Compression therapy for the treatment of chronic venous insufficiency
- David G Armstrong, DPM, MD, PhD
David G Armstrong, DPM, MD, PhD
- Professor of Surgery and Director
- Southwestern Academic Limb Salvage Alliance (SALSA)
- Keck School of Medicine, University of Southern California
- Andrew J Meyr, DPM
Andrew J Meyr, DPM
- Clinical Associate Professor
- Temple University School of Podiatric Medicine
- Section Editors
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Science Center
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
Compression therapy remains the cornerstone of management for patients with chronic venous insufficiency (venous valvular reflux). Chronic venous disease is commonly stratified using the CEAP (Clinical, Etiology, Anatomy, Pathophysiology) classification, which grades venous disease based on the presence of dilated veins, edema, skin changes, or ulceration (table 1). (See "Classification of lower extremity chronic venous disorders", section on 'CEAP classification'.)
Chronic venous insufficiency is defined as CEAP 3 to 6 and represents advanced venous disease . Chronic venous insufficiency is the most common cause of lower extremity ulceration, accounting for up to 80 percent of the approximately 2.5 million leg ulcer cases in the United States . Annual costs in the United States for the treatment of venous ulcers are estimated at more than $2 billion from costs related to frequent physician visits, care provided by nurses, compression therapy and wound care products, and potentially hospitalization.
Medical compression therapy includes garments or devices that provide static or dynamic mechanical compression to a body region. For the treatment of lower extremity chronic venous insufficiency, static compression includes compression hosiery and compression bandages. Dynamic (intermittent) compression therapy in the form of intermittent pneumatic compression pumps and sleeves may be useful under select circumstances.
The pathophysiology, clinical features and diagnosis, and management of chronic venous disease are discussed elsewhere. (See "Overview and management of lower extremity chronic venous disease".)
Compression therapy remains the cornerstone of management for patients with chronic venous disease [3,4]. For patients with venous ulceration, the benefits of long-term compression therapy (stockings or bandages) have repeatedly been demonstrated in randomized trials . Healing rates as high as 97 percent can be achieved in those who are compliant with therapy . Patients with edema, weeping, or skin changes in the absence of ulceration also benefit. The goals of treatment are ulcer healing, and reduction of extent of edema, lipodermatosclerosis, and pain. Other treatments and local wound care are discussed separately. (See "Medical management of lower extremity chronic venous disease".)
- Kistner RL, Eklof B, Masuda EM. Diagnosis of chronic venous disease of the lower extremities: the "CEAP" classification. Mayo Clin Proc 1996; 71:338.
- Brem H, Kirsner RS, Falanga V. Protocol for the successful treatment of venous ulcers. Am J Surg 2004; 188:1.
- Douglas WS, Simpson NB. Guidelines for the management of chronic venous leg ulceration. Report of a multidisciplinary workshop. British Association of Dermatologists and the Research Unit of the Royal College of Physicians. Br J Dermatol 1995; 132:446.
- de Araujo T, Valencia I, Federman DG, Kirsner RS. Managing the patient with venous ulcers. Ann Intern Med 2003; 138:326.
- O'Meara S, Cullum N, Nelson EA, Dumville JC. Compression for venous leg ulcers. Cochrane Database Syst Rev 2012; 11:CD000265.
- Mayberry JC, Moneta GL, Taylor LM Jr, Porter JM. Fifteen-year results of ambulatory compression therapy for chronic venous ulcers. Surgery 1991; 109:575.
- Harding KG. Leg ulcers. J R Soc Med 1991; 84:515.
- Baker SR, Stacey MC, Singh G, et al. Aetiology of chronic leg ulcers. Eur J Vasc Surg 1992; 6:245.
- Callam MJ, Ruckley CV, Dale JJ, Harper DR. Hazards of compression treatment of the leg: an estimate from Scottish surgeons. Br Med J (Clin Res Ed) 1987; 295:1382.
- Barr DM. The Unna's boot as a treatment for venous ulcers. Nurse Pract 1996; 21:55.
- Mosti G, Iabichella ML, Partsch H. Compression therapy in mixed ulcers increases venous output and arterial perfusion. J Vasc Surg 2012; 55:122.
- Partsch H. Compression therapy of the legs. A review. J Dermatol Surg Oncol 1991; 17:799.
- Somerville JJ, Brow GO, Byrne PJ, et al. The effect of elastic stockings on superficial venous pressures in patients with venous insufficiency. Br J Surg 1974; 61:979.
- O'Donnell TF Jr, Rosenthal DA, Callow AD, Ledig BL. Effect of elastic compression on venous hemodynamics in postphlebitic limbs. JAMA 1979; 242:2766.
- Mayberry JC, Moneta GL, DeFrang RD, Porter JM. The influence of elastic compression stockings on deep venous hemodynamics. J Vasc Surg 1991; 13:91.
- Nehler MR, Moneta GL, Woodard DM, et al. Perimalleolar subcutaneous tissue pressure effects of elastic compression stockings. J Vasc Surg 1993; 18:783.
- Jones NA, Webb PJ, Rees RI, Kakkar VV. A physiological study of elastic compression stockings in venous disorders of the leg. Br J Surg 1980; 67:569.
- Christopoulos D, Nicolaides AN, Szendro G. Venous reflux: quantification and correlation with the clinical severity of chronic venous disease. Br J Surg 1988; 75:352.
- Abu-Own A, Shami SK, Chittenden SJ, et al. Microangiopathy of the skin and the effect of leg compression in patients with chronic venous insufficiency. J Vasc Surg 1994; 19:1074.
- Gjöres JE, Thulesius O. Compression treatment in venous insufficiency evaluated with foot volumetry. Vasa 1977; 6:364.
- Lattimer CR, Kalodiki E, Kafeza M, et al. Quantifying the degree graduated elastic compression stockings enhance venous emptying. Eur J Vasc Endovasc Surg 2014; 47:75.
- Beidler SK, Douillet CD, Berndt DF, et al. Multiplexed analysis of matrix metalloproteinases in leg ulcer tissue of patients with chronic venous insufficiency before and after compression therapy. Wound Repair Regen 2008; 16:642.
- Couzan S, Leizorovicz A, Laporte S, et al. A randomized double-blind trial of upward progressive versus degressive compressive stockings in patients with moderate to severe chronic venous insufficiency. J Vasc Surg 2012; 56:1344.
- Mosti G, Partsch H. High compression pressure over the calf is more effective than graduated compression in enhancing venous pump function. Eur J Vasc Endovasc Surg 2012; 44:332.
- Mosti G, Partsch H. Compression stockings with a negative pressure gradient have a more pronounced effect on venous pumping function than graduated elastic compression stockings. Eur J Vasc Endovasc Surg 2011; 42:261.
- Lim CS, Davies AH. Graduated compression stockings. CMAJ 2014; 186:E391.
- Bowling K, Ratcliffe C, Townsend J, Kirkpatrick U. Clinical thromboembolic detterrent stockings application: are thromboembolic detterrent stockings in practice matching manufacturers application guidelines. Phlebology 2015; 30:200.
- Sippel K, Seifert B, Hafner J. Donning devices (foot slips and frames) enable elderly people with severe chronic venous insufficiency to put on compression stockings. Eur J Vasc Endovasc Surg 2015; 49:221.
- London NJ, Donnelly R. ABC of arterial and venous disease. Ulcerated lower limb. BMJ 2000; 320:1589.
- Willenberg T, Lun B, Amsler F, Baumgartner I. Ease of application of medical compression-stocking systems for the treatment of venous ulcers. Eur J Vasc Endovasc Surg 2010; 40:129.
- Choucair M, Phillips TJ. Compression therapy. Dermatol Surg 1998; 24:141.
- Partsch H, Mortimer P. Compression for leg wounds. Br J Dermatol 2015; 173:359.
- Mosti G, Partsch H. Inelastic bandages maintain their hemodynamic effectiveness over time despite significant pressure loss. J Vasc Surg 2010; 52:925.
- Weller CD, Evans SM, Staples MP, et al. Randomized clinical trial of three-layer tubular bandaging system for venous leg ulcers. Wound Repair Regen 2012; 20:822.
- Moffatt C. Variability of pressure provided by sustained compression. Int Wound J 2008; 5:259.
- Polignano R, Bonadeo P, Gasbarro S, Allegra C. A randomised controlled study of four-layer compression versus Unna's Boot for venous ulcers. J Wound Care 2004; 13:21.
- Hendricks WM, Swallow RT. Management of stasis leg ulcers with Unna's boots versus elastic support stockings. J Am Acad Dermatol 1985; 12:90.
- Keller A, Müller ML, Calow T, et al. Bandage pressure measurement and training: simple interventions to improve efficacy in compression bandaging. Int Wound J 2009; 6:324.
- Tips for the application of a compression bandage. http://en.hartmann.info/application_bandage.php (Accessed on September 28, 2010).
- Moffatt C. Four-layer bandaging: from concept to practice. Int J Low Extrem Wounds 2002; 1:13.
- Heede G. [The Pütter bandage]. Z Arztl Fortbild (Jena) 1981; 75:763.
- Wong IK, Man MB, Chan OS, et al. Comparison of the interface pressure and stiffness of four types of compression systems. J Wound Care 2012; 21:161, 164, 166.
- Thomas S, Fram P. Laboratory-based evaluation of a compression-bandaging system. Nurs Times 2003; 99:24.
- Partsch H. Compression therapy. Int Angiol 2010; 29:391.
- Zarchi K, Jemec GB. Delivery of compression therapy for venous leg ulcers. JAMA Dermatol 2014; 150:730.
- Mauck KF, Asi N, Elraiyah TA, et al. Comparative systematic review and meta-analysis of compression modalities for the promotion of venous ulcer healing and reducing ulcer recurrence. J Vasc Surg 2014; 60:71S.
- Amsler F, Willenberg T, Blättler W. In search of optimal compression therapy for venous leg ulcers: a meta-analysis of studies comparing diverse [corrected] bandages with specifically designed stockings. J Vasc Surg 2009; 50:668.
- Ashby RL, Gabe R, Ali S, et al. Clinical and cost-effectiveness of compression hosiery versus compression bandages in treatment of venous leg ulcers (Venous leg Ulcer Study IV, VenUS IV): a randomised controlled trial. Lancet 2014; 383:871.
- Brizzio E, Amsler F, Lun B, Blättler W. Comparison of low-strength compression stockings with bandages for the treatment of recalcitrant venous ulcers. J Vasc Surg 2010; 51:410.
- Mosti G, Cavezzi A, Partsch H, et al. Adjustable Velcro Compression Devices are More Effective than Inelastic Bandages in Reducing Venous Edema in the Initial Treatment Phase: A Randomized Controlled Trial. Eur J Vasc Endovasc Surg 2015; 50:368.
- Allenby F, Boardman L, Pflug JJ, Calnan JS. Effects of external pneumatic intermittent compression on fibrinolysis in man. Lancet 1973; 2:1412.
- Tarnay TJ, Rohr PR, Davidson AG, et al. Pneumatic calf compression, fibrinolysis, and the prevention of deep venous thrombosis. Surgery 1980; 88:489.
- Comerota AJ. Intermittent pneumatic compression: physiologic and clinical basis to improve management of venous leg ulcers. J Vasc Surg 2011; 53:1121.
- Nelson EA, Hillman A, Thomas K. Intermittent pneumatic compression for treating venous leg ulcers. Cochrane Database Syst Rev 2014; :CD001899.
- Nelson EA, Mani R, Thomas K, Vowden K. Intermittent pneumatic compression for treating venous leg ulcers. Cochrane Database Syst Rev 2011; :CD001899.
- Nicolaides AN, Fernandes e Fernandes J, Pollock AV. Intermittent sequential pneumatic compression of the legs in the prevention of venous stasis and postoperative deep venous thrombosis. Surgery 1980; 87:69.
- Smith PC, Sarin S, Hasty J, Scurr JH. Sequential gradient pneumatic compression enhances venous ulcer healing: a randomized trial. Surgery 1990; 108:871.
- Milic DJ, Zivic SS, Bogdanovic DC, et al. The influence of different sub-bandage pressure values on venous leg ulcers healing when treated with compression therapy. J Vasc Surg 2010; 51:655.
- Jünger M, Ladwig A, Bohbot S, Haase H. Comparison of interface pressures of three compression bandaging systems used on healthy volunteers. J Wound Care 2009; 18:474, 476.
- Dale JJ, Ruckley CV, Gibson B, et al. Multi-layer compression: comparison of four different four-layer bandage systems applied to the leg. Eur J Vasc Endovasc Surg 2004; 27:94.
- Blair SD, Wright DD, Backhouse CM, et al. Sustained compression and healing of chronic venous ulcers. BMJ 1988; 297:1159.
- Nelson EA, Iglesias CP, Cullum N, et al. Randomized clinical trial of four-layer and short-stretch compression bandages for venous leg ulcers (VenUS I). Br J Surg 2004; 91:1292.
- Ashby RL, Gabe R, Ali S, et al. VenUS IV (Venous leg Ulcer Study IV) - compression hosiery compared with compression bandaging in the treatment of venous leg ulcers: a randomised controlled trial, mixed-treatment comparison and decision-analytic model. Health Technol Assess 2014; 18:1.
- Nelson EA, Bell-Syer SE. Compression for preventing recurrence of venous ulcers. Cochrane Database Syst Rev 2014; :CD002303.
- Raju S, Hollis K, Neglen P. Use of compression stockings in chronic venous disease: patient compliance and efficacy. Ann Vasc Surg 2007; 21:790.
- Franks PJ, Oldroyd MI, Dickson D, et al. Risk factors for leg ulcer recurrence: a randomized trial of two types of compression stocking. Age Ageing 1995; 24:490.
- Van Hecke A, Grypdonck M, Defloor T. A review of why patients with leg ulcers do not adhere to treatment. J Clin Nurs 2009; 18:337.
- Brandjes DP, Büller HR, Heijboer H, et al. Randomised trial of effect of compression stockings in patients with symptomatic proximal-vein thrombosis. Lancet 1997; 349:759.
- STATIC COMPRESSION THERAPY
- Compression hosiery
- - Prescription
- - Use and care of compression hosiery
- Before placement
- Care of hosiery
- Compression bandages
- - Application
- - General tips for compression bandage placement
- Multilayer compression bandages
- - Padding (layer 1)
- - Crepe bandage (layer 2)
- - Extensible elastic bandage (layer 3)
- - Cohesive elastic bandage (layer 4)
- Unna boot
- - Patient instructions and follow-up
- Adjustable compression
- DYNAMIC COMPRESSION THERAPY
- CHOICE OF INITIAL THERAPY
- Skin necrosis
- Fungal infection
- Contact dermatitis
- COST OF COMPRESSION THERAPIES
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS