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Compression therapy for the treatment of chronic venous insufficiency - UpToDate 17/03/19, 5*50 p. m.

Official reprint from UpToDate®


www.uptodate.com ©2019 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Compression therapy for the treatment of chronic venous


insufficiency
Authors: David G Armstrong, DPM, MD, PhD, Andrew J Meyr, DPM
Section Editors: Joseph L Mills, Sr, MD, John F Eidt, MD
Deputy Editor: Kathryn A Collins, MD, PhD, FACS

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Feb 2019. | This topic last updated: Jan 29, 2018.

INTRODUCTION

Compression therapy remains the cornerstone of management for patients with chronic venous
insufficiency (venous valvular reflux). Chronic venous disease is commonly stratified using the
CEAP (Clinical, Etiology, Anatomy, Pathophysiology) classification, which grades venous disease
based on the presence of dilated veins, edema, skin changes, or ulceration (table 1). (See
"Classification of lower extremity chronic venous disorders", section on 'CEAP classification'.)

Chronic venous insufficiency is defined as CEAP 3 to 6 and represents advanced venous disease
[1]. Chronic venous insufficiency is the most common cause of lower extremity ulceration,
accounting for up to 80 percent of the approximately 2.5 million leg ulcer cases in the United
States [2]. Annual costs in the United States for the treatment of venous ulcers are estimated at
more than $2 billion from costs related to frequent physician visits, care provided by nurses,
compression therapy and wound care products, and, potentially, hospitalization.

Medical compression therapy includes garments or devices that provide static or dynamic
mechanical compression to a body region. For the treatment of lower extremity chronic venous
insufficiency, static compression includes compression hosiery and compression bandages.

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Dynamic (intermittent) compression therapy in the form of intermittent pneumatic compression


pumps and sleeves may be useful under select circumstances.

The pathophysiology, clinical features and diagnosis, and management of chronic venous disease
are discussed elsewhere. (See "Overview and management of lower extremity chronic venous
disease".)

INDICATIONS

Compression therapy remains the cornerstone of management for patients with chronic venous
disease [3,4]. For patients with venous ulceration, the benefits of long-term compression therapy
(stockings or bandages) have repeatedly been demonstrated in randomized trials [5]. Healing rates
as high as 97 percent can be achieved in those who are compliant with therapy [6]. Patients with
edema, weeping, or skin changes in the absence of ulceration also benefit. The goals of treatment
are ulcer healing and reduction of extent of edema, lipodermatosclerosis, and pain. Other
treatments and local wound care are discussed separately. (See "Medical management of lower
extremity chronic venous disease".)

Contraindications

● Peripheral artery disease – Prior to using compression therapy, it is important to confirm that
the ulcer is due to chronic venous insufficiency rather than ischemia, or of mixed origin [7-9].
In patients with nonpalpable pulses or risk factors for peripheral artery disease (PAD),
vascular evaluation including ankle-brachial index (ABI) should be performed. (See "Clinical
assessment of chronic wounds", section on 'Differentiation of chronic ulcers'.)

An ABI ≤0.5 has been proposed as an absolute contraindication to compression therapy,


although caution should be exercised in any patient with an ABI ≤0.9 [7,10-13]. One study that
evaluated compression therapy in 25 patients with mixed ulcers found that arterial perfusion
was not impeded with inelastic compression up to 40 mmHg, provided the ABI was >0.5 and
the absolute ankle pressure was >60 mmHg [14]. Nevertheless, patients with an abnormal ABI
or symptomatic PAD and venous ulcers should be referred to a vascular specialist for
evaluation and decision making regarding wound care, since compression therapy in patients
with significant PAD may lead to complications. Skin necrosis and, in a few instances,

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amputation have occurred as a result of inappropriate compression therapy [15]. (See


"Medical management of lower extremity chronic venous disease", section on 'Indications for
Referral'.)

The interpretation of noninvasive vascular studies and need for further noninvasive testing
(eg, patients with diabetes) are discussed in detail elsewhere. (See "Noninvasive diagnosis of
arterial disease".)

● Superficial or deep vein thrombosis – Compression therapy should not be used in the setting
of suspected or known acute lower extremity venous thrombosis. (See "Phlebitis and
thrombosis of the superficial lower extremity veins" and "Overview of the treatment of lower
extremity deep vein thrombosis (DVT)".)

● Heart failure – Care should be exercised with compression therapy in patients with acute and
chronic heart failure as it might lead to fluid volume shifts affecting cardiac function. (See
"Overview of the therapy of heart failure with reduced ejection fraction".)

● Acute cellulitis, infection, or necrotic tissue – Acute cellulitis, if present, is initially treated with
limb elevation and systemic antibiotics. Compression therapy should be delayed until
inflammation and pain subside. Compression therapy should also not be used in the setting of
acute infections (eg, erysipelas) and/or the presence of necrotic tissue (eg, phlegmasia
cerulea dolens). (See "Cellulitis and skin abscess in adults: Treatment".)

STATIC COMPRESSION THERAPY

Compression bandages and compression hosiery are forms of static compression therapy. Static
compression therapy is characterized by a constant pressure gradient (graded compression) from
distal to proximal in the extremity. Although compression bandages can be composed of elastic or
inelastic materials, or a combination of the two as in the case of multilayer bandages, compression
hosiery is necessarily elastic, though to varying degrees depending upon the material used.

The mechanism by which compression therapy produces beneficial effects is multifactorial. In most
(but not all) reports, compression improves venous hemodynamics by increasing deep venous flow
velocity and venous return, improving lymphatic flow and cutaneous microcirculation, and

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decreasing ambulatory venous pressures [16-25]. The optimal pressure needed to overcome
venous hypertension is not well defined, but it is generally agreed that an external pressure of 35
to 40 mmHg at the ankle is necessary to prevent capillary exudation in legs affected by venous
disease. Compression therapy may also alter the expression of certain proinflammatory matrix
metalloproteinases present in chronic venous ulcers, which results in favorable changes promoting
ulcer healing [26].

Compression hosiery — Prescription-graded compression hosiery provides a pressure gradient


across the length of the stocking. The greatest pressure is exerted at the ankle with a gradual
decrease in pressure proximally. A novel form of compression therapy with higher levels of
compression over the calf has been described but is not standard therapy [27-29]. The flexibility,
elasticity, and handling of compression hosiery depend upon the materials and type of knitting
used. Many compression stockings without rubber (latex) are now available for those patients with
latex sensitivity. Compression hosiery prescription, use, and care are discussed below.

Prescription — Lower extremity compression hosiery prescriptions vary depending on the


symptoms and signs of venous disease and patient factors [30]. The grade of compression,
stocking length, and type of stocking must be specified on the prescription (table 2). Proper
measurement and fitting of the stockings, specific patient instruction, and encouragement enhance
compliance with compression stockings. When the patient is measured for stockings, it should
preferably be done early in the morning when lower extremity edema levels are at their lowest.

Although any physician can recommend and prescribe compression hosiery, many are reluctant
due to unfamiliarity with prescribing and concerns that compression may impair circulation to the
extremity, which is a concern in patients with diabetes or peripheral artery disease. Other issues
that need to be addressed before prescribing compression hosiery include assessment of the skin
(putting on stockings can cause wounds in patients with fragile skin), ensuring the patient has
sufficient manual dexterity to put on the stockings, and whether or not a health care advocate is
available to aid in filling the stocking prescription and possibly to help put on the stockings. As
such, the main prescribers of grade II and higher compression stockings are physicians who
specialize in vascular disease (vascular medicine, vascular surgery, phlebology). (See
'Contraindications' above.)

Compression hosiery is available in five pressure gradients (<20, 20 to 30, 30 to 40, 40 to 50, and

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>50 mmHg). Compression stockings used for treating chronic venous disease need to exert a
minimum of 20 to 30 mmHg pressure at the ankle to be effective (table 2). The white "anti-
embolism" stockings commonly given to patients in the hospital exert variable compression
(ranging from 6 to 19 mmHg pressure at the ankle in one study) and are not an adequate
treatment of venous insufficiency [31]. A higher grade of compression stockings (30 to 40 mmHg)
may be needed with more severe chronic venous disease. Higher-grade compression garments
(eg, 40 to 50 mmHg or 50 to 60 mmHg) are available but are usually reserved for patients with
chronic lymphedema or in the management of burn scars. (See "Clinical staging and conservative
management of peripheral lymphedema".)

A variety of lengths of lower extremity compression hosiery are available, including knee-high,
thigh-high, chaps (unilateral waist high), standard pantyhose, and maternity pantyhose. Knee-high
stockings are sufficient for most patients and are generally well tolerated. It is important that
stockings are not pulled up to the popliteal fossa, where they can bind and cause stricture, skin
irritation, or discomfort. Thigh-high stockings are occasionally prescribed following venous surgery
and may also be useful for providing an additional level of support during periods of prolonged
travel. It is important to pull these stockings up the thigh adequately so they do not wrinkle when
the knee is bent. Otherwise these can also bind in the popliteal space, causing patient discomfort
and limiting compliance [16]. Thigh-high stockings also have a frequent tendency to roll down (in
spite of the self-adherent band at the level of the thigh).

Custom products are also available, such as open toe or zippered stockings. Open toe
compression stockings can be useful and may be better tolerated for patients with foot deformities
(bunions, rheumatoid arthritis, diabetes).

Some patients do not have the strength or mobility to pull on compression stockings. Alternatives
include stockings with a zipper and leggings with Velcro fastening bands. These are custom
options and are more expensive. Donning devices, with appropriate instruction, can help many
patients apply their stockings (figure 1) [32]. Alternately, lower-grade compression stockings (<20
mmHg) may still provide some benefit, given that any level of compression is more beneficial than
no compression at all [33].

If an ulcer is present, compression stockings can be worn over a simple dressing covering the
ulcer; however, compression stockings may be more painful to apply in this situation [34]. (See

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"Medical management of lower extremity chronic venous disease", section on 'Ulcer care'.)

Use and care of compression hosiery — Proper measurement and fitting of the stockings,
specific patient instruction, and encouragement may enhance compliance with compression
stockings. Patients should receive the following instructions:

Before placement

● Wash new compression stockings by hand before wearing to reduce some of the initial
stiffness and difficulty in application.

● Compression stockings absorb skin oils and cause the skin to dry out, so the skin should be
moisturized in the evening just prior to reclining in bed after the stockings are removed.

● Any ulcer or skin care should be undertaken just prior to placing stockings to avoid the need to
remove the stockings later in the day.

Placement

● Stockings should be put on in the morning when edema is minimal and after the placement of
ulcer dressings, if any. If there will be a delay after rising from bed (eg, shower), it is useful to
elevate the legs for 20 to 30 minutes prior to putting on the stockings.

● Patients should sit in a chair with a firm back support (not on the bed) to lean against while
applying the stocking.

● Stockings can be applied by turning the leg portion of the stocking inside-out down to the heel
(figure 1). The foot is slipped into the stretched stocking and pulled onto the foot by its folded
edge. Once the stocking is over the heel, the remainder of the stocking can be gathered and
progressively turned right-side out and gently worked up the leg. Some manufacturers
recommend wearing rubber gloves to firmly grasp the stocking as it is pulled over the heel and
up the leg.

● Higher-grade compression stockings may go on more easily if a light silk hose is worn under
the compression garment.

● A simple device, referred to as a stocking aid, butler, or donner, is helpful for patients with

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limited strength or hand mobility (eg, arthritis) or patients who have difficulty bending over (eg,
obesity, spine problems). Different types of donners are available. One type is a wire frame
with handles. The stocking is stretched over the frame, holding the stocking open and
permitting easier insertion of the foot. Pulling the handles of the donner facilitates pulling the
stocking up the leg (figure 2). Another type of donner is a tube-like sleeve that is placed in the
stocking; after the stocking is in place, the tube is collapsed and removed. Yet another is a
flexible rolling cylinder (Doff N' Donner) upon which the stocking is loaded and rolled onto the
leg.

Care of hosiery

● Skin moisturizers and agents used in ulcer care and wound drainage will soil and decrease
the longevity of stockings. Stockings should be washed after wearing each day, if possible.
Stockings can be hand or machine (delicate cycle) washed with a minimal amount of a mild
detergent in warm water and rinsed thoroughly. All hose can be hung up to dry, but stockings
with elastic should not be machine dried, as the heat will destroy the elastic fibers and the
stockings will wear out faster. Hose made of inelastic fiber can be machine dried with low heat.
The purchase of at least two pairs of stockings at a time is beneficial to facilitate the wash and
wear cycle. The elasticity of all fabrics diminishes with time and washing. In order to maintain
proper compression, ideally, stockings should be replaced every six months [35,36].

Compression bandages — Compression bandaging systems are available as either elastic


compression systems varying between one and four layers or inelastic bandages [37].
Compression bandages (multi- or single-component) must be applied by trained personnel and
changed depending on the degree of drainage [38,39].

● Inelastic – Inelastic compression therapy provides a high working pressure with muscle
contraction, and therefore during ambulation, but no resting pressure. The degree of
compression is not sustained and decreases over wear time [38,40]. Inelastic bandages do
not accommodate to changes in leg volume if edema increases during prolonged standing or
decreases when the legs are elevated. More frequent dressing changes may be needed if
there is absorption of exudate, which can become colonized and malodorous in some
patients. The most common method of inelastic compression therapy is the Unna boot, an
inelastic single-component moist bandage that is impregnated with zinc oxide or calamine

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(with or without glycerin) and hardens after application [4]. The Unna boot is relatively
inexpensive and is available in several commercial preparations in either three- or four-inch
widths. The Unna boot is easy to apply and improves healing rates compared with placebo or
hydroactive dressings [41,42].

● Elastic – Elastic compression can be provided to the lower extremity by one of several
methods, including elastic compression stockings, elastic wraps (eg, ACE), short stretch
bandages (various manufacturers), or specialized multilayered bandaging systems. Elastic
wraps are not generally used because they do not provide sufficient pressure. Multilayered
bandaging systems (eg, Profore) are usually composed of two or four layers, usually
consisting of at least one absorbent layer of wool or cotton wool (often the first layer next to
the skin) and at least one elastic layer. Some systems omit the padding layer (eg, Pütter). The
outermost layer adheres to the layer beneath to keep the bandage from slipping. Unlike the
Unna boot, elastic compression bandaging systems conform to changes in leg size and thus
sustain compression during activity and at rest. The absorptive layers also lessen the
strikethrough of fluid.

Application — Compression bandages (single or multi-component) should be applied by


trained personnel and changed by them once or twice a week, depending upon the degree of
drainage [43]. Any prior compression dressing is first removed with a dressing scissor, the skin is
cleansed, and the ulcer care is performed as needed. (See "Medical management of lower
extremity chronic venous disease", section on 'Ulcer care'.)

General tips for compression bandage placement — Compression bandage systems are
wrapped around the leg from the foot to the proximal calf. The medial and lateral malleoli, tibial
tuberosity, and tibial crest may be more or less prominent depending upon the patient's body
habitus. Compression of skin against these bony prominences may lead to ischemic changes in
the skin if the bandage is wrapped too tight. In addition, nerve compression can occur where the
nerves are more superficial. As an example, the dorsalis pedis artery and deep peroneal nerve
cross the ankle and are superficial on the dorsum of the foot where they are prone to compression
injury (figure 3).

A good compression bandage should tightly compress the leg on all sides and decrease in
pressure from the distal to the proximal leg without constricting the leg. Depending upon the size

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and circumference of the leg, 3-, 4-, or 5-inch wide (8-, 10-, 12-cm) bandages may be best suited
for the leg. Tension on the bandage is most easily controlled with the rolled-up part of the bandage
above its free edge. Only in this manner is the bandage unrolled directly onto the leg (figure 4).

The following tips apply to the placement of rigid and elastic compression bandages [44,45]:

● The knee should be flexed at a right angle during bandaging to prevent congestion in the
popliteal fossa.

● Position the ankle joint in a neutral position (ie, right-angle) prior to applying the bandages,
and maintain this position (figure 4).

● The compression bandage should start just distal to the metatarsal-phalangeal joint.

● Any depressions (eg, perimalleolar region) should be cushioned with wadding or padding to
equalize pressure in the region.

● The bandage should be unrolled directly onto the skin, pulling evenly on both free edges in the
direction of application.

● Do not pull the bandage away from the leg, because this tends to create folds in the bandage.

● The heel must be included in the dressing.

● At the knee, the bandage should include the head of the fibula.

● Generally, bandage dressings have a better grip when subsequent layers are applied
"crosswise" over the prior layer as with the Pütter cross bandaging technique [46].

A correctly applied bandage gives the patient the feeling of firm support but is relatively
comfortable. Compression bandages achieve their full effectiveness in conjunction with active
movement. Thus, if the patient walks around in the bandage, the treatment will be more successful
[44].

Multilayer compression bandages — The level of compression achieved during the


placement of flat, elastic compression bandages is determined by the physical and elastomeric
properties of the fabric, the size and shape of the limb, and the skill or technique of the clinician in

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providing the proper level of tension in the bandage fabric during its placement [43]. If the tension
and, therefore, pressure is too low, the bandage will be ineffective, but if the pressure is too high,
then, as with the rigid bandage, there is potential for tissue ischemia and necrosis [47,48]. Elastic
bandage layers are also applied starting at the base of the toes. Failure to apply proper tension
over the foot can lead to rapid accumulation of edema over the dorsum of the foot. The layers of
the bandaging system are briefly discussed below. Additional general tips for the application of
compression bandages are listed above. (See 'General tips for compression bandage placement'
above.)

Padding (layer 1) — The padding layer should cover all vulnerable areas and should
protrude from beneath the other layers at the toes and proximal leg to provide protection from the
edge of the bandage. Padding provides a layer of material to protect areas at risk for pressure
necrosis, such as the tibial crest, metatarsal bones, dorsum of the foot, medial and lateral malleoli,
and Achilles tendon.

The tibial crest (shin) is vulnerable to high levels of pressure and ischemic skin necrosis,
particularly in individuals with thin limbs, and is often unnoticed until the bandage is removed.
Simple methods such as pleating the padding or the addition of a strip of wool over the area can
provide extra protection [45]. Extra padding should also be used in those who have orthopedic foot
deformities such as hallux valgus (bunion) to prevent potential compression injury.

In patients who are prone to eczematous skin change, a light tubular cotton bandage can be
applied next to the skin before placement of the wool layer. Patients with lymphedematous
changes of the toes can be managed by first bandaging the toes with a light, mildly extensible
cotton bandage.

Crepe bandage (layer 2) — The crepe bandage provides extra absorbency and smooths
down the wool layer prior to placement of the outer elastic bandages. This layer adds little to the
compressive effect of the bandaging system.

Extensible elastic bandage (layer 3) — The extensible elastic bandage layer is the first
of two elastic bandage layers. The material provides a sub-bandage pressure of approximately 17
mmHg when applied at 50 percent extension with a 50 percent overlap using a figure-of-eight
technique [45,49]. In champagne-bottle-shaped limbs, the figure-of-eight application can be

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widened to improve the conformability of the bandage. If more pressure is required over an
edematous calf, the following techniques can be used [45]:

● Increase bandage extension >50 percent


● Increasing overlap >50 percent
● Add an additional elastic bandage layer

Similarly, in patients with thin limbs, pressure can be reduced by decreasing bandage extension
<50 percent. The wide extensibility curve (ability to stretch) of these bandages allows a degree of
flexibility during their application, but again the clinician must take care not to decrease the
pressure to an ineffective level.

Cohesive elastic bandage (layer 4) — The cohesive elastic bandage provides a greater
level of compression (sub-bandage pressure approximately 23 mmHg), and thus, it must not be
overextended [45]. It is a frequent misconception that this layer simply maintains the bandage in
position. This layer of bandaging should extend over the upper portion of the gastrocnemius
muscle to prevent slippage with care not to excessively compress in the region of the superficial
peroneal nerve (figure 3). The cohesive layer should not contact the skin directly due to the
potential for development of latex allergy. Latex-free outer layer systems are available. The two
outer elastic bandages, when used in combination, provide a sub-bandage pressure of
approximately 40 mmHg [45].

Unna boot — Inelastic paste compression bandages (ie, Unna boot) have several
disadvantages, which are discussed below, and are inferior to elastic compression (hosiery or
bandaging systems) for healing venous ulcerations. (See 'Choice of initial therapy' below.)

The Unna boot might require relatively frequent changes in heavily exudative wounds, can be
messy, can limit bathing and shoe gear, and many physicians may not have appropriate training in
techniques for applying these bandages. The desired sub-bandage pressure may be difficult to
achieve, and a substantial proportion of patients with venous leg ulcers may not receive adequate
compression therapy. In one study, optimal sub-bandage pressure was obtained in 63 percent of
nurses applying two-component bandages, 41 percent applying elastic bandages, and 40 percent
applying inelastic bandages [50]. As a result, the bandages can be improperly applied and can
worsen the venous ulcer or create new ulcers. As a result, there has been a transition to elastic

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bandages and increasing interest in the effectiveness of compression hosiery alone or as a


component of elastic bandaging as an initial therapy for the treatment of venous ulcers [51-54].

The application of the Unna boot begins at the metatarsal-phalangeal joint and ends just below the
level of the tibial tuberosity. Failure to wrap the midfoot can lead to rapid accumulation of edema.
Starting at the first metatarsal, the bandage is placed across the dorsum of the foot across the
instep and around the plantar surface, then against the original starting point. Bandaging is
continued with an upward slant overlapping the bandage one-third to one-half while moving
proximally. A figure-of-eight turn is made around the ankle. A graded level of compression should
be applied with the greatest amount of compression at the ankle with gradually less toward the
knee. Avoid excessive pressure over any bony prominences or orthopedic foot deformities.
Bandaging is continued up the leg, overlapping each turn one-third to one-half of the width of the
bandage up to the tibial tuberosity. The bandage can be cut, and additional layers can be started
again at the foot, or the bandage can be loosely wrapped in two or three turns back to the foot
level before wrapping the leg again. The standard-length Unna bandage will typically wrap from
foot to knee two or three times depending upon the diameter of the leg. For patients who have a
larger extremity, a second bandage may be needed. An overwrap of gauze can be applied to
minimize soiling of the patient's garments. Additional general tips for the application of
compression bandages are listed above. (See 'General tips for compression bandage placement'
above.)

Patient instructions and follow-up — The patient should be instructed to elevate the affected
extremity when seated and avoid prolonged standing [55]. The patient may complain of pain
initially following placement of the compression bandage, but the pain should subside. If pain
increases or new pain is experienced that is not alleviated with elevation, or there is discoloration
or numbness of the foot or toes, the bandage should be removed immediately.

The patient should be advised to keep the dressing dry; a plastic bag can be placed over the leg
when showering.

The patient should return to have the compression bandage changed once or twice per week. If
there is excessive drainage or foul odor, the patient should be instructed to return to have the
dressing changed; more frequent dressing changes up to three times a week may be needed until
drainage is controlled.

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Adjustable compression — Adjustable compression devices (eg, Circaid) have been used
primarily in the control of lymphedema. They consist of a series of overlapping, interlinked straps
that are fastened using Velcro. A small study randomly assigned patients with untreated chronic
venous insufficiency to adjustable compression (40 mmHg) versus multilayer bandaging (60
mmHg) [56]. Limb volume reductions were significantly greater in the adjustable compression
group at treatment day 7 (26 versus 19 percent). A systematic review identified two small trials
comparing adjustable compression with inelastic paste bandages and four-layer compression
bandages; there were no significant differences in ulcer area or ulcer healing, respectively [5].

DYNAMIC COMPRESSION THERAPY

Dynamic (intermittent) compression therapy, also known as intermittent pneumatic compression


(IPC), is another form of compression that does not involve bandaging. IPC may benefit those
patients who cannot tolerate static compression. In addition to generating external pressure,
intermittent compression also enhances fibrinolysis, a potentially important mechanism in reducing
fibrosis and enhancing ulcer healing [57,58].

Compression hosiery may be ineffective or not tolerated in patients with morbid obesity, severe
edema, and/or lipodermatosclerosis. IPC produces beneficial physiologic changes, which include
hemodynamic, hematologic, and endothelial effects, which may be helpful in the initial
management of these patients and may promote healing of venous ulcers [59]. However, IPC
pumps should not be used in patients with edema due to heart failure, occlusive arterial disease, or
acute cellulitis.

A systematic review of randomized trials concluded that there was insufficient evidence on which
to make definitive conclusions about the efficacy of IPC pumps in the treatment of venous
ulceration [60,61]. They may increase healing when compared with no compression therapy, but
the impact on healing when used instead of or added to compression bandaging is unclear.

IPC pumps consist of a plastic air cylinder that encases the lower leg and periodically inflates to a
preset pressure to compress the leg and then deflates. IPC pumps may consist of a single
chamber or multiple chambers that inflate sequentially from the foot to the knee. Multichamber IPC
pumps are more effective than single-chamber systems in clearing venographic dye from the deep

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venous system [62]. IPC is generally prescribed for four hours per day [63].

CHOICE OF INITIAL THERAPY

The choice of initial therapy (elastic, inelastic, single layer, multilayer) is based upon the presence,
condition, and size of the venous ulcer; level of pain; and support logistics related to type and
frequency of dressing changes and consequent patient compliance, local use and expertise, and
availability of resources (eg, nonphysician specialists who can apply and reapply complex
bandaging systems). What works well within one health care system may not work well in another.
However, for most patients, based upon systematic reviews and meta-analyses of predominantly
small randomized trials, we suggest elastic, multilayered compression rather than inelastic, single-
layer bandages for the initial treatment of venous ulceration [5,51]. Whether multilayer
compression hosiery or bandaging systems are more effective for patients with venous ulceration
is the subject of debate [5]. Inelastic bandages may be useful during the initial phase of edema
reduction, when bandages require frequent changing due to excessive weeping.

Although inelastic bandaging (ie, Unna boot) is effective (see 'Unna boot' above), systematic
reviews and meta-analyses of randomized trials found that adding a component of elastic
compression therapy results in faster ulcer healing compared with inelastic compression therapy
alone [5,51]. Benefits of elastic compression are consistent across patients with differing
prognostic profiles. In addition, high compression appears to be more effective compared with low
compression, and multilayer bandages are more effective for achieving the desired level of
compression [64,65]. Although multilayered elastic bandaging systems are more expensive per
use (table 3), the improved patient comfort may be associated with better compliance and lower
overall cost [5,66-68]. The main disadvantage of multicomponent elastic compression bandaging
systems is the degree of experience required for proper application. By comparison, although
uncomfortable to wear, inelastic bandaging (ie, Unna boot) is relatively inexpensive and, for those
experienced with its application, easy to apply [4].

Compression hosiery has some advantages over compression bandages for the treatment of
chronic venous ulcers, such as reducing the number of physician visits and problems associated
with bathing or wearing shoes [69]. But there remain issues with hosiery soilage in patients with
significant fluid exudation from weeping ulcers. The effectiveness of elastic compression hosiery

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compared with elastic bandaging was evaluated in a multicenter, randomized trial of 457 patients
with venous leg ulcers, which found that initial therapy with two-layer compression stockings
versus four-layer compression bandages resulted in similar rates of ulcer healing (71 versus 70
percent) [53]. Median time to healing was 99 days. The average cost was lower for the stocking
group, and ulcer recurrence among ulcers that healed was significantly lower in the group that
used stockings to initially heal the ulcer (14 versus 23 percent), but the authors did not assess
which treatments (local or other interventions) were used after ulcers had healed. The stocking
group had higher rates of treatment change (38 versus 28 percent) related to worsening of the
ulcer, patient discomfort, or noncompliance, and more adverse events overall, but no significant
difference in serious adverse events (defined as death, life-threatening, limb-threatening, requiring
admission, prolonging hospital stay, persistent or significant disability). A systematic review
identified four trials evaluating compression hosiery for preventing ulcer recurrences [53,70].
Recurrence was lower for high-compression hosiery compared with medium-compression hosiery
at three years in one trial, while another trial found no difference at five years. Intolerance of
compression hosiery was high.

COMPLIANCE

Venous ulcer recurrence is common due to low compliance with compression therapy, particularly
once wound healing has been achieved. Many factors contribute to low compliance, and it is
estimated that approximately 60 to 70 percent of patients are noncompliant [71], particularly with
paste compression bandages, which can be uncomfortable, leading some patients to remove them
prematurely. Patient compliance with compression stockings is also often poor, with common
patient complaints such as itching, tightness, difficulty with application, pins and needles sensation,
and rash [72].

Patient beliefs that compression therapy is unnecessary and ineffective for preventing ulcer
recurrence are significantly related to nonadherence, underscoring the importance of patient
education and a positive therapeutic relationship in the treatment of venous insufficiency [73].
Compression stockings that are made of flexible and soft materials and include features such as
zippers or Velcro fasteners are generally easier for patients to use, especially older patients, and
may increase compliance.

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Younger patients may be more compliant than older patients, and compliance is better in patients
with lesser degrees of chronic venous disease (eg, varicose veins) compared with chronic venous
insufficiency (severe edema, ulceration). In a prospective trial of younger subjects (mean age 60
years), 76 percent were fully compliant with their compression stockings, 16 percent were
"sometimes" compliant, and only 8 percent never wore their stockings [74]. In a study of 3144
patients newly referred to a tertiary care practice, the overall compliance rate was low but was
better among those with a history of deep venous thrombosis compared to those with no history of
deep venous thrombosis (50 versus 35 percent) [71].

COMPLICATIONS

Most of the complications associated with compression bandaging are avoidable. Symptoms and
signs of lower extremity ischemia can develop if the bandage is applied too tightly. Patients should
be instructed to remove the bandage if numbness, tingling, or discoloration of the toes occurs and
to seek medical attention if the symptoms do not immediately resolve. (See 'Patient instructions
and follow-up' above.)

Skin necrosis — Excessive pressure over the instep and bony prominences of the leg and foot
can cause skin necrosis. Additional padding prior to bandaging will alleviate pressure points. (See
'General tips for compression bandage placement' above.)

Fungal infection — Accumulation of exudate from the ulcer under compression dressings can
lead to foul odor and predispose to fungal infection. If the bandage becomes soaked, all occlusive
and compressive dressings should be removed and any fungal rash treated to resolution before
reapplication. Increasing the frequency of bandaging may help to manage the drainage. (See
"Dermatophyte (tinea) infections", section on 'Tinea corporis'.)

Contact dermatitis — Contact dermatitis can develop from one of the components in the
bandaging system in susceptible individuals (eg, zinc in Unna boot, latex in elastic wraps). Latex-
free elastic wraps are available. (See "Medical management of lower extremity chronic venous
disease", section on 'Contact dermatitis'.)

COST OF COMPRESSION THERAPIES


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Representative charges for compression stockings, intermittent pneumatic compression, ulcer


dressings, and skin graft equivalents are listed in the table (table 3). In the United States, the cost
of compression hosiery of at least 30 to 40 mmHg may be covered by insurance. At least partial
coverage of dressings and home intermittent pneumatic compression pumping may also be
covered, if applied or supervised by a home visiting nurse, or if prescribed in a hospital or nursing
home setting. Properly performed studies evaluating the cost effectiveness of various treatment
options are not currently available.

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions around
the world are provided separately. (See "Society guideline links: Chronic venous disorders".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics."
The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading
level, and they answer the four or five key questions a patient might have about a given condition.
These articles are best for patients who want a general overview and who prefer short, easy-to-
read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and
more detailed. These articles are written at the 10th to 12th grade reading level and are best for
patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or
e-mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Varicose veins and other vein disease in the legs (The
Basics)")

● Beyond the Basics topics (see "Patient education: Chronic venous disease (Beyond the
Basics)")

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SUMMARY AND RECOMMENDATIONS

● For patients with venous insufficiency that is associated with ulceration, we recommend
compression therapy (Grade 1B). Compression therapy (either compression hosiery or
compression bandaging systems [elastic or inelastic]) is associated with high rates of ulcer
healing for patients who are compliant. Patients with edema, weeping, or eczema, in the
absence of ulceration, also benefit from compression therapy. (See 'Indications' above and
'Static compression therapy' above and 'Compliance' above.)

● Compression therapy is contraindicated in patients with peripheral artery disease, acute lower
extremity superficial or deep vein thrombosis, acute or chronic heart failure, or in the presence
of acute cellulitis, infection, or necrotic tissue. Noninvasive arterial studies should be
performed on patients with lower extremity ulcer who have weak or nonpalpable pulses or risk
factors for atherosclerosis. Cellulitis and deep vein thrombosis should be treated prior to
placement of compression bandages. (See 'Contraindications' above.)

● Several types of compression are available and are generally divided into inelastic and elastic
compression. For the treatment of ulceration due to chronic venous insufficiency, we suggest
elastic, multilayered compression rather than inelastic, single-layer bandages (Grade 2B).
Adding a component of elastic compression therapy results in faster ulcer healing, and patient
compliance is also improved. The type of elastic compression used, typically multilayered
hosiery or bandaging system, depends upon local use and expertise and the availability of
resources. Inelastic bandages may be useful during the initial phase of edema reduction,
when bandages require frequent changing due to excessive weeping. (See 'Choice of initial
therapy' above.)

● Compression hosiery is available in a variety of lengths and styles. Compression hosiery


prescription, use, and care are discussed above. (See 'Compression hosiery' above.)

● Compression bandage systems are wrapped around the leg from the foot to the proximal calf.
Care should be taken to avoid excessive compression of skin against any bony prominences.
Walking is needed to achieve the full compressive effect of the bandage. (See 'Application'
above.)

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● Complications of compression bandaging are avoided with proper application. If the patient
complains of excessive pain following placement or new pain is experienced that is not
alleviated with elevation, or there is discoloration or numbness of the foot or toes, the bandage
should be removed immediately. If the symptoms do not resolve with bandage removal, the
patient should seek immediate medical attention. (See 'Application' above and 'Patient
instructions and follow-up' above.)

● Dynamic compression therapy is an alternative form of compression therapy that may be


useful for patients for whom standard compression therapies may be ineffective or not
tolerated (eg, morbid obesity, severe edema, and/or lipodermatosclerosis). (See 'Dynamic
compression therapy' above.)

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GRAPHICS
CEAP classification for chronic venous disorders

Clinical classification
C0 No visible or palpable signs of venous disease

C1 Telangiectasias, reticular veins, malleolar flares

C2 Varicose veins

C3 Edema without skin changes

C4 Skin changes ascribed to venous disease (eg, pigmentation, venous eczema, lipodermatosclerosis)

C 4a Pigmentation or eczema

C 4b Lipodermatosclerosis or atrophie blanche

C5 Skin changes as defined above with healed ulceration

C6 Skin changes as defined above with active ulceration

S Symptomatic, including ache, pain, tightness, skin irritation, heaviness, and muscle cramps, and other
complaints attributable to venous dysfunction

A Asymptomatic

Etiologic classification
Ec Congenital

Ep Primary

Es Secondary (post-thrombotic)

En No venous cause identified

Anatomic classification
As Superficial veins

Ap Perforator veins

Ad Deep veins

An No venous location identified

Pathophysiologic classification
Pr Reflux

Po Obstruction

Pr,o Reflux and obstruction

Pn No venous pathophysiology identifiable

Limbs in higher categories have more severe signs of chronic venous disease and may have some or all of the
findings defining a less severe clinical category. Each limb is further characterized as asymptomatic (A), for
example, C0-6,A, or symptomatic (S), for example, C0-6,S. Symptoms that may be associated with
telangiectatic, reticular, or varicose veins include lower extremity aching, pain, and skin irritation. Therapy
may alter the clinical category of chronic venous disease. Limbs should therefore be reclassified after any form
of medical or surgical treatment.

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Data from: Eklof B, Rutherford R, Bergan J, et al. Revision of the CEAP classification for chronic venous disorders:
Consensus statement. J Vasc Surg 2004; 40:1248.

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Compression stockings in chronic venous disorders

Level
Class Pressure of Indication CEAP*
support

OTC ¶ <15 mmHg Minimal Asymptomatic individuals as needed for comfort 0,1

I 15-20 Mild Minor varicosities; tired aching legs; minor ankle, leg, or foot 1,2,3
mmHg swelling

II 20-30 Moderate Moderate to severe varicosities, moderate swelling, phlebitis, 3,4


mmHg following vein ablation

III 30-40 Firm Severe varicosities, severe swelling, management of active 4,5,6
mmHg ulceration, following DVT, post-surgery

IV >40 mmHg Extra firm Lymphedema NA

* Clinical-Etiologic-Anatomic-Physiologic classification of chronic venous disorders.


¶ OTC: Over-the-counter, no prescription needed.

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Heel-pocket-out method of putting on compression


stockings

Stockings can be applied by turning the leg portion of the stocking inside-out
down to the heel (A). The foot is slipped into the stretched stocking and
pulled onto the foot by its folded edge (B). Once the stocking is over the heel,
the remainder of the stocking can be gathered and progressively turned right-
side out and gently worked up the leg (C).

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Using a stocking donner to put on compression stockings

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Nerves prone to stretch or compression in lithotomy

Sciatic and femoral nerve stretching occurs with hip flexion and external
rotation. The fibular (peroneal) nerve is superficial in the proximal leg and
this site is prone to compression. The posterior tibial nerve is stretched with
ankle dorsiflexion and is at risk when the foot is in stirrups.

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Compression bandage placement

Shown is a basic example of the application of a compression bandage for the


treatment of chronic venous insufficiency. The bandage is applied from the toes to the
tibial tuberosity, moving from distal to proximal in an overlapping manner. Care is taken
to avoid bunching or wrinkling of the dressing during application which can cause
localized pressure. Multilayer compression bandages have two to four layers including a
layer of soft padding and at least one elastic layer; each layer is applied in a similar
manner.

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Representative costs to treat venous disease

Life-span of
Supply Expense/unit Unit
item

Compression stockings

Over the counter knee high (<15 mmHg $$ per pair 6 months
compression)

30-40 mmHg knee high, fitted $$ per pair 6 months

30-40 mmHg thigh high, fitted $$ per pair 6 months

Higher grade, custom $$$ per pair 6 months

Jobst Ulcer Care $$ per pair 6 months*

CircAid legging $$$$ each extremity 6 months

Unna Boot Kit $ per kit 1 to 2 weeks

Four layer compression wrap $$ per kit 1 to 2 weeks

DuoDerm occlusive dressing (4 cm x 4 cm) $ per dressing 3 to 5 days

Nonadherent dressing (2 cm x 3 cm) ¢ per dressing 1 per day

Intermittent pneumatic compression $$$$$ rental per month Not applicable

¢: ≤$1 USD.
$: ≤$19 USD.
$$: $20 to $199 USD.
$$$: $200 to $499 USD.
$$$$: $500 to $1999 USD.
$$$$$: >$2000 USD.

USD: United States dollar.


* Decreased lifespan when used with to treat active ulcer.

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