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CHAPTER
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10
Mechanism and Effects of Compression Therapy
HUGO PARTSCH
Compression therapy is a very effective treatment modality
whose mechanisms are not yet fully understood.
The clinical effects depend mainly on two factors, inter-
face pressure and stiffness.
Interface pressure is the pressure exerted by a compression device on a specifi c skin area. Stiffness is defi ned by
the increase of the interface pressure induced by the increase
of the circumference of a limb segment when muscles are
contracting.
1
INTERFACE PRESSURE
Compression Hosiery
The pressure ranges given for compression hosiery are
measured in the laboratories of the producers by determining
the force that is necessary to stretch the ankle part of the
stocking in transverse direction. The pressure values are
calculated from the force-extension diagram of the elastic
fabric, the so-called hysteresis curve, projected to a leg
model with defi ned circular cross sections using Laplace’s
law. This formula describes the relationship between the
interface pressure P, which is directly proportional to the
tension (T) of the bandage and inversely proportional to
the radius (R) of the curvature to which it is applied (P =
T/R). The proportion of stretch and force, which corresponds
to the steepness of the so-called slope in the hysteresis curve,
refl ects the elasticity of the material of the stocking.
Several industrial measuring systems for obtaining hysteresis curves are used, such as the Hosy method, the Hatra
tester, the Instron method, the French ITF method, and
2
others.
Table 10.1 gives a comparison of compression classes for
ready-to-wear and custom stockings used in several coun-
tries. The range of compression pressures and the description of these classes vary among different countries.
Therefore, it is recommended to use the pressure range in
mm Hg rather than compression classes for a better universal
understanding. However, comparisons may also be problematic since the given ranges are measured by different
methods. These facts underline the necessity of in vivo pressure measurements on the individual leg, at least in future
clinical studies.
The unit for pressure is 1 Pascal (Pa), which is 1 Newton
(N) per square meter. In the medical fi eld, for example,
measuring blood pressure, the usual unit for pressure is the
weight of one cubic millimeter of mercury.
The pressure values in Table 10.1 refer to the ankle
region, called the level B. Proximal measuring points on the
leg are:
• B1, the point at which the Achilles tendon changes into
• C, corresponding to the calf at its maximum girth
• D, just below the tibial tuberosity
• E, over the patella
• F, between K and E
• G, 5 cm below K in the upright position
• H, at the greatest lateral trochanteric projections of the
• K, at the center point of the crutch
As the circumference of the leg progressively increases, a
compression gradient is produced, which is defi ned by the
European prestandard as follows: for level B1, 70–100%;
for C and D, 50–80%; and for F or G, 20–40% for compression class III and IV; 20–60% for the classes A–I; and 20–
50% for class II.
1
the calf muscle
buttock
The Vein Book
103
All rights of reproduction in any form reserved.
Copyright © 2006, Elsevier Inc.
104 Chapter 10/Mechanism and Effects of Compression Therapy
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TABLE 10.1 Compression Classes Used in Several Countries (Values are mm Hg, 1 mm Hg = 1,333 hPa)
Compression class EU (CEN)64 USA UK (BS 6612)65 France Germany
A 10–14 (light)
I 15–21 (mild) 15–20 (moderate) 14–17 (light) 10–15 18–21 (light)
II 23–32 (moderate) 20–30 (fi rm) 18–24 (medium) 15–20 23–32 (medium)
III 34–46 (strong) 30–40 (extra fi rm) 25–35 (strong) 20–36 34–46 (strong)
IV >49 (very strong) 40+ >36 >49 (very strong)
The values indicate the compression exerted by the hosiery at a hypothetical cylindrical ankle
TABLE 10.2 Compression Materials
Elastic, long-stretch material Inelastic, short-stretch material Nonstretch material
Compression stockings Short-stretch bandages Zinc paste bandages, Unna boot
Long-stretch bandages Multilayer short-stretch bandages* Velcro band devices
Extensibilty >100% Extensibility <100%* Extensibility 0–10%
Low stiffness Medium stiffness High stiffness
Exerts pressure when applied with stretch Pressure increases when movement causes calf Pressure increases when movement causes calf
muscle to contract muscle to contract
*Bandages consisting of several elastic components with an extensibility of the single layer >100%, for example as the “four-layer bandage,” will become
relatively inelastic when applied in more layers and therefore may also be ranged into this category.
66
Compression Bandages
The interface pressure of compression bandages depends
on the experience and the skill of the bandager and only
rarely is declared. For future trials it will be essential to
measure the interface pressure as a parameter characterizing
the “dosage” and hence the effi cacy of the bandage.
Several devices for measuring the interface pressure on
the individual leg have been described.2 The pressure measured under static (resting) conditions is termed resting pres-
sure; that measured on the moving patient is known as
working pressure.
When pressure data are reported it is essential to indicate
the type and size of the transducer and the exact localization
on the extremity.
3
The ankle region, which is a reference point for stocking
manufacturers (B-segment), is not a suitable location for
reliable in vivo measurement because of the radius changes
varying widely due to the bony prominences and tendons
prevailing in this segment. This is the reason why some
reports of stocking pressures have given lower values from
B than from the more proximal segment B1.
STIFFNESS
Stiffness is defi ned by the increase of compression per
centimeter increase in the circumference of the leg, expressed
in hectopascals per centimeter and/or millimeters of mercury
per centimeter.1 A very appropriate method to measure a
dynamic stiffness index during walking has been described
by a Dutch group.5 However, this technique requires sophisticated instrumentation and can be performed only in specialized laboratories.
We have proposed a very simple method that is able to
differentiate inelastic from elastic material by measuring the
difference between the standing pressure and the supine
pressure at the B1 region, which is the area where the tendinous part of the medial gastrocnemius muscle changes into
the muscular part.6 The standing position is considered to be
a snap-shot of the walking cycle. Therefore pressure sensors
also may be used that are not able to register continuous
pressure changes.
Especially when several textiles are combined in a multilayer bandage, the stiffness of the fi nal bandage will
2
increase because of the friction of the layers.
The same is
true when two compression stockings are donned over each
other.
Compared with in vitro measurements stiffness corre-
sponds to the slope of the hysteresis curve in vitro.
It has been shown that compression devices exerting the
same resting pressure have different hemodynamic effects
on venous refl ux and venous pumping function depending
on the elastic property of the material.
terized by the stiffness, which plays an important role
concerning the performance of a compression device during
standing and walking, and which can be measured in vivo.
4
This can be charac-
COMPRESSION MATERIAL
Based on the principles mentioned earlier, several textiles
used for compression therapy can be differentiated (see
Table 10.2).
Physiological Effects of Compression Therapy 105
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Resting vs. Working Pressure
90
80
70
60
50
40
mmHg
30
20
10
0
Standing
FIGURE 10.1 Interface pressure measured on the medial aspect of the
leg (B1) of an elastic and an inelastic bandage. Both bandages are fi rmly
applied and exert a pressure of 60 mm Hg immediately after application in
the standing position. During walking much higher pressure peaks are
obtained with inelastic than with elastic material. When the patient lies
down and also after 24 hours, elastic bandages show only a mild reduction
of pressure. The more intense pressure loss of the inelastic material is the
reason why these bandages also are tolerated during nighttime, and why
they should be renewed when getting too loose.
Walking
umbent
Rec
After 24 h
Elastic
Inelastic
stretch bandages may better be tolerated in the resting position. The pressure loss of up to 40% in the fi rst two hours
is caused by an immediate reduction of the limb volume and
should be taken into account by applying an inelastic bandage
with a much higher strength than an elastic bandage, which
needs some experience. Due to the pressure fall, inelastic
bandages are well tolerated also during nighttime. In patients
with massive edema they should be reapplied after short
periods of time in the initial phase when they get loose. Later
on they may be worn for one week and longer. In the presence of arterial occlusions inelastic bandages should be
applied with a very low resting pressure, which should be
adjusted to the systolic ankle pressure in order not to interfere with the reduced arterial infl ow. During movement
there will be a massage of the limb, which may be compared
with intermittent pneumatic compression. Bandages applied
with several elastic layers get similar elastic properties as
short-stretch bandages.
Intermittent pneumatic compression offers adjunctive
benefi cial effects, especially in patients with a restricted
walking ability. In addition to the decongestive effect, an
increase of arterial fl ow and a release of vasoactive and
anticoagulatory mediators from the endothelial cells have
been documented during the last few years.
8,10
PERFORMANCE OF
COMPRESSION MATERIALS
Elastic textiles exert pressure by being stretched. During
walking only small pressure peaks will occur since the
elastic material gives way with every step. The working
pressure is therefore not much higher than the resting pressure (see Figure 10.1). Due to the retraction of the elastic
fi bers there is only a small reduction of interface pressure in
the sitting and lying position. A continuous high resting
pressure may cause unpleasant feelings during rest and is
strictly contraindicated in patients with arterial occlusive
disease. Therefore elastic bandages and fi rm medical compression stockings should be removed over nighttime. The
main advantage of elastic material is that it can also be
handled by nonexperienced staff and even by the patients
themselves.
Short-stretch material and completely rigid devices show
a high working pressure with high peaks during walking that
are able to occlude leg veins intermittently, thereby reducing
ambulatory venous hypertension.
During walking, nonyielding material will exert similar
effects as intermittent pneumatic compression, especially
concerning the release of anti-infl ammatory, anticoagulatory, and vasoactive mediators from the endothelial cells.
These effects are probably the reason for the fact that the
best healing rates of venous ulcers have been described with
multilayer high-pressure bandages.9 A considerable fall of
pressure will occur when the patient lies down, so that short-
7,14
8
Therapy Phase and Maintenance Phase of
Compression Therapy
In general, we prefer multilayer short-stretch or completely nonelastic material for the therapy phase of severe
stages of chronic venous insuffi ciency like venous ulcers,
for lymphedema, and also for acute phlebitis and deep vein
thrombosis.11 When the leg ulcers are healed and when the
extremity is fairly free from edema, elastic material, preferably compression stockings, is used in order to maintain this
condition (maintenance phase).
PHYSIOLOGICAL EFFECTS OF
COMPRESSION THERAPY
Some physiological effects of compression therapy as
documented in several studies are summarized in Table
1,12
10.3.
The application of continuous compression is contraindicated in patients with advanced peripheral arterial disease or
severe sensory impairment.
Several effects of compression therapy have been
demonstrated in the acute experiment using intermittent
pneumatic compression. It may be assumed that similar
effects will also occur during walking with inelastic
bandages.
106 Chapter 10/Mechanism and Effects of Compression Therapy
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TABLE 10.3 Effects of Compression Therapy
(Stockings and Bandages)
Parameters Effect
Tissue pressure Increase
Edema Decrease
Venous volume Decrease
Venous velocity Increase
Blood shift into central compartments Increase
Venous refl uxes Decrease
Venous pump Improvement
Arterial fl ow Increase (intermittent
compression)
Microcirculation Improvement
Lymph drainage Improvement
Tissue Pressure and Edema
By increasing the tissue pressure compression works
against fi ltration, which is the most important mechanism
to prevent or to remove edema. Occupational leg swelling
in sitting and standing professions can be prevented by light
compression stockings, which are also able to reduce mild
edema.13 Reduction in intradermal edema can be measured
with ultrasound in patients with CVI and lipodermatosclerosis. Severe stages of limb swelling benefi t more from
inelastic compression devices exerting higher pressure.
Compression may reveal benefi cial effects also in nonphlebological causes of edema like infl ammatory edema
(arthritis, cellulitis), cardiac, dysproteinemic, renal edema,
lymphedema, and cyclic idiopathic edema.
2
Venous Volume and Venous
Blood Flow Velocity
Depending on the exerted pressure and the body position,
external compression is able to narrow or to occlude superfi cial and deep leg veins.
In the supine position an external pressure of 10–
15 mm Hg is enough to decrease the venous diameter. The
resulting increase of blood fl ow velocity as clearly shown
by measuring the circulation time with isotopes15 is the
rationale for recommending light compression stockings for
thromboprophylaxis in bedridden patients.
Venous volume can be assessed using air-plethysmography (APG) that shows a signifi cantly more pronounced
reduction by inelastic than by elastic compression, even
when the resting pressure is the same.
In the upright position elastic stockings will have only a
minor effect on decreasing the diameter of the leg veins.16
However, a very small decrease of venous diameter will
result in an overproportional decrease of the local blood
14
4
volume as demonstrated by several plethysmographic
studies.
4,12
Blood Shift into Central Compartments
Firm compression bandages applied on both lower
extremities may redistribute blood toward the central parts
of the body. This can lead to an increase of the preload of
the heart by about 5% and should be avoided in patients with
borderline cardiac function.
17
Decrease of Venous Refl uxes and
Improvement of the Venous Pump
Using APG in patients with deep venous incompetence,
it could be shown that compression with increasing interface
pressure was associated with a decreasing amount of total
refl ux measured by venous fi lling index.
A statistically signifi cant reduction of refl uxes was
achieved with pressures over 30 mm Hg for inelastic and
over 40 mm Hg for elastic material.
The reduction of venous refl uxes in patients with chronic
venous insuffi ciency by external compression explains the
improvement of the venous pumping function. Plethysmographic studies have shown an increasing improvement of
the venous pump with increasing stocking pressures, starting
with an ankle pressure of around 20 mm Hg.
Higher compression pressure using stiff material leads to
short phases of intermittent occlusion of the deep veins with
every step during muscle contraction. Such intermittent
occlusions of deep veins on the leg can be visualized by
Duplex.14 By encasing the veins in a rigid envelope ambulatory venous hypertension may thereby be reduced in patients
with deep venous incompetence.7 Similarly, a progressively increasing pressure on the thigh by using a blood
pressure cuff blown up to 40–80 mm Hg led to a progressively decreasing vein diameter and to an abolishment of
refl ux when the femoral vein segment contained incompetent valves.
18
Reduction of venous refl uxes and improvement of ambulatory venous hypertension by external cuff
compression could be demonstrated even in patients without
any valves (avalvulia). This effect therefore cannot be
explained by the common explanation of a coaptation of
distended valve leafl ets, but seems rather to be due to the
intermittent occlusion of the incompetent vein during
walking.
19
Confl icting results have been reported concerning an
improvement of ambulatory venous hypertension by compression stockings.
2,7
This may be explained by the fact that
the pressure exerted by stockings is too low in order to suffi ciently compress the veins in the leg in the upright position.
In addition, the elastic material gives way with every step,
4
7,20
Physiological Effects of Compression Therapy 107
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whereas inelastic, short-stretch bandages with a double as
high resting pressure are able to achieve intermittently short
venous occlusions during muscle systole while walking. In
patients with severe stages of chronic venous insuffi ciency
a higher compression pressure is needed to improve the
disturbed venous pumping function, whereas lower pressure
is suffi cient in simple varicose veins.
20
The key mechanism of compression therapy to reduce
ambulatory venous hypertension in patients with severe
chronic venous insuffi ciency is an intermittent occlusion of
the veins during walking.
In contrast, continuous obliteration of veins by external
compression may be desirable after varicose vein surgery in
order to stop bleeding and after sclerotherapy to prevent
refi lling of blood.
To achieve complete venous occlusion the external pressure has to be higher than the intravenous pressure, depending on the body position. It could be demonstrated that an
occlusion of the leg veins can be obtained with an external
pressure in the range of 20 mm Hg in the supine position, but
that in the sitting and standing positions the pressure has to
be between 50 and 70 mm Hg.14 With compression stockings
such pressure ranges can be achieved only when rolls or
pads are applied over the vein. According to the law of
Laplace this will increase the local pressure due to the reduction of the local radius.
by an intermittent pneumatic pressure pump. Several experiments with intermittent pneumatic compression have demonstrated an increase of arterial fl ow in patients with arterial
22
occlusive disease.
The deciding mechanisms of action are
the reduction of edema, an increase of the arteriovenous
pressure gradient, myogenic mechanisms, and the release of
vasoactive substances from the endothelial cells.
Compression accelerates blood fl ow in the enlarged capillary loops and reduces capillary fi ltration due to enhanced
tissue pressure. Blood fl ow and partial oxygen tension in the
skin increase and the endothelial adhesion of leukocytes is
normalized. Different studies using electron microscopy
were able to show a restoration of the structural changes
in the media myocytes in stripped veins and a tightening
of intercellular junctions. Increasing fl ow velocity demonstrated by laser Doppler fl uxmetry may reduce the likelihood
of white blood cells interacting or sticking to endothelium
with release of various factors.23 Effects on mediators
involved in the local infl ammatory response may explain
both the immediate pain relief that occurs with good compression, and ulcer healing.
2,9
Model experiments with intermittent pneumatic compression were able to demonstrate that there is an increased
release of fi brinolytic mediators and of the endothelial relaxing factor (EDRF) nitrogen oxide from the endothelial cells
depending on the amount of shear stress produced by the
compression waves.
8
Arterial Flow and Microcirculation
A reduction of arterial fl ow will occur when the external
compression pressure exceeds the intra-arterial pressure.
This may happen in patients with arterial occlusive disease
with a reduced peripheral arterial pressure. In order to avoid
ischemic skin lesions from external compression it is therefore essential to measure the peripheral arterial pressure by
a Doppler probe before strong compression bandages or
stockings are applied. It is generally accepted that a Doppler
ankle-brachial index (ABI) of less than 0.5 is a contraindication for compression therapy. However, external compression does not invariably mean reduction of arterial fl ow.
H.N. Mayrovitz reported on several experiments concerning
arterial blood fl ow and compression and was able to demonstrate an increase of the pulsatile fl ow below the knee
in healthy volunteers using nuclear magnetic resonance
fl owmetry.
Patients with edematous legs and with an ABI between
0.5 and 0.8 may benefi t from inelastic or short-stretch bandages applied with a mild resting pressure due to the edema
removing massage effect that will occur with every ankle
movement. Completely inelastic bandages together with
walking have a similar effect as intermittent pneumatic
compression. The rhythmic pressure peaks of an inelastic
bandage during walking can be compared with those exerted
21
Lymph Drainage
Several benefi cial mechanisms of compression therapy
on the swollen extremity may be explained by its effects on
the lymphatic system:
• Reduction of capillary fi ltration
• Increase of capillary reabsorption
• Shift of fl uid into noncompressed parts of the body
• Increase of lymphatic reabsorption and lymphatic
transport
• Breakdown of fi brosclerotic tissue
• Down-regulation of pro-infl ammatory cytokines and
receptors for growth factors.
External compression increases the interstitial pressure and
prevents fl uid from fi ltering out of the capillary network.
The amount of the lymphatic load thereby is decreased.
Compression removes more water than protein from
the tissue, thereby increasing oncotic tissue pressure and
reinforcing the need for sustained compression. Therefore in chronic edema, success is dependent on continued
compression.
Compression together with movement enhances the contraction of the lymphangion.
24
108 Chapter 10/Mechanism and Effects of Compression Therapy
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TABLE 10.4 RCTs and Systematic Reviews on Compression Therapy
First column: Indications, following the CEAP classifi cation; second column: number of RCTs identifi ed; columns 3–7: levels of
recommendation A, B, C (see later) for bandages (column 3) or different stockings with their pressure ranges (columns 4–7)
Indication Ref # Bandage Stocking 10–14 Stocking 15–21 Stocking 23–32 Stocking 34–46
C0S, C1S 3 B B
C1 Sclerother. 2 B B
C2A 1 C
C2S 1 C
C2 Pregnancy 1 B B
C2 Surgery 7 C C C C
C2 Sclerother 3 C C C
C3 1 B
C4b (LDS) 1 B
C5 Multiple B B B
C6 Multiple A B
DVT Multiple A–B A–B
Prevention
Flight 2 B B
DVT Therapy 3 B B
PTS 3 A A
Prevention
Lymphedema 5 B C C
Levels of Recommendation:
A: Large RCTs, metaanalysis of homogenous results
B: Only one or smaller RCTs
C: Observational studies, consensus among participants of the consensus meeting
It has been demonstrated that both compression bandaging and exercise stimulated the movement of stagnating
lymph through the lymph collector in lymphedema patients,
in which the lymphatic trunks are fi lled. This is probably
one explanation for the reduction of intralymphatic hypertension by complex decongestive therapy.
Intermittent pneumatic compression enhances prefascial
lymph drainage. Unna boots are able to increase subfascial
lymph transport, which is reduced in postthrombotic
syndrome.
Consequent compression leads to a morphological
improvement of pathological initial lymphatics in patients
with lipodermatosclerosis, which can be demonstrated by
indirect x-ray lymphography.
CLINICAL EFFECTS OF
COMPRESSION THERAPY
The use of compression therapy in various clinical
indications is based mainly on experience.
Only a few randomized controlled trials (RCTs) are
available that prove the effi cacy of compression treatment
on the level of evidence-based medicine.
Table 10.4 summarizes the outcome of an international
consensus meeting in which all RCTs and systematic reviews
have been scored.
25
Up to now there are only three areas for which evidencebased medicine data show clear clinical benefi ts of compression therapy: active venous ulceration, prevention of
postthrombotic syndrome after deep vein thrombosis, and
prevention of thromboembolic events after surgery when
combined with anticoagulatory prophylaxis.
In venous ulcers several RCTs have shown that compression is better than no compression and that high pressure is
more effective than low pressure. Confl icting results are
coming from studies comparing different compression materials, mainly due to the fact that frequently, good bandages
have been compared with poor bandages applied by inadequately trained staff. This underlines the need to measure
pressure and stiffness of the compression products in future
trials.
Compression stockings after proximal deep vein thrombosis (DVT) are able to reduce the incidence of a postthrombotic syndrome some years after the acute event to one half.
Immediate mobilization of mobile patients with DVT using
compression has been shown not only to reduce pain and
swelling in the acute stage but also to achieve less postthrombotic changes after some years.
The overview given in Table 10.4 does not mean that
compression is less or not effective in areas with recommendation levels B and C, but that we need more trials in
order to improve the scientifi c evidence for compression
devices in the future.
References 109
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References
1. CEN European Prestandard. Medical compression hosiery, European
Committee for Standardization. Brussels. 2001. 1–40.
2. Partsch H, Rabe E, Stemmer R. Compression therapy of the extremities. Paris: Editions Phlébologiques Francaises. 1999.
3. Partsch H, Clark M, Bassez S, Becker F, Benigni JP, Blazek V et al.
Measurement of lower leg compression in vivo: Recomendations for
the performance of measurements of interface pressure and stiffness:
A consensus statement, Dermatol Surg. 2006. 32: 229–238.
4. Partsch H, Menzinger G, Mostbeck A. Inelastic leg compression is
more effective to reduce deep venous refl uxes than elastic bandages,
Dermatol Surg. 1999. 25: 695–700.
5. Stolk R, Wegen van der-Franken CPM, Neumann, HAM. A method
for measuring the dynamic behavior of medical compression hosiery
during walking, Derm Surg. 2004. 30: 729–736.
6. Partsch H. The static stiffness index. A simple method to assess the
elastic property of compression material in vivo, Dermatol Surg. 2005.
31: 625–630.
7. Partsch H. Improvement of venous pumping function in chronic venous
insuffi ciency by compression depending on pressure and material,
VASA. 1984. 13: 58–64.
8. Dai G, Tsukurov O, Orkin RW, Abbott WM, Kamm RD, Gertler JP.
An in vitro cell culture system to study the infl uence of external pneumatic compression on endothelial function, J Vasc Surg. 2000. 32:
977–987.
9. Cullum N, Nelson EA, Fletcher AW, Sheldon TA. Compression for
venous leg ulcers (Cochrane review). In: The Cochrane Library, Issue
2, 2002. Oxford: Update software.
10. Kessler CM, Hirsch DR, Jacobs H et al. Intermittent pneumatic compression in chronic venous insuffi ciency favorably affects fi brinolytic
potential and platlet activation, Blood Coagul Fibrinolysis. 1996.
7: 437–446.
11. Blättler W, Partsch H. Leg compression and ambulation is better than
bed rest for the treatment of acute deep vein thrombosis, Int Angiol.
2003. 22: 393–400.
12. Vin F, Benigni JP. Compression therapy. International Consensus
Document Guidelines according to scientifi c evidence, Int Angiol.
2004. 23: 317–345.
13. Partsch H, Winiger J, Lun B. Compression stockings reduce occupational swelling, J Derm Surg. 2004. 30: 737–743.
14. Partsch B, Partsch H. What is the optimum pressure dose for leg vein
compression therapy? J Vasc Surg. 2005. 42: 734–738.
15. Partsch H, Kahn P. Venöse Strömungsbeschleunigung in Bein und
Becken durch “Anti-Thrombosestrümpfe.” Klinikarzt. 1982. 11: 609–
615.
16. Lord RS, Hamilton D. Graduated compression stockings (20–30 mm Hg)
do not compress leg veins in the standing position, ANZ J Surg. 2004.
74: 581–583.
17. Mostbeck A, Partsch H, Peschl L. Änderungen der Blutvolumenver-
teilung im Ganzkörper unter physikalischen und pharmakologischen
Maßnahmen, VASA. 1977. 6: 137–141.
18. Partsch H, Menzinger G, Borst-Krafek B, Groiss E. Does thigh compression improve venous hemodynamics in chronic venous insuffi ciency? J Vasc Surg. 2002. 36: 948–952.
19. Partsch B, Mayer W, Partsch H. Improvement of ambulatory venous
hypertension by narrowing of the femoral vein in congenital absence
of venous valves, Phlebology. 1992. 7: 101–104.
20. Stöberl C, Gabler S, Partsch H. Indikationsgerechte Bestrumpfung—
Messung der venösen Pumpfunktion, VASA. 1989. 18: 35–39.
21. Mayrovitz HN. Compression-induced pulsatile blood fl ow changes in
human legs, Clin Physiol. 1998. 18: 117–124.
22. Delis KT, Nicolaides AN. Effect of intermittent pneumatic compression of foot and calf on walking distance, hemodynamics, and quality
of life in patients with arterial claudication: A prospective randomized
controlled study with 1-year follow-up. Ann Surg. 2005. 241(3): 431–
441.
23. Abu-Own A, Shami SK, Chittenden SJ, Farrah J, Scurr JH, Smith PD.
Microangiopathy of the skin and the effect of leg compression in
patients with chronic venous insuffi ciency, J Vasc Surg. 1994. 19:
1074–1083.
24. Földi E, Jünger M, Partsch H. The science of lymphoedema bandaging,
EWMA Focus Document. Lymphoedema bandaging in practice.
London:MEP Ltd. 2005. pp. 2–4.
25. Partsch H, ed. Evidence based compression therapy, VASA. 2003.
Suppl. 63.
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CHAPTER
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11
Classifying Venous Disease
BO EKLÖF
The Swedish physician and scientist Carl von Linné published a classifi cation of plants based on the number of
stamina and pistils in 1735 in Systema Naturae. Today, classifi cation of diseases is a basic instrument for uniform diagnosis and meaningful communication about the disease. In
chronic venous disorders (CVD) reliance for too long has
been placed on the clinical appearance of the superfi cial
effects of CVD, such as spider veins, varicose veins, swelling, skin changes, and ulcerations, without requiring accurate objective testing of the venous system to substantiate
the diagnosis. This practice has caused errors of diagnosis
and has been largely responsible for the poor correlation of
results between treatment methods. There have been several
classifi cations in the past that have added to our understanding of CVD, but all lack the completeness and objectivity
needed for scientifi c accuracy.
PREVIOUS CLASSIFICATIONS OF CVD
The most commonly used classifi cation, particularly in
Europe, was Widmer’s classifi cation from 19781 of chronic
venous insuffi ciency:
Stage I: Edema and dilated subcutaneous veins with corona
phlebectatica
Stage II: Trophic lesions of the skin with hyper- or depig-
mented areas
Stage III: Healed or active ulcer
The criticism against this clinical classifi cation was the nonspecifi city of Stage I, and the absence of differentiation
between trophic changes in Stage II.
In 1979
vein (GSV) incompetence:
2
Hach suggested a grading of great saphenous
Grade I: Refl ux in the groin
Grade II: Refl ux to above the knee
Grade III: Refl ux to just below the knee
Grade IV: Total refl ux to the ankle
Hach’s thesis was that in severe refl ux of the GSV, a
viscious internal circle developed because of the large
venous blood volume with dilatation of the popliteal and
femoral veins leading to deep venous incompetence if the
GSV incompetence was not treated.
In 1980,
you could achieve further improvement from other means
after compression therapy. Could surgery or sclerotherapy
be helpful? He recommended a classifi cation based on
involvement of superfi cial, perforator, and deep veins using
objective measures such as foot volumetry and ambulatory
venous pressure to discriminate between “betterable” (bess-
erbare) and “not betterable” (nicht besserbare) patients.
In 1985,4 Sytchev published a classifi cation very similar
to the present CEAP classifi cation, as follows.
Clinical classes
Stages of regional circulatory-trophic disorders:
• Compensation
• Decompensation (cyanosis, edema, cruralgia, or leg
pain)
Degrees:
• By the end of the day
• By midday
• At the beginning of the day
Phases:
• Functional trophic disorders (hyper-, hypo-, and
anhidrosis of the skin)
3
Partsch asked whether in patients with CVD,
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111
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