Choosing wisely when it comes to medical compression stockings

During the 64th annual meeting of the German Society for Phlebology (DGP) in late September 2022, the Bauerfeind symposium focused on different areas of application of medical compression stockings. DGP President, Prof. Dr. Markus Stücker, and Prof. Dr. Michael Jünger were the scientific chairs. Five experts reported on the current research situation and shared their practical experience.

Professor Dr. Markus Stücker, Ruhr University, Bochum, Bochum Vein Center: Post-operative compression

In his presentation, Professor Dr. Markus Stücker pointed out the insights gained in post-operative thrombosis prevention since the 1990s. He quoted a study from 2020¹ that examined compression in combination with low-molecular-weight heparins following elective surgery. It was unable to demonstrate any benefits of compression therapy on post-operative thromboses. Following phlebological procedures, compression therapy does not primarily target the reduction of the risk of developing thrombosis but the prevention of post-operative symptoms. The AWMF Guidelines relating to invasive varicose vein treatment therefore recommend using compression therapy immediately after open varicose vein surgery for at least one week. According to the guidelines, compression can be beneficial following endovenous thermal ablation and the duration of treatment can range from two days to six weeks to suit individual requirements.

In this context, Professor Markus Stücker highlighted to two recently published meta-analyses² that investigated the effects of compression therapy following endovenous thermal ablation using laser or radio frequency catheters plus mini-phlebectomy. The result: patients with compression suffered from pain less frequently during the first seven to ten days following surgery. There were no other differences compared with treatment without compression. The second study also noticed a quicker return to daily activities when compression was used. According to Professor Markus Stücker, the purpose of compression therapy in this area is the reduction of symptoms, since there is a generally low incidence of post-operative thrombosis in varicose vein surgery.  

“A prescription is intended to help with pain reduction. Patients should feel better when wearing the stockings, which most patients confirm.”

Dr. Jana Schäfer, Bonn University Hospital, Clinic and Polyclinic for Dermatology and Allergology: Compression in cases of inflammatory dermatosis

Dr. Jana Schäfer presented successful applications of compression as an accompanying therapeutic element in cases of inflammatory dermatosis conditions using the examples of psoriasis, sarcoidosis, necrobiosis lipoidica and erythema nodosum. In cases of pyoderma gangrenosum, leukocytoclastic vasculitis and livedoid vasculopathy, she also recommended considering medical compression stockings (MCS) to supplement treatment. Dr. Jana Schäfer then talked about a study recently conducted by Elizabeth Webb et al. examining compression to prevent recurring erysipelas, which was published in The New England Journal of Medicine³ in 2020. According to the study, erysipelas occurred much later and less often thanks to MCS, patients were admitted to hospital less, and they enjoyed a better quality of life. Further benefits included: stabilization of the skin’s integrity, physical skin protection, and support of the immune response. In cases of acute erysipelas, Dr. Jana Schäfer referred to the results of a retrospective analysis showing that compression therapy does not lead to clinical deterioration and does not trigger sepsis. In her opinion, it is a good start to attach greater importance to compression therapy during everyday clinical practice when treating acute erysipelas on the lower leg. The guidelines also mention inflammatory dermatosis of the legs as an indication for compression therapy. When explaining the mode of action, Dr. Jana Schäfer focused on the effects of microcirculation based on its importance for treating inflammatory skin conditions: a recent study⁴ published in 2021 confirmed the reduction in pro-inflammatory biomarkers in cases of chronic venous insufficiency (CVI) following compression therapy. Another study⁵, where the expression of proteins was observed in patients with varicose veins, resulted in an improvement of endothelial function, coagulation and inflammation as well as a reduction in oxidative stress. A further study⁶ investigating CVI confirmed an increase in capillary density due to MCS. An improvement of the cutaneous microcirculation and transcutaneous partial pressures⁷ has also been demonstrated, also in patients with mild CVI⁸. 

“There is still a lot to do, and we need much more data to substantiate everything,” 

summarized Dr. Jana Schäfer and encouraged the audience to consider compression therapy in cases of symptoms on the lower legs if patients are suffering from inflammatory skin conditions.

Dr. Michael Jünger, Professor at Greifswald University Hospital, Clinic and Polyclinic for Skin Diseases: Personalized treatment using medical compression stockings

In order to highlight the different options of personalized treatment using MCS, Professor Dr. Michael Jünger first presented a study⁹ with patients suffering from CVI and peripheral arterial disease (PAD). Compression using the VenoTrain angioflow knee-high stocking in Ccl 1 resulted in a significant reduction of venous symptoms. The skin was not injured, the arterial pulsation in the skin’s circulation was maintained, and problems with venous congestion decreased. When treating venous leg ulcers, several comparative studies¹⁰ found that the healing rate was also higher when a two-component stocking system was used, compared to bandages. The product used here was the VenoTrain ulcertec. In addition to a knee-high version, it is also available with a thigh-high liner. The latter prevents shifting the edema to the thigh, as was shown in another paper¹¹. 

Many patients are older and have musculoskeletal impairment, e.g. due to rheumatism. A study¹² conducted at Greifswald University Hospital therefore examined which products patients could cope with in terms of donning and wearing comfort. The researchers compared knee-high stockings with Ccl 1 and Ccl 2. 

Professor Michael Jünger drew the following conclusion from the results: “The compression class 1 lower leg stocking is much easier to use and should be prescribed more readily than a class 2 stocking.” The wearing comfort of compression class 1 MCS was also rated higher. 

People with dry and sensitive skin have particular requirements. Special compression stockings with integrated skin care substances are available for this group of patients. A test¹³ with the VenoTrain cocoon skin care stocking confirmed higher skin moisture. At the end, Professor Michael Jünger talked about easier telehealth interaction using the Mobil Skin app¹⁴, which patients can use to communicate with their physicians and send photos as well as text messages. Data is converted into diagrams to inform the medical decision-making process for the next steps. A survey confirmed that patients were happy with this type of follow-up care and felt more confident. 

Professor Dr. Birgit Kahle, Schleswig-Holstein University Hospital, Lübeck Campus, Dermatology Department: Compression class 1 – comfortable and effective?

At the beginning of her presentation, Professor Dr. Birgit Kahle pointed out that, surprisingly, compression classes 1 to 4 have a lower contact pressure in Germany compared to those in the UK or France, for example. The “UIP recommendations based on proven effectiveness” also indicate Ccl 1 for milder forms only. Professor Birgit Kahle contrasted this with the EFFESTO study¹⁵, which confirms the effectiveness of compression class 1 in occupations with extensive standing. Also with regard to other studies, Professor Birgit Kahle emphasized the following: 

“I can strongly confirm that symptoms and edema associated with varicose veins may improve with compression class 1.” 

This is also substantiated in patient reports. Furthermore, Professor Birgit Kahle presented her own study¹⁶, where patients were examined in a supine position using MRI, with and without wearing Ccl 1 compression garments. The results primarily showed a significant increase in arterial flow volume. These changes were highly significant in stage C3 and C4 patients, less so in subjects with healthy veins. The conclusion was that Ccl 1 MCS are effective even when patients are lying down. But what about C5 patients in which the ulcers have healed? Professor Birgit Kahle presented another study¹⁷ that showed the following: As expected, patients with high compliance had the lowest rate of recurrence, but this rate was also lower with any compression class – including Ccl 1. According to Professor Birgit Kahle, all studies indicate the following finding: The stages C2, C4, and C5, should be added to the UIP recommendations for proven effectiveness of Ccl1 in the stages C0s, C1s, and C3. Physicians in private practices should not be guided purely by a number, especially since these numbers are assigned differently all over the world. Her conclusion: “The German Ccl1 is definitely effective for different stages of venous disorders.”

MD José Antonio Diaz, Vanderbilt University Medical Center Nashville, Tennessee, USA, Surgical Research: reducing pathological changes to the vein walls

José Antonio Diaz, MD highlighted the self-regulating balance between cellular and metabolic processes in the vein walls and lumens in his presentation. Both systems interact. As a result, problems in the vein walls also affect blood flow, leading to inflammatory processes and cellular damage. 

According to MD José Antonio Diaz, by employing physiological or pathological regeneration or restructuring of existing tissue, restoration of the tissue function will be most successful if tissue damage is halted early enough. Otherwise, fibrosis will develop when an increasing number of cells adjacent to damaged cells are affected as part of the “healing” process. The following aspects must be considered: tissue remodeling, increased fibroblasts, and increased matrix metalloproteinases (MMP) activity. All these aspects can be observed in cases of post-thrombotic syndrome (PTS), for example. To prevent the development or treat tissue damage, it is essential to understand the course of the condition triggered by specific molecules, says José Antonio Diaz, MD. The identification of SPM (specialized pro-resolving mediators) of bioactive levels in the human body, the role of Galectin 3 during experimental Deep Vein Thrombosis (DVT), and other discoveries in addition to advancing areas such as regenerative medicine were, therefore, critical milestones.  

At the moment, reversibility supports research in restoring tissue, stopping the progression of a condition, or influencing its course. To this end, fish oils, for example, were examined that alleviate cardiovascular diseases by inhibiting vascular inflammation. Research is also taking place into treating experimental venous thromboembolism (VTE) using resolvin, which is a promising approach. José Antonio Diaz, MD, was convinced that the anti-inflammatory strategies, including the potential anti-inflammatory effect of compression, help to reduce the speed of disease progression and hopes for more research on restoring the original healthy state. He finished his presentation confidently, saying: 

“Modern-day medicine opens horizons that we couldn’t even imagine years ago!”

Save the date: Saturday, May 6, 2023 – Phlebology Forum 

Dr. med. Christine Zollmann from the Venous and Skin Diseases Practice in Jena would like to invite you to the 9th Phlebology Forum taking place at Bio-Seehotel in Zeulenroda-Triebes, Germany. This certified professional development event will be eligible for collecting CME credits. Experts will discuss current insights relating to the diagnosis and treatment of conditions associated with the venous and lymphatic systems. There will be time for questions and discussions after every presentation. The full agenda as well as all information relating to registration and participation can be accessed at www.phlebologie-forum.de. 

1 Pihlaja et al. Eur J Vasc Endovasc Surg. 2020; 59: 73-80
2 Hu et al. Eur J Vasc Endovasc Surg 2022; Ma et al. Ann Vasc Surg 2022
3 Webb E. et al. N Engl J Med. 2020
4 Tkaczyk et al. Acta Angiol. 2021
5 Monux et al. J Vasc Surg, Venous Lymphat Disord. 2021
6 Klyscz et al. Der Hautarzt. 1997
7 Wollina U et al. The International Journal of Lower Extremity Wounds. 2006
8 Grenier E et al. Phlebology. 2016
9 Markus Stücker et al: Sicherheit eines Kompressionsstrumpfes für Patienten mit chronisch venöser Insuffizienz (CVI) und peripherer arterieller Verschlusskrankheit (pAVK) JDDG 2020 18: 207-14

10 M. Jünger et al: Efficiacy and tolerability of an ulcer compression stocking for therapy of chronic venous ulcer compared with a below knee compression bandage; results from a prospective, randomized, multicentre trial. Curr Med Res Opinion (2004) 20: 1613-1623

11 W. Konschake, H. Riebe, P. Pediaditi, H. Haase, M. Jünger, S. Lutze: Compression in the treatment of chronic venous insufficiency: Efficacy depending on the length of the stocking. Clinical Hemorheology and Microcirculation 64 (2016) 425-434 

12 J. Goetz, E. Kaisermayer, H. Haase, M. Jünger, H. Riebe: Better wearing comfort of knee-length elastic compression stockings with an interface pressure of 18-21 mmHg compared to 23-32 mmHg in elderly people after a one day trial – influence of foot deformities, rheumatism and arthritis. Clin Hemorheol Microcirc (2019); E. Kaisermayer: Dissertation Universitätsmedizin Greifswald 2016 

13 Thea Westphal et al: Vasa (2019), 48, 502-508

14 K. Ringwald, A. Arnold, H. Haase, M. Jünger, S. Lutze: Telemedizinische Nachsorge von Patient:innen mit Hauterkrankungen Dermatologie 2022 

15 Blättler W, Kreis N, Lun et al. Leg symptoms of healthy people and their treatment with compression hosiery. Phlebology 2008; 23;:214

16 Langan, E.A., Bayer, A., Burmeister, J., Recke, A., Bergmann-Köster, C., Loff, D., Kahle, B.K. (2022). Class I compression therapy improves lower limb vascular flow volume in patients with chronic venous insufficiency – a magnetic resonance imaging study. JDDG: Journal der Deutschen Dermatologischen Gesellschaft, 2022; 20:508-9

17 Clarke-Moloney M, Keane N, O’Connor V, Ryan MA, Meagher H, Grace PA, Kavanagh E, Walsh SR, Burke PE. Randomised controlled trial comparing European standard class 1 to class 2 compression stockings for ulcer recurrence and patient compliance. Int Wound J. 2014 Aug;11(4)404-8.

Images: Bauerfeind, Thomas Hauss