Classification of Compression Stockings ICC Meeting, Copenhagen, May 17, 2013. pressure of compression stockings matters (clinical importance of pressure) Giovanni Mosti; Lucca, Italy
disclosure no conflict of interest
pressure of compression stockings matters pressure and stiffness are the main determinants of the effectiveness of every compression device comparing compression materials with the same stiffness does the pressure matter?
pressure of compression stockings matters 1. experimental data ejection fraction venous reflux 2. clinical data
mmhg pressure and ejection fraction Interface Pressure Static Stiffness Index 100 30 EF % 80 60 40 mm Hg 25 20 15 10 20 0 Minimum 25% Percentile Median 75% Percentile Maximum supine 19.00 21.00 22.00 23.00 25.00 liner standing 20.00 22.50 23.00 25.00 27.00 supine 31.00 37.00 38.00 40.75 43.00 elastic lit standing 32.00 39.75 42.00 44.50 46.00 5 0 Minimum 25% Percentile Median 75% Percentile Maximum liner 1.000 1.000 1.500 2.000 2.000 elastic kit 1.000 1.000 2.500 5.250 6.000
pressure and ejection fraction ejection fraction 100 80 EF % 60 40 20 0 Minimum 25% Percentile Median 75% Percentile Maximum baseline 18.43 26.47 31.20 40.78 57.20 liner 27.89 36.94 44.08 52.03 66.60 elastic kit 38.23 49.82 60.77 68.82 95.25
pressure and ejection fraction Interface Pressure 1 "Progressive" Interface Pressure 2 "Progressive" mm Hg 100 90 80 70 60 50 40 30 20 10 0 Minimum 25% Percentile Median 75% Percentile Maximum supine B1 11.00 17.00 18.00 19.00 21.00 standing B1 15.00 19.00 20.00 21.00 24.00 supine C 20.00 25.00 27.00 28.00 32.00 standing C 23.00 28.25 30.00 31.00 34.00 mm Hg 100 90 80 70 60 50 40 30 20 10 0 Minimum 25% Percentile Median 75% Percentile Maximum supine B1 24.00 30.25 33.00 34.75 39.00 standing B1 28.00 35.25 37.50 39.00 43.00 supine C 42.00 45.00 46.00 47.75 55.00 standing C 45.00 49.25 51.00 54.00 55.00
pressure and ejection fraction Ejection Fraction 100 80 EF % 60 40 20 0 Minimum 25% Percentile Median 75% Percentile Maximum baseline 11.22 31.54 34.90 39.85 56.54 1 progressive 28.45 45.40 53.33 59.99 91.09 2 progressive 38.32 51.96 67.53 77.68 100.0
pressure and reflux in patients with DVI
venous reflux and compression 12 patients with severe axial GSV reflux reflux volume 80 baseline 20 mm Hg 40 mm Hg 60 mm Hg 60 ml/sec 40 20 0 Minimum 25% Percentile Median 75% Percentile Maximum baseline 24.70 29.28 44.05 53.08 58.60 elastic 25.30 27.88 40.15 52.10 57.10 inelastic 11.80 19.80 21.20 28.93 42.10 elastic 10.80 16.38 22.30 25.38 29.80 inelastic 0.0 4.950 8.800 13.38 18.60 elastic 0.0 0.0 1.050 4.150 7.800 inelastic 0.0 0.0 0.0 0.0 0.0 Mosti G, Partsch H. Duplex scanning to evaluate the effect of compression on venous reflux. Int Angiol. 2010 Oct;29(5):416-20.
venous reflux and compression 80 70 60 interface pressure mm Hg 50 40 30 20 10 0 Minimum 25% Percentile Median 75% Percentile Maximum supine 19.00 21.00 21.50 22.75 24.00 1 ECS 2 ECS 3 ECS standing 14.00 22.00 24.50 25.75 29.00 supine 34.00 35.00 36.50 37.75 38.00 standing 37.00 38.25 40.00 41.00 42.00 supine 53.00 53.25 54.00 55.00 56.00 standing 56.00 57.00 57.50 59.00 60.00
venous reflux and compression reflux VFI 12 11 10 9 8 7 6 5 4 3 2 1 0 baseline 1 stocking 2 stockings 3 stockings
clinical data C1-C3s: French class 1 stocking is effective in reducing pain and improving quality of life Benigni JP et al. Efficacy of class 1 elastic compression stokings in the early stages of chronic venous disease. Int Angiol 2003; 23: 383-93
clinical data C2-C4: there is no evidence that elastic stockings exert any beneficial effect therefore that pressure counts. This severe conclusion despite the fact that all studies report beneficial effects on symptoms comparing ECS with different pressure ranges or ECS vs no compression is due to poor quality of the studies Future research should consist of a large RCT of participants with trunk varices either wearing or not wearing compression stockings to assess the efficacy of this intervention. Shingler S, Robertson L, Boghossian S, Stewart M. Compression stockings for the initial treatment of varicose veins in patients without venous ulceration. Cochrane Database Syst Rev. 2011 Nov 9;(11):CD008819.
clinical data C2-C4: there is no evidence that elastic stockings exert any beneficial effect therefore that pressure counts. If compression stockings are found to be beneficial, further studies assessing which length and pressure is the most efficacious could then take place. Shingler S, Robertson L, Boghossian S, Stewart M. Compression stockings for the initial treatment of varicose veins in patients without venous ulceration. Cochrane Database Syst Rev. 2011 Nov 9;(11):CD008819.
C1 after sclerotherapy: clinical data compression (E.S. 23-32 mm Hg) is more effective than no compression in getting better outcomes (more effectiveness, less pigmentation) pressure counts (if we do not have comparison between 2 different pressure ranges) Kern P, Ramelet AA, Wu tschert R, Hayoz D. Compression after sclerotherapy for telangiectasias and reticular leg veins: a randomized controlled study. J Vasc Surg. 2007;45:1212-6.
clinical data C2 post procedures: comparison of elastic stockings exerting 23-32 mm Hg at ankle versus the same stocking on top of an eccentric compression device (local pressure significantly increased) better outcomes concerning pain, haematoma, bruising, bleeding with higher pressure Mosti G, Mattaliano V, Arleo S, Partsch H. Thigh compression after great saphenous surgery is more effective with high pressure. Int Angiol. 2009 Aug;28(4):274-80. Lugli M, Cogo A, Guerzoni S, Petti A, Maleti O. Effects of eccentric compression by a crossed-tape technique after endovenous laser ablation of the great saphenous vein: a randomized study. Phlebology. 2009 Aug;24(4):151-6.
clinical data C2s pregnancy comparison of 3 groups 1: no compression 2: class 1 compression stockings 3 class 2 compression stockings compression prevent reflux at SFJ and symptoms no difference between the 2 compression classes Thaler E, Huch R, Huch A, Zimmermann R. Compression stockings prophylaxis of emergent varicose veins in pregnancy: a prospective randomized controlled study. Swiss Med Wkly 2001;131:659-62.
clinical data C3 prevention: compression (15-20 mm Hg) is more effective than no compression in preventing oedema in long haul flight compression (E.S. 11-21 mm Hg) is more effective than no compression in preventing occupational oedema Hagan MJ, Lambert SM. A randomised crossover study of low-ankle-pressure graduated-compression tights in reducing flight-induced ankle oedema. Med J Aust. 2008 Jan 21;188(2):81-4. Partsch H, Winiger J, Lun B. Compression stockings reduce occupational swelling. J Derm Surg 2004; 30:737-43.
clinical data C3 prevention: graduated vs anti-graduated elastic stockings in preventing occupational oedema: higher pressure over the calf is more effective Interface Pressure GECS Interface Pressure PECS mm Hg 50 40 30 20 mm Hg 45 40 35 30 25 20 10 0 Minimum 25% Percentile Median 75% Percentile Maximum supine 18.00 20.00 22.00 24.25 27.00 B1 standing 19.00 23.00 25.00 27.00 31.00 supine 15.00 17.75 19.00 21.00 26.00 C standing 15.00 19.00 22.00 23.25 29.00 15 10 5 Minimum 25% Percentile Median 75% Percentile Maximum supine 11.00 16.00 18.50 20.25 23.00 B1 standing 9.000 17.75 20.00 23.00 27.00 supine 20.00 25.75 29.00 32.50 36.00 C standing 22.00 29.75 31.50 35.00 43.00 Mosti G, Partsch H. Occupational Leg Oedema is More Reduced by Antigraduated than by Graduated Stockings. Eur J Vasc Endovasc Surg. 2013 May;45(5):523-7.
clinical data C4b: elastic stocking exerting 30-40 mm Hg versus no compression. significant reduction of lipodermatosclerosis with ECS was reported Vandongen YK, Stacey MC. Graduated compression elastic stockings reduce lipodermatosclerosis and ulcer recurrence. Phlebology 2000;15:33-7
clinical data C5: comparison of class II and class III ECS to prevent ulcer recurrence in the prevention of ulcer recurrence the higher the pressure the lower the recurrence rate Nelson EA: prevention of recurrence of venous ulceration: randomized controlled trial of class 2 and class 3 elastic compression. J Vasc Surg 2006;44:803-8
clinical data C6: three groups: 1. tubular elastic device (36 mm Hg) 2. the same compression device + 1 elastic bandage (54 mm Hg) 3. the same compression device + 2 elastic bandages (74 mm Hg) healing rate of the third group significantly > the second group significantly > the first group: the higher the pressure the greater the healing rate attention: poor compliance with higher pressure Milic D et al. The influence of different sub-bandage pressure values on venous leg ulcers healing when treated with compression therapy. J Vasc Surg. 2010 Mar;51(3):655-61.
clinical data Prevention of DVT: metanalysis of 18 studies Elastic stockings vs no compression: ES reduce the occurrence of DVT by 50% (13% vs 26%) Elastic stocking + another prevention system vs nothing: in the treatment group the occurrence of PTS is reduced by 75% (4% vs 16%) Sachdeva A, Dalton M, Amaragiri SV, Lees T. Elastic compression stockings for prevention of deep vein thrombosis. Cochrane Database Syst Rev. 2010 Jul 7;(7):CD001484.
clinical data Prevention of PTS: elastic stocking vs no compression. Elastic stockings (30-40 mm Hg) reduce the occurrence of PTS. 1. Brandjes DPM, Bu ller H, Hejboer H et al. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis. Lancet. 1997 Mar 15;349(9054):759-62. 2. Prandoni P, Lensing AW, Prins MH et al. Below-knee elastic compression stockings to prevent the post-thrombotic syndrome: a randomized, controlled trial. Ann Intern Med. 2004 Aug 17;141(4):249-56
conclusion 1. pressure of elastic stockings counts 2. when higher pressure is compared with lower pressure, higher pressure is always more effective 3. when a pressure of 23-32 mm hg or higher is compared with nothing any pressure is more effective 1. caution with strong pressure exerted by elastic devices: it can be hardly tolerated
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