Journal of J Lasers Med Sci 2024;15:e2 Original Article

Lasers doi 10.34172/jlms.2024.02

in Medical Sciences http://journals.sbmu.ac.ir/jlms

Comparative Efficacy of Postoperative Compression

Methods After EVLT for Great Saphenous Vein
Insufficiency
ID ID ID ID
Niki Tadayon1* , Mostafa Mousavizadeh1 , Fateme Yousefimoghaddam2 , Faezeh Jadidian3 , Mohammadmoein
ID
Mirhosseini4 , Naser Hadavand5
1
General and Vascular Surgery Ward, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences
(SBMU), Tehran, Iran
2
Research fellow, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran
3
School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
4
Laser Application in Medical Sciences Center, Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran
5
Rajaie Cardiovascular Medical and Research Institute, Iran University of Medical Sciences, Tehran, Iran
*Correspondence to
Niki Tadayon, Abstract
Email: [email protected] Introduction: The preference for endovascular techniques in treating varicose veins, particularly
in the great saphenous vein (GSV), has increased due to their minimally invasive nature and
Received: November 5, 2023 reduced complications. Post-operative care, especially involving compression therapy, remains
Accepted: February 17, 2024 crucial to improve outcomes, prevent varicose vein recurrence, and enhance overall recovery.
ePublished: February 28, 2024
This study aimed to evaluate the efficacy of eccentric compression therapy compared to
alternative post-operative care methods following endovenous laser treatment (EVLT) for GSV
insufficiency.
Methods: This prospective randomized clinical trial encompassed 88 EVLT procedures for
GSV insufficiency. The participants were divided into two groups, each receiving different
postoperative compression methods, and were evaluated over a specified period. The primary
outcome was the pain scale after EVLT; meanwhile, the secondary outcome measured in the
present study was the rate of GSV occlusion after EVLT.
Results: Both groups underwent all EVLT procedures successfully without any complications.
At the one-month duplex ultrasound (DUS) follow-up, the sapheno-femoral junction occlusion
rates were 97% (43 out of 44) for group A (eccentric compression plus gradual compression
stocking) and 95% (42 out of 44) for group B (only gradual compression stocking). Ecchymosis
was observed in only 12 patients across both groups, accounting for an overall occurrence of
13.6%. Group A patients reported significantly lower analgesic usage (10%) compared to group
B (18%), although this difference did not reach statistical significance. Analysis of postoperative
pain data utilizing the visual analog scale (VAS) showed a median value of 5.5 in group B
patients, which decreased to 3.1 with the application of eccentric compression. Moreover, there
was less ecchymosis in group A observed by one week.
Conclusion: This study contributes to the ongoing discourse on the efficacy of postoperative
compression in varicose vein treatment. It underscores the necessity for more comprehensive,
well-designed studies to yield clearer conclusions and provide better guidance for post-
procedure care.
Keywords: Compression stocking; Varicose vein; Endovenous laser treatment (EVLT); Pain; VAS;
Eccentric compression therapy.

Introduction transition away from conventional methods like high

The preferred choice for both vascular specialists and ligation and stripping towards less invasive techniques
patients in treating great saphenous vein (GSV) varicosities like radiofrequency ablation (RFA) and endovenous laser
is now the use of new endovascular techniques.1,2 This treatment (EVLT).3
shift from open surgery to less invasive approaches is Following a successful endovascular laser procedure,
due to the lower risk of complications associated with proper post-operative care is crucial to enhance patient
minimally invasive procedures for treating superficial outcomes, alleviate symptoms, and prevent the recurrence
truncal insufficiency. Consequently, there has been a of varicose veins. The traditional consensus is that the

Please cite this article as follows: Tadayon N, Mousavizadeh M, Yousefimoghaddam F, Jadidian F, Mirhosseini M, Hadavand N.
Comparative efficacy of postoperative compression methods after EVLT for great saphenous vein insufficiency. J Lasers Med Sci. 2024;15:e2.
doi:10.34172/jlms.2024.02.
Tadayon et al

utilization of compression therapy is advantageous after recanalization rates.8

any varicose vein treatment, as it improves patient comfort This study aimed to evaluate the efficacy of eccentric
and reduces the risk of complications such as phlebitis.4 compression therapy in comparison to alternative post-
Nevertheless, the efficacy of this strategy when compared operative care techniques in preventing varicose vein
to alternative compression techniques for varicose vein recurrence and managing postoperative pain after EVLT
procedures has not been thoroughly investigated, and on GSV.
there is a lack of agreement regarding the most suitable
degree of compression and duration of therapy. Methods
Compression therapy following GSV sclerotherapy, Study Population
surgery, and ablation encompasses a diverse range of This study was a prospective randomized clinical trial
approaches, spanning from minimal compression to two comprising two treatment groups, each with 44 limbs
prevalent methods of compression therapy: compression in 44 individuals. Conducted from September 2023
stockings and bandages. These methods are typically to November 2023, it included 88 consecutive EVLT
employed for short-term purposes. Additional categories procedures for GSV insufficiency (Figure 1: study
of compression therapy include adjustable Velcro devices, process). Eligible participants were between 18 and 75
compression pumps, and hybrid devices.5 years old and in good general health, and they presented
Eccentric bandages offer significant benefits when it with superficial venous insufficiency classified as C2 to
comes to targeting specific anatomical regions. Their C5 according to the CEAP classification.
ability to provide customized compression levels on a Prior to treatment, a duplex ultrasound (DUS) scan
particular area, such as the thigh’s GSV, makes them
highly advantageous.6 Bandages and compression
stockings are both effective in promoting proper blood
circulation and preventing stasis. One significant benefit
is the capability to customize the compression profile
based on the patient’s needs and apply precise pressure to
specific areas.7
The primary objective of post-procedure compression
is to improve the closure of the lumen in the treated
vein in order to prevent any negative effects, as well as
recanalization and recurrence. The dosage and manner
in which compression is applied are crucial factors in
maintaining vein occlusion in various body positions.
Techniques such as eccentric, eccentric concentric, or
tangential compression may enhance the compression
profile. By using specially designed pads, localized
pressure can be applied to the treated vein. The use of
compression therapy following treatments for GSV issues
is well-known, but it can be challenging to achieve effective
pressure on the inner thigh. According to Laplace’s law,
pressure at the thigh can be increased by reducing the
curvature. One approach to achieving this is by using an
eccentric compression device in addition to the standard
concentric compression, such as a stocking or bandage.
However, the concentric compression needs to be strong
in order to activate the eccentric device, which then
applies pressure to the inner thigh. Additionally, securing
the eccentric compression device can be problematic, as
finding the right position can be challenging and skin
damage may occur from contact or the vacuum effect
created around the device.
Recent studies have investigated the effectiveness
of these specialized compression profiles after EVLT
and have found that eccentric compression reduces the
severity of post-operative pain. However, short-term
Figure 1. Application of Eccentric Compression Using the Wool Roll
follow-up did not reveal any differences in recurrence or

2 Journal of Lasers in Medical Sciences Volume 15, 2024

 Compression methods post GSV laser treatment: comparative insights

assessed reflux at the saphenofemoral junction (SFJ) around the GSV. Endovenous laser ablation employed a
during the Valsalva maneuver. Participants meeting 1470-nm diode laser (LASEmaR® 1500 Eufoton) generator
specific criteria, including a GSV diameter of 5 to 15 mm at 8 W, using a continuous emission pullback technique at
at 3 cm from the SFJ in a standing position with truncal 1 cm every six seconds. The 3-centimeter segment near
reflux exceeding 500 milliseconds, were enrolled for the SFJ was treated twice if deemed necessary.
active intervention.
The patients could not join this trial if (1) they did not Compression Methods
agree to attend scheduled follow-up visits on days 7 and In this study, protective adhesive gauze was used to cover
30, (2) they had a history of varicose vein treatment, (3) the skin at the location where the GSV was punctured.
they were known cases of chronic liver or kidney disease, Group A patients received eccentric cylindrical
(4) they had a history of deep vein thrombosis, pulmonary compression along the GSV, extending from the knee
embolism, or post-thrombotic changes observed during to the groin, following the method described by Lugli et
DUS examination, (5) they were pregnant, and (6) they al.9 Conversely, patients in group B did not undergo this
were unwilling or unable to apply elastic compression. eccentric compression procedure. Additionally, all treated
limbs in both groups were fitted with 20-30-mm Hg
Randomization elastic stockings (SIGVARIS® open Toe Thigh-Highs w/
To mitigate potential selection bias, a telephone Grip-Top 20-30 mm Hg).
randomization service assigned patients to two study
groups, ensuring blinded randomization. The attending Outcome Measurement
surgeon remained unaware of the post-operative The Primary outcome of the present study was the scale
compression method until after conducting the EVLT of pain after EVLT. After each procedure, the patient’s
procedure in the operating room. Group A received pain level during surgery was assessed by using a visual
eccentric compression plus gradual elastic stocking, analog scale (VAS) consisting of a 10 cm horizontal
while group B received treatment solely with gradual line. The scale ranged from zero, indicating no pain, to
elastic stocking. The method of analysis was intention- ten, indicating the worst pain ever experienced. This
to-treat (ITT), so the analysis included all randomized assessment was conducted by a nurse not involved in the
participants, regardless of dropout status. surgical team. All the patients, regardless of their assigned
group, were instructed to resume walking immediately
Statistical Analysis after the operation and were discharged within three
Data analysis employed SPSS 13.01 software (SPSS hours. While analgesics were not routinely prescribed, the
Inc, Chicago, Ill). Results are presented as the mean patients were advised to take 500 mg of Acetaminophen if
and standard deviation. Group differences in nominal they experienced intolerable pain. The patients were also
variables were assessed by using chi-square testing, while instructed to keep a record of their pill intake. Follow-
the t-test for independent samples compared linear up appointments were arranged for one week and one
variables following a normal distribution. All statistical month after the surgery. At these appointments, the
tests were two-tailed, with the significance level set at P elastic stockings and eccentric compression were taken
< 0.05. There was no difference in baseline characteristics off, the VAS was administered, and the relevant data were
between groups, so we did not perform multivariable documented. The patients were requested to provide
analysis. The study sample size was calculated with two information about the highest level of pain they had
comparison groups and equal sample size using the experienced in the days or weeks following the operation.
following formula for a continuous primary outcome. To evaluate and compare the secondary outcome, we
The significance level and the power of the study were conducted a routine postoperative duplex scanning one
defined as 0.05 and 0.8, respectively (n=2(σ2)Z1−α/2 / σ2). month after EVLT to verify the successful obliteration.
This was confirmed by the presence of a noncompressible
EVLT Technique GSV with thickened walls and no flow observed during
Skin preparation and draping preceded percutaneous the color DUS examination.
cannulation of the GSV, with the patient in reverse
Trendelenburg. A 6 French sheath (Arrow® Percutaneous Results
Sheath) was inserted into the GSV using the Seldinger Between September and November 2023, a total of 88
technique. A 6 French straight catheter was then participants (54 women and 34 men) aged between 21 and
advanced to the SFJ over a hydrophilic J-tipped 0.035- 72 were enrolled, with 44 individuals allocated to Group
inch wire. A 600-micrometer laser fiber was introduced A (receiving eccentric compression plus progressive
through the catheter, positioned 10 mm distal to the SFJ compression) and 44 individuals to Group B (using
under ultrasound guidance. A local anesthetic solution progressive compression stockings exclusively). All the
(2% lidocaine with 1:200 000 adrenaline) was infiltrated patients randomized to each group attended follow-up

Journal of Lasers in Medical Sciences Volume 15, 2024 3

Tadayon et al

visits, so there was not any dropout from the study. The group. Group A patients used significantly fewer pain
two groups were largely similar in most aspects, although relievers (10% reported their use) compared to group
there was a notable age difference, with Group A showing B (18%), although this difference was not statistically
a statistically significant older average age compared to significant. The analysis of postoperative pain data using
Group B. The right limb was affected in approximately VAS revealed a median value of 5.5 in group B patients,
66% of the patients. The average diameter of the treated which decreased to 3.1 with the application of eccentric
GSV measured 7.8 mm in a standing position. Notably, compression. The compression group exhibited a notably
there were no substantial differences between the two lower median pain score on day 7 in comparison to the
groups in terms of CEAP classification (see Table 1). The group solely relying on stockings. However, there was no
mean CEAP clinical grade was 2.6 in Group A and 2.7 in noteworthy disparity in the pain score on day 30. Patients
Group B, showing minimal variance between the groups. who underwent concurrent phlebectomies and wore
Both groups successfully underwent EVLT procedures compression stockings displayed identical pain scores
during the day without any complications (Pulmonary as the other patients in group A, but they experienced
thromboembolism [PTE] and deep venous thrombosis more severe pain scores than the other patients in group
[DVT]). The SFJ occlusion rates at a one-month DUS B, both on days 7 and 30. Moreover, group A exhibited
follow-up were 97% (43 out of 44) for group A and 95% less bruising on day 7. It is important to note that none of
(42 out of 44) for group B. the patients complained of excessive heat production due
No participants dropped out of the study. The to the compression, and no cases of eczema developed
evaluation of pain during surgery indicated a median on the skin as a result of the compression.Both treated
value of 0.8 (ranging from 0 to 7), and no sedation groups exhibited similar characteristics across various
was required for any of the subjects. There were no parameters, ensuring comparability between them. These
significant complications such as deep vein thrombosis, included median linear energy density (LEED), the total
pulmonary embolism, hematomas, skin burns, or tingling energy applied for GSV ablation, the length of GSV
sensations. Only 12 patients in both groups exhibited ablated during the procedure, and the median dosage of
bruising, with an overall incidence of 13.6%. There locally administered anesthetic, as detailed in Table 2.
were no cases of superficial venous thrombosis in either
Discussion
Table 1. Baseline Data Comparing Two Groups ‎ Building upon the existing role of compression therapy in
enhancing results following varicose vein treatment,4 our
Group Aa Group Bb P Value
investigation seeks to analyze the distinct effectiveness
Patients 44 44 0.045
of eccentric compression therapy in comparison to
Age 52 SD 14 49 SD 11 alternative post-operative approaches after EVLT for GSV
Men/Women 18/26 16/28 N.S. insufficiency.
Height (cm) 163 SD 6.8 165 SD 6.6 N.S. Compression stockings, also known as support
Weight (kg) 69 SD 12 72 SD 13 N.S. stockings or gradient stockings, are legwear designed to
BMI 26 SD 4.5 27 SD 4.2 N.S.
apply pressure to the lower extremities. The pressure is
highest at the ankle and gradually decreases as it moves up
Right lower limb 30 28
the thigh. This pressure gradient helps improve blood flow
Left lower limb 14 16
and reduce swelling by aiding in the upward movement
GSV diameter (mm) 7.7 SD 0.7 7.9 SD 0.6 N.S. of blood against gravity.10 The ease of putting on and
CEAP c
2.6 SD 0.12 2.7 SD 0.15 N.S. taking off these stockings encourages patient compliance,
‎BMI, body mass ‎index; GSV, Great saphenous vein; SD, standard deviation and their subtle appearance makes them suitable for
a
Eccentric plus gradual compression stocking; b Only gradual compression
stocking; c CEAP stands for clinical manifestations (C), etiologic factors (E),
daily wear. Additionally, there are various compression
anatomic ‎distribution of disease (A), and underlying pathophysiologic (P). levels available, allowing medical professionals to

Table 2. Procedure data

Group Aa Group Bb
‎
Minimum Maximum Mean Minimum Maximum Mean P Value

LEED (J/cm) 42 56 48 42 56 49 0.08

Total energy 920 2193 1438 660 2240 1471 0.89

Ablated saphenous length (cm) 15 45 30 14 46 30.3 0.12

Power (W) 7 8 7.75 7 8 7.7 0.21

Anesthetic solution (cc) 200 450 344 300 450 359 0.33
LEED, Linear energy density.
a
Eccentric plus gradual compression stocking; b Only gradual compression stocking.

4 Journal of Lasers in Medical Sciences Volume 15, 2024

 Compression methods post GSV laser treatment: comparative insights

tailor treatment to individual patients. However, some over a sturdy rubber foam pad that was firmly attached
drawbacks exist. Correct sizing and application can to the skin along the vein track using adhesive plasters.
be challenging, they may be uncomfortable and could This resulted in a local pressure of over 60 mm Hg. The
potentially cause allergies or skin irritations. third group utilized a stiff, non-elastic adhesive bandage
Compression wraps come in diverse materials and exerting pressure around 40 mm Hg. The study found
weaves, each with its unique elastic properties.11 These that outcomes related to pain, hemorrhage, and bleeding
wraps, applied at varying pressures, might yield a significantly favored patients treated with either the
compression pattern distinct from that of stockings. stocking atop the rigid device or the inelastic adhesive
Moreover, in cases involving unconventional limb shapes bandage, compared to those using elastic stockings alone.
or specific wound care needs, wraps are often preferred. In Lugli and colleagues’ study,18 200 patients undergoing
However, the downside lies in the time-consuming EVLT were randomly assigned to two groups: one
application of wraps, requiring proper training for receiving a single elastic stocking applying 35 mm Hg
medical practitioners to ensure consistent compression. pressure at the ankle, and the other group using the same
For patients seeking a discreet treatment option, the stocking combined with a self-made cotton roll firmly
bulkiness of wraps might pose an issue. The spectrum affixed to the skin along the vein track using plasters to
of compression devices spans from rigid, non-elastic locally increase pressure. The primary focus of the study
wraps exerting pressures exceeding 50 mmHg to elastic was post-procedure pain, which was notably lower in
stockings with barely measurable pressures.12 the group receiving the cotton roll beneath the stocking.
The primary goal of employing compression therapy Bradbury et al18 utilized rolls of orthopedic wool placed
after superficial vein treatments is to maintain the over the trunk and main tributaries following ultrasound-
occlusion of the treated vein, thereby preventing potential guided foam sclerotherapy. These rolls were secured with
bleeding and recanalization. Achieving this necessitates non-stretch bandages. Subsequently, a class II stocking
applying external pressure that surpasses the internal was fitted, and patients were instructed to walk for 15
pressure of the treated vein. Magnetic resonance imaging minutes before leaving. Patients were advised to wear the
has confirmed that a pressure below 10 mm Hg is adequate bandage and stocking for either 5 or 7 days. During a one-
for occluding the GSV in the supine position. However, month follow-up, 1056 patients (84.4%) experienced no
when in a sitting or standing position, significantly complications or side effects.
higher pressure is required to effectively restrict the veins. However, the efficacy of employing intense compression
Observations from Magnetic resonance imaging and pressure has been contested by various publications. Some
DUS reveal that, while standing, compression pressure suggest that strong elastic stockings might exhibit similar
needs to exceed 50 mm Hg on the lower leg and reach a or greater efficacy compared to light elastic stockings
pressure greater than 30-40 mm Hg at the thigh level for or bandages. Moreover, it is proposed that compression
optimal occlusion.13,14 therapy might be less effective post-EVLA compared to
Currently, there is still a lack of agreement regarding other treatments due to the occluded saphenous vein
the most effective intensity or duration of compression necessitating higher compression levels. Additionally,
administered after particular therapies.15 At present, achieving effective compression on the inner aspect of
compression therapy encompasses five categories: the thigh poses challenges, making additional eccentric
compression bandages, compression stockings, adjustable compression necessary to augment pressure in this region.
Velcro devices, compression pumps, and hybrid devices.
Out of these, compression stockings and bandages are Conclusion
frequently employed for temporary use after varicose vein The study findings propose that adding eccentric
treatment. It is believed that compression therapy helps compression to class 2 high thigh stockings in cases
relieve symptoms associated with GSV sclerotherapy and involving GSV insufficiency, alongside treatments like
surgery.16 However, the effectiveness of this approach endovenous thermal ablation, sclerotherapy, and/or
following intervention, particularly after EVLT, has phlebectomy, may initially reduce post-procedural pain.
not been extensively detailed. In order to effectively However, at one-week follow-up, pain levels between the
narrow down or obstruct the venous lumen, the applied groups become similar. Further research is needed to
compression pressure must surpass, or at the very least assess the long-term effectiveness and patient satisfaction
closely align with the intravenous pressure.6 of these combined treatment methods.
In a study conducted by Mosti et al,17 54 patients who These results suggest that utilizing compression
underwent flush ligation and stripping were divided into stockings after endothermal ablation and concurrent
three groups receiving different types of compression. phlebectomy and/or sclerotherapy can minimize
The first group received a single elastic stocking applying ecchymosis and early post-treatment pain. Nevertheless,
very light pressure of approximately 10 mm Hg on the by day 30, pain outcomes equalize between the groups.
thigh. The second group applied an identical stocking Notably, a subset of patients undergoing phlebectomy

Journal of Lasers in Medical Sciences Volume 15, 2024 5

Tadayon et al

appears to derive the most benefit from this combined the American Venous Forum, Society for Vascular Surgery,
treatment. Additional research is required to assess the American College of Phlebology, Society for Vascular
Medicine, and International Union of Phlebology. J Vasc Surg
long-term effectiveness and patient satisfaction associated
Venous Lymphat Disord. 2019;7(1):17-28. doi: 10.1016/j.
with these approaches. jvsv.2018.10.002.
7. Ye K, Wang R, Qin J, Yang X, Yin M, Liu X, et al. Post-operative
Authors’ Contribution benefit of compression therapy after endovenous laser
Conceptualization: Niki Tadayon. ablation for uncomplicated varicose veins: a randomized
Data curation: Mostafa Mousavizadeh, Fateme Yousefimoghaddam, clinical trial. Eur J Vasc Endovasc Surg. 2016;52(6):847-53.
Mohammadmoein Mirhosseini. doi: 10.1016/j.ejvs.2016.09.005.
Formal analysis: Fateme Yousefimoghaddam, Faezeh Jadidian. 8. Yie K, Jeong EH, Hwang EJ, Shin AR. Stocking-only versus
Methodology: Niki Tadayon, Mostafa Mousavizadeh. additional eccentric compression after below-the-knee truncal
Project administration: Niki Tadayon. vein sclerotherapy: a SOVAECS prospective randomized
Supervision: Niki Tadayon. within-person trial. J Vasc Surg Venous Lymphat Disord.
Validation: Mostafa Mousavizadeh, Mohammadmoein Mirhosseini. 2023;11(6):1122-9.e3. doi: 10.1016/j.jvsv.2023.07.009.
Visualization: Faezeh Jadidian. 9. Lugli M, Cogo A, Guerzoni S, Petti A, Maleti O. Effects of
Writing–original draft: Niki Tadayon, Mostafa Mousavizadeh, eccentric compression by a crossed-tape technique after
Fateme Yousefimoghaddam. endovenous laser ablation of the great saphenous vein:
Writing–review & editing: Niki Tadayon, Naser Hadavand. a randomized study. Phlebology. 2009;24(4):151-6. doi:
10.1258/phleb.2008.008045.
Competing Interests 10. Hirai M, Iwata H, Hayakawa N. Effect of elastic compression
This article is based on the research and findings from Mostafa stockings in patients with varicose veins and healthy controls
Mousavizadeh M.D.’s dissertation for completion of vascular and measured by strain gauge plethysmography. Skin Res Technol.
endovascular surgery fellowship. The data and analysis presented 2002;8(4):236-9. doi: 10.1034/j.1600-0846.2001.80401.x.
in this article build upon the research conducted in the thesis. 11. Partsch H, Clark M, Mosti G, Steinlechner E, Schuren J,
Otherwise, authors declare no conflict of interest regarding the Abel M, et al. Classification of compression bandages:
submitted article. practical aspects. Dermatol Surg. 2008;34(5):600-9. doi:
10.1111/j.1524-4725.2007.34116.x.
Ethical Approval 12. Meissner MH. Lower extremity venous anatomy. Semin
The study received approval from the ethical committee of Laser Intervent Radiol. 2005;22(3):147-56. doi: 10.1055/s-2005-
Application in Medical Sciences at Shahid Beheshti University of 921948.
Medical Sciences (43007135). All participants provided informed 13. Kakkos SK, Timpilis M, Patrinos P, Nikolakopoulos KM,
consent for the evaluation and anonymous publication of their Papageorgopoulou CP, Kouri AK, et al. Acute effects of
medical and demographic data for scientific purposes. The study graduated elastic compression stockings in patients with
protocol has been registered and approved in the Iranian Registry symptomatic varicose veins: a randomized, double-
of Clinical Trials (identifier: IRCT20170614034531N1). blind, placebo-controlled trial. Eur J Vasc Endovasc Surg.
2018;55(1):118-25. doi: 10.1016/j.ejvs.2017.10.004.
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