The Static Stiffness Index: an important parameter to characterise compression therapy in vivo.

The compression pressure, which corresponds to the dosage of compression therapy, has been widely neglected up to now, not only concerning scientific literature, but also in clinical practice. It is evident that compression pressures in the upright position and during walking are clinically more relevant than just the resting pressure. The Static Stiffness Index (SSI), which is the difference between standing and resting pressure, is a valuable parameter characterising the efficacy of a specific compression product to narrow/occlude the venous lumen. This is a prerequisite for reducing venous reflux and exerting a massaging effect necessary to improve the venous pumping function during movement. This article provides an overview of the recent literature on the SSI, which supports the recommendations of the International Compression Club. In addition, it aims to provide an insight on the importance of the SSI in daily practice, as an educational tool as well as in defining the properties of applied compression therapy in clinical research.

Interface pressure measurements at the thigh under eccentric compression (Mediven Post Op Kit).

The use of a special foam pad for thighs under compression allows an increase in the interface pressure. The interface pressures obtained under one and two compression stockings (23 mmHg at the ankle) in the supine position are 10.7+/-2 mmHg and 19.1 mm+/-2.9 mmHg respectively without interposing a pad and 37.5+/-5 mmHg and 58.5+/-9 mmHg on the medial side of the thigh when interposing a special pad.

Compression bandages: influence of techniques of use on their clinical efficiency and tolerance.

AIM: A bandage is characterized by its components and by its properties evaluated in vitro: stretch theoretical pressures calculated with a dynamometer. A bandage is also characterized by properties evaluated in vivo: interface pressures at rest and during contraction. The aims of this study were to evaluate interface pressures and stiffness of medium stretch bandages and to vary the techniques of bandage in order to obtain a bandage with the lowest possible resting pressure and the highest possible working pressure. METHODS: The interface pressures of Biflex 16 bandages of 7 mx8 cm and of Biflex 17 of 5 mx8 cm were measured with the Kikuhime device. Five techniques to make a bandage were used: two with an overlap of 50% and 75% respectively and a stretch of 30%, two with a superimposition of 2 bandages used in the same conditions as above, and one in spica (in turns of 8-technique). RESULTS: The achieved pressures are related to the technique of making a bandage and the number of layers at the measurement points. The best result is obtained with the Biflex 16 with an use in spica without stretch: the resting pressure is low and the working pressure is high. The stiffness index and the low resting pressure are sufficient to give a good clinical efficacy. CONCLUSION: This technique of use should be appropriate for the treatment of trophic disorders with a satisfactory effect of auto-massage and a maximum of safety even in a patient confined to bed or with a decreased ankle-brachial index (between 0.6 and 0.9).

Comparison of 1% and 3% polidocanol foam in ultrasound guided sclerotherapy of the great saphenous vein: a randomised, double-blind trial with 2 year-follow-up. "The 3/1 Study".

OBJECTIVES: To compare 1% and 3% POL foam in treating the great saphenous vein (GSV) by ultrasound guided sclerotherapy. DESIGN: Multicentre, prospective, randomised, double-blind trial with 2 year-follow-up. PATIENTS AND METHODS: 148 patients with GSV reflux (saphenous trunk diameter 4-8 mm) were randomised to undergo ultrasound guided foam sclerotherapy using either 1% or 3% POL foam in a single session. Foam production was standardised using a sterile disposable syringe kit including sterile air and the Turbofoam machine. Duplex ultrasonography was used to assess the outcome at 3 weeks, 6 months, 1 year, 18 months and 2 years. The main criterion of success was the disappearance of the venous reflux. The length of occlusion of the vein (only measured at 3 week-echography assessment) was a secondary criterion. Side effects were assessed. RESULTS: 74 patients were included in each group. The mean volume of foam injected was 4.4 ml for the 3% group and 4.6 ml for the 1% group. After 3 weeks, reflux was abolished in 96% (71 patients) of the 3% group and 88% (68 patients) of the 1% group (NS). The mean occlusion length of the vein was 38 cm for the 3% group and 34 for the 1% group (NS). After 2-years, reflux was absent in 69% of the 3% group and 68% of the 1% group (NS). 14 patients were lost to follow-up at 2 years. CONCLUSION: This study demonstrates equivalent efficacy for 1% POL and 3% POL foam in sclerotherapy of the GSV where the trunk is less than 8 mm in diameter. These data obtained two years of follow-up confirm our previously reported 6 month-follow-up data published in 2005.

Efficacy, safety and acceptability of a new two-layer bandage system for venous leg ulcers.

OBJECTIVE: To evaluate the efficacy, tolerability and acceptability of a new two-bandage compression system in the local management of venous or mixed aetiology ulcers predominantly of venous origin. METHOD: This was a prospective non-comparative open label phase III clinical study. Forty-two patients were recruited from 12 centres. Inclusion criteria included ulcers with at least 50% granulation tissue, a surface area of 2-20 cm2, an ulcer duration of 1-24 months, an ankle circumference of less than 28 cm, and no history of deep vein thrombosis in the three months before enrolment. The primary endpoint was reduction in ulcer surface area, and secondary endpoints were the evolution of leg oedema and patient comfort. During the six-week follow-up, patients underwent weekly clinical assessments and their ulcer surface area was measured by planimetry and photography every alternate week. RESULTS: The mean ulcer surface area at inclusion was 7 +/- 6 cm2. The mean surface reduction after six weeks was 58.5%, with 24% of the treated wounds healing in a mean time of 25.9 +/- 9.46 days. The patients considered that the new compression system had a better effect on quality of life, evaluated by parameters such as pain, heat, itching and general comfort, than the system worn before entry into the study. Patient concordance with the new system was excellent and 86% of leg ulcers improved or healed after six weeks. Local tolerance was considered very good. CONCLUSION: This new two-bandage compression system is effective and well accepted by patients.

Is obesity an aggravating factor in chronic venous disease? Results of a French epidemiological study in male patients.

AIM: In a recent epidemiological study on chronic venous disease (CVD) in French male patients, a correlation was found between obesity and disease severity. The objective of this study was to further analyze the relationship between age and/or obesity, and CVD severity as assessed by the CEAP C-class. METHODS: Each physician taking part in this cross-sectional study included the first 3 adult male patients consulting for the first time and presenting at least one sign and one symptom of CVD. Patients' socio-demographic and clinical data were collected, and findings for obese (body mass index BMI: >30 kg/m(2)), overweight (25 60 years experienced trophic disorders, i.e., CEAP classes C4, C5, and C6). CONCLUSIONS: This study does not show any relationship between the CEAP C-class and obesity in male patients. Obesity was thus probably not an aggravating factor in CVD but a simple reflection of ageing.

Relationship between medical compression and intramuscular pressure as an explanation of a compression paradox.

BACKGROUND: Using standing magnetic resonance imaging (MRI), we recently showed that medical compression, providing an interface pressure (IP) of 22 mmHg, significantly compressed the deep veins of the leg but not, paradoxically, superficial varicose veins. OBJECTIVE: To provide an explanation for this compression paradox by studying the correlation between the IP exerted by medical compression and intramuscular pressure (IMP). MATERIAL AND METHODS: In 10 legs of five healthy subjects, we studied the effects of different IPs on the IMP of the medial gastrocnemius muscle. The IP produced by a cuff manometer was verified by a Picopress® device. The IMP was measured with a 21G needle connected to a manometer. Pressure data were recorded in the prone and standing positions with cuff manometer pressures from 0 to 50 mmHg. RESULTS: In the prone position, an IP of less than 20 did not significantly change the IMP. On the contrary, a perfect linear correlation with the IMP (r = 0.99) was observed with an IP from 20 to 50 mmHg. We found the same correlation in the standing position. CONCLUSION: We found that an IP of 22 mmHg produced a significant IMP increase from 32 to 54 mmHg, in the standing position. At the same time, the subcutaneous pressure is only provided by the compression device, on healthy subjects. In other words, the subcutaneous pressure plus the IP is only a little higher than 22 mmHg-a pressure which is too low to reduce the caliber of the superficial veins. This is in accordance with our standing MRI 3D anatomical study which showed that, paradoxically, when applying low pressures (IP), the deep veins are compressed while the superficial veins are not.

Chronic venous disease in the male. An epidemiological survey.

AIM: Chronic venous disease affects large numbers of men but there are fewer references to them than to women in the literature. The aim of our study was to determine the time lapse between the first symptom(s) and/or clinical signs of venous disease in the male and the first consultation with an angiologist to define the status of the veins within this population, and to demonstrate any possible links between the characteristics of the disorder in accordance with the CEAP international classification. METHODS: The design was a cross-sectional descriptive survey. Each physician had to include the first 3 patients examined for the first time. Each male patient had to present at least 1 sign and 1 symptom of chronic venous disease. After randomization, 192 physicians included 561 patients: 494 have been analyzed. RESULTS: The examined patients had a mean age of 49.3+/-13.7 years, mean height of 1.76+/-0.07 m, mean weight of 78.2+/-11.2 kg and a BMI of 25.3+/-3.3. The disorder had been developing for a mean 76.8+/-90.3 months prior to the specialist consultation. The longer the time span between the onset of the condition and the first consultation with a specialist, the more advanced was the condition as was also true with the increasing age of the patients. The following associations were observed: the incidence of trophic disorders increased with age (odds-ratio 1.47). The severity of the disease increased the greater the extent of obesity (odds-ratio 3.5). CONCLUSION: The risk of trophic disorders was higher in shop workers, craftsmen (odds-ratio 3.7) and workers (odds-ratio 2.68) than in executives, in those working in a standing position (odds-ratio 1.5), in those whose father had the condition (odds-ratio 1.9), in the event of a popliteal reflux (odds-ratio 3.2) rather than affecting a saphenous trunk (small saphenous vein odds-ratio 2.5, great saphenous vein odds-ratio 1.9). Thirty-two percent of patients with trophic disorders had already worn elastic compression prior to the specialist consultation. After this consultation, the numbers for whom this was prescribed rose to 87%.

Efficacy of Class 1 elastic compression stockings in the early stages of chronic venous disease. A comparative study.

AIM: The aim of this study was to compare the efficacy of Class 1 (10-15 mmHg at the ankle) compression stockings with that of reference stockings of identical appearance during the early stages of chronic venous disease (CVD). METHODS: A prospective multi-center randomized double blind crossover study was conducted on 2 groups of female patients presenting with CVD with a CEAP classification of C1-3SEp As1-5. The efficacy of Class 1 compression stockings was evaluated with respect to global painful discomfort (visual analog scale), each symptom of CVD, the daily behavior of the patient, changes in the volume of the legs, and the functioning of the venous pump (D-PPG). The compliance level of each patient was measured by the number of days that she wore the stockings for at least 6 hours, and tolerance was measured by the reporting of ensuing undesirable events. RESULTS: A total of 125 patients were included in the study and were analyzed for intent to treat. Highly significant differences favoring Class 1 compression stockings were noted with respect to both global painful discomfort and each symptom of CVD with the exception of paresthesia. The relief of symptoms that resulted from the use of the Class 1 compression stockings was twice that which resulted from the use of the reference stockings. Differences that favored the Class 1 compression stockings were also observed with respect to 2 quality-of-life factors (mood and daily work activity). Good compliance in the use of the stockings was reported for 95% of the patients, and tolerance was higher for the Class 1 compression stockings group than for the reference group. CONCLUSION: The regular wearing of Class 1 graduated elastic compression stockings during a 15-day period results in a significant improvement in the symptomatology of early-stage chronic venous disease, i.e., in the relief of global painful discomfort as well as in quality-of-life criteria. A high level of patient compliance in the wearing of the stockings was achieved in this study.

Prescription of compression stockings in France in primary care.

OBJECTIVES: Recent French data describing real-life compression stocking use are lacking. This study aimed to describe the actual situation for patients who were prescribed compression stockings by their general practitioner and to assess annual treatment costs from a societal perspective. METHODS: A retrospective analysis using Disease Analyzer database data from 6349 adults with at least one compression stocking prescription between July 2009 and June 2010. RESULTS: Mean patient age was 58 years, and 72.3% of patients were women. Seven out of 10 patients received only a single compression stocking prescription over one year. The estimated mean annual per patient cost was 152.2 ± 100.7 Euros. CONCLUSION: Most patients received only a single compression stocking prescription during one year. General practitioners prescribing compression stockings more often may have a better understanding of venous disease and may manage their patients differently. Although more expensive, this approach may be one which should be accepted more widely.

Venous symptoms in C0 and C1 patients: UIP consensus document.

This UIP document provides an update on venous symptoms in CO and C1 patients. The correlation between venous symptoms and the presence of telangiectases and/or reticular veins is one of the most controversial topics in chronic venous disorders. As symptoms may be non-specific of chronic venous disease, it is important to differentiate venous symptoms from symptoms of other causes. Some data from the Bonn Vein Study suggest that the risk to develop venous symptoms is increased in women, advanced age and obesity. Treatment is based on physical advice, elastic compression, venoactive drugs, sclerotherapy, correction of foot static disorders and reduction of body weight. Future research should be promoted on venous symptoms in epidemiological and follow-up studies, about the relationship between female hormone levels and symptomatic telangiectasias, and between venous pain and foot static disorders in C0s C1s patients.

Chronic edema of the lower extremities: international consensus recommendations for compression therapy clinical research trials.

Chronic edema is a multifactorial condition affecting patients with various diseases. Although the pathophysiology of edema varies, compression therapy is a basic tenant of treatment, vital to reducing swelling. Clinical trials are disparate or lacking regarding specific protocols and application recommendations for compression materials and methodology to enable optimal efficacy. Compression therapy is a basic treatment modality for chronic leg edema; however, the evidence base for the optimal application, duration and intensity of compression therapy is lacking. The aim of this document was to present the proceedings of a day-long international expert consensus group meeting that examined the current state of the science for the use of compression therapy in chronic edema. An expert consensus group met in Brighton, UK, in March 2010 to examine the current state of the science for compression therapy in chronic edema of the lower extremities. Panel discussions and open space discussions examined the current literature, clinical practice patterns, common materials and emerging technologies for the management of chronic edema. This document outlines a proposed clinical research agenda focusing on compression therapy in chronic edema. Future trials comparing different compression devices, materials, pressures and parameters for application are needed to enhance the evidence base for optimal chronic oedema management. Important outcomes measures and methods of pressure and oedema quantification are outlined. Future trials are encouraged to optimize compression therapy in chronic edema of the lower extremities.

The efficiency of pain control using a thigh pad under the elastic stocking in patients following venous stripping: results of a case-control study.

BACKGROUND: The use of a specific thigh foam pad placed under compression stockings increases interface pressure. The interface pressure obtained under 2 medical compression stockings of 15 to 20 mm Hg at the ankle, is 14 ± 2.2 mm Hg in the middle of the thigh in the horizontal position and rises to 49.2 ± 4.7 mm Hg when an appropriate thigh foam pad is interposed. Thigh compression could be useful in relieving pain after surgery of the great saphenous vein. OBJECTIVE: The aim of this study was to compare pain intensity on day 1 and day 7 and global mean pain during the week after stripping of the great saphenous vein between patients to whom a pad has been added at the thigh level under the compression stocking (case) and patients wearing a compression stocking only (control). METHODS: Case-control study conducted in daily surgical practice by patients having undergone surgical stripping. Main criteria: pain self-evaluation on visual analogue scale from day 1 to day 7 adjusted for analgesic consumption. No pain evaluation was conducted on Day 0 because of the fact that the elastic compression was applied in the operating room on a patient still under anesthesia. Results. A total of 53 patients were included in the study: 36 in the pad group and 17 in the control group. Patients were similar in respect of age, sex ratio, body mass index, professional status, and CEAP (clinical, etiologic, anatomic, and pathophysiologic) classification. On day 1, pain was 40.8 ± 20.8 in the control group and 27.4 ± 24.2 in the pad group (P = .05). On day 7, pain was 15.3 ± 13.4 in the control group and 3.7 ± 5.5 in the pad group (P < .0001). Global mean pain during the week after stripping surgery was 156.5 ± 80.6 in the control group and 80.1 ± 82.01 in the pad group (P < .0001). CONCLUSION: The results of this case-control study show that the addition of a pad at thigh level under the elastic compression stocking significantly reduces pain experienced by patients during the week after stripping surgery by 49%.