Compression Therapy

Compression therapy with support stockings and other bandages is a form of therapy that uses local pressure on the venous vascular system of the leg to increase the flow rate of blood. It is one of the most important therapeutic measures in the treatment of venous diseases in phlebology (medical specialty dealing with the detection and treatment of vascular diseases). Compression therapy is also used to treat lymphatic drainage disorders and surgical and burn scars. In addition to medical support stockings, there are compression bandages, medical thrombosis prophylaxis stockings (MTPS), and so-called intermittent pneumatic compression (IPC; also: apparative intermittent compression, AIK), which will only be briefly discussed here.

Indications (areas of application)

  • Chronic venous insufficiency (CVI)/conductive venous insufficiency – is defined as hypertension (high pressure) in the venous system leading to changes in the veins and skin. CVI leads to venous outflow obstruction as well as microcirculatory disturbances and trophic changes in the affected area (lower legs and feet).
  • Chronic wounds (wound treatment)
  • Lipedema – chronic progressive, dysproportional, symmetrical subcutaneous fat proliferation.
  • Lymphedema – proliferation of tissue fluid caused by damage to the lymphatic system.
  • Edema
    • Postoperative and post-traumatic edema
    • Edema during pregnancy
    • Edema or signs of congestion during immobility (eg, bed rest).
    • Cyclic idiopathic edema – water retention in the tissues (edema), of unknown genesis (origin).
  • Postthrombotic syndrome (PTS) (all stages) – permanent consequential damage after thrombosis in the deep venous system.
  • Deep vein thrombosis (TBVT) or deep vein thrombosis (DVT).
  • Thrombophlebitis – acute thrombosis of the superficial veins with inflammation.
  • Thrombosis prophylaxis – preventive measures against thrombosis; e.g. postoperative, long-haul flight, etc.
  • Ulcer prevention – in the context of a serious disease of the veins can occur an open, poorly healing wound (called ulcer).
  • Ulcus cruris venosum – ulcer that has arisen as a result of chronic venous insufficiency (CVI) (= venous ulcer).
  • Varicosis (all stages)
    • Primary varicosis – degenerative migratory disease of the epifascial, intrafascial and transfascial veins of the legs (connective tissue weakness).
    • Secondary varicosis – extensive formation of varices as a result of other venous disease.
    • Varicose veins during pregnancy
  • Condition after
    • Healed phlebitis (inflammation of the veins)
    • Thrombosis
    • Venous surgery

Contraindications

Absolute contraindications

  • Decompensated heart failure (cardiac insufficiency).
  • Advanced peripheral arterial disease* (pAVD; progressive stenosis (narrowing) or occlusion (blockage) of the arteries supplying the arms/ (more commonly) legs, usually due to atherosclerosis (arteriosclerosis, hardening of the arteries)).
  • Phlegmasia coerulea dolens – acute thrombotic occlusion of all veins of a leg, which can lead to loss of the limb.
  • Septic phlebitis – inflammation of the superficial veins associated with sepsis (blood poisoning).

* Advanced pAVD (critical ischemia) is present when at least one of the following parameters has been measured: Ankle-brachial index (ABI) < 0.5, ankle artery pressure < 60 mmHg, toe pressure < 30 mmHg, transcutaneous partial pressure of oxygen (tcpO2) < 20 mmHg at the dorsum of the foot. Relative contraindications

  • Pronounced weeping dermatoses (skin disease).
  • Chronic compensated heart failure
  • Mild to moderate peripheral arterial occlusive disease (pAVD)
  • Advanced peripheral polyneuropathy (generic term for diseases of the peripheral nervous system associated with chronic disorders of peripheral nerves or parts of nerves).
  • Florid infectious diseases, such as initial phase of erysipelas (non-purulent infection of the skin and subcutaneous tissue (subcutis), which is predominantly caused by ß-hemolytic group A streptococci (GAS (group A streptococci); Streptococcus pyogenes)).
  • Pain caused by the therapy
  • Severe sensory disturbance of the extremity
  • Intolerance or allergy to materials used.

The procedure

The focus of treatment with compression therapy is usually the lower extremity, since it is here that conditions occur that are favored by gravity, among other factors. These include changes in the venous vessels, often due to venous valve insufficiency (weakness of the venous valves), as well as edema (water retention in the tissues). In the upper extremities, for example, after breast cancer surgery with removal of the lymph nodes, lymphatic congestion can occur, resulting in lymphedema, which can be treated with the aid of compression therapy. Compression therapy is also indispensable in the postoperative care of patients after a surgical intervention on the venous system. Venous valve insufficiency in particular causes venous blood to back up in the legs. This stasis decreases blood return to the heart, causes secondary edema, and increases the risk of thrombosis. Thrombosis is a complete or partial occlusion of an arterial or venous vessel due to intravascular (within the vessel) blood clotting. One of the risks of thrombosis in the deep veins of the leg is thromboembolism (a blood clot that breaks loose from a venous vessel near the heart and travels through the bloodstream, for example, to the pulmonary vessels, where it can interrupt the important blood supply and lead to pulmonary embolism). Compression therapy counteracts this process and can be used both prophylactically and therapeutically. The following effects can be attributed to compression therapy:

  • Increase tissue pressure – leads to increased reabsorption of edema.
  • Compression of superficial veins
  • Acceleration of venous blood flow
  • Reduction of the venous diameter
  • Strengthening of the muscle pump – the muscle pump contributes significantly to the return of venous blood to the heart
  • Effect on the fibrinolytic function (fibrin cleavage or dissolution of blood clots) of the endothelium (the surface of the vessels is called the endothelium;it has the property to counteract the formation of blood clots).

The following are the variants of compression therapy:

  • Compression bandages/phlebological compression bandage (PKV) – These bandages are also used for pre- and post-treatment in vein surgery. Because of the different material properties, the treating physician should be familiar with the varieties of bandages.There are semirigid bandages (zinc paste bandage), elastic bandages (made of viscose, cotton, and polyamide), and adhesive and adhesive bandages used as intermittent bandages and permanent bandages.Compression bandages are divided into different categories according to an international consensus recommendation:
    • Light: <20 mmH
    • Medium: ≥ 20-40 mmHg
    • Strong: ≥ 40-60 mmHg
    • Very strong: 60 mmHg
  • Medical compression stockings (MCS) – These stockings exert concentric pressure on the leg, decreasing from distal (torso) to proximal (torso). They have a controlled pressure of at least 15 mmHg at the ankle and are used to improve or at least prevent worsening of the pathological (disease-related) conditions of venous disease. FMDs are used especially in patients with phlebological and lymphological diseases. They are also used for burns and scar treatment.Stockings can be distinguished by compression classes (see table: Compression classes, pressure and therapy):
  • Medical thrombosis prophylaxis stockings (MTPS) – These stockings are used to minimize the risk of phlebothrombosis (blood clots in the deep veins of the legs) in bedridden patients. They are also used for pre-, intra- and postoperative thrombosis prophylaxis, as well as thrombosis prophylaxis during pregnancy and after childbirth.
  • Support stockings – Support stockings are freely available in stores and serve primarily to improve the general well-being. They prevent heavy legs and hydrostatic edema (leg swelling, for example, due to prolonged standing) without disease value.
  • Intermittent pneumatic compression (IPC; also: appliance-induced intermittent compression, AIK) – In this treatment, the limb is in a cuff that builds up excess pressure from the outside in a rhythmic sequence. This causes mechanical expulsion of edema and accelerates blood flow. Compression is used for thrombosis prophylaxis, for edema and also for peripheral arterial occlusive disease (pAVK).

Compression classes, pressure and therapy

Compression class Pressure in the ankle area Therapy
I 18-21 mmHg incipient venous disease
II 23-32 mmHg Truncal varicose veins and postthrombotic syndrome (PTS).
III 34-46 mmHg Lipedema, lymphedema and PTS
IV > 49 mmHg severe lymphedema

Compression therapy with support stockings and other bandages is now part of the standard therapy for venous disorders and is essential after venous surgery. Possible side effects

  • Common side effects of compression therapy include skin dryness (xeroderma) and pruritus (itching). Prevention through consistent skin care with basic therapeutics containing, for example, 5% urea.

Further notes

  • A Cochrane meta-analysis comes to the following evident statements regarding compression therapy of venous leg ulcers:
    • Faster healing under compression therapy than when no compression therapy is used.
    • Compression therapy with one component is less effective compared with compression therapies with multiple components
    • 2-component bandages are comparably effective to 4-component bandages
    • Dressings with short-stretch bandages are less effective than compression therapy with stockings of higher compression classes