1. Claude Franceschi Elastic compression Rational in venous disease

2. COMPRESSION: DEFINITION Pressure resulting from action-reaction at the interface (contact) of 2 bodies

3. COMPRESSION Positive clinical effects in venous and lymphatic diseases are today indisputable

4. BUT COMPRESSION Pathophysiological Interpretation Techniques Indications Are still today disputed

5. Clinical effect Leg COMPRESSION lowers the Trans-Mural Pressure At the Micro-circulation: Drainage improvement achieves Edema Volume reduction Ulcer and wounds healing Pain relieve At the Venous bed: Stasis reduction prevents Thrombosis

6. TRANS-MURAL PRESSURE (TMP) = Intra-Venous Lateral Pressure (IVLP) – Extra-Venous Pressure (EVP) IVLP is the sum of : Hydrostatic Gravitational Pressure + Residual Lateral Pressure + Valvo-muscular Pump Lateral Pressure EVP is the sum of: Tissue Pressure + Atmospheric Pressure IVLPEVP TMP

7. COMPRESSION Decreases TMP By adding its pressure to the physiological EVP At the Veins and Venous end of the Capillaries level IVLPEVP TMP Compression Resulting lower TMP

8. COMPRESSION Presses Veins and venous end of the Capillaries THROUGH the tissues Tissues Compression V

9. Compression efficacy varies according to Leg features Bulk Modulus

10. The Bulk Modulus of the leg exerts a variable resistance to the transmission according to the rigidity of its components: Bulk modulus ( K) K Coefficient relates stress (compression pressure P) to strain ( leg volume change :V/dV) i.e resistance to compression K = P.V/dV P= K.dV/V TMP = ( IVLP + K. dV/V) – Sub-Compression Pressure

11. Bulk modulus K Resistance External Compression Pressure IVP Tissues strain TMP = ( IVLP + K. dV/V) – Sub-Compression Pressure

12. The more the K leg (tissue sclerosis hypodermitis, ulcer…) The less the PTM reduction. So the more the compression pressure must be.

13. Compression efficacy varies according to Compression means A- H omogeneity (isostatic) or Heterogeneity (heterostatic) B- Elasticity

14. Liquid Pc Horizontally isostatic Vertically progressive Into liquid immersion Compression -Independent of the leg shape -Horizontally isostatic -Vertically downwards progressive

15. Gaz cuff pressure Pc Horizontally isostatic Vertically isostatic Pneumatic compression Compression -Independent of the leg shape -Horizontally isostatic -Vertically isostatic

16. : Bandage compression : LAPLACE’S LAW For the same stretch force F, the sub-bandage pressure P decreases when the average radius of the leg increases Pressure = F/wr= F/r when w=1cm P: hPascal F: cNewton w= bandage width r= cylinder radius 1mmHg = 1,333 hPa = 1,359 cm water depth = 0,00131 atm w R F F P F = P.wr

17. : Bandage compression : LAPLACE’S LAW Pressure = F/wr= F/r when w=1cm For the same stretch force F, the sub-bandage pressure P decreases when the average radius of the leg increases D C B A For the same stretch force, the resulting sub-bandage decreases from the ankle up to the buttock A>B>C>D

18. Circular : homogeneous sub-bandage pressure Non Circular : heterogeneous sub-bandage pressure Bandaging stretch force F1 = Cte pressure: F5>F4>F3>F2 F1 P=+ P=++ F1 Resulting sub-bandage pressure depends also on the arc angle of the leg where applied F1 P =0

19. For more homogeneous compression: Circularization of the leg with additional dressing ( soft pads) For wanted heterogeneous compression: Addition of small angle arc pads

20. For more wanted heterogeneous compression: Unwanted local compression as pedal or tibial arteries pathway (tunnel effect)

21. BANDAGE EFFECTS TMP REDUCTION 1- Venous volume flow is not increased 2- Intravenous Pressure is not reduced but 1-Blood velocity is increased 2-Blood volume (stasis) is reduced -Phlebitis prevention -Tension pain reduction 3-Drainage is improved -Edema reduction -Hypodermatis and ulcer cure and prevention

22. Anelastic? Elastic? Effects on TMP

23. Elastic Bandage Changes its length (strain) with the tensile stress. Sub-bandage pressure results from: A- the reaction force to the stress/strain of the leg B-Elastic Potential energy (tensile force) Anelastic Bandage Doesn’t change its length (strain) with the tensile stress. Sub-bandage pressure results from: A- the reaction force to the stress/strain of the leg

24. Hugo Partsch Measurement of sub-bandage pressure variations according to Elastic and ANElastic in: Supine Standing Walking postures (Hugo Partch)

25. In addition to these postures, and pressure measurements We can deduce the TMP variations in the same postures + in feet lifted position Hugo Partsch 10 20 3O3O 40 50 60 80 90 70 - 10 - 20 0 10 0 P mmHg Elastic TMP ANElastic TMP IVP + BulkM TMP = ( IVP + BulkM) – Compression Pressure WALKING Elastic

26. For the same sub-bandage pressure in supine posture, The anelastic bandage exerts more pressure than the Elastic when standing and walking.

27. For the same bandage pressure in supine posture, The anelastic bandage reduces more the TMP than the Elastic when standing.

28. For the same bandage pressure in supine posture, The anelastic bandage reduces more the TMP than the Elastic when walking.

29. 10 20 3O 40 50 60 80 90 70 -10 - 20 0 100 P mmHg Elastic Pressure ANElastic Pressure IVP + BulkM Elastic WALKING TMP = ( IVLP + K. dV/V) – Sub-Compression P REST

30. 10 20 3O 40 50 60 80 90 70 -10 - 20 0 100 P mmHg Elastic TMP ANElastic TMP IVP + BulkM WALKING Elastic TMP = ( IVLP + K. dV/V) – Sub-Compression P REST

31. Elastic Bandage Is active and exerts a constant driving pressure. So, the sub-bandage pressure can overcome the IVLP and reverse the TMP when IVLP lessens (supine and lifted feet) leading to pain and ISCHEMIA Anelastic Bandage Is passive and transmits back to the pressure of the leg. So, the sub- bandage pressure varies in proportion to the IVLP preventing pain and ischemia when IVLP and TMP lessen ( supine and lifted feet postures)

32. 10 20 3O 40 50 60 80 90 70 -10 - 20 0 100 P mmHg Elastic TMP ANElastic TMP IVP + BulkM WALKING Elastic TMP = ( IVLP + K. dV/V) – Sub-Compression P Ischemia

33. BANDAGE Efficacy/SAFETY Doppler at the fore-foot : 1 st intermetarsal space in supine position checks the quality of the arterial flow in order to avoid excessive compression

34. Anelastic Bandage Is preferable to the Elastic BUT: 1- Less Conformability : ability to follow the contours of a limb provided by multidimensional extensibility and no Stockings available (bandages only). This can be avoid using low extensibility degree bandages

35. Anelastic Bandage Is preferable to the Elastic BUT: 2- Anelastic Compression pressure reduces along the day time This can be due to: RELAXATION effect ( secondary less compression for the unchanged volume) and/or Edema reduction by the “massage” during walking An elevated feet posture combined with an elastic bandage during 1 or 2 hours before applying the AnElastic bandage avoids this phenomenon. This procedure can be renewed every 3 or 4 days.

36. Proposal: Anelastic Bandage Is preferable to the Elastic BUT less Conformability : ability to follow the contours of a limb provided by multidimensional extensibility and no Stockings available (bandages only).

37. SEVERE VENOUS INSUFFICIENCY) Anelastic compression Draining posture for 2 hours + elastic compression Replace elastic compression by non elastic bandage Check the forefoot arterial pressure with Doppler ANELASTIC COMPRESSION permits a STRONGER COMPRESSION so MORE EFFICIENT and LESS DANGEROUS THAN ELASTIC PROCEDURE Then

38. Arteropathy IV th stage : Thanks to Gravitational Pressure, Seating posture increases foot arterial pressure, relieves pain and helps for gangrene healing Anelastic light bandaging prevents stasis edema Check the forefoot arterial pressure with Doppler

39. Normal Individuals Light elastic compression Moderate Valve Incompetence Light/ Moderate elastic compression Moderate Venous Obstacle AV Fistule Light/ Moderate elastic compression Phlebitis prevention Light elastic compression

40. PARADOX 1 Unexpected venous diameter reduction by compression stocking of deep, but not of superficial veins. Hugo Partsch,Giovanni Mosti,Jean-François Uhl.Veins and Lymphatics 2012; volume 1:e3 Conclusion :“This short report using MRI in the standing position showed surprisingly stronger compression effects on the deep than on superficial veins. This is in complete contrast to the traditional concept that compression would affect more the superficial than the deep veins”. Yet, this is emodynamically obvious, since the IVLP in the GSV is necessarily higher than in deep vein, otherwise the first one wouldn’t darin into the second. In addition, in this case, the GSV is totally incompetent, so GHSP is not fractionned and EVLP ismaximum, while the deep veins are competent and the GHSP fractionning reduces the EVLP even if slightly in standing.

41. PARADOX 2 Compression Stockings with a Negative Pressure Gradient Have a More Pronounced Effect on Venous Pumping Function than Graduated Elastic Compression Stockings G. Mostia,*, H. PartschEur J Vasc Endovasc Surg (2011)42, 261-266 Conclusion:Stockings exerting a higher pressure on the calf than on the ankle show a greater efficacy in increasing the venous ejection fraction from the leg. Actually, the Ejection Fraction is the % of the blood volume ejected relatively to the volume at rest. So EF can increase while the ejected volume keep unchanged, when the calf volume at rest is reduced by a bandage. Nevertheless, the more the compression lowers the TMP at the calf, the less the stasis and the calf unpleasant tension.

42. GRAZIE PER L’ATTENZIONE