Compression Bulletin 34 special edition

Medical Compression Stockings in Venous and Lymphatic Disorders. Consensus Group: Eberhard Rabe, Hugo Partsch, Juerg Hafner, Christopher Lattimer, Giovanni Mosti, Martino Neumann, Tomasz Urbanek, Monika Hübner, Sylvain Gaillard, Patrick Carpentier.

Medical compression stockings in venous and lymphatic disorders

Consensus Group: Eberhard Rabe, Hugo Partsch, Juerg Hafner, Christopher Lattimer, Giovanni Mosti, Martino Neumann, Tomasz Urbanek, Monika Hübner, Sylvain Gaillard, Patrick Carpentier

Recommendations 1–9

Chronic Venous Disorders: Symptoms, QoL and Oedema

1. Use of MCS to alleviate venous symptoms in CVD

Five studies have reported compression provides relief of aching, pain, leg cramps and restlessness (2), (3), (4), (5), (6) (Grade 1B)

2. Use of MCS to improve QoL and venous severity in CVD

Three studies have reported compression either improves QoL, healing and pain or treatment effectiveness as measure by the VCSS (7), (8), (9) (Grade 1B)

3. Use of MCS to prevent leg swelling in CVD and in healthy individuals at risk of leg swelling

RCT conducted in Australia demonstrated that low-ankle pressure GCTs help to prevent flight induced ankle edema (10) (Grade 1B)

4. Use of MCS to reduce leg swelling in CVD and occupational leg swelling

Three studies have reported compression stockings are able to reduce ankle and leg edema (11), (12) (Grade 1B)

Chronic Venous Disorders: Skin Changes

5. Use of MCS for improvement of skin changes in patients with CVD

Regularly observed in routine clinical practice; there is a paucity of evidence from RCTs (Grade 1C)

6. Use of MCS for improvement of lipodermatosclerosis in patients with CVD

RCT of 153 patients randomized to either below-knee MCS or no MCS showed MCS can improve skin changes in patients with lipodermatosclerosis (13) (Grade 1B)

Chronic Venous Disorders: Venous Leg Ulcers

7. Use of MCS to reduce recurrence of VLU

Three RCTs and a Cochrane review show trends of lower rates of venous ulcer recurrence with higher-compression MCS; compliance was lower in “high” compression groups and had positive outcome (14), (15), (16), (17) (Grade 1A)

8. Use of ulcer MCS (“ulcer kits”) to improve VLU healing

Five RCTs reported improvement in VLU healing with use of ulcer MCS (18), (19), (20), (21), (22) (Grade 1A Upgraded from 1B in the 2008 consensus statement)

9. Use of ulcer MCS (“ulcer kits”) to reduce pain in patients with VLU

RCT showed that, in patients treated with MCS and bandages, pain is alleviated promptly and effect is equivalent between two treatment modalities (18) (Grade 1A)

Recommendations 10–17

Chronic Venous Disorders: Post-venous interventions

10. Further studies needed to provide data on use of MCS for prevention of CVD progression

Insufficient information from RCTs on prevention of CVD progression by MCS to allow for evidence-based recommendation (No Grade)

11. Use of MCS in initial phase after GSV treatment to reduce postoperative side effects

Five RCTs reported reduction of side effects with use of MCS (23), (24), (25), (26), (27) (Grade 1B)

12. Use of additional eccentric compression to enhance effectiveness of MCS in reducing postoperative side effects

Two RCTs reported postoperative reduction in pain (28), (29) and one RCT reported reduction in pain and hematoma (30) (Grade 1B)

13. Limit prolonged use of MCS to improve clinical success after GSV interventions

Seven RCTs either did not follow patients for long enough or failed to demonstrate benefits from ongoing MCS use (23), (24),(28), (29), (30), (31), (32) (Grade 1B)

14. Use of MCS after liquid sclerotherapy of C1 veins to achieve better outcomes

RCT reported improved vessel disappearance with MCS (27) (Grade 2B)

Acute Venous Disorders: Deep vein thrombosis

15. Use of immediate compression to reduce pain and swelling, thereby allowing instant mobilisation in acute DVT. Compression should be used immediately after DVT event

Two RCTs reported reduction in pain and swelling with use of immediate compression (33), (34) (Grade 1B Downgraded from 1A in the 2008 consensus statement); One RCT reported that when compression is initiated ≥ 2 weeks, there is no effect on resultant pain levels (35) (Grade 1B*)

16. Use early compression and mobilization in addition to anticoagulation to avoid thrombus propagation after the DVT event. Compression should be used immediately after the DVT event.

Two RCTs reported less thrombus progression with immediate compression, compared with no compression or delayed compression (33), (34), (35), (36) (Grade 1B)

Acute Venous Disorders: Superficial Vein Thrombosis

17. Use of MCS in patients with SVT (*Downgraded from 1A in the 2008 consensus statement)

A Cochrane review supports that compression of thrombosed vein relieves symptoms of SVT and accelerates healing (37) (Grade 1C); One RCT reported that in patients with SVT treated with LMWH, aside from reduction of thrombus growth after 1 week, no additional benefit for symptomatic outcomes has been demonstrated (38) (Grade 1C)

Recommendations 18–25

Acute Venous Disorders: Post-Thrombotic Syndrome

18. Use of MCS as early as possible after diagnosis of DVT in order to prevent PTS

Six RCTs have reported benefit of compression in reducing PTS incidence (39), (40), (41), (42), (43), (44). One RCT emphasizes importance of immediate application of MCS in acute phase of DVT (44). One RCT reported no benefit from compression to prevent PTS when compression was started 2 weeks after diagnosis and when at ≥ 3 days compression per week was accepted as good compliance (45). Current evidence still supports compression therapy for PTS prophylaxis in clinical practice, at least in symptomatic patients (Grade 1B Downgraded from 1A in the 2008 consensus statement)

19. Use of MCS for treatment of symptomatic PTS

Data on the physical management of PTS are sparse (46), (47), (48). RCT reported significant improvement in haemodynamic parameters (49) (Grade 1B)

Acute Venous Disorders: Thromboprophylaxis

20. Use of TPS as basic component of mechanical prophylaxis in patients undergoing major surgery

Several studies support use of TPS in patients undergoing surgery (50), (51), (52), (53), (54) (Grade 2C)

21. Mechanical methods of thromboprophylaxis, including TPS, should be considered, especially where anticoagulants are contraindicated

Current guidelines (55), (56) and a meta-analysis support use of compression where anticoagulants are contraindicated (57) (Grade 2B)

22. Use of MCS during long-distance travelling, to prevent DVT incidence in patients at risk; in high-risk patients, combine use of MCS with anticoagulant thromboprophylaxis

An RCT (58), Cochrane review (59) and several consensus meetings (60) support use of MCS for preventing DVT in long-haul travellers and high-risk patients (Grade 2B)

23. Do not use below-knee TPS as sole method for DVT prophylaxis in stroke patients

A Cochrane review reported there is insufficient high-quality evidence to say whether thigh-high or knee-high TPS is more effective (61) (Grade 2B)

24. If TPS is considered in stroke patients for DVT prophylaxis, we suggest use of thigh-length TPS over knee-length TPS stockings

An RCT reported less frequent DVT with thigh-length TPS (62) (Grade 1B)

Lymphedema: Prevention and Improvement of Lymphedema

25. Use of MCS for lymphedema maintenance therapy (Not enough evidence to make a recommendation on the use of compression for the prevention of lymphedema)

2013 consensus of ISO reports MCS are mainly used to maintain long-term lymphedema reduction; the highest level of compression that patients can tolerate (20-60mmHg) is likely to be most beneficial (63) (Grade 1A Upgraded from 1B in the 2008 consensus statement)

Conclusion & comments of the editors
                                This consensus document, an update from the 2008 ICC document, reports the scientific evidence on the use of MCS in venous and lymphatic disorders. In contrary to the 2008 consensus the recommendations given do not focus on the C-classes of the CEAP classification but mainly on the clinical outcome of the treatment. In the last years several new RCTs have been published showing the improvements that MCS provide in reducing venous symptoms and signs. In chronic venous disease, MCS are a main indication for the improvement of venous symptoms, QoL and oedema (Grade 1B) independently from the underlying venous disease.
In addition to the use of MCS on venous leg ulcer (VLU) recurrence prevention which is well documented (Grade 1A) recent studies have now added good evidence on the use of specially designed ulcer MCS (ulcer kits) in treatment of VLUs (Grade 1A) and in reducing pain in these patients (Grade 1A).
As recommended in most of the current recommendations and guidelines, compression has become standard practice after varicose vein surgery to reduce bruising, pigmentation, pain and oedema, and also to improve efficacy. Now that venous interventions have become less invasive fewer side effects may be expected. Consequently, the need for compression is less clear. Recent studies indicate that in most of the interventions for varicose veins (C2) there is still a benefit of MCS during the first post-interventional week for the reduction of pain, oedema and bruising (Grade 1B) but no benefit of longer compression could be demonstrated. However, in patients with ongoing CVD symptoms, despite previous interventions, a continuation of compression therapy with MCS is still indicated.
There is still insufficient information available to recommend the use of MCS for the prevention of CVD progression. Further studies are required for an evidence-based recommendation.
Despite controversies about the use of compression in DVT caused by results from recent studies the authors of this consensus document recommend the immediate use of compression in DVT patients to reduce pain and swelling (Grade 1B) and the ongoing use of compression with MCS to prevent PTS (Grade 1B).
The beneficial effect of MCS in the maintenance of long-term lymphedema reduction is undisputed and well documented (Grade 1A).
Thromboprophylactic stockings (TPS) were recommended for bedridden patients in the 2008 consensus (Grade 1A). However, their value has been questioned in the light of recent trials. This is because prescription of the newer and very effective anti-thrombotic drugs make it difficult to attribute a potentially positive treatment effect to the use of TPS. Consequently this document recommends the use of TPS as a component of mechanical prophylaxis in patients undergoing major surgery (Grade 2C) and in all patients where anticoagulation is contraindicated (Grade 2B) on a low level of evidence.
In future studies small electronic devices sewn into the fabric and able to measure interface pressure or temperature may improve information about true compliance with compression.
Although more research is always required, the place of MCS as a treatment is now firmly established for most venous and lymphatic conditions, as well as for venous symptoms in people without any morphological venous changes.

                            