What is the best course of action for a patient presenting with right foot pain, redness, and poor blood return, with varices in both legs, who has been using overly tight compression socks?

Immediate Evaluation for Deep Vein Thrombosis

This patient requires urgent evaluation for deep vein thrombosis (DVT) given the constellation of right leg redness, poor blood return, and foot pain—compression stockings should be discontinued immediately until DVT is ruled out.

Urgent Diagnostic Workup

The clinical presentation of unilateral leg redness with poor perfusion raises serious concern for DVT, which must be excluded before addressing the varicose veins. Based on the moderate pretest probability in this scenario:

Initial Testing Strategy

• Start with a highly sensitive D-dimer test as the preferred initial approach 1

  • If D-dimer is negative, no further testing is needed and DVT is effectively ruled out 1
  • If D-dimer is positive, proceed immediately to proximal compression ultrasound (CUS) or whole-leg ultrasound 1

• Alternative approach: Begin directly with proximal CUS if the patient has comorbid conditions that elevate D-dimer levels (making a false positive likely) 1

  • If proximal CUS is negative, either repeat in 1 week or perform D-dimer testing 1
  • If proximal CUS is positive, treat immediately for DVT without waiting for confirmatory venography 1

Critical Pitfall to Avoid

Do not attribute leg redness and poor blood return solely to varicose veins or compression stocking complications—this presentation demands DVT exclusion first. The "poor blood return" description is particularly concerning and atypical for simple varicose veins.

If DVT is Confirmed

Anticoagulation Management

• Initiate anticoagulation immediately with low molecular weight heparin, fondaparinux, or unfractionated heparin 2
• This is the cornerstone of DVT treatment; compression therapy is only adjunctive 3

Compression Therapy Approach

• Use compression therapy for symptomatic relief of acute pain and edema (30-40 mmHg at the ankle) 2, 3
• Encourage early ambulation with compression rather than bed rest, though defer if edema and pain are severe 2
• Do not use compression stockings routinely for post-thrombotic syndrome prevention—current evidence does not support this practice 2, 3

If DVT is Ruled Out

Management of Varicose Veins

Once DVT is excluded, the varicose veins can be addressed:

• Properly fitted compression stockings at 20-30 mmHg pressure for initial management of symptomatic varicose veins 3
• The patient's report of "too tight" stockings suggests either improper fitting or excessive compression pressure 3
• Consider surgical evaluation for definitive treatment (stripping, thrombectomy) if conservative measures fail, particularly given the pronounced right-sided varices 4, 5

Proper Compression Stocking Guidelines

• Ensure professional fitting with sized-to-fit stockings for each individual patient 3
• Knee-high graduated elastic compression stockings are typically sufficient 3
• Avoid compression if ankle-brachial index is <0.6, as this indicates arterial insufficiency 3

Additional Considerations

For idiopathic or severe varicose veins without clear cause, investigate underlying conditions including autoimmune diseases, malignancy, or thrombophilia 4. The unilateral predominance and severity warrant this evaluation.