What is the proper way to prescribe compression stockings for patients with venous insufficiency?

How to Prescribe Compression Stockings for Venous Insufficiency

For patients with chronic venous insufficiency, prescribe knee-high graduated compression stockings at 20-30 mmHg initially, escalating to 30-40 mmHg for more severe disease, with proper fitting and patient education being essential for adherence. 1, 2

Compression Pressure Selection by Disease Severity

Mild Chronic Venous Insufficiency (CEAP C1-C3)

• Start with 20-30 mmHg compression for initial treatment of mild venous insufficiency with symptoms like leg heaviness, pain, or mild edema 1, 2
• Even lower pressure stockings (15-20 mmHg, Class 1) demonstrate measurable improvement in quality of life and reduction of limb edema in mild disease 3
• This pressure range is sufficient to increase venous blood flow velocity in the supine position and prevent leg swelling after prolonged sitting or standing 4

Moderate to Severe Venous Insufficiency (CEAP C4-C6)

• Prescribe 30-40 mmHg compression for more advanced disease including skin changes, healed or active venous ulcers 1, 2
• Higher pressures (>50 mmHg) are needed in the upright position for intermittent occlusion of incompetent veins and reduction of ambulatory venous hypertension during walking 4
• For venous leg ulcers specifically, 30-40 mmHg inelastic compression is superior to elastic bandaging for wound healing 2

Special Populations Requiring Modified Pressure

• For patients with ankle-brachial index (ABI) 0.6-0.9: Reduce compression to 20-30 mmHg, which remains both effective and safe 1
• Absolute contraindication when ABI <0.6: Do not prescribe compression therapy as this indicates arterial disease requiring revascularization 1, 2

Stocking Specifications and Fitting

Length and Type

• Knee-high graduated elastic compression stockings are sufficient for most patients, including those with iliofemoral involvement 2
• Graduated compression (higher pressure at ankle, decreasing proximally) is the standard design 1
• Open-toe or closed-toe options are available; choice depends on patient preference and foot involvement 5

Proper Fitting Protocol

• Measure and fit stockings individually to each patient - this is non-negotiable for efficacy 1, 2
• Measurements should be taken in the morning when edema is minimal
• Key measurements include ankle circumference, calf circumference, and leg length from floor to knee
• Provide detailed instructions on proper application and removal techniques to improve adherence 2

Duration and Timing of Use

Daily Wear Schedule

• Stockings should be worn daily during waking hours (at least 10 hours per day for optimal compliance) 3
• Apply stockings in the morning before getting out of bed when edema is minimal
• Remove at night before sleeping

Treatment Duration

• For chronic venous insufficiency, ongoing use is required as long as symptoms persist 1
• The older 2012 recommendation of 2 years for post-DVT patients is no longer supported by current evidence 2
• For acute DVT with severe edema, consider initial intermittent pneumatic compression followed by transition to daily elastic compression stockings 2

Critical Contraindications and Safety Checks

Absolute Contraindications

• ABI <0.6 - indicates severe arterial disease requiring revascularization before any compression 1, 2
• Acute cellulitis or dermatitis
• Severe peripheral arterial disease with rest pain

Relative Contraindications and Cautions

• Peripheral neuropathy (reduced ability to detect excessive pressure)
• Severe leg deformity preventing proper fit
• Known allergy to stocking materials 2

Monitoring for Adverse Effects

• Skin breakdown, particularly in elderly or diabetic patients 2
• Discomfort leading to non-compliance 2
• Skin dryness and itching (consider stockings with integrated skin care for patients with dry skin) 6

Common Pitfalls to Avoid

Pitfall #1: Prescribing without proper ABI assessment - Always check ABI before prescribing compression, especially in patients over 50, diabetics, or smokers 1, 2

Pitfall #2: Inadequate patient education - Poor application technique is a major cause of treatment failure. Demonstrate proper donning and doffing, and consider providing written instructions or video resources 2

Pitfall #3: Starting with insufficient pressure - While 20-30 mmHg is appropriate for mild disease, patients with CEAP C4-C6 require 30-40 mmHg for adequate therapeutic effect 1, 2

Pitfall #4: Using compression as monotherapy for venous ulcers - Compression is essential but should be part of comprehensive wound care including infection control and addressing underlying venous pathology 2

Pitfall #5: Prescribing for post-thrombotic syndrome prevention - Current evidence does not support routine use of compression stockings to prevent post-thrombotic syndrome after DVT, though they may help with symptom management in established cases 2

When Compression Stockings Are NOT Indicated

• Routine post-thrombotic syndrome prevention after DVT - The American Society of Hematology suggests against routine use based on very low certainty evidence 1, 2
• VTE prophylaxis in hospitalized patients - Pharmacological prophylaxis is preferred; if contraindicated, intermittent pneumatic compression is superior to graduated compression stockings 1
• Stroke patients for VTE prophylaxis - A large trial showed no benefit and increased risk of lower-extremity skin damage (39 additional events per 1000 patients) 7