Interventional treatment of SVI aims to abolish reflux and can be achieved by occluding incompetent veins using endovenous thermal ablation (EVTA), ultrasound guided foam sclerotherapy (UGFS), one of the newer non thermal non tumescent methods (NTN); or by surgically removing them. All are effective and offer patients significant improvement in HRQoL (1). Though rare, the most common major complication of SVI intervention is venous thromboembolism (VTE). More frequently, patients report postprocedural pain, which is associated with a HRQoL reduction lasting up to two weeks. Following SVI treatment, patients typically undergo a short period of postprocedural compression, which is hypothesised to limit bruising and swelling thereby reducing postprocedural discomfort in addition to reducing the risk of VTE and increasing anatomical occlusion success rates. Compression is however unpopular with patients and thus compliance rates can vary(2). This systematic review summarise randomised controlled trials evidence of postprocedural compression following treatment of SVI.

A review was carried out in accordance with the Preferred Reporting Instrument for Systematic reviews and Meta-Analysis (PRISMA) guidelines, and the protocol was prospectively registered on PROSPERO CRD42020209918. Inclusion criteria English language reported randomised clinical trials (RCTs) of adult patients were eligible for inclusion if they involved a comparison of compression regimes against one another or against no compression following treatment for symptomatic SVI of Clinical aEtiological Anatomical Pathophysiological (CEAP) class 2-5 patients involving the great saphenous vein, small saphenous vein, anterior accessory saphenous vein, or any combination of these. Analysis was performed using Review Manager (version 5.4, The Cochrane Collaboration, 2020) with statistical heterogeneity being assessed using I squared test and a fixed effects model being used where heterogeneity was deemed low. Continuous outcomes were analysed using mean difference (MD) and 95% confidence intervals (CI), or standardised mean difference and 95% CI where studies measured the same outcome using different scales. Categorical outcomes were analysed using risk ratios with 95% CI and a narrative summary was undertaken for data that could not be analysed by meta-analysis.

Titles and abstracts of 812 original articles were screened of which 23 were selected for full text review. Of those, 18 met the selection criteria. A total 2584 limbs were treated in the included studies using EVTA in seven studies, open surgery in six, UGFS in four, and one study combined EVTA and surgery(3-20); Table1. Four studies compared the use of compression post SVI treatment to no compression (3,7,16,18). Postprocedural pain was formally assessed in only one study (3), which reported very low pain scores in both groups. There was a small difference in favour of 1 week of compression, however this failed to reach the threshold of statistical significance. Four studies compared a compression duration of 1-3 days versus 1-2 weeks (5,6,8,20). In all four studies, mean postprocedural pain measured at 1-2 weeks post-procedure on a 100mm VAS was significantly lower when compression was applied for 1-2 weeks compared to 1-3 days (5,6,8,20). Suitable metanalysis data was obtained for three studies (5,6,20) and showed a mean reduction in pain of 11 (8 - 13); p<0.001 when using 1-2 weeks of compression; Figure 1. Out to six months of follow up, anatomical occlusion and disease specific HRQoL were not significantly different when comparing 1-2 weeks versus 1-3 days of compression. Five studies compared the use of different types of compression post SVI treatment (4,13,15,17). Comparing 23mmHg stockings versus 35mmHg stockings; postprocedural pain on 100mm VAS at 1 week was very low in both groups but statistically lower in the 35mmHg group (4±7 vs 15±19 p=0.010) (17).

Postprocedural compression of 1-2 weeks following SVI treatment is associated with reduced pain when compared with shorter duration and likewise higher interface pressure. Further research is required to identify the optimal interface pressure and type of compression and to understand the impact of compression on VTE.

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