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The venous and lymphatic systems are mutually complimentary and interdependent.
If either system loses normal functionality (chronic venous insufficiency [CVI] or lymphoedema), it creates additional pressure either burdening or overloading the other system. These systems are inseparable, overload of either system allows the other system to play an auxiliary role of fluid return via functional anastomosis. Phlebolymphoedema represents a combined condition of CVI and lymphatic insufficiency most often caused post deep vein thrombosis (DVT) or localised tissue damage such as a leg ulcer, which results in organic damage of lymphatic collectors.
Phlebologic indications are caused by incompetent venous valves. When venous valves weaken, blood can flow backwards and increase the pressure in the peripheral venous system, known as venous hypertension. If venous hypertension is sustained over time, the vein walls stretch, and the valves can’t close. This further increases hypertension, which can lead to swelling, discomfort and varicose veins. If symptoms are not addressed, chronic venous insufficiency can develop.
Chronic venous disease (CVD) refers to other chronic conditions related to or caused by veins that become diseased or abnormal.
These problems can include varicose veins and spider veins, leg swelling and leg pain, chronic venous insufficiency, post-thrombotic syndrome, leg ulcers and vascular malformations.
Compressive leg garments are part of the management strategy of CVD.
In lymphology, compression garments are used in the treatment of lymphatic diseases, the primary target being to remove and keep lymphatic fluid away from the extremities. In phlebology, compression garments are used in the treatment of vascular diseases, the primary target being to enhance and keep up venous blood flow.
Gradient compression reduces swelling and helps prevent the pooling of fluid in the venous or lymph systems and in the interstitial spaces. This results in a clinically proven improvement to the venous and lymph fluid return, thus providing beneficial effects for persons with oedema or venous disease.
Gradient compression garments work by increasing the tissue pressure to help balance the flow of fluid across the capillaries of the limb, which helps to reduce swelling. Compression garments are engineered to counteract the effects of hydrostatic pressure by applying the greatest pressure in the lower leg and decreasing up the leg correlating to the decreasing venous pressure. The compression level is measured in millimetres of mercury (mmHg).
Working pressure/resting pressure
When a short stretch compression bandage is applied to the lymphedematous limb it supports the tissues without ‘squeezing’ because its fabric does not contain elastic materials.
This means that the bandage is not capable of shortening around the limb after application and is therefore not exerting ever-increasing pressure during inactivity.
This dynamic is called resting pressure and is considered safe and comfortable for long-term treatment.
Conversely, the stability of the bandage creates a very high resistance to stretch when pressure is applied through internal muscle contraction and joint movement.
This force is called working pressure.
The multi-layering of these bandages creates a soft ‘cast-like’ environment which fully resists these forces and further prevents refilling of evacuated lymph fluid. Additionally, the exercise regimen prescribed for each patient is maximised by this working pressure as these forces promote further lymph removal.
Common indications for compression
Accurate compression is important for a wide range of vascular disorders:
- Minor to severe varicosities
- Severe oedema
- Lymphatic oedema
- Tired, aching legs and minor swelling
- Post thrombotic syndrome
- Orthostatic hypotension
- Superficial thrombophlebitis.
The therapy phase of compression therapy does the following:
- Reduces oedema
- Softens lipodermatosclerosis
- Heals ulcers
- Reduces inflammation
- Reduces pain (phlebitis and deep vein thrombosis).
Inelastic or short-stretch bandages are preferred.
The maintenance phase is used to:
- Keep extremity free of oedema
- Prevent skin changes
- Prevent ulcer recurrence
- Prevent inflammation and pain
- Reverse skin discolouration and fibrosis in early CVI (hemosiderin staining)
Elastic material (eg stockings) is sufficient in most cases.
Differences between short and long stretch compression garments
In long-stretch compression, compression continues 24/7 and comes from the outside. There is no effect on deep lymphatics. They deliver low working pressure and high resting pressure. They offer permanent compression and need to be taken off at night and reapplied in the morning.
Short stretch garments have high compression when the patient is in action and lighter compression at rest. Compression comes from the inside, with the activation of the muscle pump. There is an effect on deep veins. They deliver high working pressure and low resting pressure. The muscles inside work against the compression device. Every 24 hours reapplication is recommended. Short-stretch bandages are most used in CVD Management especially when it comes to oedema management.
In zinc paste bandages, once dried, they have semi-rigid properties, providing an extremely high working and low resting pressure. They are highly efficient in oedema reduction. Every 24 hours reapplication is recommended.
In multi-layer systems, the combination delivers high working pressure and low resting pressure. The muscles inside ‘work’ against the system. They offer up to seven days’ wear at a time.
Aims of bandaging
The aim of bandages are:
- To encourage fluid to move from the base of the limb to the correct drainage areas
- To prevent the accumulation of lymph in the tissues
- To improve limb shape
- To improve skin condition
- To provide muscles with an outer casing.
They work by reducing ultra-filtration and enhancing muscle pumps. This prevents re-accumulation of lymph. They reverse fibrosis/skin changes, stop lymphorrhoea, enhance venous flow to promote wound healing.
In multilevel lymphatic bandaging, the pressure reduces by 25%-50% after two hours. Due to the reduction in pressure, bandages should be reapplied daily. The very high pressure of the bandages is absolved and dissipated by the padding layer. Bandaging continues until no further reduction of the limb is obtained.
Compression is altered by:
- Sub-bandage pressure is directly proportional to bandage tension. When stretching increases, compression increases. The higher the circumference, the lower the compression. Adding padding under bandage reduces compression
- The width of the bandage affects compression. 10cm wide bandage applied with the same stretch as 5cm wide bandage will apply half pressure (force is distributed over twice the area)
- The number of layers affects compression. Applying two layers of a bandage will double the pressure.
Compression treatment is absolutely contraindicated in the case of insufficient arterial perfusion, in the case of ankle-brachial pressure index lower than 0.5. Always refer these cases to vascular surgeons.
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