Compression garments

Chronic or recurrent lymphedema or phlebedema as well as chronic venous hypertension or chronic venous insufficiency are indications for individually tailored compression garments. In addition, compression serves to reduce the volume of the venous malformation, thereby reducing localized intravascular coagulation and the incidence of thrombophlebitis, while at the same time reducing pain and the feeling of heaviness and pressure, especially in the lower extremities.

Thus, from a medical point of view, wearing a compression garment is indicated for almost all patients with venous and lymphatic malformations as well as arteriovenous malformations, especially of the lower extremities. Compression and simultaneous exercise are particularly effective.

In practice, it is usually sufficient to wear the compression garment only during the day, as the hydrostatic pressure on the lower limb is significantly lower at night when lying down, even without compression.

It is especially important for patients to wear compression garments when they need to stand or sit for long periods of time without being able to move, or when the body is under heavy physical strain.

Good skin care and skin hygiene must be ensured at the same time, since even an optimally fitted compression garment is a mechanical strain on the skin.

The following concomitant diseases are considered contraindications for compression, but these must be discussed in detail in each individual case.

Absolute contraindication:

• Acute infections and inflammation
• Extremely poorly perfused (ischemic) extremity
• Open skin areas and wounds

Relative contraindication:

• Heart failure (due to redistribution of blood volume)
• Arterial hypertension
• Extra-anatomic arterial bypass (subcutaneously guided)
• Advanced peripheral polyneuropathy or other forms of hypoesthesia
• Malignant edema

Especially in patients with vascular anomalies and possibly accompanying soft tissue hyperplasia, who often have asymmetric or abnormally configured extremities, an individually tailored compression product is obligatory in order to:

• obtain an optimal, homogeneous compression effect at each individual site.
• increase therapy compliance through better adaptation and wearing comfort.
• achieve individually different compression effects at different points of the same extremity if necessary.
• reduce skin damage at sensitive areas (back of the knee, back of the foot)

For this purpose, an exact measurement of the patient's individual limb has to be made using a measurement chart. This chart must always be updated before a new compression product is manufactured. The exact, thorough and competent measurement of the individual limb is the most important basis for appropriate therapy. Incorrectly fitted compression garments are worse than none at all. Presentation of the current measurement chart to the attending physician is also an important diagnostic tool and documents the patient’s long-term progress by providing objective numbers on the increase or decrease in circumference.

A basic distinction is made between circular-knitted (seamless) and flat-knitted (slightly harder and with a seam) compression garments.

Circular-knitted compression stockings are mainly used for venous malformations and are technically produced with the same number of stitches over the entire length but with different stitch sizes. They are highly stretchable (stockings with elastic fibers) and normally have a lower working pressure than flat-knitted compression stockings.

Flat-knitted compression stockings contain a seam and are stitched evenly row by row. The number of stitches varies, not the stitch size. Their advantage is their very good individual adaptability to very variable body shapes. The parts of the stocking are produced individually, then sewn together. The material has very little stretch (stockings without elastic fibers) and has a higher working pressure on the tissue. They are therefore used for very individual body shapes and when high compressive pressure is required, such as lymphatic malformation, large extremities or fatty tissue hyperplasia. Compression garments for difficult situations are usually made in flat-knit fabric, but require a perfect fit.

The material of the compression garment should fit the individual body contours as closely as possible and not cause locally increased pressure or skin irritation when worn. Particularly vulnerable areas are the back of the knee, the elbow and the back of the foot or instep. If the skin chafes here, the compression garment must be corrected. Special care should also be taken if the seams in the compression garment are too bulky, as they must not put too much strain on the skin.

The appropriate compression class must be selected by a physician according to clinical criteria. This is particularly important for children, as compression can also influence body growth. It is usually somewhat higher (stronger compression) in lymphedema than in phlebedema. The following table gives an overview of the compression classes and respective indications for vascular anomalies.

In children, especially as they grow, the compression class selected must be slightly lower than in adults. This is because the hydrostatic pressure is somewhat lower, especially in the lower extremities, due to their shorter body length, and because physiological soft tissue growth should not be hindered during growth.

However, permanent significant long-term compression in growing children can also help to reduce or even reverse disproportionate tissue hyperplasia and even enlargement of limb circumference to a lesser extent. This therapy must be very closely monitored by physicians.

In addition, a somewhat higher compression effect (and thus compression class) should be chosen for the lower extremity than the upper extremity because of the higher hydrostatic pressure caused by gravity when the person is in an upright position.

A deep, subfascial intramuscular malformation (usually venous) is more difficult to compress effectively than a superficial one and therefore requires a higher compression class, since the compression pressure decreases with the increasing depth of the lesion.

Basically, if compliance is expected to be or actually is poor, a slightly lower compression class that is easier to wear is preferable to a compression garment with a higher compression class that is not worn at all and remains in the drawer. Explaining the necessity and practical application of the compression garment further increases therapy adherence. Appropriate simple technical dressing aids are helpful and should always be included, especially with higher compression classes.

An important principle when prescribing individually tailored compression products is the circumference or dimension of the body regions to be compressed:

• The compression must start far distally and extend beyond the most distal end of the malformation. Otherwise, this will lead to a constriction effect, especially on toes/foot or finger/hand with increased congestion. Finger gloves or toe caps are helpful here.
• If the toes themselves or the fingers are not congested, one can try to leave them free of compression. This greatly increases wearing comfort and thus also compliance. However, attention should be paid to possible constrictions.
• The proximal end of the compression must be more proximal than the most proximal extension of the lymphatic or venous malformation (principle: compression length greater than length of disease extension). The upper end of the compression must therefore be above the top end of the lesion.
• If the compression garment is too short and does not completely enclose the lesion over its full length,  there is a ballooned, squeezed enlargement of the protruding, non-compressed portion of the malformation with increased swelling there and also worsening of the symptoms.
• If fingers or toes have to be included in the compression, an individually tailored, two-piece custom-made glove with a separate foot and toe part (toe cap) or a separate glove with finger parts has proven to be a good choice, as these significantly increase wearing comfort and compression accuracy and also make the garments much easier to put on. On a disfigured foot, individual toes caps can be customized. On the fingers, omitting compression on the fingertips is often felt to be a relief, if this is possible.

In practice, it may be necessary to compress an entire body quadrant in patients with larger vascular anomalies, especially with accompanying soft tissue hyperplasia such as in Klippel-Trénaunay syndrome, when the buttocks or genitals are involved. This can be done, for example, with so-called one-legged trousers, in which one leg is completely compressed together with compression pantyhose, while the other healthy leg is kept short (“Bermuda section”) without a compression effect on the unaffected extremity.

The local compression effect can be further increased in certain circumscribed manifestations of vascular malformations (e.g. venous blow-out aneurysm or circumscribed epifascial lymphatic malformation) by the precise incorporation of a precisely fitted compression pad at a certain location. This is often particularly valuable at the knee, ankle or foot. However, the requirement for accuracy of fit must be considered particularly important, as there is also a greater risk of a pressure sore at these points.

The necessity of wearing the compression garment must be explained exactly to the patient. The following instructions must be given: When and in which situations this is particularly important (e.g. when sitting and standing for long periods without exercise). If the garment is worn consistently, the symptoms may improve and further complications can be prevented.

Parents of affected children, in particular, also require special education. It is actually a well-meaning intention of these parents to protect their child from possible restriction of freedom, mobility or quality of life by the compression garments. In this case, appropriate education about the positive acute and prophylactic long-term effects for the child is helpful. The children themselves quickly realize that adequate compression leads to less pain as well as less pressure and heaviness and a longer walking distance. Therefore, if the indication is correct, children will soon be able to wear their compression garments all by themselves.

However, there are many reasons for not wearing the compression garments, as this diagram shows.

Prescribing the individually customized compression products required for these special patients sometimes leads to problems in practice, as these custom-made products are relatively expensive and usually require additional payments from the patient. In the case of vascular anomalies, however, there is a clear medical indication for these custom-made products.

According to the current interpretation of the social legislation in Germany, statutory health insurance entitles every patient to two new pairs of individually customized compression garments every six months. The costs of insufficient compression exceed the costs of adequate compression therapy in the long term because of complications and deterioration of the clinical picture. From a medical point of view, the compression effect of even a very good compression material decreases significantly after 3 to 4 months, and so does the medical effect. Patients who have to apply compression permanently during the day must also be able to change their compression garment for hygienic reasons in order to wash it. If problems arise with the prescription and costs, a medical expert opinion on the necessity of adequate compression is often required.

For children, their continual growth in body length must also be taken into account, which requires short-term size changes.

If the compression garment has holes or cracks (often in very mobile children), is too dirty and cannot be cleaned (cave: risk of infection/erysipelas) or the compression effect has visibly decreased, an earlier re-prescription (even before 6 months have elapsed) is necessary.