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Background The therapeutic effectiveness of compression therapy depends on the selection of compression hosiery. Objectives To assess efficacy and tolerability of graduated elastic compression stockings (GECS) and inverse graduated elastic compression stockings (PECS). Methods Thirty-two healthy volunteers and thirty-two patients with chronic venous insufficiency were analysed; wear period: one week for each stocking type (randomised, blinded). Primary outcome: volume reduction of ‘Lower leg’ (Image3D®) and ‘Distal leg and foot’ (water plethysmography). Secondary outcomes: clinical symptoms of chronic venous insufficiency assessed by the Venous Clinical Severity Score, side effects and wear comfort in both groups. Results Volume of ‘Lower leg’: significant reduction in healthy volunteers (mean GECS: −37.5 mL, mean PECS: −37.2 mL) and in patients (mean GECS: −55.6 mL, mean PECS: −41.6 mL). Volume of ‘Distal lower leg and foot’: significant reduction in healthy volunteers (mean GECS: −27 mL, mean PECS: −16.7 mL), significant reduction in patients by GECS (mean: −43.4 mL), but non-significant reduction by PECS (mean: −22.6 mL). Clinical symptoms of chronic venous insufficiency were improved significantly better with GECS than with PECS, p Conclusion GECS and PECS reduce volume of the segment ‘Lower leg’ in patients and healthy volunteers. Patients’ volume of the ‘Distal lower leg and foot’, however, were diminished significantly only by GECS ( p = 0.0001). Patients’ complaints were improved by both GECS and PECS, and GECS were superior to PECS.

Objectives To study the differences in impact on venous hemodynamics between larger size strong graduated elastic compression stockings (GECS) and appropriate size strong/moderate GECS. Method In healthy legs fitted for a small (Group S; n = 8) and large (Group L; n = 8) GECS, air plethysmography was performed without GECS, with an appropriate size strong GECS (GECS1), with a three-size too large strong GECS (GECS2), and with an appropriate size moderate GECS (GECS3) in this order. Results In Group S, interface pressure with GECS2 was equal to or higher than that with GECS3. Decreased venous volume, unchanged ejection volume, and decreased residual volume were achieved by GECS, but differences in these parameters among GECS were not observed. Although insignificant, a similar tendency was found in Group L. Conclusions A larger size strong GECS seemed to have equivalent interface pressure and impact on venous hemodynamics compared to an appropriate size moderate or strong GECS.

Compression therapy is extremely effective in promoting ulcer healing. Which material to use, if elastic or inelastic, is still a matter of debate. This paper will provide an overview on the recent findings in compression therapy mainly for venous or mixed ulcers which are the great majority of leg ulcers. In this paper it will be demonstrated that inelastic compression has been proved to be significantly more effective than elastic compression in reducing venous reflux, increasing venous pumping function and decreasing ambulatory venous hypertension. In addition it is comfortable, well accepted by patients and achieved an extremely high healing rate in venous ulcers. With reduced pressure inelastic compression is able to improve venous pumping function in patients with mixed ulcers without affecting but improving the arterial inflow. It will be also clearly shown that studies claiming a better effect of elastic compression compared to inelastic in favouring healing rate have significant methodological flaws making their conclusions at least doubtful. In conclusion inelastic- is significantly more effective than elastic compression in reducing ambulatory venous hypertension which is the main pathophysiological determinant of venous ulcers and demonstrated to be very effective in getting ulcer healing. New multicentric, randomized and controlled studies, without methodological flaws, will be necessary to prove that elastic- is at least as effective as inelastic compression or, maybe, more effective.

Compression therapy is still the cornerstone in the treatment of PTS. The therapy is primarily focused on the decrease of the AVP, enhancement of the microcirculation and reduction of the edema. In our practice, most patients are initially treated with short stretch bandage to reduce the edema. Medical Elastic Compression Stockings (MECS) class II (CEN 23–32 mm Hg)or class III (CEN 34–46 mm Hg) with a high stiffness index are prescribed after the edema is disappeared. The prescription will be for a lifelong usage of stockings. Correction of saphenous reflux, deobstructing and stenting might be considered in certain patients with PTS.

Introduction: arterial involvement may coexist in about 15–30 of venous ulcers. In this case compression therapy maybe applied, only by expert caregivers, with a reduced pressure which must not overcome the arterial pressure at ankle and foot level. It remains to assess if such a reduced pressure may be effective also on the impaired venous hemodynamics. Aim of this paper is to present an overview of the data we have, showing the effects on venous hemodynamics of a reduced compression pressure. Material and methods: in different groups of patients affected by deep and superficial venous incompetence, venous reflux and ejection fraction (EF) from the lower leg were measured in baseline conditions, without any compression, and after application of different elastic and inelastic compression devices exerting different pressure ranges from 20 to 60 mm Hg. The compression pressure was always recorded simultaneously with venous reflux of EF assessment. Results: strong pressures show the greatest effect in reducing/abolishing venous reflux and increasing EF but also a reduced pressure in the range of 20 to 40 mm Hg is effective in improving venous hemodynamics provided inelastic materials are used. Conclusions: inelastic but not elastic materials exert a standing pressure which is significantly higher than in supine position even starting from a reduced supine pressure of 40 mm Hg which does not impair the arterial inflow. This strong pressure is able to reduce and even abolish the venous reflux and improve the EF up to restoring its normal range. A reduced or modified compression pressure is able to significantly improve the venous hemodynamics without affecting the arterial inflow in patients with mixed ulcers, provided inelastic materials are used.

Background Compression stockings are the cornerstone of the treatment of chronic venous disorders, but practical acceptability is an important limitation in the elderly. Objective To evaluate the practicability of compression stockings in elderly patients. Methods Twenty women aged 68–85 years without major disability were asked to put on, wear for three hours and take off Solegg® and Solegg® Fine compressive stockings (15–20 mmHg) in random order on different days, and to rate through questionnaires the difficulties and discomfort they experienced in comparison with their usual non-compressive stockings (controls). Results Foot and heel insertions of the compression stockings, as well as their removal, were found significantly more difficult, whereas comfort when they were on was higher. In the whole, the compression stockings were found to be more agreeable than the controls. Conclusion Difficulties regarding putting on and removal of the compression stockings remain significant but are counterbalanced by a better comfort when they are on.

The purposes of this study were to (1) investigate compression levels beneath an inelastic legging equipped with a new pressure-adjustment system, (2) compare the inelastic compression levels with those provided by a well-known elastic stocking, and (3) evaluate each support's gradient compression production. Eighteen subjects without venous reflux and 12 patients with previously documented venous reflux received elastic and inelastic compression supports sized for the individual. Skin surface pressures under the elastic (Sigvaris 500, 30–40 mm Hg range, Sigvaris, Inc., Peachtree City, GA) and inelastic (CircAid C3 with Built-in-Pressure System [BPS], CircAid Medical Products, San Diego, CA) supports were measured using a calibrated Tekscan I-Scan device (Tekscan, Inc., Boston, MA). The elastic stocking produced significantly lower skin surface pressures than the inelastic legging. Mean pressures (± standard error) beneath the elastic stocking were 26 ± 2 and 23 ± 1 mm Hg at the ankle and below-knee regions, respectively. Mean pressures (± standard error) beneath the inelastic legging with the BPS were 50 ± 3 and 38 ± 2 mm Hg at the ankle and below-knee regions, respectively. Importantly, our study indicates that only the inelastic legging with the BPS produces significant ankle to knee gradient compression ( p = .001).

The evolution of microcirculatory methods and the definition of the concept of venous microangiopathy allow the study in a quantitative way of microcirculatory changes produced by pharmacologic treatments at the areas most frequently and severely affected by chronic venous insufficiency (CVI), venous hypertensive microangiopathy, and venous ulcerations. This pilot study compares subjects with CVI, in the area most affected by venous hypertension in a 2-week registry. Elastic compression, compression plus Viatromb® (lyposomal spray gel heparin), Lioton® (gel including heparin), and Viatromb® alone were compared. Subjects were evaluated for laser Doppler flux, transcutaneous partial pressure of oxygen (TcPO2), and partial pressure of carbon dioxide (PCO2) and CVI analogic symptom scale. In the Viatromb® groups (B and D), significant decreases in laser Doppler flux, PCO2, and CVI score were observed. The decrease was proportionally more important in the elastic compression plus Viatromb ® group. Partial pressure of oxygen (PO2) was significantly increased. No significant changes were observed in the Lioton® group. There was a good effect for compression only. These differences are significant, as they can be observed even in small groups (10-15 patients). No treatment side effects were observed, and compliance and tolerability were very good.

Background: Below-knee elastic compression stockings are widely used for the treatment of chronic venous insufficiency. The exact amount of pressure exerted by these stockings on different parts of leg and in different postures remains controversial. Objective: To examine the pressure exerted by correctly fitted class II below knee compression stockings at different levels and postures in normal subjects. Methods: Seven healthy human volunteers (mean age 38 years) were fitted with CEN class II below-knee compression stockings. Interface pressure measurements were recorded at 4 cm intervals from the malleolus to the top of the stocking on the medial and lateral aspects of the leg in supine, sitting and standing postures. Results: The interface pressure at 4 cm and 32 cm above the medial malleolus was not significantly different from the recommended values for class II socks and did not change significantly with posture. In the supine position the pressure at the mid-calf (12 cm) was greater than at the ankle (p < 0.05), creating a reverse pressure gradient, which increased further on standing (p < 0.05). Conclusion: The pressure profile under correctly fitted class II socks varies with posture due to the change in shape of the leg. The resulting profile deviates from the theoretical ideal of a graduated pressure gradient that adapts with posture. The clinical significance of this effect is not known.

Objective: Updating the status of the European standardisation for medical elastic compression stockings, including custom-made stockings (class 030606, EN29999), knitted from threads made of natural fibres or synthetic fibres and elastic threads. Design: Review of the literature. Setting: Department of Dermatology at the University Hospital of Maastricht (The Netherlands). Methods: Systematic review of the European regulations within the European Committee for Standardisation (CEN), by a special committee researching non-active medical devices (CEN/TC205). A special working group was set up for medical elastic compression stockings (CEN/TC205/WG2) and for anti-embolism stockings (CEN/TC205/WG2/P1) linked to the scientific background and literature on medical elastic compression stockings. Results: CEN/TC205 formalised a European prestandard (prEN12718) for medical elastic compression stockings. The pre-standard describes five compression classes, instructions for measurement, instructions for residual pressure and instructions for knitting. Still lacking is a good instrument for the comparison of laboratory measurements and a durability test. The problem of the elasticity coefficient is neglected in the standard. Conclusions: Normalisation of non-active medical devices is an important quality instrument. The medical profession should give attention to adequate compression classes, a good understanding of the elasticity coefficient and the durability of stockings.

Objective: To review the recent medical literature with regard to the use of compressive therapy in healing and preventing the recurrence of venous ulceration. Methods: Searches of Medline and Embase medical literature databases. Appropriate non-indexed journals and textbooks were also reviewed. Synthesis: Elastic compression therapy is regarded as the ‘gold standard’ treatment for venous ulceration. The benefits of elastic compression therapy in the treatment of venous ulceration may be mediated through favourable alterations in venous haemodynamics, micro-circulatory haemodynamics and/or improvement in subcutaneous Starling forces. Available data indicate compressive therapy is highly effective in healing of the large majority of venous ulcers. Elastic compression stockings, Unna boots, as well as multi-layer elastic wraps, have all been noted to achieve excellent healing rates for venous ulcers. In compliant patients it appears that approximately 75% of venous ulcers can be healed by 6 months, and up to 90% by 1 year. Non-healing of venous ulcers is associated with lack of patient compliance with treatment, large and long-standing venous ulceration and the coexistence of arterial insufficiency. Recurrence of venous ulceration is, however, a significant problem after healing with compressive therapy, even in compliant patients; approximately 20-30% of venous ulcers will recur by 2 years. Conclusions: Compressive therapy is capable of achieving high rates of healing of venous ulceration in compliant patients. Various forms of compression, including elastic, rigid and multi-layer dressings, are available depending on physician preference, the clinical situation and the needs of the individual patient. Compressive therapy, while effective, remains far from ideal. The future goals are to achieve faster healing of venous ulceration, less painful healing and freedom from ulcer recurrence.

Objective: To evaluate the effect of thigh-length compression stockings on the venous blood pool and interstitial oedema in patients with varicose veins. Setting: Department of General Medicine, University of Heidelberg, Germany. Patients: Forty-six patients with unilateral long saphenous varicose veins. Main outcome measures: The effects of compression stockings on optoelectronically measured volumes of normal legs and legs with varicose veins in supine and upright positions. Results: Changing body position from a supine to an upright position leads to an increased leg volume by venous blood pooling (236.5 ml and 255.5 ml, respectively, p < 0.001). The volume difference between normal legs and legs with varicose veins in the supine position was 172.5 ml, and in the upright position 187.0 ml ( p < 0.001). After putting on compression thigh-length stockings, the volume of both normal legs and legs with varicose veins decreased by 314.5 ml and 358.0 ml (acute compression effect). Elastic compression for 8 h produced no significant additional reduction in the leg volumes. Wearing the stockings for 7 successive days failed to reduce the volume in the normal legs, whereas a further reduction in the legs with varicose veins was measured (supine position 61.0 ml, p < 0.05; upright position 72.0 ml, p < 0.05) (long-term compression effect). Conclusions: Wearing compression stockings rapidly reduces venous blood pools of the legs. Long-term wear is necessary to mobilize the interstitial limb oedema in patients with superficial venous insufficiency.

Objective: To evaluate the response of the deep veins of the leg to an inclination from supine (reverse Trendelenburg) and assess the influence of gradient elastic compression stockings on such response. Design: Prospective study in healthy volunteers. Setting: University affiliated community hospital, Glenview, Illinois, USA. Participants: Ten healthy volunteers. Interventions: High-resolution ultrasound imaging was carried out to study the leg veins in the supine and 45° reverse Trendelenburg position, with and without thigh-length gradient elastic compression stockings. Main outcome measures: Vein cross-sectional area changes after the use of compression stockings in the supine position and after 30 and 60 min in a reverse Trendelenburg position. Results: Significant dilatation of the leg veins was observed during the reverse Trendelenburg position. This was partially prevented by the use of gradient elastic compression stockings. Conclusion: Elastic compression of the legs significantly reduces the dilatation of the medial gastrocnemius veins of the calf that occurs in healthy volunteers as a result of inclination from supine.

A prospective study to determine the incidence of deep vein thrombosis in passengers on long haul flights, and to determine the efficacy of elastic compression stockings in reducing this incidence....

Objective: To determine the current usage of prophylactic regimes to prevent deep vein thrombosis in surgical departments in Italy. Design: Survey by questionnaire sent to 500 surgical departments. Participants: Surgical departments performing more than 500 surgical operations, selected randomly by the process of quota sampling. Main outcome measures: Assessment of the methods or prophylaxis, reasons for use of prophylaxis and assessment of outcome of prophylactic measures. Results: There were 326 completed questionnaires returned indicating that prophylaxis was used routinely in 58% of the centres, 29% of centres used more than 1 method of prophylaxis with subcutaneous heparin and elastic compression being the most commonly used modalities. Conclusion: Insufficient use of prophylactic measures to prevent deep vein thrombosis in Italy still leads to an excessive number of postoperative venous thromboses.

The long-term haemodynamic effect of elastic compression has been evaluated in 16 patients (20 limbs) with superficial venous incompetence. Ambulatory venous pressure (AVP) and pressure recovery time (RT90) were measured with foot vein canulation. Air-plethysmography was used to measure venous volume, venous reflux and the ejecting capacity of the calf muscle pump, before and after the application of graduated elastic stockings, for 4 weeks. Limbs were tested without the stockings. Elastic compression for 4 weeks produced a significant reduction in the venous volume ( P < 0.01), a significant decrease in venous reflux and an increase in the ejecting capacity of the calf muscle pump ( P < 0.01). The above changes explain the significant reduction in AVP and prolongation of RT90 ( P < 0.01) which was observed. The results indicate that there is a considerable improvement in venous haemodynamics after 4 weeks support with graduated elastic compression.

A prospective randomized study was performed to compare different periods of bandaging after varicose vein surgery. No difference was found from wearing an elastic support for 1, 3 or 6 weeks after surgery.

Seventy-six patients with venous ulceration of 108 legs were treated by the ligation of incompetent calf perforating veins, with saphenous ligation and stripping where necessary and with the addition of knee length elastic compression stockings for those with deep venous reflux. Review at a mean 6 years after treatment has shown that 74% remain healed and there is no significant difference between those with and without deep vein incompetence. Where patients with rheumatoid arthritis and/or arterial insufficiency were excluded, 84% remain healed.

The haemodynamic effect of elastic compression has been evaluated in 23 patients (26 limbs) with superficial venous incompetence. Ambulatory venous pressure (AVP) and pressure recovery time (RT90) were measured with foot vein canulation. Also the functional venous volume (VV) (venous capacitance), venous reflux and the ejecting capacity of the calf muscle pump were measured with air-plethysmography. The above measurements were made with and without a graduated compression elastic stocking. Elastic compression produced a significant reduction in VV ( P < 0.01). Also a significant decrease in venous reflux and increase in the ejecting capacity of the calf muscle pump ( P < 0.01). The above alterations explain the significant reduction in AVP and prolongation of RT90 ( P < 0.01) which was observed as a result of elastic compression. The measurements made in this study demonstrate in an objective and quantitative way the beneficial effect of elastic stockings in patients with superficial venous incompetence and how this effect is achieved.

The value of elastic compression and defibrotide, a profibrinolytic and antithrombotic drug, in patients with venous hypertension, lipodermatosclerosis and ulceration was assessed in a cross-over trial. Elastic compression alone and in association with defibrotide (800 mg/day) were completed the study (18 were treated with the combined treatment in the first 3 months and 14 in the second period). We evaluated the decrease of the areas of liposclerosis and ulceration by computerized analysis of the areas. We also studied the decrease of leg circumference and subjective clinical improvement by an analogue scale line. Patients were also evaluated by laser-Doppler flowimetry, transcutaneous PO2 and PCO2 measurements, capillary permeability and fibrinolytic activity. Both forms of treatment were active in reducing the areas of liposclerosis and ulceration but combined treatment with defibrotide and elastic compression was significantly more effective in reducing both liposclerosis and ulceration, and in improving microcirculatory parameters and capillary permeability. The improvement in objective evaluation was comparable to the clinical improvement measured by the analogue score. The positive variation of all parameters studied was associated with a significant increase of fibrinolytic activity during the administration of defibrotide. No side effects were observed during this study. These results suggest that defibrotide treatment is effective in treating liposclerosis and ulceration in postphlebitic limbs with venous hypertension, improving both microcirculatory parameters and subjective symptoms.

A low oxygen tension might contribute to the dermatological changes produced by deep venous insufficiency and venous stasis. Since elastic support is often prescribed for stasis disorders, it would be of value to know whether compression alters the oxygen tension in affected skin. We performed studies in which the transcutaneous Po2 (TcPo2) was determined for the foot or lower leg in subjects with normal veins (n = 9) or with dermatitis caused by documented deep venous insufficiency (n = 14). Measurements were made using O2-sensing electrodes placed 1–2 cm apart; surface temperature was 45°C for one electrode (producing maximal vasodilation of the underlying skin) and 42°C for the other (producing submaximal vasodilation). The vasodilation index (VI = TcPo2 at 42 °C/TcPo2 at 45°C) was used as an index of vasomotor tone. In normal limbs, TcPo2 (mmHg) and VI were affected by the subject's posture (TcPo2 = 38.8 at 42°C and 61.4 at 45°C when supine; 40.8 at 42°C and 74.6 at 45°C when upright with legs dependent; VI = 0.63 supine and 0.53 upright). In limbs with venous stasis, TcPo2 and VI were considerably lower (TcPo2 = 23.6 at 42°C and 51.5 at 45°C when supine; 20.8 at 42°C and 60.5 at 45°C when upright; VI = 0.48 supine and 0.37 upright). Following the application of an elastic wrap to the limbs with stasis, upright values for TcPo2 and VI were substantially improved (TcPo2 with compression = 28.8 at 42°C and 62.4 at 45°C; VI = 0.46). We conclude that (1) TcPo2 is reduced in regions of skin affected by stasis dermatitis, and (2) elastic compression improves TcPo2 (during upright posture) in limbs with stasis dermatitis.