Hugo Partsch

Classification of Compression Bandages: Practical Aspects

BACKGROUND Compression bandages appear to be simple medical devices. However, there is a lack of agreement over their classification and confusion over the use of important terms such as elastic, inelastic, and stiffness. OBJECTIVES The objectives were to propose terms to describe both simple and complex compression bandage systems and to offer classification based on in vivo measurements of subbandage pressure and stiffness. METHODS A consensus meeting of experts including members from medical professions and from companies producing compression products discussed a proposal that was sent out beforehand and agreed on by the authors after correction. RESULTS Pressure, layers, components, and elastic properties (P-LA-C-E) are the important characteristics of compression bandages. Based on simple in vivo measurements, pressure ranges and elastic properties of different bandage systems can be described. Descriptions of composite bandages should also report the number of layers of bandage material applied to the leg and the components that have been used to create the final bandage system. CONCLUSION Future descriptions of compression bandages should include the subbandage pressure range measured in the medial gaiter area, the number of layers, and a specification of the bandage components and of the elastic property (stiffness) of the final bandage.

Neuropathy Associated with Acrodermatitis Chronica Atrophicans Clinical and Morphological Features

Neurological manifestations of Lyme borreliosis are varied but well-known in the second stage. Their usual pattern consists of painful peripheral nerve involvement such as meningopolyneuritis Garin-Bujadoux-Bannwarth (MPN-GBB), cranial nerve paresis, and meningiti~.’’.’~.~~ Sometimes encephalitis and myelitis have been o b ~ e r v e d . ~ Apart from these well-described and self-limiting neurological disorders, several cases of chronic central nervous system (CNS) disease have been attributed to Lyme borreliosis.’,’’ In most cases this association was based principally on serological findings, although this may suffer from a strong bias, as up to 32% of apparently healthy individuals may show elevated Borrelia antibody titers.” As we were looking for well-defined cases of chronic Lyme borreliosis, we concentrated our neurological investigations on patients with acrodermatitis chronica atrophicans (ACA), which is a chronic skin disorder with established borrelial etiology. However, in these patients no C N S involvement was detected. Yet, we saw a significant number of patients with peripheral neuropathy, which we are going to discuss here.

Adjustable Velcro® Compression Devices are More Effective than Inelastic Bandages in Reducing Venous Edema in the Initial Treatment Phase: A Randomized Controlled Trial

OBJECTIVE/BACKGROUND The objective of this study was to compare the efficacy and comfort of inelastic bandages (IBs) and adjustable Velcro compression devices (AVCDs) in reducing venous leg edema in the initial treatment phase. METHODS Forty legs from 36 patients with untreated venous edema (C3EpsAsdPr) were randomized to two groups. Patients in the first group received IBs (n = 20) and those in the second AVCDs (n = 20). Both compression devices were left on the leg day and night, and were renewed after 1 day. Patients in the AVCD group were asked to re-adjust the device as needed when it felt loose. Leg volume was calculated using the truncated cone formula at baseline (T0), after 1 day (T1) and after 7 days (T7). The interface pressure of the two compression devices was measured by an air filled probe, and the static stiffness index calculated after applying compression at T0 and T1, and just before removal of compression on T1 and T7. Patient comfort with regard to the two compression systems was assessed by grading signs and symptoms using a visual analog scale. RESULTS At T1, the median percent volume reduction was 13% for the IB group versus 19% for the AVCD group; at T7 it was 19% versus 26%, respectively (p < .001). The pressure of the IBs was significantly higher compared with the AVCDs at T0 (63 vs. 43 mmHg) but dropped by > 50% over time, while it remained unchanged with AVCDs owing to the periodic readjustment by the patient. Comfort was reported to be similar with the two compression devices. CONCLUSION Re-adjustable AVCDs with a resting pressure of around 40 mmHg are more effective in reducing chronic venous edema than IBs with a resting pressure of around 60 mmHg. AVCDs are effective and well tolerated, not only during maintenance therapy, but also in the initial decongestive treatment phase of patients with venous leg edema.

High Compression Pressure over the Calf is More Effective than Graduated Compression in Enhancing Venous Pump Function

BACKGROUND Graduated compression is routinely employed as standard therapy for chronic venous insufficiency. AIM The study aims to compare the haemodynamic efficiency of a multi-component graduated compression bandage (GCB) versus a negative graduated compression bandage (NGCB) applied with higher pressure over the calf. METHODS In 20 patients, all affected by greater saphenous vein (GSV) incompetence and candidates for surgery (Clinical, etiologic, anatomic and pathophysiologic data, CEAP C2-C5), the ejection fraction of the venous calf pump was measured using a plethysmographic method during a standardised walking test without compression, with GCB and NGCB, all composed of the same short-stretch material. Sub-bandage pressures were measured simultaneously over the distal leg and over the calf. RESULTS NGCBs with median pressures higher at the calf (62 mmHg) than at the distal leg (50 mmHg) achieved a significantly higher increase of ejection fraction (median +157%) compared with GCB, (+115%) with a distal pressure of 54 mmHg and a calf pressure of 28 mmHg (P < 0.001). CONCLUSIONS Patients with severe venous incompetence have a greater haemodynamic benefit from NGCB, especially during standing and walking, than from GCB.

Compression for the management of venous leg ulcers: which material do we have?:

Compression therapy is the most important basic treatment modality in venous leg ulcers. The review focusses on the materials which are used: 1. Compression bandages, 2. Compression stockings, 3. Self-adjustable Velcro-devices, 4. Compression pumps, 5. Hybrid devices. Compression bandages, usually applied by trained staff, provide a wide spectrum of materials with different elastic properties. To make bandaging easier, safer and more effective, most modern bandages combine different material components. Self-management of venous ulcers has become feasible by introducing double compression stockings (“ulcer kits”) and self-adjustable Velcro devices. Compression pumps can be used as adjunctive measures, especially for patients with restricted mobility. The combination of sustained and intermittent compression (“hybrid device”) is a promising new tool. The interface pressure corresponding to the dosage of compression therapy determines the hemodynamic efficacy of each device. In order to reduce ambulatory venous hypertension compression pressures of more than 50 mm Hg in the upright position are desirable. At the same time pressure should be lower in the resting position in order to be tolerated. This prerequisite may be fulfilled by using inelastic, short stretch material including multicomponent bandages and cohesive surfaces, all characterized by high stiffness. Such materials do not give way when calf muscles contract during walking which leads to high peaks of interface pressure (“massaging effect”).

Practical Aspects of Indirect Lymphography and Lymphoscintigraphy

The objective of this presentation is to discuss practical issues related to the use of indirect lymphography and lymphoscintigraphy in the differential diagnosis of lymphedema. Indirect lymphography demonstrates the filling of initial lymphatics and of lymph collectors. Lymphoscintigraphy is utilized to generate morphological and functional imaging information about the lymphatic drainage. For the functional evaluation of lymphatic drainage, quantitative measurement of the lymph node uptake can be performed. The practical implications of these diagnostic interventions are discussed.

Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs-UIP consensus document. Part II. Anatomy

OBJECTIVES Duplex ultrasound investigation has become the reference standard in assessing the morphology and haemodynamics of the lower limb veins. The project described in this paper was an initiative of the Union Internationale de Phlébologie (UIP), The aim was to obtain a consensus of international experts on the methodology to be used for assessment of anatomy of superficial and perforating veins in the lower limb by ultrasound imaging. DESIGN Consensus conference leading to a consensus document. METHODS The authors performed a systematic review of the published literature on duplex anatomy of the superficial and perforating veins of the lower limbs; afterwards they invited a group of experts from a wide range of countries to participate in this project. Electronic submissions from the authors and the experts (text and images) were made available to all participants via the UIP website. The authors prepared a draft document for discussion at the UIP Chapter meeting held in San Diego, USA in August 2003. Following this meeting a revised manuscript was circulated to all participants and further comments were received by the authors and included in subsequent versions of the manuscript. Eventually, all participants agreed the final version of the paper. RESULTS The experts have made detailed recommendations concerning the methods to be used for duplex ultrasound examination as well as the interpretation of images and measurements obtained. This document provides a detailed methodology for complete ultrasound assessment of the anatomy of the superficial and perforating veins in the lower limbs. CONCLUSIONS The authors and a large group of experts have agreed a methodology for the investigation of the lower limbs venous system by duplex ultrasonography, with specific reference to the anatomy of the main superficial veins and perforators of the lower limbs in healthy and varicose subjects.

Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part I. Basic principles.

OBJECTIVES Duplex ultrasound investigation has become the reference standard in assessing the morphology and haemodynamics of the lower limb veins. The project described in this paper was an initiative of the Union Internationale de Phlébologie (UIP). The aim was to obtain a consensus of international experts on the methodology to be used for assessment of veins in the lower limbs by ultrasound imaging. DESIGN Consensus conference leading to a consensus document. METHODS The authors invited a group of experts from a wide range of countries to participate in this project. Electronic submissions from the experts were made available to all participants via the UIP website. The authors prepared a draft document for discussion at a UIP Chapter meeting held in San Diego, USA in August 2005. Following this meeting a revised manuscript was circulated to all participants and further comments were received by the authors and included in subsequent versions of the manuscript. Eventually all participants agreed to the final version of the paper. RESULTS The experts have made detailed recommendations concerning the methods to be used for duplex ultrasound examination as well as the interpretation of images and measurements obtained. This document suggests a methodology for complete assessment of the superficial and perforating veins of the lower limbs, including recommendations on reporting results and training of personnel involved in these investigations. CONCLUSIONS The authors and a large group of experts have agreed to a methodology for the investigation of the lower limbs venous system by duplex ultrasonography.

Reticulate eruptions: Part 2. Historical perspectives, morphology, terminology and classification.

Reticulate eruptions of vascular origin may represent an underlying arterial, venous, microvascular or combined pathology. In the presence of arterial pathology, individual rings are centred around ascending arterial vessels that supply the corresponding area of skin within an arterial hexagon that clinically presents with a blanched centre. Confluence of multiple arterial hexagons generates a stellate (star‐like) pattern. In the presence of a primary venous pathology, individual rings correspond to the underlying reticular veins forming multiple venous rings. Focal involvement of a limited number of vessels presents with a branched (racemosa) configuration while a generalized involvement forms a reticulate (net‐like) pattern. ‘Livedo’ refers to the colour and not the pattern of the eruption. Primary livedo reticularis (Syn. cutis marmorata) is a physiological response to cold and presents with a diffuse blanchable reticulate eruption due to vasospasm of the feeding arteries and sluggish flow and hyperviscosity in the draining veins. Livedo reticularis may be secondary to underlying conditions associated with hyperviscosity of blood. Livedo racemosa is an irregular, branched eruption that is only partially‐blanchable or non‐blanchable and always signifies a pathological process. Retiform purpura may be primarily inflammatory with secondary haemorrhage or thrombohaemorrhagic, as seen in disseminated intravascular coagulopathy.

Reticulate eruptions. Part 1: Vascular networks and physiology

Reticulate pattern is one of the most important dermatological signs of a pathological process involving the superficial vascular networks. Vascular malformations, such as cutis marmorata congenita telangiectasia and benign forms of livedo reticularis, and sinister conditions, such as meningococcal meningitis or Sneddons syndrome, can all present with a reticulate pattern. The clinical presentation and morphology is determined by the nature and extent of the underlying pathology and the involvement of a particular vascular network. This review has been divided into four instalments. In the present paper, we discuss the anatomy and physiology of the complex network of vascular structures that support the function of the skin and subcutis.