How do compression stockings work in treating varicose veins?

How Compression Stockings Work in Varicose Veins

Mechanism of Action

Compression stockings apply graduated external pressure to the lower extremity, with maximum pressure at the ankle that decreases proximally, which counteracts venous hypertension by reducing vein diameter, improving venous valve function, and enhancing the muscle pump mechanism to promote venous return. 1

The physiological effects include:

• Reduction of vein diameter - External compression physically narrows the superficial veins, which improves valve coaptation and reduces pathologic reflux 2
• Enhancement of venous flow velocity - The graduated pressure gradient (typically 20-30 mmHg at ankle) accelerates blood flow toward the heart, reducing venous stasis 1, 2
• Reduction of peripheral edema - Compression increases tissue pressure, which opposes fluid extravasation from capillaries and promotes reabsorption of interstitial fluid 3
• Improvement of muscle pump efficiency - The external support enhances the effectiveness of calf muscle contractions in propelling blood proximally 2

Clinical Effectiveness: The Evidence Gap

There is insufficient high-quality evidence to determine whether compression stockings are effective as the sole treatment of varicose veins in the absence of active or healed venous ulcers. 1, 4, 5

What the Evidence Shows:

• Symptom improvement is inconsistent - While multiple studies report subjective symptom improvement with compression stockings, these assessments were often not properly controlled comparisons between randomized arms, making them subject to significant bias 4, 5
• One recent RCT showed benefit - A 2025 study demonstrated that class I compression stockings (18-21 mmHg) significantly reduced symptom frequency and severity in patients with uncomplicated varicose veins (CEAP C2s-C4a), with improvement in pain, swelling, and heaviness 3
• Physiological measures show minimal effect - Studies measuring objective parameters like ankle circumference showed no clear differences, though one study found reduced edema with compression versus placebo 4

Current Guideline Recommendations:

The 2013 National Institute for Health and Care Excellence guidelines recommend offering external compression only if interventional treatment is ineffective, and as first-line therapy only in pregnant women. 1

• Endovenous thermal ablation is now first-line treatment for symptomatic varicose veins with documented reflux, and need not be delayed for a trial of external compression 1, 2
• Insurance requirements may mandate compression trials - Despite lack of evidence, some insurance companies require a trial of external compression (typically 3 months with 20-30 mmHg stockings) before approval of interventional treatments 1, 2, 6

Practical Application When Compression Is Used

Appropriate Pressure Levels:

• 20-30 mmHg graduated compression is the typical recommendation for varicose veins without ulceration 1, 2
• Higher pressures (30-40 mmHg) may be used for more severe edema 2
• Post-procedure compression - After sclerotherapy or thermal ablation, 35 mmHg compression provides better symptom control and tissue healing than 23 mmHg compression in the immediate post-operative period 7

Patient Populations Where Compression Remains Relevant:

• Pregnant women - Compression is recommended as first-line therapy during pregnancy when interventional procedures are contraindicated 1
• Patients not candidates for intervention - Those with medical contraindications, who decline intervention, or awaiting procedures 1
• Adjunctive post-procedure management - After endovenous ablation or sclerotherapy to reduce post-operative symptoms 8, 7
• Advanced disease with ulceration (C5-C6) - Compression has demonstrated value in venous ulcer management, though this is beyond the scope of uncomplicated varicose veins 2

Critical Limitations and Pitfalls

Compression stockings alone do not address the underlying pathophysiology of saphenous vein reflux and have no proven benefit in preventing disease progression when significant reflux is present. 2, 6

• Compliance is problematic - Studies report high dropout rates due to discomfort, difficulty with application, appearance concerns, and perceived ineffectiveness 4, 5
• Symptom relief is temporary - Any benefit disappears when stockings are removed, as the underlying venous reflux persists 2
• No effect on disease progression - Recent randomized trials show compression therapy does not prevent progression of venous disease when significant reflux exists 2
• Delays definitive treatment - Mandatory compression trials before interventional therapy delay effective treatment without clear benefit 1, 2

The Paradigm Shift in Varicose Vein Management

Over the past decade, there has been a significant change in treatment recommendations due to lack of evidence supporting compression stockings and the rise of minimally invasive endovascular techniques with superior outcomes. 1

• Thermal ablation success rates - Endovenous thermal ablation achieves 91-100% occlusion rates at 1 year with improved quality of life and fewer complications than surgery 2, 9
• Compression as monotherapy is outdated - For patients with documented saphenofemoral or saphenopopliteal junction reflux, endovenous thermal ablation addresses the underlying pathophysiology rather than merely managing symptoms 1, 2, 9