CONTENTS  •  Volume 14  Number 1 1999

Editorial

Original Articles

9     A Randomised Trial of Different Compression Dressings Following Varicose Vein Surgery
R. Bond, M. A. Whyman, D. C. Wilkins, A. J. Walker and S. Ashley

12    A Pilot Study Comparing the Use of Below-Knee and Above-Knee Graduated Stockings in Patients with Superficial Venous Incompetence
D. C. Berridge, K. G. Mercer, C. Thornton. M. J. Weston and D. J. A. Scott

17    The Physiological Effect of Graded Compression Stockings on Blood Flow in the Lower Limb:  An Assessment with Colour Doppler Ultrasound
T. Benkö, I. Kalik and M. N. Chetty

21    There is no Benefit from 6 Weeks’ Postoperative Compression after Varicose Vein Surgery:  A Prospective Randomised Trial
M. G. T. Raraty, M. G. Greaney and S. D. Blair

26    Injury to the Common Peroneal Nerve During Surgery of the Lesser Saphenous Vein
G. Lucertini, A. Viacava, A. Grana and P. Belardi

29    Anatomical Distribution of Chronic Venous Insufficiency in a Chinese Population
A. C. W. Ting. S. W. K. Cheng, L. L. H. Wu and G. C. V. Cheung

33    Venous Haemodynamics and Morphology in Relation to Recanalisation and Thrombus Resolution in Patients with Proximal Deep Venous Thrombosis
S. Rosfors and A. Norén

Letters

In this issue of Phlebology a number of authors attempt to study the means by which compression can best be used to treat patients with venous disease. It always gives me great pleasure to point out that the earliest references to the use of bandaging for the treatment of leg ulcers come from Hippocrates, 450 years BC. Despite the huge advances in technology in the intervening years, compression remains one of the most effective ways to achieve venous ulcer healing. Although we now recognise that many patients with venous ulceration have valvular incompetence confined to the superficial veins, many still have ulceration associated with deep vein incompetence. A small proportion of patients with deep vein incompetence benefits from surgical intervention. So at least half the patients with venous leg ulcers are best treated by compression. But how best to compress the leg? There is a British prejudice that elastic compression is best. This continuously applies compression to the skin, even at rest. In the rest of Europe, there is a conviction that inelastic compression is best. This applies much more compression when the patient stands and is considered to be appropriate for the management of leg ulcers and chronic skin changes. it is deduced that since the venous pressure in the leg veins is highest when the patient stands, greatest compression should he applied to counteract the damaging effects of venous hypertension during standing. The supporters of inelastic compression suggest that the lower compression on lying supine makes this type of bandage more easily tolerated, an important consideration when recommending that patients wear compression garments. There is little objective literature to support either camp, although it is generally accepted that higher levels of compression are more effective than lower levels of compression. The paper by Yang et al. in this issue investigates this point in a physiological way. Using air plethysmography he was able to show that the venous filling index was reduced but the ejection fraction could not be improved in patients with venous disease, whether he used elastic or short-stretch compression. So this offers no support to either camp and these findings are consistent with a number of other authors who have considered this problem in different ways.

However, compression is also used many aspects of therapy in patients venous disease, including following surgical treatment of’ varicose veins. A number of authors have shown that stripping the saphenous veins has advantages in preventing recurrence from persisting saphenous trunks. However, removing the long saphenous vein results in post-operative bruising which may cause significant discomfort for the patient. In the paper by Raraty et al. the authors investigate whether inelastic Panelast bandaging worn for a week is more effective than crepe bandages followed by TED stockings worn for 6 weeks. Although the short-stretch bandage produced less bruising. this resulted in no difference in the pain and mobility experienced by the patients. Since the patients were initially bandaged using crepe, one could argue that the poor elastic qualities of these accounted for the differences in bruising between the patient groups, rather than the superiority of short stretch bandaging. There is little doubt that crepe bandages have very poor elastic properties and this paper shows a possible solution to the reduction of post-operative bruising after varicose vein surgery.

A further field where compression stockings have remarkable effects considering their simplicity is the prevention of post-operative deep vein thrombosis. Two further authors in this issue, Benkö and Berridge in very similar studies have investigated the physiological effects of compression on blood flow in the veins of the leg, specifically investigating the differences between below knee and above knee stockings. This is yet another area where long held views appear to remain valid! Virchow published his triad of factors which lead to venous thrombosis more than 100 years ago. The authors of both these papers concentrate on one of these, venous stasis, and study flow velocities using duplex ultrasonography. The results of these investigations are very informative of the physiological effects of compression, which could not be easily deduced before the advent of duplex ultrasonography. Extrapolation of these findings to clinically efficacy in preventing venous thrombosis remains more of a problem. Virchow’s Triad is still accepted as valid, even when applied to post-operative venous thrombosis, but which aspect of this is addressed by anti-embolism stockings to prevent venous thrombosis remains unclear. It could be some other aspect of the venous system not discussed by Virchow.

Compression stockings and bandages will be very valuable to the 21st century phlebologist, as they are today. Curiously the best way apply compression in the treatment of’ venous diseases is far from fully understood. Still less is known about how it heals ulcers and prevents post-operative venous thrombosis!

The Editor wishes to acknowledge and thank the individuals listed below who have provided their time and valuable experience to review manuscripts during the past year.

A. Bradbury, M. J. Callam, W. B. Campbell, J. Caprini, A. D. B. Chant. Tim Cheatle, C. R. R. Corbett. Paul R. Cordts, S. Darke, Ralph DePalma, J. Earnshaw, B. Eklof, U. Franzeck, Jerome Guex, U. Hoffmann, Robert Kistner, D. J. Leaper, Nick London, P. S. Mortimer, H. A. M. Neumann, A. N. Nicolaides, Lars Norgren, Andreas Oesch, H. Partsch, Michel Perrin, Eberhard Rabe, S. Rose, C. V. Ruckley, U. Schultz-Ehrenburg, R. A. P. Scott, J. H. Scum Shukri Shami, C. P. Shearman, E. Stranden, D. Sumner, D. J. Tibbs, W. Vanscheidt, R. Young, Linda M. de Cossart.

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D. Yang, Y. K. Vandongen and M. C. Stacey
Department of Surgery, The University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia

Objective: To evaluate the influence of minimal-stretch and elasticated bandages on calf muscle pump function in patients with chronic venous disease.

Design: An open, randomised, crossover study.

Setting: University Department of Surgery, Fremantle Hospital, Perth, Australia.

Subjects: Twenty patients with chronic venous disease and recently healed chronic venous ulcers.

Method: Five different bandaging regimens were applied on each patient, and calf muscle pump function was assessed by using air plethysmography.

Results: There was no significant difference in the venous filling index (\‘FI) and ejection fraction (EF) between the five different bandage regimens, and also no significant difference in four of the five bandage regimens over a 7-day period (p>0.05). However, the VFI was significantly reduced and the EF was not significantly altered after the application of both elasticated and minimal-stretch bandages (p<0.05, = p>0.05 respectively).

Conclusion: All the bandage regimens used in this study have a similar influence on calf muscle pump function, and may therefore have a similar effect on the healing of chronic venous ulcers.

Keywords: Air plethysmography; Calf muscle pump function; Compression bandages; Venous insufficiency; Venous ulcers

Correspondence and offprint requests to: Associate Professor Michael C. Stacey, University Department of Surgery, Fremantle Hospital, Fremantle, WA 6160, Australia. 

Tel: +61-8-9431 2500; Fax: +61-8-9431 2623; E-mail: mstacey@cyllene.uwa.edu.au

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R. Bond, M. R. Whyman, D. C. Wilkins, A. J. Walker and S. Ashley 
Vascular Surgical Unit, Derriford Hospital, Plymouth, UK

Objective: TED anti-embolism stockings, Panelast self-adhesive elasticated bandages and Medi Plus class II stockings are three different dressings commonly used to provide compression following surgery for varicose veins. The aim of this study was to determine which of the three dressings was most acceptable to patients.

Design: Forty-two patients undergoing bilateral varicose vein surgery were randomised to receive a different dressing on each leg in order to determine if a particular type of dressing was superior in its ability to reduce postoperative pain and provide adequate comfort without reducing mobility. The dressings were worn for I week, during which daily pain scores were recorded for each leg followed by a simple questionnaire to determine comfort and mobility.

Results: There was a significant reduction of mobility experienced by patients wearing Panelast bandages compared with the other two dressings (p <0.05). However, there were no significant differences between the dressings with regard to the degree of postoperative pain experienced, and in all other respects the dressings were equally tolerated.

Conclusion: The choice of compression dressings used for varicose vein surgery should depend primarily on the personal preference of surgeons as well as financial considerations.

Keywords: Compression bandaging; Compression stockings; Varicose vein surgery

Correspondence and offprint requests to: Mr Simon Ashley, MS, FRCS, Vascular Surgical Unit. Level 4. Derriford Hospital. Plymouth PL6 8DH, UK. 

Tel: 01752 792155: E-mail: simon.ashley@phnt.swest.nhs.uk

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D. C. Berridge’. K. G. Mercer¹, C. Thornton¹, M. J. Weston² and D. J. A. Scott¹
Departments of ¹Vascular and Endovascular Surgery and ²Radiology, St James’s and Seacroft University Hospitals NHS Trust. Leeds, UK

Objective: Investigation of the effects of high- and low-ankle-pressure, above- and below-knee compression stockings on the haemodynamics of normal and superficially incompetent venous systems.

Design: Prospective duplex study of a normal group and a venous incompetence group randomised to high- or low-pressure stockings.

Setting: Vascular services of a University Hospital.

Subjects: Six subjects with normal venous haemodynamics (12 limbs) and 12 patients with superficial venous incompetence (20 limbs).

Methods: Subjects wore below-knee and then above-knee stockings for I week each. Duplex scans were performed at the outset and end of the study and on fitting and after wearing each stocking type.

Main outcome measures: Duplex-derived femoral and popliteal venous velocities were measured and indexed against the initial velocity.

Results: Below-knee stockings produced only minor changes. Above-knee stockings produced increased velocities in normal subjects. Similar changes were only seen with higher-pressure stockings in patients with incompetence.

Conclusion: Above-knee, high-ankle-pressure stockings produce increased deep venous flow velocities.

Keywords: Antithrombosis stockings; Blood flow velocity; Femoral vein; Popliteal vein; Ultrasound, Doppler, duplex; Venous insufficiency

Correspondence and offprint requests to: D. C. Berridge, Consultant Vascular Surgeon. Department of Vascular and Endovascular Surgery, St James’s and Seacroft University Hospitals NHS Trust, Beckett Street, Leeds LS9 7TF. UK. 

Tel: 01 13-2065416: Fax: 0113-2460098.

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T. Benkö¹, I. Kalik² and M. N. Chetty³
Departments of ‘Orthopaedics and ²Radiology, Birmingham Heartlands Hospital, and ³Dcpartment of Radiology, Hillingdon Hospital, Uxbridge, UK

Objectives: To assess the physiological effect of’ low-pressure graded compression stockings (GCS) on the blood flow of the lower limb with the use of colour Doppler.

Design: A randomised controlled study.

Setting: X-ray Department in a teaching hospital.

Patients: Forty-five healthy, adult, voluntary subjects.

Method: Subjects were randomised into three groups to either wear thigh- or knee-length GCS of the same type or no stockings. The diameter and cross-sectional area of the femoral and popliteal veins and the peak venous velocities were measured with colour Doppler before the application of GCS and after 20 mm bed rest with the stockings in situ.

Results: Measurements showed a significant increase of the peak velocity in the femoral vein with thigh-length GCS (p <0.002). There was a significant decrease of the popliteal vein diameter and cross-sectional area with thigh-length GCS (p<0.05). There was no significant change in the knee-length GCS group and the control group, in which patients did not wear stockings. A paired t-test was used to determine the significance of the changes.

Conclusions: Thigh-length GCS have an effect of increasing venous peak velocity in the femoral vein, hence decreasing venous stasis. Furthermore, they decrease the dilatation of the popliteal vein, which may reduce the risk of intimal tears occurring, which may contribute to venous thrombogenesis. Other methods can given more information in assessing the effect of various lengths of stocking on venous stasis.

Keywords: Colour Doppler; Compression stockings; Stasis; Thromboembolism; Ultrasonography

Correspondence and offprint requests to: T. Benkö, Department of Orthopaedics, Barnsley General Hospital, Gawber Road, Barnsley S75 2EP, UK. 

Tel: 01226-730000.

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There is no Benefit from 6 Weeks’ Postoperative Compression Varicose Vein Surgery: A Prospective Randomised Trial

M. G. T. Raraty, M. G. Greaney and S. D. Blair
Department of Surgery, Clatterbridge Hospital, Bebington, Wirral, Merseyside, UK

Background: It is often recommended that patients should wear compression stockings for 6 weeks after varicose vein surgery. The aim of this trial was to ascertain whether this is necessary.

Method: Following a standardised operation for primary varicose veins, patients were randomised to receive postoperative compression with either Panelast Acryl adhesive short-stretch bandages for 1 week or crepe bandages for 16 h followed by 6 weeks wearing of TED antiembolic stockings. Symptoms were quantified by questionnaire and clinical assessment at 1 and 6 weeks.

Results: Postoperatively there was significantly more bleeding in the crepe/TED group and a larger area of bruising at the end of the first week (117.5 cm² vs. 96 cm², p<0.02; Mann-Whitney U-test). However, this did not correlate with any difference in discomfort or activity between the two groups. There was no statistical difference in the symptoms reported after the first week. Twenty-seven patients out of 52 randomised to TEDs discarded them before the end of the 6 weeks. Both groups returned to full activities and work after similar periods (Panelast 18.5 days vs. crepe 20.0 days).

Conclusion: There was no benefit in wearing compression for more than 1 week. Wearing Panelast bandages for the first week did significantly reduce pain on the first postoperative day, bleeding and the extent of bruising.

Keywords: Compression; Postoperative management; Varicose vein surgery

Tel: 0151-604 7054.

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G. Lucertini, A. Viacava, A. Grana and P. Belardi 
Section of Vascular Surgery, University of Genova, Italy

Objective: To evaluate the incidence and associated problems of common peroneal nerve (CPN) injury, which can occur during short saphenous vein (SSV) surgery.

Design: A retrospective cohort study.

Setting: Section of Vascular Surgery in a University Hospital.

Patients: In a consecutive series of 88 patients (3 1 male, 57 female, ages ranging from 35 to 68 years, mean 49), 104 lower extremities were operated on for SSV insufficiency.

Interventions: Each patient was assessed by clinical examination, duplex scanning and in some cases by venography (ascending venography and/or varicography). Surgery was carried out via a longitudinal or transverse approach in the popliteal region or the posterior aspect of the thigh.

Main outcome measures: Haemodynamic criteria, cosmetic outcome and complications of the surgical procedures due to SSV insufficiency were considered. In particular, we focused on neurological complications.

Results: Abnormality of foot dorsiflexion was observed in two out of 104 (2%) cases. This complication was caused by injury to the CPN. Recovery had occurred 1 year later.

Conclusions: Two factors seem to be essential in preventing this neurological complication: (a) good knowledge of surgical anatomy and (b) a cautious, accurate surgical technique. The incidence of this complication has been underestimated, but its importance and medico-legal implications must be emphasised.

Keywords: Common peroneal nerve; Short saphenous vein; Varicose veins

Tel: 0039-10 3537330; Fax: 0039-10 3537318.

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A. C. W. Ting, S. W. K. Cheng, L. L. H. Wu and G. C. Y. Cheung
Department of Surgery. University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong

Objective: To study the anatomical distribution of chronic venous insufficiency (CVI) in a Chinese population by means of duplex scanning.

Procedures: A total of 582 limbs in 291 patients with primary venous insufficiency were classified clinically into three different groups according to SVS/ISCVS criteria and evaluated prospectively with duplex scanning.

Results: One hundred and thirty-one limbs were classified into group I (CEAP clinical class 0), 291 into group II (CEAP clinical classes 1 and 2) and 160 into group III (CEAP clinical classes 3-6). Mixed deep and superficial venous incompetence was found in 70% and 83% of limbs in groups 11 and III, respectively. Reflux was also demonstrated in 73% of group I limbs.

Conclusions: Most of our patients had mixed deep and superficial venous incompetence. The prevalence of deep venous incompetence in this population, in which deep vein thrombosis is rare, suggests a pattern of venous incompetence other than postphlebitic deep vein valvular dysfunction. The prevalence of reflux in the asymptomatic contralateral limbs implies a bilateral predisposition to venous reflux and thus a possible developmental origin of CVI.

Keywords: Anatomical distribution; Chinese; Chronic venous insufficiency

Tel: (852)-28554962; Fax: (852)-25554961.

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S. Rosfors and A. Norén
Department of Clinical Physiology, Cardiovascular Center, Karolinska Institute at South Hospital, Stockholm, Sweden

Objective: Follow-up studies of deep venous thrombosis (DVI) are needed to gain increased knowledge of the process of recanalisation over time. In this study modern diagnostic techniques were used to analyse changes in venous circulation during the process of recanalisation and thrombus resolution.

Design and setting: Prospective follow-up study of patients with symptomatic DVT referred to a vascular diagnostic laboratory. The patients were evaluated by repeated examinations with colour duplex ultrasound and computerised strain-gauge plethysmography.

Patients: Eighteen consecutive patients with acute DVT occluding the calf veins and femoro-popliteal vein segments.

Main outcome measures: Ultrasonographic assessment of thrombus resolution and flow patterns in deep and superficial veins. Plethysmographic determination of venous volume and venous outflow capacity.

Results: At 3 months’ and 6 months’ follow-up, 33% and 56%, respectively, were recanalised hut almost all limbs still had some degree of functional outflow obstruction. Duplex evaluation further demonstrated a complex pattern of recanalisation with thrombus resolution from above, from below or both. Computerised strain-gauge plethysmography showed a progressive time-related increase in venous outflow capacity and venous volume over 6 months, hut volumetric variables could not be used to distinguish between limbs with patent veins and those with still-occluded veins. None of the limbs had completely compressible femoro-popliteal venous segments at the end of the follow-up.

Conclusion: The combination of these two modern diagnostic techniques, suitable for repeated studies, can provide detailed information on morphological and haemodynamic changes occurring during the process of recanalisation and thrombus resolution.

Keywords: Colour duplex ultrasonography; Deep venous thrombosis; Recanalisation; Strain-gauge plethysmography; Venous obstruction

Tel: -46 8 616 35 35: Fax: 46 8 616 35 12;  E-mail: stefan.rosfors@fys.sos.sll.sc

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Copyright © 2000 Philip Coleridge Smith