Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3661_Библиотеки_им_академика_М_И_Перельмана
.pdf
12
https://t.me/med1917
Compression Therapy
Erik A. Maus
INTRODUCTION
Venous insufficiency is an extremely common problem.
According to the Framingham study, there are more
persons in the US with venous insufficiency than with
coronary and peripheral artery disease. Many patients
with venous insufficiency do not seek medical attention
until late in the course of the disease, and in many of those
who do seek medical help, venous insufficiency is not
adequately diagnosed or treated. Most patients with
venous problems have leg heaviness, edema, pruritus, or
other symptoms for years (or even decades) before they
get medical advice. Some seek medical help for the first
time after they have had bleeding from a varicose vein or
after they have developed a venous stasis ulcer which
indicates the final stage of venous insufficiency.
Although most physicians know that compression is the
treatment of choice for venous insufficiency, there is a
lack of proper understanding on when and how to prescribe compression garments. For example, practitioners
frequently prescribe stockings to patients with untreated
leg swelling with the hope that the garments will reduce
the edema. However, stockings are designed to keep
edema from forming and only minimally reduce existing
leg edema.
The varicose veins and venous insufficiency should be
treated by correcting the underlying problem, managing
symptoms, and managing and preventing complications.
As discussed elsewhere in this book, venous hypertension
due to reflux or obstruction is common in patients with
varicose veins. The pathophysiology of venous hypertension is complex, and a full review goes beyond the scope
of this chapter. However, it is important to keep in mind
the mechanisms that lead to edema formation and the
damage to the veins and skin that result from sustained
venous insufficiency and are responsible for the signs and
symptoms of this disorder.
In this chapter, I will discuss the use of different compression devices to manage venous insufficiency and its
complications, such as edema, pain, and ulceration. I will
describe the initial management of edema with compression bandages, such as Unna boots, short-stretch bandages,
and multilayer bandages. This information will help the
reader to manage efficiently edemas of etiologies other
than to venous insufficiency. These bandaging techniques
are invaluable for managing venous stasis ulcers.
Although my focus will be on the use of compression
stockings, I will also discuss alternatives for patients who
are unable or unwilling to use compression stockings.
These devices have allowed us to treat edema in patients
with abnormally shaped limbs, peripheral neuropathy, or
concomitant peripheral vascular disease, in whom standard compression may be associated with complications
such as skin breakdown, inadequate distribution of compression forces, or limb ischemia. The goals of compression therapy in the patient with venous insufficiency are
to reduce the amount of blood in the lower extremities,
promote venous flow from the superficial venous system
to the deep venous system, prevent edema fluid from
accumulating, and improve associated symptoms such as
pain, heaviness, and overall discomfort. The use of compression stockings is of great value in the prevention or
amelioration of the post-thrombotic syndrome and is an
important tool after endovenous ablation, microphlebectomy, or sclerotherapy of incompetent veins (Table 12.1).
Although we live in an era of evidence-based medicine and
I have presented the most up-to-date information, there
have been no rigorous studies on the effectiveness of compression therapy. Therefore, many of the recommendations come from experience and individual observations.
As always in medicine, common sense combined with
continuous learning should guide practitioners in the art
of prescribing. I also offer cost-effective alternatives,
because compliance is often jeopardized by the cost of
compression garments, which are not always covered by
insurance companies.
PHYSIOLOGY AND ANATOMY
As described earlier in this book, the venous system is a
network of deep and superficial veins interconnected
by perforating veins that bring blood from the lowpressure superficial system into the deep veins. Venous
return from the periphery to the heart relies mainly on
the negative pressure created during inspiration and by the
164
https://t.me/med1917
Treatment of Leg Veins
Normal
Artery
A B
Skin
Lymph
vessel
Vein
Skin
venous insufficiency
Compression
forces
External compression increases
tissue pressure counteracting
increase in hydrostatic pressure
Table 12.1 Indications for compression bandages
versus compression garments
Compression
Condition
Unresolved edema X
Lymphedema X X
Severe stasis
dermatitis (acute
deep or superficial)
Venous thrombosis X
Venous stasis ulcer X X
Varicose veins X
Prophylaxis and
treatment of
post-thrombotic
syndrome
Maintenance of limb
volume after edema
reduction
Prevention of
venous stasis ulcer
recurrence
Deep vein
thrombosis
prophylaxis
Venous insufficiency X X
A compression garment or compression bandaging may be
appropriate based on body habitus, presence of obesity or
physical limitations.
bandages
X
X X
X X
X
X
Compression
garments
Edema due to
Increase in
lymphatic
load
Venous backflow
increasing ultrafiltrate
Figure 12.1 Simplified mechanisms of
action of compression garments for leg
venous insufficiency
contractile activity of the calf muscles. Valves promote
unidirectional blood flow, and their ability to work effectively is critical for fighting gravity between breaths and
muscle relaxations.
The main cause of venous insufficiency is malfunctioning valves due to post-thrombotic syndrome, obstruction,
or primary degeneration of the venous wall. If the valves
fail to close, the column of blood distal to the malfunctioning valve increases. This increases the hydrostatic
pressure, which is transmitted all the way to the capillary
level and increases blood ultrafiltrate. As a result, edema
forms that initially is clinically not noticeable, because the
lymphatic vessels compensate for the increase of interstitial fluid formation. When the lymphatic transport gets
saturated, the patient develops phlebolymphedema that
gets progressively worse if the venous hypertension is not
resolved. In addition to edema formation, extravasation of
white and red blood cells, plasma proteins, and alpha-2microglobulin lead to chronic inflammation, dermatitis,
hyperpigmentation, tissue damage, growth factor trapping, local hypoxia, and lipodermatosclerosis. The increase
in ultrafiltration can only be alleviated by treating the
underlying condition (e.g., thrombus) or by increasing
the tissue pressure trough external limb compression
(Fig. 12.1).
PATIENT SELECTION
Patients need to have sensation in the affected limb and
be able to communicate, because excessive pressure could
cause pain from ischemia resulting in ulceration or tissue
necrosis. Ideally, patients should be able to apply and
remove the garments by themselves or they should have
Table 12.2 Types of compression bandages and treatments for which they are indicated
https://t.me/med1917
Indication
Edema
Compression type
Short-stretch bandage X X X X X
Medium-stretch bandage X X X X
Long-stretch bandage X X
Multilayer compression system X X
Unna’s boot X X
Compression legging
a
Especially helpful for patients with physical limitations or decreased sensation.
a
reduction Ulcer
X X X X
Edema
treatment
Post-phlebotic
syndrome
165
Compression Therapy
Post-procedure after
ablation, phlebectomy,
sclerotherapy
Box 12.1 Common considerations associated with
prescribing compression therapy
v Shape of leg
v Age of patient
v Skin characteristics
v Presence of arthritis or obesity
v Weakness
v
Presence of peripheral vascular disease
v Extension of varicosities (knee versus thigh versus genital)
a provider who is able to assist with these tasks. Elderly
and debilitated patients are less likely to tolerate higher
levels of compression and associated conditions such as
arthropathy, morbid obesity, and paresis need to be considered before prescribing a particular garment or bandage.
Sometimes it is better to accept lower degrees of compression and have the patients comply with treatment
than to insist in higher compression and have the patient
reject treatment at all due to discomfort or incapacity of
getting the garments on. Common factors affecting
the prescription of compression therapy are discussed in
Box 12.1.
TYPES OF COMPRESSION
Compression therapy has been used for centuries to
manage venous insufficiency and varicose veins. The
ancient Greeks applied tight leather boots to contain the
swelling. Today, natural and synthetic materials are used
to produce compression stockings and bandages. Bandages
can be characterized as long or short stretch based on the
degree of elasticity. Inelastic fabric can also be used to
manage severe venous insufficiency.
The choice of the compression to be used on each
patient should be individualized, and several factors should
be considered to optimize outcome and assure patient
compliance. Most patients with varicose veins do not need
bandages, unless the swelling is not resolved by elevation
of the affected limb. Practitioners should not use longstretch bandages such as ACE
®
wraps on these patients,
because long-stretch bandages provide high resting pressures that could cause skin ischemia when the patient is
supine (Table 12.2). Patients with edema should be bandaged with short-stretch bandages such as Comprilan
®
This type of bandage provides low resting pressure and
high active pressures when the patient walks.
An alternative used to manage patients with complicated venous insufficiency such as those with stasis ulcerations and uncontrolled edema, is a four-layer compression
system (Profore™) that consists of a padded first layer
followed by a cotton bandage, a long-stretch bandage, and
a cohesive medium-stretch bandage (Table 12.2). This
system has the advantage of lasting up to 1 week, unlike
the short-stretch bandages, which need to be readjusted
almost every day as the edema is reduced. Other systems
such as the 3M™ Coban™ 2 Layer Compression System
provide similar results.
The traditional Unna’s boot remains a good alternative
for patients with stasis dermatitis, edema and ulceration.
This bandage consists of a first layer of calamine lotion
and zinc oxide impregnated inelastic bandage that is
applied directly on the skin followed by the application of
a medium-stretch cohesive bandage (Coban™).
• Compression stockings
Compression stockings are not designed to reduce edema.
Their main purpose is to keep the edema from coming
back. Compression stockings are available by prescription
and over the counter. In the US only stockings that
provide less than 20 mmHg at the ankle can be purchased
over the counter. These are usually of insufficient
.
166
https://t.me/med1917
Treatment of Leg Veins
Table 12.3 Classes of compression strengths and
indications
Class Compression Strength indication
Class 0 10–20 mmHg Minimal symptoms with
Class I 20–30 mmHg Mild to moderate symptoms
Class II 30–40 mmHg Moderate symptoms
Class III 40–50 mmHg Severe symptoms, history of
Class IV
The above classification of compression classes varies from
country to country and there might be also some variation
among different brands.
>60 mmHg
prolonged standing
or varicose veins
ulceration
Severe symptoms, difficult to
control edema, significant
skin fibrosis
compression for the patients with symptomatic diseases
of the veins.
how to prescribe compression stockings
Stockings can be prescribed to patients with all forms of
venous insufficiency (Table 12.1) if the following criteria
are met:
v Patient has sensation in the lower extremity.
v Ankle/brachial index is >0.7.
v Edema is under reasonable control.
v Patient can remove the stockings.
Compression stockings are classified on their level of
pressure (Table 12.3), length, fabric, and fabrication
(custom made versus standard measures). Class II stockings should probably be prescribed for patients with varicose veins or venous insufficiency and mild symptoms.
However, if a patient has co-morbidities that could interfere with donning of the stockings, a class I stocking may
be appropriate. Class III stockings should be prescribed
for patients with more severe symptoms and signs, especially if they have a history of post-thrombotic syndrome
or venous stasis ulcerations. A careful examination should
be performed to rule out the presence of arterial insufficiency, because stockings could lead to skin breakdown if
the circulation is further impaired.
The next step in prescribing stockings is choosing the
length. There are knee-high stockings, thigh-high stockings, pantyhose, and thigh-high stockings with hip attachments (Fig. 12.2). The choice should be made based on
the location of the varicosities or the location of the
venous insufficiency. If a patient is going to undergo
endovenous ablation of the greater saphenous vein, thighhigh stockings should be ordered before the procedure.
If the problem is limited to the lower leg, knee-high
stockings are probably sufficient. Stockings are made with
Figure 12.2 Knee- and thigh-high stockings
Figure 12.3 Stocking with zipper on back, particularly useful in the
presence of venous stasis ulcers. The zipper prevents disruption of
any underlying dressing used on the ulcer as would occur with the
application of a regular stocking
closed or open toes. Because stockings generally do not
provide compression to the toes, the patient can choose
whether the stocking has open or closed toes based on
personal preference.
The type of fabric is important for selected patients
with skin fibrosis or in those that have severe venous reflux
that leads to rapid edema formation. These patients
benefit more from flat weave stockings such as JOBST
®
Elvarex
, but Medi, Juzo and all major stocking manufacturers carry flat weave stockings. Flat weave materials
tend to be more sturdy and supportive than regular fabric
and tend to last also longer. For patients with sensitive
skin, silk liners can be incorporated into the stockings to
decrease discomfort. Stockings come in a variety of colors,
and there are some that look like normal socks (JOBST
ActiveWear
®
sock). For patients with stasis dermatitis or
open sores, there are stockings with a silver liner that has
antimicrobial and anti-inflammatory properties. Sigvaris
and JOBST
®
make a stocking with a zipper that can be
used if the patient has active ulceration (Fig. 12.3).
Instructions on how and when to use stockings are very
important. Stockings should be applied to dry skin as soon
as possible after getting out of bed to prevent accumulation of fluid. Patients should be instructed not to sleep
with the stockings on as capillary flow can be compromised when the patient is supine.
Finally, the clinician has to decide whether the patient
can be fitted with standard-size stockings or if the
_
®
Compression Therapy
https://t.me/med1917
167
stockings need to be custom made. The stockings on the
shelf at a medical supply store will fit most patients, but
patients with morbid obesity, prominent foot arches, or
other anatomical anomalies may need stockings designed
specifically for them. These custom-made stockings are
more expensive and take several weeks to be made. Physicians should become familiar with local vendors that
have certified fitters, to provide the patient with the
garment that meets his or her needs.
There are many brands of compression stockings and
their quality is generally similar. There are some variations
among different products so that one brand might work
better than another for a given patient.
The number of stockings prescribed can improve compliance. At least two stockings should be prescribed so
that one can be worn while the other is being washed.
Patients should be instructed to follow the washing and
drying directions, because the life of the stockings can be
shortened if bleach or strong detergents are used. Patients
should avoid applying any oily substances to the skin under
the stockings, because oily products can damage the
fabric. Compression stockings should be replaced at least
every six months, because they lose their elasticity.
Special techniques can facilitate the application of
stockings. These include the use of rubber gloves, sliding
devices, and metal frames with extending handles to help
don the stockings. These devices are particularly helpful
for elderly and obese people, because some strength and
flexibility are required to don the stockings (Fig. 12.4).
the use of compression stockings after
sclerotherapy and other venous
interventions
Although no large studies on this subject have been performed, using compression stockings after sclerotherapy
may minimize hyperpigmentation and bruising and may
decrease the incidence of superficial thrombophlebitis.
Compression may also result in direct apposition of
treated venous walls, leading to better outcomes. A recent
randomized controlled study that compared the overall
disappearance of reticular and telangiectatic veins in sclerotherapy patients did not find a significant difference
between those who had used stockings and those who had
not. However, hyperpigmentation and venous thrombosis
significantly decreased in the group that received compression stockings.
Despite the widespread use of compression hosiery,
there still seem to be gaps and questions in relation to
their use in the treatment of varicose veins. A recent
systematic review published by Palfreyman & Michaels
points to the overall lack of well-designed and wellpowered randomized trials. The following can be concluded from the literature:
Subjects with mild venous insufficiency benefit from
wearing compression stockings with ankle pressure of
10–20 mmHg.
v Higher compression is required for patients with
ulcers or skin fibrosis.
v Use of stockings is associated with less pain.
v Foot volume does not increase as significantly in
patients wearing stockings as in those who do not
wear stockings.
v Patients who wear compression stockings have a
statistically significant reduction in reflux.
v Venous emptying increases in patients who wear
compression stockings.
v The use of compression stockings reduces recurrence
of venous ulcerations.
v Compression stockings can decrease the risk and
degree of severity of post-phlebotic syndrome.
Figure 12.4 Jobst® Stocking Donner is a compression stocking aid
designed to help those with limited hand strength and dexterity put on
their support wear and compression stockings. Rubber gloves greatly
facilitate donning and removal of stockings and protect the fabric from
damage frequently caused by fingernails
WHEN COMPRESSION STOCKINGS ARE NOT
AN OPTION
Some patients are unable or unwilling to use stockings
(Box 12.2). For these patients, there are other elastic and
Box 12.2 Contraindications to compression stockings
v Insensate extremity
v Arterial insufficiency (ankle/brachial index <0.7)
v Patient who cannot communicate
v Uncontrolled edema of any cause
v Patient who cannot remove stocking in case of pain
v Heavily exudating dermatitis or ulcers
v Severe limb deformity
168
https://t.me/med1917
Treatment of Leg Veins
Table 12.4 Alternatives to Compression Stockings
with Contact Information
Company and
Garment Brand
contact info Website
Figure 12.5 FarrowWrap™. An excellent adjustable alternative to
stockings. Useful in both maintenance and reduction of edema
non-elastic compression garments that consist mainly of a
foot and a leg piece of fabric with stripes that are adjusted
and secured with Velcro
FarrowWrap™ and CircAid
®
(Fig. 12.5). Examples include
®
(Table 12.4). Unlike stockings, these garments may be worn at night by some
patients if they are unable to put them on and off themselves or if they have such degree of venous insufficiency
that they develop swelling despite being in the supine
position. They have the advantage of being adjustable so
that the patient can determine how much compression he
or she can tolerate.
Farrow Wrap® Farrow Medical
CircAid leggings CircAid Medical
Leg Assist®
compression
sleeves and
CompreFit
Universal
ReadyWrap units Solaris, Inc.
Innovations Bryan,
TX.
1-877-417-5187
Products, Inc.
San Diego, CA
1-800-247-2243
BiaCare Corporation
Zeeland, MI
1-866-931-0876
West Allis, WI
1-866-768-8253
www.
farrowmedical.
com
www.circaid.
com
www.biacare.
com
www.
solarismed.
com
medical necessity are provided. In the US, Medicare does
not pay for compression garments unless skin breakdown
is present.
Although compression garments will not make varicose
veins or venous reflux disappear, they can significantly
reduce the incidence of complications that can be painful
and costly. Overall, the short- and long-term use of garments is cost effective if one considers for example, that
the development of a stasis ulcer could cause the patient
significant pain, absence from work, multiple medical
visits, etc. (The average time required for healing of
a non-chronic venous ulcer is 6 weeks with adequate
wound care.)
PITFALLS AND PEARLS
• Economic implications
Compression garments are by no means inexpensive and
cost is frequently a major problem in determining adhesion to therapy. Prices vary greatly based on the type of
the garment and degree of compression. At the time this
chapter was written the average cost of already made class
II knee-high stockings was US$45 (range of US$35–
US$90). The same degree of compression and size of a
custom-made pair averages US$150 and US$350 for
thigh-high stockings. While the alternative compression
garments such as FarrowWrap™ and CircAid
expensive, they tend to last longer than the stockings that
need to be replaced around every six months. Many
private insurance companies currently cover compression
garments if adequate documentation and a letter of
®
are more
v Stockings are not designed to decrease edema.
v Do not prescribe stockings to patients with sensory
neuropathy or sensory damage.
v Carefully prescribe if the patient has arterial
insufficiency. Avoid if ABI is less than 0.7.
v Heart failure is not an absolute contraindication to
compression therapy.
v Patients should avoid using creams and lotions under
the stockings to protect the fabric.
v Abnormally shaped legs benefit more from custom-
made or non-elastic garments.
v A pressure gradient must always be kept with the
pressure higher at the ankle and lower at the calf.
v Deep vein thrombosis is not a contraindication to
compression therapy.
TROUBLESHOOTING
https://t.me/med1917
patient complains that the stocking is
‘cutting’ the circulation
The proximal end of the stocking frequently leaves a mark
on the skin that is interpreted by the patient as a ‘cut in
circulation’. This is not a complication, and patients need
to be reassured that a slight indentation is normal. If there
is evidence of skin breakdown, the compression is probably too strong or the edema may have worsened. In these
circumstances, a brief course of short-stretch bandaging
to the leg is indicated.
patient complains that the stocking does
not fit properly
This may be due to the garment not being applied correctly. It is important to see if the seam of the garment is
straight and that the stocking is not overstretched.
patient’s skin is irritated
Some patients with sensitive skin may develop irritation
under stockings after they first put them on. This problem
can frequently be corrected by washing stockings before
the patient first uses them. If the problem persists, silk
liners may be worn under the stockings to avoid direct
contact with the skin.
patient cannot put the stocking on
Several donning devices can be tried. These can usually be
purchased at medical supply stores that specialize in compression garments. Metal frames (Fig. 12.4) and floor mats
may help the patient slide the foot into the stocking. If
patients have additional comorbidities such as arthritis,
back problems, or weakness or are unable to reach their
toes, a Velcro
CircAid
pression stockings.
®
®
legging, such as a FarrowWrap™ or
would be a much better alternative than com-
stocking rolls down
This frequent problem is seen when the compression
stockings were purchased before the edema was reduced
and so the leg is too small for the stocking. In this case,
the stockings need to be replaced with smaller ones and
the patient needs to be properly measured. Sometimes,
the compression stocking can roll down even if patients
are properly fitted. A silicon band at the proximal end
usually solves this problem (Fig 12.6).
patient has leg cramps, numbness,
or discoloration
This may be a symptom of excessive compression. If this
happens, the patient might need to try stockings that
provide less compression.
169
Compression Therapy
Figure 12.6 Silicone bands to help keep stockings in place
patient has swelling
Some patients develop swelling while wearing compression stockings. In this case, the stockings may not be
strong enough and so a stronger-compression stocking will
be required. If the edema returns while the patient is
wearing the stockings, the stockings may have lost their
elasticity because of age, damage from improper washing
or drying, or chemical damage from skin lubricants or
lotions. Washing stockings in cold water may help regain
some of the lost strength until new stockings are available.
Edema always must be decreased before the patients are
measured for new stockings. Some patients, especially the
extremely large and strong-built may develop swelling
despite using compression. If that is the case and the
highest compression has been tried without success,
changing to a flat-weave stocking might be the answer as
this material is stronger and has less tendency to stretch.
In addition to this another alternative to increase compression is to apply two stockings on the same limb, for
example a 40–50 mmHg plus a 20–30 mmHg that will
provide 60–80 mmHg. This approach might be significantly cheaper than trying to order a custom made garment
of that compression.
INSTRUCTIONS FOR PATIENTS
v Apply stockings as soon as you get out of bed, before
your legs swell.
v Stockings must be applied on completely dry skin.
v You may use lubricating creams or skin moisturizers
after removing the stockings but never before you
put them on, because they may damage the fabric.
v Do not fold the top of the stocking down.
v Remove any jewelry that might snag your hosiery.
v As you put on your stocking, do not ‘bunch up’ the
fabric in the foot.
v Working upward, use rubber gloves to help spread
the fabric evenly.
170
https://t.me/med1917
Treatment of Leg Veins
Figure 12.7 Mediven® Butler Off helps patients take off compression
stockings without awkward bending and use of force. The device is
inserted into the compression stocking and gentle pressure is applied
to push the stocking down over the heel
v Replace the stockings every six months (or sooner, if
they lose their elasticity).
v Use assistant devices to remove stockings (Fig 12.7).
FURTHER READING
Aschwanden M, Jeannertet C, Koller MT, et al 2008 Effect of
prolonged treatment with compression stockings to prevent
post-thrombotic sequelae: A randomized controlled trial. Journal
of Vascular Surgery 47:1015–1021
Flour M 2008 Creative compression treatment in challenging
situations. International Journal of Lower Extremity Wounds
72:68–74
Nelson EA, Bell-Syer SEM, Cullum NA 2000 Compression for
preventing recurrence of venous ulcers. Cochrane Database of
Systematic Reviews Issue 4. Artn. No: CD002303
Nootheti PV, Cadag KM, Magpantay A, et al 2009 Efficacy of
graduated compression stockings for an additional 3 weeks after
sclerotherapy treatment of reticular and telangiectatic leg veins.
Dermatological Surgery 35:53–58
Palfreyman SJ, Michaels JA 2009 A systematic review of
compression hosiery for uncomplicated varicose veins.
Phlebology 24(Suppl 1):13–33
Raffetto JD, Khalil RA 2008. Mechanisms of varicose vein
formation: valve dysfunction and wall dilation. Phlebology
23:85–98
Raju S, Hollis K, Neglen P 2007 Use of compression stockings in
chronic venous disease: patient compliance and efficacy. Annals
of Vascular Surgery 21:790–795
Raju S, Neglen P 2009 Chronic venous insufficiency and
varicose veins. New England Journal of Medicine 360:2319–
2327
Соседние файлы в папке Библиотека им академика М.И. Перельмана