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PubMed1998

Effective treatment of lymphedema of the extremities.

OBJECTIVE: To define the immediate and long-term volumetric reduction following complete decongestive physiotherapy (CDP) for lymphedema. DESIGN: Prospective study of consecutively treated patients. SETTING: Freestanding outpatient referral centers. PATIENTS: Two hundred ninety-nine patients referred for evaluation of lymphedema of the upper (2% primary, 98% secondary) or lower (61.3% primary, 38.7% secondary) extremities were treated with CDP for an average duration of 15.7 days. Lymphedema reduction was measured following completion of treatment and at 6- and 12-month follow-up visits. INTERVENTION: Complete decongestive physiotherapy is a 2-phase noninvasive therapeutic regimen. The first phase consists of manual lymphatic massage, multilayered inelastic compression bandaging, remedial exercises, and meticulous skin care. Phase 2 focuses on self-care by means of daytime elastic sleeve or stocking compression, nocturnal wrapping, and continued exercises. MAIN OUTCOME MEASURES: Average limb volumes in milliliters were calculated prior to treatment, at the end of phase 1, and at 6- to 12-month intervals during phase 2 to assess percent volume reduction. RESULTS: Lymphedema reduction averaged 59.1% after upper-extremity CDP and 67.7% after lower-extremity treatment. With an average follow-up of 9 months, this improvement was maintained in compliant patients (86%) at 90% of the initial reduction for upper extremities and lower extremities. Noncompliant patients lost a part (33%) of their initial reduction. The incidence of infections decreased from 1.10 infections per patient per year to 0.65 infections per patient per year after a complete course of CDP. CONCLUSIONS: Complete decongestive physiotherapy is a highly effective treatment for both primary and secondary lymphedema. The initial reductions in volume achieved are maintained in the majority of the treated patients. These patients typically report a significant recovery from their previous cosmetic and functional impairments, and also from the psychosocial limitations they experienced from a physical stigma they felt was often trivialized by the medical and payor communities.

Bandages↗

PubMed2002

Incidence of thromboembolism after transurethral resection of the prostate (TURP)--a study on TED stocking prophylaxis and literature review.

OBJECTIVE: To assess the incidence of clinically evident pulmonary emboli and deep vein thromboses in patients undergoing transurethral resection of the prostate (TURP) with the routine use of graduated elastic compression stockings (TED) in all patients and the addition of low-dose heparin in selected high-risk patients. PATIENTS AND METHOD: A retrospective analysis of clinically evident thromboembolic complications within 4 weeks of operation in 883 patients operated in a single hospital during a 4-year period. RESULTS: Four patients (0.45%) developed pulmonary emboli (PE), of which two (0.23%) were fatal. There was one clinically evident deep vein thrombosis (DVT) in a high-risk patient (0.11%). None of the 14 high-risk patients receiving additional low-dose heparin required a blood transfusion. CONCLUSION: Clinical thromboembolic complications following TURP are rare. TURP patients have a low risk for DVT, but an intermediate risk for pulmonary emboli. Pulmonary emboli may occur without identifiable risk factors and despite TED stocking prophylaxis.

Aged↗

PubMedDate not supplied

[Compression in lymphedema].

The author discusses the indications and contraindication of compression. The study of auto-immune complexes in the circulating blood has shown a significant increase in lymphedema patients with erysipeloid inflammations and a definite increase, but less marked, in lymphedema patients without a past history of fever. Then, the compression values are studied in the 5 stages of the treatment of lymphedema by compression: elevation with Thuasne 18 bandages, Lymphapress and if necessary Tubing (always general anesthesia) limited to the leg. For the thigh, lymphatic "drainage" is recommended. Then comes the walking bandage (non elastic !). Once the edema has disappeared, elastic stockings (compression e.g. 60 mm at the level of the malleolus) are custom made. Statistics of 57 cases, where the regular replacement of the stockings after 9 to 13 years was controlled, conclude the study.

Bandages↗

PubMed1988

Venous thrombosis after abdominal surgery. A comparison between subcutaneous heparin and antithrombotic stockings, or both.

In an open controlled study, 248 consecutive patients (age more than 40 yrs) admitted for major abdominal surgery were randomized to one of three prophylactic antithrombotic treatments. Eighty-five patients received subcutaneous heparin, 74 patients had graduated compression stockings to the knee (TED stockings), and 89 patients had both subcutaneous heparin and stockings. Treatment began on the evening before operation and continued to complete mobilization, or for not less than five days postoperatively. On the fourth or fifth postoperative day, the patients underwent a 99mTc-plasmin test of the lower limbs as a test for deep vein thrombosis. There were 29.7% positive tests in the stocking group, 29.4% in the group with heparin prophylaxis, and 25.8% in the combined group. Differences between treatments were not statistically significant.

Abdomen↗

PubMed1984

Response of femoral venous oxygen tension to graduated pressure stockings--possible relationship to deep vein thrombosis.

Venous oxygen tension (pO2) was measured in discrete samples of blood obtained through the femoral vein of cardiac catheterisation patients before, during and after application of sustained external graduated pressure in the form of compression stockings (T. E. D. Kendall). There was a significant reduction (p less than 0.05) of pO2 from the baseline value both 30 sec and one minute after the application of the pressure stockings. Thereafter, the pO2 rose to baseline values. Two minutes after the stockings were removed there was again a significant reduction (p less than 0.05) of pO2 from the baseline value. We suggest that the decrease in venous pO2 on application of external pressure may be a reflection of washing out of stagnant hypoxic blood from the venous valve pockets, which may be related to the formation of deep vein thrombosis (DVT).

Blood Gas Analysis↗

PubMed1992

Mechanism of action of external compression on venous function.

Compression stockings and bandages have been shown to improve venous haemodynamics and may act by reducing venous reflux. The aim of this study was to assess the mechanism of action of compression therapy on venous function and to determine whether such treatment may correct valvular incompetence. Both lower limbs of 36 patients (median age 59 (interquartile range 45-65) years) were assessed by duplex ultrasonographic scanning. There were 17 limbs with popliteal vein reflux, 19 with long saphenous vein (LSV) reflux and 21 with short saphenous vein (SSV) reflux. A water-filled adjustable pressure cuff was applied around the knee and inflated gradually, while continuously assessing the veins for reflux using ultrasonographic imaging. The external pressure applied by the cuff was noted when reflux was abolished or when the vein was completely occluded. In four (24 per cent) of 17 popliteal veins, eight (42 per cent) of 19 LSVs and three (14 per cent) of 21 SSVs reflux was abolished before occlusion of the vein. The cuff pressures required to achieve restoration of valvular function were significantly lower than those required to occlude the veins. It is possible, in some refluxing veins, to correct valvular dysfunction by external compression therapy. Coaptation of valvular cuffs to restore valvular competence may be the mechanism of action of compression therapy in venous disease.

Aged↗

PubMed1999

The effect of compression therapy on venous haemodynamics in pregnant women.

OBJECTIVE: To study the influence of compression on the haemodynamics of the deep venous system in pregnancy. DESIGN: A prospective, observational study. SETTING: The phlebological unit of the department of dermatology at a university hospital. POPULATION: Fifteen pregnant women with no previous signs of chronic venous insufficiency. METHODS: Parameters of the venous pump function were assessed by strain-gauge plethysmography. Blood flow velocity, flow volume and vessel diameter in the superficial femoral vein were measured by duplex sonography. All examinations were performed with and without applied compression stockings (25-32 mmHg) at two different stages of gestation and after delivery. In addition, subjective symptoms were graded. RESULTS: Venous pump function improved and refilling time lengthened significantly when compression was used during gestation and postnatally. Duplex sonography showed an increase in blood flow velocity and flow volume in the superficial femoral vein with applied compression; the vessel diameter increased slightly. Subjective symptoms of the leg, graded on an arbitrary scale, were reduced by regular compression therapy. CONCLUSION: Our results indicate that compression improves the clinical symptoms of venous congestion and the venous haemodynamics of the legs during pregnancy and in the postpartum period. Thus, the regular use of compression during pregnancy and the puerperium may reduce the incidence of thromboembolic events.

Bandages↗

PubMed1984

Postoperative deep vein thrombosis--early diagnosis and prophylaxis.

The incidence of postoperative deep vein thrombosis (DVT) was investigated using the 125I-fibrinogen method and measurement of beta-thromboglobulin on surgical and gynecological patients. It was definitely lower in Japan as compared to Western countries. The age of 50 or more and malignant diseases were significant as risk factors for development of DVT. The presence of hypercoagulability before surgery and on the first postoperative day in addition to postoperative impaired fibrinolysis was considered to be the most important factor in development of DVT. The efficacy of the graded compression stocking for the prevention of DVT was confirmed, reducing from 13.5 per cent to 4.0 per cent. Furthermore, the most effective preventive method is the use of an intermittent pneumatic compression device for high risk patients with DVT.

Adult↗

PubMed1989

Intermittent compression units for the postphlebitic syndrome. A pilot study.

The postphlebitic syndrome is a common affliction with limited therapeutic options. Patients who fail to respond to treatment with graded elastic compression stockings often develop a chronic pain syndrome manifested by intractable pain and swelling. Because lymphedema, a condition also associated with leg pain and swelling, has been successfully treated by intermittent compressive therapy with an extremity pump, we conducted a pilot study of compressive therapy in patients with severe postphlebitic syndrome. All five patients studied had dramatic improvement in symptoms and functional status without side effects. Although a large randomized trial is needed to properly evaluate compressive therapy, it appears to be very effective in selected patients.

Adult↗

PubMedDate not supplied

The LONFLIT4--Concorde Deep Venous Thrombosis and Edema Study: prevention with travel stockings.

BACKGROUND: The LONFLIT1+2 studies have established that in high risk subjects after long flights (> 10 hours) the incidence of deep venous thrombosis (DVT) is between 4% and 6%. The LONFLIT4 study was designed to evaluate the control of edema and DVT in low-medium risk subjects. The aim of this study was to evaluate edema and its control with specific stockings (ankle pressure between 20 and 30 mm Hg) in long-haul flights. The first part of the study included flights lasting 7-8 hours and the second part included flights lasting 11-12 hours. Ultrasound scans were used to assess thrombosis before and after the flights and a composite edema score was used to evaluate edema and swelling. A group of patients with microangiopathy associated to edema (diabetes, venous hypertension, anti-hypertensive treatment) were also included to evaluate the preventive effects of stockings during flight. Part I: DVT evaluation: Of the 74 subjects in the stocking group and 76 in the control group (150), 144 completed the study. Dropouts were due to low compliance or traveling and connection problems. Age and gender distribution were comparable in the 3 groups as was risk factor distribution. In this part of the study there were no DVTs. Edema Evaluation: The level of edema at inclusion was comparable in the two groups of subjects. After the flight there was an average score of 6.9 (1) in the control group. In the stocking group, the score was on average 2.3 (1), three times lower than in the control group (p < 0.05). Part II: DVT evaluation: Of the 66 included subjects in the stocking group and 68 in the control group (134), 132 completed the study. Dropouts were due to low compliance or connection problems. Age and gender distribution were comparable in the two groups. In the stocking group no DVT was observed. In the control group, 2 subjects had a popliteal DVT and 2 subjects had superficial venous thrombosis (SVT); in total 4 subjects (6%) in the control group had a thrombotic event; the incidence of DVT was 3%. The difference (p < 0.02) is significant. EDEMA EVALUATION: The composite edema score at inclusion was comparable in the two groups. After the flight there was a score of 7.94 (2) in the control group, while in the treatment group the score was 3.3 (1.2). MICROANGIOPATHY STUDY: In all these subjects, the level of edema was very high in the control group and significantly lower in the compression stocking group. Stockings are effective in controlling edema during flights even in subjects with microangiopathy and edema. Compression was well tolerated in normal subjects and in patients. CONCLUSION: The Kendall Travel Socks (Tyco Healthcare, Mansfield, MA, USA) which provide 20-30 mm Hg pressure at the ankle, are effective in controlling edema and reducing the incidence of DVT in both low-medium-risk subjects and in patients with microangiopathy and edema in long-haul flights (7-11 hours).

Aerospace Medicine↗

PubMed1999

Influence of lower limb pneumatic compression on pulmonary artery temperature: effect on cardiac output measurements.

OBJECTIVES: To characterize the decreases in pulmonary artery temperature that coincide with the inflation cycle of pneumatic calf compression stockings and to examine their effects on the thermodilution measurement of cardiac output. DESIGN: Three-part observational study. SETTING: University hospital surgical intensive care unit. PATIENTS: Postoperative patients with indwelling pulmonary artery catheters. INTERVENTION: Thermodilution cardiac output measurements with and without pneumatic calf compression. MEASUREMENTS AND MAIN RESULTS: Phase 1 (n = 18) examined the effects of pneumatic compression on pulmonary artery temperature. There was no effect on pulmonary artery temperature (device off, 37.468+/-0.008 degrees C; device on, 37.458+/-0.014 degrees C), but the difference between the maximum and minimum pulmonary artery temperatures was increased (off, 0.031+/-0.006 degrees C; on, 0.055+/-0.012 degrees C [p < .001]). Phase 2 (n = 12) found that the mean thermodilution cardiac output with 10 mL of cold (0-5 degrees C) injectate was unchanged by pneumatic compression (off, 7.00+/-2.28 L/min; on, 6.89+/-2.22 L/min). However, when the compression devices were operating, the variability between the individual measurements was increased, as reflected by larger coefficients of variation (off, 3.19+/-1.96; on, 8.72+/-6.56 [p < .02]). Similar results were obtained during phase 3 (n = 5), when cardiac output was measured with room temperature Injectate. CONCLUSIONS: Intermittent pneumatic calf compression increased lower limb venous return, causing acute but transient decreases in pulmonary artery blood temperature. This did not affect the accuracy of thermodilution cardiac output measurements that were made using 10 mL of either cold or room temperature injectate.

Bandages↗

PubMed1979

Effect of elastic compression on venous hemodynamics in postphlebitic limbs.

To determine whether elastic compression alters the venous hemodynamics in the postphlebitic limb, we measured venous pressure patterns in 11 postphlebitic limbs with and without elastic compression stockings. Following cannulation of a dorsal vein of the foot, the patients underwent measurements of basal resting pressure, maximum percent decrease in venous pressure with exercise (delta VPex), peak systolic venous pressure during exercise (SVPmax), the amplitude of the pressure swing, and venous return time. Elastic compression did not alter basal resting pressure, delta VPex, or venous return time. By contrast, SVPmax decreased from 139 +/- 0.3 mm Hg to 11 +/- 8 mm Hg with elastic compression. If venous ulcers are related to the high pressure developed in the superficial veins during calf muscle systole, then elastic compression may be beneficial by decreasing systolic venous pressure and its subsequent deleterious consequences.

Bandages↗

PubMed2004

Efficacy of mechanical prophylaxis for venous thromboembolism in patients with brain tumors.

Patients with brain tumors are at considerable risk for the formation of venous thromboemboli. One method of preventing these complications is mechanical prophylaxis in which an external pneumatic compression device and graduated elastic compression stockings are used. Evidence indicates that these devices prevent deep venous thrombosis (DVT) and pulmonary embolism (PE) by limiting venous stasis and increasing fibrinolytic activity at both the local and systemic levels. The authors present evidence for the occurrence of both mechanisms and discuss the use of mechanical compression in the setting of surgery for brain tumors. They also present data proving the efficacy of these devices in patients who undergo craniotomy with motor mapping for resection of glioma and in whom the contralateral leg receives no prophylaxis. Finally, they comment on the use of anticoagulation therapy both in addition to and in place of mechanical prophylaxis.

Anticoagulants↗

PubMed1992

Contemporary treatment of venous lower limb ulcers.

The postphlebitic syndrome is a significant management problem that affects a large number of patients. Primary prophylaxis of deep-vein thrombophlebitis would reduce the risk of developing the postphlebitic syndrome and should be considered in high-risk patients. Patients who have had a phlebitis should be monitored with noninvasive tests of the deep venous circulation for the development of venous valve incompetence. Patients with venous hypertension should be placed in compression stockings to prevent the postphlebitic syndrome. In patients who progress to venous ulceration, several aggressive measures must be undertaken. Systemic treatment includes management of obesity, edema, immobility, poor nutrition, and comorbid illnesses. Some patients may require a short hospitalization of bed rest, lower limb elevation, and daily dressings and wound care. Outpatient therapy requires sustained compression of 35 to 40 mmHg at the ankle for many months to allow the ulcer to heal. The standard bandage material is Unna's boots, which is applied every one to two weeks by a trained nurse. Cadexomer iodide is an effective local treatment that helps debride the ulcer and accelerate healing. Finally, pentoxifylline therapy has also been shown to significantly improve the healing of venous ulcers.

Bandages↗

PubMed1988

Elevated levels of 6-keto-prostaglandin-F1a from a lower extremity during external pneumatic compression.

The synthesis of either fibrinolytic serine proteases or platelet inhibitory ecosonoids by the intact endothelial cell may limit thrombus development. In a preliminary study from this laboratory, an elevation in the level of 6-Keto-prostaglandin-F1å, the stable metabolite of prostacyclin (PGI2) was demonstrated in femoral vein plasma obtained during surgical treatment from an extremity undergoing external pneumatic compression. Simultaneously, no elevations in thromboxane B2, the stable metabolite of thromboxane A2, were observed. The present study is an inclusive prospective series of 26 patients. A single pneumatic compression stocking was applied to the left limb in patients who underwent an operation under general anesthesia. Base line venous samples (3 milliliters) were obtained from the femoral vein on the experimental side and the control contralateral side, as well as from the upper limb. Additional samples were drawn at 30 and 60 minutes after the onset of compression. Nine samples per patient (234 total) were analyzed for 6-Keto-prostaglandin-F1å by competitive binding radioimmunoassay in duplicate in a single blind manner. Base line values for the upper limb, right leg and left leg were 0.08 + 0.01 nanogram per milliliter; 0.14 + 0.03 nanogram per milliliter, and 0.13 + 0.02 nanogram per milliliter, respectively (no statistical difference). By 60 minutes of compression, control samples increased to 0.40 + 0.07 nanogram per milliliter (right leg) and 0.42 + 0.08 nanogram per milliliter (upper limb) while the experimental leg increased to 0.71 + 0.13 nanogram per milliliter (p less than 0.05 versus right leg, p less than 0.005 versus upper limb). There was no statistical difference at 60 minutes between the men and women.

6-Ketoprostaglandin F1 alpha↗

PubMedDate not supplied

Magnetic resonance venography in the diagnosis and management of May-Thurner syndrome.

Isolated left lower extremity swelling secondary to left iliac vein compression was first described by McMurrich in 1908, and defined anatomically by May and Thurner in 1957 and clinically by Cockett and Thomas in 1965. The left iliac vein is usually located posterior to the right iliac artery and can be compressed between the artery and the fifth lumbar vertebrae. Symptoms include left lower extremity edema, pain, varicosities, venous stasis changes, and deep venous thrombosis. Evaluation of these patients historically included a venous duplex scan to rule out deep venous thrombosis and an abdominal computed tomography scan to rule out pelvic mass. This paper describes the use of magnetic resonance imaging and venography in the evaluation of patients with isolated left lower extremity swelling. A retrospective analysis of a series of 24 patients who presented with symptomatic left lower extremity edema was performed. Infrainguinal deep venous thrombosis and valvular reflux was evaluated by duplex scan. The presence of suprainguinal deep venous thrombosis and pelvic mass was evaluated by magnetic resonance imaging. Magnetic resonance imaging was used to define the anatomic characteristics of the May-Thurner syndrome. Patients identified with the syndrome were treated either conservatively with lower extremity compression and elevation or with angioplasty and stenting. Follow-up of this subset of patients was performed with clinical assessment of the resolution of their symptomatic lower extremity edema as well as quality of life assessments via phone interviews. Twenty-four patients were evaluated for isolated left lower extremity swelling. Seven patients had positive results on duplex scans for deep venous thrombosis. Magnetic resonance imaging results demonstrated 1/24 (4%) had a pelvic mass compressing the iliac vein; 2/24 (8%) patients had iliac vein thrombosis; 1/24 (4%) patients with a history of deep venous thrombosis demonstrated a long stenotic segment of the left iliac vein unrelated to its association with the right iliac artery; 9/24 patients (37%) had anatomic evidence of May-Thurner syndrome; and 2/24 patients (8%) had isolated left lower extremity swelling of unknown etiology. Five patients diagnosed with May-Thurner syndrome were treated conservatively with compression stockings and leg elevation. Four patients with May-Thurner syndrome underwent iliac vein angioplasty and stenting. Technical success was 100%. On clinical follow-up, the patients with May-Thurner syndrome have had improvement/resolution of their symptoms. There have been no complications from either therapy. May-Thurner syndrome is a clinical entity of left iliac vein compression by the right iliac artery, resulting in isolated left lower extremity swelling and may be a precipitating factor for iliofemoral deep venous thrombosis. Magnetic resonance imaging is the best modality for diagnosis of this entity as it can rule out the presence of pelvic masses and deep venous thrombosis while simultaneously demonstrating the anatomy characteristic of this syndrome.

Adolescent↗

PubMed1995

Dermal oedema in lipodermatosclerosis: distribution, effects of posture and compressive theraphy evaluated by high-frequency ultrasonography.

Although leg oedema is believed to contribute to the pathogenesis of lipodermatosclerosis and leg ulcer, little is known about the cutaneous distribution of water in lipodermatosclerosis. In lipodermatosclerosis accompanied by leg ulceration, a subepidermal low echogenic band is seen in the high-frequency echograms of the skin at the boundary of the wound. Since skin echogenicity is inversely related to the amount of water contained, it has been assumed that the subepidermal low echogenic band corresponds to oedema in the papillary dermis. In this study we evaluated dermal oedema in lipodermatosclerosis by quantifying changes of skin echogenicity in 20 patients with lipodermatosclerosis and 20 age- and sex-matched controls. In order for us to evaluate the influence of the upright posture on skin water content, echogenicity was determined three times a day in various regions of the lower and upper extremities. Next morning, after ultrasound examination of the ankle skin, a compressive stocking was applied for 12 h and then the measurements of echogenicity were repeated. At any time of the day, ankle and calf skin was less echogenic in lipodermatosclerosis than in the control. The low echogenic area was confined to the subepidermal region. During the day the low echogenic area expanded in patients with lipodermatosclerosis. This phenomenon was reversed by leg compression. These results indicate that in lipodermatosclerosis oedema is located mainly in the papillary skin. An upright position causes aggravation of oedema, whereas application of compression protects against accumulation of water in the skin during the day.

Aged↗

PubMedDate not supplied

Importance and advantages of intermittent external pneumatic compression therapy in venous stasis ulceration.

Venous ulcers are seen following postthrombophlebitic syndrome with venous insufficiency and can begin as a result of minor trauma. In this retrospective study the authors examined the value of external intermittent pneumatic compression therapy in chronic venous ulcers. Results in 1,250 patients with postthrombophlebitic syndromes, 235 of these patients with leg ulcers, revealed that this modality of therapy shortens the therapy duration, lowers the total therapy cost, and hastens the return to active life in comparison to the classical therapy with compression stockings and antiaggregant or low-dose oral anticoagulant therapy. In the light of their findings they propose the wider use of this adjuvant therapy.

Adult↗