Practical Ambulant Phlebology.

Preface

The rapid development of Phlebology, particularly in the last twenty years, has made it abundantly clear that the many problems and demands of this field require a specialized approach.

However diseases of the venous system receive little attention either in the clinical teaching or the practical training of medical practitioners.

More than 25% of the adult German population show marked pathological changes to the veins; 15% chronic venous insufficiency and more than 1.2 million suffer from chronic leg ulcers.

The cost of treating leg ulcers alone is over DM 2.5 billion.

There are far too few Phlebology specialists to deal with this huge patient population.

This is not intended to provide the non-specialist with the much needed comprehensive training, but rather to give practical advice on the ambulant care of patients with venous disorders. It also aims to provide assistance in reaching a decision on further measures needed for the diagnosis and treatment of the patient by other health care professionals.

The quantitatively large problem of venous disorders can only be comprehensively tackled by the close cooperation of specialists and general practitioners. Early and proper diagnosis and therapy are particularly important for the quality of life and working ability of those 90% of patients with venous disorders whose disease is progressive.

Brief account of Pathogenesis

The tendency to develop changes to the veins is based on an often inherited anomaly of superficial veins, sometimes combined with analogous damage to the deep veins.

In detail, these changes most frequently consist of partial phlebectasia of the saphenous veins near their respective terminations, although chronic dilatation of the entire saphenous vein or large sections thereof, also occurs.

The development of local varicosis is also promoted by invisible dysplastic damage to the walls in the large or small branches. Even under physiological conditions of blood flow, these sections of dysplasia act as sites of least resistance and allow the progressive formation of the varicosis which spreads to other parts of the vessel. However, the most active mechanical factor is valvular incompetence at the terminations of the saphenous veins, enabling the pathological changes in volume and pressure to occur with the resulting strain on the vascular wall.

Additional factors of the environment, life style, physiological and pathophysiological effects can also accelerate the degeneration of the veins and therefore deserve special consideration.

Risk Factors

90% of all cases of venous disease are caused by factors promoting thrombosis, such as occupations involving prolonged periods of sitting or standing, combined with a genuine susceptibility towards changes in the walls of veins. The quantity and quality of the risk factors and hence the number and severity of venous disorders, increase with age.

Similar risk factors also form the basis upon which varicosis arises and are particularly important in its progression.

The risk factors described below are often present, but in principle, all thrombosis and stasis promoting effects should be considered:

Lack of movement
- Occupations with prolonged periods of sitting or standing
- Confinement to bed
- Long flights or car journeys with bent legs
- Long evenings spent watching television
- Immobility, even of only one limb (plaster cast)

Contact sports and activities that induce high abdominal pressure
- Extreme physical exertion at work, leisure or sport, with or without the induction of high abdominal pressure (e.g. playing a wind instrument, weight lifting, etc.).

Obesity
While obesity is not a confirmed contributory factor in venous diseases, overweight people tend not to exercise, which promotes venous stasis. However, obesity undoubtedly favors the occurrence of thrombosis.

Clothing
- tight clothing
- high heels (the calf muscle pump does not operate if heels are higher than 6-8 cm)
- sloppy footwear

Several pregnancies

Heat
- Experiments have confirmed that heat causes physiological and pathophysiological dilatation of veins. Enlargement of veins can induce congestion, but it has not been proven that overheating produces permanent stretch damage.

Flat/splay feet

Estrogens
- Estrogens combined with heavy smoking act as a thrombogenic factor.

Other risk factors to be considered in thrombosis prophylaxis:
- Surgery, especially in the abdominal region, hip replacement
- Patients with varicose veins are particularly at risk
- Dehydration
- Hypercoagulability, e. g. drug induced
- Immobility, even of only one limb (paralysis, plaster casts, etc.)
- Thrombophlebitis (primary or secondary deficiency of AT III, Protein C or S).

Protective Measures

The damage caused to the venous wall by insufficiency of the venous valves and the increase in volume is irreversible. Protective measures merely prevent progression of the existing disease.

The pathogenic parameters, reduced rate of flow and increase in volume, can be positively influenced by the following measures:

Compression hosiery

Exercises
- specific exercises to activate the pump in the calf veins and ankle, especially suitable for bedridden patients.

Sports
- Walking
- Dancing
- Cross country skiing
- Golf
- Swimming
- Cycling

Vacation
- Preferably not in hot climates (not above 20 degrees C)
- Hill walking and rambling

Weight reduction if overweight

Elevation of the legs
- Several times daily for 5 - 10 minutes

Choice of suitable occupation, or change of employment if necessary

Orthopaedic inserts
- for flat/splay feet

Cold showers of the feet
- Several times daily for 3 - 5 minutes

Drug therapy
- Medication to increase venous tone

Compression Therapy

The fundamental effect of compression therapy, the primary and most important conservative treatment of peripheral venous diseases, is to increase venous flow, thereby influencing the main factor in the removal and prevention of complications.

Without compression therapy, conservative treatment alone will never be successful.

Compression therapy affects the hemodynamics of venous flow.
1.External compression reduces the pathological distension of the veins.
2. Compression can approximate the insufficient venous valves and restore their functional effectiveness.
3. By reducing the volume of the veins, the rate of blood flow in them is increased.
4. The fibrinolytic activity of the venous wall is increased and the risk of thrombosis reduced.

Compression bandaging is indicated for the initial treatment of complications.

Once the diagnosis has been confirmed, compression hosiery allows considerable advantages over bandaging in preventing the recurrence of symptoms and further deterioration .

Venous diseases tend to show progression and therefore require a consistent compression therapy treatment program.

Compression Bandaging

Compression bandaging is used to counteract edema or dermatogenic complications.

Compression bandaging produces short term measured compression of both superficial and deep tissue veins. Congestion is reduced by high working pressure and movement.

Bandaging compresses tissues and veins and provides resistance to the calf musculature. The more inelastic the bandaging material, the less the resistance yields on walking.

In cases prone to swelling, inelastic bandaging restricts the increased passage of lymph from the capillaries into the tissue and so protects against it becoming "boggy" and sustaining nutritive damage.

On walking, the tissue fluid is actively expelled, the flow of lymph is increased and the protein content of the tissue is reduced.

By decreasing the diameter of the veins, there is an increase in venous return and thrombosis formation is prevented. Superficial inflammation of the veins is reduced more quickly with compression bandaging and movement than with local treatment alone. If the deep venous system is involved, then naturally the same guidelines apply as for the treatment of deep vein thrombosis.

For compression bandaging to be effective, it is essential that the correct technique is used when applying firm, limited stretch bandages to produce graduated pressure that reduces in a distal to proximal direction.

The choice between crepe and tape bandages depends on the type of disease and the attitude of the patient towards the therapy program.

The more acute and extensive the congestion in the tissue, the more inelastic the bandage should be and the higher the compression pressure.

The necessary technique and experience in bandaging and creating the optimal pressure graduation, generally precludes self bandaging by the patient.

Compression Hosiery

The main purpose of medical compression hosiery is to maintain the results of treatment and to avoid further complications. The disappearance of swelling and pain of the affected leg is prolonged by compression hosiery and relapses are prevented.

At working pressure, the leg "works" against the garment, at resting pressure, the garment "works" against the leg.

Unlike compression bandaging with its high working pressure, compression hosiery exerts a resting pressure, which varies depending on the garment's class of compression. The daily buildup of pressure is controlled by the limited ability of the hosiery to stretch, therefore, incompetent venous valves are approximated, venous return is accelerated, the fibrinolytic activity of the venous wall is increased, and the risk of thrombosis reduced.

Compression hosiery is better tolerated and easier to put on than compression bandages. Compression hosiery is therefore generally more acceptable to the patient.

Compression hosiery today is usually manufactured as a two-way stretch compression stocking, i. e. they are elastic both lengthwise and widthwise. The stocking's graduated pressure, decreasing from the ankle upwards is ensured both in ready made and made to measure hosiery. This precision and accuracy in compression is controlled, in Germany, by the Hohenstein Institute which issues the "manufacturer association quality mark" for medical compression stockings.

The earlier description "elastic stockings" can be misleading. It is not the material, but the compression that determines the effectiveness of the hosiery and natural elasticity is by no means incorporated into all hosiery. The term "elastic stockings" is often the first obstacle to good patient compliance, where as "modern medical compression hosiery" often helps to break down patient reservations relative to compression therapy.

"Support" hosiery, where compression is below compression Class I, (20-30 mmHg) is of no proven medical benefit and is therefore not available on prescription.

In Germany, two pairs of compression hosiery stockings (two stocking pairs or two pantyhose) are allowed per year with the permission of the National Health Insurance Program. For hygienic reasons, two pairs of stockings or pantyhose should be prescribed on the first occasion. Since sweat and ointment residues attack the elastic fibers of the hosiery, prescribing two pairs prolongs the stockings life. Medical compression hosiery that is washed and changed daily lasts considerably longer.

Compression hosiery, when properly and regularly cared for, retains its therapeutic compression effect for at least six months.

Modern Compression Hosiery

The development of modern compression hosiery, such as MEDI hosiery, has rendered the prejudice against unattractive and uncomfortable elastic stockings obsolete.

Modern compression stockings and pantyhose are made using two way stretch knitting techniques, that provides not only adjustment for slight length differences, without changing the graduated pressure, but is also elastic in all directions. The stockings, therefore, do not wrinkle.

Modern compression hosiery, such as MEDI hosiery, is so transparent that it is practically indistinguishable from normal fine fashion hosiery. MEDl's are available in fashionable colors and can be worn comfortably and confidently by the patient during leisure, work, and on social occasions. MEDI medical compression stockings are manufactured from yarn and dye colors that are hypoallergenic. The most advanced manufacturing techniques make MEDI hosiery porous to air and virtually allows the skin to breathe freely. This reduces or prevents patients from sweating, itching, etc...

The prescribing of modern compression hosiery is an important component of improved patient compliance and improved therapeutic results.

Classes of Compression

The division of compression into four classes enables the amount of applied pressure to be matched to the venous disorder of the legs.

Class 1 (20-30 mmHg)
For a feeling of heaviness and tiredness in the legs; slight varicose veins without marked edema; onset of varicosis during pregnancy.

Class 2 (30-40 mmHg)
For more marked symptoms. Varicose veins; moderate edema; marked varicosis in pregnancy; slight post-traumatic swelling; after healing of minor ulcers; after superficial venous inflammation; after sclerotherapy and varicose vein operations.

Class 3 (40-50 mmHg)
For all conditions resulting from chronic (Post-thrombotic) venous insufficiency; severe edema; white atrophy; dermatosclerosis; after healing of crural ulcers; reversible lymphedema.

Class 4 (50-60 mmHg)
For severe cases of lymphedema. Class III and By wearing two compression stockings, one over the other, the compression values are almost doubled. This fact can be useful in difficult cases - ie. in inadequate pressure of Class IV in lymphedema; immobility with difficulties putting on the hosiery and in extreme obesity.


Hosiery lengths
Below knee (calf) A - D
Above knee (mid-thigh) A - F
Thigh length A - G
Pantyhose A - M
Maternity tights A - MU


Hosiery accessories
It is extremely important for the effectiveness of any compression hosiery, that the stocking be properly fitted and worn correctly.

The stockings must neither slip down nor cut into the skin of the leg.

To prevent the hosiery from slipping, especially with patient movement, an appropriate attachment device may be prescribed.

In the past, non-elastic suspenders or garter belts were prescribed for men and women. This is still possible today, but the aesthetic sensitivity of patients currently demands other solutions. The more recent fixing of the stocking with a hypoallergenic adhesive glue or tape has been increasingly supplanted by hosiery with a non-slip silicone top band, a thigh with waist attachment stocking or pantyhose.

Also, to avoid the stocking "cutting" into the skin, it is important to follow the manufacturer's information relative to the circumference of the leg size. If this is done, then the silicone top band is the ideal attachment, especially for men, as it avoids the need to wear a men's leotard or pantyhose which may reduce patient compliance in older males.

With more conical leg shapes, the stockings can be held up by prescribing a thigh with waist attachment stocking, which attaches thigh length stockings to a waist attachment. In addition to conical shaped legs, pantyhose are particularly suitable for young women, on grounds of compliance. Pantyhose always ensure a correct graduation of pressure up to the thigh.

Compression hosiery, of whatever length, should never be "turned over" at the top, because this can cause the stocking to cut into the skin.

Made to Measure (MTM), or Ready Made Hosiery ?

An exact fit of the medical compression hosiery is essential for optimal effectiveness.

Made to measure garments should be prescribed if ready made hosiery fails to take into account:
a) Extremes of body size
b) Considerable differences in leg length
c) Partial amputations; deformed legs and/or feet
d) For pantyhose - different classes of compression needed for each leg

It should be remembered that two-way stretch hosiery compensates for slight differences in leg length. Ready made hosiery is normally adequate.

As a rule:
Made to measure garments - as many as are necessary, but not more than required.

Prescribing of medical compression hosiery

The prescribing of medical compression hosiery was regulated, in Germany, by Bulletin 5 (October 1974) of the Federal Association of Physicians Participating in Health Insurance Program and in the Guidelines of 13.7.1982.

The following details must be given when prescribing:
1) Number of hosiery garments
2) Style of hosiery required
3) Compression class according to the Indications Table
4) If necessary, mark "Made to measure"
5) If necessary, the prescribing of hosiery accessories
6) Diagnosis
7) Any additional remarks e.g. name of make, etc..

Fitting Aids.

Damage to the compression stockings can impair their functioning. Correct and careful donning of the hosiery is just as important as the right care.

The patient will find instructions for the care of the hosiery in each package or box.

The patient can and should be taught how to apply their compression stockings when they are first prescribed - if not in the doctor's office, then by the medical appliance supplier.

To avoid damage, rings, bracelets, etc., should be removed before applying the stockings. Wearing even household rubber gloves has proven useful. Finger and toenails should be short and smooth.

The medi Butler is of great assistance in donning medical compression stockings. With this aid, patients with restricted mobility or those who are considerably overweight can put on the stockings, even those of high classes of compression, easily and with almost no effort.

The Butler can be used to apply all styles of stockings. For example, with pantyhose, one leg should be pulled on as far as the calf, and then the procedure repeated with the other leg.

The medi Butler is prescribable in certain conditions and is available at most medical appliance suppliers.

medi Butler Instructions.

Place the medi Butler on a firm base.










Pull the upper edge of the stocking up over the semi-circle portion of the frame so that the inner surface of the stocking is facing outside. Continue to do this until the heel is outside the semi-circle.








Place the tip of the foot up to the heel of the stocking in the opening. Put the entire foot through the stocking and frame until the foot rests on the floor.









Gradually pull up the medi Butler and then draw it backwards away from the leg.

Drug Therapy.

A logical treatment of venous disorders with drugs is directed towards increasing the tone of the veins, accelerating venous flow, reducing venous pressure, normalizing capillary wall function and protecting against edema by the normalization of the exchange of materials in the tissue.

Drug therapy alone is of little benefit in the conservative treatment of venous disorders. Here, compression as the base therapy, is of particular importance.

Experimental studies have shown a venotonic effect with some drugs e.g. with flavonoids. Whether this experimental evidence is sufficient to alleviate subjective discomfort, to remove or even to prevent edema, is a matter of some debate.

So far, unequivocal proof of has been presented for three drugs with differing constituents. The pharmacological sites of action are different. Two important uses have meanwhile been demonstrated: First is an edema protective effect (flavonoids, rutosides, Ruscus alkaloids). This effect is produced by a sealing of the capillaries, so reducing the increased passage of fluid into the tissues that occurs in chronic venous insufficiency. The increase in venous tone is brought about by a reduction in venous blood volume and an acceleration of flow, relieving the strain on the peripheral tissues.

The undoubted efficacy of diuretics can be utilized to remove edema, but great attention should be paid to the risk of disorders of water and electrolyte imbalance and the possibility of paradoxical edema formation, e.g. through stimulation of the renin-angiotensin system. Diuretics should only be used for short periods, or intermittently if at all. They are not suitable for the prophylaxis of venous edema.

The use of drugs for thrombosis prophylaxis requires a specific indication.

The Importance of Compliance and Acceptance in the Treatment of Venous Disorders.

The aim of ambulant or in-patient therapy of venous disorders of the legs is to first treat complications, but also to introduce protective measures to prevent progression.

Of the roughly 1.2 million patients with venous leg ulcers in the Federal Republic of Germany, about one third sought medical treatment only after the ulcers became manifest.

This suggests that the majority of patients with crural ulcers - adequate patient information notwithstanding - came to serious harm during the treatment of their venous leg disorders either due to a lack of self initiative or at least, through self neglect.

The consequences are often premature incapacity for work and costs of more than DM 2.5 billion per year for the treatment of venous leg ulcers alone.

Epidemiological studies show that about 12 million Germans have varicosis of the saphenous veins requiring treatment and some 3.5 million suffer from manifest chronic venous insufficiency. The end stage of these venous disorders is venous leg ulcers. Following the treatment of existing complications, it is largely the self motivation of the patient and high compliance with the compression therapy that contribute to preventing progression to the end stage.

The care of patients with venous disorders is lifelong and requires a controlled strategy in relation to compliance.

Not every leg ulcer is venous.

Naturally, with combination of a venous disorder and ulcerative skin changes, the possible purely dermal genesis must be considered and investigated. Particularly with elderly patients, an accompanying peripheral arterial occlusive disease should first be excluded before any ulcer treatment is started, or if such disease is present, then appropriate therapy given.

In the differential diagnosis of venous leg ulcer, diseases should first be excluded before crural ulcer is diagnosed.

Unfortunately, this point is often insufficiently explored.

Measures to Improve Compliance.

A strategy to improve compliance in the treatment of venous leg disorders with the aim of preventing progression, can be broadly divided into three categories:

Education - Behavior - Organization
Educational measures primarily relate to the imparting of information and instructions.
Detailed explanations of
- Pathogenesis
- Acute symptoms
- Treatment of complications
- Prognosis in poor compliance

Desired changes in behavior
-describe risk factors and protective measures.

Risk factors:
- Lack of movement
- Contact sports and activities inducing high abdominal pressure
- Obesity
- Tight clothing
- Several pregnancies
- Heat
- Estrogens in high doses especially when combined with smoking.

Protective measures:
- Prolonged compression therapy
- Movement
- Exercises
- Elevating the legs
- Choice of occupation, change if necessary
- Orthopaedic inserts
- Cold foot/leg showers

Organizational improvements - describe possible, pleasant forms of prophylaxis and their incorporation into everyday life.
- Modern, transparent compression hosiery in fashionable colors
- Aids for fitting compression hosiery
- Individually suited sports
- Vacation planning with the possibility of walking in the right climate
- Fitness and abolition of obesity by sport and movement
- Regular walks with a partner.

Many studies have confirmed that maintenance of compliance rises with thenumber of appointments with the doctor. The monitoring of compliance, especially with compression therapy, should therefore be associated with the necessary three month or six month supply of compression hosiery. In doubtful cases, it is worth reminding the patient.

It is also important to include the patient's medical appliance supplier in the process. The supplier can be a useful source of information about new developments in this field and helpful in patient referral. Furthermore, the acceptance of this medical aid can be aided by the coordinated advice of the supplier and the doctor.

It is worth checking that symptoms have been relieved in a patient after the first prescription of compression hosiery or change in prescription (e.g. if compression class increases or decreases) once the hosiery has been worn for about 14 days and washed several times.

Properly fitted compression hosiery should not allow any edema to form more than 1 cm daily increase in circumference of a normally shaped leg.

Any pain, feeling of strain or numbness, heaviness in the legs, skin irritation or constriction during the wearing of the hosiery is indicative of poor fitting and should be corrected immediately.

Dyspnoea and anginal pain can be signs of unrecognized or inadequately treated heart disease, which becomes symptomatic through the displacement of blood from the legs into the body. In this case, a reduction in the level of compression can sometimes prove beneficial.

Particular problems are likely in patients with combined venous and arterial perfusion disorders, especially if associated neuropathy is also present. Here it is important to first determine whether haemodynamically relevant restrictions in arterial blood flow occur with the necessary class of compression. If this is the case, then hosiery with a lower applied pressure should be used or compression hosiery avoided altogether. This always applies to patients with microangiopathy and any associated neuropathy, because perfusion disorders of the skin can occur which are not detected by the patient due to the neuropathy.

Brief overview of Phlebology Conditions.

Primary Varicose Veins.

Varicosis in Pregnancy.

Insufficiency of the Perforators.

Inflammatory Venous Diseases.

Deep Vein Thrombosis. (DVT)

Venous Leg Ulcer.

Venous Angiodysplasia.

Juvenile Varicosis.

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