Managing patients with chronic venous disease (CVD) remains one of the most challenging tasks for a health care professional. This condition presents with multiple manifestations with various degrees of severity. If untreated, CVD tends to progress to dermatosclerosis and skin ulcers, which are not only difficult to heal but also hard to prevent from recurring. For centuries, compression therapy was the main and, in many cases, the only therapeutic modality for long-term management of patients with CVD. Recently, venous interventions became an effective treatment for superficial and deep venous diseases, showing benefits for patient quality of life and symptom relief as well as for ulcer healing and prevention of ulcer recurrence. The role of compression therapy has become questionable and frequently challenged. Increasing controversies in the medical literature related to compression therapy have created confusion among practitioners and unfortunately resulted in less than optimal outcomes for some patients.
The major challenge for defining the appropriate place for compression therapy in the management of CVD is the lack of high-level evidence. Since compression therapy continues to be the standard of care, conducting new randomized trials is ethically and methodologically difficult. In such situations, evidence-based guidelines may be helpful in guiding the care of patients and clarifying the strength of the evidence supporting certain uses of compression. Recently published multisocietal practical guidelines for compression therapy after invasive treatment of superficial veins of the lower extremities1 serve exactly this purpose.
Developed by a multispecialty group of experts, these guidelines1 followed the same methodology as the previous venous ulcer guidelines from the American Venous Forum (AVF) and the Society for Vascular Surgery (SVS).2 Systematic analysis of the literature showed that the level of evidence varies depending on a question, and the strength of recommendations in many cases is based on the best practice. These guidelines1 make 7 recommendations, divided into 4 sections, based on 3 modalities of intervention. The modalities are thermal ablation or stripping of saphenous veins (including the necessity of compression and how long it should be used), sclerotherapy, and superficial interventions in the presence of venous ulcer.
For the management of patients with venous ulcers, the guidelines recommend compression therapy over no compression therapy to increase venous leg ulcer (VLU) healing rates and decrease the risk of ulcer recurrence; this is based on grade 1, B-level of evidence literature.2,3 For patients with mixed arterial ulcers and VLUs, they2,3 suggest limiting the use of compression to patients withan ankle-brachial index exceeding 0.5 or if absolute ankle pressure is > 60 mm Hg. This additional recommendation is based on grade 2, C-level of evidence literature.1,2
These recommendations, along with the entire multisocietal document,1 need to be considered in the right context. These guidelines specifically focus on the role of compression therapy as it relates to procedure outcomes. Comprehensive management of any patient with CVD neither starts nor ends with venous intervention. Currenly, CVD is an incurable disease, and any treatment can only alleviate symptoms and slow the disease’s progression; it cannot make a patient disease-free. In other words, any intervention should be viewed only as one of the many components of a comprehensive treatment plan. This does not mean venous intervention should be used for inappropriate patients at inappropriate times. However, to limit the role of compression therapy to only procedure-related short- and medium-term outcomes would be a mistake. The AVF-SVS Venous Ulcer Guidelines2 state specifically that compression therapy is recommended for all ulcer patients but also give this recommendation a score of grade 1 based on the highest level of evidence (A). It is important to mention that patients with healed ulcers (C5 of CEAP [Clinical, Etiology, Anatomy, Pathophysiology] classification) should be included in the terminology “patient with venous ulcers.” Without continuous, life-long compression therapy, half of venous ulcers will recur4; venous intervention can only reduce this recurrence rate, though it cannot eliminate the prospects of recurrent ulceration.
The same logic should be applied to the management of patients with venous edema. Venous intervention can reduce swelling by a substantial degree in some patients. However, the majority, if not all, of these patients need continuous compression to maintain these results. Even for some patients with simple varicose veins, compression therapy should continue indefinitely, not because it may improve the outcomes of venous procedures, but because of the nature and natural history of CVD.
Practicing evidence-based medicine means the clinical decision process is based on integration of all knowledge modalities, including relevant basic science, socioeconomic factors, and an understanding of patient preferences. Practical guidelines help to understand when and why certain decisions should be made but do not replace clinical judgement. Deciding whether to recommend compression therapy after venous intervention should follow the same principles. Taking consideration of the pathophysiology of venous disease and the known mechanisms of compression therapy, it is clear most patients with CVD can benefit from compression therapy. Despite the lack of high-level clinical evidence for some aspects of compression therapy, the overall theme of the latest multisocietal guidelines1 is that using compression therapy after venous procedures remains the best practice. n
Fedor Lurie is Associate Director of Research, Education and Vascular Laboratory at Jobst Vascular Institute, Promedica, Toledo, OH, and Adjunct Research Professor at the University of Michigan, Ann Arbor. These guidelines were part of a collaborative effort by the Society for Vascular Surgery.
1. Lurie F, Lal BK, Antignani PL, et al. Compression therapy after invasive treatment of superficial veins of the lower extremities: clinical practice guidelines of the American Venous Forum, Society for Vascular Surgery, American College of Phlebology, Society for Vascular Medicine, and International Union of Phlebology. J Vasc Surg Venous Lym Dis. 2019;7(1):17-28.
2. O’Donnell TF Jr, Passman MA, Marston WA, et al; Society for Vascular Surgery, American Venous Forum. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery® and the American Venous Forum. J Vasc Surg. 2014;60(2 Suppl):3S-59S.
3. Ubbink DT, Santema TB, Stoekenbroek RM. Systemic wound care: a meta-review of Cochrane systematic reviews. Surg Technol Int. 2014;24;99-111.
4. Marston WA, Carlin RE, Passman MA, Farber MA, Keagy BA. Healing rates and cost efficacy of outpatient compression treatment for leg ulcers associated with venous insufficiency. J Vasc Surg. 1999;30(3):491-498.