“Treatment is also guidedby the nature of symptoms”

Theory provides rigid scoring systems, yet real-world clinical practice may vary. Professor Dr. Birgit Kahle from the Department of Dermatology at Schleswig-Holstein University Hospital, Campus Lübeck, Germany, always bases her treatment concept for chronic venous insufficiency on patients’ symptoms.

life: How can advanced vein problems be categorized and differentiated?

Prof. Kahle: There are different systems for classification to determine the severity of chronic venous insufficiency (CVI). CEAP classification is one of them. I believe that, when a physician’s letter is written or a diagnosis is reported, an established classification system like CEAP should be used to enable clear communication within the medical profession. It is important for the individual patient to know whether they have a relevant venous disorder. Clarifying this is part of the doctor-patient consultation, where the CEAP classification is hardly used. This means that everyday clinical work focusses on the patient, rather than a complex classification system.

Is this because various aspects come together in one patient?

Prof. Kahle: Because the classification systems help to describe a clinical picture. In everyday clinical practice, has been shown time and again that there is a wide inter-subject range, even within individual classification classes. There are stage C4 patients who don’t have any symptoms. And there are individuals with stage C0 or C1 who suffer greatly. C0 to C6 describes the clinical picture. However, there is more to it: The “E” for Etiology, for example, meaning why the condition is like that Anatomy, i.e. “A”, refers to which segments are affected. And patho­physiology, the “P”, refers to what pathological processes play a role in these vein problems.

Do you mean the symptoms are the decisive factors for treatment?

Prof. Kahle: In addition to the hemodynamic condition, treatment is also guided by the nature of symptoms. What exactly is the problem? Does the patient experience a feeling of heaviness or pain? Does the patient have a swollen leg or is it the esthetic appearance that affects the patient? Then we’ll have a look at the pathologies. How sick is the patient from a hemodynamic perspective? Can an intervention achieve an improvement? A classification can be useful when evaluating the condition, but it should not be used alone to make a treatment decision. One example: one of my first patients was 87 years old. In cross-section, the diameter of his varicose veins was up to two centimeters. He did not show any typical skin abnormalities that develop in advanced CVI and stated that he had no typical venous complaints. Despite the impressive varicosis, he had stage C2, i.e. a chronic venous disorder. He merely had varicose veins, no edema or pain, so he had never worn compression stockings or compression bandages.

When do you consider compression therapy as useful?

Prof. Kahle: I’m a great believer in compression therapy. It’s the foundation for venous treatment. The focus must be on the specific patient. You have to get a clear picture: what exactly is the problem, what needs to be treated? If the deep veins are damaged, after thrombosis for example, compression therapy plays a key role. When venous leg ulcers have healed, some patients think that they no longer need to wear compression garments during everyday activities because they feel fine without. But study results substantiate that the recurrence rate can be significantly lowered when compression products are worn even after the venous leg ulcer has healed. There’s research on the one side, our experience on the other. We have to educate patients and motivate them. Technology does us a great service in that respect.

How do you convince patients that compression therapy is the right approach?

Prof. Kahle: I generally examine patients using Duplex ultrasound to determine the flow/time volume of the blood in the relevant vascular section – with and without a compression stocking. Then I turn the screen to the patients. They can see how the speed of blood flow has accelerated with the compression product as a direct result of the vessel’s diameter decreasing. You can also clearly see how much quicker the venous blood flows when compression is applied. This first-hand experience during the examination helps to better communicate the effectiveness of compression therapy, significantly increasing compliance.

Does this mean that patients will happily wear compression classes 2 or 3?

Prof. Kahle: More isn’t necessarily better in every situation. One thing is certain: compression class 1 worn on the leg is more effective than class 2 in the closet. I generally prescribe compression class 1 compression stockings quite a lot. We were able to demonstrate in a current study how much even class 1 can help when the patient is lying down.¹ But patients need to be patient when it comes to expectations concerning the quick and lasting alleviation of problems. Of course, wearing the compression stocking has an immediate positive effect on hemodynamics. But the noticeable effect on the decongestion in the leg and on symptoms subsiding can take two to three weeks.

How many patients are sent to you for a diagnostic work-up? What do you bear in mind when prescribing compression stockings?

Prof. Kahle: The material plays a key role particularly in patients with weak connective tissue or a tendency to develop edema.
I write down the relevant compression class with the additional comment: ‘high level of stiffness²’. I then ask patients to come and see me again. If the stocking doesn’t fit properly concerning the position on the leg or size, a corresponding corrective prescription will be issued so that the unsuitable compression stockings can be exchanged. In my experience, people with symptomatic venous disorders wear their compression stockings very reliably. I tell patients whose work involves a lot of standing: It’s a work stocking – put it on at the start of the day and take it off in the evening. I tell athletes who may be able to compensate well for varicose veins that the stocking helps them to recover more quickly. I urge everyone to care for their skin regularly, preferably every day.

Do you have any suggestions for family physicians?

Prof. Kahle: If there are unspecified skin abnormalities on the legs, e.g. eczematous foci or pigmentation, swelling or congested veins in the ankle area, I advise my colleagues to arrange a phlebological diagnostic work-up.

Images: Pat Scheidemann

1. Langan E.A., Bayer A., Burmeister J., Recke A., Bergmann-Köster C., Loff D., Kahle B. 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 ↩︎
2. Definition of the term ‘stiffness’ according to University Professor Dr. Hugo Partsch: “This term characterizes the elasticity of a compression garment and is defined by the increase in pressure caused by an increase in the circumference of the compressed leg segment as a result of muscle contraction, for example when standing up from a lying position or with each step when walking. The stiffness therefore determines the level of the working pressure compared to the resting pressure.” ↩︎