To excel in phlebology, the physician must understand the basic concepts of compression, including physiologic effects, common terms, rationale for the use of compression in the prevention and treatment of varicose and telangiectatic veins, as well as the rationale and use following sclerotherapy, ambulatory phlebectomy, and endovenous ablation. Although modern compression stockings have been an invention of twentieth-century medicine, the concept of compression for varicose veins dates back to antiquity. Compression therapy for treatment of venous disease was mentioned in the Old Testament (Book of Isaiah, chapter 1, verse 6).1 Roman soldiers noted that the application of tight bindings to the legs could reduce leg fatigue. In the late 1700s, Theden used modified lace-up dog leather stockings, originally described by Fabrizio d’Aquapendente (1537–1619), in the treatment of varicose veins of pregnancy.
Nelson Goodyear developed elastic medical compression bandages and stockings, made possible by the invention of vulcanization in 1842. Rubber harvested from the rain forests of Brazil was turned into elastic threads to weave stockings. Although uncomfortable, stockings made from rubber threads were utilized until Jonathan Sparks patented a method for winding silk and cotton around the rubber threads. This allowed more widespread use of elastic compression.2
As technical advances in the manufacturing process were made during the late 1800s and early 1900s, ultrafine rounded latex yarns (particularly with the later advent of circular-knitting versus flat-knitting techniques) became available that permitted the construction of modern compression stockings. Two-way stretch stockings were then developed. Rubberless compression stockings became available with the development of synthetic elastomers in the 1960s, giving rise to the modern seamless, relatively comfortable compression hose available today.
Normal force generated within the venous system by muscle contraction is additive with external applied pressure (Table 15-1). This augmentation of the calf-muscle pump occurs by external application of graduated compression and increases the return flow upward from the leg.3 In ambulatory patients with superficial venous insufficiency, improvement can be demonstrated with graduated compression stockings with an ankle pressure of as little as 18 mmHg.4 After 90 days of elastic compression with a 30- to 40-mmHg graduated compression stocking, patients with cutaneous manifestations of venous stasis demonstrate noteworthy improvements in the structural pattern of dermal connective tissue.5 Compression reduces the edema which separates the skin and dermal tissues from direct contact with the superficial capillary network as this edema resides primarily in the papillary dermis.6
TABLE 15-1Physiologic Effects of Compression |Favorite Table|Download (.pdf) TABLE 15-1 Physiologic Effects of Compression
Mechanically externally enhances the calf-muscle pump
Diverts flow into competent veins by closing incompetent superficial veins
Makes incompetent valves work by decreasing diameter between leaflets of valves in varicose veins
Reduces edema which separates the skin from capillaries
Augments lymphatic flow