How does compression really work?

Transcription

1 How does compression really work? Felizitas Pannier Private Practice Phlebology & Dermatology, Bonn, Germany Many thanks to Hugo Partsch, Horst Gerlach and Hans-Jürgen Thomä for some of the pictures

2 Compression in praehistoric time: Cave paintings in the Sahara 2 Photographed by R. Tournay reproduced in: Compression Therapy of the Extremities Editions Phlébologiques Françaises, 2000

3 J.W. Goethe 1817 healed from an Ulcer by compression 3 ein von Serenissimo (Großherzog Carl August) höchst selbst verordneter Schnürstrumpf [hat] Wunder getan und wenn sich das Übel so fort und fort vermindert, so werde ich s gar bald los.

4 Compression Improvement of hemodynamics Reduces venous refluxes Promotes venous pump Improvement of symptoms and edema formation Improves microcirculation Reduces oedema Promotes lymphatic drainage

5 Pressure

6 Compression classes defined by ankle resting pressure

7 Which pressure is necessary to compress leg veins? 5 the pressure of the bandage has to exceed the intravenous pressure Partsch B et al. J Vasc Surg. 2005, 42: mm Hg

8 Graduation of compression stockings

9 Act round Laplace Law: Pressure = Tension / Radius

10 In SUPINE POSITION superficial veins can easily be compressed Medi ulcer kit, Liner 18 mm Hg Medi ulcer kit, 2 layers, 35 mm Hg Courtesy H.Partsch

11 In STANDING POSITION deep veins can only be compressed with very high pressure 42 mm Hg 82 mm Hg Courtesy H.Partsch

12 Improvement of hemodynamics The resting pressure below compression devices is not able to compress leg veins in the standing position to a higher extent During ambulation (muscle pump) subdevice pressure peaks occur Pressure peaks under the bandage during walking lead to an intermittent occlusion of leg veins (Hugo Partsch) The extent depends on the material used

13 Intermittent venous occlusion impedes venous reflux Artificial valve effect X 0-40 mm Hg 60 mm Hg Courtesy H.Partsch Not due to adaptation of valve remnants

14 Mean ambulatory venous hypertension mm Hg patients with CVI 60 elastic non-elastic 40 p<0, compression pressure (mm Hg): 0 14,3 30,8 23,2 53,6 no compress. one GEC two GEC one short two short normal range Partsch H, VASA 1984;13:58-64

15 Pressure in a dorsal foot vein, walking on a tread mill Deep valvular incompetence (PTS) Ambulatory venous hypertension No bandage Elastic bandage Inelastic Courtesy H.Partsch

16 Compression Improvement of hemodynamics Reduces venous refluxes Promotes venous pump Improvement of edema formation Improves microcirculation Reduces oedema Promotes lymphatic drainage

17 -5cm in 5 days Courtesy H. Partsch

18 Compression in leg swelling How much compression is necessary to treat leg swelling?

19 Mosti G, Picerni P, Partsch H: Compression stockings with moderate pressure are able to reduce chronic leg oedema. Phlebology 2012;27: Aim: To compare the efficacy of compression stockings and inelastic, high-pressure bandages concerning leg volume reduction in patients with chronic leg oedema. Methods: 42 legs, 30 patients with chronic venous leg oedema were randomized to strong inelastic bandage (IB) or elastic stocking (ES) (23-32 mmhg). Water displacement volumetry after 2 and 7 days Results: no significant difference between stockings and bandages significant reduction in leg volume after 2 days -9.6% [95% CI ] by ES -11.5% [95% CI %] by IB and after 7 days -13.2% [95% CI ] by ES -15.6% [95% CI ] by IB pressures over 60 mmhg produced by bandages showed a negative correlation with volume reduction.

20 Partsch H, Winiger J, Lun B: Compression stockings reduce occupational leg swelling. Derm Surg 2004;30: Aim: to investigate which compression pressure is necessary to prevent leg swelling Methods: 12 volunteers, volume of both lower legs was measured in the morning and 7 h later, the difference being defined as evening edema (EE) (ml) The procedure was carried out for 4 days, in which the subjects wore below-knee stockings of different compression levels Results: average EE of the noncompressed legs 62.4 ml left leg and 94.4 ml right leg (n.s.) light support stockings: EE significantly reduced to 40.3 ml compression class A: EE significantly reduced to ml compression class I: EE significantly reduced to ml compression class II: EE significantly reduced to ml Conclusion: Calf-length compression stockings with a pressure range between 11 and 21 mmhg are able to reduce or totally prevent evening edema

21 Low compression pressure is able to reduce evening edema Evening oedema 200 < mm Hg 100 ml Light Support Compression Class A Compression Class I * *** *** *** Compression Class II Partsch H. et al: Dermatol Surg May;30(5):737-43;

22 The lowest venous ulcer recurrence rates were seen in patients who were compliant with hosiery regardless of the compression level. In total, 11 (11.1%) study patients did not adhere to wearing the prescribed compression hosiery; 7 of these developed a new ulcer within the 12-month period. There was no statistically significant difference between the two groups in compliance at either 3 or 12 months (P = and 0.564, respectively).

23 Reasons why low compression is effective Antiinflammatory properties Closing of endothelial gaps (Herouy) Activation of lymphangions Others

24 Stiffness

25 Stiffness DEFINITION: Pressure increase by increase of leg circumference Friction between layers increases stiffness Higher friction also with adhesive (cohesive) materials Characterizes the proportion of tolerability (rest) and efficacy (work) Therefore this is the deciding parameter of practical interest ICC Consensus, Derm Surg. 2008;34:600-09

26 Static Stiffness Index (SSI) = pressure (in vivo) in standing position minus pressure in lying position

27 Messung der Stiffness in vivo 1 Static Stiffness Index ¹ (SSI) ¹ Partsch: The SSI: A simple Method to acsess ( ) Dermatol Surg 2005,

28 Compression stocking Class II SSI 5 Lying dorsiflexions standing

29 Zinc paste strong after application SSI 50 Lying dorsiflexions standing

30 Druck [mmhg] Stiffness 680 dtex 475 dtex 330 dtex Toleranzkanal einer Kompressionsklasse max min tan Stiffness Dehnung [%] Dr. Thomä Stiffness beim Kompressionstrumpf 21. Bonner Venentage

31 Consequences of pressure and stiffness Compression stockings differ in pressure AND stiffness due to different knitting and material Within one compression class different stiffness levels are available but up to today not classified Not only the pressure but also the stiffness is responsible for the compensation of clinical signs and symptoms Since recently stiffness of a stocking can be measured in vitro Up to today no RCTs exist comparing low and high stiffness in different indications

32 Summary Compression stockings with low ankle pressure (and stiffness) are able to compensate symptoms and moderate edema Compression stockings improve ulcer healing and recurrence To improve hemodynamics in severe CVI higher pressure and / or higher stiffness are necessary

33 Thank you very much for listening