Because varicose veins are an affliction that is both physically and visibly apparent, and it can bring discomfort in performing normal routines, people are concerned with the potential harm they may cause. Often, people tend to neglect a medical concern if the trouble it is causing does not seem as serious. There are common misconceptions that varicose veins are merely a cosmetic concern and a natural part of aging. For this reason, people are not fully aware of the risk involved and at times, it may cause people to avoid learning what can be done to help.
Varicose vein is large, swollen, and ropey veins that appear bluish in color, usually occurring in the legs. They are commonly a result of weakened valves within the vein that impair the body’s ability to efficiently circulate blood. This form of vein disease is the most common, as 60% of Americans have some form of it. As the disease is most likely to occur in aging people, it is the number one diagnosis for those who are treated in the hospital over the age of 60 in the United States. However, this form of vein disease can also affect a number of younger people as well. Approximately 25% of the sufferers are between the ages of 30 and 40. It is more common in women than in men.
Overview of Varicose Veins
There are a large number of different preparations of compression available from specialized medical hosiery to multi-layer bandaging; the application and level of compression attainable often depends on local expertise and resources. Despite the beneficial effects of compression, in particular with leg ulcer healing, patient compliance is often poor mainly because cosmetic satisfaction is not achieved, and the evidence base for the efficacy of different forms of compression is variable. The mechanism of action of different forms of compression is also not well understood.
Valves within the veins are important in preventing backward flow of blood. When they fail in their function, blood collects in the veins and causes them to become enlarged or varicose. Any vein has the potential to become varicose, but the veins most commonly affected are those in the legs and feet. This is due to the increased pressure on the veins caused by standing and walking. In the United States, it is estimated that 15% of men and 25% of women are affected by varicose veins. Although there is no universally accepted method for preventing the progression of the condition, it is widely accepted that use of compression at an early stage can be effective in reducing symptoms and preventing the veins from becoming more pronounced. Compression therapy is considered to be the gold standard in the conservative treatment of varicose veins.
Importance of Compression Therapy
There are many treatments for varicose veins but of recent date, surgical therapy (e.g. saphenofemoral ligation and stripping), in comparison to other options, has been subject to more stringent appraisal. This is because although surgical therapy is effective at removing the visible varicose veins, it also carries the risk of adverse events and complications. There is therefore an ongoing debate about the appropriateness of surgical therapy, particularly in patients with early or mild disease. An important study on this matter has been the comparison of surgery with injection treatment or compression hosiery in varicose veins trials (CHERVVT). This was a multicentre randomised controlled trial that compared surgical treatment with injection of polidocanol and compression hosiery, or elastic compression stockings, in patients with varicose veins. This, and other studies, have suggested that conservative therapy with either injections or compression is more appropriate for those with early or mild disease. Compression therapy is the application of an external mechanical force to the body, it is a technique used in many medical conditions to control edema and other symptoms. In the context of varicose veins, it is applied using specially designed stockings or bandages which are intended to apply controlled external pressure to the legs.
Varicose veins are enlarged, dilated, and tortuous veins that are visible and palpable beneath the skin surface. Varicose veins are very common, particularly in westernized countries. It is estimated that at least one third of the population will develop varicose veins at some stage. Although there is a high prevalence of varicose veins, it is estimated that one in every twentieth patients with varicose veins will go on to develop a leg ulcer, which is a more severe form of venous disease.
Effectiveness of Compression Therapy
Changes in skin microcirculation caused by compression therapy have been investigated. A study on patients with chronic venous insufficiency proved that the application of compression bandages increased oxygen tension levels in the skin. This is important in preventing skin damage as a result of venous disease. Another study has shown that compression therapy causes a reduction in microhemorrhaging in the skin. These blood spots are a result of damaged capillaries and are thought to be responsible for pigmentation round the ankles seen in chronic venous insufficiency. When these capillaries burst, the iron in the hemoglobin is oxidized to form hemosiderin. This is deposited in the skin and is believed to be a major contributor to venous leg ulcers. By preventing hemosiderin deposits and improving skin oxygen levels, compression therapy can help to prevent the occurrence of leg ulcers in the future.
Severity of symptoms improves with compression therapy. Patients experience impressive reduction in cheaper, safer, and more comfortable to wear low compression hosiery compared to the “gold standard” of high compression bandages. The most dramatic effects have been seen in edema where a 90% reduction has been recorded when using compression therapy. Compression therapy maintains the reduction in leg volume in the long-term.
Reduction of Symptoms
The main aim of this research was to evaluate the effectiveness of compression therapy in reducing the incidence of recurrence of ulceration and in preventing the development of ulceration for patients with chronic venous insufficiency. The results are encouraging. Patients treated with compression bandaging over a two-year period had significantly fewer ulcers than control patients, and there was a delay in onset which was inversely related to adherence to the bandaging. Compressive stockings have also been shown to be effective in the prevention of ulcer recurrence in patients that have had ulceration. The incidence of recurrence of ulcers was reduced by half in the treatment group for at least 3 years. It can be concluded that compression therapy is highly effective in reducing symptoms of CVD.
Improvement in Blood Circulation
A more recent and novel development is the use of intermittent pneumatic compression, which has been shown to decrease the aspiration and activation of granulocytes, and reduce edema in an acute injury model.
It is widely acknowledged that the improvement in blood flow is greatest with compression using high pressure and high working energy. Although the actual pressure required to achieve this is not known precisely, it is understood that a pressure gradient should be produced from the lower leg to the thigh. This allows conservation of energy in a phase during muscle contraction, and dissipation of energy in the late phase. This is particularly important in the ambulatory patient who is prone to muscle fatigue and delayed onset muscle soreness if the pressure is too high.
The hemodynamics of compression are still not fully understood; however, it is thought that the increased pressure on the tissues provides a better balance of forces within the vein. This is particularly so at the level of muscle action. Normally, the calf muscle pump causes the highest pressure change during early stance phase; however, in patients with venous disease, this occurs too late. The increased tissue pressure causes a better alignment of the vein valves and an earlier action of the muscle pump.
The use of compression in venous disease causes a reduction in ambulatory venous pressure and reflux, and an increase in velocity of the blood flow in the superficial and deep veins. This has been shown using various objective measures. The velocity of blood flow is suggested using the rate of healing of a chronic venous ulcer and reduction in edema.
A study indicates that compression bandaging and stockings are the most conservative measures to improve blood flow. The positive effects of compression on circulation are well documented, and it has been suggested that compression causes arteriole dilation. This is particularly important in patients with peripheral arterial disease, in whom a reduction in ABI might cause critical ischemia. It may also lead to a reduction in microangiopathy in poorly controlled diabetes.
Varicose veins can occur secondary to venous hypertension, in which blood becomes congested and pools in the lower extremities. The underlying issue in patients with varicose veins is reflux at the saphenofemoral and saphenopopliteal junctions. This reflux causes pooling of blood in the venous system.
Compression Therapy and Improvement in Blood Circulation
Prevention of Complications
Venous incompetence in the presence of venous hypertension can lead to a series of complications stemming from the inflammatory response to the microcirculatory changes that have occurred. An increase in venous pressure causes leakage of fluid and blood from the veins into the surrounding tissues. This can cause an increase in pigmentation around the ankle due to red blood cell degeneration releasing iron, which is a potent skin irritant. A more severe outcome of this would be the development of a venous ulcer. Tissue fluid and inflammation cause the skin to become fragile; even minor trauma can result in an ulcer. It has been documented that up to 3% of the population will suffer from an active venous ulcer. This has a huge impact on the individuals’ quality of life and also carries a high economic burden. An international study of patients with chronic venous disease showed that almost half the QoL impact came from problems associated with venous ulcers. Since venous ulcers are hard to heal and have a high rate of recurrence, it makes it an attractive proposition to try and prevent them from occurring. Compression in the treatment of venous ulcers has been widely regarded as the gold standard of treatment. There are high rates of ulcer healing and freedom from recurrence with the use of compression. It comes as no surprise that it is seen as the best way to prevent ulcers developing. A Cochrane review of 29 RCTs involving 2420 patients found that there was a significant reduction in the occurrence of new ulcers in the groups treated with compression compared to those who had no treatment or were treated with just dressings. This study found that higher pressure provided more protection against ulcer recurrence.
Usage Guidelines for Compression Therapy
In a follow-up to medial leg ulcer patients, it was found that class 2 hosiery was not enough to prevent ulcer recurrence and was often damaged. This resulted in more ulcers and other dermatological complications.
Compression hosiery is used once the ulcer is healed to prevent its recurrence. Typical class 1 and 2 hosiery provides a pressure of 15-20mmHg and 20-30mmHg respectively. This is sufficient if there are no underlying venous complications. Class 3 and 4 hosiery is adequate if there are complications. The pressure for class 3 is 30-40mmHg and for class 4 is above 40mmHg.
The primary and initial treatment of an ulcer is an aggressive approach in the use of compression bandaging. A review identified the four-layer system as the most effective reversal treatment for chronic venous ulcers. This type of bandaging
