Inelastic versus elastic leg compression in chronic
venous insufficiency – what are the effects on venous hemodynamics
In the venous
disease of the lower limbs, compression therapy is considered as an important component
of the treatment. There are many ways to deliver the compression therapy to the
legs in the venous disease patients. Compression
therapy can treat venous stasis, venous hypertension, and venous edema.
Different methods of compression therapy have been described periodically over
the last 2,000 years. In addition to static compression, specialized
compression pumps have been developed to treat resistant edema. A technique of
massage called manual lymphatic drainage has emerged to treat primary and
secondary lymphedema. Objectives of compression therapy are to reduce the
swollen limb to minimum size, maintain that size, and allow the patient to
participate in the care of his limb whenever possible. Reduction therapy is
achieved by limb elevation, compression pumps as necessary, and compression
wraps. Maintenance therapy largely consists of compression wraps or compression
stockings. Nonelastic devices have found a place in treating severe lymphedema
but it should be emphasized that periodic follow-up must be done during
maintenance therapy so that adjunctive maintenance measures can be added as
needed. In tropical countries under humid conditions people find it difficult
to tolerate the compression therapies unlike those living in the cold
countries. People (farmers) working in the wet fields refuse to wear the compression
bandages. We need to need monitor the compression therapy measures at regular
intervals and make sure that the people regularly apply them.
A brief
history of compression
Descriptions
of limb compression therapy are found in the Corpus Hippocraticum (450-350
BC). Because the Greeks believed that “all wounds, especially those of
the lower limbs, contradict standing, sitting or walking,”
they used compression to counter the adverse effects of gravity and upright
posture. Guy de Chauliac, a French anatomist and surgeon, published the first
mention of compression therapy for varicose veins in Chirurgica magna (1363),
a leading reference textbook for almost four centuries. Giovanni Michele
Savonarola (1440) formalized “conservative treatment” for varicose veins. His Practica describes
how bandages should be started at the distal part of the limb and worked upward
to the proximal portion. Savonarola’s successor at Padua University was
Fabricio d’Aquapendente
(1537-1619), who further refined these bandaging methods. The first description
of laced stockings (made from dog leather) can be found in his De
chirurgicis operationibus. (Contrary to popular belief, this is not the
reason why “going barefoot” came to be known as “airing out your dogs”). William
Harvey’s 17th century description of the circulation of blood
led to an understanding of the physiological rationale for limb compression. By
the latter 18th century, Johann Christian Anton Theden
(1714-1797) was postulating that compression “reduces somewhat the flow of
humours, stimulates the activity of the skin over the suffering areas and
increases the returning flow of humours.”The use of sponges under a
compression device (to apply additional pressure over specific areas) was
introduced by E. Home and others (1797). The need for a bandage that could be
applied by the patient led H.A. Martin in Boston to develop a clothless
bandage made of pure rubber, which could be placed directly atop the skin and
held in place by another bandage. Thomas Baynton advocated adhesive bandages
and promoted their use after they became commercially available toward the end
of the 19th century. The zinc oxide paste dressing, introduced
by P.G. Unna in 1885, is still in use today. Ready-to-use zinc oxide bandages
came onto the market after the First World War (Varicosan, Glauco, Weicosana,
others). Modern elastic stockings were born on October 26, 1948 when William
Brown, of Middlesex, England, submitted a patent for compression hose.
The
first compression pumps were introduced in 1902 when Hofmeister proposed a treatment
for arm edema in which the limb was placed within a metal cylinder filled with
mercury. In 1917, Hartel used an air-filled tube for the same
purpose. Hammersfahr (1931) published his treatment of venous stasis using an
air cushion that filled and emptied rhythmically. Karl Linser developed a
massage boot that utilized an air-filled chamber in which the pressure varied
as the subject walked.
Manual
lymphatic drainage has been used to remove extremity edema for more than 50
years. The original technique used soft massage to stimulate lymphatic vessels
and propel fluid through their channels. Because 20% or more of patients with
chronic venous insufficiency also have a component of lymphedema, manual
lymphatic drainage may have a role in a compression therapy program for chronic
venous insufficiency.
Nonelastic
devices. The Circaid® (see Fig) provides rigid nondistensible resistance to the
limb. It can be applied over a compression stocking for additional compression.
Topical
compression therapy provides a means to treat or prevent these adverse effects.
Limb compression (1) alters the tissue pressure gradient, which reduces edema
formation and increases edema resorption; (2) reduces the caliber of the veins
and increases venous flow velocity; (3) reduces orthostatic reflux, residual
volume, and ambulatory venous pressure (in part, by re-recruiting venous valves
and reducing reflux in the perforating vessels); and (4) improves the
effectiveness of the muscle pump.
Mayberry
et al (1991) - In 16 patients with CVI – compression therapy affect was studied
on – femoral, popliteal vein velocities (duplex scan), reflux and ambulatory
venous pressures direct measurement. Although stocking produced substantial
superficial vein, they produced only modest increases in the popliteal vein
velocity and no significant improvement in deep venous hemodynamics. These
authors analysed another 8 studies (previous) and said the differences in the
findings were due to consistencies in the study designs.
R
K Spence et al (1996 -JVS) found that inelastic compression (see fig Circaid) has
a significant effect on deep venous hemodynamics by decreasing venous reflux
and calf muscle pump function better than compression stockings. They concluded
that initially the superficial reflux should be adequately treated with
stockings. Those with extensive clinical symptoms caused by abnormal deep
venous hemodynamics and primary calf muscle pump dysfunction may benefit more
from the inelastic compression.
