This video is based on a presentation given to the Venous Forum at the Royal Society of
Medicine on Thursday 27th April. It is pitched at a medical audience, but members of the
public may find it of interest. Compression after sclerotherapy might seem a rather strange
topic for discussion. Surely everyone knows that compression is essential after sclerotherapy.
Not much controversy there you might think and not much to talk about really. We have
"known" for over 50 years that compression is essential. Professor George Fegan in the
1960's refined the technique of sclerotherapy for varicose veins and published his experience
of treating over 13000 patients emphasising the importance of compression. The rationale
for compression is based on Fegan's "empty vein technique", thereby reducing superficial
and deep vein thrombosis, pain, phlebitis and bruising. The empty vein technique promotes
healing by fibrosis rather than thrombosis so the efficacy of sclerotherapy is improved
and recurrence by neovascularisation is reduced. So that's what all vein specialists do now,
don't they? Well, I conducted a random poll of phlebologists to ask what their current
practice is. It wasn't scientific survey and it was not sufficiently large to analyse statistically.
I posed the question on Linkedin and I emailed my professional colleagues.
In the UK, certainly among members of the British Association of Sclerotherapists, compression
after sclerotherapy is regarded as mandatory and compression is applied after treatment
for any size of vein. Most use compression stockings, some additionally use bandages
and eccentric compression. Professor Andrew Bradbury uses bandages and
stockings after both microsclerotherapy to reticular veins and telangiectasias and after
foam sclerotherapy to varicose veins to which he additionally applies eccentric compression.
Andrew's general comment was "the more compression the better" and other members such as Claire
Judge, Julie Halford, Sue Topp, Martyn King, Steve Tristram, Chris Lattimer and Simon Payne
are in agreement. They all use graduated elastic compression stockings with various methods
of eccentric compression with or without additional bandaging. Duration of compression varies,
but most feel that 3-5 days of continuous compression are needed. Interestingly, Simon
Payne places the bandages over the stocking, so the patient can remove the bandage without
disturbing the stocking. Steve Tristram for example uses tourniquets
to apply pressure immediately after injection and he also uses an ingenious method of bubble
wrap inside tubigauze for eccentric compression held in place with a Pehaft bandage.
Chris Lattimer partially applies a thigh-length class 2 graduated elastic compression stocking to
the knee, folded back on its self before foam sclerotherapy. He uses eccentric peri-venous
tumescence for great saphenous sacculations, and concentric peri-venous tumescence compression
occasionally for the entire great saphenous vein to reduce its volume. After sclerotherapy
he uses a thigh length stocking with waist attachment for 3 weeks.
Outside the UK, the use of compression after sclerotherapy is far more diverse. For example,
some vein specialists use only bandages and no stockings, some use compression for larger
veins i.e. not for reticular veins or telangiectasia, some phlebologists use compression selectively
and some don't use compression at all.
Mauizio DiGiacomo compresses larger veins for 48 hours and only sometimes compresses
smaller veins. Zil Yassine uses eccentric compression in addition to a stocking to reduce
phlebitis as does Eduardo Toledo de Aguiar. Ricardo Olmos Cardenas uses bandages exclusively.
Patrizia Pavei does not use compression at all on small veins and she uses a combination
of bandages and stockings for larger veins. Thomas Eaton offers compression but lets the
patient decide. He believes it is unnecessary after any type of sclerotherapy.
Finally, these 2 very influential vein specialists have completely opposite views. Juan Cabrera
states that the usefulness of compression after sclerotherapy is beyond doubt and Jean
Jerome Guex states that is useless. So despite a phlethora of various "consensus statements"
and published guidelines from various associations and learned societies, in practice, experts
around the world are doing all sorts of different things.
So what does the published data tell us and can it help us? A much quoted study comes
from Hamel-Desnos. It looked at 60 patients having foam sclerotherapy to saphenous veins.
Half were randomised to a 15-20mmHg stocking worn during the day for 3 weeks and half wore
nothing. At 28 days, there were no differences in outcome. The study has been criticised
for the low compression of the stocking and the relatively high non-compliance rate, but
it remains an important and frequently cited publication.
This study looked at different bandaging regimens after foam sclerotherapy. It suggested that
24 hours of bandaging is just as effective as 5 days and given that TED stockings were
used, it raises the question whether compression is useful at all. TED stockings you will recall
are designed for use in patients lying in hospital beds to prevent DVT and there is
some suggestion that they are not effective in the standing position.
Kern's study looked at 100 female patients with a lateral thigh vein telangiectasia and
reticular veins. After one session of sclerotherapy, half were randomised to wear a stocking for
3 weeks and half wore nothing. At 6 weeks, there was no subjective differences in patient
satisfaction, no observed differences in matting, staining or microthrombi. The difference in
vessel clearance 63% versus 70% was very small. If we now turn to the "empty vein" hypothesis,
we know that the work of Hugo Partsch shows that very large pressures are required to
empty a superficial vein and that these are very unlikely to be achieved for any length
of time with any bandaging technique let alone a stocking.
What about perivenous tumescence? Well this study suggests that administering tumescent
local anaesthetic around a vein to reduce its diameter and to produce local compression
does not improve results. And here is an issue that the literature fails
to address and which vein specialists rarely discuss. Clearly, the legs on the right are
easier to bandage and stockings are more likely to fit. Bandages applied to the lady on the
left are likely to either slip down before she reaches home or they are likely to dig
in painfully the next day. I also suggest that it will be very difficult to find a a
pair of stockings to fit comfortably. Who is at fault if the patient fails to comply
with the compression regimen? So in summary Mr Chairman, ladies and gentlemen,
I think there is insufficient evidence to convince me to persist with a regimen of firm
compression after sclerotherapy which patients are reluctant to accept for a benefit that
is marginal at best. Like many of my colleagues, I now offer compression and let the patient
decide whether to wear it and for how long based on how comfortable they feel. Thank
you for watching my video.