To compress or not to compress: The eternal question of the place of compression after endovenous procedures

The management of varicose vein disease has witnessed a dramatic transformation over the past decade. Surgery for this common condition, long considered the ‘gold-standard’ treatment, has gradually been replaced by endothermal ablation and ultrasoundguided foam sclerotherapy (UGFS). These minimally invasive techniques have allowed a more rapid improvement in patients’ quality of life and return to normal activities. The focus on enhancing patients’ experience even further has led to the introduction of newer, non-thermal, non-tumescent (NTNT) technologies. These completely obviate the need for uncomfortable thermal ablation and tumescent infiltration with possibly a similar level of efficacy as radiofrequency ablation (RFA) and endovenous laser ablation (EVLA) in the short term. The next potential area where a substantial difference in the management of varicose veins can be made is the use of compression therapy following endovenous ablation. It is widely believed that compression reduces post-operative swelling, haematoma formation and pain following surgery for varicose veins, but no irrefutable evidence exists. Edwards et al. surveyed the members of the Vascular Society of Great Britain and Ireland and found that 75% used either elastic or non-elastic bandages post-operatively, with 77% changing to compression stockings afterwards. There was a high variability with respect to the length of time the bandages and stockings were worn for. Another questionnaire survey of the members of the same society demonstrated that following endothermal ablation, 87% of responders stated that they used compression stockings and 60% used bandages. Similar numbers used compression stockings and bandages after foam sclerotherapy. Once again, however, there was marked inconsistency in the length of time these were prescribed for. Bakker et al. carried out a randomised controlled trial looking at the use of compression stockings for two days compared to seven days following EVLA of the great saphenous vein (GSV). At one week, the physical function, vitality and pain score was significantly better in the seven-day compression group. By 6 weeks though, there were no major differences between the two groups. Elderman et al. also looked at the effect of compression stockings post-EVLA of the GSV. Patients were randomised to receiving either compression stockings or no stockings. Those in the no compression group had significantly worse pain scores up to seven days and used analgesia more frequently than the group randomised to compression. These two studies appear to indicate a benefit in the short term of compression therapy in patients undergoing EVLA, but are limited by the considerable dropouts in both studies (40 patients of the original 109 approached in the Bakker et al. study and 32 patients from Elderman et al. trial). The role of compression therapy followingUGFS has also been investigated. Hamel-Desnos et al.conducted a randomised study looking at the use of compression stockings post-foam sclerotherapy. Class 2 compression stockings (pressure exerted: 15–20mmHg) were used. No significant differences were found in the pain scores, inflammation, ecchymosis, induration, pigmentation or matting at 14 and 28 days. Compliance was an issue with only 40% of patients wearing compression stockings everyday. Due to the relatively small sample size (60 patients in total), the study may not have been powered sufficiently to enable detection of a significant difference between the groups. O’Hare et al. evaluated the use of compression bandaging for 1 and 5 days in patients having UGFS followed by TED stockings for two weeks. At the six-week point, no significant differences were noted in the