Footprint of a Giant

After researching and speaking with Dr. Hugo Partsch, it’s difficult to say what is most impressive about him. His contributions to the fields of phlebology, angiology, lymphology and dermatology are renowned. But what captivates us most is that despite his earning a reputation globally as a thought leader across several disciplines and having leadership roles in multiple medical congresses and societies, very little can be found about Dr. Partsch beyond his body of work—a body of work which has likely touched every venous and lymphedema specialists.

You won’t find any attempts at self-promotion, and although he has spoken at countless scientific meetings, there are very few past interviews to draw from. The few that are available are decidedly focused on medical science, and any opinions he provides are backed by evidence gleaned from a lifetime of practice.

In the world of compression, Dr. Partsch is a giant, and one who is leaving an immense footprint on the field. This is why we feel honored and fortunate to have the opportunity to speak with him, and share his thoughts with our readers.

VM: Dr. Partsch, please share with our readers your background and how you came to practice in the field of venous disease.

After studying medicine in Vienna, Austria, Freiburg and Kiel (Germany), I started to work in a district hospital and then at the Wilhelminen Hospital in Vienna, where I received the degree of a general practitioner.

Thereafter, I specialized in dermatology and was appointed Professor of Dermatology at the Medical University of Vienna. I established an outpatient department for vascular diseases at the Hanusch-Hospital in Vienna, and then served as the head of the Dermatological Department of the Wilhelminen Hospital, where I specialized in peripheral vascular diseases for 15 years.

My main interest is peripheral vascular diseases, and my scientific research publications focus on compression therapy and on the diagnosis and management of acute and chronic venous disease, vascular malformations, leg and foot-ulcers and lymphedema.

I am honorary president of the International Union of Phlebology and honorary member of several international medical societies. In 2005, I created the International Compression Club (ICC), which is a forum linking medical experts with manufacturer’s representatives in an effort to promote the science behind compression therapy, propose research trials and organize consensus meetings on several important issues like the classification of compression material and evidence-based indications for compression treatment.

VM: There have been some recent studies that have created confusion as to the effectiveness of compression therapy in the treatment of edema, CVI, DVT and other venous-related diseases. Can you share your thoughts on this?

Some studies have raised doubt on the efficacy of external compression in different indications. I would like to mention the so-called SOX trial that was recently published in Lancet. The purpose of this large, randomized multicenter trial was to investigate if elastic compression stockings (ECS) worn for two years after a first, symptomatic, proximal deep vein thrombosis (DVT) are able to prevent post-thrombotic syndrome (PTS) according to the recommendations in all relevant guidelines.

Patients with a first episode of a proximal DVT were randomized during the treatment phase of their acute DVT into one group that received 30-40mmHg belowknee compression stockings, and into another group that got so-called placebo-stockings (5mmHg). The stockings were sent to the patients by mail so that treatment started after two weeks on average, and the patients were followed up with every six months by local study investigators. At these occasions, the patients were asked for their compliance and the degree of the post-thrombotic syndrome, according to Ginsberg’s criteria (pain and swelling for more than one month), and the Villalta scale was assessed (a sum scale combining subjective complaints and objective signs like swelling, erythema etc.).

After two years, there was no significant difference concerning the cumulative incidence of PTS between active ECS versus placebo. Results were similar in patients who reported frequent use of stockings.

The authors concluded that “ECS did not prevent PTS after a first proximal DVT; hence, the findings do not support routine wearing of ECS after DVT.”

In this study there were, in fact, several points that negatively affected the outcome: Frequent users of ECS were defined as those who used their stockings for at least three days per week at three study visits. This means that this group of “champions of compliance” also included those who had no compression on the leg most of the time (four days per week). I wonder what would have happened if half of the patients also would have taken their warfarin for only half of the time, or even less? Especially in the initial treatment phase, this would have revealed extremely bad outcomes concerning recurrences also leading to PTS, and the conclusion of such a study could hardly be that warfarin does not work.

If proper compression is started during the acute phase of DVT, the patient can feel its beneficial effects immediately. Swelling subsides quickly and the patient is able to walk with less pain. This provides positive motivation and certainly improves the compliance to wear stockings during the following weeks and months. The organizational prerequisite for providing adequate care of acute DVT, not only concerning optimal anticoagulation, but also regarding adequate compression and stocking supply, has been introduced in Europe in the leading centers. At this occasion, the patient is instructed how to don and doff a strong stocking, which is an important stimulus to carry on with wearing ECS. This situation is very much different from receiving a stocking by mail two weeks after DVT, and then being told to wear them for up to two years, without initial assistance. A vein specialist would never prescribe a 30- 40mmHg stocking to be applied by an inexperienced patient without demonstration and verbal motivation.

When patients in the study were asked if they believed to be randomized into the 30-40mmHg ECS group or the placebo group, half of them could not tell. There is only one explanation: they lie and have not even tried to apply the stocking. Everybody donning a 30-40mmHg stocking for the first time would certainly say it is an extremely strong stocking.

As with other Canadian studies, the rate of leg ulcers in the SOX trial in the first month after DVT is amazingly high, which is in contrast with all scientific papers recommending immediate walking with compression in acute DVT cases, which do not report any ulcers up to two years.

VM: What recent studies can you cite that you feel properly represent the efficacy of compression and what were the significant findings?

Here’s one example: Up to now, compression was declared to be a strict contraindication in patients with concomitant arterial occlusive disease (AOD). In contrast to this dogma, several studies have shown that compression is able to increase arterial flow, not only in healthy persons, but also in patients with AOD. This is not only true for intermittent pneumatic compression, which led to a recommendation of specially designed pumps even for the severest forms of AOD, but also recently for sustained compression using inelastic material applied with moderate pressure.

Excluding patients with an ABPI of less than 0.5, which is critical ischemia by definition, inelastic bandages not exceeding an initial pressure of 40mmHg not only increase arterial inflow under the bandage, but also improve the venous pumping function in patients with mixed arterialvenous ulceration.

As long as the ABPI is higher than 0.5, such moderately applied inelastic bandages (“modified compression”), together with walking exercises, are therefore the conservative method of choice, at least in those patients in whom arterial recanalization has failed or does not promise to be successful (especially in elderly patients without typical arterial resting pain). The term “modified compression” also includes daily bandage changes in the initial treatment phases, allowing close inspection of the skin concerning any potential pressure damage.

VM: What types of studies would you like to see in the future and how would you like to see them administered?

Prerequisites for a good compression study promising reproducible results include a clear definition of the compression product used, and the declaration of the pressure exerted in resting and standing position and during walking.

Consensus papers concerning the classification of compression bandages and on the in-vivo measurement of compression pressure and recommendations on how to test new compression products, were worked out by groups of international experts and can be found at www. These papers are helpful in order to use commonly agreed upon terminology—for example, the terms “stiffness,” “elastic and inelastic,” or the definition of “mild, moderate and strong pressure.”

For trials assessing compression stockings, the dosage of compression should be measured on the tested leg and not just rely on the information given by the producers based on the individual leg size. As repeatedly discussed in recent ICC meetings, it would also be desirable to get information from the stocking producers regarding the stiffness of their products. Stiffness is defined by the increase of compassion pressure when the calf muscle contracts by standing up or walking. Stiff materials provide “intelligent compression” because they exert high pressures when it’s needed during standing and walking by compensating the higher intravenous pressure in these body positions. In the resting position, their pressure is low and tolerable.

Instruments to check the individual patient’s compliance would be highly welcome.

As with new drugs, the producers of new compression devices should consider experimental “phase I” studies before they undertake clinical trials to assess the principle efficacy of a new device in a special dosage.

VM: In one of your reviews in the Annals of Vascular Diseases on PubMed*, Compression Therapy: Clinical and Experimental Evidence, you cite the lack of compression having to pass any pharmacological trials to confirm clinical efficacy and therapeutic dose range. How significant of a step would this be toward ending the debate regarding efficacy and what factors should be included in phase I and phase II studies of this nature?

Usually the efficacy of compression is assessed only by clinical studies, for which ulcer healing is the most used model indication. Although ulcer healing is an extremely relevant and clear-cut outcome parameter, such trials may be confounded by many circumstances, especially concerning different underlying conditions from the side of the patient, as well as from the skill and experience of the treating physician. Pre-clinical studies, focusing on objective outcome parameters that can be measured experimentally, have revealed important new insights and led to a list of requirements defining an optimal compression device.

Today, we are able to measure the dose of compression, which is the compression pressure, at different sites of a diseased leg, and at the same time we can also quantify the corresponding effects concerning reduction of edema by volumetry or of venous caliber changes, separately for superficial and deep veins by MRI. Dynamic parameters like venous reflux or venous pumping function can be assessed by Duplex, venous pressure measurements or plethysmographic methods. By using all these methods, we are able to establish a “dose-response relationship” regarding compression and its effects on edema reduction and improvement of venous pump function.

As an example to emphasize the value of preclinical compression studies, TED stockings have been used not only for thromboprophylaxis purposes during bedrest, but also by some surgeons after varicose vein intervention in ambulant patients. By MRI investigations, it could clearly be shown that such stockings exerting 18mmHg at the ankle, and 5-10mmHg at most at the thigh level, are able to narrow superficial and deep veins in the horizontal position, justifying the assumption that they would accelerate blood flow velocity. However, this is not the case in the upright position, since much higher pressure is needed to empty the filled veins. No wonder that clinical studies with such light stockings after varicose vein treatment were negative. The money spent to perform such negative studies could have been saved.

VM: In an article published in the Journal of Vascular Surgery that you co-wrote with Dr. Giovanni Mosti, it was noted that inelastic bandages maintain their hemodynamic effectiveness over time despite significant pressure loss. Your results highlighted the effectiveness of inelastic bandages in the treatment of CVI and DVT. Can you summarize your findings for us?

Every compression device loses pressure with time, mainly due to the induced edema reduction of the treated extremity. This pressure loss is especially seen with inelastic material, and is less observed with elastic textiles and compression stockings.

The pressure loss of inelastic bandages is more pronounced in the resting position than in the standing position, because stiff, inelastic material exerts higher pressure during muscle contraction than in the relaxed, resting position. This explains the fact that after wearing inelastic bandages over a period of one week, they still have more effect concerning an increase of the calf muscle pump than compression stockings, despite a pressure loss of more than 50%, resulting in a resting pressure at that time, which is even lower for the bandage compared to stockings. This shows that inelastic material is hemodynamically more efficient than elastic material (e.g. compression stockings) when applied with the same or even lower resting pressure.

VM: Do you feel that the effectiveness of inelastic bandages is misunderstood?

Certainly, both the kind of application and the effectiveness of inelastic bandages are widely misunderstood. During application of inelastic bandages, the pressure of the bandage mainly depends on the manual strength of the bandager, in relation to the local curvature of the extremity. Taking into account the immediate pressure loss, an initial pressure of around 60mmHg is recommended in normally sized legs with unimpeded arterial circulation.

Due to Laplace´s law, large legs need more power to achieve this pressure than small legs. Some exercise of the bandager, supported by practical demonstration by experts or by using a pressure measuring instrument, is required to obtain this pressure. Several studies checking the skill of bandagers revealed that most inelastic bandages applied— even by experienced nurses—are applied too loosely. This is obviously also the main reason that in several comparative studies, inelastic material revealed a poorer outcome than bandages containing elastic material.

Correctly applied short stretch material provides a stronger massaging effect when the calf muscle contracts during walking, and leads to a more intense improvement of the venous pumping function .At the same time, the pressure in the resting position is much lower and well-tolerated.

This does not mean that inelastic material works only during exercise and has no effect in immobile patients. To prevent lower leg edema in wheelchair patients, a pressure of 40mmHg in the sitting position is sufficient. Additional active or passive dorsiflexions of th ankle or toes will create intermittent pressure peaks, acting like a massage.

In America, Unna boot bandages, named after the German dermatologist Unna who invented zinc paste, received some reputation, especially for ulcer treatment. However, such bandages are usually applied with very light pressure and would be much more effective if they would be carefully modeled exerting initial pressures of around 60mmHg. The European tradition of strong inelastic bandaging was imported to the new world, mainly by the different schools for lymphedema treatment, using short stretch bandages incorporated into the concept of decongestive lymphatic therapy (DLT).

VM: Are there new advancements in compression that you feel are significant?

Advances in compression therapy relate more to better understanding and use of existing materials, including some new variations, than to the development of new products.

The main merit gained from new products is easier handling and self-applicability, leading to increased compliance. Examples are Velcro strap devices, which can be applied and readjusted by the patients themselves. Such devices are a very good alternative to make use of the advantages of inelastic compression without the need for specialized and experienced medical staff.

Other examples are the development of two-component bandages, using cohesive material to cover the underlying “comfort layer,” or socalled adaptive compression therapy (ACT), which uses a combination of sustained and intermittent compression provided by air-filled cuffs around the leg. This helps keep the pressure at a constant level.

VM: In your studies with respect to DVT, mobility combined with compression and anticoagulants has netted great success in patient recovery. Do you feel the community is aware of these results and if not, what studies should they be referencing to get up to speed?

In mobile patients with deep vein thrombosis, we recommend walking exercises supported by good compression, in addition to exact anticoagulation. This regime reduces pain and swelling immediately and has been adopted by most centers in Europe. A continuation of compression for the subsequent months has shown that the incidence of post-thrombotic ulcers could be drastically reduced.

As a consequence from the controversies with the SOX trial, it would be important to have studies that clearly report the clinical signs and symptoms by using CEAP, VCCS and QOL, including quantitative parameters like leg volume, thrombus extension, Lowenberg test and pedometer, starting from the acute stage of DVT and registered at any follow-up visit.

In general, it needs to be underlined that good compression should always be combined with walking exercises in order to optimize its effectivity. Inelastic, stiff compression material will achieve high pressure peaks with every step when the calf muscle contracts. The resulting massaging effect can be compared with the effect of an intermittent pneumatic pressure pump, stimulating shear stress in the microcirculation and consequently promoting the release of anti-inflammatory, antithrombotic and vasoactive mediators from the endothelial cells.

VM: The challenge of patient compliance with compression use is ongoing. Are there any particular methods or strategies that you can share to help other doctors increase patient compliance?

The most important way to improve patient compliance with compression therapy is to make sure the patient understands its beneficial effects, particularly as it relates to relief of pain and swelling. If the patient experiences improvement, he or she will be motivated to continue compression.

Diaries should be filled out daily by the patient, or the use of thermo-probes may be used in the context of clinical trials. The patient’s confidence may be gained more easily by starting treatment using fixed compression bandages, which will stay on the leg for a determined amount of time, and to continue with stockings when the patient has experienced improvement. Fixed bandages have also an advantage, in that compliance is not an issue as long they stay on the leg.

VM: Are there any other topics that you would like to discuss or expand on that will help the readers improve their knowledge of compression or venous disease in general?

It is important to note that, especially in the more advanced stages of venous disease—like in CEAP C3- C6, but also in the acute phase of deep and superficial vein thrombosis—good compression therapy remains a cornerstone of conservative management. This is also true for lymphedema and for all its non-lymphatic precursors like chronic venous edema and edema in connection with morbid obesity and immobility.

Future studies would be especially desirable concerning the effects of compression on inflammation, on lymphatic drainage, its connection with immunological factors and on tissue composition, including fatty tissue.

Compression therapy is still an underestimated and underused treatment modality that is frequently delegated to inexperienced staff, where it is performed as a kind of alibi treatment in a very inappropriate fashion. Better understanding of this important managing tool should be spread in the field of theoretical and practical education in medical training centers and postgraduate courses, especially in the field of vascular medicine.