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ZusammenfassungDer derzeit aktuelle Terminus Oberflächenthrombose spiegelt besser als der alte Begriff Thrombophlebitis die Ernsthaftigkeit des Krankheitsbildes wider, welches bei etwa 25% der Patienten mit weitere thromboembolischen Komplikationen wie tiefen (Bein)Venenthrombosen und Lungenembolien einhergeht. Treten die Oberflächenthrombosen in Varizen auf, sollten diese nach Abheilung der akuten OVT saniert werden. Oberflächenthrombosen abseits der Varizen treten gehäuft bei malignen Grunderkrankungen, Thrombophilie und anderen Risikofaktoren der tiefen Beinvenenthrombose auf. Obwohl die Diagnose in der Regel klinisch gestellt werden kann, ist die Duplexsonographie unverzichtbar, um die Ausdehnung des Thrombus und ein mögliches Übergreifen des Thrombus in das tiefe Beinvenensystem zu erfassen. Dabei ist das komplette Venensystem beider Beine vollständig zu sonografieren, da der entscheidende Faktor für die Oberflächenthrombose die Hyperkoagulabilität ist und daher begleitende tiefe Venenthrombosen durchaus auch auf der Gegenseite auftreten können. Die Therapie der Oberflächenthrombose ist gestaffelt nach den betroffenen Gefäßen: 1) Bei kleinkalibrigen Astthrombosen sind Kühlung, Kompressionstherapie, nicht steroidale Antiphlogistika sowie eine Stichinzision mit Thrombusexpression angezeigt. 2) Bei Oberflächenthrombosen der Saphenavenen und großkalibriger Varizenäste über 5cm Länge wird eine Antikoagulation in Prophylaxedosierung über 4–6 Wochen empfohlen, begleitet durch eine Kompressionstherapie über 3 Monate. Bei Risikofaktoren wie Krebsleiden, Autoimmunerkrankungen oder Befall nicht variköser Venen kommt es nicht selten erst nach Absetzen einer 6wöchigen Antikoagulation zu thromboembolischen Komplikationen, so dass bei diesen Patienten entsprechende Instruktionen sinnvoll sind. 3) Reicht der Thrombus näher als 3 cm an das tiefe Venensystem heran bzw. greift er auf die tiefen Venen über, wird wie bei einer tiefen Beinvenenthrombose therapiert.

ZusammenfassungEinleitung: Nach phlebologischen Operationen oder Interventionen sollen durch eine adäquate Kompressionstherapie postoperative bzw. postinterventionelle Komplikationen wie Thrombophlebitiden, Hämatome, Hyper-pigmentierungen oder Matting reduziert werden. Auch die Lebensqualität beziehungsweise die Zufriedenheit der Patienten soll durch die Anwendung einer Kompressionstherapie steigen. Hinsichtlich der Dauer der Kompressionstherapie nach unkomplizierten Eingriffen existieren jedoch widersprüchliche Angaben. In angloamerikanischen Empfehlungen wird nur noch eine Dauer von einer Woche als notwendig erachtet.Methode: Eine nicht-repräsentative Umfrage wurde unter Mitgliedern der Deutschen Gesellschaft für Phlebologie durchgeführt.Ergebnis: Es zeigten sich deutliche Unterschiede. So wird beispielsweise nach Cross- und Saphenektomie der V. saphena magna mehrheitlich 3 Wochen eine Kompressionstherapie angewendet. Nach endovenöser Therapie oder Sklerosierung von Stammvenen wird mehrheitlich 2–3 Wochen lang therapiert. Dabei wird hauptsächlich ein Kompressionsstrumpf der deutschen Klasse 2 mit einem Druck von 23–32 mmHg angewendet. Schlussfolgerung: Diese Daten stehen in deutlichem Gegensatz zu den Empfehlungen der angloamerikanischen Leitlinien.

SummaryThe following article is a summary of important benchmarks of the new guideline for diagnostics and treatment of the lipoedema, whish was updated October 2015.

Under the direction of the German Society of Phlebology (Deutsche Gesellschaft für Phlebologie) and in cooperation with other specialist associations, the S1 guideline on intermittent pneumatic compression (IPC) was adopted in January 2018. It replaces the previous guideline from March 2005. The aim of the guideline is to optimize the indication and therapeutic use of IPC in vascular diseases and edema. An extensive literature search of MEDLINE, existing guidelines, and work relevant to the topic was performed. In view of the often methodologically weak study quality with often small numbers of cases and heterogeneous treatment protocols, recommendations can often only be derived from the available data using good clinical practice/expert consensus. Intermittent pneumatic compression is used for thromboembolism prophylaxis, decongestive therapy for edema, and to positively influence arterial and venous circulation to improve clinical symptoms and accelerate ulcer healing in both the outpatient and inpatient care setting. The therapy regimens and devices used depend on the indication and target location. They can be used as outpatient and inpatient devices as well as at home for long-term indications. A target indication is thrombosis prophylaxis. IPC should be used in severe chronic venous insufficiency (stages C4b to C6), in extremity lymphedema as an add-on therapy and in peripheral arterial occlusive disease (PAOD) with stable intermittent claudication or critical ischemia. IPC can be used in post-traumatic edema, therapy-resistant venous edema, lipedema and hemiplegia with sensory deficits and edema. Absolute and relative contraindications to IPC must be taken into account and risks considered and avoided as far as possible. Adverse events are extremely rare if IPC is used correctly. If the indication and application are correct-also as an add-on therapy-it is a safe and effective treatment method, especially for the treatment of the described vascular diseases and edema as well as thrombosis prophylaxis.

In the context of compression therapy, padded bandages are designed to prevent skin damage, increase adherence and support the success of therapy. Routine use is discussed, because comparative studies are lacking.This study examines effectiveness, comfort, and impact of short-stretch bandages without padding compared to underpadded bandages.In all, 61 healthy participants wore padded bandages foam or synthetic cotton wool on one leg and nonpadded bandages on the other. On both sides, a resting pressure of 50 mm Hg was generated. After 60 min resting pressure, skin condition, comfort, pain, and fitting of the bandages were assessed.All bandages showed pressure losses after 1 h; 82.0% of nonpadded bandages had a pressure drop of 9 mm Hg or more. The following were observed in unpadded bandages: constrictions (100.0%), severe redness (77.0%) and bruises (42.6%). Comfort was rated as pleasant by 3.3% without padding, by 83.9% with foam padding, and by 73.3% with synthetic cotton wool padding. Nonpadded compression bandages caused in 62.3% pain from 1-3 (numerical rating scale 0-10).Padded compression bandages maintain the therapy-relevant pressure better, provide more comfort, and cause less pain and skin problems than nonpadded compression bandages. These aspects are crucial for adherence, and therapeutic success. After 1 h of use on the healthy leg, there were obvious differences. Significantly more side effects may appear after several hours of use on previously damaged skin. Therefore, compression bandages should always be padded.

Both varicosis and postthrombotic syndrome are manifestations of chronic venous disease - a widespread disease. Even at an early stage there are visible vascular symptoms, feeling of heaviness and tendency to swelling. In advanced stages, skin alterations and chronic wounds follow. Chronic venous insufficiency as a progressive disease can lead to significant limitations in the quality of life. Adequate diagnosis and therapy is therefore essential. A causal therapy that removes varices or occluding processes should be targeted whenever possible. Accompanying or if a causal therapy is not desired or possible, a symptom-oriented treatment can be considered. The therapy regimen should be individually tailored depending on the leading clinical symptoms, the comorbidities and the patient's wishes. Conservative therapy is the basic measure and should be known to every practitioner.

Implementation of guideline recommendations for the diagnosis and therapy of lipedema and lymphedema seems to be problematic in daily routine. Systematic data for Germany are missing. The aim of the study was data collection regarding diagnosis and therapy of lymphologic diseases in an outpatient setting.Monocentric, prospective survey of patients from a lymphologic outpatient clinic using a standardized questionnaire focusing on diagnostics and therapy at the initial diagnosis.In all, 72 patients (83.3% women) with lymphedema (n = 26), lipedema (n = 14) or lipolymphedema (n = 32) were included; 44.4% had symptoms more than 5 years before the initial diagnosis. Main symptoms were swelling of the leg and foot (especially lymphedema) and feeling of heaviness (especially lipedema). In 75%, the initial diagnosis was made by a medical specialist. The basic diagnostics recommended by the guidelines-medical history (73.6%) and clinical examination (84.7%)-were done in most of the patients. After the initial diagnosis, 46% of the patients had decongestion therapy of different intensity and quality. A total of 58.3% of the patients were directly provided a prescription for a medical stocking. Only a few patients received instructions for breathing exercises (22.2%), self-performed lymphatic drainage (6.9%) or muscle exercises (8.3%).There are still deficits in the diagnosis and especially in the therapy of patients with lymphologic diseases in an outpatient setting. Further education and training are necessary for physicians, physiotherapists, medical supply businesses, and patients.

If compression bandaging is not performed in a professional manner, the objectives of the therapy may not be achieved and side effects or complications may result.This cross-sectional observational survey examines the handling of the treatment options: short-stretch bandages with padding, multicomponent compression systems, and adaptive compression bandages.During several training sessions on the topic of compression therapy, 137 participants performed compression bandagings on each other. In this regard, they were asked to achieve a predetermined pressure range (short-stretch bandages: 50-60 mm Hg, multicomponent compression systems: 40-50 mm Hg, adaptive compression bandage: 35-45 mm Hg). To evaluate the efficiency, the time used for application, the achieved pressure value, and the comfort were determined.Of the 302 bandagings (n = 137 participants), 28.4% lay within the given target pressure value range. This included 11.2% of performed short-stretch bandages, 35.2% of multicomponent compression systems, and 85.0% of adaptive compression bandages. Significant differences in the mean deviations are found between the treatment options. The bandage was described as being comfortable by 37.7% of users of short-stretch bandages with padding, by 65.0% of those wearing a multicomponent compression system, and by 94.6% of participants with an adaptive compression bandage.In practice, short-stretch bandages are still the most frequently used care option for the creation of a phlebological compression bandage. In this survey, they proved to be unsafe, time-consuming, and uncomfortable in relation to other treatment options. Multicomponent compression systems and adaptive compression bandages are treatment options that may be a contemporary alternative which also bares more comfort for the patient.

ZusammenfassungGetriggert durch eine Adipositas können venöse (Adipositas-assoziiertes Dependency-Syndrom) und lymphatische Abflussstörungen (Adipositas-assoziiertes Lymphödem) entstehen, die per se eine Kompressionstherapie erforderlich machen oder weitere Komorbiditäten mit Indikation zur Kompressionstherapie bestehen. Bei adipösen Patienten sind für die Kompression einige Besonderheiten zu beachten:– eine initiale suffiziente Entstauungsphase mit Polster- und Bandagematerialien,– eine Strumpfversorgung mit hoher Stiffness (Materialien mit hoher Festigkeit, ggf. Flachstrick) und optimale Passform (sorgfältige Anpassung),– alltagstaugliche Versorgungsformen, ggf. geteilte Versorgungen,– Notwendigkeit von Hilfsmitteln oder Hilfspersonen zur Sicherung der Anwendung,– begleitende konsequente, intensiv rückfettende Hautpflege und optimierte Hygiene zur Reduktion von Komplikationen und Nebenwirkungen und– eine regelmäßige ärztliche Passkontrolle der Kompression am Bein.Manchmal sind – insbesondere bei der Erstversorgung und bei komplizierten Körperformen – mehrfache Nachbesserungen der Strumpfversorgung notwendig erforderlich, bis ein optimaler Sitz erreicht wird.

Die Kompressionstherapie mit verschiedenen medizinischen Verbanden und Strumpfsystemen gilt als Basismasnahme der phlebologischen und lymphologischen Therapie. Sie kann allein oder in Kombination mit anderen interventionellen oder operativen Masnahmen angewendet werden. Ziel des aktuellen Beitrags ist es, auf drei derzeit in Diskussion befindliche, aktuelle Aspekte der Kompressionstherapie einzugehen. Dazu zahlen: Kompressionstherapie bei peripherer arterieller Verschlusskrankheit, Vorteile der sogenannten progressiven Kompressionstherapie und Kompressionstherapie als Prophylaxe des postthrombotischen Syndroms.

Compression therapy, together with modern moist wound treatment, is the basis for a successful conservative treatment of patients with chronic leg ulcers. In clinical practice, it is often the patients themselves who apply compression therapies. Many of the mostly elderly patients, however, are not able to reach their legs and feet due to movement restrictions, such as arthritis, arthrosis and even obesity. An adequate compression therapy also requires extensive experience and regular training. In practice only the minority of patients can perform bandaging well and therefore this should not be recommended. Self-management with do-it-yourself medical devices will become more and more important in the future. In addition to the psychological factors, cost aspects and demographic change, an expected lack of qualified nursing staff due to the number of elderly patients who are potentially in need of care means that self-management is becoming increasingly more important. For the essentially important compression therapy of patients with chronic leg ulcers, there already exist various therapy options. The needs, preferences and abilities of the patients concerned can be considered when selecting the appropriate system. Particularly for the self-management of compression therapy, adaptive compression bandages are suitable for patients with leg ulcers during the initial decompression phase and ulcer stocking systems in the subsequent maintenance phase.

Die Kompressionstherapie mit verschiedenen medizinischen Verbanden und Strumpfsystemen gilt als Basismasnahme der phlebologischen und lymphologischen Therapie. Sie kann allein oder in Kombination mit anderen interventionellen oder operativen Masnahmen angewendet werden. Es besteht gute Evidenz fur die Anwendung der Kompression bei fortgeschrittenen Venenerkrankungen (CEAP C4-C6), in der Therapie der Thrombose und des postthrombotischen Syndroms sowie in der Therapie des Lymphodems. Schlecht ist die Datenlage jedoch hinsichtlich der Anwendung der Kompression bei unkomplizierten Venenleiden (CEAP C1-C3), bei der Thrombophlebitis sowie beim Lipodem, wenngleich sie auch in diesen Indikationen von den jeweiligen Leitlinien empfohlen wird. In den letzten Jahren sind vor allem die Nebenwirkungen der Kompression sowie die Compliance der Patienten bezuglich der Kompression in den Vordergrund geruckt. Eine differenziertere Betrachtung der Eigenschaften und Moglichkeiten moderner Kompressionsmaterialien (Anpressdruck, Stiffness, Strickart etc.) ermoglicht eine individualisierte Versorgung der Patienten.

Compression therapy is well-tried treatment with only few side effects for most patients with leg ulcers and/or edema. Despite the very long tradition in German-speaking countries and good evidence for compression therapy in different indications, recent scientific findings indicate that the current situation in Germany is unsatisfactory. Today, compression therapy can be performed with very different materials and systems. In addition to the traditional bandaging with Unna Boot, short-stretch, long-stretch, or multicomponent bandage systems, medical compression ulcer stockings are available. Other very effective but far less common alternatives are velcro wrap systems. When planning compression therapy, it is also important to consider donning devices with the patient. In addition to compression therapy, intermittent pneumatic compression therapy can be used. Through these various treatment options, it is now possible to develop an individually accepted, geared to the needs of the patients, and functional therapy strategy for nearly all patients with leg ulcers.

ZusammenfassungMultiresistente Erreger bereiten zunehmend Probleme in der medizinischen Versorgung. Wenngleich das Hauptaugenmerk bei verschiedensten Untersuchungen auf dem Methicillin-resistenten S. aureus (MRSA) liegt, so gibt es doch auch weitere Keime, die zunehmende Bedeutung im klinischen Alltag und hier v.a. auch in der mehrheitlich ambulanten Versorgung von Patienten mit chronischen Wunden erlangen. Insbesondere konnte in den letzten Jahren eine Zunahme an multiresistenten gramnegativen Erregern (z.B. Pseudomoas aeruginosa, Echericha coli) beobachtet werden. Diese spielen bisher zwar vornehmlich im stationären Sektor eine Rolle, scheinen aber entsprechend aktueller Studiendaten auch für den ambulanten Bereich zunehmende Wichtigkeit zu haben. Erfolgt weder stationär noch ambulant eine Eradikation, werden die Erreger von einem Sektor in den anderen weiter getragen. Der folgende Artikel gibt einen Überblick zu den aktuellen Top 5 der multiresistenten Erreger.

Phlebologic diseases have become extremely common and have major socio-economic impact. However, the percentage of dermatologists working in phlebology appears to be decreasing according to the data of the German Society of Phlebology (DGP).To investigate the reasons for this development, we--on behalf of the DGP--sent a questionnaire to 120 German Departments of Dermatology in autumn 2012.In 76 returned questionnaires, the number of physicians with additional fellowship training in phlebology averaged 1.5; the average number of those who fulfill the criteria for training fellows in phlebology was 0.9. In 71.1 % of the departments there was a phlebologist. A special phlebologic outpatient clinic existed in 73.7 % of the departments. Sonography with Doppler (89.5 %) and duplex (86.8 %) was used as the most frequent diagnostic tool. For therapy, compression (94.7 %), sclerotherapy (liquid 78.9 %, foam 63.2 %, catheter 18.4 %), endoluminal thermic procedures (radio wave 28.9 %, laser 17.1 %) and surgery (especially crossectomy and stripping 67.1 %, phlebectomy of tributaries 75 %) were used. The average number of treatments was very heterogenous in the different departments.Phlebology definitely plays an important role in dermatology. Most departments fulfill the formal criteria for the license to conduct advanced training in phlebology. A wide spectrum of phlebological diagnostic and therapeutic procedures is available.

Venous leg ulcers are the most severe complication of chronic venous insufficiency. Based on the pathogenesis and the clinical evidence, the first step in treating a venous leg ulcer should be the treatment of the venous insufficiency. According to the guidelines of the German Society of Phlebology, several methods are available: the surgical or interventional therapy of varicosities, the stenting of stenotic pelvic veins in a post-thrombotic syndrome, direct surgical intervention at the ulcer as excision, debridement or fasciotomy. In the case of an arthrogenic venous stasis syndrome, physical therapy can be helpful. Additionally wound dressings, medicinal therapy and reduction of pain are relevant.There is a good level of evidence only for sufficient compression therapy and elimination of varicosities by surgery or sclerotherapy.

Patients with leg ulcers often have contact sensitizations. Modern wound care products claim low allergic potential.To analyze the patch test results in leg ulcer patients with focus on modern care wound products.95 leg ulcer patients were tested with the standard German patch test series as well as frequently used wound care products.61% of the patients had at least one positive reaction. Most frequent reactions were seen with tert-butylhydroquinone, povidone iodine, balsam of Peru, a hydrogel, fragrance mix I and II, Amerchol L101 and gentamicin. There were 14 reactions to modern wound care products with highest sensitization rates for hydrocolloids and hydrogels. Patients sensitized to wound care products had significantly more positive patch test reactions.There are sensitisations against modern wound care products, especially hydrogels. That should be considered in patch test of leg ulcer patients.

Der Begriff der Phlebitis besagt zunachst nicht mehr oder weniger, als dass eine Entzundung in einer Vene vorliegt. Dahinter verbirgt sich allerdings eine ganze Reihe von atiologisch und klinisch sehr unterschiedlichen Phanomenen mit verschiedenen Bedeutungen. Die Differentialdiagnose phlebitischer Veranderungen ist daher in arztlichen Kreisen nicht zuletzt wegen einer grosen nomenklatorischen Sprachverwirrung wenig gelaufig und so kann man nicht selten erleben, dass ein Patient mit einer banalen aseptischen Varikophlebitis, bereits mit einem Antibiotikum versorgt, zur weiteren Diagnostik in der phlebologischen Sprechstunde erscheint.

Die Varikose stellt nach allgemein akzeptierter Auffassung eine angeborene Erkrankung mit einer ihr immanenten Tendenz zur Progression dar. Das Lebensalter gilt als ein wesentlicher Realisationsfaktor und damit wird auch die Zeitdauer der manifesten Erkrankung zu einem wesentlichen Faktor fur die Auspragung der Folgen der krankheitsbedingten venosen Hypertonie, wie Beschwerden und Komplikationen. Unter dem Aspekt des Lebensalters der Betroffenen und der Krankheitsdauer bzw. der Zeitdauer der gestorten venosen Hamodynamik, sind zwei Altersgruppen besonders zu beachten, Kinder und Jugendliche sowie altere und alte Patienten.

The frequency of venous diseases makes a simple screening method desirable. The aim of this study was to evaluate a questionnaire as a screening instrument for varicose veins as compared to venous refilling time measured by photoplethysmography. In 1830 industrial employees a survey and a photoplethysmography were performed. According to the venous refilling time (vRT), patients were classified as "healthy" or "morbid". The answers were compared. In 31.9% a pathological vRTor =25 seconds was found. The prevalence of a pathological vRT increased with age. The survey answers referring to venous disease in their parents, thrombophlebitis, leg swelling, leg heaviness, hyperpigmentation and visible varicosities were able to distinguish between persons with physiological and pathological vRT. The questionnaire acquired a specificity of90% if symptoms were characterized as "repeatedly"/"marked". There was significant concordance between the questionnaire answers and the vRT measurement. Thus, both methods are applicable for screening of venous disease. Particularly, the questionnaire allows a simple, patient-based estimation of the individual risk.

Although compression therapy is the corner stone of phlebological therapy, less is known about the patients' view of compression. The aim of the study was to answer the following questions: Are there differences in the use of compression and the quality of life during compression therapy depending on the device (bandages, stocking [medical compression stockings, MCS], length, compression class) or indication of compression?Questioning of 200 consecutive phlebological patients (C2-C6) with a compression therapy time of2 weeks. Analysis of 110 returned questionnaires (rate of return 55%).Twenty-nine point one percent voted the therapy as "comfortable". About 37% of the patients had an improvement of their leg symptoms by using compression therapy. Most patients (105/110) wore their compression therapy for more than 6 hours/day. The main side effects were dryness of the skin (58.5%), itching (32.7%), slipping (29.1%) or constriction of the compression device (24.5%). There were no significant differences in the side effect spectrum or the usage according to the type of compression device or the indication for the treatment (varicose surgery/ sclerotherapy). Patients with a leg ulcer and longer duration of compression therapy experienced a worse quality of life.Patients accept the recommended compression therapy (alone or in combination with other phlebological therapies) as a necessary therapy. Compression devices are really used by the patients. According to the main side effect (dryness of the skin), improvement is essential (skin care, caring MCS). Especially patients with indication for a long-term or even life-long compression therapy should be advised in detail.