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412 LIFELONG MANAGEMENT
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Box 9.1 Endovenous Ablation
Endovenous ablation should be considered for all patients with
venous insuciency with referral to vascular services to assess
need for venous intervention and to reduce the risk of recurrence (NICE2021; Wounds UK2022).
Endovenous ablation seals o or ‘ablates’ the main underly-
ing faulty vein that is feeding the varicosities. This is done
either by heat, laser or glue.
It has the same benets in terms of vein function compared
to traditional surgery, but is less invasive.
The procedure is done as a day case, under a local anaes-
thetic, and is viewed as a minimally invasive procedure.
It should be considered for all patients with venous insu-
ciency to reduce the risk of ulceration.
Is compression therapy required after surgery?
Successful endovenous ablation can eliminate the need for
long- term compression in patients with purely venous
hypertension (i.e. structural venous disease).
If there is some functional disease (e.g. failure of the calf muscle
pump), compression may need to continue with specialist
assessment.
Source: Adapted from Wounds UK2022; NICE2021.
recurrence after healing and referral to vascular services for venous
intervention has been considered (NICE2021) (see Table9.2).
Hosiery should be remeasured and replaced according to
manufacturer’s guidelines, usually every three to six months, three
months for British Standard and six months for European Standard
(Wounds UK2021).
The purpose of using compression therapy after ulcer healing is to
control lymphoedema/chronic oedema and reduce venous hypertension to prevent further ulceration (Wounds UK 2022). The aim of the
compression therapy is also to slow venous disease progression.
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TABLE 9.2
Who may require
lifelong
compression?
Who may not require
lifelong
compression?
Source: Adapted from Wounds UK (2022).
Lifelong compression.
Individuals with venous disease where vascular or
surgical correction is not possible.
Individuals with chronic oedema/ lymphoedema
where the underlying condition has not been
corrected (e.g. a valve replacement for heart
failure, or someone who has undergone a gastric
bypass and now has a healthy body mass index).
People with a healed traumatic wound with no
signs of venous disease. If it is the individual’s
rst episode of a traumatic wound, lifelong
compression is not required at this stage.
Individuals who have had successful endovenous
ablation with purely venous hypertension
(i.e.structural venous disease).
Compression therapy has a therapeutic eect by applying external pressure to the lower limb, which supports the supercial veins
and counteracts raised capillary pressure. It encourages the lymphatic system to reduce oedema and the venous system to return
blood from the limb towards the central circulation (Ritchie and
Warwick2018).
In a healthy leg the valves and the calf muscle pump work in
conjunction to ensure that the blood does not slip back down to the
foot causing stagnation of the blood in the tissues. Patients who have
damaged valves and immobility are at greater risk of the veins coming under pressure and the valves becoming incompetent.
More discussion on how compression therapy works as part of
eective clinical management can be found in Chapter8.
ASSESSING FORCOMPRESSION HOSIERY
Medical hosiery should be selected based on the outcomes of a full
holistic assessment, patient preferences and after planning of clear
goals and aims of treatment with review dates. People who become
familiar with wearing leg ulcer compression hosiery kits to heal their
leg ulcers have been found to have a greater willingness to wear compression hosiery to maintain their skin integrity and have a lower
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recurrence rate in the future (NICE2020). This may be attributed to
them seeing the hosiery help to heal the leg ulceration, building faith
in the treatment, and because they may have been able to incorporate compression hosiery wearing into their everyday life successfully (Ashby et al. 2014). Practitioners should consider transition
from bandages to leg ulcer hosiery as soon as it is clinically indicated
to allow people to take the next steps in recovery and transition to
step-
down interventions. (These are discussed in more detail in
Chapter8.)
Table9.3 oers some key steps to consider when assessing for
compression hosiery.
TABLE 9.3
Step Approach
Listen and explore Explore the patient’s understanding, concerns and
Assess Assess the limb and the patient to determine the
Key steps toconsider when assessing forcompression hosiery.
hopes related to medical compression hosiery.
What do they understand about their current
condition and how compression can help?
Do they require education to help them to understand
how the therapy will work?
Acknowledge the physical and psychological issues
that come along with living with a lifelong
condition of venous hypertension.
most appropriate medical compression hosiery
clinically.
Involve the patient in choosing the hosiery– they will
be more likely to wear it.
Include a full holistic assessment and ankle brachial
pressure index (ABPI).
You may need to pay particular attention to the limb
shape; if there is an unusual limb shape or
swelling, bespoke hosiery is required.
Is there a large amount of swelling, lymphorrhoea or
skin fragility? If so, consider other options rst to
manage the limb and reduce the oedema prior to
application of hosiery. Seek specialist help
if needed.
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TABLE9.3
Step Approach
Consider patient’s
ability
Check t Check how the medical compression hosiery ts on the
Patient preference Ask the patient if they are happy with the appearance
(Continued)
Consider the patient’s ability to apply the compression
hosiery, for example their manual dexterity and their
body size and shape.
Are they able to put the hosiery on themselves?
Will they need an aid (see later Table9.9) to
assist or help?
Might they require a family member or carer to apply the
hosiery? Do they have this support available to them?
What information do the patient and the carer need
to receive to enable them to decide?
leg(s), around the ankle(s) and the feet to ensure there
is an eective t that is not too loose or too tight.
Check that the hosiery is smooth on the leg and not
wrinkled or digging in or rolling down.
Watch the patient apply the hosiery to ensure that it is
tting correctly. This may take several appointments
to get them applying the hosiery correctly. Make sure
the patient knows to come back if the hosiery gets
holes in it or ladders.
Advise the patient how to care for their hosiery–
washing and care instructions.
and t of the medical compression hosiery.
If they are comfortable with the aesthetics ofthe
hosiery, they are more likely to wear the garment.
Ask them what would make them more likely to
wear the hosiery?
Source: Adapted from Wounds UK (2021).
CHOOSING ANDPRESCRIBING HOSIERY
There has been a vast evolution of hosiery over the last few years and
there are now more choices than ever before. While this means
increasing choice for people who need to wear compression hosiery
garments, this may also lead to confusion for practitioners with multiple brands, measurements required and measurement forms to
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choose from. Garments should be prescribed by an appropriate practitioner (Health Service Executive (Ireland) 2022). The practitioner
who measures and prescribes compression hosiery must have sound
knowledge of how to measure and select the correct compression
hosiery garments to ensure eective treatment.
Inconsistencies have been observed in the prescribing and
provision of compression garments (Health Service Executive
(Ireland)2022). In part this may be owing to the large variety of products available. Practitioners need to undertake careful assessment
and choose the most appropriate treatment option.
All decisions and prescriptions need to be fully documented,
including in the patient’s notes, along with limb measurements and
the type of garment selected, its size and class. During prescribing
and dispensing, it is important to refer to the manufacturer’s recommendations and measurements to ensure that the most appropriate
garment is chosen. The manufacturer’s ordering instructions should
be consulted to ensure the person receives the correct product.
Thebrand name, garment style and compression class, as well as the
manufacturer’s codes for the garment and its style, should be recorded
on the prescription (Wound Care People2019). As there is a large
variety of products available, practitioners may prefer to prescribe
from a smaller range of hosiery from the local formulary initially, in
order to gain experience of appropriate use, therapeutic performance
and acceptability to people.
British andEuropean Standards
Dierences exist between British, French and German hosiery, as
explained in Table9.4.
Each of these standards has its own testing methods and all use
laboratory testing. This enables them to repeat the test with validity
and give measured results when testing new products for design,
build and then classication.
Differences Between Flat- Knit andCircular- Knit Hosiery
Circular- Knit Garments
The fabric for this type of garment is knitted on a cylinder with circular needles. The way they are made means there is no seam to the
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TABLE 9.4
hosiery classes.
Compression
class
Class 1– Mild
compression
Class 2– Moderate
compression
Class 3– Strong
compression
Class 4– Extra- strong
compression
Source: Adapted from Wounds UK (2021).
Dierence between British, French andGerman Standard
German
British
Standard 40
(BS-
661210),
month
3guarantee
(Partsch2003)
14–17 mmHg 10–15 mmHg 18–21 mmHg
18–24 mmHg 15–20 mmHg 23–32 mmHg
25–35 mmHg 20–36 mmHg 34–46 mmHg
Not available >36 mmHg >49 mmHg
French
Standard
(AFNOR
NF 30.102A)
(Levick2003)
Standard
(RAL GZ 387/1),
6- month
guarantee
(Földi and
Földi1983)
garment. Many patients prefer them as they are more cosmetically
acceptable and there is a great choice in colour, nish and styles.
These types of garments are used for ready- to- wear hosiery,
which is best suited to patients where there is no oedema present and
minimal limb distortion (Anderson and Smith 2014), it predominantly acts on the veins to promote venous return rather than on tissue pressure that will address oedema. Circular-
knit hosiery is elastic
and so inappropriate for managing moderate or severe lymphoedema/
chronic oedema, in the presence of limb distortion or if there is a risk
of rebound oedema. The circular knit makes the stocking liable to
expand in response to increasing swelling of the limb. It may also
cause damage to the limb by the hosiery rolling or digging into the
esh, forming a tourniquet that can result in skin breakdown and
trauma (Wound Care People2019).
Flat- Knit Garments
The fabric for these garments is knitted at on a machine and then
the edges are sewn together and inlaid with a thicker yarn, creating a
seam. Flat- knit hosiery primarily works to increase tissue pressure,
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which manages swelling and oedema within the limb, but has a secondary function on the veins to support venous return. With these
types of garments the fabric is relatively thick and sti, meaning that
it lies across skin folds without cutting into the skin. This construction creates a semiand is particularly suitable for those with chronic oedema. Its reduced
elasticity and stretch support the limb, applying pressure to the lymphatics. This provides a micro- massage eect and is less likely to
move on the limb or into deep skin folds.
This type of garment is usually used for made- to- measure garments because it can be easily adapted to an altered limb shape
(International Lymphoedema Framework2006; Wounds UK2021).
rigid fabric that resists the swelling of the limb
Choosing theMost Effective Treatment
Overall, an understanding of the materials used in a given compression garment and the accessories available to improve the therapeutic eect of garments helps inform clinical decisions about the
optimal garment to choose for the most eective treatment for the
patient’s presentation of lymphoedema/chronic oedema.
One consideration is stiness, which is dened as the pressure
increase produced by the compression hosiery per 1 cm of increase in
leg circumference. It is the ability of the bandage/hosiery garment to
oppose the muscle expansion during contraction (Mosti2012). This
therefore aects the levels of compression exerted by dierent types
and classes of hosiery. Circular- knit garments are said to have a lower
static stiness index, with at knits having a higher static stiness
index (Wounds UK2021). There is more information about stiness
and the static stiness index in Chapter8.
Table9.5 oers suggestions for medical compression hosiery and
additional treatments for venous insuciency and oedema, based on
the CEAP classication (see Chapter5).
Limb Size andShape
Every eort should be made to reduce the oedema of the limb prior
to measurement and application of compression hosiery.
If the limb shape is altered or unusual, then o- the- shelf hosiery
is not an option, but there is the option of made- to- measure hosiery
and wraps these can be complicated to measure for the practitioner
must understand and have the skills for this. It is important for the
practitioner to have knowledge of the hosiery garments that are
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TABLE9.5 Treatments forvenous insuciency andoedema.
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Clinical indications Medical compression hosiery suggestion Additional treatment suggestions
CO No visible signs or palpable
signs of venous disease
C1 Telangiectasis or
reticular veins
C2 Varicose veins
C2r Recurrent varicose veins
C3 Oedema
C4 Changes in skin and
subcutaneous tissue
secondary to CVD
C4a Pigmentation or eczema
C4b Lipodermatosclorosis or
atrophie blanche
C4c Corona phlebectatica
C5 Healed ulcer
C6 Active venous ulcer
Venous insuciency CEAP classication (Lurie etal.2020)
C6r Recurrent active
venous ulcer
No treatment required No treatment required
Circular- knit, o- the- shelf, RAL standard compression
CC1 (18–21 mmHg) or CC2 (23–25 mmHg) may be
appropriate
For patients who do not t in standard sizes, made- to-
measure, circular- knit, RAL standard options
should be considered. If there is signicant shape
distortion, at- knit, made- to- measure hosiery in
CC1–3 should be considered.
knit, o- the- shelf, RAL standard compression
CircularCC2 (23–25
For patient not tting into standard sizes, circular-
knit, made- to- measure, RAL standard hosiery
should be considered.
Two-
layer compression hosiery kit or compression
bandaging providing a combined 40
should be used.
mmHg) may be the most appropriate.
mmHg
Daily skincare and emollient regimen to
maintain skin integrity.
Simple ankle/calf exercises to enhance
calf muscle pump function.
Increase activities/mobility, such as short
walks or water exercises (e.g. walking
in shoulderor aqua cycling, but not swimming).
AGP referral scheme may be available
in some areas.
Limb elevation on resting.
Weight loss/maintenance (referral to
dietician or bariatric services).
If oedema is venous related and is
persistent or worsening, patients
should be seen by a vascular specialist
to explore venous interventions to aid
symptoms (NICE2021).
high water, aqua- aerobics
(Continued)
TABLE9.5 (Continued)
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Clinical indications Medical compression hosiery suggestion Additional treatment suggestions
Chronic oedema/lymphoedema
stage 0–2 (latency mild
or moderate)
Circular- knit, o- the- shelf, RAL standard compression
may be suitable in the early stages.
Flat- knit, made- to- measure, RAL standard hosiery
should be considered in most cases.
CC1–4may be most appropriate according to the
holistic assessment of the individual and their
circumstances.
Chronic oedema/lymphoedema
Stage 3
Flat- knit, made- to- measure, RAL standard compres-
sion hosiery with high SSI is often most suitable.
CC3 (35–45 mmHg) or CC4 (>49 mmHg) may be most
appropriate, however CC2 (25–35
2016)
Oedema classication (International Society of Lymphology
CC, compression class; CVD, cardiovascular disease; SSI, static stiness index.
Source: Adapted from Wounds UK (2021).
considered according to the holistic assessment of
the individual and their circumstances.
mmHg) may be
Daily skincare and emollient regimen to
maintain skin integrity.
Simple ankle/calf exercises.
Avoid sitting with legs dependent or
sleeping in a chair at night- time; this
may undermine all compression
treatment/management.
Increase activities/mobility, such as short
walks or water exercises (e.g. walking
in shoulder- high water, aqua- aerobics
or aqua cycling, but not swimming).
AGP referral scheme may be available
in some areas.
Limb elevation on resting.
Consider simple/manual lymphatic
drainage.
As for chronic oedema/lymphoedema
stage 0–2.
Weight loss/maintenance (referral to
dietician/bariatric services).
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available on their trust’s formulary, and those that are best suited to
the individual, as not all garments will be available to them. The practitioner also needs to know where to refer patients on when specialist
advice is needed in choosing and measuring a patient for compression hosiery.
Compression therapy is only eective if the patient’s limbs
are measured properly and the garment is applied correctly.
Inappropriately measured and applied compression can cause
trauma and pressure and damage the skin, particularly if the garment rolls during wear or is too tight and digs into the skin (Robertson
etal.2014). Experiences like these can lead to patients not wanting to
continue with treatment.
Made-
to- Measure Hosiery
This should be considered when:
The limb does not t within the measurement guide.
The limb is an unusual shape.
The measurement around the malleolus is particularly wide.
Flat knit is required for the management of lymphoedema and
chronic oedema.
The clinician may also need to consider other types of materials
for garments to be made from, for instance in the case of allergy to
latex the patient may need cotton- rich garments (Wounds UK2021).
These garments require a greater number of measurements to be
taken to ensure they t the patient correctly. It is possible for some
styles of these garments to have zips up the back that can aid in application, but care must be taken not to cause trauma to the skin and the
patient’s dexterity needs to be considered. Each manufacturer will
have a dierent type of measurement form and measurements that
are required.
Measuring people’s legs for bespoke hosiery can be dicult to
begin with and so seeking support to develop your practice or accessing extra training to be able to measure and t for made- to- measure
garments may be recommended, but once you have achieved competence they are a vital tool in the tool kit when transitioning people
who have established oedema from bandages to hosiery.
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