by Terri Morrison RN, BS, CEO, Morrison Vein Institute
Do we have evidence-based studies on compression therapy post-venous procedures? Do we have guidelines? Yes and yes. Let’s take a brief look at the literature for support.
For compression therapy to be effective for CVI , chronic vein disease or post procedures, there must be an understanding of the venous system as well as graduated medical support stockings. Simply put, misdirected blood cannot get out of the legs unless we elevate them or wear 30 mmHg graduated support hose. Compression limits or prevents leakage of blood into the surface venous system during calf muscle contraction, so it will not leak out to the superficial system. The compression pressure or mmHg must exceed ambulatory venous pressure so blood will go up in the deep system to the heart. This improves calf muscle pump function and reduces excess venous and interstitial fluid volume-capacity, increasing absorption of tissue-fluid by the capillaries and lymphatic vessels.
“Compression stockings help prevent swelling from CVI and the post-procedure inflammatory process. Why do we care? Post-treatment inflammation may be the cause of matting and angiogenesis. How do we control the inflammatory response? Compression has an anti-inflammatory action at the perivenous space.”
Partsch H, editor: Evidence Based Compression Therapy. An Initiative, of the International Union of Phlebology, Vasa34, 2004; Goldman MP, Bergan JJ, Guex JJ: Sclerotherapy Treatment of Varicose and Telangectatic Leg Veins,ed 4, Philadelphia, 2007, Mosby/Elsevier.
“Daily experiences have taught us that strong compression after surgery and after endovenous procedures of large veins reduces pain, inflammation and hematoma formation more effectively than low compression. Sclerotherapy is meant to cause endothelial destruction, resulting in inflammation and then closing down of the vein. Staining, thought to develop as endothelial destruction depending on its degree, allows for extravasation of RBCs through the damaged vessel wall. Resulting inflammation contributes to the ineffective digestion or hemolysis of iron blood products such as hemosiderin and ferritin. These are thought to be insoluble or indigestible residues of hemoglobin. The extravasation of the blood and blood products is most likely in those vessels under significant gravitational pressure or injection pressure. We need to take a look at what causes staining and then the possible methods to avoid or minimize it.”
Sclerotherapy Treatment of Varicose and Telangiectatic Leg Veins by Dr. S.M. Goldman, J. Bergan and J.J. Guex, and Vein Diagnosis and Treatment, A Comprehensive Approach by Drs R. Weiss, M. Weiss and C. Feied.
“The causes of staining, then, are thought to be both in the technique of the sclerotherapy and the intrinsic qualities of the patent. The factors related to the sclerotherapist are: vessel chosen, the solution, the concentration of the solution, the injection pressure exerted and the immediate post-injection
compression (both manually and then with support hose). The factors related to the patient are: vessel depth, diameter, wall fragility, total body iron stores, altered iron transport mechanisms, histamine sensitivity or release, post-treatment compression compliance and concurrent medicines.”
Post Sclerotherapy Hyperpigmentation: Can It Be Prevented? Kathy Melfy, BSN, RN Co-Chair ACP Nursing Section and Nick Morrison MD: ACP Vein line
“Compression treatment with medical compression stockings may improve the result of the treatment of spider veins.” In response, the frequency of pigmentations decreases significantly. The local eccentric compression significantly increases the local pressure in the area of sclerotherapy and improves the efficacy of sclerosis.
Goldman PM, Beaudoing , Marley W, Lopez L, Butie Compression in the treatment of leg teleangiectasia: a preliminary report. J Dermatol Surg, Oncol 1990; 16:322–5. Weiss RA, Sadick NS, Goldman MP, Weiss MA. Post-sclerotherapy compression: controlled comparative study of duration of compression and its effects on clinical outcome. Dermatol Surg 1999; 25:105–8. . Massay RA. Regarding the use of compression stockings after sclerotherapy. Dermatol Surg 1999;25:517.
“Medical compression made of elastics with cotton, Lycra, spandex and newer high-tech fabrics is graduated, with the strongest support starting at the ankles and feet and gradually decreasing towards the top of the garment. This gradual support works in conjunction with the pumping action of the calf muscles. The hemodynamic effectiveness of the various compression materials is determined by the degree of stiffness, which can be characterized as the ratio of maximum working pressure (pW /pR) while standing.”
Phlebology 2007; 36 197-204
How long do I have to wear compression stockings?
Monkey Survey answer:
44% of the ACP nursing section said three weeks after cosmetic injections, and 27% said two weeks. “Wearing compression stockings 23-32mm Hg for three weeks enhances the efficacy of sclerotherapy of leg telengectasias by improving clinical vessel disappearance.”
Compression after sclerotherapy for telangiectasias and reticular leg veins: A randomized controlled study Philippe Kern, MD, Albert-Adrien Ramelet, MD, Robert Wütschert, MD, and Daniel Hayoz, MD, Vevey, Lausanne, and Neuchâtel, Switzerland ( J Vasc Surg 2007;45:1212-16); Efficacy of Graduated Compression Stockings for an additional 3 weeks after Sclerotherapy Treatment of Reticular and Telangiectatic Leg Veins, 2008, Dermatologic Laser associates of La Jolla, Inc., with a research grant from Sigvaris and Medi, USA.
What compression strength should we use after leg vein sclerotherapy?
Answer: 42% of the ACP nursing survey said 20-30 mmHg, 33% said 30-40 mmHg. Most medical compression stockings exert a pressure between 15 and 40 mm Hg on the distal leg. “Thirty mmHg support stockings worn for three weeks post sclerotherapy has been researched in the United States and found to be not only effective for closing veins immediately post injection, but also for better long-term outcome.”
Post-Sclerotherapy Compression: Controlled Comparative Study of Duration of Compression and Its Effects on Clinical Outcome. Dermatologic Surg., 1999; 25:105- 108; Core Curriculum for Phlebology Nurses, ACP
Since sustained external compression pressure should never exceed the intraarterial pressure, the patient is evaluated for arterial disease (Doppler ankle brachial pressure index, ABPI) prior to sclerotherapy or any ablative procedures before prescribing a post-treatment compression regimen. Stiff/short stretch materials with reduced pressure (15-30 mmHg) may be used post procedure for ABPI: 0,6-1,0; whereas for ABPI of 1,0- 1,3, there is no contraindication for compression. “Compression therapy will only work when the compression device is worn. Non-adherence is the most important factor limiting the effectivity of compression therapy.”
Partsh H, Rabe E, Stemmer R: Compression therapy of the Exremities, Paris, 1999, Editions Phebologiques Francaises.
To overcome this problem, the most important elements are adequate education and counseling of the patient, especially when treatment is started for the first time.
If phlebology providers believe in the effectiveness of compression sclerotherapy, wear compression stockings or hose themselves in the office, and help patients with donning and doffing techniques (e.g., rubber gloves, butler applicator, Slippie gator, etc.), practitioners will have better compliance results with their patients. If this minimizes staining, matting, and improves long-term outcomes, then we and our patients will be happier.
With the ACP’s recent election of a delegate to the International Compression Society, under the guidance of Drs. Hugo Partch of Vienna and Giovanni Mosti from Italy, we may strengthen compression standards and eventually reach a consensus regarding compression therapy in phlebology.