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324 Chapter 32 Diagnostic algorithm for chronic venous disorders
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32.6 RADIOLOGIC IMAGING
Venous outow obstruction can play a key role in contributing to the pathophysiology and symptom complex of
initial-onset and recurrent varicose veins and more commonly in venous ulceration. Increased resistance to venous
outow in combination with valvular incompetence can
be responsible for the recalcitrant ulcer. Computed tomography (CT) or magnetic resonance imaging (MRI) of the
venous system can conrm the presence of venous obstruction (see Chapter 16).
necessary for optimal evaluation of venous disorders when
using CT. Large zones of the body can be imaged in a short
period of time. However, ow artifacts can occur if homogeneous mixing does not occur between the blood and contrast. This is less true for the lower extremities compared to
the large central veins in the thorax.
The most common compression syndrome is iliac vein
compression syndrome (previously May-Thurner syndrome). Cross-sectional imaging can provide accurate measurements of the degree of venous compression, though
some concern exists regarding whether the requisite supine
patient positioning during these studies reects normal
physiology.
is compressed by the right common iliac artery, though
symptomatic compression of right-sided, external, or internal iliac veins may also occur.
tional imaging can reveal other causes of compression,
such as pelvic masses, bone spurs, iliac artery aneurysms,
retroperitoneal brosis, and inammatory processes. Each
modality can also be useful for making the diagnosis of
acute venous thrombosis and provide an accurate picture
of overall clot burden, particularly in certain circumstances
when the duplex examination is limited, such as in the
presence of large wounds, morbid obesity, and marked
interstitial edema. MRI remains a better imaging modality
if orthopedic hardware is present.
38,39
Most commonly, the left common iliac vein
35–37
Intravenous contrast is usually
40,41
Furthermore, cross-sec-
32.7 INVASIVE IMAGING
visualization of the deep veins with this technique, the use
of a tilt-table, Valsalva maneuver, and manual compression
of the thigh may be helpful. Manual contrast injection in
10- to 20-mL boluses is preferred, rather than the use of
a power injector. Retrograde transit of contrast without
the visualization of valves highlights the incompetent veins
and can be very helpful when contemplating possible treatments such as valve reconstruction or auto-transplantation.
Other salient points in optimizing the diagnostic potential of venography include using selective and super-selective cannulation of venous tributaries to provide better
venous lling, maximizing valve closure by keeping the
patient supine when performing retrograde cannulation
(ipsilateral or contralateral), and using larger amounts of
contrast over longer periods of injection time. Multiple
planar views at 90-degree obliquities (e.g., 45-degree left
anterior oblique versus 45-degree right anterior oblique)
can help further reveal a venous stenosis that is not appreciated fully on a typical anterior-posterior image. When
using a power injector for larger vein visualization, venous
trauma can be avoided by using multiple side-hole catheters and decreasing the injection pressure to approximately
half that of arterial injections (200–400 pounds/inch).
32.7.2 Intravascular ultrasound
Despite the use of multiplanar projections with contrast
venography, venous obstruction may be difcult to fully
dene. Intravascular ultrasound (IVUS) has become the
criterion standard for investigation of obstructive venous
pathology. These include the various forms of iliac vein
compression syndrome, external compression, scarring,
synechiae, congenital abnormalities, and residual chronic
thrombus (see Chapter 15). IVUS provides an accurate
cross-sectional representation of pathology and may be
more accurate than multiplanar venography and CT to
denitively specify where lesions begin and end as well as
measure diameters and areas.
vide more accurate evaluation after intervention.
44,45
Similarly, IVUS can pro-
32.7.1 Contrast venography
Contrast venography remains vital to providing an accurate evaluation of venous anatomy, reux, and obstruction
(see Chapter 14). Detailed descriptions of ascending and
descending venography are beyond the scope of this discussion, though the techniques described by Rabinov and
42
Paulin
tively.
for dening venous outow obstruction. Venipuncture of a
foot vein, popliteal vein, femoral vein, or common femoral
vein is selected based on information from previous studies. This technique allows both diagnostic evaluation and
the potential for endovascular treatments. Insufation of a
tourniquet on the calf can assist in lling the deep veins of
the lower extremity if performing ascending venography
from the injection of a foot vein.
tomic pattern of valvular reux and function. To maximize
and Kistner43 serve as thorough overviews, respec-
Ascending venography remains a primary technique
Descending venography allows denition of the ana-
32.8 DIAGNOSTIC ALGORITHMS
Evaluation of the patient presenting with one or multiple
signs of CVD requires a thorough assessment to dene the
underlying etiology and direct appropriate medical and/
or invasive treatments. Performing a thorough history and
physical exam is the critical starting point to form a differential diagnosis and guide next steps for diagnostic testing.
Next, duplex ultrasonography can provide information
regarding patency and competence of the deep and supercial venous systems, as well as some hints as to whether
obstruction may be present. For some patients, this provides sufcient information to correctly diagnose and treat
the underlying pathology, while more complex patient presentations may require further evaluation. Duplex can also
evaluate perforator veins and pelvic veins, vital for patients
presenting with advanced (C5/6/6r) disease or whose
symptom severity is not well-explained by ndings of a
standard lower extremity duplex exam. Indirect noninvasive tests are utilized less commonly than duplex in modern
References 325
https://t.me/med1917
practice but may give valuable information when standard
duplex evaluation is not well tolerated (e.g., in the setting
of ulcers or severe pain) or is inconclusive. Finally, either
cross-sectional truncal imaging by CT or MRI and/or contrast venography with IVUS may be needed to evaluate for
compressive or occlusive venous pathology.
These diagnostic tests and imaging studies help the
providers and team with directing treatment, predicting
prognosis, and providing a baseline for comparison during
follow-up. The algorithm presented (Figure 32.1) is designed
to help the health care professional provide complete care
Paent presents
with concern for
Perform complete history
and physical examinaon
Consistent with
lymphedema component
Consistent with venous
pathology
of these problems and further ensure that more signicant
underlying venous pathophysiology is addressed. Additional
pathology such as lymphedema and venous malformations
may overlap with CVD; thus, the algorithm should not be an
either/or decision but one that takes into account other concomitant etiologies. While resources and treatment options
can vary depending on the health care delivery system, the
algorithm emphasizes diagnostic options in a logical order
to provide a thorough and timely diagnosis. Lastly, the pertinent guideline from the 2022 SVS, AVF, and AVLS Guidelines for CVD has been provided.
9
CVD
Overlap with chronic pain
syndromes, restless legs,
etc.
32
Perform venous
Proceed with evaluaon
for lymphedema
duplex examinaon
Proceed with evaluaon
for chronic pain syndromes,
restless leg, etc.
Consider addional
indirect noninvasive tests
Consider cross-seconal
imaging or invasive tests
32.1 The suggested algorithm for the diagnosis of CVD may vary depending on presentation, history, and physical examination.
Multiple diagnostic options and modalities exist and should follow this prescribed order, depending on the initial constellation of
signs and symptoms. As determined by ndings, treatment can commence at any stage after complete history and physical examination.
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N, Jayaraj A. Ambulatory venous pressure,
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*37. Toh MR, Damodharan K, Lim M, Yap C,
Chong TT, Tang TY. Computed tomography venography versus intravascular
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Lymphat Disord. 2020 Nov;8(6):
1122–1123.
CHAPTER
Compression therapy for chronic
(a)
(b)
https://t.me/med1917
venous disease and venous ulceration
Sergio Gianesini, Leo J. Daab, Erica Menegatti, Yung-Wei Chi,
33.1 RATIONALE
Compression therapy is rst-line treatment for chronic
venous disease (CVD) with or without venous ulceration
alone or in conjunction with other therapies (Figures 33.1
and 33.2). The goal is to improve symptoms and function-
33
Hugo Partsch, and Gregory L. Moneta
(c)
33.2 Large venous ulcer requiring 15 months for healing with
compression bandages/elastic stockings/nutritional supplementation. On the left before treatment, on the right at 15 months.
ality, heal ulcers, and prevent ulcer recurrence. Patients with
ulcers will not all heal rapidly or completely with compression alone or as an adjunct to other therapies, and ulcer
recurrence is a problem.
include older age, obesity, deep venous reux, arterial insufciency, poor compliance with therapy and long-standing
or large ulcers, or multiple recurrences of ulceration.
Ambulatory compression can be with elastic stockings,
paste gauze boots (Unna boot), and multilayer elastic
wraps, dressings, and bandages. Pneumatic compression
devices are also employed.
1
Risk factors for treatment failure
2,3
33.2 MECHANISM
33.1 Healing of a venous ulcer with an elastic stocking (a) 1
month, (b) 2 months, and (c) 3 months.
DOI: 10.1201/9781003328971-37
Ambulatory venous hypertension and the presence of elevated venous pressure at the ankle during exercise facilitate
tissue damage associated with CVD. Specic mechanisms
327327
328 Chapter 33 Compression therapy for chronic venous disease and venous ulceration
https://t.me/med1917
are subjects of active research and include endothelial
shear stress increase and neutrophil/monocyte activation.
Increased capillary permeability promotes leakage of
plasma proteins and cytokines into the extravascular space.
A perivascular brin cuff can form, potentially impeding
wound healing, but such cuffs are discontinuous around
capillaries, and ulcers can heal despite their presence at the
ulcer border.
ping of leukocytes with release of harmful free radicals,
proteolytic enzymes, and cytokines.
4
Increased venous pressure may lead to trap-
5
No matter the biochemical etiology of venous ulceration,
ambulatory venous hypertension must be overcome to promote healing. Compression therapy should create internal
pressures evenly distributed within the leg to maximize effects
of calf muscle contraction and optimize venous return: Pascal’s law, which states pressure applied to an enclosed system
with an incompressible uid is evenly distributed.
6,7
Compression promotes uid movement into the venous and lymphatic
systems due to generating pressure gradients between the
interstitial and intravascular space. The greater the pressure
increase, the greater the force promoting venous return. Optimal pressures required for therapeutic effects are debated.
8
Gravity drives lower extremity intravenous pressure,
with effects depending on body position. It must be overcome for the treatment of CVD. Leg vein intravenous
pressure reects the weight of the blood column between
the site of measurement and the right atrium. Supine ankle
venous pressure is 10–20 mmHg.
9
Lower leg veins are narrowed by external pressures of 10–20 mmHg that restore
valve competency, with veins totally occluded by pressures
of 20 mmHg. Venous narrowing by such low pressures
may explain the favorable effects of thromboprophylactic
stockings exerting pressures of 15–20 mmHg in recumbent
patients. During standing, lower leg intravenous pressures
rise to 60 mmHg, depending on subject height, and external pressures of 35–40 mmHg are needed to narrow the
veins, while venous occlusion requires pressures up to 70
10
mmHg.
The major hemodynamic effects of compression
in upright subjects can therefore only be expected with
interface pressures >35–40 mmHg. Based on microcirculatory investigations and patient compliance proles, an
upper limit of 60 mmHg for externally applied sustained
compression appears safe without hindering compliance
with therapy. Intermittent pressure peaks with walking
can, however, considerably exceed 60 mmHg.
10
Complete venous closure may not be necessary. Valve
competency is restored by external pressures far lower than
needed to achieve vein closure. Properly tted graduated
compression stockings result in venous rell time normalization and improved residual volume fractions linearly
correlating with reux severity.
11,12
Calf ejection fraction
may also be facilitated by stockings applying more pressure
at the calf rather than with graduated compression applying more pressure at the ankle.
13
Inelastic bandages, resistant to changes in leg circumference, produce more pronounced and sustained venous
reux reductions compared to elastic material with the
same resting pressure. Inelastic bandages applied with a
resting pressure >50 mmHg demonstrate signicant reductions in ambulatory venous pressure in patients with severe
venous insufciency walking on a treadmill.
14
This may be
explained by intermittent occlusion of leg veins exerted
by ambulatory pressure peaks of 80 mmHg with inelastic bandages. Such effects cannot be achieved with elastic
stockings that increase ambulatory interface pressures only
3–8 mmHg above resting pressures.
11
Many possible local skin and subcutaneous tissue microcirculatory and hemodynamic variables may benet from
compression therapy. Perimalleolar subcutaneous pressure
increases with elastic compression, and increased subcutaneous pressure should obviate Starling forces favoring capillary uid leak and create Starling gradients favoring uid
movement from the interstitial space into lymphatics
15
(Fig-
ure 33.3). These observations correlate with the obvious fact
33.3 Wick needle and transducer for evaluating changes in subcutaneous metabolism mediated by external compression devices.
Straight
clamp
Needle
C-ARM
Transducer
Micrometer
33.3 Patient evaluation 329
Transmitted venous hypertension
Ulceration
Altered lymphatics
Epidermis
Dermis
Subcutaneous
https://t.me/med1917
Arteriole
Venule
33.4 Ulcer bed and underlying structure with potential altered environment.
conditions associated with CVD such venous thromboembolism; hypercoaguable states; and other medical conditions promoting edema such as cardiac, liver, and renal
dysfunction need consideration, remembering strong compression applied to both lower extremities may shift considerable blood volume toward the heart. Strong compression
may therefore be contraindicated in some patients with
severe cardiac dysfunction. Systemic conditions that affect
wound healing such as diabetes mellitus, immunosuppression, and malnutrition are evaluated and improved as much
as possible prior to and during compression therapy.
Findings associated with CVD include lower extremity edema, varicose veins, and evidence of CVD-associated
chronic skin changes of lipodermatosclerosis, hemosiderin
33.5 Tortuous subdermal capillary characteristic of advanced
chronic venous disease.
deposition, and evidence of previously healed ulcers: atrophie blanche. A denitive diagnosis of ulceration secondary
to CVD must be made prior to undergoing compression
that elastic and nonelastic bandages reduce lower extremity
edema in CVD patients. With edema reduction, cutaneous
and subcutaneous metabolism may improve, with enhanced
oxygen diffusion and nutrient transport to skin and subcutaneous tissue cellular elements.
Effects of compression therapy on alterations in cutaneous and subcutaneous biochemistry remain largely
unknown (Figure
33.4). Anti-inammatory cytokine
interleukin 1 receptor antagonist (IL-1 Ra) levels increase
with compression, with reductions of inammatory cytokines such as tumor necrosis factor alpha (TNF-α) and
vascular endothelial growth factor (VEGF) partially
responsible for increases in microvascular permeability
and for proliferation of tortuous, elongated cutaneous capillaries prone to injury, correlating with ulcer healing
16–18
(Figure 33.5).
treatment of a leg ulcer. Venous insufciency and/or obstruction must be documented in the noninvasive vascular laboratory or, in selected cases, by venography or intravascular
ultrasound prior to initiating compression therapy.
Possible arterial insufciency must be assessed by
physical examination and/or noninvasive studies. Venous
ulceration with coexisting arterial insufciency, especially
if severe, is difcult to heal with arterial insufciency—a
recognized risk factor for nonhealing of venous ulceration.
the presence of severe arterial insufciency. Already diminished skin perfusion pressures can be further diminished,
leading to increased risk for critical ischemia. Compression
may be essentially contraindicated in patients with an
ankle-brachial systolic blood pressure ratio <0.5. However,
patients with lesser degrees of arterial insufciency may
tolerate and benet from compression therapy.
33.3 PATIENT EVALUATION
Finally, compression therapy works best when patients
understand their disease and therapy goals. Prior to starting compression therapy, and at every clinic and/or home
About 70% of leg ulcers are venous.19 Evaluation of CVD
patients therefore begins with a history and physical examination to exclude nonvenous etiologies. Medication use;
health or wound care visit, patients must be educated
about their disease and the need to comply with treatment plans.
Tissue hypoxia/
malnutrition
Fibrin deposition
and edema
Dilated capillaries
20
Compression therapy can be counterproductive in
21
33
330 Chapter 33 Compression therapy for chronic venous disease and venous ulceration
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33.4 FORMS OF COMPRESSION
THERAPY
Two main actions associated with compression are edema
reduction and hemodynamic improvement. The rst can
be obtained with limited pressure doses. The latter requires
specic compression features.
33.4.1 Compression dosage
Pressure exerted on the skin by a compression device is
the “interface pressure.” It expresses the “dose” of pressure
and magnitude of compression. Interface pressure data are
conicting in that, with similar subcutaneous thicknesses
and lower limb shapes, studies have showed variations of
>50% in pressures applied to the subcutaneous tissue.
The law of LaPlace provides a partial explanation for data
variation. It indicates that limb shape can inuence interface pressure that is also related to the tension and number
of compression layers applied and inversely correlated with
limb circumference and widths of compressive bandages.
All these variables, in turn, might have signicant consequences on the nal measured interface pressure of a compression garment or bandage.
Material stiffness is equally important to interface pressure in determining compression effects. Material stiffness
reects a material’s ability to counteract lower limb expansion in response to swelling induced by gravitational forces.
The static stiffness index is calculated by subtracting interface pressure at the B1 level (where the tendinous part of
the gastrocnemius muscle turns into the musculature) in
a supine subject from the B1 interface pressure with the
subject standing. A static stiffness >10 indicates rigid/stiff
compression (hemodynamic effects), while a value <10 is
associated with elastic anti-edema effects.
33.4.2 Graduated elastic compression
stockings
Compression therapy is most common with gradient elastic compression stockings (ECSs). Natural compression
occurs in an aquatic environment. This reects the Stevin
law: where hydrostatic pressure exerts graduated compression on immersed limbs equivalent to 0.7 mmHg/centimeter of water.
Conrad Jobst, were made to simulate gradient hydrostatic
forces exerted by water in a swimming pool.
ECSs are available in various compositions, strengths,
and lengths and can be customized. They may be round or
at-knit, based on manufacturing process and desired nal
elastic properties. Round-knit stockings are knitted seamlessly along their entire length using the same number of
needles but with stitch size variations. Flat-knit stockings
are produced with the same stitch size. Different circumferences are created by changing needle numbers. Different
compositions facilitate use in patients with different body
shapes, leg sizes, and contours, providing the ability to
adapt to different leg circumferences, deep skin folds, and/
or edema of the forefoot/toes.
Graduated ECSs are classied based on ankle absolute
interface pressure. Different ranges of interface pressures
27
Gradient ECSs, initially developed by
22
23
24
25
26,27
28
27,29
TABLE 33.1 Different graduated compression stocking
classications based on interface pressure
USA (mmHg; U.S.
standard)
15–20 15–20 15–17
20–30 20–36 18–21
30–40 >36 23–31
40–50 34–46
>50
France (mmHg;
AFNOR)
10–15
Germany
(mmHg; RAL)
are used in different regions of the world, fueling prescriber and user confusion (Table 33.1). ECSs are available in four strengths based on interface pressure. Class 1,
10–15 mmHg, are available over the counter and through
the internet. Class 2, 20–30 mmHg; class 3, 30–40 mmHg;
and class 4, 40–50 mmHg generally require prescriptions.
ECSs are less bulky than other forms of compression
therapy and can be worn with normal footwear and allow
daily wound inspection. ECSs have the advantage that
effects, unlike compressive bandages, are operator independent and dependent on ECS strength. However, ECSs
must be worn to be effective and are easily removed or
“forgotten” by noncompliant patients.
The benets of ECSs in compliant patients for healing
of venous ulceration are well-documented. The rst reasonably rigorous study using modern statistical analysis
was a retrospective review of 113 venous ulcer patients
treated with below-knee 30–40 mmHg ECSs.
30
Complete
ulcer healing occurred in 99/102 (97%) patients compliant
with stockings versus 6/11 (55%) who were noncompliant (P < 0.0001). Mean healing time was 5 months. Ulcer
recurrence was less in ECS-compliant patients; 29% at 5
years versus 100% at 3 years in noncompliant patients.
Not all centers, however, have had such favorable results
healing venous ulcers with ECSs. Older, less compliant
patients and populations with higher percentages of recurrent or long-standing ulcers will not do as well. Nevertheless, modern reviews have further conrmed the utility of
ECSs for healing venous ulcers.
31
Patient compliance begins with patient education and
reinforcement at every ofce and clinic visit. Many patients
are initially intolerant of compression because of hypersensitivity adjacent to ulcers or at sites of previously healed
ulcers. This intolerance can sometimes be overcome by initially tting the patient with lower-strength ECSs followed
by higher-strength stockings. An obvious disadvantage is
the added expense of “introductory” stockings.
Compliance with ECSs was evaluated in 3144 new
CVD patients from 1998 to 2006. Full or partial compliance was reported by 37% of patients; 63% did not use the
stockings or abandoned them. Thirty percent of noncompliant participants could not specify a reason for noncompliance; 25% did not have a prescription; 14% did not feel
they helped; 13% reported a sensation of “cutting off” circulation; 8% felt the stockings were too hot; 2% reported
limb soreness; 2% poor cosmesis; 2% unable to apply; 2%
itching or contact dermatitis; and 2% cost.
32
33.6 Donning devices for elastic stockings. (A) Silk sleeves
https://t.me/med1917
allow the open-toe stocking to slip more easily onto the foot.
The sleeve is pulled out after application. (B) The so-called
“Butler” device. The patient loads the stocking on the wire
frame, steps into it, and then pulls up on the device to apply
the stocking.
Donning aids assist in the application of elastic stock-
33
With open-toe stockings, an inner silk sleeve can
ings.
be placed over the forefoot to allow the stocking to slide
smoothly during application. Another device allows the
patient to load the stocking onto a wire frame. The patient
steps into the stocking and pulls the device upward, thereby
applying the stocking (Figure 33.6).
Evidence is not robust, but ulcer recurrence after healing appears to be lessened by ECS and other forms of compression.
unwillingness of many insurers to provide coverage for ECSs
in spite of evidence demonstrating their cost-effectiveness.
34,35
An additional problem after ulcer healing is the
36
ECSs are used to prevent post-thrombotic syndrome
(PTS), which results in 25%–50% of patients following
deep venous thrombosis and can lead to venous ulceration.
However, the SOX trial, a randomized, placebo-controlled
trial, questioned the use of ECSs for PTS prevention.
37
Patients (n = 410) were randomly assigned to either 30–40
mmHg ECSs or placebo stockings, <5 mmHg of pressure,
and followed for 2 years. The cumulative incidence of PTS
was 14.2% in patients with the active ECSs and 12.7%
in the placebo arm, indicating no ECS benet. Previous
open-label, small, single-center studies did show a benet
in using compression to prevent PTS.
38
While the utility of
compression stockings for PTS prevention remains unclear,
once someone has developed PTS, compression therapy
remains a cornerstone of management.
ECS therapy improves quality of life (QoL) in patients
with CVD. In a prospective study, 112 patients with CVD
treated with 30–40 mmHg ECSs were administered a questionnaire quantifying CVD symptoms, cosmesis, depression, and sleep alterations, with overall improvement in
severity scores at 1 month, with further improvements at
33.4 Forms of compression therapy 331
39
16 months.
the spectrum of CVD: CEAP classes 1–6.
QoL improvement with ECSs extends across
40
33.4.3 Paste boots
A popular compression method was developed by the German dermatologist Paul Gerson Unna. The Unna boot has
been used to treat venous ulcers for many years. There are
many versions. It is basically a compression bandage: typically a three- or four-layer dressing. It requires application
by trained personnel. A rolled gauze bandage impregnated
with calamine, zinc oxide, glycerin, sorbitol, gelatin, and
magnesium aluminum silicate is rst applied with graded
compression from the forefoot to just below the knee.
Additional layers are continuous gauze dressing followed
by an outer layer of elastic wrap applied with graded compression. The bandage stiffens after drying, and the resulting rigidity aids in preventing edema. The supine resting
pressure on the distal lower leg immediately after application may be 50–60 mmHg. Unna boots are changed weekly
or sooner if the patient has signicant ulcer bed drainage.
The Unna boot requires minimal patient involvement,
providing continuous compression and topical therapy.
An Unna boot also has disadvantages. It is uncomfortable
for some patients, adversely affecting compliance. Ulcers
cannot be monitored between applications. Application
is labor intensive and the compression provided operator
dependent. Patients can develop contact dermatitis to components of the Unna boot. A 15-year review of 998 patients
with venous ulcers treated with Unna dressings found 73%
of ulcers healed, with a median healing time of 9 weeks.
A randomized, prospective study compared Unna boot to
polyurethane foam dressing in 36 venous ulcer patients
with superior healing over 12 months for the Unna boot
patients (94.7% vs 41.2%).
42
33.4.4 Compressive bandages
Purported advantages of multilayered compressive dressings include long maintenance of compression, even compression distribution, and better exudate absorption. A
wide variety of compression materials with different textures are available, resulting in bandages with variable
interface pressures and stiffness.
33.4.4.1 Classification
Bandages are classied according to the percent elongation
of the material following application of a 10 N/cm force
0%–10% (rigid)
•
• 10%–100% (short stretch)
• >100% (long stretch)
33.4.4.2 Pressure
Pressure, layers, components, and elastic properties (P-LAC-E) are important features of compression bandages. The
pressure delivered depends on the wrapping technique,
limb radius/curvature, number of layers, and material elastic properties.
In the supine position, pressure ranges in the gaiter area
are classied according to a consensus conference proposal
33
41
43
:
332 Chapter 33 Compression therapy for chronic venous disease and venous ulceration
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TABLE 33.2 Pressure ranges of compression bandages
measured supine at B1, where the Achilles tendon
changes into the muscular component of the
gastrocnemius muscle
Recommendation mmHg
Mild <20
Moderate 20–40
Strong 40–60
Very strong >60
47
(Table 33.2).43 Interface pressures exerted during standing
and walking increase based on material elasticity. “Strong”
and “very strong” bandages produce higher interface pressures than ECSs.
33.4.4.3 Layers
Single-layer bandages usually have an overlap of up to
50%. Multilayer bandages consist of several single-layer
bandages.
33.4.4.4 Components
Bandage components are materials in compression bandages. For multilayer bandages, at least two different bandage materials are applied over each other for the length
of the bandage. Beside padding, protection, and retention,
bandage materials inuence interface pressure and stiffness
(Figure
33.7).
33.4.4.5 Elastic properties
The elasticity of materials used in a compressive bandage
(as well as fabrics in ECSs) is determined with in vitro
measurements using extensometer devices that assess
power exerted to distend the material and resulting stretch:
a so-called hysteresis curve.
achieve a pressure of about 40 mmHg at the gaiter area.
“Strong” bandage material will need to be stretched less
than “weak” bandage material to achieve this pressure.
Compressive bandages have varying degrees of stiffness,
with stiffness dened as the increase in pressure applied per
centimeter increase in leg circumference. A higher stiffness
indicates relative bandage inelasticity. An inelastic bandage
is dened as having a pressure increase of >10 mmHg moving from a supine to standing position, whereas an elastic
bandage has pressure increases <10 mmHg from supine to
standing. High stiffness (inelasticity) bandages include bandages of two 5-meter-long, short-stretch bandages applied
in opposite directions (e.g., Comprilan, Rosidal K, Pütter
bandage). Inelastic kits have components of padding, foam
material, short-stretch bandages, and a protecting hoselayer (Rosidal Sys bandage). The main component of these
bandages is cotton, which is permeable to air, well tolerated, and washable for reuse (Comprilan, Rosidal).
More layers of similar elastic materials create bandages
with increased inelastic properties. This also happens when
two ECSs are donned over each other or when several components of different materials are applied as friction increases
between the rough surfaces of different layers which will, in
addition to the ber elastic strain, oppose expansion of the
11
In general, one attempts to
33.7 Proper bandaging technique with 50% overlap with each
wrap around the leg.
leg to gravitational forces. Bandages with high friction are
cohesive bandages that adhere to the underlying layer and
adhesive bandages that adhere to the skin.
Applying several elastic layers over each other also creates a bandage with rather high stiffness (four-layer bandage,
Profore). The nal bandage exerts an interface pressure of
about 40 mmHg on the supine distal lower leg. The Coban2
layer kit is two layers with adhesive surfaces. It is an easy-toapply, stable, nonbulky, high-stiffness bandage.
There are two main disadvantages of inelastic bandages. Loss of pressure starts immediately after application. The initial resting pressure will decrease 25% 1 hour
after application due to immediate limb volume decreases.
Another disadvantage is proper application is difcult and
requires training. Rapid pressure drops mean inelastic bandages are applied with much higher initial tension than
elastic bandages. Inadequate bandaging technique may be
the main reason for the poor outcomes in some studies.
Elastic bandages are the Ace bandage, Surepress, and
Perfekta. Proguide kits consist of a padding layer and an
elastic bandage. Elongation of elastic bandages leads to a
low increase in pressure. Such bandages may exert a relatively high resting pressure but will only minimally increase
pressure during walking (“low working pressure”). They are
relatively easy to apply by untrained staff and patients. The
main disadvantage is high resting pressure and the uncomfortable feeling of the constricting force of the elastic bers.
High resting pressure is also responsible for skin damage
that may occur, particularly in patients with arterial disease
and over sites prone to pressure such as the ankle tendon.
Stiffer, more inelastic bandages may have greater effects
on deep venous hemodynamics than less stiff bandages.
There are greater improvements in venous lling index
with the short-stretch, more inelastic bandages.
44
45
33.4 Forms of compression therapy 333
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A relatively stiff bandaging system (multilayer wrap of
orthopedic wool, crepe bandages, and Coban bandages)
used in 148 ulcerated limbs refractory to simple wraps
found measurements of compression declined only 10%
over 1 week and 74% of ulcers healed at 12 weeks.
46
A direct comparison between a relatively elastic bandaging regimen and a relatively inelastic regimen randomized venous ulcer patients to an elastic bandaging regimen
(n = 57) or an inelastic regimen (n = 55). Larger ulcers took
longer to heal with the elastic bandaging, but complete
healing at 26 weeks was no different: 58% of those treated
with the more elastic bandage and 62% of those treated
with the inelastic system.
47
Dramatic results have been reported in healing very
large venous ulcers with a heelless, open-toe, elastic, multilayered compression device knitted into a tubular conguration. One hundred and thirty-eight patients with
very large venous ulcers (20–210 cm
2
) were randomized
to treatment with the multilayered tubular device (n = 72)
versus bandaging plus compression stockings (n = 66).
Cumulative healing was 93% in the group treated with
the multilayered tubular dressing and 51% in the group
treated with bandaging plus compression stockings.
48
The Venous Ulcer Study IV, VenUS IV, a randomized,
controlled trial involving 453 participants from 34 centers
in England and Northern Ireland, stratied patients by ulcer
duration and area to evaluate the clinical effectiveness and
cost-effectiveness of compression with two-layer hosiery
versus four-layer compression bandages. The primary
endpoint was time to heal. Maximum follow-up was 12
months. Median time to healing was 99 days in the hosiery
group and 98 days in the bandage group. Economic analysis
indicated a signicant advantage for the hosiery group.
53
Pertinent points for the use of compression bandages
are summarized in Table 33.3.
33.4.5 Legging orthosis
Compression wraps using patient-adjustable strips appear
competitive in clinical outcomes and cost-effectiveness
compared to bandaging. These devices require patient
education in application and adjustment to reach desired
interface pressures. They facilitate self-management by
potentially obviating problems of other devices such as
need for application by a professional, inadequate application, and decreased compression over time. Patients can
maintain long-lasting consistent compression without frequent professional bandage changes.
54,55
Circ-Aid is such
a legging orthosis consisting of multiple pliable, rigid,
adjustable compression bands. The bands are held in place
with Velcro wrap around the leg from the ankle to the knee
(Figure 33.8). Bands are adjustable and compression tailored as limb edema decreases. Such devices are especially
useful in patients unable or unwilling to wear ECSs and
may be superior to ECSs in preventing limb swelling in
advanced CVD limbs.
33.4.6 Pneumatic compression devices
External pneumatic compression devices are adjuncts
for CVD treatment.
edema or morbid obesity, they may be particularly useful.
Single- or multi-chamber compression bladders are available and should have dedicated protocols of ination/dea-
management are lacking, so individual patient application
is largely empiric. Relative contraindications are arterial
insufciency and uncontrolled congestive heart failure.
Pneumatic compression devices that provide sequential
gradient intermittent pneumatic compression (IPC) have
received the most attention. Results with these devices suggest
56
For patients with CVD with severe
33
TABLE 33.3 Key points for compressive bandages
• Elastic bandages are easier to handle than inelastic bandages and may be applied by untrained staff or patients.
• Inelastic material should be applied with much higher resting pressure, pressing the bandage roll toward the leg as if molding clay.
Patients should immediately walk for at least 30 minutes to decrease edema and decrease the pressure exerted by the bandage.
• Bandages are applied with less tension and ample amounts of orthopedic wool padding to patients with small ankle circumferences.
• The initial turn may start at the base of the toes, around the ankle, or between the heel and the dorsal tendon to x the bandage.
• Ankle joints are bandaged with maximal dorsal extension and the tendon protected with cotton.
• Overlapping is carried out in a spiral fashion or with gures of eight (herringbone pattern).
• The proximal end of a knee-high bandage covers the bular head.
• No gaps. Each turn overlaps the previous turn by 50% (Figure 33.6).
• Bandage materials must be nonallergenic.
• Pads can increase local pressure over ulcers or lipodermatosclerotic areas.
• Pain may indicate arterial ischemia, and the bandage must be removed immediately.
• Bandaging of the lower leg is sufcient for the majority of patients with CVD.
• Walking exercises are essential to optimize the effect of compression therapy. However, compression is also able to reduce edema in
immobile patients or in those with severely restricted mobility. Inelastic xed bandages are preferred for this indication because of the
lower resting pressure.
• After walking, pressure drops, and the bandage will loosen after a few days as edema decreases. It should then be changed or overwrapped with a short-stretch bandage.
• The bandage is changed every 7 days on average, sooner if exudate is a problem.
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