Aspects of compression research

At the International Union of Phlebology World Congress in September 2022, Prof. Dr. Kasuo Miyake was honored with the Bauerfeind Phlebology Award. He and the award winners from 2018 and 2015, Prof. Alberto Caggiati and Dr. habil. Győző Szolnoky, explain their research methods as well as their implications for clinical practice, and compression therapy in particular. 

Pioneering new methods

Prof. Dr. Kasuo Miyake from São Paulo, Brazil, is one of the world’s leading vascular surgeons, renowned for innovative technical treatment methods, especially when it comes to varicose veins. Together with Prof. Fabricio Santiago from the Venous and Lymphatics Disease Institute in Goiânia, Brazil, he received the Bauerfeind Phlebology Award in 2022 for the design of the study, “Effects of wearing medical compression stockings on occupational leg edema”, with regard to job-related activities that involve extensive periods of standing.

life: What is the design of your study, what does your research activities focus on, and how can the study results be applied in practice?

The main focus of our study is on exploring whether the use of medical compression stockings is better than drainage treatment. We will recruit people who work at a hair salon and suffer from edema at the end of their work day. We will measure the leg volume in the morning and at the end of the day. The subjects will either wear Bauerfeind compression stockings or receive one hour of lymphatic drainage of the lower extremities halfway through their work day. This study can have a global impact on the use of medical compression stockings in occupations subjected to extensive standing.

For Professor Miyake, compression is not just a research topic, it also has practical relevance to him as a vascular surgeon. He works at the Hospital das Clínicas in São Paulo and has his own private clinic, Clínica Miyake, also in São Paulo. He performs highly specialized procedures using the CLaCS method. The acronym stands for Cryo-Laser & Cryo-Sclerotherapy, a method he developed for the treatment of leg vein disorders. The treatment range includes CLaCS under sedation, phlebectomies combined with CLaCS, and endovenous laser therapy and phlebectomies combined with CLaCS. 

Your father was a phlebologist and vascular surgeon as well. Does CLaCS represent a family tradition? 

Prof. Miyake: Yes, he really did give me essential input to develop CLaCS. I developed the procedure based on my doctorate. In his own doctoral thesis, my father already proved the reliability of 75% dextrose (D75) as an agent for sclerotherapy. D75 doesn’t cause skin ulcers following anaphylactic reactions. He recommended the use of D75 only, without detergents. I followed his advice – and when I started to look into transdermal lasers, I decided to combine the laser with D75. This turned out to be an effective synergy. And a little later, I discovered that minor phlebotomies can be avoided in 86% of all cases. This means that advantages include safety, the option for more major procedures because of the lack of toxicity and the effectiveness to obtain a quicker result.

How important is compression therapy to you before and after surgery? What do you recommend to your patients in this respect?

Prof. Miyake: I believe that the most important aspect of compression therapy is the quality of the compression product. In nearly all studies in specialist literature, too little consideration is given to the pressure applied and the compressive quality before conclusions are drawn. I’ve been prescribing Bauerfeind products since 2007. My recommendation is compression class 1, which is sufficient and pleasant for patients after undergoing surgery, thus eliminating the need to lie down with elevated legs.

How compression is related to the heart

Dr. habil. Győző Szolnoky, apl. Professor für Dermatologie an der Universität Szeged (Ungarn), forscht zu den systemischen Effekten von Kompression. He received the Phlebology Award in 2015 for his study “Elastic compression elicited beneficial cardiovascular effects: a complex clinical study in healthy, lymphedematous and lipedematous individuals.” His current research project, “Lipedema with and without compression: the curious case of the heart”, takes up the findings of the previous study.

life: What did your award-winning study from 2015 focus on?

Dr. Győző Szolnoky: In comparative clinical studies, we examined heart function and the size of the ventricles with and without custom-made class 2 flat-knit pantyhose in patients with secondary lymphedema and lipedema, using three-dimensional speckle-tracking echocardiography (3DSTE).  

What insights into lymphedema did you gain?

Dr. Szolnoky: Our findings indicate that compression reduces peripheral arterial resistance, which could improve cardiac afterload. This decreased afterload could explain the significantly reduced LV basal rotation after 60 minutes of wearing the stockings. In addition to local edema reduction, this has a positive effect on heart function.

How can this effect be described for lipedema patients, especially with heart function abnormality? 

Dr. Szolnoky: Compression modifies the LV rotational mechanism but maintains the twist. Rotational changes can be caused by peripheral arterial dilation, leading to a reduced afterload, as well as by a shift of fluid from the lower extremities, resulting in a higher preload. Ventricular function can be specified by calculating the proportional changes in length. The increased LV basal tension observed in lipedema patients could be due to compensating effects to maintain the LV pumping function. Unlike left atrial expansion, LV expansion is increased by wearing compression pantyhose. 

Does that mean that, in cases of lipedema, heart function could be improved by wearing compression stockings?

Dr. Szolnoky: At the moment, it’s still hard to derive specific treatment recommendations from basic research. From a cardiology point of view, patients whose heart shows no signs of rotational anomalies may get a minor benefit because the peripheral arterial resistance is likely to be reduced to a certain degree, combined with an improved LV pumping function.

Echogenicity and tissue inflammation

As a vascular surgeon at a private clinic in Rome, Italy, Prof. Dr. Alberto Caggiati sees different types of venous edema every day. This is part and parcel of a phlebologist’s practice – but in Alberto Caggiati’s case, his daily work sparked his scientific interest: What impact do you see in the morphology of cutaneous and subcutaneous layers in legs with venous edema after four weeks of wearing a class 2 compression stockings? Using ultrasound, Caggiati examined structural changes in 18 patients, thus forging a new path. He was honored for this study design in 2018.

The ultrasound examinations showed that regular use of compression stockings reduces signs of tissue inflammation, both on a cutaneous and subcutaneous level. The number of cases with legs exhibiting dermal edema reduced considerably, and the typical three-layer appearance of the skin was recognizable again (with reduced thickness of the skin layers). The substantially reduced echogenicity of the subcutaneous layer was striking. All these sonographic signs demonstrate a significant decrease in inflammation with regard to edematous legs: “We already knew about the positive impact of compression on these patients,” explains Professor Caggiati, “my examination now points to a previously unknown anti-inflammatory effect on both the dermal and the hypodermal layers. This anti-inflammatory effect is probably responsible for the alleviation of symptoms.” In Caggiati’s opinion, the study results relating to effect and benefit of veno-lymphatic drainage reinforce the existing recommendations for compression stockings.

Images: Bauerfeind, privat