Common comorbidities in compression therapy for chronic venous disease: a challenge for the feet
The Bonn Vein Study shows that the probability of chronic venous disease increases with age (98 percent of people over 60 have changes in the venous system).1 Basic therapy is medical compression in combination with exercise.
At the same time, the likelihood of comorbidities such as diabetes mellitus (with possible polyneuropathy = PNP) or peripheral arterial disease, increases with age. Both comorbidities are considered risk factors in the S2k guideline "Medical Compression Therapy" or - depending on their severity - even contraindications for compression therapy.2 Therefore, special caution is required here.
Contraindications in the case of certain comorbidities
Type 2 diabetes mellitus (approximately 20.5 percent of people over 60 years of age3) can lead to damage to the peripheral nervous system: diabetic polyneuropathy. This is distally accentuated and leads in stocking-shaped spread to sensory deficits. Among other things, sensory disturbances such as numbness and insensitivity to pressure and pain occur. Patients can then no longer perceive foreign objects, for example a small stone in the shoe or folds of an incorrectly fitted stocking. Therefore, the perfect fit of the medical compression stocking (MCS) is of particular importance here. In the case of diabetic foot syndrome (DFS) with acute lesion / ulceration, compression therapy with MCS is not possible.2
In the advanced stage, peripheral arterial disease represents the classic contraindication for compression therapy. External pressure can additionally impair the lack of arterial blood flow. However, this applies explicitly to the severe manifestation, for example if one of the following parameters applies:2
- ABPI < 0.5 (ankle-brachial pressure index),
- Ankle artery pressure < 60 mmHg,
- Toe pressure < 30 mmHg, or
- TcPO2 < 20 mmHg at the dorsum of the foot.
Compression therapy also possible in certain comorbidities after risk-benefit analysis
Although mild or moderate peripheral arterial occlusive disease (ABPI < 0.9 and > 0.5) are risk factors for compression therapy, compression can be performed if the expected benefit outweighs the potential harm (risk-benefit analysis).2 This form of peripheral arterial disease (Fontaine stage I - II or Rutherford category 1 - 3) affects approximately 21 percent of people over 65 years of age.4
In addition, peripheral arterial disease can lead to functional and structural changes in the skin and soft tissue due to the lack of supply: soft tissue atrophy. As the tissue recedes, the important protective and cushioning function on the foot is lost, and bony prominences become more prominent, increasing the risk for critical pressure points.
A medical compression stocking must also meet special requirements for these patients. Frequently, these two comorbidities - diabetes mellitus and peripheral arterial disease - are also associated.
Specific challenges in patients with PAD and / or diabetes mellitus:
- general tissue atrophy
- trophic disorders of the skin
- sandpaper-like hyperkeratosis
- trophic edema
- hyperkeratosis in pressure-exposed areas
- dry skin
Specific requirements for medical compression therapy in comorbidities
The international consensus document on risks and contraindications in medical compression therapy confirms the need for specific properties of the compression material in venous patients with coexisting peripheral arterial disease and / or diabetes mellitus.5
Supplementary recommendations for everyday care from the S2k guideline on medical compression therapy and the International Consensus Paper "Risks and contraindications of medical compression treatment"2, 5
- It is recommended that every patient receiving medical compression therapy be screened in advance for the presence of potential risk factors. These include advanced peripheral arterial disease and advanced microangiopathy, often present in the context of diabetes mellitus. (consensus paper, recommendation 1, highest recommendation level "recommended")
- Special precautions are suggested for patients with polyneuropathy or loss of sensibility, for example as a result of diabetic neuropathy. These include padding of bony prominent structures, verification of fit, selection of a low CCL, and close monitoring. (consensus paper, recommendation 10, high recommendation level "suggested")
- In every patient with an ABPI (ankle-brachial pressure index) < 0.9, the effect of medical compression therapy should be monitored closely. (consensus paper, recommendation 14, highest recommendation level "should")
- Advanced peripheral arterial disease should be considered a contraindication if any of these parameters apply: ABPI < 0.5, ankle artery pressure < 60 mmHg, toe pressure < 30 mmHg, or TcPO2 < 20 mmHg dorsum of foot. (consensus paper, recommendation 12&13 and S2k guideline recommendation 31, highest recommendation level "should").
- Severe sensitivity disorders of the extremity and advanced peripheral neuropathy (e.g., in diabetes mellitus) should be considered as risks accordingly. (S2k guideline recommendation 32, highest recommendation grade "should").
- "To avoid side effects and risks of compression therapy, the rules of proper implementation should be observed. This includes padding of areas at risk of pressure and regular skin care (S2k guideline recommendation 33 - highest level of evidence "should")".
Study proves: mediven angio* meets these specific requirements for a medical compression stocking
A scientific study confirms that compression therapy with medical compression stockings is possible and safe for these patients.6
- The use of the mediven angio* medical compression stocking has been shown to be useful and safe for both compression classes 1 and 2. Both compression classes are well tolerated.
- The microcirculation is stable under both compression classes and in all physiological body positions and is comparable to the values of healthy subjects.
- During the course of therapy, patients should receive close medical monitoring to ensure that they benefit as much as possible from medical compression therapy.
With mediven angio, a unique medical compression stocking is now available that has been developed precisely for the special requirements of these patients - with particular attention to these challenges, especially in the sensitive foot area:
Solid ribbed structure: Ideal ratio between resting and working pressure
- Optimised compression effect on the venous system with due regard to the arterial vascular status and / or absent sensitivity to pressure and pain
Merino-Plush in the entire foot: Unique padding from the tip of the toes up to and above the ankle bone
- Reduction of pressure peaks and
- Avoidance of lesions at bony predilection sites (e.g. ankle, metatarsal head)
Extra-long, flat seam: Seam ends proximally of the metatarsophalangeal joints I and V
- Reduction of pressure peaks and
- Avoidance of acral lesions developing on the toes and their joints
This clinical study investigated the safety of patients with chronic venous disease and mild to moderate peripheral arterial disease and / or diabetes mellitus in compression therapy with mediven angio*. The scientific study proves the following for compression classes 1 and 2:6
- stable microcirculation
- no skin lesions
- no abrasions
- no pressure points
- high wearing comfort
Safe and patient-specific compression therapy: the medi treatment traffic light
Without concomitant disease
Chronic venous disease (CEAP C0s - C5) without concomitant disease: approx. 98 % of people over 60 years of age.1
- Compression therapy with mediven round garment (for example mediven plus)
- Patient-individual care
Mild to moderate PAD / diabetes mellitus type 2 / diabetic PNP
Chronic venous disease (CEAP C0s - C5) and mild to moderate PAD: approx. 21 % of those over 65 years of age.4
Chronic venous disease (CEAP C0s - C5) and diabetes mellitus type 2 / diabetic PNP: approximately 20.5% of those over 60 years of age.3
- Compression therapy with mediven angio
- Unique and safe
Severe PAD / diabetic foot syndrome (DFS)
Chronic venous disease and advanced PAD
- Contraindication for compression therapy
Chronic venous disease and diabetic foot syndrome (DFS)
- No supply of medical compression stockings
The solution for concomitant PAD and / or Diabetes
Round knit compression stockings for venous diseases
Diagnosis & treatment
Everything you need to know about venous disorders and treatment
Sources and references:
1 Rabe E et al. Bonner Venenstudie der Deutschen Gesellschaft für Phlebologie. Phlebologie 2003; 32:1–14.
2 Rabe E et al. S2k Leitlinie: Medizinische Kompressionstherapie der Extremitäten mit Medizinischem Kompressionsstrumpf (MKS), Phlebologischem Kompressionsverband (PKV) und Medizinischen adaptiven Kompressionssystemen (MAK). Published online at: www.awmf.org/leitlinien/detail/ll/037-005.html (Last access: 08.09.2021).
3 Bericht der nationalen Diabetes-Surveillance 2019. Diabetes in Deutschland. Robert Koch-Institut.
4 Lawall H et al. S3-Leitlinie zur Diagnostik, Therapie und Nachsorge der peripheren arteriellen Verschlusskrankheit. Published online at: www.awmf.org/leitlinien/detail/ll/065-003.html (Last access: 08.09.2021)
5 Rabe E et al. Risks and contraindications of medical compression treatment - A critical reappraisal. An international consensus statement. Phlebology 2020;35(7):447–460.
6 Rother U et al. Safety of medical compression stockings in patients with diabetes mellitus or peripheral arterial disease. BMJ Open Diab Res Care 2020;8:e001316.
* Intended purpose: mediven angio
Round-knitted medical compression stocking used for compression of the lower extremities, mainly for the treatment of disorders of the venous system.