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Under Pressure: Compression Therapy in Chronic Venous Disease and Beyond · European Society for Vascular Surgery

0:07
Hello and welcome to the ESVS podcast. I'm Joana
0:12
Ferreira and today we're going to explore the
0:15
role of compression therapy in chronic venous
0:17
disease. This episode is supported by Urgo Medical.
0:21
As always, the content and editorial independence
0:24
of this podcast remain entirely under the control
0:28
of the ESVS podcast team. Chronic venous disease
0:31
is one of the most prevalent vascular conditions
0:34
worldwide, affecting 40 % of the general population
0:38
in its various forms, ranging from telangiectasis
0:41
and varicose veins to the most advanced stage
0:45
venous leg ulcers. Despite this enormous clinical
0:49
burden, One of our oldest and still one of the
0:53
most effective therapeutic tools remains compression
0:56
therapy, which is recommended by the 2022 ESVS
1:01
guidelines to reduce symptoms across the different
1:04
stages of the CAP classification. To discuss
1:08
this important topic, it is a great honour to
1:11
welcome Professor Melina Vega de Ceniga. Welcome,
1:15
Professor Melina de Ceniga. Would you like to
1:18
briefly introduce yourselves to our listeners?
1:21
Hello. It's lovely to be here again in the ESVS
1:24
podcast, but on the other side. I am an angiologist
1:28
and vascular surgeon from the north of Spain.
1:30
I am currently the head of department in the
1:33
University Hospital of Galeca, Osansolo, and
1:35
I have an academic background as well. I teach
1:38
pre -graduates in the University of the Basque
1:40
Country and post -graduate courses for trainees.
1:44
I was strongly involved in the ESVS podcast from
1:46
the start in 2019, pre -COVID. Seems like a lifetime
1:50
ago, doesn't it? Yeah. And we invited you because
1:53
you have an extensive expertise in chronic venous
1:57
disease and compression therapy. So starting
2:00
talking about venous leg ulcer. We know that
2:03
compression therapy is recommended to improve
2:06
ulcer healing. However, the compression therapy
2:09
is used far beyond venous leg ulcer alone. Can
2:12
you walk us, can you explain different indication
2:16
for compression therapy in clinical practice?
2:21
Well, there are quite a few clinical scenarios
2:23
where compression therapy is a tool to use. Chronic
2:26
venous disease at any clinical stage, including
2:29
not only the cornerstone of conservative treatment,
2:32
but also during pre - and post -operative period
2:35
when invasive treatment of the superficial or
2:38
the deep venous system is performed. But also
2:40
venous thrombolic disease, and this includes
2:43
the acute phase of deep vein thrombosis, post
2:46
-thrombotic syndrome, superficial venous thrombosis,
2:49
and the thromboprophylaxis. Compression is very
2:52
typical for laparoscopic surgery and intensive
2:55
care units, for example, and especially in the
2:58
temporary time when maybe pharmacological thromboprophylaxis
3:02
is contraindicated. There's also the scenario
3:04
of traumatic open wounds and post -traumatic
3:07
edema. Also, large limb hematomas, which may
3:11
require or not drainage and often involve to
3:14
skin necrosis and ulceration. And then we can
3:17
also use compression therapy in limb edema of
3:20
various autologies, including lymphedema, postoperative
3:24
edema, even revascularization edema, occupational
3:27
edema, orthostatic edema, and it can even help
3:30
in lip edema. More recent evidence has extended
3:34
indications to hypertensive ulcers. And even
3:38
some diabetic foot ulcers that we will talk about
3:42
later on. Well, that's a good point because it
3:44
is not limited to vascular specialists. For example,
3:48
a dermatologist recently told me that she frequently
3:51
prescribed compression therapy in patients with
3:54
skin infections such as cellulitis. I would like
3:58
to add a comment on the way we prescribe compression
4:01
therapy. And often it's just like that. the patient
4:04
requires compression therapy in general. Well,
4:06
we would not dream of prescribing antiplatelet
4:09
therapy just like that in general, like which
4:12
drug specifically or which dose. That's up to
4:15
the primary care physician or the nurse or even
4:17
the patient to figure out. We've prescribed antiplatelet
4:20
therapy, right? However, we do that with compression
4:23
therapy. We recommend compression therapy in
4:26
general. And I think that's mainly because we
4:29
don't know much about compression therapy. It's
4:32
not detailed in our books. We don't receive specific
4:35
training for compression therapy in the residency
4:37
program. And although there are lots of courses
4:40
and workshops on endovascular techniques, for
4:43
example, or open surgery tips and tricks and
4:45
so on, there are none for compression therapy
4:47
for vascular surgeons. There are lots of courses
4:51
for nurses. There are actually quite a few documents
4:53
out there, including clinical practice guidelines
4:55
for compression therapy, but somehow they don't
4:58
reach vascular surgeons. Is it maybe because
5:01
we have not shown any interest before? But this
5:04
is not just knowledge and skills for nurses.
5:07
Vascular surgeons must master them as well. Considering
5:10
compression is an everyday therapeutic tool that
5:13
we prescribe and use, and we've seen a whole
5:15
list of indications, this is an important gap
5:17
in our knowledge and in our training that must
5:19
be filled. Learning the specific concepts, the
5:22
scientific background, and there's a lot of evidence
5:24
underlying compression therapy, and learning
5:27
bandaging manual skills. I have to say that the
5:30
ESBS has picked up on that gap and we are starting
5:33
to address it, well, starting this podcast and
5:36
hopefully adding workshops for vascular surgeons.
5:40
Well, that's a really very interesting point.
5:44
Can you help us and our listeners to better understand
5:49
the benefits of compression therapy? How does
5:53
the application of external pressure improve
5:56
venous function? pathophysiological element in
6:00
chronic venous disease is ambulatory venous hypertension.
6:04
When venous valves fail and there is reflux or
6:08
flow is obstructed or the calf muscle pump is
6:11
dysfunctional, venous pressure remains elevated
6:13
during walking instead of dropping as it normally
6:16
would. Chronically, this leads to a cascade.
6:19
Leukocyte endothelial adhesion, increased capillary
6:22
permeability, extravasation of fluid and blood
6:26
cells into the interstitium, tissue inflammation,
6:29
capillary thrombosis, and ultimately, cutaneous
6:33
infarction and ulceration. Now, edema of other
6:35
etiologies also enters this vicious cycle of
6:38
leukocyte endothelial adhesion, increased capillary
6:41
permeability, extravasation of fluid and cells,
6:44
and tissue inflammation. External compression
6:47
counteracts this through several mechanisms governed
6:51
by the Laplace and the Starling equations. So
6:53
it reduces the ambulatory venous hypertension
6:56
and it improves venous return, making the calf
6:59
muscle pump more efficient. It reduces venous
7:02
diameter, improving the function of incompetent
7:05
valves. It reduces hydrostatic edema by increasing
7:08
tissue pressure. And it improves lymphatic drainage.
7:12
But it also improves microcirculation through
7:15
reflex relaxation of the precapillary sphincters.
7:18
And secondarily, it reduces venous wall and tissue
7:21
inflammation. favoring the remodeling and wound
7:24
healing, which is why it's also used in other
7:27
alters that maybe don't have a venous origin.
7:30
Compression therefore exerts its therapeutic
7:32
effect during both the decongestion and the maintenance
7:35
phases to achieve healing or to reduce recurrence.
7:40
Well, so the mechanism is a little bit complex.
7:44
And according to the ESGS guidelines on chronic
7:47
venous disease, there is four compression modalities
7:50
available, elastic compression stockings in elastic
7:53
and elastic bandage, adjustable compression garments,
7:57
and intermittent pneumatic compression. So let's
8:02
focus on stockings and bandage. How do you choose
8:06
in your clinical practice between stockings and
8:09
bandage? So here again is knowledge that we should
8:13
acquire. Now, there is a lot of interesting and
8:15
evolving technology in compression therapy, built
8:18
just like in endovascular technology, and we
8:20
should actually keep up with the devices available,
8:23
the evidence underlying each of these devices,
8:26
and actually the evolution that's coming. Now,
8:28
the choice of compression material depends on
8:31
the clinical phase of the disease, some patient
8:34
characteristics, and some practical factors.
8:37
The devices that we currently have available
8:39
are compression bandages, and these can be mono
8:43
or multi -component, inelastic or elastic, graduated
8:46
compression stockings of classes 1 to 4, self
8:49
-adjustable inelastic garments, and intermittent
8:52
pneumatic compression. Bandages are applied by
8:56
trained professionals, usually nurses. Because
8:59
they are the ones who see the patients on a regular,
9:01
short -term basis. But we vascular surgeons can
9:04
apply them in the ward, for example, when we
9:06
have new nurses who might be inexperienced with
9:09
bandaging, or in the outpatient clinic, or even
9:11
in the OR right after surgery. We must acquire
9:15
this manual skill for patient care and also for
9:17
teaching, for teaching our trainees and teaching
9:19
nurses if they need to be taught. So the bandages
9:23
are very practical, as they can be left in place
9:25
for several days, and they are preferable in
9:28
the active ulcer phase. Also, in our hospital
9:31
and our wound unit, we favor bandages for ulcers
9:34
of different etiologies. Stockings are self -administered
9:37
by the patient. They are better suited for the
9:39
maintenance phase, after ulcer healing. So class
9:43
3 stockings have demonstrated halving, so reducing
9:46
to half, venous ulcer recurrence rates, compared
9:48
to no compression at all. Class 2 stockings are
9:51
somewhat less effective, but have better adherence
9:54
because they're more comfortable to put on and
9:56
take off. And adherence itself is actually a
9:59
critical outcome variable. Now, some technical
10:01
aids like doffing or donning devices or silicone
10:04
rollers or sliding bags should always be mentioned
10:07
or offered to the patient to improve adherence,
10:10
taking into account the patient's physical ability,
10:12
cognitive capacity, economic situation, or social
10:15
support. We also use stockings in our ward for
10:18
post -operative edema. We'll maybe talk about
10:21
this more in detail a bit later on. Those are
10:24
very practical points that our listeners can
10:27
apply in their daily clinical practice. So thank
10:30
you. You mentioned that bandage play a key role
10:34
in the management of activeness leg ulcers. However,
10:38
not all bandage system are the same. Could you
10:43
explain the differences between short stretches
10:46
and long stretches bandage? or between inelastic
10:49
and elastic compression systems? Right. Bandage
10:54
components are classified by their extensibility,
10:57
that is, the degree of elongation under a standardized
10:59
force. So inelastic or non -stretch bandages
11:02
have a 0 to 30 % elongation. The Unaboot is an
11:07
example of this type of bandage. They generate
11:09
very high static stiffness, meaning A large pressure
11:13
difference between standing and supine with strong
11:16
pressure peaks during muscle contraction that
11:19
intermittently occlude venous flow and boost
11:22
the calf pump effect. Because while walking,
11:24
the muscle will actually compress against that
11:27
rigid bandage. However, there is no pressure
11:30
at rest. They are very well tolerated at rest
11:32
because they're rigid and they don't reduce the
11:35
diameter at rest. Short stretch bandages have
11:39
an elongation of 30 to 100%. So they're also
11:42
very rigid. They have high working pressure and
11:45
low resting pressure. And long stretch bandages
11:48
can elongate to over 100%. So they generate...
11:52
high resting pressure. They retain that elasticity
11:55
that makes them go back to their original size
11:58
at rest. So they keep that high resting pressure,
12:01
but they have low working pressure because while
12:04
walking, the muscle will alter, will stretch
12:07
those bandages. So they are poorly tolerated
12:09
in patients with venous ulcers, and they actually
12:12
carry a lower safety profile. When used as a
12:15
sole component, they're actually not often, I
12:18
would say maybe never. used as a sole component
12:21
due to that risk of over -compression at rest.
12:24
Multicomponent systems combine elastic and inelastic
12:28
components to achieve both an adequate working
12:30
pressure with the inelastic component and yet
12:33
some pressure during rest, but low resting pressure,
12:38
so keeping tolerance, good tolerance to these
12:41
systems. So they make the most of both kinds
12:43
of bandages. This is why... Combining those properties
12:47
of long -stretch and short -stretch or inelastic
12:51
bandages, they consistently outperform monocomponent
12:54
systems in healing RCTs. You mentioned multilayer
12:59
compression systems. Could you tell us about
13:02
the evidence supporting their use? Any strong
13:04
evidence? Yes, actually the evidence is substantial.
13:08
A Cochrane meta -analysis updated in 2021 with
13:12
48 RCTs demonstrated that compression therapy
13:16
achieved higher 12 -month ulcer healing rates
13:19
with a ratio of 1 .77, shorter healing times
13:23
and less pain compared to no compression, with
13:26
improved quality of life and no increase in adverse
13:29
events. Within the compression systems, the combination
13:32
of elastic and inelastic components, that's multi
13:34
-component systems, outperformed those containing
13:37
only inelastic components in both healing rates
13:40
and healing time. Four -layer multi -component
13:43
bandages were more effective than pure inelastic
13:46
systems, with a hazard ratio of 1 .32. And then
13:50
two -layer multi -component systems showed equivalent
13:53
efficacy to four -layer systems, which are actually
13:56
no longer used, with better patient -reported
13:58
comfort. Class III elastic stockings were more
14:02
effective than inelastic bandages after 2 to
14:04
4 months with a ratio of 1 .62, although not
14:08
class I or class II stockings. The 2023 Cochrane
14:12
review also confirmed that class III stockings
14:15
reduced to half the recurrence rates compared
14:17
to no compression as secondary prophylaxis. Now,
14:20
from a cost -effectiveness perspective, multi
14:23
-component bandages have consistently proved
14:25
to be the most cost -effective option, followed
14:27
by a double -layer elastic stockings and then
14:30
inelastic bandages. Well, you have clearly showed
14:34
us that there is a strong body evidence supporting
14:37
compression therapy. And moving on to some practical
14:41
aspects, what are the key principles clinicians
14:44
should keep in mind when applying compression
14:47
bandage? For example, What role does padding
14:51
play? Well, this is best learned in a workshop
14:56
with hands -on bandaging. But to try to convey
14:59
this in audio, correct application requires attention
15:04
to several principles, actually derived from
15:06
Laplace's law. Pressure is proportional to the
15:10
tension applied and the number of layers, and
15:12
inversely proportional to the limb circumference.
15:15
And this has some actual practical implications.
15:18
So areas of smaller diameter, and that's the
15:20
ankle and the bony prominences in the malleoli,
15:23
in the tibial crest, the fibula head and the
15:26
Achilles tendon, receive disproportionately higher
15:28
pressure because of this law? And they are at
15:31
risk of tissue injury and nerve compression if
15:33
you're not really careful with the way you bandage.
15:36
So what we do is we pad those. We use padding
15:39
material. We use cotton, a cotton bandage, a
15:43
simple cotton bandage, to pad those areas. So
15:46
that padding material must always be interposed
15:48
between these smaller and at -risk areas, especially
15:51
the bony areas, and the bandage. Limbs can be
15:56
very different. They can be wide or they can
15:58
be narrow, or they can be wide in some places
16:00
and narrow in other places, and they can be longer
16:02
or shorter. So the limbs' perimeters must also
16:06
be conformed to try to make them as homogenous
16:09
as possible, not a narrow area which will receive
16:11
more pressure than a very large cuff, for example.
16:15
So they can be conformed again with padding,
16:17
with cotton wool, before bandaging. So those
16:20
with regular shapes or fibrotic deformities or
16:24
calf muscle atrophy in older patients, that can
16:26
create, as I have said, an even pressure distribution,
16:29
and that can be conformed. Corrective padding
16:32
can restore that smooth cone shape, allowing
16:35
for the bandage to distribute the pressure uniformly.
16:38
And also, before applying the bandage, the skin
16:41
should be washed, dried. We tend to use hyperoxidized
16:45
fatty acids. to reduce the sense of itching,
16:49
but other products can be used as well. And in
16:52
subsequent dressing changes, always take a look
16:54
at possible areas of redness or possible areas
16:57
of pain. Identify those, because those probably
17:00
need more padding. And the wound interface as
17:04
well, the dressing, must be compatible with the
17:06
compression system and with the exudate management
17:08
requirements. That's the other topic I would
17:12
like to discuss with you. That is the interaction
17:15
between the wound and compression therapy. How
17:20
do you choose the interface between the wound
17:22
and compression material? Well, a very important
17:25
element is exudate. And we know that venous ulcers
17:28
tend to be very exudative, especially at the
17:30
beginning. Once compression therapy is installed,
17:32
the edema reduces and then the level of exudate
17:35
usually goes down. So in different phases at
17:38
the beginning and then as we go along, the dressing
17:40
must be compatible with that level of exudate.
17:42
So highly exudative ulcers require absorbent
17:45
dresses that can prevent the strike through and
17:48
the maceration under the bandage that will remain
17:50
a few days. And the dressing must also protect
17:54
the wound from the mechanical pressure of the
17:56
bandage without creating additional pressure
17:58
concentrations. Like I mentioned before, there
18:01
can be some pressure points that we must avoid.
18:04
It's important that the dressings that we use
18:07
on the bandage are non -adhesive, because the
18:09
bandage will keep the dressing in place, so that
18:12
adhesion is not necessary, and the adhesive silicone
18:14
can macerate and harm the periosteal skin under
18:17
compression. The interface choice must also not
18:22
compromise the overall pressure profile of the
18:24
system, so very thick or very rigid dressings
18:27
can artificially elevate that local pressure
18:30
in the area of the wound. And remember that in
18:33
areas of bony prominences, especially those that
18:36
are adjacent to the wound, need additional padding
18:38
to make sure we do not create those special points
18:43
of extra pressure. And ultimately, the wound
18:46
care plan and the compression system should be
18:49
conceived as a single integrated strategy. I
18:52
was not aware of the potential problems associated
18:55
with adhesive materials. And you also highlighted
18:59
the importance of adequate padding, which seems
19:03
important to prevent development of new ulcers.
19:06
So as I mentioned before, vascular surgeons don't
19:10
know much about bandaging. So when we start,
19:12
and I can tell my own process, it's better to
19:15
be extra careful with extra padding if you're
19:19
not totally sure and you're starting to bandage.
19:21
And once you become more confident, you have
19:23
more experience, you can... put in exactly the
19:27
right amount of padding. So you can never go
19:29
too far with padding. That will reduce the pressure
19:32
on certain areas. So that is a safety measure.
19:35
So that padding is very important. That's, yes,
19:38
that makes sense. And early in our discussion,
19:43
you mentioned Unaboot. In fact, I use Unaboot
19:46
quite frequently in my clinical practice. Do
19:50
you think there is a role for Unaboot in Venus
19:55
disease? Yes. And anecdotally, actually, the
19:58
Unaboot is the most used compression therapy
20:01
in Brazil. There's a recent published study about
20:03
that. The Unaboot is, and I think I mentioned
20:06
it before, it's a monocomponent inelastic bandage,
20:09
so 0 to 30 % elongation. And it's typically a
20:13
zinc oxide impregnated cotton gauze. It generates
20:17
very high static stiffness, so it provides strong
20:20
working pressure peaks during ambulation and
20:22
very low resting pressure. So it's very well
20:25
tolerated. It can remain in place for several
20:27
days, and its limitations are really that it
20:30
soils its single use and it loses pressure relatively
20:34
quickly. But in the 2021 Cochrane review and
20:38
subsequent meta -analysis, it shows similar healing
20:41
efficacy to multi -component systems in a head
20:43
-to -head comparison, although It tends to be
20:46
slightly less cost -efficient than multi -component
20:49
kits, but it does remain a valid guideline -supported
20:52
option, particularly in settings where multi
20:54
-component kits might not be available. Well,
20:58
let's talk a little bit about contraindications.
21:01
Could you tell us about the main contraindication
21:04
to compression therapy? Right, let's begin with
21:07
pressure levels per ICC standards. So, they are...
21:11
mild, less than 20 millimeters of mercury, medium,
21:14
20 to 39 millimeters of mercury, strong, that's
21:18
40 to almost 60, and very strong, 60 or above.
21:22
Right, well, mild levels are used in early stages
21:25
of chronic venous disease, occupational edema,
21:27
or elderly patients with low mobility status
21:30
in whom we want to prevent edema or treat mild
21:33
edema, for example. Medium levels are used in
21:36
chronic venous disease, maintenance after venous
21:39
also healing. Adapted pressure for mixed arteriovenous
21:42
ulcers and ulcers of other etiologies, where
21:45
we need compression but we want to be extra safe
21:47
with 20 mm of mercury instead of 40. And for
21:50
active venous leg ulcers and no PAD, a target
21:53
of 40 mm at the ankle is recommended. 60 mm is
21:57
used for lymphedema and post -thrombotic syndrome
22:00
as a rule of thumb. The absolute contraindications
22:04
of compression therapy are PAD with an ankle
22:08
brachial index under 0 .6 or ankle systolic pressure
22:11
under 60 millimeters of mercury or toe pressure
22:14
under 30 millimeters of mercury or TCPO2 under
22:18
20 millimeters of mercury. Congestive, severe
22:21
congestive heart failure, so that's NEHA 304,
22:24
without adequate or clinical hemodynamic control
22:27
and confirmed allergy to any material used in
22:31
the device. So these are the only absolute contraindications.
22:35
There are other some special considerations in
22:38
which pressure must be adapted to the patient's
22:41
anatomy or the clinical situation. And one of
22:44
the most interesting ones or the one that usually
22:47
causes greatest concern or greatest doubts is
22:51
peripheral arterial disease. So it's an absolute
22:53
contraindication when the PAD is severe, that
22:57
is ABI under 0 .6, but it's not contraindicated
23:01
when there is mild or moderate PAD. Right, let's
23:04
dig into this a bit further. So the arterial
23:06
status must be assessed before starting compression
23:08
in any patient for any etiology, that is, distal
23:12
pulse palpation. So if distal pulses are very
23:15
clear, that allows for starting compression therapy
23:18
without further investigation. In the case of
23:21
absent or doubtful pulses, and let's consider
23:25
that We are talking about patients with edema,
23:27
so they might be doubtful. That moves to require
23:31
an ankle brachial index. If ABA measurement should
23:35
not be reliable because the patient is diabetic,
23:37
so there's calcification, or maybe because of
23:40
the wound location, you can't really do it well,
23:42
the other options are toe brachial index and
23:44
transcutaneous oxygen pressure. Those are alternatives.
23:49
ascertaining the arterial status by distal pulses,
23:52
ABI or alternatives is adamant because we want
23:55
to make sure we're not in that situation of absolute
23:58
contraindication. Now in ABI between 0 .6 and
24:01
0 .8, compression can be considered. Medium level
24:05
compression that is around 20 millimeters of
24:08
mercury is safe and effective in these patients,
24:11
especially those with mixed ulcers with a venous
24:14
ulcer but an arterial component as well. And
24:17
also used with expertise, compression can be
24:20
very useful also in diabetic foot ulcer. We talked
24:23
about the reduction of inflammation and the improvement
24:27
of microcirculation. So that can be done, but
24:29
I do recommend doing this in wound units and
24:33
with certain expertise. You also have to be careful
24:35
to choose the right device, do the bandaging
24:38
technique well, careful padding and close monitoring
24:41
in patients with mild or moderate peripheral
24:44
arterial disease. There are other situations,
24:47
special situations like heart failure. So severe
24:49
heart failure in the acute phase with the disease
24:52
out of control, that is an absolute contraindication.
24:55
But when the patient is starting to respond to
24:57
medication, compression with low pressures and
25:00
a close hemodynamic monitoring can be used. And
25:02
in chronic patients with chronic heart failure,
25:05
any health one or two, there are no restrictions
25:07
to compression therapy and that can help with
25:09
lower limb chronic edema. Other situations. superficial
25:13
and deep venous thrombosis. Compression reduces
25:16
pain and edema, and they are not a contraindication.
25:19
Actually, I mentioned at the beginning of the
25:21
podcast, they are an indication. Invasculitis.
25:24
Compression therapy can be beneficial for reducing
25:27
the inflammation, the pain, and the edema. In
25:29
infection, and you mentioned that, infection
25:31
with systemic signs, compression therapy can
25:33
be delayed until stabilization. So we have had
25:36
patients admitted with cellulitis, secondary,
25:39
for example, to a venous leg ulcer. So they are
25:41
starting on systemic antibiotics, and in a couple
25:44
of days, when the cellulitis is subsiding, there
25:47
is less pain, less inflammation, then we start
25:49
with compression bandages, even at 40 millimeters
25:51
of mercury. Or you can choose to start at 20
25:54
mmHg if you are concerned about patient tolerance
25:57
and then scale to the 40 mmHg indicated level
26:01
in subsequent dressing and bandit changes. Other
26:05
situations I can mention requiring careful risk
26:08
-benefit evaluation that can include severe skin
26:11
fragility or dermatological conditions where
26:14
lower pressures, maybe modified materials and
26:17
additional padding can be used. combined with
26:20
thorough patient education. And we use compression
26:24
in bypasses in the post -operative period of
26:27
bypasses of all kinds, lower limb bypasses, even
26:30
subcutaneous insider bypasses. We use thigh -high
26:34
stockings. And our trick is to use one size larger.
26:37
So the pressure exerted will be mild, will be
26:39
under 20 millimeters of mercury, enough to prevent
26:42
or reduce edema. and it will be easier to put
26:45
on and take off over the wound dressings. We
26:48
actually did an internal study to make sure what
26:51
we were doing was safe, and it did prove safety.
26:54
We had no bypass occlusions, and we had a reduced
26:56
rate of surgical wound breakdown because of the
26:59
reduction of the edema. So primary healing of
27:03
the wounds was better. A very important method
27:07
for our clinical practice. Many of us tend to
27:11
assume that compression therapy should be avoided
27:13
altogether in patients who have undergone bypass
27:16
surgery. However, you explained to us that when
27:20
patients are carefully assessed and appropriate
27:22
precautions are taken, compression therapy can
27:26
be used safely and can provide benefits. 100
27:35
millimeters of mercury or more. And what you're
27:37
doing, external compression will be up to 20
27:40
millimeters of mercury. What you have to be careful
27:43
is that the elastic stocking doesn't have creases
27:45
that create precise points of extra pressure.
27:50
So you have to educate the patient to keep that
27:52
stocking well straightened and make sure that
27:56
throughout the day they straighten that stocking.
27:58
And as I said, we use one size larger because
28:01
otherwise it would hurt them to actually put
28:03
it up over the... wounds, the surgical wounds.
28:06
And those tricks actually help a lot with the
28:08
postoperative edema. They can get up and walk
28:10
earlier. Actually, we do it within 24, 48 hours.
28:14
So they can walk without all that edema when
28:16
they start walking. And we also found that besides
28:20
reducing the surgical wound breakdown, we actually
28:23
discharge the patients a couple of days earlier
28:25
as a mean. That is a very useful point. Another
28:30
challenge you mentioned earlier is patient adherence
28:34
to compression therapy. As we all know, compliance
28:38
can be difficult, particularly in warmer climates.
28:42
And based on your experience, what strategies
28:45
do you use to improve adherence and motivate
28:48
patients to continue with compression therapy?
28:51
Well, yes, non -adherence to compression therapy
28:54
is a major global problem. I think we find that
28:57
in every country. In chronic venous disease,
28:59
The non -adherence rates have been reported to
29:02
be as high as 80 % across studies, and that directly
29:05
contributes to prolonged healing times of venous
29:08
layers, so higher costs, also recurrence. Adherence
29:12
is determined by a lot of factors, some related
29:14
to the patient. like pain or physical limitations
29:18
or skin problems or body image, even lack of
29:21
social support. Professional factors as well
29:23
and lack of specific training. And that might
29:26
be one of the reasons why compression is not
29:29
used worldwide in the treatment of venous leg
29:33
ulcers or insufficient patient education or a
29:36
poor therapeutic relationship. So the patient
29:39
leaves the outpatient clinic with a bandage that
29:41
he or she takes off the following day. And there's
29:45
also some factors related to a system like limited
29:48
resource accesses, maybe multi -component bandages
29:50
not available everywhere, or economic barriers.
29:53
These adherence problems with factors and possible
29:56
solutions, actually, these have been extensively
29:58
addressed in two previous Wonderful ESVS podcasts.
30:02
Now, strategies that work include a holistic,
30:07
patient -centered, transdisciplinary approach
30:09
that integrates Well, the medical and the social
30:14
and the emotional dimensions of the patient.
30:17
I think it begins with being very specific in
30:20
the type of compression therapy described. Like
30:22
I mentioned at the beginning, we can't just say
30:25
compression therapy. It's actually better to
30:27
pinpoint, is it a stocking? Is it a bandage?
30:30
What is the degree of compression? How are we
30:33
going to use it? Lung and so on. And then the...
30:36
The interview with the patient is key. Making
30:38
clear to the patient that compression therapy,
30:41
when we have indicated, is non -negotiable. It
30:43
is part of the therapeutic program. You can't
30:46
take it. Make sure that the patient understands
30:48
that. Without the compression, that also will
30:51
not heal. So there has to be a joint agreement
30:53
and a compromise to follow through. So I'm going
30:56
to put the bandage on. You're going to keep it
30:58
on and we'll be in touch. And the next time we
31:00
meet, you're going to tell me how comfortable
31:02
it was or if there was a specific point where
31:05
you had pain. And I will listen to that, make
31:07
sure I adapt the padding or I adapt the level
31:10
of compression and have kind of a joint agreement
31:13
on how we're going to do this. And maybe setting
31:16
short, medium and long -term objectives. You
31:20
can keep this bandage on until our next visit.
31:22
And in our next visit, okay, you were comfortable.
31:25
It's not as bad as you thought. You keep it on
31:27
till next week. And then with the weeks, the
31:30
patient will see the evolution of the ulcer.
31:32
And that's probably going to make him more loyal
31:35
to the treatment and make sure adherence is kept.
31:39
You also have to involve the family. and the
31:42
support networks. You have to convince the family
31:44
as well that compression therapy is not optional,
31:47
that it's mandatory. So they don't have external
31:49
pressure saying, oh, well, if it hurts, take
31:51
it off. And also, I think we also mentioned this,
31:54
providing technical aids like devices to help
31:57
them put the stockings on or off if they're using
31:59
stockings to reduce recurrence, as we mentioned,
32:04
and adapting the treatment to the patient's routine.
32:06
And that will factor. might condition our choice
32:11
of bandage or stocking, for example. And a lot
32:13
of information. So that patient -health practitioner
32:17
relationship, when we talk about the things that
32:20
concern the patients, we warn them about common
32:22
symptoms. We talk about pressure or itching or
32:26
heat or exudate and alert signs requiring consultation.
32:30
In our wound unit, the patients have the telephone
32:33
number of the wound unit in case they need to
32:35
be seen earlier than their next appointment,
32:38
for example. And also taking a bit of time to
32:42
address the whole lifestyle of the patient, recommending
32:46
exercise, balanced diet. So adherence is complex.
32:49
It's not just a one -off prescription, especially
32:51
with compression therapy. It is actually a dynamic,
32:54
continuous process that will require sustained
32:57
follow -up and refinement and adaptation. Yes,
33:01
I really like that approach, particularly the
33:03
idea of setting small achievable goals. It is
33:07
a strategy that I have not previously considered,
33:11
but it makes a lot of sense. And staying on the
33:15
topic of endurance, I'd like to move to ulcer
33:17
recurrence. We know that long -term compression
33:20
therapy is recommended to reduce the risk of
33:23
illness like ulcer recurrence. And based on your
33:26
experience, what strategies do you use to minimize
33:29
the risk of ulcer recurrence while maintaining
33:32
a good long -term endurance to compression therapy?
33:36
Yes, yeah, recurrence rates are so high. They
33:39
have been reported to be up to 30 % two years,
33:42
40 % at three years, and even 60 % at five years.
33:47
The risk is substantially reduced by, I think,
33:50
two complementary strategies. The first is, when
33:54
possible, the correction of the underlying venous
33:57
pathology. So patients who underwent surgical
34:01
or interventional procedures to reduce that ambulatory
34:04
venous pressure had a recurrence rate of 27%.
34:07
versus 67 % in those who did not in one study.
34:11
Early venous ablation of incompetent superficial
34:13
venous systems is a cost -effective intervention
34:16
that should be considered as first -line treatment
34:19
in combination with compression, as I said, whenever
34:21
possible. And that was proved clearly in the
34:24
EVRA trial published in 2018. Now, the second
34:28
strategy is indefinite compression therapy after
34:30
healing. We talked about compression stockings.
34:33
Now class 3 stockings reduce recurrence by approximately
34:37
50 % compared to no compression. Class 2 are
34:41
somewhat less effective, but they achieve better
34:43
endurance. So it's better to have lower pressure
34:48
stocking that you will use continuously than
34:50
a high pressure stocking that you will never
34:52
use. A Canadian health technology assessment
34:54
actually estimated that 50 to 80 % reduction
34:57
in recurrence with elastic stockings, regardless
35:00
of compression class. So the key here is actually
35:02
wearing them. The preferred modality for long
35:05
-term secondary prophylaxis is graduated compression
35:08
stockings, supported by appropriate medical aids,
35:11
again, to put them on and take them off. Sustained
35:14
patient education, this is key, and a motivational
35:16
program. maximize adherence over time so the
35:20
patients need to understand that recurrence is
35:22
a possibility and that it's in their hands reduce
35:25
that recurrence and talk to them use this compression
35:28
stockings and adapt them maybe like we said lower
35:31
pressure to increase the amount of time that
35:34
they're going to use them Other pathologies,
35:36
which are not venous leg ulcers, in which compression
35:39
therapy is used, like other etiologies of ulcers,
35:42
postoperative edema, calciflaxis, hypertensive
35:45
ulcers, trauma, hematomas, etc., they have lower
35:48
recurrence rates. They're more of a one -off
35:50
event, but it will depend really on the patient's
35:52
characteristics, on the age, on the mobility,
35:55
and other underlying chronic pathologies. So
35:59
in these cases, besides the treatment of the
36:02
underlying diseases, of course, low pressure,
36:05
that's mild, knee -high stockings, might be considered
36:07
for maintenance for the prevention of that orthostatic
36:10
edema. Well, Professor Molina, we are reaching
36:13
the end of our podcast. Thank you very much for
36:16
joining us today and for sharing your expertise
36:19
and practical advices on compression therapy.
36:23
I'm sure our listeners have learned a lot from
36:26
this discussion. And before concluding, is there
36:29
any final advice would you like to give to our
36:33
listeners? My last message, I think, is I am
36:38
passionate about fulfilling this gap in knowledge.
36:43
I myself have had to learn about this, which
36:46
I didn't learn about, not in medical school,
36:49
not in my training years. So I've had to learn
36:51
it as a consultant. And it is so useful. I use
36:55
it every day, not only in venous leg ulcers,
36:58
but as I said, in a lot of pathologies. So getting
37:01
the skill, which is really not difficult, considering
37:04
that the manual things, the manual skills we
37:07
learn in the OR, this bandaging is easy in comparison,
37:11
but you still have to learn it. So I really encourage
37:14
everyone who's listening to read documents, to
37:18
become aware that we have this gap in knowledge,
37:21
to fill it, to read. And if you can, and I hope
37:25
that the ESVS will be organizing this, go to
37:28
a workshop, one where a very, very specialized
37:31
nurse will teach you how to bandage well. tips
37:34
and tricks, how to use one or the other device,
37:37
and that will give you a very, very useful tool
37:40
for your everyday clinical practice. Professor
37:42
Melina de Senega, thank you very much for joining
37:46
us today and for sharing your expertise and practical
37:50
insights. Compression therapy may be one of the
37:54
oldest treatments in vascular medicine, but as
37:58
today's discussion has shown, it remains one
38:01
of the most effective and evidence -based interventions
38:04
we have from symptoms relief to ulcer healing
38:08
and prevention of recurrence. Thank you for listening
38:11
to the ESVS podcast. Don't forget to follow us
38:15
on Spotify, Apple Podcasts, SoundCloud and the
38:18
ESVS library. You can also consult the 2022 ESGS
38:23
Clinical Practice Guidelines on the Management
38:25
of Chronic Venous Disease for further reading.
38:28
If you found this episode useful for your daily
38:31
clinical practice, please share it with your
38:35
colleagues, trainees and members of your multidisciplinary
38:38
team. Until next time, keep the pressure on!