronary
artery bypass grafting, the GSV is still necessary in a significant
number of patients.
and the internal mammary artery can accommodate only one
or two graft segments.
Sclerotherapy of ‘varicose’ (abnormal) veins does not
impede the vascular vein surgeon from harvesting appropriate
conduits for coronary artery bypass. The structural quality of
vein grafts is of decisive importance for the maintenance of
patency. Patency half-life with a good-to-excellent graft is 10.5
years, versus 0.5 years when fair and poor-quality grafts
xii
70
Sclerotherapy is also as effective as compara-
76
78
This is especially important regarding use of the
79
Most patients require multiple grafts,
3,17,19,68,69
These
or sclerosed.3
71–74
75
is to treat
(including those taken from varicose veins) are used.80 A more
recent study cites an incidence of graft failure at 30 months of
68% in patients grafted with diseased veins, versus 27% when
healthy veins were used.
‘early’ varicose veins is thought to halt their progression into
larger, more severe varices.
81
Most importantly, treatment of
82,83
Early treatment may prevent
the development of valvular incompetence. Therefore, not
only is sclerotherapy not detrimental to coronary bypass grafts
but it may help in providing better conduits for this procedure
should the need arise.
Perhaps more significant in this age of cost control, sclerotherapy has been demonstrated to be much less costly than
surgical procedures in the treatment of varicose veins.
84–87
In
lieu of the inpatient hospital ligation and stripping operation,
sclerotherapy treatment is performed on an outpatient basis,
permitting patients to return to work immediately after the
procedure. Newer surgical techniques practiced in ambulatory
surgical centers allow SFJ ligation, or radiofrequency or endoluminal laser closure of the GSV to be performed without
general anesthesia. In this setting, the traditional expense of
surgical procedures is lessened. However, even with the most
modern surgical treatments, the morbidity and cost of surgery
is greater than that of sclerotherapy.
However, when SFJ incompetence is present, a limited ligation and stripping procedure, or endovenous RF or laser
closure followed by immediate ambulatory phlebectomy with
sclerotherapy 3 to 6 weeks later, may be necessary. Because of
the ‘limited’ nature of the procedure (as described in Chapter
10), hospitalization is not required and the procedure is performed under local anesthesia in an outpatient surgical facility.
The patient leaves ambulatory after the hour or so procedure,
resuming normal activities within 24 hours. In addition to cost
savings, patients’ preference for outpatient sclerotherapy has
been a major reason for the modernization of varicose vein
treatment.
rence of varicose veins (usually to a minor degree) in 88% of
patients who were treated with sclerotherapy alone.
84
This preference has occurred despite the recur-
84
Unfortunately, the straightforwardness of sclerotherapy –
performed with a simple syringe and sclerosing solution in an
awake patient with rapid recuperation – is thought by those
without an adequate knowledge of phlebology to be entirely
cosmetic in nature. This has led to medical reimbursement in
the United States being withheld or trivialized by medical
insurance companies. Some have even suggested changing the
name of sclerotherapy to ‘endovenous chemical ablation’
which appears to have a more formidable name.
88
We believe
that it is best not to try and change a name to ‘mislead’ but
to educate.
In summary, the presence of varicose and telangiectatic
veins is not a normal physical finding but a medical disease
deserving of treatment. Varicose and telangiectatic veins may
be symptomatic, representing an obvious manifestation of
venous disease with its resultant complications, and may pose
medical risks and complications in and of themselves. According to Hippocrates, the only advantages of having varicose
veins are that ‘the bald are not subject to varicose veins; but
should they occur, the hairs are reproduced’, and ‘if varicose
veins or hemorrhoids occur during mania, the mania is
89
cured’.
Fortunately, the majority of patients with varicose and telangiectatic veins do not have a life-threatening problem.
Therefore, treatment should be as simple as possible, with the
least risk of significant side effects. Modern sclerotherapy treatment has been demonstrated to fulfill these requirements with
efficacy that is comparable with operative procedures. This
textbook examines the pathophysiology and practical application of sclerotherapy treatment for varicose veins and
telangiectasias through a review of the world literature, presentation of experimental studies, and recommendations
derived from the practices of the contributing authors.
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xiv
A P P E N D I X
https://t.me/med1917
Compression Hosiery, Compression Bandages,
and Pressure Pads
A
Compression Hosiery
In addition to the large manufacturers and distributors listed,
nearly 100 other manufacturers of graduated compression
hosiery can be found worldwide. Many of these companies
have a limited sales and distribution region. I have included
companies that I have personal experience with. With the
background provided in Chapter 6, the reader should be able
to evaluate each stocking company to decide which brand and
type of stocking will be best for his or her practice.
Activa healthcare
Activa Healthcare was founded in 1998 when it introduced its
revolutionary range of Activa hosiery. Using new manufacturing techniques and yarns previously confined to luxury underwear, a range was available which both nurses and wearers
found extremely comfortable, clinically effective and attractive. Equally importantly it was no longer a battle to get on.
Being aware that hosiery was only half the story, Activa
then developed the Actico cohesive inelastic bandage system
for treating leg ulceration and chronic oedema. Actico bandages are safe and easy to apply. The bandages are also cohesive, meaning the bandages stick to themselves and will not
slip down.
Activa has a downloadable Hosiery Selector which instantly
works out the size hosiery a patient needs by simply keying
in their measurements, which is all part of making life easier
for patients and clinicians alike. www.activahealthcare.co.uk/
selector
Available from:
Activa Healthcare Ltd
1 Lancaster Park, Newborough Road,
Needwood, Burton on Trent,
Staffordshire DE13 9PD
UK
Phone: +44 (0) 8450 606 707 / +44 (0) 1283 576800
Fax: +44 (0) 1283 576808
Email: information@activahealthcare.co.uk
Bauerfeind
Bauerfeind is based in Zeulenroda, Germany, a town where
the manufacturing technology for producing compression
stockings was developed in the early years of the 20
Bauerfeind was founded in 1929 and today offers a wide
assortment of premium quality medical compression therapy
solutions under the brand Venotrain®. Bauerfeind USA, Inc.
was established more than 25 years ago and has just moved
to new offices in Marietta, Georgia.
Venotrain® products are designed to provide effective
therapy, excellent wearing comfort and great durability. The
assortment includes products with different levels of stiffness
to allow for an optimum therapeutic effect depending on the
condition they are designed to manage/treat. VenoTrain micro
©
2011 Elsevier Ltd, Inc, BV
DOI: 10.1016/B978-0-323-07367-7.00023-6
th
century.
has higher elasticity and is ideal for the management of varicose veins and perfect for patients post venous procedures.
The product line is available in different compression classes,
multiple styles and a wide range of colors to match the needs
of different people and life styles. The newly developed
Venotrain®business is designed as a contemporary dress sock.
Most product lines are sized according to the newly developed
‘Perfect Fit’ system.
For more severe venous conditions, Bauerfeind offers solutions with short stretch characteristics, to deliver a higher
working pressure. Examples of product lines that fall into this
category include Venotrain® impuls and VempTrain soft. The
flat knitted custom-made SoraLife-line is specially designed
for the management of lymphedema.
From the very beginning, Bauerfeind has been a pioneer
and is well known for a series of significant innovations. The
first compression therapy system for treatment of leg ulcers
was launched in 2000 under the Venotrain® ulcertec name.
VenoTrain® micro balance, launched in 2006, is the first stocking with an integrated skin care complex. Finally, Bauerfeind
developed the revolutionary measuring system Image3D
(now: Bodytronic). It’s an easy-to-use system for measuring
limbs, fitting and dispensing the appropriate ready-to-wear or
customized product. More than 100 000 legs have been measured to date and in 2009, these data were used to launch the
new ‘Perfect Fit’ sizing system, which further helps Bauerfeind
consolidate its position as a leader in the field.
Available from:
Bauerfeind AG
Triebeser Straße 16 Triebeser Straße 16
07937 Zeulenroda-Triebes 07937 Zeulenroda-drive
Germany
Telefon: 036628-66-10 00 Phone: +49 (0) 36628-66-10 00
Fax: 036628-66-19 99 Fax: +49 (0) 36628-66-19 99
E-Mail: info@bauerfeind.com
Website: http://www.bauerfeind.com
CircAid medical
Since the early 1990s CircAid Medical, in San Diego, CA, has
developed and produced patented, in-elastic, adjustable compression garments for the management of venous and lymphatic disease. The CircAid® product line offers a unique
design incorporating Velcro® closures that enable a patient
to wrap the compression garment around the limb reducing
the difficulty associated with elastic compression garments.
The in-elastic behavior of the CircAid products is based on the
principles of bandaging providing a low resting pressure with
a high working pressure when ambulatory. The latest offerings, Juxta-Lite
materials which provide improved conformability and comfort
to the patient’s limb. The Juxta-Lite is designed to be able to
provide a range of compressions from 20-50 mmHg with a
single product making it the perfect alternative to both bandaging and elastic compression stockings.
TM
and Juxta-FitTM, incorporate Breathe-O-Prene®
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A
Compression Hosiery, Compression Bandages, and Pressure Pads
Available from:
CircAid Medical Inc.
9323 Chesapeake Drive; Suite B-2
San Diego, CA 92123, USA
Phone: +1 858-576-3550
Fax: +1 858-576-3555
E-mail: info@circaid.com
Website: www.circaid.com
Cizeta medicali S.p.A.
Cizeta medical stocking are all produced in the Cuggiono
facilities and distributed with the brand VARISAN® and in the
following lines:
VARISAN® TOP (Ral certified): the specialist line constructed
in all the segments, with close and open toe, two high,
in 1, 2 and 3 Ccl., also available with cotton inside. The
Arm Sleeve and gloves, and the knee length stocking
with a zipper are also produced within the TOP line.. For
the TOP line, a made to measure service, custom fitting
to each patient, is available.
VARISAN® FASHION (Ral certified): the fashionable medical
stocking in 1 and 2 Ccl. Compression and in three colours.
VARISAN® CLASSIC (Ral certified): the original line,
available in 1 and 2 Ccl.
VARISAN® SOFT (ASQUAL certified): the medical stocking
with the lower compression. Available in 1 and 2 Ccl. of
the French standard, and in five colours.
Available from:
CIZETA MEDICALI S.p.A.
Via IV Novembre, 46
20102 Cuggiono (MI) Italy
Phone: +39 02 9721811
Fax: +39 02 97240734
Website: www.cizetamedicali.com
Gloria-Med
Gloria has manufactured medical graduated compression
stockings on Lake Como in Italy since 1926, and its products
are appreciated worldwide. The Gloria product range of readymade compression stockings includes a complete selection of
compression classes, fabric compositions, and styles. A ‘GloriaMed Soft Series’ composed of synthetic fibers provides compression with optimal comfort. The stockings are ointment,
cream, and ultraviolet resistant. The ‘GloriaMed Cotton Series’
is composed of natural cotton wound around spandex for
comfort for elderly people or in case of skin allergies. The
‘Strong Series’ is composed of natural rubber with a high
therapeutic efficacy. The ‘Lady Gloria Series’ is sheer and
attractive and is available in fashionable colors to combine
style and medical compression.
All ‘GloriaMed’ stockings are Hohenstein tested and certified. Gloria also develops medical CD ROMs and literature in
the vascular field.
Available from:
Gloria Med Pharma Srl
Via Diaz, 7
22017 Menaggio
Lake Como
Italy
Contact Name: Alex Peroschi
Phone: +39 0344 32123
Fax: +39 0344 32035
E-mail: a.peroschi@gloriamed.com
Gloria Med USA
Gloria Med USA is a sister company of Gloria Med Group. The
products range from ready-made to custom-made compres-
2
sion stockings including a complete selection of compression
classes, fabrics and styles. All ‘GloriaMed’ series stockings have
German GZ-RAL certification and are distributed worldwide:
• ‘GloriaMed Micro’ series contains microfiber yarns in
order to achieve a stylish look with medical effectiveness.
Available in 20-30 and 30-40 mmHg compression,
closed toe.
• ‘GloriaMed Soft’ series is composed of synthetic fine yarns
and available in 20-30 and 30-40 mmHg compression,
either open or closed toe to provide optimum comfort,
durability and satisfaction for patients.
• ‘GloriaMed Comfort’ series contains superior quality
cotton, and is hypoallergenic, well suited for patients
with dermatological problems or who live in warm and
humid climates. Available in 20-30 and 30-40 mmHg
compression, open toe.
• ‘Lady Gloria’ series are attractive, soothing, elegant and
stylish stockings and pantyhose, available in
15-20 mmHg support compression open or closed toe,
and 20-30 mmHg only closed toe.
• ‘Man’Support’ series are elegant, stylish and comfortable
cotton man’s socks, available in 15-20 mmHg
compression, closed toe.
• ‘GloriaPress’ compression bandages are also available.
Available from:
Gloria Med USA
1107 Fair Oaks Ave. # 462
South Pasadena, CA 91030, USA
Contact Name: Rachel Bhagat
Phone: +1 877-390-5347
Fax: +1 626-398-5347
E-mail: info@gloriamedusa.com
Website: www.gloriamedusa.com
Innothera
Innothera is the largest French manufacturer of compression
stocking. The Varisma range (including Varisma Comfort®,
Varisma Comfort Model®, Varsima Seduction®, Varisma
Transparence®) is very comfortable, aesthetic and easy to slip
on with a pressure at 17.5 mmHg and Actys with a pressure
at 25 mmHg.
Available from:
Innothera Laboratoires
22 Avenue Aristide Briand
94110 Arcueil
BP35
France
Phone: +33 1 46 15 19 00
Fax: 01 46 63 43 60 Fax: +33 1 46 63 43 60
Website: http://www.innothera.com
Jobst (a brand of BSN medical)
Arising from a desire to treat his own venous insufficiency,
which resulted in stasis ulceration, Conrad Jobst, inventor and
engineer, designed and patented the graduated compression
stocking in the 1940s and 1950s in the United States. The original stocking was custom-made from a template-cut bobbinet
fabric. The template consisted of a vertical strip of paper to which
horizontal strips of paper were attached and then cut to the size
of the leg. Graduation was achieved by reducing the length of
the horizontal template strips by the appropriate percentage.
Jobst manufactures several types of graduated medical compression stockings. The Jobst Custom Support stocking conforms to the original design concept of Conrad Jobst. Jobst
Custom Supports are made with a unique bobbinet fabric.
This fabric is composed of either natural rubber or Lycra®,
cotton, and nylon. Each stocking is engineered individually to
design a garment with precise measurements taken every 1
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inches along the leg. Counterpressures are prescribed according to the severity of the condition as described by the physician. Five classes of compression are most often used – 25, 30,
35, 40, or 50 mmHg – commencing at the ankle and decreasing proximally. However, higher or lower compression can be
engineered into the supports.
Vairox graduated compression stockings are moderateweight ready-to-wear seamless support stockings available in
four styles: knee length, with or without a zipper; thigh length;
thigh length with waist attachment; and waist-high length.
They are available in 12 sizes and in two compression ranges:
30 to 40 mmHg and 40 to 50 mmHg. Depending on the style,
a maximum of five measurements is needed to fit a patient.
(Knee-length style requires only three measurements.)
Fast-Fit graduated compression stockings are ready-made
and lightweight. They can be obtained without a prescription.
The stockings are constructed of a seamless blend of nylon
and Lycra. Fast-Fit stockings are available in four styles: knee,
thigh, waist, and maternity. Also, they are available as closedor open-toe stockings in small, medium, and large sizes in a
mild (18 to 25 mmHg) or moderate (25 to 35 mmHg) compression range at the ankle. Only one leg and foot length is
available, limiting its use for some patients.
Ultimate Sheer is the newest ready-made graduated compression stocking from Jobst. It is composed of uncovered
Lycra and nylon. This style is available as either a closed-toe
knee-high or pantyhose with compression of 30 to 40 mmHg.
Available from:
BSN medical, Inc.
5825 Carnegie Boulevard
Charlotte, NC 28209-4633, USA
Phone: +1 704-554-9933
Fax: +1 704-551-8581
Website: www.jobst-usa.com
1
JuZo
JuZo medical two-way stretch compression stockings have
been manufactured for more than 80 years in Germany by
Julius Zorn, Inc., and are manufactured and distributed by the
same company in the United States. These support stockings
are available in seven styles: below-knee stocking, half-thigh
stocking, thigh stocking, thigh stocking with hip attachment,
thigh stocking with panty part, compression leotard, and compression leotard for maternity. These styles are available in
both closed-toe and open-toe designs and are all seamless.
They are also available in four compression classes: 25, 35, 45,
and 60 mmHg. As with most large stocking manufacturers,
One unique advantage of the JuZo line is the availability
of different textile coatings over the compression threads.
Standard compression threads are covered with cotton on the
inner layer, which comes in contact with the skin (JuZo-Varin
cotton style). For an easier and smoother fit, the compression
threads of the inner stocking layer are covered with silk in the
JuZo-Varin soft-in style. A style with a woollen lining in the
knee area is also available to help prevent chaffing.
Another unique aspect of this stocking line is the relative
increase in the elastic knit in the upper thigh area of the Varilastic model. This allows maintenance of proper compression
in patients with large-diameter thighs and also helps prevent
slippage as the patient moves.
Available from:
Julius Zorn, Inc. (JuZo)
80 Chart Road
Cuyahoga Falls, OH 44223, USA
Phone: +1 800-222-4999
Fax: +1 800-645-2519
Website: www.juzousa.com
2
International medi-surgical
International Medi-Surgical distributorship supplies two types
of graduated compression stockings: Ibici from Italy and Sirlex
Radiante from France.
The Ibici line is available in assorted colors in compression
classes 0, I, and II.
The Sirlex Radiante line is also available in assorted colors
in compression classes I, II, and III.
Available from:
International Medi-Surgical
PO Box 3000187
Houston, TX 77230, USA
Phone: +1 800-745-8346
Fax: +1 713-794-0115
Medi USA
Throughout their 80-year history, Medi has been a worldwide
leader in the medical compression therapy industry. Dedicated to innovative phlebology product development, conscientious quality control, and total customer satisfaction, Medi
has forged an unmatched reputation for creativity, reliability,
and dedicated customer support. Medi offers its products
in more sizes and styles than any other manufacturer in
the world.
Medi differentiates itself from other compression companies by its use of uncoated spandex threads. Medi offers its
products in ready-to-wear styles as well as custom-made. This
allows Medi to fit every patient no matter what their shape
and size. Medi has seven ankle, 14 calf, and two lengths on
each style of its 10 styles of products. They also offer up to 10
styles in ready to wear. You can get open toe or closed toe
depending on your preference. Medi offers compression
classes from 12 to 60 mmHg. Medi also offers its products in
an uncoated technology that allows for the greatest natural
elasticity for ease of application.
Medi’s products come with a 6-month compression guarantee and a 30-day wearing comfort guarantee. These are the
strongest guarantees in the industry. Medi products are also
maufactured with Medisilk – an innovative spandex yarn that
has outstanding natural elasticity that allows every stocking
made to maintain its original compression and shape. Medi’s
products are machine washable and dryable for patient
convenience.
Medi’s most popular materials include:
• Radiance: Exceptionally shear medical compression
stockings with a softer feel, for day or evening wear. This
product is the sheerest product on the market with a
6-month compression guarantee in writing. Available in
16–40 mmHg, three colors, and up to four styles.
• Elegance: Sheer, silky medical compression for women in
a variety of styles and fashion colors. This product has
an air-permeable knit due to its hybrid microfiber.
Patients will feel cool and dry all day long. Available in
12–40 mmHg, up to 18 colors, and five styles.
• Plus: Discreet, open- and closed-toe compression for
men and women with active lifestyles. This is the ideal
product for those patients looking for a degree of
discretion to conceal their varicose veins, blemishes, or
scarring. Available in 20–50 mmHg, beige color, and 10
styles.
• Active: Discreet compression in a ribbed dress sock. Men
and women will enjoy the ribbed sock styling of the
Active line with their slacks or suits. Available in
12–40 mmHg, four colors, and calf style.
• Assure: Economical therapy for men and women
designed to meet managed care price guidelines. Assure
offers great ‘price/value’ with all of the benefits of the
Compression Hosiery
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Compression Hosiery, Compression Bandages, and Pressure Pads
Medi product line. Available in 16–40 mmHg, beige or
black color, open- or closed-toe, and five styles.
• Forte: Strong fabric designed to address the specific needs
of vigorous compression therapy. Ideal product for
lymphedema patients, maximum concealment of
blemishes, discolored veins, and scarring. Forte offers
maximum durability. Available in 30–50 mmHg, beige
color, and three styles.
• Lymphedema sleeves/gauntlets/gloves: Designed to aid
in the management of primary and secondary
lymphedema of the hand and arm. Medi makes these
products in seven circular and five flat-knit ready-to-wear
sizes as well as custom-made garments. Available in
20–40 mmHg, three colors, and six styles.
Available from:
Medi USA
6481 Franz Warner Parkway
Whitsett, NC 27377, USA
Phone: +1 800-633-6334
Fax: +1 888-570-4554
Website: www.mediusa.com
Medicusstr.1
D – 95448 Bayreuth
Germany
Website: www.medi.de
c/Canifó n 2-6
E – 8901 Barcelona
Spain
Prenatal cradle
The Prenatal Cradle supports the abdomen and round ligaments of the lower back without constricting the baby. Its
loose-fitting and comfortable design uniquely offers support
while the open abdomen promotes the baby’s comfort, allows
for air circulation, and permits frequent skin miniaturization.
It is completely adjustable. There is no need to remove any
part for toileting and normal lingerie can be worn.
Available from:
Prenatal Cradle Inc.
PO Box 443
Hamburg, MI 48139-0443, USA
Phone: +1 810-231-2983
Fax: +1 810-231-2941
Sigvaris
Sigvaris was founded in 1864 by the Ganzoni family and
initially manufactured rubber products. In the late 1950s the
company decided to apply their expertise to medical products.
In conjunction with Dr. Karl Sigg, a vascular surgeon, Sigvaris
designed the first ready-made compression stocking for
patients with serious venous disorders.
Sigvaris is known for their Precise Fit Sizing system that
offers 16 separate sizes to ensure each patient obtains the
maximum level of comfort through a perfect fit. The Sigvaris
sizing system takes both circumference and length into
account. A precise fit is important because it increases patient
comfort, as well as compliance, which leads to better therapeutic results.
Sigvaris offers five main lines of medical compression socks
and stockings for men and women: Cotton 230 series, Truly
Transparent 770 series, Select Comfort 860 series, Cushioned
Cotton Rx 360 series, and the Natural Rubber 500 series. Each
of Sigvaris’ medical compression series are offered in a wide
variety of styles, sizes, colors, and compression levels, to
match every type of lifestyle and therapeutic need. Although
it increases the cost of producing the product, one of the signature quality features of a Sigvaris compression garment is
4
the use of double covered yarn which improves the ease of
donning, enhances durability, and makes the garment softer.
Double covered yarn is one of the key differences between
Sigvaris products and the products produced by other manufacturers that use bare spandex yarn.
In addition to its medical compression products, Sigvaris
offers an over-the-counter line of support socks and stockings,
called Samson and Delilah, that provide 15–20 mmHg of
compression. Samson and Delilah is a comprehensive line of
products for men and women including styles and colors for
dress, casual wear, work, travel, and athletic activities. Sigvaris
also offers maternity stockings to help prevent varicose veins
during pregnancy.
Sigvaris’ reputation for sponsoring educational programs
for the medical community through lectures, round table discussions, and videos for the advancement of veno-lymphatic
care is unparalleled in the industry. Sigvaris also supports
medical research of veno-lymphatic disorders by sponsoring
case studies, the publication of textbooks, and medical
meetings.
Headquartered in Winterthur, Switzerland, Sigvaris has
manufacturing facilities in the United States, Brazil, France,
and Switzerland, and worldwide sales distribution. For more,
information visit www.sigvarisusa.com.
Venosan
Venosan Medical Therapeutic Compression Stockings and
Panty Hose are developed and manufactured under the control
of Salzmann Medico of Switzerland. These support stockings
are available in six basic ready-to-wear models, including
below-knee stocking, over-knee (half-thigh) stocking, thigh
stocking, thigh stocking with hip attachment, compression
pantyhose, and maternity compression pantyhose. These
stockings are available in closed-toe and open-toe styles and
with short or long foot lengths, and all are seamless. Only four
sizes and one length of the Ultraline 4000 stocking is required
to fit 90% of legs. The four compression classes include 20 to
30 mmHg, 30 to 40 mmHg, 40 to 50 mmHg, and 50 to
60 mmHg. Five different colors are available.
The stockings are manufactured on circular knitting
machines. Venosan 4000 stockings are manufactured from
refined Dupont Lycra and Tactel multisoft and micro fibers in
a special sandwich technique. This produces a Tactel Climate
Effect (TCE) that transports moisture away from the skin,
leaving both leg and stocking dry. This has a cooling effect in
the summer and a warming effect in winter.
By use of a new Lycra yarn with a flat strength/stretch curve,
the Ultraline 4000 stockings can be donned with less effort
than many other graduated support stockings.
Available from:
Venosan North America, Inc.
718 Industrial Park Ave.
PO Box 1067
Asheboro, NC 277204-1067, USA
Phone: +1 800-432-5347
Fax: +1 800-849-0946
E-mail: venosan@worldnet.att.net
Website: www.venosan.com
Compression Bandages
A complete discussion of the various manufacturers and types
of compression bandages is beyond the scope of this text.
Dozens of companies, large and small, distribute in the United
States. In addition, many veterinary products used for horses
are quite useful and cost-effective in phlebology. The reader is
referred to Chapter 6 for a discussion on the relative uses of
short-stretch, long-stretch, and inelastic bandages. Although I
use many types of compression bandages for treating venous
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insufficiency, I only use one short-stretch bandage to supplement compression with graduated support stockings when
treating a patient with varicose veins.
Medi-Rip
The Medi-Rip compression bandage is particularly useful in
applying localized pressure to a segment of the leg. Since the
bandage sticks only to itself, it must be applied circumferentially around the limb. Thus it can be applied only in an
approximate graduated manner by the nurse or physician.
Graduation in support is achieved by wrapping the bandage
either more or less tightly around the leg. In addition, support
padding underneath the bandage can provide a localized
increase in compression pressure.
It is recommended that this bandage be used when compressing lateral thigh varicosities. A graduated compression
stocking applies a limited compression in this proximal location and applies even less compression to the lateral aspect of
the limb by virtue of its oval configuration. Therefore, applying pads or cotton balls on the lateral thigh and compressing
them locally with a bandage will increase the compression
strength without unduly compromising the advantage of
using graduation in compression.
The composition of the bandage fabric is 99% cotton and
1% polyurethane (spandex). The warp is constructed with
longitudinal threads of alternating cotton, twisted spandex
thread, and twisted cotton threads in a 3 : 1 ratio. Threads are
twisted 1950 times per meter in an alternating clockwise and
counterclockwise manner. An equal number of clockwise and
counterclockwise twisted threads maintain proper stability.
Fill threads of the weft are woven with 100% cotton for
strength and porosity.
A fine latex spray is then applied to the fabric. The unique
application of the spray adheres only to the surface of the yarn
and does not occlude the openings between, thus maintaining
the porosity, breathability, and absorption qualities of the
cotton fabric.
Available from:
Conco Medical Company
Bridgeport, CT 06610, USA
Tubigrip
Tubigrip is an elasticized surgical tubular bandage knitted
from either 100% cotton (flesh shade) or 67% cotton and
33% rayon (natural shade). Covered elastic threads are laid
into the material to form continuous spirals. When it is
applied to the affected area the elastic moves within the
bandage, evening pressure over the contours of the body.
Tubigrip is best used as a cover or support bandage for
compression pads in patients allergic to adhesive tape or
Medi-Rip tape. In these circumstances, the compression pad
can be held in place before application of the graduated
support stocking by a layer of Tubigrip. Using Tubigrip as a
support bandage is cumbersome and of doubtful validity as a
graduated support stocking because of the ease with which the
bandage can migrate with movement of the leg.
The amount of pressure to apply can be selected by choosing the appropriate size of Tubigrip with the aid of the Tubigrip
Tension Guide. Because the tension guide measures only the
widest diameter of the limb, true graduated compression
cannot be obtained. It is recommended that Tubigrip be
applied as a double layer with the cut edges uppermost. The
second layer should overlap the first by 2 to 3 cm to prevent
occlusion.
Tubigrip Shaped Support Bandage is an anatomically
shaped compression bandage available in a range of full-leg
and below-the-knee sizes that provide a degree of graduated
compression to the limbs. The material stretches only in a
radial direction, thus providing firm support without slipping.
Size choice is determined by measuring the widest diameter
of the limb; therefore a ‘true’ graduation in pressure with the
greatest pressure at the ankle cannot be obtained.
Available from:
Se Pro Healthcare, Inc.
Montgomery, PA 18936, USA
Pressure Pads
Swisslastic compression bandages
These are available in short-stretch, medium-stretch, and longstretch styles as well as adhesive and cohesive forms.
Available from:
Venosan North America, Inc.
718 Industrial Park Ave.
PO Box 1067
Asheboro, NC 277204-1067, USA
Phone: +1 800-432-5347
Fax: +1 800-849-0946
E-mail: venosan@worldnet.att.net
Website: www.venosan.com
Pressure Pads
At times, additional pressure is required in a localized area.
The use of foam rubber padding, tightly twisted firm rolls of
cotton wool, or cotton balls, as previously mentioned in
Chapters 6, 9, 12, and 15, can provide this additional compression. Foam rubber padding may also be required to distribute compression more evenly around the leg. The ankle
area (where the greatest degree of compression is applied by
a stocking) is the most irregularly contoured part of the leg.
Here, the medial and lateral malleoli jut out of the smooth
plane of the leg, resulting in a concavity posteriorly. When
patients complain about compression stockings, they usually
complain about pain in this area. Various pads have been
constructed to fill this concavity and more evenly distribute
the compression.
Such padding fills the pocket formed by the bridging of
elastic material from the malleolus to the Achilles tendon. The
padding also creates additional pressure in this area to prevent
pooling of fluids (Fig. A.1).
Jobst stasis pads
Three types and sizes of Jobst Stasis Pads are available to fit
the concavity properly: small crescent, large crescent, and oval.
Figure A.1 Foam pad placed to fill the concavity behind the lateral
malleolus. (Courtesy of Julis Zorn, Inc.)
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A
Compression Hosiery, Compression Bandages, and Pressure Pads
Pads are made of a layer of foam rubber and a layer of polyurethane foam. They are washable and reusable.
Available from:
Beirsdorf-Jobst, Inc.
5825 Carnegie Boulevard
Charlotte, NC 28209-4633, USA
Phone: +1 704-554-9933
Fax: +1 704-551-8581
Website: www.jobst-usa.com
JuZo-Helastic
The JuZo-Helastic model 3022 compression stocking is made
with a specially designed pressure pad at the lateral malleolar
area. The pressure pads are sewn into elastic knitted pockets
and connected to the two-way stretch stocking to preserve the
two-way stretch properties of the fabric. The pads are composed of silicon.
Available from:
Julius Zorn, Inc. (JuZo)
80 Chart Road, Northhampton
PO Box 1088
Cuyahoga Falls, OH 44223, USA
Phone: +1 800-222-4999
Fax: +1 800-645-2519
Website: www.juzousa.com
Other Contacts
Compression stockings
Pierre Fabre
29 Avenue du Sidobre
F – 81106 Castres
France
Salzmann AG
Salzmann MEDICO
Rorschacherstr.304
CH – 9016 St.Gallen
Switzerland
Email: info@salzmann-group.ch
Website : www.salzmann-group.ch
Varitex
PO Box 723
NL – 2003 Haarlem
The Netherlands
Phone: +31 (23) 531 93 17
Fax: +31 (23) 532 60 00
Website: http://www.varitex.nl
Thuasne
118-120, rue Marius Aufan
BP 243
92307 Levallois-Perret Cedex
France
Phone: 01 41 05 92 92
Fax: 01 41 05 89 85
Website: www.thuasne.com
Innothéra Lab.
7-9, rue François-Vincent Raspail
94110 Arcueil
France
Phone: 01 46 15 19 00
Fax: 01 46 63 43 60
Website: www.innothera.com
Cognon Morin
Rue d’Arsonval
BP 228
86102 Chatellerault Cedex
France
Phone: 05 49 21 40 91
Fax: 05 49 02 06 98
Website: www.cognon-morin.com
Gibaud
73, Rue de la Tour
BP 78
42029 Saint-Etienne Cedex 1
France
Phone: +33 4 77 91 30 30
Fax: +33 4 77 79 62 66
Website: www.gibaud.com
AmesWalker Support Hosiery
856 Route 206, Suite 6B
Hillsborough, NJ 08844, USA
Contact Name: Paul Amatangelo
Phone: +1 866-232-3655
Fax: +1 908-359-9471
E-mail: supporthos@earthlink.net
Website: www.ameswalker.com
Carolon Company
601 Forum Parkway
PO Box 1329
Rural Hall, NC 27045, USA
Contact Name: Scott Wilson
Phone: +1 800-334-0414 ext. 1021
Fax: +1 336-969-6999
E-mail: scott@carolon.com
Website: www.carolon.com
Bandages
ConvaTec
Professional Services
PO Box 5254
Princeton, New Jersey 08543-5254
USA
Website: http://www.convatec.com
Paul Hartmann AG
Paul Hartmann Str.12
D – 89522 Heidenheim
Website: www.hartmann.info
3M Deutschland GmbH
Carl-Schurzstrasse 1
D – 41453 Neuss
Germany
3M Corporate Headquarters
3M Center
Building 270-4N-01
St. Paul, MN 55144-1000, USA
Phone: 1-888-364-3577
Website: www.3m.com/Coban2Layer
GIBAUD SAS
73 Rue de la tour, BP78
F – 42002 Saint Etienne Cedex 1
France
Website: www.gibaud.com
Karl Otto Braun GmbH & Co KG
Lauterstr.50
D – 67752 Wolfstein
Germany
Website: www.kob.de
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