indications for medical compression stockings in venous and … · 2020. 8. 14. · compression is...

Review Article

Indications for medical compressionstockings in venous and lymphaticdisorders: An evidence-basedconsensus statement

Eberhard Rabe1, Hugo Partsch2, Juerg Hafner3,Christopher Lattimer4, Giovanni Mosti5, Martino Neumann6,Tomasz Urbanek7, Monika Huebner8, Sylvain Gaillard9 andPatrick Carpentier10

Abstract

Objective: Medical compression stockings are a standard, non-invasive treatment option for all venous and lymphatic

diseases. The aim of this consensus document is to provide up-to-date recommendations and evidence grading on the

indications for treatment, based on evidence accumulated during the past decade, under the auspices of the International

Compression Club.

Methods: A systematic literature review was conducted and, using PRISMA guidelines, 51 relevant publications were

selected for an evidence-based analysis of an initial 2407 unrefined results. Key search terms included: ‘acute’, CEAP’,

‘chronic’, ‘compression stockings’, ‘compression therapy’, ‘lymph’, ‘lymphatic disease’, ‘vein’ and ‘venous disease’.

Evidence extracted from the publications was graded initially by the panel members individually and then refined at

the consensus meeting.

Results: Based on the current evidence, 25 recommendations for chronic and acute venous disorders were made. Of

these, 24 recommendations were graded as: Grade 1A (n¼ 4), 1B (n¼ 13), 1C (n¼ 2), 2B (n¼ 4) and 2C (n¼ 1). Thepanel members found moderately robust evidence for medical compression stockings in patients with venous symptoms

and prevention and treatment of venous oedema. Robust evidence was found for prevention and treatment of venous leg

ulcers. Recommendations for stocking-use after great saphenous vein interventions were limited to the first post-

interventional week. No randomised clinical trials are available that document a prophylactic effect of medical compres-

sion stockings on the progression of chronic venous disease (CVD). In acute deep vein thrombosis, immediate

compression is recommended to reduce pain and swelling. Despite conflicting results from a recent study to prevent

post-thrombotic syndrome, medical compression stockings are still recommended. In thromboprophylaxis, the role of

stockings in addition to anticoagulation is limited. For the maintenance phase of lymphoedema management, compres-

sion stockings are the most important intervention.

Conclusion: The beneficial value of applying compression stockings in the treatment of venous and lymphatic disease is

supported by this document, with 19/25 recommendations rated as Grade 1 evidence. For recommendations rated with

Grade 2 level of evidence, further studies are needed.

Keywords

Compression stockings, chronic venous disease, deep vein thrombosis, post-thrombotic syndrome, lymphoedema

1Department of Dermatology, University of Bonn, Bonn, Germany2Department of Dermatology, Medical University of Vienna, Austria3Department of Dermatology, University Hospital of Zurich, Zurich,

Switzerland4Josef Pflug Vascular Laboratory, West London Vascular and

Interventional Centre, Ealing Hospital & Imperial College, London, UK5Angiology Department, Clinica MD Barbantini, Lucca, Italy6Department of Dermatology, Erasmus University Hospital, Rotterdam,

The Netherlands

7Medical University of Silesia Department of General Surgery, Vascular

Surgery, Angiology and Phlebology, Katowice, Poland8SIGVARIS AG, St Gallen, Switzerland9SIGVARIS Management AG, Winterthur, Switzerland10Centre de Recherche Universitaire de La Léchère, Equipe THEMAS,

Université Joseph Fourier, Grenoble, France

Corresponding author:

Eberhard Rabe, Department of Dermatology, University of Bonn,

Sigmund-Freud-Str. 25, 53105 Bonn, Germany.

Email: [email protected]

Phlebology

2018, Vol. 33(3) 163–184

! The Author(s) 2017

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DOI: 10.1177/0268355516689631

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Introduction

Compression therapy for the management of chronicvenous disease (CVD) and lymphoedema is a readilyavailable, non-invasive treatment option which iswidely practiced and extensively documented.1–3

However, there is a paucity of guidelines derived fromevidence reported in clinical trials for the managementof patients using compression therapy.4 Currently, themajority of recommendations are based on expert opin-ion rather than evidence. The purpose of this documentwas to review the current evidence from the literaturesupporting compression performed by medical com-pression stockings (MCS) and use this to compile andgrade recommendations for use in clinical practice.

The International Compression Club (ICC) is an adhoc group of experts that includes clinicians involved incompression therapy, as well as technical specialists fromcompanies manufacturing compression devices for clin-ical use. The ICC published a consensus statement in2008 on the use of compression therapy in the manage-ment of venous and lymphatic diseases.4 The aim of thisarticle is to provide an update of the 2008 consensusstatement in order to answer the clinical questions thatwere outstanding. Importantly, the 2008 consensus state-ment was based on the clinical manifestation (C) stages ofthe Clinical-Etiology-Anatomy-Pathophysiology (CEAP)classification.5 However, this consensus statement isbased on the clinical goals of treatment, with recommen-dations based on the primary outcome of compressiontreatment focusing on MCS only. The recommendationsin this consensus document are not intended to establishthe superiority of MCS or compression pressures overother compression devices or treatment modalities.

Methods

Consensus panel

The consensus group that contributed to this statementcomprised eight international experts experienced incompression therapy, representing different medicaldisciplines (angiology, dermatology and vascular sur-gery). They were selected by Eberhard Rabe (the pri-mary author) who appointed a consensus meetingChair, Hugo Partsch, and the remaining members.The responsibility of the Chairs, supported by a secre-tary, Sylvain Gaillard, was to perform and refine theliterature searches, to use their personal records andknowledge, and to select/compose the initial recom-mendations as a framework for discussion.

Study design

A systematic literature search was performed for art-icles published between 1 January 2007 and 8 July 2015

using PubMed. Key search terms included ‘acute’,‘CEAP’, ‘chronic’, ‘compression therapy’, ‘compressionstockings’, ‘lymph’, ‘lymphatic disease’, ‘vein’ and‘venous disease’. The searches produced 2407 resultsinitially and, subsequently, a total of 1789 results,after refinement (Figure 1).

Studies were deemed eligible if they were randomisedcontrolled trials (RCTs) or observational studiesreporting on the use of MCS and published in theEnglish language. Published evidence on the effective-ness of MCS was reviewed and critically appraised bythe Chairs, who concentrated on RCTs that addressedthe use of compression for a large number of clinicalindications. In addition, the consensus group memberssearched their personal collections of papers for rele-vant medical literature. Reviews were not evaluated andduplicate publications within the CEAP classes wereexcluded. The results of this search strategy were fur-ther refined by the consensus meeting Chairs, whomanually selected a total of 109 potentially relevantpublications from the list, as well as from an additionalmeta-analysis. After a decision to include only litera-ture on compression stockings, a further review by theconsensus meeting Chairs identified 51 relevant publi-cations, which were selected as the evidence base forreview and critical appraisal.

The evidence was graded according to the recom-mendations of Guyatt et al.6 (Table 1). For this, rat-ings of ‘high’, ‘moderate’ or ‘low’ were given to threecore components of the respective studies: study qual-ity; risk of bias; and benefit versus risk. An initialgrading of the evidence and preliminary recommenda-tions was developed by the meeting Chairs. The taskof making the final selection of papers was dividedamongst all the panel members, with reference to therecommendations on grading. In September 2015, allpanel members met in Frankfurt to share their opin-ions and reach a consensus on a set of recommenda-tions and on their final grading of evidence, using thepreliminary recommendations and initial grading. Infinalising their proposals, the panel used the 2008ICC-consensus statement as a basis and concentratedon new publications that were published since 1January 2007.

Recommendations

Patients with chronic venous disorders and healthyindividuals

Improvement of venous symptoms, quality of life and

oedema. Venous symptoms, which include heavinessand tension or increasing pain, volume and oedemaformation in the lower leg whilst standing or sitting,during the course of the day or in warm environments,

164 Phlebology 33(3)

are common in the general population and are indica-tions for treatment with MCS.

Earlier studies reported that venous symptoms, qual-ity of life (QoL) and oedema formation, in patients withlower clinical classes of chronic venous diseases (CVD)(C1s–C3), can be significantly improved by low-pressurecompression stockings, compared with placebo stock-ings.7,8 Blättler et al.9 reported similar findings for theuse of leg compression stockings with an ankle pressure�15mmHg (Table 2). Blazek et al.10 reported that, forindividuals with professions that require them to standfor prolonged periods, such as hairdressing, and whoexperience venous symptoms (including leg pain, feel-ings of swelling and heaviness), wearing leg compressionstockings (15–20mmHg) can alleviate these symptoms.A prospective randomised study that comparedthigh-high compression stockings (20–30mmHg) withsclerotherapy in patients with C1 CVD showedthat compression therapy provides significant relief ofaching (p< 0.0001), pain (p¼ 0.002), leg cramps(p¼ 0.003) and restlessness (p< 0.05), while sclerother-apy provides superior broad-spectrum symptom relief.11

Furthermore, in two prospective randomised studies inpatients with mild, moderate or severe CVD, Couzanet al.12,13 compared progressive compression stockings

(i.e. where pressure progressively increases from theankle to the calf, where the pressure is the highest)with degressive compression stockings (pressuredecreases gradually from the ankle to the calf, wherethe pressure is the lowest). Feelings of heaviness, painand other lower leg symptoms were significantly alle-viated in both groups, but better results were achievedin the progressive compression stockings group.

Mosti et al.14 have demonstrated that compressionstockings exerting a pressure of approximately30mmHg are nearly as effective for reducing chronicleg oedema as high-pressure bandages with an initialpressure over 60mmHg. In another study, Mostiet al.15 randomised 40 legs (28 patients) with chronicvenous oedema to either short-stretch bandages of ini-tial median pressure 67mmHg (interquartile range(IQR): 55.7–73.0) applied weekly for two weeks, fol-lowed by an elastic stocking for two weeks (group A)or an initial light stocking of median pressure24.5mmHg (IQR: 21.2–26.5) for 1 week followed bysuperimposing a second stocking for three weeks(group B). They reported an initial improvement in legvolume at one week that was independent of the pres-sure applied, with the reduction maintained by super-imposing a second stocking. In a randomised controlled

Figure 1. PRISMA flow diagram of relevant literature identified.

PRISMA: Preferred Reporting Items for Systematic reviews and Meta-Analyses; RCTs: randomised controlled trial.

Rabe et al. 165

setting, Sell et al.16 compared the effectiveness of com-pression stockings with surgery in patients with uncom-plicated varicose veins. At two years, treatmenteffectiveness (as measured by the venous clinical severityscore (VCSS) and the venous segmental disease score(VSDS)), was demonstrated by both treatment modal-ities, but was greater with surgery. Brizzio et al.17 com-pared the effect of multiple-layer short-stretch bandageswith compression stockings (15–25mmHg) on the rateof healing, pain and QoL, in patients with venous legulcer (VLU), and where local pressure over the ulcer wasincreased by pads. In both groups, pain was reduced by50%. Healing rates at 90 days were similar (36% and48% for compression stockings and bandages, respect-ively) and time to healing was identical. In an RCTcomparing the effectiveness of a four-layer compression

bandage (CB) system and a Class 3 (30–35mmHg) com-pression hosiery system on healing and QoL in patientswith VLUs, Finlayson et al.18 reported that, at 24 weeks,there was no significant difference between groups inhealing, QoL or pain measures, although a four-layersystem produced a more rapid response.

Long-distance travellers should benefit from stockingsfor the prevention of oedema, especially when combinedwith mobilisation. An RCT conducted in Australiademonstrated that low-ankle pressure graduated compres-sion tights (GCTs) reduce flight-induced ankle oedemaand subjectively rated travel symptoms of leg pain, dis-comfort and swelling, and improve energy levels, ability toconcentrate, alertness and post-flight sleep.19

For the majority of studies discussed, different com-pression pressure levels have been compared. It is

Table 1. Grading recommendations.6

Grade

Description of

recommendation Benefit vs. risk

Methodological quality of

supporting evidence Implications

1A Strong recommendation,

high-quality evidence

Benefits clearly outweigh

risk and burdens, or

vice versa

RCTs without important

limitations or over-

whelming evidence

from observational

studies

Strong recommendation,

can apply to most

patients in most cir-

cumstances without

reservation

1B Strong recommendation,

moderate-quality

evidence



vice versa

RCTs with important

limitations (inconsist-

ent results, methodo-

logical flaws, indirect,

or imprecise) or

exceptionally strong

evidence from obser-

vational studies

Strong recommendation,

can apply to most

patients in most cir-

cumstances without

reservation

1C Strong recommendation,

low-quality or very

low-quality evidence



vice versa

Observational studies or

case series

Strong recommendation

but may change when

higher-quality evidence

is available

2A Weak recommendation,

high-quality evidence

Benefits closely balanced

with risks and burden

RCTs without important

limitations or over-

whelming evidence

from observational

studies

Weak recommendation;

best action may differ

depending on circum-

stances or patients’ or

societal values

2B Weak recommendation,

moderate-quality

evidence

Benefits closely balanced

with risks and burden

RCTs with important

limitations (inconsist-

ent results, methodo-

logical flaws, indirect,

or imprecise) or

exceptionally strong

evidence from obser-

vational studies

Weak recommendation;

best action may differ

depending on circum-

stances or patients’ or

societal values

2C Weak recommendation,

low-quality or very

low-quality evidence

Uncertainty in the esti-

mates of benefits, risks

and burden; benefits,

risk and burden may be

closely balanced

Observational studies or

case series

Very weak recommenda-

tions; other alterna-

tives may be equally

reasonable


important to highlight that even low-pressure MCS(10–20mmHg) are able to reduce symptoms andoedema. In consequence, the pressure level should beadapted to the severity of the disease and limited to thelowest pressure leading to symptom and oedema relief.This will also improve patient compliance. Finally, weconclude that all levels of compression improve venoussymptoms and oedema.

Recommendation 1: We recommend the use of MCS to

alleviate venous symptoms in patients with CVD

(GRADE 1B)


improve QoL and venous severity scores in patients

with CVD (GRADE 1B)


prevent leg swelling in patients with CVD and in

healthy individuals at risk of leg swelling (e.g. during

long flights; occupational leg swelling) (GRADE 1B)


reduce leg swelling in patients with CVD and occupa-

tional leg swelling (GRADE 1B)

Improvement of skin changes caused by chronic venous

disease. The improvement of skin changes – includingeczema, induration and lipodermatosclerosis, caused bychronic venous insufficiency (CVI) – by compressiontherapy is regularly observed in routine clinical prac-tice. However, there is a paucity of evidence fromRCTs. The recommendation to use MCS for theimprovement of skin changes in general is thereforebased on low-level evidence.

Recommendation 5: We suggest MCS for the improve-

ment of skin changes in patients with CVD (GRADE

1C)

Vandongen and Stacey20 reported that MCS reducedthe area of lipodermatosclerosis in patients with healedvenous ulceration. A total of 153 patients with recentlyhealed VLUs were randomised to either below-kneegraduated MCS or no stockings. In patients in the com-pression group, the area of lipodermatosclerosis hadreduced significantly, compared with the controlgroup, after six months (p¼ 0.01) and 12 months(p¼ 0.04). Within two years of patients entering thestudy, the area of lipodermatosclerosis was significantlylarger in patients with ulcer recurrence than in thosewho did not re-ulcerate (293 cm2 vs. 50 cm2).Lipodermatosclerosis was determined both visuallyand by palpating the leg. A line was drawn on theskin and along the border of the lipodermatosclerosis,traced onto polythene and the area measured usingplanimetry.

Recommendation 6: We recommend MCS for the

improvement of lipodermatosclerosis in patients with

CVD (GRADE 1B)

Prevention of venous leg ulcer recurrence. Following VLUhealing, the ulcer recurrence rate depends on thecompensation of the venous insufficiency (either byablation of superficial venous reflux, improvementof deep venous pathology, where possible, or com-pression treatment). In a Cochrane review thatincluded RCTs published until June 2000, Nelsonet al.21 investigated the effect of compression onVLU recurrence. No studies compared compressionversus no compression, while one RCT compared‘high’ compression with ‘moderate’ compressionMCS and one study investigated different medium-pressure MCS. Compliance rates were significantlyhigher with medium compression vs. high compres-sion MCS, and wearing MCS reduced the recurrencerates significantly. Nelson et al.22 compared theeffectiveness of a ‘moderate’ (18–24mmHg) and a‘high’ (25–35mmHg) compression MCS on venousulcer recurrence rates in patients with recentlyhealed VLU, with a five-year follow-up. There wasno significant difference between the two groups butthe recurrence rate in the ‘high’ compression MCSgroup was lower.

Clarke-Moloney et al.23 randomised 100 patientswith healed VLU to European Class 1 (18–21mmHg) or Class 2 (23–32mmHg) MCS. After12 months’ follow-up, there was no statistically sig-nificant difference in the ulcer recurrence ratebetween MCS classes, although a greater numberof patients in the Class 1 group developed a recur-rence and non-compliant patients were at signifi-cantly greater risk of recurrence (p� 0.0001).Patients who were compliant with MCS, regardlessof the compression level, had the lowest venous ulcerrecurrence rates. In a double-blind RCT conductedwithin a nursing home setting, Kapp et al.24 com-pared the effectiveness of a 23–32mmHg and a34–46mmHg compression stocking on venous ulcerrecurrence. The overall adherence to treatment waslow (44%). Non-adherence was significantly higher inthe high-pressure MCS group (p¼ 0.003). Risk ofrecurrence was greater in the ‘moderate’ compressiongroup than the ‘high’ compression group. Adherenceto treatment was found to significantly predict ulcerrecurrence (p¼ 0.005).

The results of these studies show a trend oflower rates of venous ulcer recurrence with higher-compression MCS. However, compliance was lower inthe ‘high’ compression groups compared with the ‘mod-erate’ compressions groups. In all studies, compliance

Rabe et al. 167

with compression treatment significantly reduced VLUrecurrence.


reduce recurrence of VLU (GRADE 1A)

Improvement of venous leg ulcer healing. VLUs are one ofthe most important complications of CVI and theyhave a great impact on patients’ QoL. CBs are widelyused in VLU treatment. A properly applied CB iseffective but can be associated with problems of pres-sure drop during the first hours and a lack of standard-isation, especially if the patient applies thebandages themselves. Thus, CBs should be applied bytrained staff.

In past decades, special ulcer MCS (‘ulcer kits’) havebeen developed that comprise a two-layer stockingsystem. The understocking keeps the ulcer-dressing inplace and can be used overnight, whilst an additionalhigher-pressure overstocking is usually worn duringthe day.

Following an earlier study by Partsch andHorakova,25 who reported that MCS for venousulcers may be an effective approach for fit and coopera-tive patients, Jünger et al.26 reported that ulcer MCS(ulcer kit), when compared with standard CB, weresuperior in improving the healing rate of VLUs of amoderate size. Time to healing was similar in bothgroups. As discussed earlier, similar results werereported by Brizzio et al. and also in comparison withbandages.17

In a prospective, clinical pilot study, Dolibog et al.27

randomised 70 patients with unilateral VLUs to com-pression therapy by intermittent pneumatic compres-sion, MCS or short-stretch CB for 15 days. Allpatients received saline-soaked gauze dressings alongwith micronised purified flavonoid fraction, diosmin,hesperidin and oral Daflon 500mg once daily. Woundsize reduction and percentage of wounds healed weresignificantly higher in the groups receiving IPC orstockings than in the groups using short-stretchbandages.

Ashby et al.28 randomised 457 patients out of a totalof 3411 ulcer patients, presenting with VLUs of medianareas 4.1 cm2 and 3.7 cm2 to either two-layer ulcer MCS(ulcer kit) or four-layer bandage treatment, respect-ively. Median time to ulcer healing was 99 days (95%confidence interval (CI) 84–126) in the hosiery groupand 98 days (95% CI 85–112) in the bandagegroup. The ulcer healing rate was similar in thetwo groups (70.9% hosiery and 70.4% bandage).Finlayson et al.18 reported results that were similar tothese, although in their study the four-layer systemshowed a more rapid response.

Based on the current literature, the healing rates ofVLUs are comparable between ulcer MCS (ulcer kit)and CB systems. This does not apply for circumferen-tial ulcers or ulcers of larger size.

Recommendation 8: We recommend the use of ulcer MCS

(‘ulcer kits’) to improve VLU healing (GRADE 1A)

Recommendation 9: We recommend the use of ulcer

MCS (‘ulcer kits’) to reduce pain in patients with

VLU (GRADE 1A)

Prevention of clinical progression in chronic venous

disease. Prevention of CVD progression, such as fromlower clinical classes to more severe disease, includingVLU, is one of the main goals of treatment. There isinsufficient information from RCTs on the preventionof CVD progression by MCS that would allow for anevidence-based recommendation. However, in a case–control study by Kostas et al.,29 who investigated CVDprogression in the contralateral leg of patients treatedfor varicose veins, non-compliance with compressionwas reported as one of the risk factors for overallCVD progression.

Recommendation 10: Insufficient data are available on

the use of MCS for the prevention of CVD progression,

so we recommend further studies are needed to be able

to make evidence-based recommendations

Reduction of side effects after venous interventions. The useof post-treatment compression to reduce side effectssuch as pain, oedema, bruising and thromboembolicevents is suggested in most guidelines, in regard tovenous interventions for varicose veins including highligation and stripping, endovenous thermal ablation orsclerotherapy. The duration of compression therapy isnot clearly defined in most of the guidelines and, overthe past decade, endovenous procedures have becomesignificantly less invasive, as a result of the introductionof new devices and methods.

Most RCTs have been limited to great saphenousvein (GSV) interventions. One paper on compressionafter interventions for subcutaneous varicose veins sug-gests that less traumatizing surgical methods may notneed post-procedural MCS.30

Results from one RCT are available after sclerother-apy in C1 varicose veins.31 Therefore, evidence-basedrecommendations can only be given for C1 varicoseveins.

Older studies have compared different types or dur-ations of compression therapy without concludingwhether compression after interventions is beneficial ornot, or on the optimal treatment duration.32–36


In a more recent RCT, Houtermans-Auckel et al.37

reported that wearing MCS for four weeks after highligation and stripping of the GSV, following CB use forthree days, had no additional benefit on limb oedema,pain, complications and return to work. In a rando-mised study comparing thromboembolic-deterrent(TED) stockings for one or three weeks after GSV,high ligation and stripping, and three days of post-operative bandaging, Biswas et al.38 reported no benefitin wearing TED stockings for more than one week withrespect to postoperative pain, number of complications,time to return to work and patient satisfaction for up to12 weeks following surgery. Mariani et al.39 comparedMCS (23–32mmHg) with CB after varicose vein sur-gery, and reported no difference in postoperative pain,but improvement of oedema and QoL in the stockinggroup after seven days. A study by Mosti et al.40

included 54 patients who had invagination strippingof the GSV and side-branch evulsion under local anaes-thesia and were treated for one week, postoperatively,either by thigh-length compression stockings, adhesivebandages or eccentric compression pads fixed withtapes and a superimposed thigh-length stocking ontop. Effective reduction of pain and hematoma wasobtained with a high local pressure by eccentric com-pression pads taped to the skin along the strippingchannel and a compression stocking on top. Benigniet al.41 compared pain intensity on Days 1 and 7 andglobal mean pain during the week following strippingof the GSV in patients for whom either a pad had beenadded at thigh level under an MCS or patients with anMCS only. Pain was significantly reduced in the padplus MCS group (p< 0.0001). Lugli et al.42 comparedpostoperative pain for one week after endovenous laserablation of the GSV in patients using a special crossed-tape technique that produces higher eccentric compres-sion, compared with those not using pads. In the groupusing the tape technique, postoperative pain was signifi-cantly reduced (p< 0.001).

Bakker et al.43 reported that MCS for periods longerthan two days after endovenous GSV ablation withoutsimultaneous phlebectomies reduce pain and improvephysical function during the first week after treatment.Reich-Schupke et al.44 reported that 23–32mmHgMCSare superior to 18–21mmHg MCS, providing fasterresolution of clinical and ultrasound-verified oedemaand feelings of pain, tightness, and discomfort of theleg in the first week after varicose vein surgery, but notin the longer post-surgical period up to six weeks.Regarding pain or complications after foam sclerother-apy of the GSV, Hamel-Desnos et al.45 found no signifi-cant difference between patients whowerewearing 15–20mmHg thigh-highMCS and those without compression.

Kern et al.31 reported that wearing MCS (23–32mmHg) for three weeks can enhance the efficacy of

sclerotherapy of C1 varicose veins by improving clinicalvessel disappearance.

Most of the available studies have limitations. Inmany cases, the interface pressure is not reported orvery low. The data, however, show no benefit ofMCS for time periods of longer than a week.

Three studies have shown that local high interfacepressure, along the GSV at the thigh, can reducepain.40–42

In summary, one week of MCS treatment usingthigh-length 20–40mmHg stockings after GSV inter-ventions can be recommended. Pressure enhancementalong the treated vein with additional eccentric paddingmay be helpful.

Recommendation 11: We recommend the use of MCS

in the initial phase after GSV treatment to reduce post-

operative side effects (Grade 1B)

Recommendation 12: We recommend additional eccen-

tric compression to enhance the effectiveness of MCS in

the reduction of postoperative side effects (Grade 1B)

Improvement of therapeutic outcome after venous

interventions. The clinical benefit of ongoing MCStreatment after successful correction of pathologicalchanges in the superficial system, or after the reduc-tion of recurrent varicose veins, warrants recommen-dation of long-term MCS use in these scenarios. Olderstudies have been unable to show a benefit for inter-mediate- or long-term use of MCS after venous inter-ventions.32–36 A better cosmetic outcome after threeweeks of compression stocking was shown in onlyone trial in which small spider veins had been trea-ted.31 The more recent studies either did not followthe patients for a long enough period of time or hadfailed to demonstrate benefits from ongoing MCS useafter the initial postoperative period.37–42,45 However,not all patients return to asymptomatic clinical classC0 after venous interventions, even if they haveimproved clinically, and so may still require MCStreatment. These patients include those who arepost-thrombotic after superficial insufficiency treat-ment, or patients with healed or active VLU, aftervaricose vein treatment. Prevention of ulcer recurrencestill includes MCS use.

Recommendation 13: We do not recommend routine,

prolonged use of MCS for improving clinical success

after GSV interventions, except for those patients with

ongoing symptomatic CVD that benefit from a contin-

ued MCS treatment (Grade 1B)

Recommendation 14: We suggest the use of MCS after

liquid sclerotherapy of C1 veins to achieve better out-

comes (Grade 2B)

Rabe et al. 169

Patients with acute venous disorders

Deep vein thrombosis

Use of compression in combination with an effectiveanticoagulant to mobilise patients with acute DVThas long been used in Europe, and is the basis formodern home-based therapy.46 Home treatmentbecame accepted for the management of acute DVTafter reports that walking with compression does notlead to a higher incidence of pulmonary embolism (PE),compared with bedrest.47,48 There is, however, a pau-city of evidence from RCTs on the benefits of compres-sion for acute DVT.

Reduction of pain

In a study in patients with proximal DVT, Blättler andPartsch49 assessed the rate of clinical improvement withcompression plus immediate deliberate ambulation, incomparison with bedrest without compression, using avisual analogue scale (VAS) to monitor pain anda modified Lowenberg test to monitor provoked pain.The study demonstrated superiority of compression(stockings or bandages), over bedrest without compres-sion, for the reduction of pain.49 Roumen-Klappeet al.50 evaluated the effect of immediate bandagingvs. no bandaging on the development of PTS. Theyreported that improvement of clinical symptoms anddecrease of leg circumference was significantly betteron Day 7 after compression, compared with nocompression.

However, it has been reported that when compres-sion is initiated after two weeks or more, there is nodifference between compression- and placebo-stockingsin the resultant pain levels.51

Reduction of oedema

Swelling of the affected leg – a sign that is easily quan-tifiable in acute proximal DVT – is rarely reported instudies.

Blättler and Partsch49 measured differences in max-imal calf circumference in patients with unilateral,acute proximal DVT and reported that, in the firstnine days, oedema was significantly reduced with com-pression, compared with bedrest and no compression(p< 0.001).

Improvement of walking and QoL

Walking ability, as assessed by quantifying the dailywalking distance, was investigated only in onestudy.49 Compression from bandages and stockingswas able to increase the mean daily walking distancefrom 2km (at Day 1), to 4 km (at Day 9). A significant

improvement in QoL parameters – particularly thoserelated to physical functioning – was demonstrated inthe group using compression, compared with thoseusing bedrest and no compression (p< 0.05 for stock-ings; p< 0.001 for bandages).49

Recommendation 15: We recommend immediate com-

pression to reduce pain and swelling, thereby allowing

instant mobilisation in acute DVT (Grade 1B)

Reduction of thrombus growth

Arpaia et al.52 randomly assigned 73 patients with DVTto elastic compression hosiery starting either immedi-ately after diagnosis or two weeks afterwards. The resi-dual thrombus was measured by compressionultrasonography after 14 and 90 days. The investigatorsreported that, in the group treated with early compres-sion, there were significantly more recanalised venoussegments than in the group treated with delayed com-pression. Additionally, recanalisation of popliteal DVTveins, expressed as the reduction of vein diameter, wasbetter in the early compression group than in controlsat both Day 14 and 90. Blättler and Partsch49 reportedless thrombus progression with compression, comparedwith no compression, as assessed by ultrasound.

Recommendation 16: We recommend immediate com-

pression and mobilisation in addition to anticoagula-

tion to avoid thrombus propagation in acute DVT

(Grade 1B)

Superficial vein thrombosis

A Cochrane review of RCTs evaluating topical, medicaland surgical treatments for superficial thrombophlebitisincluded several RCTs that, over the past few years,have reported beneficial effects of different anticoagula-tion regimens with compression stockings as an adjuncttreatment modality in superficial vein thrombosis(SVT).53 Boehler et al.54 compared the effect of thigh-length compression stockings (21–32mmHg) versus nocompression for a period of three weeks, to understandthe therapeutic effect on isolated SVT of the legs. Allpatients received low-molecular-weight heparin(LMWH), and non-steroidal anti-inflammatory drugs(NSAIDs) were allowed. The primary outcome variablewas the reduction of pain, as assessed by a VAS and theLowenberg test. Secondary outcomes were the con-sumption of analgesics, thrombus length, skin ery-thema, D-dimer, and QoL. There was no significantdifference between the groups for all tested outcomevariables. At Day 7, patients in the compression


stocking group had experienced a significantly fasterthrombus regression (p¼ 0.02). The outcomeof this study does not exclude potential benefits ofstronger compression bandages, worn day andnight. Experience from routine practice, as high-lighted in the 2012 SVT consensus statement,has emphasized that compression of the thrombosedvein relieves the symptoms of SVT and accelerateshealing.55

Recommendation 17: We recommend MCS in patients

with SVT (Grade 1C).

In patients with SVT who are treated with LMWH,

aside from a reduction of thrombus growth after 1

week, an additional benefit for symptomatic outcomes

has not been demonstrated

Post-thrombotic syndrome

Post-thrombotic syndrome (PTS) is a common compli-cation of DVT caused by chronic damage to the venousoutflow.56 Besides the mechanical flow disturbancesdue to flow obstruction and reflux, a chronic inflamma-tory process with ongoing remodelling of the venouswall is also responsible for clinical symptoms, andthese have been featured in the scoring system proposedby Villalta and Prandoni.57 This score records the pres-ence and severity of five symptoms (cramping, heavi-ness, pain, paraesthesia, pruritus) and six clinical signs(calf tenderness, induration, oedema, pigmentation,redness, venous ectasia) with the inclusion of venousulceration as the most severe stage.3

The additional use of the CEAP system has beenrecommended to provide further information.58

Importantly, clinical changes should also be describedin the acute phase of DVT.

Two RCTs have separately reported the benefits ofwearing elastic compression stockings (ECS), in termsof the risk of PTS.59,60 In a subsequent study, Prandoniet al.61 stated that thigh-high compression stockingswere no more effective than knee-high stockings, butwere less well tolerated. Aschwanden et al.62 conductedan RCT whereby patients were assessed six monthsafter routine compression with MCS; it was reportedthat prolonged compression therapy after proximalDVT significantly reduces the symptoms associatedwith PTS, and may prevent post-thrombotic skinchanges. Musani et al.63 concluded, from a meta-analysis of five RCTs, that wearing MCS after DVTreduces the incidence of a PTS.

The findings of these studies have been challenged byKahn et al. in a large multicentre RCT that did not findsignificant differences in the cumulative incidence of PTSdefined with Villalta’s scale between patients who were

randomized to 30–40mmHg stockings or to placebostockings.64 This study has, however, been criticised bya number of groups. Poor compliance, differences inpatients’ characteristics, the use of different anticoagu-lants (including new oral anticoagulants), the use of ‘pla-cebo-stockings’ which may have been effective and thedelay in the application of MCS have been suggested aspossible explanations for the lack of effectiveness of ECSin this trial.65,66 However, it must be highlighted that thestudies supporting compression to prevent PTS also havelimitations (e.g. lower number of included patients). In arecent RCT,67 in which both the Villalta-Prandoni Scoreand Venous Clinical Severity Score instruments wereused to monitor PTS, the MCS group had a lower inci-dence of PTS, comparedwith the control group, but onlyat the one-month cut-off. At 6 or 12 months, no differ-ence in the incidence of PTS was detected between thegroups. This result highlights the importance of theimmediate application of MCS in the acute phase ofDVT.67

A meta-analysis of eight RCTs concluded that theevidence to date supports the use of compression forreducing the risk of PTS. Nevertheless, the authorsstated that the findings need to be interpreted with cau-tion, in view of the heterogeneity in the studies thatwere included in the meta-analysis.68 Individualisingmanagement for patients is undergoing investigationand is expected to provide further insight into how toprovide patients with optimal management choices.69

The consensus panel concluded that current evidencestill supports compression therapy for PTS prophylaxisin clinical practice, at least in symptomatic patients.


as early as possible after diagnosis of DVT in order to

prevent PTS (Grade 1B)

Comment: Current evidence still supports compression

therapy for PTS prophylaxis in clinical practice, at least

in symptomatic patients

Therapy of PTS

Data on the physical management of PTS aresparse;66,70,71 the most valuable data are obtainablefromulcer-healing studies, because VLUs are consideredthe severest form of post-thrombotic syndrome and PTSare the main cause of the ulceration in many cases. Asystematic literature review conducted to identify themost superior compression method for promoting ulcerhealing and reducing recurrence in patients with lowerextremity venous ulcer disease determined that moder-ate-quality evidence supports the use of compression andlow-quality evidence supports the effect of compressionon ulcer recurrence.72

Rabe et al. 171

Recently, Lattimer et al.73 have reported on thebenefits of compression on haemodynamic parametersin PTS.


for the treatment of symptomatic PTS (Grade 1B)

Thromboprophylaxis

Two types of compression garments are used forthromboprophylaxis: thromboprophylactic stockings(TPS) and MCS. TPS with a pressure range between15 and 18mmHg should be differentiated from MCSthat are specifically designed for patients with venousor lymphatic pathology. TPS are able to decrease thevenous diameter in the prone position, thereby increas-ing venous blood flow velocity, which provides thephysical conditions needed to avert blood flow stagna-tion.74 TPS are therefore indicated during bedrest,though not for fully mobilised patients.

MCS that are specifically designed for patients witha venous or lymphatic pathology are also preferred foruse in individuals when in sitting positions (e.g. using awheelchair, during long-distance travel).

Avoid DVT after surgical interventions

In an era of increasingly well-tolerated and effectiveanti-thrombotic drugs, the role of TPS has becomeless prominent, although there is a large body of evi-dence in support of their effectiveness.

Early pioneering work by Turpie et al.,75 usingradiolabelled fibrinogen scanning, has demonstratedthat TPS alone or in combination with IPC is effectivein preventing DVT in neurosurgical patients.

Several RCTs have demonstrated a significant reduc-tion in thromboembolic events in neurosurgical patientswhen stockings were used in combination with anti-coagulants, compared with stockings alone.76,77 ACochrane review that compared TPS alone vs. TPSwith other DVT prophylactic methods, based on 19RCTs, concluded that TPS reduced the incidence ofDVT after surgery.78 However, the scientific evidenceis questionable, in view of the dubious combination ofphysical and pharmacological prophylaxis used.78 Inpatients for whom anticoagulants are contraindicated,physical modalities – including TPS, as well as IPC – arestill recommended.79–81

An international consensus report recommends theuse of TPS in addition to early ambulation and suffi-cient hydration, for patients undergoing minor surgerywith low risk (low level of evidence). Anticoagulantprophylaxis is recommended for moderate- and high-risk patients undergoing surgery.82

In high-risk patients undergoing abdominal surgery,a combination of TPS and IPC is more effective thanTPS alone.83

Well-fitting stockings are recommended in patientswith VLUs or venous leg oedema during and after sur-gery, independent from thromboprophylaxis.82

The question of whether use of TPS offers a furthersignificant benefit as an adjunct to pharmacologicalthromboprophylaxis in surgical inpatients was investi-gated in a recent systematic review of 27 RCTs. Noclear benefit of adding TPS to pharmacological throm-boprophylaxis in such patients could be identified,mainly because of the heterogeneity of the results,which precluded a valid summation analysis.84

For patients undergoing orthopaedic surgery, theaddition of TPS use to an effective anticoagulant hasbeen questioned.85–87

Chin et al.87 reported that the use of TPS alone isable to reduce DVT in Asian patients who have had atotal knee replacement, in comparison to a controlgroup of patients, although IPC and enoxaparin werefound to be more effective.

Recommendation 20: We suggest the use of thrombo-

prophylactic stockings as a basic component of mech-

anical prophylaxis in patients undergoing major

surgery (Grade 2C)

Recommendation 21: Mechanical methods of throm-

boprophylaxis, including thromboprophylactic stock-

ings, should be considered, especially where

anticoagulants are contraindicated (Grade 2B)

DVT prophylaxis in medical patients andlong-distance travellers

In recent years, there has been an increase in researchon venous thromboembolism (VTE) prevention inhigh-risk scenarios, particularly in hospitalised medicalpatients, outpatients with cancer, chronically immobi-lised patients, long-distance travellers, and in patientswith asymptomatic thrombophilia.

Scurr et al.88 described asymptomatic calf veinthrombosis after long-haul flights in 10% of passen-gers without compression stockings, while those whowore MCS did not develop DVT. Clarke et al.89 con-ducted a Cochrane review to assess the effectiveness ofMCS for preventing DVT in long-haul travellers andconcluded that airline passengers can expect a sub-stantial reduction in the incidence of symptomlessDVT and leg oedema if they wear compressionstockings.

Several consensus meetings have proposed theuse of LMWH and/or MCS in high-risk long-distancetravellers.90


Mechanical thromboprophylaxis with MCS or IPCwas recommended by Kahn et al.79 for acutely ill hos-pitalised patients at increased risk of thrombosis whoare bleeding or are at high risk of major bleeding, atleast until the bleeding risk is decreased.

Recommendation 22: We suggest the use of MCS

during long-distance travelling, to prevent DVT inci-

dence in patients at risk (Grade 2B); in high-risk

patients, we suggest a combination of MCS with anti-

coagulant thromboprophylaxis (Grade 2C)

DVT prophylaxis in stroke patients

There is a paucity of information on the prevention ofVTE among high-risk patients.91 The CLOTS trials,which investigated patients who have had a stroke, pro-vide reliable data. In the outcome-blinded RCT of 2518patients (CLOTS I), where the primary outcome wasthe occurrence of symptomatic or asymptomatic DVTin the popliteal or femoral veins, thigh-length TPScaused skin problems in 5% of patients and did notreduce the incidence of DVT.92 A comparison betweenthigh-length and knee-length stockings (CLOTS II)revealed that proximal DVT occurred more often inpatients with stroke who wore below-knee stockingsthan in those who wore thigh-length stockings.93

A Cochrane review, conducted to determine whetherthigh-high or knee-high TPS would be more effective inpostoperative surgical patients, reported that there isinsufficient high-quality evidence to answer thisquestion.94

The CLOTS III trial demonstrated that IPC is aneffective method of reducing the risk of DVT and pos-sibly improving survival in a wide variety of patientswho are immobile after stroke.95

It may be assumed that TPS may help reduce depend-ent oedema in stroke patients with reduced mobility.

Recommendation 23: We do not recommend below-

knee TPS as the sole method for DVT prophylaxis in

stroke patients (Grade 2B)

Recommendation 24: If TPS is considered in stroke

patients for DVT prophylaxis, we suggest the use of

thigh-length TPS over knee-length TPS stockings

(Grade 1B)

Patients with lymphoedema

Prevention of lymphoedema

There is paucity of data on the use of MCS for theprevention of lymphoedema. A recent RCT that

compared thigh-length 21–32mmHg stockings withusual care, 6 months after inguinal lymph node resec-tion as a result of cancer, reported no significant differ-ences between groups in the incidence of oedema,median time to the occurrence of oedema, incidenceof genital oedema, frequency of complications, health-related QoL (HRQoL), or body image.96

Comment: More trials are needed to clarify the poten-

tial role of compression stockings for preventing lym-

phoedema after surgery

Improvement of lymphoedema

Compression is certainly the most important compo-nent in the context of ‘decongestive lymphatic ther-apy’ (DLT) – both for the treatment and for themaintenance phase. However, data endorsing thisconcept are lacking.97 Appropriately fitting compres-sion garments are recommended for long-termmaintenance therapy.

A major problem in assessing the efficacy of com-pression garments in lymphoedema is that the use ofstockings in all studies was combined with additionaltreatment modalities, and primarily manual lymphdrainage (MLD). In an RCT in which 95 patientswith breast cancer-related arm lymphoedema were ran-domly assigned to either compression garments (con-trol) or daily manual lymphatic drainage andbandaging followed by compression garments (experi-mental), Dayes et al.98 were unable to demonstrate asignificant difference in improvement in lymphoedemabetween the two groups. The authors indicated that thefailure to detect a difference may have been a result ofthe relatively small size of the trial.

Johannsson et al.99 surveyed the current evidence, inregard to the treatment of lymphoedema, and con-cluded that less emphasis should be placed on MLDand more on early diagnosis, compression, weight con-trol and exercise, when managing patients with cancer-related lymphoedema.

The published data are mainly on volume changes,while symptoms and QoL assessments are inconsist-ently reported. The traditional concept of starting lym-phoedema therapy by compression bandages (‘therapyphase’) followed by stockings (‘maintenance phase’) issupported by the outcome of an RCT which demon-strated that multilayer bandaging as an initial phase oftreatment for lymphoedema patients, followed by hosi-ery, achieves greater and more sustained limb-volumereduction than hosiery alone.100

MCS are mainly used to maintain long-term lym-phoedema reduction. There is evidence that high-compression stockings (30–40mmHg) are effective;

Rabe et al. 173

generally, the highest level of compression that thepatient can tolerate (20–60mmHg) is likely to be themost beneficial.101


for lymphoedema maintenance therapy (Grade 1A)

Discussion

The place of MCS in managing chronic and acutevenous and lymphatic disorders is discussed below.Consideration of the effectiveness of different lengths(below-knee, thigh-length, waist-high, etc.), compres-sion pressures, or degrees of stiffness of MCS has notbeen included because information about the influenceof these factors on therapeutic outcomes is either miss-ing or associated recommendations have beeninconsistent.

Importantly, we acknowledge that several studieshave limitations that led to lower grading of anumber of the recommendations. Limitations includelow numbers of patients included in the respective stu-dies, as well as instances where MCS was not comparedwith no compression or placebo. In some studies, thecomparator MCS had different pressure levels or a dif-ferent compression method was applied; thus, a faircomparison of the interventions was not done.

Chronic venous disorders

In chronic venous disease, MCS are now a main indi-cation for the improvement of venous symptoms, QoLand oedema (Grade 1B). This is particularly true for thetreatment of occupational leg oedema and the reduc-tion of venous symptoms/oedema during long-distancetravel (Grade 1B).

The clinical observation that stockings reduce thepigmentation and induration of lipodermatosclerosisand venous eczema has not been confirmed in largeclinical trials, because of the methodological difficultiesof measurement. More studies are needed to confirmtheir benefit in treating venous skin changes.

The use of MCS on ulcer recurrence prevention iswell documented (Grade 1A). However, evidence ontheir use in treating established ulcers is less clear.Since the 2008 consensus document,4 specially designedulcer MCS (ulcer kits) have been developed. They con-sist of a two-layer stocking system for uniform gradu-ated compression and ease of application. Theirbeneficial effect on VLU healing has been reported inseveral clinical trials.26,28

Although it is intuitive that MCS reduce the relent-less radial tension in veins during dependency, there isstill insufficient information available to recommend

their use for the prevention of CVD progression.Further studies are required for an evidence-basedrecommendation.

As recommended in most of the current recommen-dations and guidelines, compression has become stand-ard practice after varicose vein surgery to reducebruising, pigmentation, pain and oedema, and also toimprove efficacy.102 Now that venous interventionshave become minimally invasive, fewer side effectsmay be expected. Consequently, the need for compres-sion is less clear. Recent studies indicate that in most ofthe interventions there is still a benefit of MCS duringthe first post-interventional week.38,39,44 These findingsrelate especially to the reduction of pain, oedema andbruising.

Information on the long-term benefits derived fromthe use of MCS in the early postoperative phase is lack-ing in the literature. Interestingly, some benefit aftersclerotherapy in C1 varicose veins has been reported.

31

In patients with ongoing CVD symptoms, despiteprevious interventions, a continuation of compressiontherapy with MCS is still indicated. Unfortunately, stu-dies that compare MCS with no compression or placebocompression are rare. More commonly, different typesof compression have been compared, but with inconsist-ent results falling short of any recommendation.

Acute venous disorders

The recommendation to use MCS in the acute stage ofDVT to reduce pain and swelling and allow immediateambulation is based on two studies.49,50 Although thisregime has been widely accepted,103,104 more studies areneeded on optimal compression therapy. Researchquestions that still need to be addressed include:should the length of the stocking be adjusted to thelevel and extent of the disease?; what compressionstrength is best, and for how long?; and should themobility of the patient be taken into consideration?Ideally, such studies should begin in the acute stage,after confirmation of the diagnosis, and should concen-trate not only on the morphology of the thrombus, butalso on the reduction of leg swelling, pain, and onimproving QoL. Similar considerations should beapplied to the use of MCS in SVT. However, to date,only one such RCT has been conducted.54 Well-conducted studies will be able to determine the extentand benefit of MCS in the long-term prevention of PTS.Implantable electronic devices sewn into the fabric ofthe stocking should help improve treatment becausethey have the potential to provide feedback on usage.This approach may be necessary to record patient com-pliance, because this remains one of the major chal-lenges in the management of venous or lymphaticdisorders.


An alternative approach is to provide some type ofawareness training to remind the patient regularlyabout the usefulness of compression therapy.However, though rewarding, such training is verytime consuming. The immediate feeling of relief frompain and swelling in the acute stage of venous throm-bosis, combined with the assumption that MCS reducefurther thromboembolic events, may be the best argu-ment to maximise patient compliance.

Insufficient data are available from prospectiveRCTs for identifying those patients requiring treatmentwith MCS, for the purpose of preventing PTS.

Whilst those patients with proximal DVT and a highthrombus burden seem to be the most suitable for treat-ment, PTS is frequently seen in patients without a cleardiagnosis of previous DVT. This suggests that allpatients may benefit from MCS after DVT. In agree-ment with recommendations 3–5 in this document, ahigh-level recommendation for using MCS in suchpatients can be justified (Grade 1B).

TPS were recommended for bedridden patients in the2008 consensus (Grade 1A).4 However, their value hasbeen questioned in the light of recent trials.78,92,93 This isbecause prescription of the newer and very effective anti-thrombotic drugs make it difficult to attribute a poten-tially positive treatment effect to the use of TPS.

This document recommends the use of TPS as acomponent of mechanical prophylaxis in patientsundergoing major surgery (Grade 2C). Correctly mea-sured TPS should be considered in all patients whereanticoagulation is contraindicated (Grade 2B).Stocking–skin interface pressures can be measuredeasily with small portable devices. They are recom-mended clinically to ensure a good compression profile,especially for legs of non-standard proportions, and arerecommended in all research studies.

Lymphatic disorders

The beneficial effect of MCS in the maintenance oflong-term lymphoedema reduction is undisputed andwell documented (Grade 1A). However, detailed stu-dies are required to examine their potential role forthe prevention of lymphoedema after radiotherapy,cancer and lymph-node dissection. In selecting outcomeparameters for such studies, there should be consider-ation not only of the oedema, but also of the mobilityof the patients, their QoL and the ease of applicabilityof compression garments.

Other indications

Compression has an anti-inflammatory effect and isoften recommended for inflammatory conditions thathave an oedema component. These may include

cellulitis, some forms of vasculitis, and systemic medicaltreatments. Compression stockings may help also in thereduction of oedema and nausea during pregnancy.There is a growing demand for their use in sports medi-cine where they may have an effect on reducing recov-ery time. In these cases, compression can be used withgood clinical success in daily practice but there is a lackof randomised comparative studies that have examinedthese indications.105

Contraindications

It is best practice not to offer MCS to patients withsevere congestive cardiac failure, as there is a risk thatthey may develop systemic fluid overload. However,reducing moderate oedemas, without shifting largerblood volumes towards the right heart, can be achievedusing light MCS.

Another successful indication for light MCScould be the post-reconstructive oedema after success-ful bypass surgery. The use of light MCS(15–21mmHg) in these two indications is based on clin-ical experience only, and deserves further study in thefuture.

In patients with critical limb ischaemia, with systolicankle pressure below 70mmHg or following arterialbypass grafting, compression stockings are contraindi-cated as there is a risk of ischaemia or local skin necro-sis, especially if the limb is elevated.

There are other local conditions in which stockingsmay cause damage. These include advanced peripheralneuropathy, fragile tissue paper skin over the bonyprominences, dermatitis and allergic reactions to thefabric.

For unusual leg sizes, shapes or deformities, a stand-ard ‘off-the-shelf’ stocking is unlikely to fit the patient.In these cases, MCS should be customised to the indi-vidual limb measurements.

Conclusion

This consensus document reports an update of thescientific evidence on the use of MCS in venousand lymphatic disorders. Compared with the ICCconsensus document in 2008, several new RCTshave been published showing the improvements thatMCS provide in reducing venous symptoms andsigns. Although more research is always required,the place of MCS as a treatment is now firmly estab-lished for most venous and lymphatic conditions, aswell as for venous symptoms in healthy people. Theconsensus statement was awarded first prize in theoral abstract presentation section at the 30thAnnual Congress of the American College ofPhlebology 2016, Anaheim, California.

Rabe et al. 175

Tab

le2.

Evi

dence

critic

ally

revi

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litera

ture

sear

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(continued)


Tab

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�Pai

nal

levi

ated

equal

lyin

both

groups

Finla

yson

et

al.1

8M

CS

vs.ban

dag

es

Pat

ients

:n¼

103

Dro

pouts

:n¼

16

�H

eal

ing

of

venous

leg

ulc

ers

equal

lyeffect

ive

with

both

syst

em

s,but

more

rapid

resp

onse

with

ban

dag

es

Kap

pet

al.2

4M

CS

modera

tepre

ssure

vs.M

CS

hig

hpre

ssure

Pat

ients

:n¼

100

Dro

pouts

:n¼

69

�N

on-c

om

plia

nt

pat

ients

:w

ound

recu

rrence

9

tim

es

more

likely

�M

odera

teco

mpre

ssio

n:ri

skre

curr

ence

thre

e

tim

es

great

er

than

with

hig

hco

mpre

ssio

n

Dolib

og

et

al.2

7IP

Cvs

.M

CS

vs.ban

dag

es

Pat

ients

:n¼

70

Dro

pouts

:N

A

�W

ound

size

reduct

ion

and

perc

enta

geof

wounds

heal

ed

sign

ifica

ntly

hig

her

ingr

oups

rece

ivin

gIP

Cor

MC

Sth

anin

groups

usi

ng

short

-str

etc

hed

ban

dag

es

Ash

by

et

al.2

8M

CS

vs.ban

dag

es

Pat

ients

:n¼

457

Dro

pouts

:n¼

14

�B

oth

treat

ments

equal

lyeffect

ive

atheal

ing

venous

leg

ulc

ers

�H

igher

rate

of

treat

ment

chan

gein

MC

S

group

Reduct

ion

of

side

effect

s

afte

rve

nous

inte

rven-

tions/

impro

vem

ent

of

thera

peutic

outc

om

e

afte

rve

nous

inte

rventions

Kern

et

al.3

1M

CS

vs.none

(aft

er

C1

scle

roth

era

py)

Pat

ients

:n¼

100

Dro

pouts

:n¼

4

�T

hre

ew

eeks

of

MC

Sw

ear

ing

enhan

ced

scle

roth

era

pyeffic

acy

by

impro

ving

clin

ical

vess

eldis

appear

ance

Houte

rman

s-

Auck

elet

al.3

7M

CS

vs.none

(follo

win

g3

day

sof

ban

dag

es)

(aft

er

surg

ery

)

Pat

ients

:n¼

104

Dro

pouts

:n¼

8

�N

oad

ditio

nal

post

opera

tive

benefit

of

MC

S

longe

rth

an3

day

saf

ter

stri

ppin

g(w

ith

resp

ect

tolim

boedem

a,pai

n,co

mplic

atio

ns

and

retu

rnto

work

)

Bis

was

et

al.3

81

week

TPS

vs.3

weeks’

TPS

(aft

er

surg

ery

)

Pat

ients

:N

A�

No

benefit

from

thre

ew

eeks’

TPS

afte

r

unco

mplic

ated

vein

surg

ery

(with

resp

ect

to

post

opera

tive

pai

n,num

ber

of

com

plic

atio

ns,

tim

eto

retu

rnto

work

,pat

ient

satisf

action)

Mar

ianiet

al.3

9M

CS

vs.ban

dag

es

Pat

ients

:n¼

60

Dro

pouts

:N

A

�M

CS:

less

oedem

a,im

pro

ved

QoL

and

com

plia

nce

Most

iet

al.4

0M

CS

vs.ban

dag

evs

.

ecc

entr

icco

mpre

ssio

n

padþ

MC

S

(aft

er

surg

ery

)

Pat

ients

incl

uded:n¼

54

Dro

pouts

:N

A

�Pad

sþ

MC

S:best

resu

lts

with

resp

ect

topai

n

reduct

ion

and

hae

mat

om

a

�M

ajor

adve

rse

eve

nts

:m

ore

frequent

inM

CS

group

�M

inor

adve

rse

events

:re

port

ed

inal

lgr

oups,

most

frequent

inpad

and

MC

Sgr

oup

Benig

niet

al.4

1M

CSþ

com

pre

ssio

n

pad

vs.M

CS

alone

(aft

er

surg

ery

)

Pat

ients

:n¼

54

Dro

pouts

:n¼

1

�Pad

additio

nundern

eat

hM

CS:

post

opera

tive

pai

nsi

gnifi

cantly

reduce

d

(continued)

Rabe et al. 177

Tab

le2.

Continued

Tre

atm

ent

goal

Refe

rence

sTre

atm

ent/

com

par

ison

Pat

ient

info

rmat

ion

Outc

om

e

Lugl

iet

al.4

2Ecc

entr

icco

mpre

ssio

nvs

.

none

(aft

er

lase

r)

Pat

ients

:n¼

200

Dro

pouts

:N

A

�Ecc

entr

icco

mpre

ssio

n:post

opera

tive

pai

n

inte

nsi

tygr

eat

lyre

duce

d

Bak

ker

et

al.4

3M

CS

for

48

hvs

.M

CS

for

7day

s

(aft

er

EV

Lab

lation)

Pat

ients

:n¼

86

Dro

pouts

:n¼

10

�C

om

pre

ssio

nfo

rlo

nge

rth

an48

hre

duce

s

pai

nan

dim

pro

ves

phy

sica

lfunct

ion

duri

ng

the

first

week

afte

rtr

eat

ment

Reic

h-S

chupke

et

al.4

4Low

pre

ssure

MC

S

(18–22

mm

Hg)

vs.

modera

tepre

ssure

MC

S(2

3–32

mm

Hg)

Pat

ients

:n¼

88

Dro

pouts

:N

A

�23–32

mm

Hg

MC

Sar

esu

peri

or

to

18–21

mm

Hg

MC

Sin

fast

er

reso

lution

of

oedem

aan

dfe

elin

gsof

pai

n,tigh

tness

,an

d

dis

com

fort

of

the

leg

inth

efir

stw

eek

afte

r

vari

cose

vein

surg

ery

,but

not

inth

elo

nge

r

post

-surg

ical

peri

od

up

tosi

xw

eeks

Ham

el-D

esn

os

et

al.4

5M

CS

vs.none

(aft

er

scle

roth

era

py)

Pat

ients

:n¼

60

Dro

pouts

:N

A

�N

odiff

ere

nce

betw

een

both

groups

afte

r

scle

roth

era

py,

when

com

par

ing

effic

acy,

side

effect

s,sa

tisf

action,sy

mpto

ms

and

QoL

(b)

Acu

teven

ou

sd

iso

rders

Reduct

ion

of

pai

nK

ahn

et

al.5

1M

CS

vs.pla

cebo

MC

SPat

ients

:n¼

806

Dro

pouts

:n¼

114

2–3

weeks

afte

rD

VT

�N

odiff

ere

nce

inpai

nsc

ore

betw

een

groups

�N

oev

idence

for

subgr

oup

inte

ract

ion

by

age,

sex

or

anat

om

ical

eve

nt

of

DV

T

Reduct

ion

of

thro

mbus

grow

th

Boehle

ret

al.5

4M

CS

vs.none

Pat

ients

:n¼

80

Dro

pouts

:n¼

7

�M

CS:

no

sign

ifica

nt

additio

nal

benefit

to

LM

WH

and

NSA

IDS

inth

etr

eat

ment

ofSV

T

afte

r3

weeks

(with

resp

ect

topai

n,

NSA

IDco

nsu

mption,th

rom

bus

lengt

h,

ery

them

a)

�M

CS:

fast

er

thro

mbus

regr

ess

ion

atD

ay7

DV

Tpro

phy

laxis

inm

ed-

ical

pat

ients

and

long-

dis

tance

trav

elle

rs

Gao

et

al.8

3Pre

opera

tive

TPSþ

IPC

duri

ng

opera

tion

vs.

pre

opera

tive

TPSþ

none

duri

ng

opera

tion

Pat

ients

:n¼

108

Dro

pouts

:N

A

�T

PSþ

IPC

:th

rom

bosi

sm

ore

effect

ively

pre

-

vente

dth

anw

ith

TPS

alone

(aft

er

gynae

co-

logi

calpelv

issu

rgery

)

Cohen

et

al.8

5T

PSþ

fondap

arin

ux

vs.

fondap

arin

uxþ

none

Pat

ients

:n¼

856

Com

ple

ted

study:

n¼

151

Ultra

sonogr

aphers

were

blin

ded

totr

eat

ment

�T

PS:

no

additio

nal

benefit

when

use

dw

ith

fondap

arin

ux

ove

rth

euse

of

fondap

arin

ux

alone

(aft

er

hip

surg

ery

)

Cam

pore

seet

al.8

6T

PS

vs.LM

WH

7day

svs

.

LM

WH

14

day

s

Pat

ients

:n¼

1761

Dro

pouts

:n¼

9

�LM

WH

:re

duce

da

com

posi

teend

poin

t

asym

pto

mat

icD

VT,sy

mpto

mat

icve

nous

thro

mboem

bolis

man

dm

ort

ality

more

than

TPS

(aft

er

knee

arth

rosc

opy

)

Chin

et

al.8

7T

PS

vs.in

term

itte

nt

pneum

atic

com

pre

s-

sion

vs.LM

WH

vs.

none

Pat

ients

:n¼

440

Dro

pouts

not

dis

cuss

ed

Ultra

sonogr

aphers

were

blin

ded

totr

eat

ment

�D

VT

pre

vale

nce

sign

ifica

ntly

low

er

with

IPC

or

LWM

H(b

ut

not

with

TPS)

com

par

ed

to

contr

ol(a

fter

knee

arth

rosc

opy

)

(continued)


Tab

le2.

Continued

Tre

atm

ent

goal

Refe

rence

sTre

atm

ent/

com

par

ison

Pat

ient

info

rmat

ion

Outc

om

e

DV

Tpro

phy

laxis

in

stro

kepat

ients

Dennis

et

al.9

2T

PS

vs.none

Pat

ients

:n¼

2518

The

study

was

outc

om

e-b

linded

�T

PS:

risk

of

DV

Tdev

elo

pm

ent

afte

rac

ute

stro

kenot

reduce

d

�C

S:sk

inbre

aks,

ulc

er,

blis

ters

,sk

innecr

osi

s

more

com

mon

when

com

par

ed

topat

ients

without

TPS

CLO

TS

Tri

al

Colla

bora

tion

93

TPS

thig

h-lengt

hvs

.knee-

lengt

h

Pat

ients

:af

ter

stro

ken¼

3114

Dro

pouts

atfir

stsc

reenin

g:

n¼

302

Dro

pouts

atse

cond

scre

enin

g:

n¼

1832

Ultra

sonogr

aphers

were

blin

dto

treat

ment

�T

hig

h-lengt

hst

ock

ings

:occ

urr

ence

of

pro

x-

imal

DV

Tle

ssfr

equent

than

with

belo

w-k

nee

stock

ings

Pre

vention

of

PT

SPra

ndoniet

al.6

1M

CS

thig

h-lengt

hvs

.M

CS

knee-lengt

h

Pat

ients

:n¼

267

Dro

pouts

:n¼

11

�T

hig

h-lengt

hM

CS:

no

bett

er

pro

tect

ion

agai

nst

PT

Sth

anbelo

w-k

nee

MC

Sþ

less

-well

tole

rate

d

Asc

hw

anden

et

al.6

2M

CS

26–31

mm

Hg

vs.

none

Pat

ients

:n¼

169

Dro

pouts

:n¼

45

The

study

lack

sad

equat

epow

er

tosh

ow

asi

gnifi

cant

diff

er-

ence

for

the

pri

mar

youtc

om

e

�Pro

longe

dco

mpre

ssio

nth

era

pyaf

ter

pro

x-

imal

DV

T:sy

mpto

ms

sign

ifica

ntly

reduce

dþ

-

post

-thro

mbotic

skin

chan

ges

may

be

pre

vente

d

Kah

net

al.6

4A

ctiv

eM

CS

30–40

mm

Hg

vs.pla

cebo

MC

S(a

pplie

d2–3

weeks

afte

rac

ute

DV

T)

Pat

ients

:n¼

806

Dro

pouts

:n¼

114

Auth

ors

use

the

term

‘mas

kin

g’

rath

er

than

‘blin

din

g’but

stat

e

that

most

pat

ients

and

inve

s-

tiga

tors

were

unaw

are

of

treat

ment

allo

cation.

�M

CS:

PT

Snot

pre

vente

daf

ter

afir

stpro

xim

al

DV

T

Jaya

rajan

d

Meis

sner6

7M

CS

30–40

mm

Hg

vs.

none

Pat

ients

:n¼

69

Dro

pouts

at12

month

s:n¼

14

Dro

pouts

at24

month

s:n¼

37

Ass

ess

or

(diff

ere

nt

from

inve

sti-

gato

rw

ho

initia

llysa

w

pat

ient)

was

blin

ded

totr

eat

-

ment

allo

cation

�M

CS:

PT

Sin

cidence

was

low

er

than

inco

ntr

ol

group

at1-

and

3-m

onth

cuto

ff,but

not

at

late

rvi

sits

Thera

pyof

PT

SLat

tim

er

et

al.7

3M

CS

18–21

mm

Hg

belo

w-

or

above

-knee

vs.M

CS

23–32

mm

Hg

belo

w-

or

above

-knee

Pat

ients

:n¼

34

(40

legs

–6

had

bila

tera

ldis

eas

e)

Eac

hpat

ient

acte

das

their

ow

n

contr

olan

dw

ere

test

ed

with

allfo

ur

stock

ings

inra

ndom

ord

er

�C

om

pre

ssio

n:hae

modyn

amic

par

amete

rson

air

ple

thys

mogr

aphy

sign

ifica

ntly

impro

ved

�H

aem

odyn

amic

benefit

not

sign

ifica

ntly

chan

-

ged

with

the

clas

sor

lengt

hof

stock

ing

(continued)

Rabe et al. 179

Tab

le2.

Continued

Tre

atm

ent

goal

Refe

rence

sTre

atm

ent/

com

par

ison

Pat

ient

info

rmat

ion

Outc

om

e

(c)

Lym

ph

ati

cd

iso

rders

Pre

vention

of

lym

phoedem

a

Stuiv

er

et

al.9

6M

CS

23–32

mm

Hg

vs.

none

Pat

ients

:n¼

80

Aft

er

ingu

inal

lym

ph

node

dis

-

sect

ion

Dro

pouts

at6

month

s:n¼

11

Dro

pouts

at12

month

s:n¼

12

The

num

ber

of

dro

pouts

was

hig

her

than

expect

ed

resu

ltin

g

ina

larg

er

chan

ceof

aty

pe-I

I

err

or.

RR

were

stab

le

thro

ugh

out

the

study

�N

osi

gnifi

cant

diff

ere

nce

sbetw

een

groups

in

oedem

ain

cidence

,m

edia

ntim

eto

oedem

a

occ

urr

ence

,ge

nital

oedem

ain

cidence

,co

m-

plic

atio

nfr

equency

,Q

oL

or

body

imag

e(a

fter

ingu

inal

lym

ph

node

dis

sect

ion)

Impro

vem

ent

of

lym

phoedem

a

Day

es

et

al.9

8D

aily

man

ual

lym

phat

ic

dra

inag

eþ

ban

dag

ingþ

com

pre

ssio

nsl

eev

e

30–40

mm

Hg

vs.

com

pre

ssio

indications for medical compression stockings in venous and … · 2020. 8. 14. · compression is...

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