Compression Bandaging Style for Venous Insufficiency
For venous insufficiency, use inelastic (short-stretch) compression bandages or multi-layer compression systems rather than elastic stockings, particularly for severe disease (C5-C6) and venous ulcers, as they provide superior intermittent pressure peaks during ambulation that better reduce ambulatory venous hypertension. 1
Optimal Bandaging Technique
Pressure Application Pattern
- Apply "negative graduated compression" where higher pressure is exerted at the calf rather than the distal ankle, as this achieves improved ejection fraction in refluxing vessels and higher extrinsic pressures compared to traditional graduated compression (higher at ankle, lower proximally). 1
- Place the compression bandage over the calf rather than just the distal leg for improved pressure distribution and ejection fraction. 1
Compression Pressure Targets
- Use 30-40 mm Hg inelastic compression for venous ulcers (C6 disease) and ulcer prevention (C5 disease), as this is superior to elastic bandaging for wound healing. 1
- For less severe disease (C2-C4), start with 20-30 mm Hg as minimum effective pressure. 1
- For patients with ankle-brachial index (ABI) between 0.6-0.9, reduce compression to 20-30 mm Hg, which remains both safe and effective. 1
Bandage System Selection
Inelastic Systems (Preferred for Active Disease)
- Short-stretch multi-layer bandages (e.g., Unna boot, 3-4 layer systems) are the gold standard for venous ulcers, providing high static stiffness index (SSI >10 mm Hg) that creates intermittent pressure peaks exceeding 50 mm Hg during walking—essential for occluding incompetent veins and reducing ambulatory venous hypertension. 2, 3
- Velcro inelastic compression systems are equally effective as 3-4 layer inelastic bandages. 1
- Systems like Rosidal Sys, Porelast, and Coban maintain high stiffness (SSI >10 mm Hg) even 12 hours after application. 4
When Elastic Stockings Are Acceptable
- Elastic compression stockings (20-30 mm Hg) are adequate for mild disease without ulceration, primarily increasing venous flow velocity in supine position and preventing leg swelling. 2
- However, elastic stockings cannot achieve the high intermittent pressure peaks (>50 mm Hg) needed in upright position for optimal therapeutic effect in severe disease. 2
Critical Pre-Treatment Assessment
Mandatory Arterial Evaluation
- Always check ABI before applying compression—this is the most dangerous error to avoid. 1, 5
- When ABI <0.6, compression is contraindicated as it indicates arterial disease requiring revascularization first. 1
- Approximately 16% of venous leg ulcer patients have unrecognized concomitant arterial disease. 5
Application Principles
Bandaging Technique
- Multi-component systems (2-4 layers) provide sustained therapeutic pressure with high stiffness. 6
- Maintain compression day and night, changing weekly for optimal effect. 7
- Place foam pads over incompetent perforating veins in the ulcer area to enhance local pressure. 7
Common Pitfalls to Avoid
- Don't use traditional graduated compression (higher at ankle) for severe venous disease—the negative graduated approach (higher at calf) is biomechanically superior. 1
- Avoid bandages that are too tight at the knee, as this paradoxically worsens venous return. 5
- Don't rely on elastic stockings alone for venous ulcers—they lack the high working pressure needed for healing. 2, 3
Evidence Strength Considerations
The recommendation for inelastic over elastic compression is based on hemodynamic studies showing superior venous pumping function and ambulatory venous pressure reduction with high-stiffness systems. 2, 3 While both systems reduce pain and improve quality of life similarly, inelastic compression demonstrates better wound healing rates for venous ulcers. 1, 7 The negative graduated compression technique represents newer evidence from the American College of Radiology showing improved physiologic outcomes compared to traditional graduated compression. 1