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Compression therapy in venous disease

We recently discussed opportunities to exchange information published in our journals and/or by authors affiliated with our Phlebology societies. This editorial on compression therapy is our first such collaboration. Compression remains an important intervention in the management of venous and lymphatic disease – even in this time of high-tech innovation. Pannier et al. reported on prevalence and acceptance of medical compression stockings (MCS) based on results from the Bonn Vein Study. This was a cross-sectional study of randomly recruited residents living in and around Bonn from November 2000 to March 2002. Of the 3072 patients, 23% had received phlebological treatment (13% male, 31% female). MCS was used in 15%, with a range of 1% in C0 up to 82% in those with C5/6. At the time of the survey, MCS was worn by 31% of those who had ever worn stockings in the past. Compliance was high: MCS were worn five or more days per week by 73% of patients and eight or more hours per day by 89%. On average, 71% of the participants said that the disease for which MCS was prescribed had improved as a result of MCS therapy. Despite the long history of use of compression, there has been a lack of agreement and clarity regarding classification and terms to describe bandaging systems. Studies have shown that the haemodynamic effect of compression depends primarily on interface pressure and stiffness: higher pressure being better than lower pressure to correct superficial and deep venous incompetence. To many, the concept appears as a heuristic principle despite lacking evidence of its clinical value. Partsch et al. recently published a consensus document in order to provide terms to describe bandaging systems and to propose a classification based on in vivo measurements of sub-bandage pressure and stiffness. van der Wegen-Franken et al. demonstrated considerable variation in static and dynamic stiffness of different brands of elastic MCS. Little evidence-based medicine exists to assess the effect of stiffness of compression stockings. Well-designed clinical trials are required. Although much remains to be understood and controversies remain, there is an evidence-basis for benefits of compression for some of the commonly accepted indications. These are reviewed here in brief. Compression for occasional venous leg symptoms and oedema Amsler and Blättler performed a meta-analysis of randomized, controlled trials that compared stockings exerting an ankle pressure of 10–20 mmHg with placebo or no treatment, and with stockings exerting a pressure of more than 20 mmHg. Healthy subjects at risk for occupational leg symptoms and oedema, patients with C1–3 CVD, or varicose vein patients after surgery were studied. Calf length stockings were used exclusively. Eleven RCTs fulfilled criteria. Despite significant methodological heterogeneity, and sometimes sub-standard reporting, the meta-analysis suggested that leg compression with 10–15 mmHg is an effective treatment for chronic venous disorders. A study of the same authors appearing in this issue of Phlebology shows that some leg-related symptoms have a psychic rather than venous cause and cannot be treated with compression. Relief of the organic-type symptoms was related to reduction of leg volume. Stockings providing more than 20 mmHg were not well-tolerated by the group of individuals with low-grade symptoms.