French sclerotherapy and compression: Practice patterns

Abstract

Based on the recommendations of experts, and supported by a low level of proof, compression after sclerotherapy is applied all over the world.

Objective:

Investigating the practice of French vascular physicians for sclerotherapy and the use of post-sclerotherapy compression.

Methods:

A questionnaire concerning their practices was sent to French vascular physicians through their regional vascular medicine professional development associations.

Results:

A total of 366 vascular physicians replied to the questionnaire, of whom 63% (229/366) were in private practice, 6% (21/366) in hospitals and 31% (115/366) had a mixed private–hospital practice. Sclerotherapy was practised by 88% (323/366) of them. Two-thirds of the vascular physicians used sclerosing foam and practised sclerotherapy using ultrasound guidance. Less than one-third of the vascular physicians regularly applied compression after sclerotherapy. When compression was applied, it was usually after treatment of saphenous or accessory saphenous veins and, in most cases, medical compression stockings of 15–20 mm Hg were used. With respect to the period recommended for wearing compression, this ranged from 48 h to 1 week for 65% (193/299) of the vascular physicians questioned.

Conclusion:

The great majority of vascular physicians who answered the questionnaire employ ultrasound guidance to perform sclerotherapy and use sclerosing foam. Compression after sclerotherapy is diversely applied in France and does not comply with the recommendations of the French Health Authorities who recommend wearing a stocking of 15–20 or 20–36 mm Hg for a period of 4–6 weeks. Thus, less than one-third of the vascular physicians regularly used elastic compression and when they did, it was usually a medical compression stocking of 15–20 mm Hg, for 1 week or less.

Keywords

Sclerotherapy compression ultrasound-guided sclerotherapy sclerosing foam varicose veins varices

Introduction

Conventional surgery, which has been supplanted by thermal ablation techniques, is no longer the treatment of reference for saphenous vein insufficiency.^1–3

Thermal ablation is indeed less invasive than surgery, producing results that are at least equivalent, but there is difficulty in developing it in France, since it is not yet reimbursed by the national health insurance system. Due in particular to the low cost, foam sclerotherapy is also widely used in the world for treating saphenous vein insufficiency.^2,3 It is current practice in France, but on an international level, while constantly increasing, its use varies depending on the countries.

Compression after sclerotherapy is used diversely, depending on the country, but also depending on the regions of a particular country. Currently, practice is mainly based on the experience of each practitioner, on what is customary, and on consensus of experts. The level of proof of an interest in compression in this indication is low.⁴

In France, despite the absence of scientific proof, the French Health Authorities (Haute Autorité de Santé (HAS)), in a report published in 2010, recommend, after sclerotherapy or varicose vein surgery, wearing a medical stocking of 15–20 or 20–36 mm Hg or elastic bandages for a period of 4–6 weeks.⁵

The purpose of this work is to assess the practices of French vascular physicians and whether they perform sclerotherapy and post-sclerotherapy compression.

Methods

The Société Française de Médecine Vasculaire (SFMV) is a national professional development association for vascular physicians, i.e. angiologists, whose members consist of 21 regional vascular medicine associations (RVMA).

Almost all vascular physician (VPs) in France are members of the SFMV and all members of the SFMV are VPs (angiologists).

Phlebologists in France, members of the French Society of Phlebology, are for the vast majority, also VPs, and members of the SFMV. Surgeons practicing sclerotherapy in France are very rare; they are not members of the SFMV.

In total, the SFMV represented slightly more than 1400 members in 2010.

In France, VPs perform arterial and venous echo-Doppler investigations and, on a national level, perform the vast majority of sclerotherapy treatments on all types of varices in the lower limbs, including saphenous trunks.

This assessment of professional practice was initiated by the Normandy RMVA. A data collection form was created and distributed to members of the various RMVAs in France through the president of each region (Figure 1 ‘investigation form’). The presidents could agree or disagree to the participation of their region. If they participated, the forms were sent via e-mail, post, or directly to regional gatherings, as chosen by the region’s president. All the forms were collected and centralised by the Normandy RMVA. The form asked for demographic data as well as sclerotherapy practice and techniques and whether or not compression was used or recommended after treatment.

Figure 1.

Investigation form.

Furthermore, the distribution of questionnaires by region should make it possible to assess any geographical disparity of practices. There are major climate variations in France, depending on the season and the regions, with oceanic, continental and Mediterranean climates being represented within the same national territory.

The investigation conducted with VPs, i.e. angiologists, who are members of an RMVA was performed between April 2010 and November 2010.

Statistics

The statistical analysis was performed using a Statistical Analysis System. The comparisons of qualitative variables were performed using the Chi-Squared test and the Fisher test for groups of less than five. A value of P < 0.05 was adopted as significant for interpreting the results.

Results

General data about the participants

Of the 21 RMVAs, only three did not take any part in the investigation. A total of 366 VPs replied to the questionnaire, giving a participation level of 25%. Seven RMVAs had a regional participation higher than 30%.

The average age of the participating VPs was 49.4 (extremes of between 30 and 69 years). The distribution by gender of the VPs who replied was equivalent, 54% being female and 46% male; 63% of the VPs were in private practice, 6% in hospital practice and 31% had a mixed practice.

Sclerotherapy had never been practised by 12% of the VPs (average age of 51). Women were more numerous in this group who purely performed vascular duplex scan, 63% of them being female and 37% male.

Eighty-eight per cent of the VPs (average age of 49) performed sclerotherapy, mainly private (66%) or mixed (31%) practice. Few hospital doctors used sclerotherapy (2.5%).

Sclerotherapy methods

Of all the VPs who participated in the investigation, 66% use ultrasound-guided sclerotherapy (USGS) and sclerosing foam (SF), this figure representing 75% of the VPs practising sclerotherapy.

In this case, SF is used in the following proportions: 22% rarely, 27% fairly often, 17% often and 34% very often (Table 1). SF is used in different ways, depending on the type of vein to be treated (Figure 2). Practitioners mainly use SF for treating saphenous veins, accessory saphenous veins or tributary veins. The use of SF is less frequent in the case of telangiectasia (17%) or reticular veins (31%). About 10% of the VPs treated all types of veins with SF.

Table 1.

Practice of sclerotherapy, ultrasound guided sclerotherapy and sclerosing foam.

	n/N	%
Sclerotherapy
Yes	323/366	88.3
No	43/366	11.7
Ultrasound-guided sclerotherapy
Yes	244/323	75.5
No	77/323	23.8
Foam sclerotherapy
Never	77/323	23.8
Rarely	52/323	16.1
Quite often	66/323	20.4
Often	42/323	13.0
Very often	81/323	25.1

Figure 2.

Indication of sclerosing foam depending on the type of vein (percentage).

Use of compression after sclerotherapy

General data. Six per cent of VP never applied compression after sclerotherapy and 17% did so rarely; half the VPs applied it often or quite often, and 30% of VPs applied them regularly (Table 2).

Compression was used differently for different types of veins (Figure 3). Compression was mainly applied as part of the treatment for saphenous trunks (73%) or accessory saphenous veins (76%). Just over 12% of practitioners applied compression for the treatment of all types of veins.

Type of compression. Medical compression stockings (MCSs) were used mostly, especially thigh stockings (Figure 4). An elastic or adhesive bandage was applied, respectively, by 22 and 25% of VPs, respectively. Multi-layer bandages and eccentric compression were applied by 3 and 2% of VPs, respectively. As for the compression force, 15–20 mm Hg MCSs (class 2 – French norm) were used by about 89% of VPs; 30–40 mm Hg (class 3) was used in 20% of cases and superimposed stockings in 7% of cases.

Application of the compression. During the consultation, this was performed by the patient himself/herself in 46% of cases and by the VP in 37% of cases (Table 3). When the compression was applied, it was to be worn in the daytime in 80% of cases; 19% of VPs recommended that it be worn permanently.

Length of time during which compression had to be worn. About 65% of the VPs recommended wearing compression for between 48 h and 1 week (Figure 5). Where compression was to be worn for more than 1 month, the VP requested that it be worn throughout the period of sclerotherapy treatment or in the long term due to the patient having chronic venous disease.

Estimate of observance according to the VP. About 80% of VPs believed that more than 50% of their patients indeed wore their compression in the way that had been recommended to them (Figure 6).

Table 2.

Use of compression after sclerotherapy.

	n/N	%
Never	20/323	6.2
Rarely	54/323	16.7
Quite frequently	69/323	21.4
Frequently	82/323	25.4
Regularly	98/323	30.3

Figure 3.

Application of compression depending on the type of vein (percentage).

Figure 4.

Type of compression used (percentage).

Table 3.

Application of compression.

	n/N	%
Put on by:
Patient alone	140/301	46.5
Yourself	112/301	37.2
Patient or yourself	49/301	16.3
Application on examining table
Yes	199/261	76.2
No	62/261	23.8
Wearing
Daytime	240/298	80.5
Day and night	58/298	19.5

Figure 5.

Length of time compression worn (percentage).

Figure 6.

Estimate by the vascular physician of the actual wearing of compression (percentage).

Variations according to the regions of France

Participation based on the regions was disparate, with a very variable participation rate (0–60%). We therefore compared the practices between the northern and southern regions of France.

The participation of VPs in northern France was greater than that of VPs in the south with 32 and 18% of regional participation, respectively. There was no significant difference between the two VP populations in terms of age, gender and activity. Sclerotherapy, USGS and the use of SF were similar. Compression after sclerotherapy was applied in an equivalent manner.

On the other hand, the application of an elastic bandage and the use of a MCS of class 15–20 mm Hg were more frequent in the northern regions. Superimposition of MCS was more often performed in the south. The VPs in northern France more often allowed the patient to apply the compression himself/herself after sclerotherapy. The period of compression after sclerotherapy appears to be shorter in the practice of VPs in northern France; the latter in fact more often applied compression for 48 h, whereas the VPs in the south more often asked for compression to be applied for 2 weeks (Figure 7).

Figure 7.

Length of time compression worn North/South.

Discussion

Few investigations of sclerotherapy practice and the use of SF have been performed. Only two fairly recent research projects, in the United Kingdom⁶ and the United States,⁷ have been found in the literature. The 25% rate of national participation in our investigation is quite low compared to those in the two studies, which were 47 and 31%, respectively; nevertheless, this rate of 25% represents 366 of French angiologists.

This difference could be due to the method of distributing the data collection forms used in our investigation. The distribution was actually performed through each RVMA president, whose decision it was as to whether or not to perform the investigation and whether or not to issue reminders within each RVMA. Another explanation could be that some angiologists in France practice only duplex-scan examinations, and no sclerotherapy; so this particular population of VPs was probably not highly motivated to complete the questionnaire.

Another limitation of this investigation is that the VPs who replied to our questionnaire are probably among the most assiduous of the attendees at Professional Development courses; this might have caused a bias in recruitment.

Our investigation shows that sclerotherapy is mainly practiced in France in private practices, and very little in hospitals. French VPs use SF and ultrasound guidance as common practice. This practice seems to be comparable to that described in the American study in which 87% of practitioners treating venous insufficiency use foam USGS, but with considerable variations depending on the regions of the USA. The main indications for sclerotherapy techniques in the USA are recurrent great and small saphenous vein and varicose tributaries. In the United Kingdom, only 25% of surgeons use foam USGS, mainly on recurrent varicose veins, non-saphenous veins and, above all, on the elderly.

As for elastic compression after sclerotherapy, this is diversely used depending on the country or even in the regions of the same country. Various post-sclerotherapy compression protocols that vary in terms of pressure and length of time have been offered, though without defining the benefits of each. O’Hare demonstrated, in a randomised controlled study, that wearing compression for 5 days showed no advantage over wearing it for 24 h after foam sclerotherapy session for treating varices.⁸

In the case of surgery, a meta-analysis of randomised controlled trials concerning the time recommended for compression after surgery of the great saphenous vein shows that there is no benefit in requiring the wearing of compression for a period greater than 1 week.⁹ This term can be reduced to periods of between 36 h and 3 days according to studies performed by Pittaluga and Chastanet¹⁰ and Houtermans-Auckel et al.¹¹

The official recommendations, however, are not uniform within the country.

In the USA, the Vascular Surgery Society and the American Venous Forum suggest that after foam sclerotherapy, compression should be applied using short stretch bandages or MCS of 30–40 mm Hg or a combination of both, to be worn for a period of 1–2 weeks.¹

The British report of the National Institute for Health and Clinical Excellence (NICE) in 2013, concerning the diagnosis and treatment of varices, specifies that it is not clear whether compression should be applied after operative treatment of varices (endothermal ablation, foam or surgery). It is simply recommended that, if a stocking or bandage is applied after treatment, the period during which compression should be worn should not exceed 7 days.²

European recommendations,⁴ in the absence of scientific proof, grant a very low grade of recommendation (grade 2C according to the classification by Guyatt et al.¹²) for the application of compression after sclerotherapy. They assign a grade 2 B for compression using a 23–32 mm Hg stocking for 3 weeks, after telangiectasia sclerotherapy.

In France, in a report published in 2010, the HAS recommended that after sclerotherapy or varicose vein surgery, a 15–20 or 20–36 mm Hg MCS or short stretch bandages should be worn for a period of 4–6 weeks.⁵

Our investigation clearly shows that in practice, French VPs, without great disparity depending on region, do not comply with the national recommendations. In fact, on the one hand, only 30% of them regularly use compression after sclerotherapy and on the other hand, when it is used, it is in class 15–20 mm Hg (89%), for a period generally lasting 48 h to 1 week (65%).

There are probably several reasons for this gap between recommendations and practice. In France, unlike in the English-speaking countries, compression after sclerotherapy has not been in regular use, historically and culturally (‘the French school’). The scientific proof, that is nearly absent, concerning the importance of compression in this indication, does not seem to be of such a nature as to quickly change the habits of the French VPs, especially because most of the time it is a constraint imposed upon the patient.

The rate of thrombosis after foam sclerotherapy is assessed at only 0.6%,¹³ but in theory, post-sclerotherapy compression could reduce this risk and reduce the amount of pain in the case of post-sclerosing phlebitis.¹⁴

Nevertheless, only two randomised controlled trials (RCTs) comparing sclerotherapy with or without compression have been published to date.

The first RCT concerns the sclerotherapy of telangiectasia and reticular veins. While this trial shows a benefit for the wearing of compression stockings in the clinical vessel disappearance (photographic criteria), on the other hand, there is no difference in patient satisfaction scores.¹⁵

The second concerns SF treatment of the saphenous veins. On the venous occlusion criteria (Duplex-scan assessment) and the quality-of-life questionnaires there is equivalent efficacy for both arms with and without compression.¹⁶

These two RCTs were not able to show any benefit for compression in respect of side effects.

Lattimer et al.¹⁷ also demonstrated that during the putting on of a MCS, the blood flow increased very significantly at the sapheno-femoral junction. He deduced that the sudden and massive flow of foam to the femoral vein, caused by the putting on of compression after the foam injection into the GVS, could increase the risk of systemic complications of foam and could reduce the rate of occlusion of the GVS.

In the case of chronic venous disorder, a reduction in symptomatology may be accepted but there is no benefit in terms of development of the venous disorder or in terms of recurrence.^2,18,19

In our investigation, we questioned VPs as to the estimates they had in the observance of their compression patients. Around 80% of the VPs believed that compression is worn by their patients for more than half the prescribed period.

This estimate also incorporates the use, by certain VPs, of adhesive or elastic bandages at the initial phase of treatment.

In the study performed by Hamel-Desnos et al., observance of compression in the compression group was on average 11 days out of the 21 days requested, and only 40% of the patients in this group actually wore their compression for the 21 days.¹⁶

In the context of chronic venous disease, several studies show that compliance with compression is poor. In Raju’s study, covering 3144 patients, only 21% of patients wore MCS and 12% use them most of the time.²⁰ The reasons given for failure to use an MCS are diverse. No reason (30%), no benefit contributed (14%), impedes circulation (13%), too hot to wear (8%), pain in the limb (2%), looks ugly (2%), inability to put it on without help (2%), contact dermatitis and itching (2%). In Ziaja’s study covering 11,689 patients similar compliance with compression was found, since MCSs were only used by 25.6% of patients.²¹ The reason most frequently advanced to explain this non-compliance was the high cost of MCSs.

Finally, according to the NICE² (United Kingdom), the benefit of compression after interventional treatment for varicose veins is unclear. They recommend, for future research, that studies answer these questions: ‘What is the clinical and cost effectiveness of compression bandaging or hosiery after interventional treatment for varicose veins compared with no compression? If there is benefit, how long should compression bandaging or hosiery be worn for?’

They suggest an RCT with six arms:

1 arm with compression and 1 without, in each of 3 groups (endothermal ablation, ultrasound-guided foam sclerotherapy, surgery); each arm should have subgroups for compression type and duration. Adherence to compression treatment and the impact of adherence on effectiveness should also be evaluated. A cost-effectiveness analysis should be performed.

These recommendations highlight the difficulty and the complexity of research in this field.

Conclusion

The vast majority of French VPs who replied to the questionnaire practice USGS and use SF.

In the case of elastic compression after sclerotherapy, French VPs do not apply the official recommendations of the French health authorities (the HAS), since less than one-third of the VPs regularly apply compression. When compression is applied, most of the VPs prescribe MCSs of 15–20 mm Hg for a period of less than or equal to 1 week. This survey highlights an important and controversial area of Phlebology practice. Clinical studies are lacking, and the compliance of VPs and patients with the official recommendations would probably be greater if a scientific demonstration of the efficacy thereof were to be established in the future.

Footnotes

Acknowledgements

The authors would like to thank Jean-Noël Poggi, President of the ARMVs for his involvement, and all the VPs who are members of various ARMVs, for their participation in this study.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

None declared.

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