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Objective: The aim of this study was to test whether an investigational two layer stocking exerting 27-29 mmHg pressure at the medial supramalleolar level, but without compression in the foot and heel, is easier to put on and take off than a standard stocking of the same compression class (23-32 mmHg), and also to assess the prevention of diurnal oedema with both types of stocking., Methods: This was an open label randomised controlled trial, which included 47 patients. All participants were at least 65 years of age and suffered from chronic venous disease class C3 - C6 in one leg. The primary end point was donning success; secondary endpoints were doffing success, prevention of diurnal oedema over one day, and the comfort of wearing the stocking. Patients were randomly allocated to one of two groups. Both types of compression stocking were compared in each group for ease of donning and doffing in the manner of a crossover study. Subsequently, patients wore the stocking type assigned to their group for a whole day to evaluate comfort and the effect on diurnal leg volume., Results: All participants were able to don the investigational stocking unaided, compared with 75% for the standard stocking (p < .001). Unaided removal success was 100% with the investigational stocking vs. 66% for the standard stocking (p < .001). There was no significant difference in leg volume reduction between the study groups after a day of wear. The investigational stocking was also rated as being more comfortable than the standard stocking (p < .001)., Conclusion: The investigational stocking, which has no compression in the foot or heel area, is significantly easier to don and doff, with no inferiority in oedema prevention, compared with a standard stocking of the same compression class., (Copyright © 2020 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: The literature supports the use of graduated compression stockings (GCS) for leg edema. Nevertheless, there is a paucity of data on the GCS effect on limb edema related to sitting, standing, and walking. Data of different limb shapes and their impact on GCS-exerted pressure are lacking. This investigation provides evidence-based information on the effect of GCS on edema reduction and the impact of limb circumference gradients on GCS pressure., Methods: Thirty healthy individuals (15 men and 15 women; mean age, 32 ± 5 years) were included. All the participants underwent lower limb volume (Kuhnke formula) measurement, before and after sitting for 30 minutes, wearing below-ankle noncompressive socks. The same assessment was repeated 7 days later, in the same participants, but with wearing of below-knee 16 to 20 mm Hg GCS. At 7-day intervals, 1 week with below-ankle noncompressive socks and 1 week with below-knee 16 to 20 mm Hg GCS, all the participants repeated the same protocol including standing and walking. Ten participants underwent bioimpedance assessment (Biody Xpert II; eBIODY, La Ciotat, France) before and after sitting, standing, and walking. In the same group, B and B1 interface pressure values were measured., Results: Data collection was completed in all 60 limbs. Sitting or walking without GCS led to no significant volume changes, whereas volume was decreased by the use of GCS (-4.8% [P < .00001] and -4.4% [P < .00001], respectively). Standing up without GCS led to an increase in volume (2.7%; P < .0001), whereas limb volume was decreased (4.6%; P < .0001) by use of GCS. Bioimpedance showed extracellular water reduction only while walking with GCS (from 40.55% ± 1.66% to 40.45% ± 1.71%; P < .017). Mean interface pressure was 19 ± 5 mm Hg (B) and 16 ± 5 mm Hg (B1). The interface pressure variation from B to B1 was not homogeneous among participants (mean percentage variation of -13% ± 25%, ranging from -54% to 16%). A negative linear trend between pressure variation and circumference percentage increase was found; the subanalysis excluding the two outliers showed a strong negative linear correlation (Pearson coefficient r = -0.96)., Conclusions: GCS led to a significant limb volume reduction irrespective of limb position and muscle pump function. However, extracellular fluid is mobilized only during muscle contraction while walking with GCS. Interestingly, different lower limb circumference variations influence the interface pressure gradient, indicating the importance of proper fitting of both B and B1 during prescription. These data provide a foundation to future investigations dealing with GCS effect on fluid mobilization and with limb geometry impact on compression performance., (Copyright © 2020 Society for Vascular Surgery. All rights reserved.)

Objective: Despite the modern appeal of wearing compressive garments during physical activities, the literature is lacking in quality data and controversial in the investigations dealing with the pathophysiologic mechanism by which graduated compression stockings (GCS) affect the calf pump activation in healthy individuals. The aim of the investigation was to provide insight into the clinical effects of GCS use during a standardized walking exercise., Methods: Twenty physically active healthy volunteers (mean age, 34 ± 5 years; body mass index, 22 ± 2 kg/m 2 ) underwent lower limb ultrasound scanning to exclude vascular impairment. All individuals performed continuous aerobic exercise, walking for 30 minutes on a treadmill, under cardiac monitoring, at 70% of individual estimated maximal heart rate according to the Tanaka equation. The study population performed the standardized walk without GCS (baseline) and at 1 week performed the same standardized walk wearing knee-length 20 to 30 mm Hg GCS (compression). All individuals underwent a lower limb volume assessment by truncated cone formula before and after the walk and a perceived exertion assessment by means of the validated Borg scale at the end of the exercise protocol., Results: All individuals had normal venous and arterial ultrasound examination findings. No significant postural defects were reported. Both legs were assessed in all 20 individuals for a total of 40 cases with and 40 cases without GCS. In the baseline group, the median (interquartile range) lower limb volume changed from 2496 (770) mL before exercise to 2512 (805) mL (P = .2597) after exercise. The compression group reported a significant lower limb volume change from 2466 (670) mL before exercise to 2276 (567) mL (P = .0001) after exercise. Mean perceived exertion was 13 (11) and 11 (1) in the baseline and compression groups, respectively (P = .0001). The interface pressure exerted by the GCS was 24 (2) mm Hg. No complaints in terms of discomfort were reported after use of GCS., Conclusions: In healthy individuals, GCS (24 [2] mm Hg) use during a continuous standardized walk of 30 minutes is associated with a significant decrease in lower limb volume and a decrease in perceived exertion. The mechanism by which GCS impart their effect during physical activity may involve improved muscle pump function and reductions in inflammatory pathways. Further study will need to validate the mechanisms of the function of GCS used during physical exercise., (Copyright © 2019 Society for Vascular Surgery. All rights reserved.)

Objectives: To compare two different medical compression stockings after varicose vein treatment., Patients and Methods: A randomized single-blind controlled study on two compression regimes after saphenous catheter foam sclerotherapy + phlebectomy was performed. After pads and 5 mmHg contention sock, 23 mmHg (group A, Struva 23®) or 35 mmHg (group B, Struva 35®) medical compression stocking was applied 24 h/day for seven days; subsequently 21-23 mmHg medical compression stocking in daytime. Symptoms, compliance, skin findings, and bioimpedance spectroscopy parameters were assessed., Results: A total of 94 patients (48 and 49 limbs in groups A and B, respectively) were enrolled. Three (T3) and seven (T7) days post-operatively, most symptoms were significantly milder in group B, especially pain and heaviness at T7 and at day 40 (T40). Ambulation, medical compression stocking stability/tolerability and skin healing were significantly better in group B, with p = 0.046, 0.021/0.060, and 0.010, respectively, at T7. Bioimpedance parameters increased at T7 and decreased at T40 in both groups; leg reactance and limb L-Dex improved in group B at T7 and T40, respectively (p = 0.039 and 0.012)., Conclusions: Compression with 23 and 35 mmHg medical compression stocking after catheter foam sclerotherapy + phlebectomy was effective and well tolerated at immediate/short term. Compression with 35 mmHg medical compression stocking provided less adverse post-operative symptoms and better tissue healing. Bioimpedance results confirmed a slightly better edema improvement with 35 mmHg medical compression stocking.

Guideline 1.1: Compression after thermal ablation or stripping of the saphenous veins. When possible, we suggest compression (elastic stockings or wraps) should be used after surgical or thermal procedures to eliminate varicose veins. [GRADE - 2; LEVEL OF EVIDENCE - C] Guideline 1.2: Dose of compression after thermal ablation or stripping of the varicose veins. If compression dressings are to be used postprocedurally in patients undergoing ablation or surgical procedures on the saphenous veins, those providing pressures >20 mm Hg together with eccentric pads placed directly over the vein ablated or operated on provide the greatest reduction in postoperative pain.[GRADE - 2; LEVEL OF EVIDENCE - B] Guideline 2.1: Duration of compression therapy after thermal ablation or stripping of the saphenous veins. In the absence of convincing evidence, we recommend best clinical judgment to determine the duration of compression therapy after treatment. [BEST PRACTICE] Guideline 3.1: Compression therapy after sclerotherapy. We suggest compression therapy immediately after treatment of superficial veins with sclerotherapy to improve outcomes of sclerotherapy. [GRADE - 2; LEVEL OF EVIDENCE - C] Guideline 3.2: Duration of compression therapy after sclerotherapy. In the absence of convincing evidence, we recommend best clinical judgment to determine the duration of compression therapy after sclerotherapy. [BEST PRACTICE] Guideline 4.1: Compression after superficial vein treatment in patients with a venous leg ulcer. In a patient with a venous leg ulcer, we recommend compression therapy over no compression therapy to increase venous leg ulcer healing rate and to decrease the risk of ulcer recurrence. [GRADE - 1; LEVEL OF EVIDENCE - B] Guideline 4.2: Compression after superficial vein treatment in patients with a mixed arterial and venous leg ulcer. In a patient with a venous leg ulcer and underlying arterial disease, we suggest limiting the use of compression to patients with ankle-brachial index exceeding 0.5 or if absolute ankle pressure is >60 mm Hg. [GRADE - 2; LEVEL OF EVIDENCE - C]., (Copyright © 2018 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objective Medical compression stockings are a standard, non-invasive treatment option for all venous and lymphatic diseases. The aim of this consensus document is to provide up-to-date recommendations and evidence grading on the indications for treatment, based on evidence accumulated during the past decade, under the auspices of the International Compression Club. Methods A systematic literature review was conducted and, using PRISMA guidelines, 51 relevant publications were selected for an evidence-based analysis of an initial 2407 unrefined results. Key search terms included: 'acute', CEAP', 'chronic', 'compression stockings', 'compression therapy', 'lymph', 'lymphatic disease', 'vein' and 'venous disease'. Evidence extracted from the publications was graded initially by the panel members individually and then refined at the consensus meeting. Results Based on the current evidence, 25 recommendations for chronic and acute venous disorders were made. Of these, 24 recommendations were graded as: Grade 1A (n = 4), 1B (n = 13), 1C (n = 2), 2B (n = 4) and 2C (n = 1). The panel members found moderately robust evidence for medical compression stockings in patients with venous symptoms and prevention and treatment of venous oedema. Robust evidence was found for prevention and treatment of venous leg ulcers. Recommendations for stocking-use after great saphenous vein interventions were limited to the first post-interventional week. No randomised clinical trials are available that document a prophylactic effect of medical compression stockings on the progression of chronic venous disease (CVD). In acute deep vein thrombosis, immediate compression is recommended to reduce pain and swelling. Despite conflicting results from a recent study to prevent post-thrombotic syndrome, medical compression stockings are still recommended. In thromboprophylaxis, the role of stockings in addition to anticoagulation is limited. For the maintenance phase of lymphoedema management, compression stockings are the most important intervention. Conclusion The beneficial value of applying compression stockings in the treatment of venous and lymphatic disease is supported by this document, with 19/25 recommendations rated as Grade 1 evidence. For recommendations rated with Grade 2 level of evidence, further studies are needed.

The classification of medical elastic compression stockings (MECS) according to pressure classes varies from country to country and neither provides any information on the elastic property nor on the ambulatory interface pressure profiles of the different products. Beside elasticity, MECS are also characterized by other properties such as stiffness and hysteresis. Recent research showed that MECS behaved differently in static and ambulatory conditions. Since compression therapy is most effective during ambulation, MECS should be labelled in such a way that the user can interpret its effect during walking. The importance of a more rational classification of MECS was discussed at a conference organized by the International Compression Club (ICC) attended by medical experts and representatives from MECS manufacturers. Proposals were made for labelling the MECS according to the pressure and the stiffness in an internationally acceptable format printed on the box informing both the prescribers and the patients on its properties.

Objective/background: The objective of this study was to compare the efficacy and comfort of inelastic bandages (IBs) and adjustable Velcro compression devices (AVCDs) in reducing venous leg edema in the initial treatment phase., Methods: Forty legs from 36 patients with untreated venous edema (C3EpsAsdPr) were randomized to two groups. Patients in the first group received IBs (n = 20) and those in the second AVCDs (n = 20). Both compression devices were left on the leg day and night, and were renewed after 1 day. Patients in the AVCD group were asked to re-adjust the device as needed when it felt loose. Leg volume was calculated using the truncated cone formula at baseline (T0), after 1 day (T1) and after 7 days (T7). The interface pressure of the two compression devices was measured by an air filled probe, and the static stiffness index calculated after applying compression at T0 and T1, and just before removal of compression on T1 and T7. Patient comfort with regard to the two compression systems was assessed by grading signs and symptoms using a visual analog scale., Results: At T1, the median percent volume reduction was 13% for the IB group versus 19% for the AVCD group; at T7 it was 19% versus 26%, respectively (p < .001). The pressure of the IBs was significantly higher compared with the AVCDs at T0 (63 vs. 43 mmHg) but dropped by > 50% over time, while it remained unchanged with AVCDs owing to the periodic readjustment by the patient. Comfort was reported to be similar with the two compression devices., Conclusion: Re-adjustable AVCDs with a resting pressure of around 40 mmHg are more effective in reducing chronic venous edema than IBs with a resting pressure of around 60 mmHg. AVCDs are effective and well tolerated, not only during maintenance therapy, but also in the initial decongestive treatment phase of patients with venous leg edema., (Copyright © 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Aim: Aim of the study was to measure the effect of elastic and inelastic compression on calf muscle pump function in healthy male athletes., Methods: This was an experimental study which included 21 healthy male athletes. The ejection fraction (EF) of the venous calf pump was measured comparing the effects of a variety of compression materials: 1) sport compression stockings; 2) light zinc paste bandages; 3) sport compression stockings with additional Velcro® wraps over the calf. The influence of sport stocking and wraps on the venous calibre at the largest calf circumference in the lying and standing position was investigated using MRI., Results: Inelastic compression exerting a median pressure in the standing position of 37.5 mmHg (zinc paste) and 48 mmHg (loosely applied straps over a sport stocking) achieved a significant increase of EF up to 100%. Sport stockings alone with a standing pressure of 19-24 mmHg did not show a significant change of EF. MRI demonstrated some venous narrowing in the lying but not in the standing position. By wrapping inelastic straps over the stocking an emptying of the veins in the lying and a considerable narrowing in the standing position could be observed., Conclusion: Venous calf pump function in athletes is not influenced by elastic sport stockings, but inelastic wraps either alone or applied over sport stockings lead to a significant enhancement.

Background: Previous studies have shown that so-called progressive elastic compression stockings (PECS) with a negative pressure gradient have a more pronounced effect on venous pump function than conventional, graduated stockings. The aim of this study was to investigate the effect of higher graduated and non-graduated pressures on the venous calf pump in patients with venous disease., Methods: The ejection fraction (EF) of the calf pump was measured by plethysmography under a standardized walking test in 20 patients suffering from chronic venous disease (CEAP C2-C5) without compression, (a) with one and (b) two PECS on top of each other, and (c) with one additional conventional stocking covering only the gaiter area to achieve a graduated high pressure profile. Interface pressure was measured in the gaiter area and on the calf., Results: A significant improvement of EF compared with baseline was found with all three compression modalities. The two superimposed PECS, providing median pressures of 33 mmHg in the gaiter area and 46 mmHg at calf level, increased EF significantly up into the normal range. Increasing the gaiter pressure to 56 mmHg without changing the calf pressure did not result in further improvement., Conclusions: Two PECS applied on top of each other lead to a maximal improvement of the venous pump function, which cannot be further improved by increasing the pressure in the gaiter area thereby restoring a graduated pressure profile., (Copyright © 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

The International Compression Club (ICC) is a partnership between academics, clinicians and industry focused upon understanding the role of compression in the management of different clinical conditions. The ICC meet regularly and from these meetings have produced a series of eight consensus publications upon topics ranging from evidence-based compression to compression trials for arm lymphoedema. All of the current consensus documents can be accessed on the ICC website (http://www.icc-compressionclub.com/index.php). In May 2011, the ICC met in Brussels during the European Wound Management Association (EWMA) annual conference. With almost 50 members in attendance, the day-long ICC meeting challenged a series of dogmas and myths that exist when considering compression therapies. In preparation for a discussion on beliefs surrounding compression, a forum was established on the ICC website where presenters were able to display a summary of their thoughts upon each dogma to be discussed during the meeting. Members of the ICC could then provide comments on each topic thereby widening the discussion to the entire membership of the ICC rather than simply those who were attending the EWMA conference. This article presents an extended report of the issues that were discussed, with each dogma covered in a separate section. The ICC discussed 12 'dogmas' with areas 1 through 7 dedicated to materials and application techniques used to apply compression with the remaining topics (8 through 12) related to the indications for using compression., (© 2012 The Authors. International Wound Journal © 2012 John Wiley & Sons Ltd and Medicalhelplines.com Inc.)

Venous edema of the limb presents several challenges to clinicians, particularly with regard to its definition, pathophysiology and measurement, as well as those relating to its management. Compression therapy forms the cornerstone of standard care for thromboprophylaxis and management of lower limb venous and lymphatic disorders. Venoactive drugs, of plant or synthetic origin, have also been shown to be effective and safe in the management of venous edema and/or chronic venous disease-related symptoms. This article, based on a symposium held at the XXV World Congress of the International Union of Angiology on 2-5 July 2012 (Prague, Czech Republic), provides an overview of some of the recent developments in the use of phlebotonic and compression therapy in the management of patients with lower limb venous edema, with a focus on Cyclo 3 Fort(®) and progressive compression stockings.

Introduction: Elastic compression stockings exerting a progressive pressure, higher at the calf than at the ankle (progressive elastic compression stockings, PECS), have already proved to be more comfortable, easier to put on and more effective in improving venous pumping function compared to graduated compression elastic stockings (GECS). Nevertheless, PECS could have a negative effect on the prevention and treatment of oedema or even favour oedema formation. The aim of the present study was to investigate if, in normal volunteers, PECS are able to prevent leg swelling during their working shift., Methods: A total of 30 normal volunteers (14 males, 16 females aged 36.4 ± 6.6 years) staying standing or sitting during their shift were enrolled into the study. Their leg volume was measured at the beginning and at the end of their working shift on 2 consecutive days. On one day, the volunteers did not put on any stockings; on the other day, they wore GECS on one leg and PECS on the other. The difference between the leg volume measured at the end of the shift and the basal volume in the morning was called 'occupational oedema'. Interface pressure at points B1 and C was measured immediately after stockings' application and before removal. The volunteers were asked to report about difficulty of putting on the stockings and comfort during wearing time. The results were submitted to statistical analysis., Results: The GECS and PECS groups had similar baseline leg volumes (3143 vs. 3154 ml) and occupational oedema (134 vs. 137.5 ml); after putting on the stockings, occupational oedema was reduced in both legs but the reduction was significantly greater with PECS (20 vs. 40 ml with GECS) (P < 0.05). Interface pressure at ankle level is higher with GECS both in supine and in standing position while at calf level it is higher with PECS both in supine and standing position. PECS are easier to put on and slightly more comfortable., Conclusion: PECS are easier to put on and more comfortable and produce a significantly higher reduction of occupational oedema compared with GECS in normal volunteers. Nevertheless leg volumetry, providing a global leg-volume evaluation, is not able to localise the oedema reduction and to assess if it occurs more in the calf or the ankle area. Theoretically, despite a global volume reduction, PECS could even promote a slight oedema formation at ankle level over-compensated by a greater oedema reduction at calf level. Further studies need to concentrate on patients with venous disease and on the local distribution of this global effect., (Copyright © 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Compression treatments used the following intervention for varicose veins range from no compression, to elastic stockings and compression bandaging. There is no consensus on the strength or duration of compression which should be applied following a particular treatment. The author reviews the evidence that has led him to reach his own viewpoint on this subject., Summary: Compression stockings are often prescribed after treatment of varicose veins, but these in general exert a much lower pressure in the thigh compared with firm inelastic compression bandages. It has been shown by objective investigation that it takes a pressure of 10-15 mmHg in the supine position and 40-50 mmHg in the standing position to occlude a superficial vein in the thigh. The author has published a study in which three groups of patients were studied following varicose vein surgery. One group received a strong medical compression stocking, the second group an inelastic bandaging system which achieved 63 mmHg compression in the standing position and an eccentric compression system which achieved 98 mmHg in the standing position. Adverse events after surgery were most frequent in the stocking group with fewer in the inelastic compression bandage group and fewest in the eccentric compression group. A further study has been published by another author in which elastic compression has been compared with eccentric compression following endovenous laser ablation of the saphenous vein. Eccentric compression reduced postoperative pain. Unfortunately, very little data are available to indicate the period for which compression should be applied following varicose vein treatment., Conclusions: In comparison to compression treatments following varicose vein surgery where the actual level of compression has been measured, higher levels of compression are more effective than lower levels in moderating postoperative pain and complications. Strong compression can be achieved by inelastic bandaging or by eccentric compression systems. Far fewer data are available to indicate the duration for which postoperative compression is required.

Aim: To compare the efficacy of compression stockings and inelastic, high-pressure bandages concerning leg volume reduction in patients with chronic leg oedema., Material and Methods: Forty-two legs of 30 patients with chronic leg oedema caused by venous stasis were randomized to receive a strong inelastic bandage (IB) or an elastic stocking (ES) exerting a pressure of 23-32 mmHg. Changes in leg oedema were assessed after two and seven days by water displacement volumetry, measurements of leg circumferences and of skin thickness by using Duplex ultrasound. Interface pressure was registered under the compression devices for seven days., Results: There was no significant difference between stockings and bandages, which both produced a significant reduction in leg volume after two days (-9.6% [95% CI 7.5-11.8] by ES and -11.5% [95% CI 9.9-13.2%] by IB) and after seven days (-13.2% [95% CI 10.4-16.2] by ES and -15.6% [95% CI 12.8-18.4] by IB). Bandages showed a more pronounced reduction in leg circumference and in skin thickness in the calf region. The pressure of IB in the lying position fell from initially 63 to 22 mmHg after two days, but only from 33 to 26 mmHg under ES (median values). The optimal pressure range concerning oedema reduction was found between 40 and 60 mmHg, while higher pressures produced by bandages showed a negative correlation with volume reduction., Conclusions: Compression stockings exerting a pressure of around 30 mmHg are nearly as effective as high-pressure bandages with an initial pressure over 60 mmHg in reducing chronic leg oedema.

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.

Aim: The optimal pressure to reduce chronic extremity swelling is still a matter of debate. The aim of this paper was to measure volume reduction of a swollen extremity depending on the amount of pressure exerted by compression stockings and inelastic bandages., Methods: Thirty-six patients with unilateral breast cancer related arm lymphedema were investigated in a lymph clinic in the Netherlands, 42 legs with chronic edema of the lower extremities were examined in a phlebological centre in Italy. The arm-patients were randomized to receive inelastic arm bandages with a pressure between 20-30 mmHg or 44-68 mmHg. The leg patients were either treated with compression stockings (23-32 mmHg) or with inelastic bandages (pressure 53-88 mmHg). Water-displacement volumetry and measurement of leg circumference was performed before and after compression., Results: In the arm-patients low pressure after 2 hours achieved a higher degree of volume reduction (-2.3%, 95% CI 1.0-3.6) than high pressure (-1.5%, 95% CI 0.2-2.8) (n.s.). In patients with leg edema compression stockings in the range between 20 and 40 mmHg showed a positive correlation between exerted pressure and volume reduction, bandages applied with an initial resting pressure of more than 60 mm Hg resulted in a decreasing volume reduction., Conclusion: There is obviously an upper limit beyond which further increase of compression pressure seems counterproductive. For inelastic bandages this upper limit is around 30 Hg on the upper and around 50-60 mmHg on the lower extremity.

Objectives: To measure the effect on the venous pumping function of a stocking providing a negative pressure gradient with higher pressures over the calf in comparison to a conventional graduated elastic compression stocking (GECS) in patients with advanced venous insufficiency., Design: Experimental study., Material: 30 patients with severe superficial chronic venous insufficiency were enrolled. Two elastic stocking designs exerting a pressure at ankle between 15 and 25 mm Hg were compared; a conventional GECS and a stocking exerting a higher pressure over the calf than over the ankle producing a "progressive" increase in compression (PECS)., Method: the venous calf pumping function was assessed by measuring the ejection fraction (EF) from the lower leg by a plethysmographic method during a standardised exercise. Interface pressure of the 2 compression devices was simultaneously recorded both at B1 = 12 cm above ankle, C = just above widest part of calf., Results: The mean increase of EF produced by PECS was +75% (95 CI 48, 7-101,3) compared with +32% (95% CI 16, 8-48,6) with GECS (P < 0.001). There was a significant correlation between EF and the stocking pressure measured at calf level during standing and walking., Conclusion: Stockings exerting a higher pressure on the calf than on the ankle show a greater efficacy in increasing the venous ejection fraction from the leg., (Copyright © 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Aim: The aim of this paper was to demonstrate the usefulness of magnetic resonance imaging (MRI) for detecting the ability of compression material in narrowing superficial and deep veins in the lower extremity., Methods: MRI of the legs was performed in one healthy volunteer and in 11 patients with CEAP C2-C4 without and with different kinds of compression devices. The cross section area of superficial and deep veins was measured by planimetry in mid-calf and mid-thigh slices. The interface pressure of compression was measured at the same level., Results: Examples are presented showing that the narrowing of veins does not only depend on the exerted pressure but also on the body position and the resulting distortion of the tissue. In the prone and the standing position deep veins may show a greater reduction of the cross section area than in superficial veins., Conclusion: MRI is a powerful method to assess venous narrowing by external compression. Especially in the standing position new insights regarding the effects of different compression devices may be expected.

Background: It is widely believed that the loss of compression pressure of inelastic bandages is associated with a loss of efficacy in contrast to elastic material, which maintains its pressure and performance. This study compared the effect exerted by inelastic bandages vs elastic compression stockings on the venous pumping function in patients with severe superficial venous insufficiency immediately after application and 1 week later., Methods: Ejection fraction (EF) of the calf pump was measured in 18 patients presenting with bilateral reflux in the great saphenous vein (CEAP C(3)-C(5)) without any compression and immediately after application of an inelastic bandage on one leg and an elastic compression stocking on the other leg. Measurements were repeated 1 week later, before compression removal. EF was measured using a plethysmographic technique. The changes of interface pressure of the applied compression products were recorded simultaneously with EF measurements., Results: After application, bandages and stockings achieved a significant improvement of EF (P < .001) that was much more pronounced in the bandaged legs. The median resting pressure was 45 mm Hg (interquartile range, 41-48.5 mm Hg) under the stockings and 64.5 mm Hg (interquartile range, 51-80 mm Hg) under the bandages. After 1 week, EF was still significantly improved in the bandaged leg (P < .001), but not under the stockings. At this time, the pressure under the stockings was only slightly reduced (5.9% supine, 3.6% standing), but the mean pressure loss under the bandages was much higher (54.3% supine, 35.4% standing)., Conclusion: The findings supporting inelastic compression are important in explaining the benefits of its use in chronic venous insufficiency. Inelastic bandages maintain their superior efficacy on the venous pumping function after a wearing time of 1 week, despite a significant loss of pressure., (Copyright © 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: A too high resting pressure of compression devices is poorly tolerated and may cause skin defects, especially in patients with concomitant arterial occlusive disease., Aim: To investigate whether low compression pressure will improve venous pumping function in patients with venous incompetence., Material and Methods: Venous pumping function was assessed in 20 patients with severe reflux in the great saphenous vein by measuring ejection fraction (EF) using strain-gauge plethysmography. Measurements were repeated after application of knee-high medical compression stockings and of inelastic bandages applied with a pressure of 20, 40 and 60 mmHg in the supine position., Results: EF was significantly reduced compared with healthy controls. Compression stockings exerting a median pressure of 27 mmHg (interquartile range [IQR] 25-29) in the supine and 30.5 mmHg (IQR 28.25-34.25) in the standing position produced a moderate, non-significant improvement of EF of 17%. Inelastic bandages with a resting pressure of 20.5 mmHg (IQR 20-22) in the supine position resulting in a standing pressure of 36 mmHg (IQR 33-40.75) led to a significant increase of EF of 61.5% (P < 0.01). A further increase of the resting pressure to 40 and 60 mmHg achieved an increase of the EF of 91% and 98%, respectively (P < 0.001)., Conclusions: In patients with venous pumping failure, inelastic bandages produce a significant pressure-dependent increase of EF. A significant improvement in venous pumping function was achieved with inelastic bandages even at a resting pressure of 20 mmHg.

Aim: Methods to compress thigh veins effectively after venous surgery or endovenous procedures are still disputed. The aim of this paper was to compare the clinical outcomes with three different compression devices as a function of the pressures exerted., Methods: Fifty-four patients undergoing invagination stripping of the great saphenous vein and side branch evulsion under local anaesthesia were treated postoperatively in sequential order by 1) thigh length compression stockings; 2) adhesive bandages; and 3) newly developed eccentric compression pads fixed with tapes and a thigh length stocking on top. Sub-bandage pressures were measured at mid-thigh level under these devices after application and one week later before compression was removed. Pain, hematoma, bleeding through the bandage, discomfort and skin irritations were recorded and rated as major or minor adverse events., Results: The lowest sub-bandage pressure of around 15 mmHg at thigh level in the lying position were found in group A under the compression stockings, which nominally provide 23-32 mmHg at ankle level. Group B and group C showed significantly higher values (median values of 47 and 68 mmHg respectively in lying position, P<0.001). The median pressure values in the three groups upon standing were 16 mmHg, 63 mmHg and 98 mmHg. One week later there was a pressure-drop in the lying position in the three groups of 13%, 64%, and 46% respectively. Major adverse events were seen in a total of 10 of 18 patients in group A, in 1/18 in group B, and in 0/18 in group C. Minor adverse events in the three groups consisting mainly of light discomfort for compression devices and local skin irritations were observed in 6, 6 and 15 cases respectively., Conclusions: The best results with respect to the reduction of pain and hematoma were obtained when eccentric compression pads were taped to the skin of the thigh and a compression stocking was worn on top. A possible explanation for these observations is the very high local pressures under the eccentric device.

The aim of this overview is to discuss the role of thigh compression for the management of venous and lymphatic diseases. The most important indications for thigh compression are prevention and treatment of sequelae of superficial vein procedures (surgery or endovenous procedures), prevention and therapy of deep vein thrombosis (DVT), post-thrombotic syndrome and lymphoedema. The intended effects depend mainly on narrowing/occlusion of deep and superficial veins on which the body position and the applied pressure play a crucial role. While in the horizontal position thigh veins can be narrowed by the light pressure of a thromboprophylactic stocking, much higher pressure is needed to compress thigh veins effectively during standing and walking. This is shown by magnetic resonance imaging (MRI) performed in the supine and upright position. Using pads, rolls or specially designed devices, the local pressure under conventional compression garments or bandages over a treated vein can be increased considerably. In patients with deep valve incompetence, beneficial haemodynamic effects of strong thigh compression have been demonstrated, but clinical studies in this field are still lacking. Thigh compression reduces oedema in patients with DVT and lymphoedema.

Aim: To investigate the influence of compression bandages, manufactured using materials with different elastic properties, on the impaired venous pumping function in patients with venous insufficiency., Methods: Ejection volume (EV) and ejection fraction (EF) were measured using strain gauge plethysmography distal from the patella without and with elastic and inelastic compression bandages in a total of 30 patients with major venous reflux in the great saphenous vein. The interface pressure of the bandages was measured simultaneously in the medial gaiter area. Normal values of EV and EF were obtained from 15 healthy controls., Results: Patients with venous insufficiency showed a statistically significant reduction of EV and EF compared to controls. Elastic bandages with an average pressure of 42 mm Hg in the supine position achieved a moderate increase of EV and a significant improvement of EF (p < .01), while inelastic bandages applied with comparable resting pressure (41 mm Hg) raised EV and EF into a normal range (p < .001). The improvement of the ejection fraction correlates well with the pressure differences between standing and lying (Static Stiffness Index) and between muscle systole and diastole during exercise (Pearson r = 0.69 and 0.74 respectively, p < .001). Elastic bandages applied with high stretch in order to achieve standing pressures comparable to those of inelastic bandages (>60 mm Hg) led only to a minor improvement of the venous pumping function., Conclusions: Ejected volume and ejection fraction, which are severely reduced in venous insufficiency, can be increased by compression therapy. Inelastic compression is much more effective than elastic bandages, and is able to normalize venous pumping function. With elastic bandages EV and EF always remain below the normal range even when applied with high stretch producing a resting pressure that is barely tolerable.

Objectives: To assess the validity of measuring changes of sub bandage pressure and leg circumference in different body positions for an in vivo characterization of the elastic properties of bandage systems., Design: Experimental study., Materials and Methods: Different compression bandages were applied on the leg. The variations of interface pressure and leg circumference above the inner ankle (that depends on the elastic property of the bandage) were measured simultaneously by a pressure transducer and by strain-gauge plethysmography in 50 patients. Stiffness is defined as the increase of pressure per increase of circumference., Results: The most consistent parameter to differentiate elastic from inelastic bandages was the pressure-difference between the standing and the lying position corrected for the actual increase of leg circumference (modified static stiffness index, mSSI; sensitivity and specificity 100%). Neglecting the individual changes of the circumference and considering the pressure difference alone allows a differentiation which is slightly less accurate (sensitivity 100%, specificity 88%) but much simpler to use., Conclusions: The static stiffness index is a useful tool to differentiate elastic from inelastic bandage material even without correction for the individual increase of leg circumference.