Compression stockings with a negative pressure gradient have a more pronounced effect on venous pumping function than graduated elastic stockings

Mosti G, Partsch H. Eur J Vasc Endovasc Surg. 2011;42:261-266.

Reviewed by: Attila Puskás, Targu Mures, Romania

ABSTRACT

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The objective of this experimental study was to measure the effect on the venous pumping function of a new type of stocking that provides a negative pressure gradient from the ankle to the calf (called inversely graduated or progressive elastic compression stockings [PECS]) in comparison with a conventional graduated elastic compression stocking (GECS) in patients with chronic superficial venous insufficiency stages C2 to C5.

These new PECS stockings, which provide a higher compression pressure over the calf than over the ankle, were reported to have beneficial effects for the practice of sports,¹ as well as in venous disease patients,² by providing a similar improvement in subjective symptoms than that provided by conventional stockings, albeit with better compliance. However, the impact of PECS on venous hemodynamics in venous disease patients had never been investigated before this study.

A total of 30 patients with chronic venous disease clinical stages C2 to C5 and presenting with significant reflux in the great saphenous vein due to terminal or preterminal valve incompetence, were enrolled in the study. Good joint mobility was also part of the inclusion criteria. Two types of knee-length elastic stockings exerting a pressure ranging from 15 to 25 mm Hg at the ankle were applied in a randomized order to the leg for which varicose vein surgery was planned. The standard stocking exerted a higher pressure at the ankle and a “degressive” pressure gradient at calf level (GECS). In contrast, the PECS stocking exerted a lower pressure at the ankle and was designed to exert a 50% higher pressure at calf level than that at the ankle, thus providing a negative, “progressive” pressure gradient. The pressure of each garment was measured continuously at two sites of the leg (B1 point: about 12 cm proximal to the inner ankle; C point: at the maximum calf circumference) using the Picopress device. Using strain-gauge plethysmography, ejection fraction (EF) was assessed following the method described by Poelkens et al.³ As shown in previous reports, this method can be used to assess the hemodynamic efficacy of several compression products in a noninvasive manner. Since the measurements were repeated on the same individual without changing the detector, a satisfactory reproducibility was achieved, as in previous experiments.³

The study was conducted in accordance with the guidelines for clinical studies with compression devices.⁴

The results of this study showed a significant increase in EF with both GECS and PECS (44.5% with GECS, and 52.5% with PECS). There was a positive correlation between EF and the standing and peak pressure in the calf area (C point) but not in the ankle area (B1 point). This means that the significantly higher pressure achieved by the PECS stocking over the calf is significantly more effective than lower pressure in improving a disturbed venous pumping function. An explanation for this phenomenon would be that the greater external compression exerted by PECS over the calf increases the pressure exerted on local veins during muscle systole, so that the great amount of blood pooled in the calf will be squeezed out more effectively than that of the ankle area, which is receiving lower compression. Some investigations have demonstrated that during walking there are phases when proximal intravenous pressure is higher than distal intravenous pressure, and that a continuous intravenous pressure gradient is not a general physiological principle.⁵

If the results of this study were to be validated in a larger number of patients, this would surely result in a change in the manufacturing standards of stockings. On the other hand, further studies are needed to clarify the potential benefit of PECS stockings in thromboprophylaxis, lymphedema reduction, and the prevention of deep venous damage following DVT.

References:
1. Garreau C, Pibourdin JM, Nguyen Le C, Boisseau MR. Elastic compression in golf competition. J Mal Vasc. 2008;33:250-251.
2. Couzan S, Assante C, Laporte S, Mismetti P, Pouget JF. Booster study: comparative evaluation of a new concept of elastic stockings in mild venous insufficiency. Press Med. 2009;38:355-361.
3. Poelkens F, Thijssen DH, Kersten B, Schreuwater H, van Laarhoven EW, Hopman MT. Counteracting venous stasis during acute lower leg immobilization. Acta Physiol. 2006;186:111-118.
4. Rabe E, Partsch H, Junger M. Guidelines for clinical studies with compression devices in patients with venous disorders of the lower limb. Eur J Vasc Endovasc Surg. 2008;35:494-500.
5. Stranden E, Ogreid P, Seem E. Venous pressure gradients in patients with chronic venous disease. Phlebology. 1986;1:47-50.