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Background Sclerotherapy is a non-invasive procedure commonly used to treat superficial venous disease, vascular malformations and other ectatic vascular lesions. While extremely rare, sclerotherapy may be complicated by serious adverse events. Objectives To categorise contraindications to sclerotherapy based on the available scientific evidence. Methods An international, multi-disciplinary panel of phlebologists reviewed the available scientific evidence and developed consensus where evidence was lacking or limited. Results Absolute Contraindications to sclerotherapy where the risk of harm would outweigh any benefits include known hypersensitivity to sclerosing agents; acute venous thromboembolism (VTE); severe neurological or cardiac adverse events complicating a previous sclerotherapy treatment; severe acute systemic illness or infection; and critical limb ischaemia. Relative Contraindications to sclerotherapy where the potential benefits of the proposed treatment would outweigh the risk of harm or the risks may be mitigated by other measures include pregnancy, postpartum and breastfeeding; hypercoagulable states with risk of VTE; risk of neurological adverse events; risk of cardiac adverse events and poorly controlled chronic systemic illness. Conditions and circumstances where Warnings and Precautions should be considered before proceeding with sclerotherapy include risk of cutaneous necrosis or cosmetic complications such as pigmentation and telangiectatic matting; intake of medications such as the oral contraceptive and other exogenous oestrogens, disulfiram and minocycline; and psychosocial factors and psychiatric comorbidities that may increase the risk of adverse events or compromise optimal treatment outcomes. Conclusions Sclerotherapy can achieve safe clinical outcomes provided that (1) patient-related risk factors and in particular all material risks are (1a) adequately identified and the risk benefit ratio is clearly and openly discussed with treatment candidates within a reasonable timeframe prior to the actual procedure; (1b) when an individual is not a suitable candidate for the proposed intervention, conservative treatment options including the option of ‘ no intervention as a treatment option’ are discussed; (1c) complex cases are referred for treatment in controlled and standardised settings and by practitioners with more expertise in the field; (1d) only suitable individuals with no absolute contraindications or those with relative contraindications where the benefits outweigh the risks are offered intervention; (1e) if proceeding with intervention, appropriate prophylactic measures and other risk-mitigating strategies are adopted and appropriate follow-up is organised; and (2) procedure-related risk factors are minimised by ensuring the treating physicians (2a) have adequate training in general phlebology with additional training in duplex ultrasound, procedural phlebology and in particular sclerotherapy; (2b) maintain their knowledge and competency over time and (2c) review and optimise their treatment strategies and techniques on a regular basis to keep up with the ongoing progress in medical technology and contemporary scientific evidence.

Recomendación 1.1: Compresión después de ablación térmica o escisión de venas safenas. Cuando sea posible, sugerimos que se debe usar compresión (medias elásticas o vendaje) después de procedimientos quirúrgicos o térmicos, para eliminar venas varicosas. [GRADO 2; NIVEL DE EVIDENCIA - C] Recomendación 1.2:Dosis de compresión posterior a ablación térmica o escisión de venas varicosas. Si se van a utilizar dispositivos de compresión después del procedimiento, en pacientes sometidos a ablación o procedimientos quirúrgicos en sus venas safenas, la mayor reducción de dolor posoperatorio se logra con presiones> 20 mm Hg, junto con almohadillas excéntricas colocadas directamente sobre la vena donde se realizó la operación o ablación. [GRADO 2; NIVEL DE EVIDENCIA - B] Recomendación 2.1:Duración de la terapia de compresión después de la ablación térmica o escisión de venas safenas. En ausencia de pruebas convincentes, recomendamos el mejor juicio clínico para determinar la duración de la terapia de compresión después del tratamiento. [MEJORES PRÁCTICAS] Recomendación 3.1: Terapia de compresión después de escleroterapia. Sugerimos terapia de compresión inmediatamente después del tratamiento de venas superficiales con escleroterapia, para mejorar los resultados de la escleroterapia. [GRADO 2; NIVEL DE EVIDENCIA - C] Recomendación 3.2: Duración de la terapia de compresión después de escleroterapia. En ausencia de evidencias convincentes, recomendamos el mejor juicio clínico para determinar la duración de la terapia de compresión después de la escleroterapia. [MEJORES PRÁCTICAS] Recomendación 4.1: Compresión después del tratamiento venoso superficial en pacientes con úlcera venosa en la pierna. En pacientes con úlcera venosa en la pierna recomendamos terapia de compresión, en lugar de terapia sin compresión, para aumentar la tasa de curación de la úlcera venosa de la pierna y disminuir el riesgo de recurrencia de la úlcera. [GRADO 1; NIVEL DE EVIDENCIA - B]Recomendación 4.2: Compresión después del tratamiento venoso superficial en pacientes con úlcera mixta arterial y venosa en la pierna. En pacientes con úlcera venosa en la pierna y enfermedad arterial subyacente, sugerimos limitar el uso de compresión a pacientes con índice tobillo-brazo superior a 0,5 o si la presión absoluta del tobillo es> 60 mm Hg. [GRADO 2; NIVEL DE EVIDENCIA - C]

Objectives The aim of this study was to illustrate how compression is performed worldwide in proximal DVT and if compression management has changed recently. Methods A global online survey, consisting of 36 questions, was used. The survey was solicited from membership lists of Union Internationale de Phlébologie (UIP) membership societies. For differences between the continents in comparison to Western Europe odds ratios and 95% Confidence Intervals (95%CI) where calculated. Results We received 626 answers from 41 countries. Compression is routinely used in proximal DVT in all regions (82.8%). 81.4% start compression immediately after diagnosis. In the acute phase of DVT reduction of pain and swelling (91.7%) and PTS prevention (66.2%) are the main reasons for compression. 33.2% recently changed their compression management with 43.5% starting compression earlier and 7.0% later. Conclusions Compression is still used routinely in proximal DVT in addition to anticoagulation. The changes in international guidelines towards the non-routine use of compression in proximal DVT have not caused significant changes in DVT management.

Background: Compression therapy is an important part of the treatment of patients with lymphedema or chronic venous disease. However, there is no validated questionnaire evaluating the effect of compression and its acceptance by the patient. Therefore, the aims of this study were to construct a questionnaire evaluating the effect of compression and its acceptance by the patient, that is, the Dutch ICC Compression Questionnaire (ICC-CQ), to investigate its reliability and validity, and to translate it into English. Methods and Results: Eleven experts in applying compression and 51 Dutch patients with experience of using compression were involved in the construction process. One part of the ICC-CQ has to be completed by the patient and evaluates seven domains. The other part has to be completed by the health care provider and comprises three domains. Reliability and validity of the final version was investigated in a new group of 79 Dutch-speaking patients with lymphedema or chronic venous disease, wearing compression garments (N = 52) or bandages (N = 27). Except for one domain, the Intraclass Correlation Coefficients for test-rest/interrater reliability ranged from 0.55 to 0.93. Cronbach's alpha for internal consistency ranged from 0.71 to 0.97. Eighty-nine percent of the patients fully understood the questionnaire indicating good face validity, and 87% found it complete indicating good content validity. Construct validity was considered good since 10 out of 11 hypotheses were accepted. Conclusion: The ICC-CQ is the first reliable and valid questionnaire evaluating different kinds of compression and the experience by patients with lymphedema or chronic venous disease. ispartof: LYMPHATIC RESEARCH AND BIOLOGY vol:20 issue:2 pages:191-202 ispartof: location:United States status: published

ObjectivesMedical compression therapy is used for non-invasive treatment of venous and lymphatic diseases. Medical compression therapy-associated adverse events and contraindications have been reported, although some contraindications are theoretically based. This consensus statement provides recommendations on medical compression therapy risks and contraindications.MethodsA systematic literature search of medical compression therapy publications reporting adverse events up until November 2017 was performed. A consensus panel comprising 15 international experts critically reviewed the publications and formulated the recommendations.ResultsSixty-two publications reporting medical compression therapy adverse events were identified. The consensus panel issued 21 recommendations on medical compression therapy contraindications and adverse event risk mitigation, in addition to reviewing medical compression therapy use in borderline indications. The most frequently reported non-severe medical compression therapy-associated adverse events included skin irritation, discomfort and pain. Very rare but severe adverse events, including soft tissue and nerve injury, were also identified.ConclusionThis consensus statement summarises published medical compression therapy-associated adverse events and contraindications, and provides guidance on medical compression therapy. Severe medical compression therapy-associated adverse events are very rarely encountered if compression is used correctly and contraindications are considered.

For the currently used compression therapy, the applied compression pressure is usually inadequate to exert an effective impact on the veins in different body positions. The aim was to assess the venous ejection fraction achieved by a new compression device which automatically adjusts the interface pressure to body position in an acute experimental setting.A new portable, battery driven compression device providing pressure adjusted to allow for body position, and connected to a less or very stiff calf cuff wrap was tested. In patients with superficial venous incompetence, the ejection fraction (EF) of the calf pump was measured by strain gauge plethysmography. Applied in a random sequence, values achieved without compression, with the two cuffs, and with compression stockings exerting 23-32 mmHg, were compared. The applied compression pressures were simultaneously recorded in the supine and standing positions, and during walking. Comfort was assessed by a visual analogue scale (VAS) with 0 corresponding to very low comfort and 10 to very comfortable.In 16 patients with CEAP clinical stage C3-C6, EF without compression was 37%, increasing to 46.9% with stockings, to 64.8% (p .001) by less stiff and to 75.5% (p .001) by stiffer wraps. The median interface pressure (supine/standing) was 31/56 mmHg for the less stiff device, 32/68 mmHg for the stiffer device, and 23/26 mmHg for the stockings. The static stiffness index and the walking pressure amplitudes were significantly higher than those generated by the stocking, and the highest values were found with the stiffer wrap material. The device comfort was high both in the supine and standing positions (VAS 8 ± 2).The tested devices were comfortable at rest and haemodynamically effective during walking by automatically adjusting compression pressures to body position. They are significantly more effective than elastic stockings in improving EF. The system is able to overcome the problems of fast pressure loss by continuously re-adjusting the compression pressure.

In a previous randomized controlled trial it has been demonstrated that arm compression sleeves worn immediately after breast cancer surgery, including axillary lymph node removal in addition to physical therapy are able to reduce the occurrence of early postoperative swelling and of arm lymphedema up to 1 year and to improve quality of life. The aim of the present investigation was to check the further development of the arm swelling in patients using compression sleeves or not, and to compare the quality of life in women treated due to breast cancer 2 years after surgery.Twenty from originally 23 patients who still wore their compression sleeves (15 mmHg) and 21 from 22 patients who had been randomized into the control group without compression could be seen after one more year. Arm volume measurements were performed and quality of life (QLQ-C30 and QLQ-BR23 questionnaires) was assessed.Three from 20 patients in the compression group (CG) and 6 from 21 without compression showed arm lymphedema, defined by an increase of the arm volume exceeding 10% compared with the preoperative values. Significant improvement of several quality of life parameters were found in the CG.Light compression sleeves worn for 2 years are not only able to reduce the incidence of early postoperative edema and of lymphedema, but also lead to a significant improvement of important quality-of-life parameters like physical functioning, fatigue, pain, arm and breast symptoms, and future perspectives.

Summary Guideline 1.1: Compression after thermal ablation or stripping of the saphenous veins. When possible, we suggest compression (elastic stockings or wraps) should be used after surgical or thermal procedures to eliminate varicose veins. [GRADE - 2; LEVEL OF EVIDENCE - C] Guideline 1.2: Dose of compression after thermal ablation or stripping of the varicose veins. If compression dressings are to be used postprocedurally in patients undergoing ablation or surgical procedures on the saphenous veins, those providing pressures >20 mm Hg together with eccentric pads placed directly over the vein ablated or operated on provide the greatest reduction in postoperative pain. [GRADE - 2; LEVEL OF EVIDENCE - B] Guideline 2.1: Duration of compression therapy after thermal ablation or stripping of the saphenous veins. In the absence of convincing evidence, we recommend best clinical judgment to determine the duration of compression therapy after treatment. [BEST PRACTICE] Guideline 3.1: Compression therapy after sclerotherapy. We suggest compression therapy immediately after treatment of superficial veins with sclerotherapy to improve outcomes of sclerotherapy. [GRADE - 2; LEVEL OF EVIDENCE - C] Guideline 3.2: Duration of compression therapy after sclerotherapy. In the absence of convincing evidence, we recommend best clinical judgment to determine the duration of compression therapy after sclerotherapy. [BEST PRACTICE] Guideline 4.1: Compression after superficial vein treatment in patients with a venous leg ulcer. In a patient with a venous leg ulcer, we recommend compression therapy over no compression therapy to increase venous leg ulcer healing rate and to decrease the risk of ulcer recurrence. [GRADE - 1; LEVEL OF EVIDENCE - B] Guideline 4.2: Compression after superficial vein treatment in patients with a mixed arterial and venous leg ulcer. In a patient with a venous leg ulcer and underlying arterial disease, we suggest limiting the use of compression to patients with ankle-brachial index exceeding 0.5 or if absolute ankle pressure is >60 mm Hg. [GRADE - 2; LEVEL OF EVIDENCE - C]

The aim of this study was to investigate if compression therapy (CT) can be safely applied in diabetic patients with Venous Leg Ulcers (VLU), even when a moderate arterial impairment (defined by an Ankle-Brachial Pressure Index 0.5&ndash, 0.8) occurs as in mixed leg ulcers (MLU). Materials and methods: in one of our previous publications we compared the outcomes of two groups of patients with recalcitrant leg ulcers. Seventy-one patients were affected by mixed venous and arterial impairment and 109 by isolated venous disease. Both groups were treated by tailored inelastic CT (with compression pressure &lt, 40 mm Hg in patients with MLU and &gt, 60 mm Hg in patients with VLU) and ultrasound guided foam sclerotherapy (UGFS) of the superficial incompetent veins with the reflux directed to the ulcer bed. In the present sub analysis of the same patients we compared the healing time of 107 non-diabetic patients (NDP), 69 with VLU and 38 with MLU) with the healing time of 73 diabetic patients (DP), 40 with VLU and 33 with MLU. Results: Twenty-five patients were lost at follow up. The results refer to 155 patients who completed the treatment protocol. In the VLU group median healing time was 25 weeks for NDP and 28 weeks in DP (p = 0.09). In the MLU group median healing time was 27 weeks for NDP and 29 weeks for DP (p = &minus, 0.19). Conclusions: when providing leg ulcer treatment by means of tailored compression regimen and foam sclerotherapy for superficial venous refluxes, diabetes has only a minor or no effect on the healing time of recalcitrant VLU or MLU.

Disclaimer Due to the evolving field of medicine, new research may, in due course, modify the recommendations presented in this document. At the time of publication, every attempt has been made to ensure that the information provided is up to date and accurate. It is the responsibility of the treating physician to determine the best treatment for the patient. The authors, committee members, editors, and publishers cannot be held responsible for any legal issues that may arise from the citation of this statement. Rules of evidence Management of patients with chronic venous disorders has been traditionally undertaken subjectively among physicians, often resulting in less than optimal strategies. In this document, a systematic approach has been developed with recommendations based upon cumulative evidence from the literature. Levels of evidence and grades of recommendation range from Level I and Grade A to Level III and Grade C. Level I evidence and Grade A recommendations derive from scientifically sound randomized clinical trials in which the results are clear-cut. Level II evidence and Grade B recommendations derive from clinical studies in which the results among trials often point to inconsistencies. Level III evidence and Grade C recommendations result from poorly designed trials or from small case series.1, 2 Meta-analysis Meta-analyses are included in the present document but there should be caution as to their possible abuse. Certain studies may be included in a meta-analysis carelessly without sufficiently understanding of substantive issues, ignoring relevant variables, using heterogenous findings or interpreting results with a bias.3 It has been demonstrated that the outcomes of 12 large randomized controlled trials were not predicted accurately 35% of the time by the meta-analyses published previously on the same topics.4

IntroductionCompression therapy by inelastic bandages is highly effective in achieving venous leg ulcer healing. Inelastic bandages may be expensive as they need to be changed and discarded at every dressing change. In addition, correct application is difficult in the clinical practice, even by expert healthcare personnel. The aim of our work was to assess whether adjustable compression wraps are more cost effective and more effective than inelastic bandage to achieve venous leg ulcer healing.MethodsSixty-six venous leg ulcer patients were randomized to be treated by adjustable compression wrap (CircAid® JuxtaCure®) ( n = 33) and inelastic bandage (Coban 2 Layer®) ( n = 33). Study duration was 12 weeks. During weekly visits, the ulcers were cleansed and dressed with the same products, and the only variable was the compression device. Ulcer size, ulcer pain, patient’s perception of compression systems, and compression pressure were assessed during the visits, and the material cost was evaluated at the 12th week.ResultsAdjustable compression wraps were significantly cheaper than bandages (p ConclusionsAdjustable compression wraps are significantly cheaper and more effective (not significantly) in achieving venous leg ulcer healing. Self-applicable, adjustable compression wraps are therefore a powerful, cost-effective alternative to inelastic bandages in treating venous leg ulcer.

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 (n = 4), 1B (n = 13), 1C (n = 2), 2B (n = 4) and 2C (n = 1). The panel 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 compression 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, compression 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.

Bandage application does not exert consistent compression pressure, leading to extremely variable compression when applied to patients. A new elastic bandage can exert a predefined pressure independently of healthcare providers and the size of the wrapped limb. The bandage system includes a series of non-stretchable patches that when applied to the bandage make it stiff. The aim of this work was to assess, in an experimental setting, the venous ejection fraction (EF) from the lower leg and the tolerability of this new bandage in a group of patients affected by superficial venous incompetence.EF was measured using strain gauge plethysmography under baseline conditions and the bandage was applied with a supine pressure of 20 and 30 mmHg, with and without the stiff patches, in 25 patients with severe venous reflux in the great saphenous vein. The interface pressure of the bandages was measured simultaneously in the medial gaiter area.All patients showed EF values that were significantly reduced compared with normal individuals. Elastic bandages with an average pressure of 20 and 30 mmHg in the supine position achieved a slight improvement in EF, and, after applying non-stretchable patches on the same bandage with similar resting pressure, EF was restored to its normal range (p .001). Improvement in EF correlates with the pressure differences between standing and lying pressure and between muscle systole and diastole during exercise.This study confirms that inelastic is much more effective than elastic compression for improving impaired venous haemodynamics. The test material can be applied with a predetermined pressure, which considerably enhances the consistency of application, and it is easily transformed into an inelastic system just by applying stiff patches without any stretch and without significantly increasing the comfortable supine pressure.

Breast cancer-related lymphedema (LE) remains one of the major long-term complications after surgery. Many reports showed the effectiveness of compression in breast cancer-related LE treatment, but randomized controlled trials evaluating compression garments for postoperative prevention are lacking.The aim of the study was to evaluate the potential role of light arm compression sleeves for reducing the incidence of early postoperative swelling and of breast cancer-related arm LE.A total of 45 women were pre-operatively randomly assigned to a group with compression of circular-knit sleeves in compression class I (15-21 mm Hg) for daily wearing (compression group [CG]; n = 23) or to a control group without compression (no CG, n = 22). Both groups underwent a standardized physical exercise program. Arm volumes were measured before surgery and one, three, six, nine, and 12 months thereafter.At one month, postoperative swelling was reduced only in CG. After 12 months, the average change of excess volumes (edema) reached -67.6 mL in the CG vs. +114.5 mL in the no CG (P 0.001). Significantly less edema was seen in the CG after three, six, nine, and 12 months. No significant difference between groups in health-related quality of life (measured by EORTC QLQ-C30) was observed.Fifteen to 21 mm Hg compression sleeves in combination with physical activity may be a safe and efficient option to prevent postsurgical arm swelling and development of LE.

Introduction: The adequate use of compression in venous leg ulcer treatment is equally important to patients as well as clinicians. Currently, there is a lack of clarity on contraindications, risk factors, adverse events and complications, when applying compression therapy for venous leg ulcer patients. Methods: The project aimed to optimize prevention, treatment and maintenance approaches by recognizing contraindications, risk factors, adverse events and complications, when applying compression therapy for venous leg ulcer patients. A literature review was conducted of current guidelines on venous leg ulcer prevention, management and maintenance. Results: Searches took place from 29th February 2016 to 30th April 2016 and were prospectively limited to publications in the English and German languages and publication dates were between January 2009 and April 2016. Twenty Guidelines, clinical pathways and consensus papers on compression therapy for venous leg ulcer treatment and for venous disease, were included. Guidelines agreed on the following absolute contraindications: Arterial occlusive disease, heart failure and ankle brachial pressure index (ABPI)

Objective The conservative treatment of post-thrombotic syndrome includes application of compression on the affected extremity. However, the type and the level of compression required to manage post-thrombotic syndrome are still unclear. The aim of our proof-of-concept study was to assess the compression required to reduce cross section area of post-thrombotic deep veins in 22 patients with post-thrombotic syndrome. Methods The circumference and cross section area of posterior tibial veins and saphenous vein trunk were assessed on mid-calf level using 3T magnetic resonance scanner, at increasing compression (0, 30, 40, and 50 mmHg), provided by a novel adjustable Velcro compression wrap, the CircAid JuxtaLite®. Results A significant reduction of baseline vein cross section area in post-thrombotic syndrome patients in the lying position required compression of at least 30 mmHg for posterior tibial veins, and at least 40 mmHg for the saphenous trunk. Apart from morphological changes of the compressed veins, we observed extinction of T2w signal at compression above 40 mmHg, which corresponded to accelerated blood flow in the veins, and therefore may be considered as a hemodynamic marker of compression effectiveness. Conclusion CircAid adjusted to compression level ≥40 mmHg accelerates blood flow in affected deep veins, thus it may facilitate post-thrombotic syndrome management.

The pressure exerted by a compression device on a part of the body corresponds to the dosage of the compression therapy. Therefore, the pressure course under compression materials should be investigated in different clinical situations.Pressure measurements were carried out under different compression materials in lying, standing and walking positions within the framework of training, self-experimentation and in patients with venous leg ulcers.The results showed that the pressure varied considerably depending on the material used, the firmness of application, the local configuration (body position) and the time interval between applications. A loss of pressure occurred under each compression therapy, especially under inelastic short-stretch material, mainly due to movement and edema reduction. This pressure loss is decisive for the timing of dressing changes and a reason for the good tolerance of high-pressure levels in mobile patients.Low pressures are particularly suitable for edema reduction. Hemodynamic effects require higher pressures (60-80 mmHg). For this purpose, inelastic materials are preferred which enable lower pressures when lying down (40-60 mmHg). As compression bandages are too loosely applied by many users, pressure indicators on bandages or adaptive bandages with templates are helpful to apply the material with the correct pressure. As a consequence of these findings it is postulated that, at least in studies comparing different compression media, pressure measurements should be carried out in the future, whereby the measuring point and body position should be documented.

Based on the historic reports about the life of Peregrine Laziosi (1265-1345) and a post-mortem examination 638 years after his death, the most probable diagnosis in this case was a venous ulcer on his right leg. As an act of penance, he did not lie down but stood in an upright position, praying to God for most of his adult life. Therefore he developed swollen legs and one extremity exulcerated. This is the typical story of a venous stasis ulcer. When the doctor came to amputate the leg the wound was healed (maybe due to excellent compression therapy performed by an angel, as demonstrated in many pictures and statues showing the miracle of St. Peregrine) (Canonization 1726). Cancer seems rather improbable based on the autopsy performed more than 600 years later and on the high age of Peregrine at his death. This case report from the middle ages is discussed concerning pathophysiology, prevention and therapy of stasis ulcers and some historic implications for todays practice are reported. Without any doubt St. Peregrine deserves more publicity, not only for the patients with leg ulcers, but also for the medical staff treating ulcer patients and how the fate of St. Peregrine can be prevented.

Compression is the mainstay of management of ambulatory venous hypertension, the most common sequel of which is venous leg ulceration. The logic for selecting compression is based on physical principles governing tension, pressure, volume as elegantly enshrined in the works of French mathematician philosophers Laplace and prior to him, Pascal. The application of Laplace’s law for using compression bandages to manage limb swelling consequent to unrelieved venous pressures and sequelae are described and used with Pascal’s law to comprehend the limitations of compression systems. While robust data from several reports endorse the concept of using compression, evidence also indicates the limitations of and difficulties encountered in practice of offering compression which involve, to a large part, changing position: from lying still to standing upright and being ambulant. The concept of measuring static stiffness index (SSI), described by Partsch, helps to explain these changes. SSI should be measured with the patient upstanding and at a specific point on the calf. This and guidance for offering compression for other clinical conditions are described in this chapter.

Chronic wounds are a significant health problem worldwide. Often they are initially managed with various focal treatments until a specialist becomes involved, sometimes weeks or months after treatment has begun. Even at the specialist level, practices and guidelines are inconsistent due to a lack of high-level evidence. A disease management system for chronic wounds that is simple, practical, and adoptable by a variety of wound care practitioners is needed. Such a system would guide wound care providers to address the critical aspects of wound care in a prioritized, systematic sequence, leading to faster healing of simple wounds, and timely advancement to more complex therapies for wounds that require such treatment. This paper describes an empirically developed wound care management system that has been successfully implemented and provides evidence-based rationale for each of its components. Relatively simple and practical, this system organizes an approach to any type of wound, routine or complex.

Aim Self-application of properly performed compression bandages is generally considered as problematic. Therefore, the aim of this study was to measure the pressure of self-applied short stretch adjustable compression wrap compression systems (Juxta fit™) and to compare the results with the pressure achieved by bandaging other legs using the same material. Methods In the two training courses for nurses, specifically interested in leg ulcer treatment, the new bandage type of adjustable compression wrap was explained and workshops were organized, in which the interface pressure achieved by Juxta fit™ was measured. In the first course, the nurses applied the compression system to each other, and in the second course, another group did it on their own legs. Bandagers were instructed to apply the system strongly, with a target range of more than 50–60 mmHg. Results In the first course with mutual application ( n = 34), the median pressure at the medial lower leg was 58.5 mmHg (minimal 31, maximal value 137 mmHg), in the second course in which self-application was tested ( n = 36), the corresponding values were 61.5 mmHg (minimum 35, maximum 102 mmHg). No pressures less than 30 mmHg were seen on the distal calf in either group. Conclusions In contrast to short stretch bandages that are frequently applied by bandagers with too low pressure, the adjustable compression wrap devices handled by the patients themselves produce more appropriate and more consistent pressure.

WHAT THIS PAPER ADDS In routine clinical practice edema is treated by means of inelastic bandages exerting a strong pressure but these require specialized personnel to be applied. Adjustable Velcro compression devices (AVCDs), or elastic stockings, are used only after the so called initial decongestive phase, in order to maintain the results and prevent the recurrence of the edema. This study shows that AVCDs can be more effective than inelastic bandages in exerting a very strong pressure in the initial treatment phase and are at least equally well tolerated.This study is also relevant from a practical point of view as it could change the traditional treatment of edema. The opportunity to use AVCDs in the initial decongestive phase may allow self-application and self-treatment, significantly reducing the cost of treatment with regard to materials and specialized personnel. Objective/Background: The objective of this study was to compare the efficacy and comfort of inelastic bandages (IBs) and adjustable Velcro compression devices (AVCDs) in reducing venous leg edema in the initial treatment phase. Methods: Forty legs from 36 patients with untreated venous edema (C3EpsAsdPr) were randomized to two groups. Patients in the first group received IBs (n ¼ 20) and those in the second AVCDs (n ¼ 20). Both compression devices were left on the leg day and night, and were renewed after 1 day. Patients in the AVCD group were asked to re-adjust the device as needed when it felt loose. Leg volume was calculated using the truncated cone formula at baseline (T0), after 1 day (T1) and after 7 days (T7). The interface pressure of the two compression devices was measured by an air filled probe, and the static stiffness index calculated after applying compression at T0 and T1, and just before removal of compression on T1 and T7. Patient comfort with regard to the two compression systems was assessed by grading signs and symptoms using a visual analog scale. Results: At T1, the median percent volume reduction was 13% for the IB group versus 19% for the AVCD group; at T7 it was 19% versus 26%, respectively (p 50% over time, while it remained unchanged with AVCDs owing to the periodic readjustment by the patient. Comfort was reported to be similar with the two compression devices. Conclusion: Re-adjustable AVCDs with a resting pressure of around 40 mmHg are more effective in reducing chronic venous edema than IBs with a resting pressure of around 60 mmHg. AVCDs are effective and well tolerated, not only during maintenance therapy, but also in the initial decongestive treatment phase of patients with venous leg edema.

Chronic venous insufficiency (CVI) can cause considerable morbidity and reduced quality of life. Compression therapy, such as bandages and stockings, is the cornerstone and golden standard in the prevention and treatment of CVI today. It is also shown that compression used after the healing of ulcers, reduces the rate of recurrence. It has been found that compression products with a stiff, non-elastic material, are essential for an improved haemodynamic effect, indicating that low resting pressure and high working pressure is vital, in order to achieve the most effective and well tolerated compression treatment. However, one great challenge is that by applying a stiff bandage, either as a single component or as a part in a multi-component product, one always adds, a not so easily quantified, resting pressure. In order to achieve the most effective treatment it is easy to apply the bandage in a too tight and uneven manner, often resulting in painful resting pressures. In earlier studies, it has been shown that common for todays practice is that the compression treatment is dependent on the applier and that only about 10% of the healthcare personnel managers to apply a pre-defined target bandage pressure. It has also been shown that the applied pressures decrease in effectiveness, only after a couple of hours, due to e.g. oedema reduction, resulting in poor compression treatment over time.

Compression therapy is the standard first-line treatment for chronic venous insufficiency and venous ulceration, and remains so despite progress in both ablative and reconstructive venous surgery. The goal of compression therapy is to facilitate rapid ulcer healing, maintain functional mobility of the patient, and prevent recurrence. Compression therapy is effective at promoting reasonably rapid ulcer healing. Compression therapy should create internal pressures that are evenly distributed within the leg that maximize the effect of calf muscle contraction and thus optimize venous blood return to the heart. Prior to the initiation of compression therapy for venous ulceration, patients must be educated about their chronic disease and the need to comply with their treatment plan in order to heal ulcers and prevent recurrence. Compression therapy is most commonly delivered with gradient elastic compression stockings. Stockings are less bulky than other forms of compression therapy and therefore perhaps more comfortable.

The International Compression Club, a collaboration of medical experts and industry representatives, was founded in 2005 to develop consensus reports and recommendations regarding the use of compression therapy in the treatment of acute and chronic vascular disease. During the recent meeting of the International Compression Club, member presentations were focused on the clinical application of intermittent pneumatic compression in different disease scenarios as well as on the use of inelastic and short stretch compression therapy. In addition, several new compression devices and systems were introduced by industry representatives. This article summarizes the presentations and subsequent discussions and provides a description of the new compression therapies presented.

A prospective, randomised, 12-week study was performed to evaluate the efficacy and tolerability of two compression methods for venous leg ulcers (VLUs); a new adaptive compression therapy (ACT) system, combining intermittent and sustained pneumatic compression (n = 38) and a conventional four-layer bandage system (n = 52). Primary outcomes were ulcer healing and safety. Secondary outcomes were comfort, compliance, ulcer pain, patient-perceived product performance and quality of life. Ulcer healing rate was similar (31·6% versus 42·3%, respectively, P = 0·30) between the treatments. Adverse events and patient-rated comfort were also similar. Average daily usage for the dual system was 10·5 and 1·8 hours in the sustained and intermittent modes, respectively, representing its use during 71% of waking hours. Predicted final ulcer pain was also similar (P = 0·68). Performance was subjectively better for adaptive compression and significantly higher for exudate management (P = 0·04), skin protection (P

Background Previous studies have shown that so-called progressive elastic compression stockings (PECS) with a negative pressure gradient have a more pronounced effect on venous pump function than conventional, graduated stockings. The aim of this study was to investigate the effect of higher graduated and non-graduated pressures on the venous calf pump in patients with venous disease. Methods The ejection fraction (EF) of the calf pump was measured by plethysmography under a standardized walking test in 20 patients suffering from chronic venous disease (CEAP C2–C5) without compression, (a) with one and (b) two PECS on top of each other, and (c) with one additional conventional stocking covering only the gaiter area to achieve a graduated high pressure profile. Interface pressure was measured in the gaiter area and on the calf. Results A significant improvement of EF compared with baseline was found with all three compression modalities. The two superimposed PECS, providing median pressures of 33 mmHg in the gaiter area and 46 mmHg at calf level, increased EF significantly up into the normal range. Increasing the gaiter pressure to 56 mmHg without changing the calf pressure did not result in further improvement. Conclusions Two PECS applied on top of each other lead to a maximal improvement of the venous pump function, which cannot be further improved by increasing the pressure in the gaiter area thereby restoring a graduated pressure profile.