Indications for Compression Therapy 2008

Indications for compression therapy in venous and lymphatic diseaseConsensus based on experimental data and scientific evidenceUnder the auspices of the IUPEditorial Committee: H. PARTSCH (Chairman); M. FLOUR, P. COLERIDGE SMITH (Co-Chairpersons).Members: J. P. BENIGNI, A. CORNU-THÉNARD, K. DELIS, M. GNIADECKA, F. MARIANI, G. MOSTI, H. A. M.NEUMANN, E. RABE, J. F. UHL.Faculty*: A. C. BENHAMOU (France), J. P. BENIGNI (France), D. BRANDJES (The Netherlands), A. CAVEZZI(Italy), M. CLARK (UK), P. COLERIDGE SMITH (UK), A. CORNU-THÉNARD (France), K. DELIS (Greece), M.FLOUR (Belgium), M. GNIADECKA (Denmark), F. MARIANI (Italy), G. MOSTI (Italy), H. A. M. NEUMANN (TheNetherlands), E. RABE (Germany), J. SCHUREN (Germany), J. F. UHL (France).Corresponding Faculty*: M. ABEL (Germany), R. BOT (The Netherlands), S. BRISKORN (Germany), C. GAR-DON-MOLLARD (France), J. HAFNER (Switzerland), J. HUTCHINSON (UK), K. ISSBERNER (Germany), D.KOLBACH (The Netherlands), E. KÜPPERS (Germany), K. LUTTER (Germany), S. LEAPHART (USA), U. MEYER(Germany), J. LEAL MONEDERO (Spain), C. MOFFATT (UK), H. SCHEPERS (Switzerland), S. SHAW (USA),N. VELAZQUEZ (Spain), A. VIRKUS (Germany).

Aim. The aim of this study was to review published litera-ture concerning the use of compression treatments in themanagement of venous and lymphatic diseases and esta-blish where reliable evidence exists to justify the use ofmedical compression and where further research is requi-red to address areas of uncertainty.Methods. The authors searched medical literature databa-ses and reviewed their own collections of papers, mono-graphs and books for papers providing information aboutthe effects of compression and randomized clinical trialsof compression devices. Papers were classified in accor-dance with the recommendations of the GRADE group tocategorize their scientific reliability. Further classificationwas made according to the particular clinical problem thatwas addressed in the papers. The review included paperson compression stockings, bandages and intermittent pneu-matic compression devices.Results. The International Compression Club met once inVienna and corresponded by email in order to reach anagreement of how the data should be interpreted. A widerange of compression levels was reported to be effective.Low levels of compression 10-30 mmHg applied by stockingsare effective in the management of telangiectases after scle-rotherapy, varicose veins in pregnancy, the prevention ofedema and deep vein thrombosis (DVT). High levels of com-pression produced by bandaging and strong compressionstockings (30-40 mmHg) are effective at healing leg ulcersand preventing progression of post-thrombotic syndromeas well as in the management of lymphedema. In some areas

no reliable evidence was available to permit recommenda-tions of level of compression or duration of treatment. Theseincluded: management of varicose veins to prevent pro-gression, following surgical treatment or sclerotherapy forvaricose veins, and the level of compression required totreat acute DVT.Conclusion. This review shows that whilst good evidencefor the use of compression is available in some clinical indi-cations, there is much still to be discovered. Little is knowabout dosimetry in compression, for how long and at whatlevel compression should be applied. The differing effectsof elastic and short-stretch compression are also little under-stood.[Int Angiol 2008;27:193-219]

Key words: Vascular diseases - Lymphedema - Venous throm-bosis - Stockings, compression - Bandages - Intermittentpneumatic compression devices - Review.

Compression therapy is recognized as an effec-tive treatment in the management of venous andlymphatic disease since thousands of years . Untilrecently evidence of efficacy was based on empi-rical study and little objective research had beenperformed. More detailed information has nowbeen obtained from published clinical series andrandomized controlled trials. These have beensummarized in books and monographs.1-8 Natio-nal and international guidelines on compressiontreatment have been published by a number ofdifferent societies.9-15 Many of the publishedrecommendations which suggest particular levels

Vol. 27, No. 3 INTERNATIONAL ANGIOLOGY 193

CONSENSUS STATEMENT

Funding.—We gratefully appreciate the support of the fol-lowing companies*: 3M, Bauerfeind, ConvaTec, CircAid Medi-cal, Ganzoni, Gibaud, Gloriamed, Paul Hartmann, HNE,Innothera, Lohmann & Rauscher, Medi, Orthofix, SalzmannMedico, Varitex.*Members of the International Compression Club (ICC).

194 INTERNATIONAL ANGIOLOGY June 2008

of compression to be used in specific indicationsare based on the experience of the authors ratherthan on evidence from clinical trials.16, 17

The main aim of this document is to give anoverview of existing knowledge, identifying areasof knowledge where good scientific evidence isavailable from clinical trials and areas for whichlittle or no evidence is available and which shouldbecome the subject of future research.

Materials and methods

The International Compression Club (ICC) isan ad hoc group of experts which includes clini-cians involved in the management of patients withvenous disease as well as technical specialists fromcompanies manufacturing compression devicesfor clinical use. This group was to review and tocomment critically on published literature on com-pression therapy concentrating on two issues:

1. experimental findings concerning clinicallyrelevant effects of compression therapy;

2. randomized clinical trials (RCTs) addressingthe use of compression for particular clinical indi-cations.

The ICC searched medical literature databasesas well as their own collections of papers in orderto find relevant medical literature.

The findings were presented by several mem-

bers of the group and discussed at a meeting ofthe ICC, held in May 2007 in Vienna, Austria. Theassessment of the strength of the recommenda-tions from randomized trials was based on thescoring criteria from the international GRADEgroup.18 Thereafter, the data were summarized intables that were circulated among the membersof the ICC by e-mail. The corrected version of thesetables was agreed by a majority of the active par-ticipants at a follow-up ICC meeting, held inNovember 2007 in Paris.

Results

The outcome of this initiative is summarized inTables I and II; details are given in the Appendix(Tables IA and IIA) .The tables are structured inalignment with the clinical stages of the CEAPclassification 171 supplemented by the indicationsof deep vein thrombosis (DVT), post-thromboticsyndrome and lymphedema.

A number of different methods of classifyingcompression garments is used and varies fromcountry to country. The tables are constructedusing the interface pressure of medical compres-sion stockings (MCS) given in millimeters of mer-cury (mmHg) ranges to avoid any confusion. Byinternational agreement, compression applied tothe limb by a stocking is calculated from an analy-

TABLE I.—Summary of publications (reference numbers) reporting experimental data with compression therapy. (Fordetails see Table IA in the Appendix).

Experimental effects

Compression stockings

Bandages IPCCompression pressure in mmHg

10-20 mmHg 20-30 mmHg 30-40 mmHg

Edema prevention 19-21 20, 22-24 25

Edema reduction 26, 27 22, 25, 26, 28 29 30-34

Increase venous flow velocity 35 36, 37 38-48

Reduction of venous diameter 49 37 50, 51

Reduction of venous reflux 52-54 53-55

Improvement of venous pump 56-62 58 53, 63

Reduction of ambulatory venous 64 63hypertension

Increase of arterial flow 65 66 67-76Improvement of microcirculation 28, 77-83 79 77, 84-90Improvement of lymph-drainage 91-94 95-97

IPC: intermittent pneumatic compression.


sis of the mechanical properties of the stockingsby manufacturers and not by direct interface pres-sure measurement. The pressure ranges corre-spond to the values that are assumed to be exer-ted on the ankle region based on in vitro measu-rements by the manufacturers for a certain rangeof leg circumferences.172, 173 These pressure ran-ges may not always be exactly the same as thosegiven in the individual publications due to diffe-rent national classification systems.

Intermittent pneumatic compression (IPC) isincluded since it offers an interesting model tostudy physiological effects of compression the-rapy.

Experimental data

Table I presents the summary of experimentaldata describing effects of compression therapy ondifferent physiological parameters. Table IA in theAppendix gives more detailed information. Themain focus of the outcome was put on vascularproblems of the extremities, to some extent sup-plemented by outcomes and findings from resear-

ch into trauma. However, effects of compressionon burns, scar formation or on the general circu-lation were not reviewed.

Several experimental studies demonstrated thatcompression stockings from all three pressureranges considered here are able to prevent and toreduce leg edema.19-29 External pressure increa-ses the tissue pressure.123 Interestingly a low pres-sure around 10 mmHg is enough to impede legswelling in a prolonged upright position.19-21 Dra-matic decrease of edema was also demonstratedafter IPC.30-34

Reduction of venous diameter and increase ofvenous flow velocity depend on the relative valuesof intravenous pressure and compression pres-sure. In the supine position, light antithromboticstockings are able to decrease venous diameterand to increase venous flow velocity.35-37, 49 Somestudies were unable to detect an increase of venousflow velocity by duplex ultrasonography.124-126

There are a number of factors which limits theaccuracy of duplex ultrasound in this application,but it should be noted that peak flow velocity mea-

TABLE II.—Efficacy of compression therapy stockings, bandages and intermittent pneumatic compression by randomizedcontrolled trials and meta-analyses in patients with chronic venous disorders (CEAP), venous thromboembolism andlymphedema. Only strong grades of recommendation: (1A and 1B) are indicated.18 (Reference numbers in brackets.)A complete list is given in Table IIA in the Appendix..

Indications CEAP

Compression stockings

Bandages IPCCompression pressure in mmHg

10-20 mmHg 20-30 mmHg 30-40 mmHg

EC0s, C1s 1B (98, 99)C1 after sclero 1B (100)C2 a,s ? ? ? ? ?C2s pregnancy 1B (101) 1B (101)C3 prevention 1B (21)C3 therapy ? ? ? ? ?C4b 1B (102)C5 1A (103)C6 1B (104-106) 1A (107)After procedures 1B (108) 1B (109)VTE

Prevention 1A (110-112)168 1A (111, 112)Therapy 1B (113, 114) 1B (113, 115, 116)

PTSPrevention 1A (117, 118)Therapy 1B (119)

Lymphedema ? ? ? ?Therapy 1B (120, 121) 1B (122)


sured in this way is a rather poor parameter tocharacterize the mean flow velocity under a com-pression stocking. IPC produced clearly detecta-ble flow acceleration in several experimental stu-dies.38-48 In the upright position, much higherexternal pressures are necessary in order to redu-ce the diameter of leg veins.49-51, 127 This explainsthe fact that reduction of venous reflux measuredin the upright position could only be demonstra-ted under high compression pressure exerted bystrong stockings, bandages or a Velcro-band devi-ce.52-55

Several plethysmographic studies performed inpatients with chronic venous insufficiency showedan improvement of the venous pump was produ-ced by the application of MCS, bandages 56-62 andby a Velcro band device.53

Conflicting results have been reported whenvenous function was assessed by measurement ofambulatory venous hypertension in patients withchronic venous insufficiency. Two studies assessedthe effect of application of strong stockings 64 andby strong short stretch bandages 63 and found areduction of the peak pressure values during walking.Other reports, which measured the reduction invenous pressure during walking were unable to finda significant improvement of ambulatory venoushypertension.59, 124 This example shows that an agree-ment concerning the interpretation of venous pres-sure measurements is still lacking.

The influence of external compression on thearterial flow is a critical issue. In a number of stu-dies performed especially on supine or recliningvolunteers, it was found that a sustained externalpressure >60 mmHg will diminish local bloodflow.128-131 Bandages and elastic wraps exerting apressure of around 30 mmHg do not reduce sub-bandage flow, but diminish toe perfusion.132 Innormal extremities, inelastic bandages with a pres-sure of 38 mmHg increase blood perfusion,66

13-23 mmHg arm-sleeves increase blood flow.65

An impressive series of experiments shows une-quivocally that IPC increases arterial inflow.67-76

Special devices producing short phases of pres-sure waves up to 180 mmHg have been shown toincrease arterial flow, even in patients with arte-rial occlusive disease and in severe stages of ische-mia.69-71, 73-76

Effects of compression on different microcir-culatory parameters have been reported. LaserDoppler flux in the skin increases up to a pressu-re of 20 mmHg in the supine position, and up to60 mmHg in the sitting position.77 MCS are ableto reduce capillary filtration and pericapillaryedema,78-82 to tighten paracellular junctions 83 andto increase capillary density,79, 80 thereby impro-ving tissue oxygenation.81, 82, 84 One study was una-ble to demonstrate a profibrinolytic effect of ela-stic bandages.133

Data from investigation of the microcirculationand release of biomarkers come from studies whereIPC was applied to the extremities.84-90, 134-140 Seve-ral studies describe an increase of capillary per-fusion and of tissue oxygenation,77, 84-87 which isin accordance with the observation of an increa-sed release of nitric oxide,88, 89 with an up regula-tion of the fibrinolytic potential of endothelialcells 88, 136, 137 and with a suppression of procoa-gulant activation.140 Some reports did not find anincrease of fibrinolytic activity after IPC.138, 139 Theincrease of bone mineral density after IPC 134, 135

shows that IPC is able to influence other tissuesof the limbs, and is not limited to effects on theskin microcirculation.

Experimental data concerning the effect of con-ventional compression therapy on lymphedemaare sparse.91-96 IPC is able to reduce the water con-tent of a lymphedematous extremity withoutimproving the lymphatic drainage to an adequa-te amount.95, 96 This leads to an increase of theoncotic tissue pressure 96 necessitating a conti-nuation of compression therapy by bandages andstockings.

Randomized clinical trials

In those areas in which reviews and meta-analy-ses already exist, only papers published after thesereviews were included in Table II.

For the assessment of the RCTs, the recentlyproposed GRADE system to score the recom-mendation-level of each study was used.18 Recom-mendations defined as strong (grade 1) or weak(grade 2) refer to the text in the outcome-column(Table II and Table IIA in the Appendix). The qua-lity of evidence is classified as high (grade A) ormoderate (grade B) according to the study desi-


gn and the consistency of the results. Observa-tional studies or case series corresponding to therecommendation grade C were not taken intoaccount. The ratings were based on the votes ofthe majority of the active participants at the ICCmeetings.

Several RCTs have proved the clinical efficacyof light compression stockings with a pressure<20 mmHg in the following indications:

— improvement of symptoms of venous disea-se, such as heaviness in patients with CEAP C0s-C1s 98, 99 and in varicose veins of pregnancy 101

(Grade 1B);— prevention of leg swelling related to pro-

longed sitting and standing (“occupational legedema”) (recommendation level Grade 1B);21

— prevention of venous thromboembolism inbed-ridden patients, especially after general sur-gery (Grade 1A).110-112, 168

Some trials revealed that low pressure stockingshave no, or only doubtful, benefits following vari-cose vein surgery (Grade 2B).147-149, 151

MCS with a pressure range of 20-30 mmHg pro-duce beneficial clinical effects (Grade 1B recom-mendations):

— after sclerotherapy of small teleangiecta-sias;100

— concerning an improvement of subjectivesymptoms in varicose veins of pregnancy;101

— for the treatment of acute DVT.113, 114

The recommendations for using compressionstockings with a pressure range of 20-30 mmHgin patients with asymptomatic or symptomaticvaricose veins,143, 144 for the prevention of varico-se veins after surgery 146 or of venous edema 24

and for treating venous ulcers 163 are weak (allGrades 2B).

For MCS with a pressure range between 30 and40 mmHg randomized controlled trials could befound allowing strong recommendations:

— better outcome after sclerotherapy compa-red to light bandages;108

— such stockings are able to reduce lipoder-matosclerotic areas on the leg (CEAP C4b) 102 andto heal venous ulcers 104-106 (all Grade 1B);

— MCS reduce the recurrence rate of venousulcers after healing, higher pressure ranges seemto be superior 103, 152 (Grade 1A);

— two studies were able to demonstrate thatthe rate of post-thrombotic syndrome after proxi-mal DVT can be reduced by wearing compressionstockings with 30-40 mmHg for the following years117, 118 (Grade 1A). One three-part study performedin a restricted number of patients failed to showa beneficial effect of stockings 1 year after DVT169 (Grade 2B).

Up to now no convincing data are available sup-porting the use of compression stockings inpatients with post-thrombotic syndrome 119 (Grade2B).

For the use of compression bandages strongrecommendations can be given:

— in patients with venous ulcers (CEAP C6) 107

(Grade 1A);— for the management of acute DVT 113, 115, 116

and lymphoedemaedema 120, 121 (both Grade 1B);— high pressure bandages reduce bleeding

after venous surgery,109 but lose pressure morethan MCS.150 For patient comfort stockings maybe better tolerated than bandages 108, 145 (all Grade1 B).

The classical model to assess the efficacy of com-pression therapy is the venous leg ulcer. In thisindication an extensive Cochrane review showedthat:

— compression is better than no compressionand higher pressure exerted by multilayer ban-dages provides better results than low pressure107, 164 (Grade 1A-C);

— four-layer bandages were shown to be moreeffective than three-155 or two-layer-bandages,156

than the “usual system of care” 157, 164 and thansingle layers of short stretch bandages 158, 161 (Grade1B);

— a Velcro-band device achieved faster ulcer-healing than four layer bandages 162 (Grade 1B);

— several trials did not show significant diffe-rences of ulcer healing rates between four layerand short stretch systems 153, 154, 159, 160, 164 (Grade1B).

For IPC the present level of evidence in ulcerhealing is weak.165-167 Strong levels of evidencesupport the use of IPC:

— in the area of thrombosis prevention aftersurgery 111, 112 (Grade 1A);


— in the treatment of post-thrombotic syn-drome;119

— in lymphedema 122 (both Grade 1B).

Discussion and conclusions

Our analysis focuses on the following three mainpoints which have considerable practical impor-tance:

1. What is the effective range of compressionpressure?

2. Are there differences concerning the modeof action depending on different compressionmaterial?

3. Which are the main points to be investiga-ted in future research?

These points are discussed on the basis of thepresented data, both concerning experimental andrandomized clinical studies.

Compression pressure

The levels of compression which have beenshown to be effective in different experiments arein the range between 5-10 mmHg and >120 mmHg.It is crucial to differentiate between sustained andintermittent pressure. Data from studies of theskin microcirculation show that ischemic skindamage may result from high levels of compres-sion applied for a long period of time. Dependingon the body position and the particular anatomi-cal location of the compressed skin, a sustainedpressure of 60-70 mmHg may be considered as amaximum upper limit, especially over bony pro-minences in patients with normal arterial circu-lation.128-130

In contrast, experiments with intermittent pneu-matic pumps have demonstrated an increase ofarterial blood flow using short-duration pressurepeaks >120 mmHg followed by intervals of lowpressure. These findings have been obtained involunteers with normal arterial circulation as wellas in patients with arterial occlusive disease.67-76

It was found that the relative increase of arterialflow was more pronounced in the upright (sitting)position than in the supine position.67

Light stockings (10-15 mmHg) have been repor-ted to provide beneficial effects through reduc-

tion of edema formation after prolonged sittingand standing, and an increase of venous bloodflow velocity in the supine position.19-21, 35 Theycan also be used as a “liner” to keep local ulcerdressings in place. A second stocking applied overthis liner has been introduced by some compa-nies as a special kit for treating venous ulcers.

In the upright position, higher pressures weremore effective with regard to narrowing of legveins, the decrease of venous reflux and the enhan-cement of venous pump function in patients withchronic venous insufficiency.51, 53-55 Some experi-ments were able to demonstrate a dose-responserelationship between the interface pressure andan experimental effect. High pressure, but not lowpressure, is able to reduce ambulatory venoushypertension.63

Intermittent compression not only improvesarterial inflow and microcirculation, but also hasprofound effects on the release of anti-inflam-matory, vasoactive and anticoagulatory mediatorsand substances.88-90, 136, 137, 140

Compression material

The elastic properties of the compression devi-ce play a crucial role in the relationship betweensustained (resting) pressure and the pressureduring standing and walking (working pressu-re).

A sustained pressure that is maintained day andnight is achieved by material containing elasticfibers (MCS, long-stretch, elastic bandages) whilestiff and short stretch material exerts a lowerresting pressure and high pressure peaks duringwalking, comparable to the action of intermittentpressure pumps which produce peaks by inflationof inelastic cuffs. MCS that exert a pressure of 40mmHg and more are not only difficult to apply,but in most cases also not well tolerated duringrest. If a pressure of >40 mmHg is required, it maybe preferable to achieve this with material withhigh stiffness, such as inelastic, short-stretch ban-dages, multilayer bandages or adhesive or cohe-sive bandages.

Some experiments have shown that in spite ofexerting the same resting pressure, inelastic ban-dage systems or Velcro-band devices achievemore-pronounced hemodynamic effects than ela-


stic material.53, 54 This can be explained by thehigher pressure peaks (working pressure) underthe inelastic material. With inelastic bandages,pressure peaks of 80 mmHg and more can bemeasured during walking. When the patients liedown the pressure will decline to a resting pres-sure of about 40 mmHg which is tolerable.174 Themost impressive demonstration of hemodyna-mic effects comes from experiments with inter-mittent pneumatic pumps, which can be consi-dered as models for walking with completely ine-lastic devices.

Comparisons between different compressionmaterials have been done principally in studiesinvolving patients with venous leg ulcers. It mustbe kept in mind that the application techniqueand the pressure exerted vary enormously depen-ding on the skill and the experience of the ban-dager. This is an important consideration whenevaluating studies comparing different kinds ofcompression bandages. Another important pointto be considered is possible misleading reportingin some trials, for instance when the use of a localulcer dressing together with one padding layerand one bandage layer is declared as a “three-layerbandage”. The best healing rates of venous ulcersreported to date were obtained by multilayer ban-dages expected to exert pressures of ≥40 mmHg(Grade 1A).107 In recent years, several RCTs havebeen published demonstrating better healing rateswith specially designed double-layer compressionstockings in comparison to different compressionbandages (Grade 1B).104-106, 163

Randomized controlled trials proving the cli-nical efficacy of IPC exist especially for the indi-cation of mechanical prevention of venous throm-boembolism (Grade 1A) 110-112 and for lymphede-ma (Grade 1B).122 Specially designed IPC systemshave shown promising results in patients witharterial occlusive disease.69-71, 73-76

Areas of poor knowledge (future studies needed)

EXPERIMENTAL DATA DEFICITS

Some areas in which future experiments shouldclarify open questions or endorse sparse existingobservations are summarized below:

— relationship between pressure/material/time(=dose) and volume reduction (=response) in thetreatment of edema, initial phase and mainte-nance phase of therapy, level and duration ofsustained and intermittent pressure;

— mechanism of action of different kinds ofpressure applications, effects on the physical andbiochemical properties of different tissue com-partments and on lymph-drainage;

— dose-response relationship for different pres-sures and materials on venous reflux, venous pumpand ambulatory venous hypertension;

— influence of MCS and bandages on the arte-rial circulation;

— influence of MCS and bandages on themicrocirculation, on endothelial cells, cytokines,and mediators (some data are available after IPC);

— rationale for pressure gradient in differentbody positions;

— local increase of pressure by positive eccen-tric compression: what is the experimental prooffor the efficacy of local pressure pads?

— loss of interface pressure over time with dif-ferent compression materials, correlated withchange of efficacy.

NEED FOR RANDOMIZED CLINICAL TRIALS

In general, the pressure of the compression devi-ces tested for different indications is only vaguelydescribed in the existing RCTs. In the case of MCSa compression class or a pressure range indica-ted by the manufacturers is usually given, but thepressure exerted on the individual leg remainsunclear. This is even more of a problem with com-pression bandages. There are hints coming fromexperimental and from clinical trials that the cli-nical effect of a compression product will chan-ge with the exerted pressure, which thereforeshould be measured in future trials.174

Indications in which the efficacy of compres-sion therapy is not yet well documented by RCTscorrespond to the white areas in Table II and arelisted below:

— symptomatic and asymptomatic varicoseveins (CEAP C1, C2, a,s): is compression therapyable to prevent progression and complications?

— what is the role of compression in the mana-gement of venous edema (C3)?

— sclerotherapy and interventional procedu-res of varicose veins: the quality of the compres-sion products in the reported trials is often que-stionable and the outcome parameters are weak.Up to now, no single trial compared compressionversus no compression following removal of vari-cose veins (C2) or refluxing veins (C3-C6) by sur-gery or endovenous procedures;

— optimal compression therapy for the ambu-lant management of acute DVT, adjusted to thelevel and extent of DVT and to the mobility of thepatient;

— superficial phlebitis: no single RCT demon-strates the effect of compression;

— role of compression therapy in the mana-gement of post-thrombotic syndrome;

— lymphedema: most existing RCTs comparecompression as one element of complex physicaldecongestion therapy with the same basic treat-ment in addition to another modality;

— correlation between pressure (measured invitro and in vivo) and clinical effects (reductionof edema, improvement of lipodermatosclerosis,healing rate of venous ulcers, recurrence rate afterulcer healing, improvement of pain and swellingin acute DVT);

— efficacy of newly-developed devices, e.g. supe-rimposed MCS, new pumps.

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167. Rowland J. Intermittent pump versus compression ban-dages in the treatment of venous leg ulcers. Aust N Z JSurg 2000;70:110-3.

168. Handoll HH, Farrar MJ, McBirnie J, Tytherleigh-StrongG, Awal KA, Milne AA et al. Heparin, low molecular


weight heparin and physical methods for preventingdeep vein thrombosis and pulmonary embolism follow-ing surgery for hip fractures. Cochrane Database SystRev 2000;27:CD000305.

169. Ginsberg JS, Hirsh J, Julian J, Van der Laande Vries M,Magier D et al. Prevention and treatment of postphlebiticsyndrome: results of a three-part study. Arch Intern Med2001;161:2105-9.

170. McNeely ML, Magee DJ, Lees AW, Bagnall KM,Haykowsky M, Hanson J. The addition of manual lymphdrainage to compression therapy for breast cancer relat-ed lymphedema: a randomized controlled trial. BreastCancer Res Treat 2004;86:95-106.

171. Eklöf B, Rutherford RB, Bergan JJ, Carpentier PH,Gloviczki P, Kistner RL et al. Revision of the CEAP clas-sification for chronic venous disorders: consensus state-ment. J Vasc Surg 2004;40:1248-52.

172. Partsch H, Partsch B, Braun W. Interface pressure andstiffness of ready made compression stockings: com-parison of in vivo and in vitro measurements. J Vasc Surg2006;44.809-14.

173. Mariani F, Rastel, D, Uhl JF, Lun B. The interface pres-sure of medical compression stockings. Acta Phlebol2007;8:31-9.

174. Partsch H, Clark M, Bassez S, Becker F, Benigni JP, BlazekV et al. Measurement of lower leg compression in vivo:recommendations for the performance of measurementsof interface pressure and stiffness. Dermatol Surg2006;32:229-38.

Address reprint requests to: H. Partsch, M.D., Professor of Der-matology and Angiology, Medical University of Vienna, Bau-meistergasse 85, A 1160 Vienna, Austria. E-mail: [email protected]

APPENDIX I

Tables IA and IIA refer to Table I and Table IIand summarize the results of the quoted publi-cations. The detailed description of the compres-sion products shown in the Appendix includes

brand names (printed in Italics) as quoted in theabstract of the original paper.

Comparisons between two treatment regimesare marked by A/B.

TABLE IA.—Experimental data on compression therapy.

Parameter Experiment (methods) Compression* Results Authors References(material/pressure)

Gniadecka M. ActaDerm Venereol1995;75:120-4.

Gniadecka M et al.Acta Derm Venereol2002;82:460-85.

Krijnen RM et al. JOccup Environ Med1997;39:889-94.

Van Geest AJ et al.Dermatol Surg2000;26:244-7.

MCS protect again-st leg swelling instanding position

Higher pressure(long stretch) leadsto more edemareduction

Less swelling andcomplaints withMCS

High slope moreeffective

MCS 26-36 mmHg

Setopress (long stret-ch/Comprilan (shortstretch)

30-32 mmHg, Veno-train strong; Bauer-feind)/rubber floormats

MCS, 30 mmHg:low vs high stiffnessCompriform vs Bel-lavar vs Fast fit

Dermal water con-tent (high resolutionultrasound) deter-mined 3 times a dayin 20 patients withlipodermatosclero-sis

High resolutionultrasound in 3patients (C6, C5)

Diurnal volumechanges, 114 maleworkers with CVI, 3months

APG, capillary fil-tration rate(CFR) in 29 legs withCVI

Skin echogenicity

MCS

Skin echogenicityBandages

Leg volumeMCS

Capillary filtrationMCS

22

29

23

25

(to be continued)

Edema: prevention by medical compression stockings and bandages


TABLE IA.—Experimental data on compression therapy (continued).


Jonker MJ et al. Der-matology 2001;203:294-8.

Partsch H et al. JDerm Surg2004;30:737-43.

Clarke M et al. Coch-rane Database ofSystematic Reviews2006, Issue 2.

Nehler MR et al. JVasc Surg1993;18:783-8.

Diehm C et al. Lan-cet 1996,347:292-4.

Gniadecka M et al.Removal of J AmAcad Dermatol1998;39:966-70.

Vayssairat M et al. JMal Vasc2000;25:256-62.

Onorati D et al. JMalad Vasc2003;28:21-3.

Griffin JW et al. PhysTher 1990;70:279-86.

Airaksinen O et al.Arch Phys MedR e h a b i l1991;72:667-70.

Grieveson S et al. JTissue Viability2003;13:98-100.

Reduction of DVCand of complaintswith supportstockings

Evening swellingprevented by >10mmHg, less com-plaints

Stockings reduceedema(based on 6 trials)

Higher tissue pres-sure in CVI, furtherincreased by MCS

Reduction of edemaby both treatments

Removal of dermaledema with bothcompression classes

Reduction ofedema, improve-ment of QOL

Reduction of legvolume only in the1st week

Reduction of handedema by IPC

Edema reduction,density decreased inskin, increased inmuscles

Lower pressures andshorter inflation anddeflation times moreefficient than higherpressures and infla-tion/deflation times

Class I supportstockings (14 vs 18 mmHg,Lycra, Dupont)/6mmHg

4 classes (6-25mmHg)Sigvaris Randomly applied

Different brands ofstockings 10-20mmHg

MCS 20-30m m H g / 3 0 - 4 0mmHg

23-32 mmHgMCS/horse chestnutseed extract

MCS (18-26mmHg/26 to 36mmHg)Sigvaris

10-15 mmHg/place-bo (3-6 mmHg)

MCS, 23-32 mmHg

IPC/high voltage/0

IPC

IPC Flowpac (Hun-tleigh) with differentsettings

DVC of the lowerlegs (optical device),5 days 118 healthy volun-teers

Water displacementDifference betweenevening-morningvolume=edema (12volunteers, C0-C3)

10 randomized trials(n=2 856), 9 (n=2821) comparedstockings vs nostocks

S.c. pressure in nor-mals and patientswith CVI

Leg volume (waterdisplacement)240 patients CVI, 12weeks

Water content inLDS and healed legulcers (C4-C5), 10patients

Leg volume (waterdisplacement)341 patients, C1-C3s, 4 weeks

Leg volumetry andcapillary videoscopy,11 patients C2-C4, 2weeks

Volumetry, 30patients posttrau-matic hand-edema

Leg circumferenceand CT in post-trau-matic edema (afterfracture), 16 patients

Volume measure-ment in 27 patientswith venous ankleswelling

Leg volume

Light supportstockings

Leg volume

MCS

Leg volume

Long haul flightsMCS

Perimalleolar sub-cutaneous pressureMCS

Leg volume

MCS

Skin echogenicity

MCS

Leg volume

MCS

Leg volume

MCS

Hand volume(traumatic)IPC

Leg volume(traumatic)IPC

Leg volume(venous)IPC

19

20

21

123

24

26

27

28

30

31

32

Edema reduction by medical compression stockings and bandages

Edema reduction by intermittent pneumatic compression

(to be continued)




Myerson MS et al.Foot Ankle1993;14:198-203.

Caschman J et al. JOrthop Trauma2004;18:596-601.

Partsch H et al. Kli-nikarzt 1982;11:609-15.

Mayberry JC et al. JVasc Surg1991;13:91-100.

Keith SL et al. ArchSurg 1992;127:727-30.

Macklon NS et al. BrJ Radiol1995;68:515-8.

Norgren L et al. Vasa1995;24:282-5.

Jamieson R et al. BrJ Obstet Gynaecol2007;62:1174-9

Morris RJ et al. AnnSurg 2004;239:162-71.

Nash MS et al. J Spi-nal Cord Med2000;23:221-7.

Significant reduc-tion of edema by IPC

Significant reduc-tion of swelling byIPC

Increase of venousflow velocity in everysingle case (supine)

Upright: modestincrease of peakflow in popliteal vein

No increase of peakvelocity with MCS

No significantincrease of velocity

Less reduction offlow velocity by stan-ding up

Increase of flowvelocity

Flow augmentationdepends on speed ofinflation, pressureand graded sequen-tial compression

Increase of maximalvenous velocitymore with IPC

IPC in 19 patientsdaily, 19 patientscontrol

27 patients with A-VImpulse “in-cast”system, 27 controls

MCS [10-15 mmHg]

MCS calf and thighlength, 3-40 mmHg,40-50 mmHg

MCS with andwithout IPC

3 types of supportstockings

25 mmHg MCS

Thigh length MCS

IPC and MCS

Slow SCD/fast IPC

Volume measure-ment (water displa-cement), 38 patientswith post-trauma-t i c /pos t surg i ca lankle swelling

Daily circumferen-tial ankle girth mea-surements in 64patients with anklefractures

Isotopic phlebo-graphy, Mean tran-sit time [radioisoto-pes], n=12, horizon-tal position

Duplex10 normals, 16 CVI

Duplex, peak velo-city femoral vein innormals and posto-perative patients

DopplerPopliteal vein,10 non-pregnantfemales

Duplex Femoral vein, 10females in late pre-gnancy

Duplex Femoral vein , 17females postpartum

Medline search1970-2002

Venous blood flowvelocity measuredmainly by duplex

Doppler, femoraland popliteal veins,20 patients withtetraplegia

Leg volume (postoperative, trau-matic)IPC

Leg volume(traumatic)IPC

Venous flow velocity

Thromboprophylac-tic stockings


MCS






MCS


MCS

Prevention of stasis

Review Venous flow velocity

33

34

35

124

125

126

36

37

3

8

39

Venous flow velocity/influence of medical compression stockings and bandages

Venous flow velocity/Influence of intermittent pneumatic compression

(to be continued)




Pitto RP et al. Bio-med Tech (Berl)2001;46:124-8.

Lurie F et al. J VascSurg 2003;37:137-42.

Iwama H et al. J CritCare 2000;15:18-21.

Yamashita K et al. JClin Anesth2005;17:102-5.

Kakkos SK et al. JVasc Surg2005;42:296-303.

Kakkos SK et al. IntAngiol 2005;24:330-5.

Morris RJ et al. JVasc Surg2006;44:1039-45.

Kalodiki E et al. EurJ Vasc EndovascSurg 2007;33:483-7.

Galili O et al.Thromb Res 2007;121:37-41

Coleridge Smith PDet al. Br J Surg1991;78:724-6.

Partsch H et al JVasc Surg2002;36:948-52.

Lord RS et al. ANZ JSurg 2004;74:581-5.

Partsch B et al. JVasc Surg: 2005;42:734-8.

Increase of flowvelocity, most pro-nounced in semi-erect

Increase of flowvelocity, in poplitealvein especially afterfoot compression

Increase of maxi-mum velocity, morewith plantar-calfcompression

Increase of peakflow velocity withboth methods, exer-cise had longereffect.

Similar enhance-ment of flow velocity

Higher peak velocitywith fast system, butlower volume ofblood/h

Higher peak flowvelocity with rapidsystem

Increase of peakflow velocity by SCD

Increase of peakflow velocity

Intraoperative ve-nous distension redu-ced

Compression ofthigh veins only witha local pressure>40mmHg

No diameter reduc-tion in standing,only in supine

Complete venousocclusion with 20

IPCA-V Pulse, differentbody positions

IPC foot/calf/calf +thigh, 40 mmHgcalf, 80 mmHg foot

60 mmHg calf/sequential plantar-calf IPC

IPC (AV-Pulse) 130mmHg 2 h/15 dorsi-flexions/min (by anurse), 5 min

SCD Express [newp o r t a b l edevice]/SCD

SCD (sensing venousrefill)/Venaflow Air-cast (fast inflating)

Rapidly inflating/slowly inflating ma-chines

4 layer bandage/+SCD device/0

Aviafit (new batterydriven foot pump)

A n t i - e m b o l i s mstockings/0

Blood pressure cuff,23-32 mmHg MCS

MCS 20-30 mmHg

Inflatable cuff

Duplex, femoralvein, 10 normals, 10patients hip surgery

Duplex, several veinsegments, severalbody positions, 12normals

Duplex femoral vein,10 normals

Duplex in femoralvein, 20 patientsintensive care

Duplex, 30 normals,supine and semi-erect

Duplex, 12 normalsin semi-erect posi-tion

Doppler femoralvein, 20 normals

Duplex, poplitealvein, 20 legs with C6

Doppler 22 normals

Duplex Gastrocne-mius veins duringgeneral surgeryn=40

DuplexFemoral and greatsaphenous vein(thigh),12 patients, C6

Duplex superficialand deep veins, supi-ne and standing

Duplex superficialand deep leg veins,

Venous flow velocityIPC


IPC


IPC, exercise


IPC


IPC


IPC


IPC, bandage


IPC


IPC

Venous diameter

Prophylacticstockings

Venous diameter(thigh)

MCS, Pneumaticcuff

Venous diameter

MCS

Venous diameter

40

41

42

43

44

45

46

47

48

49

50

127

51

Venous diameter by medical compression stockings and bandages

(to be continued)




Jamieson R et al. Br J Obstet Gynaecol2007;62;1174-9.

Sarin S et al. Br JSurg 1992;79:1385-6.

Spence RK et al. JVasc Surg 1996;24:783-7.

Partsch H et al. Der-matol Surg 1999;25:695-700.

Evers, EJ et al. Vasa1999;28:19-23.

Gjöres JE et al. Vasa1977;6:364-8.

Jones NAG et al. BrJ Surg 1980;67:569-72.

Partsch H. Vasa1984;13:52-7.

Christopoulos DG etal. J Vasc Surg1987;5:148-55.

Norgren L. Acta ChirScand 1988;154:505-7.

Büchtemann AS etal. Br J Obstet Gyne-col 1999;106:563-9.

Ibegbuna V et al. JVasc Surg 2003;37:420-5.

mmHg in supine, 70mmHg in standing

Reduction of dia-meter of femoralvein

Refluxes abolishedin 4/17 patients withpopliteal vein refluxby 60 mmHg

Reduction of refluxmore with Circaid

Reduction of reflux>40 mmHg,inelastic more effec-tive than elastic

Decrease of maxi-mal reflux velocityby MCS and banda-ge

Improved venouspump in mostpatients

Improved venouspumping with Sig-varis med andstrong

Increase of expelledvolume with higherpressure, no changeof refilling time

Improved venouspumping

No improvement ofrefilling time

Improvement ofvenous pump, lon-ger refilling time

Reduction of RVFindependent ofwalking speed

Thigh length MCS

Inflatable, water-fil-led cuff

MCS 30-40mmHg/Circaid

4-layer, MCS, inela-stic Band/20-60mmHg

MCS 23-46 mmHg(Venofit)/short stret-ch bandages (Com-prilan)

MCS Sigvaris

Light NHSs t o c k s / S i g v a r i smedium/Sigv strong

MCS 5 brands, 10-40mmHg Sigvaris

MCS

MCS

MCS 25-32 mmHg/0

MCS 21 mmHg/0

supine and standing

Duplex Femoral vein, 17females postpartum

DuplexUpright position36 patients withreflux

APG (venous fillingindex)

APG (venous fillingindex)21 patients, C6,deeprefluxes

Duplex: reflux velo-city popliteal vein instanding60 patients

Foot volumetry, 37patients with CVI

Foot volumetry10 normals,10 varicose veins, 10with post-thrombo-tic syndrome

Foot volumetry, 20 patients with CVI

APG

Foot volumetry,PPG, strain gaugeplethysmography

Strain gauge plethy-smography, duplex15 pregnant women

RVF (APG), tread-mill 10 patients C2-C4

Pneumatic cuff

Venous diameter(thigh)

MCS

Venous reflux

Pressure cuff

Venous refluxMCS, Velcro band-device

Venous reflux

MCS, bandages

Venous reflux

MCS, bandages

Venous pump

MCS

Venous pump

MCS

Venous pump

MCS

Venous pumpMCS

Venous pumpMCS

Venous pump

MCS

Venous pump

MCS

37

52

53

54

55

56

57

58

59

60

61

62

Venous reflux reduction by medical compression stockings and bandages

Venous pump improvement by medical compression stockings and bandages

(to be continued)




O’Donnell TF Jr et al.JAMA 179;242:2766-8.

Partsch H. VASA1984;13:58-64.

Christopoulos DG etal. J Vasc Surg1987;5:148-55.

Mayberry JC et al. JVasc Surg 1991;13:91-100.

Xakellis GC et al. JGerontol 1993;48:M6-9.

Schubert V et al. ClinPhysiol 1989;9: 535-45.

Abu-Own A et al.Eur J Vasc Endova-sc Surg 1995;9:327-34.

Mayrovitz HN et al.Adv Skin WoundCare 2004;17:197-201.

Mayrovitz HN. ClinPhysiol 1998,18:117-24.

Mayrovitz HN et al.Ostomy WoundManage 1998;44:56-67.

Bochmann RP et al.J Appl Physiol2005;99:2337-44.

van Bemmelen PS etal. Vasc Surg

Reduction of systo-lic peak pressure

Reduction of meanvenous hypertensionby inelast.bandages>50 mmHg, not byMCS

No change refilltime

No significant im-provement

Increase of dermalblood flow withpressure 60 mmHg

Decrease of LDFover a pressure of 50mmHg

Pressure >50 mmHgreduced LDF to aminimal value

Reduced averageskin blood perfusionattributable to blun-ting of hyperemia

No reduction of sub-bandage perfusion,but of toe perfusion

Increase of bloodperfusion

Increase of bloodflow up to 30 min

Increase of arterialflow especially in sit-

MCS 30-40 mmHg

MCS 10-15mmHg/elastic/inela-stic bandages >50mmHg

MCS 20-30 mmHg

MCS calf and thighlength,30-40 mmHg, 40-50mmHg

Pressure of trochan-ter produced byindenter in healthypeople

Indenter 0-110 mmHg

Indenter, compres-sion forces 50-1 500g

Support load 20mmHg 5 min

Bandages: zincpaste, elastic wrap32 (28) mmHg

Bandages: Zincpaste + Coban,Coban 38 mmHg

MCS 13-23 mmHgfor 10 min

IPC 20-120 mmHg,prone and sitting

Pressure in a dorsalfoot vein, 11 patientsPTS

Pressure in a dorsalfoot vein, 13 patientswith CVI

Pressure in a dorsalfoot vein, 16 patientsCVI

LDF

Laser Doppler andthermometry oversacrum and gluteus30 normals

LDF over the heel,10 normals,10patients

LDF over heel anddorsum of foot, 12normals

Laser Doppler distalto the bandage (toe)and under the ban-dage

Arterial pulsatileflow, nuclear magne-tic resonance flow-metry, 8 normal legs

Venous occlusionplethysmographynormal forearms(n=9)

Duplex poplitealartery, 4 patients

Venous pressure

MCS

Venous pressure

MCS, bandages

Venous pressureMCS

Venous pressureMCS

Decubitus

Decubitus

Decubitus

Decubitus

Leg blood flow,bandages

Leg blood flow,bandages

Arm blood flow

MCS

Arterial flow

64

63

59

124

128

129

130

131

132

66

65

67

Ambulatory venous hypertension/influence of medical compression stockings and bandages

Arterial flow/influence of intermittent pneumatic compression

(to be continued)




1994;19:1052-8.

Labropoulos N et al.Arch Surg1998;133:1072-5.

Delis KT et al. Eur JVasc Endovasc Surg2000;19:250-60.

Delis KT et al. J VascSurg 2000;32:284-92.


Morris RJ. Clin Phy-siol Funct Imaging2004;24:237-42.

Delis KT et al. Br JSurg 2004;91:429-34.

Labropoulos N et al.J Vasc Surg2005;42:710-6.


Ramaswami G et al.J Vasc Surg2005;41:794-801.

Abu-Own A et al. JVasc Surg 1994;19:1074-83.

Conchonnet P et al.Blood Coagul Fibri-

ting position

Increase of poplitealblood flow

Augmentation ofarterial inflow innormals and claudi-cants

IPC (foot+calf) ismost effective inaugmenting arterialcalf inflow inpatients and nor-mals

Increase of walkingdistance and ofABPI

Higher and longerhyperemia with lon-ger compression

Enhancement ofarterial flow para-meters, most effec-tive: IPC (foot+calf)

Increase of arterialflow and of LDF

Leg inflow enhance-ment exceeds 50 s inclaudicants and lasts32.5 to 40 s in thecontrols

IPC improveswalking distance,sustained at 1 year

Increase of LDFwith pressure up to20 mmHg (supine),up to 60 mmHg (sit-ting)

No profibrinolyticeffect of elastic com-

Intermittent pneu-matic foot and calfcompression

IPC (foot): 120mmHg, inflationtime: 3 s; deflationtime: 17 s

IPC (foot), IPC (calf),or both

IPC (foot) >4 h/d, 4-5 months in 25patients, 12 controls

IPC 10 s/1 min com-pression

IPC (foot), IPC (calf)or both

IPC 120 mmHg for3 s, 3/min

IPC (foot), IPC (calf),or both

Fast IPC calf andfoot for 1 h twicedaily in sitting (15patients)/walkingexercise (15patients)

Blood pressure cuff10-100 mmHg

Elastic bandage onupper limb/lower

with arterial occlu-sive disease, 11 nor-mals

Duplex poplitealartery,30 volunteers

Duplex poplitealartery, 25 normals,40 limbs of 32 stableclaudicants

Duplex, poplitealartery, sitting , 25normal limbs, 31limbs with claudica-tion

Walking distance,ABPI in 37 claudi-cants

Duplex, femoralartery, 19 normals

Duplex in autolo-gous arterial grafts,18 femoro-popliteal,18 femoro-distal

Duplex and laser Doppler in 20 limbswith critical ische-miaDuplex, poplitealartery, 26 limbs witharterial occlusions,24 normal limbs

Walking distance,ABPI in 30 patientswith claudication

LDF 15 patientswith lipodermato-sclerosis, 15 normals

Euglobulin lysistime, t-PA antigen,

IPC

Arterial flow

IPC

Arterial flow

IPC

Arterial flow

IPC

Arterial flow

IPC

Arterial flow

IPC

Arterial flow

IPC

Arterial flow

IPC

Arterial flow

IPC

Arterial flow

IPC

Blood cell velocity,pressure cuff

Fibrinolytic activity

68

69

70

71

72

73

74

75

76

77

133

Microcirculation/influence of medical compression stockings and bandages

(to be continued)




nolysis 1994;5:949-53.

Lentner A et al. Int JMicrocirc Clin Exp1996;16:320-4.

Klyscz T et al. Hau-tarzt 1997;48:806-11.

Jünger M et al.Microcirculation2000;7:3-12.

Onorati D et al. JMal Vasc. 2003;28:21-3

Agu O. Vascular2004;12:69-76.

Wollina U. Int J LowExtrem Wounds2006; 5:169-80.

Herouy Y et al. Int JMol Med 2006;18:215-9.

Kolari PJ et al. Car-diovasc Res1988;22:138-41.

Eze AR et al. AnnVasc Surg 1998;12:182-6.

van Bemmelen PS etal. Vasa 2000;29:47-52.

pression

Improvement ofvenolymphatic drai-nage

Increase in capillarydensity, decrease incapillary diameterand pericapillaryhalo diameter.

Increase of nutritivecapillaries, diameterreduction of capilla-ries and dermalpapillae

Reduction of peri-capillary edema

Improving deepertissue oxygenationduring walking withstrong MCS

Capillary filtration?tcPO2?

Tightens the para-cellular barrier viaelevated expressionof specific TJs

Increase of oxygentension

The majority ofincreased perfusionis from increasedarterial inflow

Increased skin-flux

limb/0

MCS 30 mmHg

2 weeks bandages,then 2 weeks MCS

MCS 4 weeks

MCS, 23-32 mmHg

MCS 14-35 mmHgin different bodypositions

Review on effects ofdrugs and compres-sion

MCS

IPC

Art-assist AA 1000,sitting position

IPC (Art Assist)

PAI-1 antigen, PAI-1activity in 21 nor-mals

Densitometry afteri n t r a c u t a n e o u sinjection of sodiumfluorescein,10 normals, 20 C4-C5

Video capillarymicroscopy after 4weeks of compres-sion,20 patients CVI

Fluorescence videomicroscopy, intravi-tal video capillaro-scopy, TcpO2 andlaser Doppler flow-metry, 20 patientsCVI

Video-capi l laro-scopy (and leg-volu-metry), 2 weeks, 11patients C2-C4

NIRS 10 patientsCVI

tcPO2/TcPCO2

Skin specimens,expression patternof TJs-molecules inhealthy persons andpatients with CVI

tcPO2 in 10 patientswith post-thrombo-tic ulcers (C6), 9controls

Skin perfusion of thegreat toe laser Dop-pler, in 50 normallimbs

Laser Doppler on dis-tal forefoot in 16 limbswith severe infrapo-pliteal arterial occlu-sions, 13 normals

Dermal clearance

Capillary morpho-logy,Bandages, MCS

Capillary morpho-logy, MCS

Pericapillary halo

Tissue oxygenation

Capillary filtration,tcPO2

Tight junctions

Tissue oxygenation

Skin blood flow

Skin blood flow

78

79

80

28

81

82

83

84

85

86

Microcirculation/influence of intermittent pneumatic compression

(to be continued)




Pekanmäki K et al.Vasa 1991;20:394-7.

Abu-Own A et al. JVasc Surg1994;19:1074-83.

Dai G et al. J VascSurg 2000;32:977-87.

Chen LE et al. J ApplPhysiol 2002;92:559-66.

Liu K et al. J OrthopRes 1999;17:88-95.

Albertazzi P et al.Bone 2005;37:662-8.

Morris RJ et al. ArchOrthop TraumaSurg 2005;125:348-54.

Kessler CM et al.Blood Coagul Fibri-nolysis 1996;7:437-46.

Comerota AJ et al.Ann Surg1997;226:306-13.

Macaulay W et al.Clin Orthop2002;399:168-76.

Killewich LA et al. JVasc Surg2002;36:953-8.

Increase of LDF andtcPo2

Increase of LDF andtcPo2 in sitting

IPC upregulates ECfibrinolytic potentialand influences vaso-motor tone

eNOS plays animportant role inregulating themicro-circulation inupstream muscle

Increased release ofnitric oxide causingsystemic vasodila-tion

Increase of bonemineral density

Increased uptake of[99mTc]MDP inlong bones

Enhancement offibrinolysis in 86%

Elevation in fibri-nolytic activity at180 min with alldevices in normalsubjects and post-thrombotic

No difference insystemic fibrinolysis

No significantenhancement oflocal fibrinolysis inany group

IPC

Pneumatic footpump, differentbody positions

Simulating bloodflow and vessel col-lapse conditionsduring IPC

IPC

IPC 60 min, bothlegs (distally)

IPC 2 h/day, 6months

IPC 60 mmHg for 1h

IPC twice weekly 2h, 13 weeks

5 IPC devicesapplied for 120 minin random fashion,1 per week x 5 weeks

25 patients with IPC,25 without IPCI

PC/heparin s.c./orboth up to 5 days IPC 120 min

LDF and tcPO2 in 8normals

LDF, tcPo2 on bigtoe,15 normals, 15patients with arterialocclusive disease

Expression of fibri-nolytic factors andseveral mediators onan in vitro cell cul-ture system (venousflow simulator)

IPC-induced vasodi-lation and endothe-lial NOS (eNOS)expression inupstream muscle

Diameter of musclearterioles in crema-ster muscle from 80rats

X-ray absorptiome-try, femoral neck in37 postmenopausalwomen

[ 9 9 m T c ] M D Puptake in 24 patients

Euglobulin lysistime, urokinase pla-sminogen activator,t-PA19 patients CVI

tPA Ag and Act, PAI-1 α-2-antiplasmin-plasmin complexes,vWF antigen in 6normals, 6 patientsPTS

Fibrinolytic activityafter hip replace-ment

tPA and PAI-1 fromcommon femoralvein for measure-ment of regionalfibrinolysis; 45patients with majorabdominal surgery

Tissue oxygenation,skin blood flow

Skin blood flow andskin oxygenation

Endothelium deri-ved mediators

Endothelium deri-ved mediators

Diameter of muscu-lar arterioles

Bone mineral den-sitiy

Bone scan





87

77

88

89

90

134

135

136

137

138

139

(to be continued)




Giddings JC et al.Clin Lab Haematol2004;26:269-73.

Morris RJ et al. JVasc Surg 2006;44:1039-45.

Kriederman B et al.Lymphology 2002;35:23-7.

Franzeck UK et al. JVasc Res 1997;34:306-11.

Olszewski W. BocaRaton: CRC Press;1991.

Földi E et al Lym-phology 2000;33:19-23.

Leduc A et al. In:Partsch H, editor.Amsterdam: Excerp-ta Medica; 1988.p.591-2.

Partsch H et al. ZL y m p h o l o g i e1981;5:35-9.

Miranda F Jr et al.L y m p h o l o g y2001;34:135-41.

IPC enhances fibri-nolysis and suppres-ses procoagulantactivation

Suppression of pro-coagulant activation,rapid system notsuperior

Edema reductionwith compression

Lymph pressure?after 2 weeks and 3months

Increase of lympha-tic pulsations

Down-regulation ofcytokines

Increase of proteinuptake

Increase of oncotictissue pressure

Volume decrease, noimprovement oflymph-scan

Rapidly inflating IPC

IPC/gently inflatingsystem 2 h

Control/Coban/MLD/IPC/combination

Complex physicaltherapy 2 weeksbandages

Cuff, massage

Complex physicaldecongestion the-rapy

Single and multi-chamber IPC

IPC

IPC 3 h, measure-ments before and 48h later

uPA ,tPA and PAI-121 healthy males

Analysis of bloodcoagulation and fi-brinolytic potentialin 20 healthy males

Limb circumferen-ces (truncated conemethod)

Fluorescence micro-lymphography andpressure measure-ments in cutaneouslymph capillaries, 12patients with lym-phedema

Intralymphatic flowand pressure mea-surement

Quantitative expres-sion of the upregu-lated pro-inflamma-tory cytokines andreceptors for growthfactors

Labeled albuminuptake

Labeled albumin i.v.,limb volumetry

Volume measure-ment and isotopiclymphography,11 patients



Volume reductionanimal model(Wistar rats)

Pressure in lymphcapillaries

Spontaneous con-tractions of lymphcollectors

Cytokines and recep-tors for growth fac-tors

Protein re-absorp-tion

Removal of protein

Volume reduction,lymph transport

140

46

91

92

93

94

95

96

97

Lymphedema/influence of medical compression stockings and bandagesc

Lymphedema/influence of intermittent pneumatic compression

MCS: medical compression stockings; CVI: chronic venous insufficiency; APG: air plethysmography; DVC: diurnal volume change; LDS: lipodermato-sclerosis; QOL: quality of life; IPC: intermittent pneumatic compression; SCD: sequential compression device; PPG: photoplethysmography; RVF: residualvolume fraction; PTS: post-thrombotic syndrome; LDF: laser Doppler fluxmetry; ABPI: ankle brachial pressure index; TJ: tight junctions; NOS: nitric oxidesynthase; MDP: methylene diphosphonate; Ag: antigen; tPA: global fibrinolytic activity; Act: activity; PAI-1: plasminogen activator activity.


TABLE IIA.—Outcome of RCTs and meta-analyses using medical compression stockings and bandages.

Indication Comparison Outcome Grade Authors Reference

141

98

99

142

100

108

143

144

101

145

146

147

148

149

150

109

Weiss RA et al. DermSurg 1999;25:701-4.

Vayssairat M et al. J MalVasc 2000;25:256-62.

Benigni JP et al. Phlébo-logie 2003;56:117-25.

Weiss RA et al. DermatolSurg 1999;25:105-8.

Kern P et al. J Vasc Surg2007;45:1212-6.

Scurr JH et al. Ann RoyColl Surg Engl1985;67:109-11.

Hartmann BR et al.Angiology 1997;48:157-62.

Anderson JH et al. Phle-bology 1990;5:271-6.

Thaler E et al. Swiss MedWkly 2001;131:659-62.

Shouler PJ et al. Ann RoyColl Surg Engl1989;71:402-4.

Travers JP et al. Phlebo-logy 1994;9:104-9.

Rodrigus I et al. Phlebo-logy 1991;6:95-8.

Bond R et al. Phlebology1999;14:9-11.

Raraty MGT et al. Phle-bology 1999;14:21-5.

Coleridge- Smith PD etal. Phlebology 1987;2:165-72.

Travers JP et al. Ann RoyColl Surg Engl 1993;75:119-22.

0/ 8-15/15-20 mmHgL’eggs, JC Penny

10-15/6 (Placebo ) mmHgInnothera, Paris

10-15/6 (Placebo) mmHgmicrofibres+Elasthan+Cotton

0/3/7/21 days(10-20 mmHg) Sigvaris

0/21 days(20-30 mmHg) Sigvaris

35-40 mmHg/BandageStruva medi vs Elasto-crepe

30 mmHg+ physical the-rapy/0Varisma, Viso

30-40 mmHg+drug/drug/placSigvaris 503

0/18-21/25-32 mmHgSigvaris

15/40 mmHg, 3 weeksBrevet (MCS) vs BrevetVarex (bandage)

20-30 mmHg/0medi

7d Dauerbinde, then Tubi-gripfor 1, 3, 6 weeks

TED 10-12/30-40/Band.1 wkTED vs Medi vs Panelast(Lohmann)

Band 1 week/crepe 16 h/then TED 6 weeksTED, Panelast (Loh-mann)

Crepe/elastocrepe-Ban-dage /20-30 mmHg Venosan, Salzmann

Crepe 1 day/Bandage 6daysPanelast (Lohmann)

Light compressionimproves symptoms

Improvement of QOLand edema

Improvement of QOLand pain

Better vein resolution,less pigmentation

Better vein resolution,less pigmentation

Stocking: better results,fewer side effects

Better venous function

Drug+stocking best forsymptoms (VAS)

Symptoms improved, noinfluence on progression

No difference bruising,phlebitis, 15 mmHg morecomfort

Recurrence after 1 yearreduced by MCS

Wear time: no differenceon symptoms and sideeffects

Pain and costs: no diffe-rence

Day 1: less pain, week 1:less bleeding with Pane-last

Pressure loss of banda-ges, not of MCS

Panelast less bleeding(labeled RBC) than Crepebandage

2B

1B

1B

2B

1B

1B

2B

2B

1B

1B

2B

2B

2B

2B

1B

1B

C0S, C1 SMCS

C0S, C1 SMCS

C0S, C1 SMCS

C1 scleroMCS

C1 scleroMCS

C1 scleroMCS

C2AMCS

C2SMCS

C2S pregnancyMCS

C2 after surgeryMCS/band

C2 after surgeryMCS

C2 after surgeryMCS

C2 after surgeryMCS/bandMCS



C2 after surgeryband/band

Chronic venous disorders CEAP C0-C6)

(to be continued)


TABLE IIA.—Outcome of RCTs and meta-analyses using medical compression stockings and bandages (continued).


151

145

108

21

24

102

103

152

107

153

154

155

156

157

Biswas S et al. Eur J VascEndovasc Surg 2007;33:631-7.

Shouler PJ et al. Ann RoyColl Surg Engl1989;71:402-4.

Scurr JH et al. Ann RoyColl Surg Engl 1985;67:109-11.

Clarke M et al. CochraneDatabase of SystematicReviews 2006, Issue 2.

Diehm C et al. Lancet1996,347:292-4.

Vandongen YK et al.Phlebology 2000;15:33-7.103.

Nelson E A, 2000The Cochrane Library, 1,2002.Oxford: UpdateSoftware

Nelson E A,J Vasc Surg 2006 44:803-8Cullum N et al. In: TheCochrane Library, Issue2, 2002. Oxford: Updatesoftware.

Partsch H et al. Vasa2001;30:108-13.

Meyer FJ et al. Br J Surg2002;89:40-4.

Meyer FJ et al. Br J Surg2003;90:934-40.

Moffatt CJ et al. WoundRepair Regen2003;11:166-71.

O’Brien JF et al. Br J Surg2003;90:794-8.

Postoperative bandagefor 3days, then TED 1week/3 weeks

40 mmHg/15 mmHgBrevet Varex vs Elasto-crepe

35-40 mmHg MCS/ban-dage 18 daysStruwa forte medi vs Ela-stocrepe

Review 10 RCTs (n=2856) 10-20 mmHg MCS/0Scholl, Sigvaris, Kendall,medi

30-40 mmHg/drug

30-40 mmHg/0Venosan, Salzmann

Review 2 RCTs: A)300 patients 18-24mmHg/25-35 mmHgB)166 patients twobrands of 18-24 mmHg20-40 mmHg MCS

18-24 mmHg/25-35mmHg

Systematic review, 22trials reporting 24 com-parisons

4 layer Profore/2 shortstretch Rosidal K

Zinc paste + Tenso-press/Zinc paste + Ela-stocrepe bandages

3 layer paste/4 layer ban-dage

2 layer Surepress/ 4 layerProfore bandages

4 layer Profore/usualsystem of care

3 weeks TED not betterthan 1 week

No difference bruising,phlebitis, 15 mmHg morecomfort

MCS better than Elasto-crepe, better results, lessside effects

Leg edema prevented bystockings

Reduction of leg volume(12 weeks) comparableto drug

Significant reduction ofLDS by MCS

MCS reduce recurrencerate, higher pressure bet-ter. Higher recurrencewith non-compliance

High pressure: lowerrecurrence rate

Compression more effec-tive than no compres-sion. Multilayer moreeffective than single-layerHigh pressure better thanlow pressure

No difference 12 weekshealing

No difference after 26weeks

Paste bandages higherhealing rate after 20weeks

No difference in rate ofclosure at 24 weeks, at 12weeks Profore better

4L higher and fasterhealing rates after 12weeks, reduction costs

2B

2B

1B

1B

2B

1B

A

1B

1A

1B

1B

1B

1B

1B

C2 after surgeryMCS

C2 sclerotherapyMCS/band

C2 sclerotherapyMCS/band

C3 prevention(flight)MCS

C3 preventionMCS

C4b (LDS)MCS

C5MCS

C5MCS

C6Bandages, MCS

C6 Bandages

C6 Bandages

C6 Bandages

C6 Bandages

C6 Bandages

(to be continued)




158

159

160

161

162

163

104

105

106

164

165

166

167

168

Ukat A et al. J WoundCare 2003;12:139-43.

Polignano R et al. J WoundCare 2004;13:21-4.

Franks PJ et al. WoundRepair Regen 2004;12:157-62.

Nelson EA et al. Br J Surg2004;91:1292-9.

Blecken SR et al. J VascSurg 2005;42:1150-5.

Koksal C et al. Swiss MedWkly 2003;133:364-8.

Jünger M et al. CurrentMed Res Opin 2004;20:1613-24.

Jünger M et al. Wounds2004;16:313-20.

Milic DJ et al. J Vasc Surg2007;46:750-5.

Wong KYI. The Nether-sole School of Nursing.The Chinese Universityof Hong Kong, HKSAR,China; 2007.

Mani R et al. The Coch-rane Library, Issue 2,2002. Oxford: UpdateSoftware.

Nikolovska S et al. MedSci Monit2005;11:CR337-43.

Rowland J. Aust N Z JSurg 2000;70:110-3.

Handoll HH et al. Coch-rane Database Syst Rev2000;27:CD000305.

4 layer Profore/short stret-ch Comprilan

4 Layer Profore/Unnaboot bandages

Cohesive short stretch(Actico Flexiban)/4 layerbandages

Comprilan or Rosidal/Profore bandages, system4, original 4 layer

“4 layer” (Vaseline gauze,thick gauze, felt pad, 15cm wide “elastic banda-ge”/Circaid (non-elastic)

Stocking 20-30 mmHg +hydrocolloid Comfeel/Unna boot bandage

Venotrain Ulcertec sto-cking/2 Roselastic ban-dages

Tubulcus (Rosidal mobil)/1 Rosidal K bandage

Tubulcus + elastic ban-dage/elastic bandage

Profore/Rosidal sys/localusual care 180 patients

4 RCTs reviewed

Rapid IPC/slow IPC

High stretch bandage(Setopress)/IPC (Flow-tron, HNE Healthcare)16 C6 patients, 11 eva-luated

Systematic review487 patients after hip sur-gery, 5 trials using pumps

4 layer Profore faster hea-ling

Equally effective 24weeks

Equal results healing,even in pt2 with mobilitydeficit

4 L faster healing (adju-sted analysis)

Circaid faster healingrates, equal girth reduc-tion

Equally effective

Stocking higher healingrate, not faster

Stocking higher healingrate

Higher healing rateTubulcus+bandage, lo-wer recurrence rateTubulcus vs class IIstocking

12 weeks healing: 76%short stretch, 78% fourlayer, 31% local care

Not conclusive, furthertrials needed

Rapid IPC more effecti-ve than slow IPCLeg volume decrease,

No difference betweenbandage and IPC

DVT (16/221) (7%) vs52/229 (22%); Caveat:methodological flaws,

1B*

1B

1B

1B*

1B

2B

1B

1B

1B

1B

2B

1B

2B

1B

C6 Bandages

C6 Bandages

C6 Bandages

C6 Bandages

C6 Bandages

C6Bandages/ MCS

C6Band/MCS

C6Band/MCS

C6Band/MCS +bandage

C6Bandages/localtherapy

C6IPC review

C6IPC/IPC

C6IPC/bandage

IPC

IPC

(to be continued)




110

111

112

113

115

114

116

117

169

118

Amaragiri SV et al. Coch-rane Database of Syste-matic Reviews 2000,Issue 1.

Nicolaides AN et al. IntAngiol 2006;25:101-61.

Roderick P et al. HealthTechnol Assess 2005;9:1-78.

Blättler W et al. IntAngiol 2003;22:393-400.

Aschwanden M et al.Thromb Haemost2001;85:42-6.

Arpaia G et al. Blood Coa-gul Fibrinolysis2007;18:131-7.

Jünger M et al. Curr MedRes Opin 2006;22:593-602.

Brandjes DPM et al. Lan-cet 1997;349:759-62.

Ginsberg JS et al. ArchIntern Med 2001;161:2105-9.

Prandoni P et al. AnnIntern Med 2004;141:249-56.

Systematic review:A) 7 RCTs MCS alone(n=1 027),B) 9 RCTs on a back-ground with othermethods (n=1 184), mostbased on fibrinogenuptake tests

Consensus statementRCTs with mutiple com-parisons (MCS, IPC,drugs)

Systematic review

Zinc paste band/MCS 34-46mmHg/0 Varicex F+Rosidal K/Sig-varis 503

Bandage/0Porelast

MCS immediately afterDVT/after 2 weeks, n=73

Lower leg+ thigh banda-ges/bed rest. Endpoints:pulmonary embolism,progression of thrombo-sis, nosocomial infec-tions and/or seriousadverse events in 103patients with proximalDVT

MCS 30-40 mmHg/0Varitex

MCS 20-30 mmHg/pla-cebo

MCS 30-40 mmHg/0

A) DVT 15%/29% in con-trol groupB) 3% vs 14 % in controlgroup

Mechanical methods inaddition to pharmacolo-gical prevention, me-thods of choice in highbleeding risk

Mechanical methodsreduce the risk of DVTused as monotherapy oradded to a pharmacolo-gical method

Reduction of pain andswelling improved bycompression

Equal safety (pulmonaryembolism)

More recanalized venoussegments with immedia-te compression

Better outcome in mobi-le patients: 13.5% in themobile group (n=52) vs28.0% in the immobilegroup (n=50) had adver-se events

Custom made kneelengthReduce PTS

No significant difference

Ready made knee lengthMCS reduce PTS

1A

1A

1A

1B

1B

1B

1B

1A

2B

1A

MCS

IPC, MCS

IPC, MCS

DVT therapyBand/MCS

DVT therapyBand

DVT therapy MCS

DVT therapy

Bandages

PTS preventionMCS

PTS preventionMCS

PTS preventionMCS

DVT prevention

DVT theraspy

PTS prevention

(to be continued)




119

120

121

170

122

Kolbach DN et al. In: TheCochrane Library, Issue3, 2004.

Badger C et al. The Coch-rane Library, Issue 2,2003. Oxford: UpdateSoftware.

Badger CM et al. Cancer2000;88:2832-7.

McNeely ML et al. Brea-st Cancer Res Treat2004;86:95-106.

Szuba A et al. Cancer2002;95:2260-7.

Review 2 RCTs: IPC 15mmHg/50 mmHgMCS 40 mmHg/placebo

Review Physical therapies3 RCTs 150 patients

Bandages/MCS

Band/band+MLD

IPC+DLT/DLT alone, 23patients breast cancer

IPC: 50 mmHg betterthan 15 mmHg.No clear proof for MCS

MCS beneficial, manuallymph drainage no extra-benefit.Bandage + MCS betterthan MCS

Inelastic bandage redu-ce volume more thanMCS

Mild additive effect ofMLD on volume reduc-tion

Additional mean volumereduction by IPC

PTSTherapyIPC, MCS

Lymphedema

LymphedemaBand/MCS

LymphedemaBandages

LymphedemaIPC

1B

1B

1B

1B

1B

PTS therapy

Lymphedema

RCTs: randomized clinical trials; QOL: quality of life; VAS: visual analog scale; RBC: red blood cell; TED: thrombo-embolism deterrent; LDS:lipodermatosclerosis; MCS: medical compression stockings. IPC: intermittent pneumatic compression; DVT: deep vein thrombosis; MLD: minimalluminal diameter; DLT: decongestive lymphatic therapy; PTS: post-thrombotic syndrome.

Documents

Indications for Compression Therapy 2008