What is the best way to determine the correct compression stocking pressure and fit for an adult patient with a history of vascular disease?

Determining Compression Stocking Pressure and Fit

For patients with vascular disease, start with 20-30 mmHg graduated compression stockings after confirming ankle-brachial index (ABI) ≥0.9, escalating to 30-40 mmHg for severe disease with ulceration or persistent edema. 1, 2

Critical Pre-Prescription Assessment

Always measure ABI before prescribing compression therapy—this is the most dangerous error to avoid. 2, 3

• ABI >0.9: Full compression therapy is safe; use standard pressure recommendations 2, 3
• ABI 0.6-0.9: Reduced compression of 20-30 mmHg is both safe and effective 1, 2, 3
• ABI <0.6: Compression is absolutely contraindicated; arterial revascularization required first 2, 3
• ABI >1.40: Indicates noncompressible vessels from calcification; use toe-brachial index instead 3

Approximately 16% of venous leg ulcer patients have unrecognized concomitant arterial disease, making this assessment critical. 1, 2

Pressure Selection Algorithm

Initial Pressure Based on Disease Severity

For chronic venous insufficiency with pitting edema (C3-C4 disease):

• Start with 20-30 mmHg as minimum effective pressure 1, 2, 4
• This pressure range successfully reduces edema and improves venous circulation 2

For severe disease (C5-C6: healed or active venous ulcers):

• Escalate to 30-40 mmHg compression 1, 2, 3
• Higher pressures (30-40 mmHg) demonstrate superior efficacy for wound healing and ulcer prevention 1, 2, 3
• Inelastic compression at this level creates higher intermittent pressure peaks during ambulation, producing a "massaging effect" that better reduces ambulatory venous hypertension 2, 3

Special Populations

For post-surgical patients:

• 23-32 mmHg facilitates faster resolution of edema and reduces pain, tightness, and discomfort in the early post-operative period 5
• 18-21 mmHg may be sufficient for longer-term post-surgical use 5

For VTE prophylaxis in travelers:

• 15-30 mmHg below-knee graduated compression stockings 4

Proper Fitting Technique

Stocking Type Selection

Graduated compression stockings are preferred, with highest pressure at the ankle decreasing proximally 2, 4

• Below-knee stockings are typically sufficient for lower leg edema 2
• Higher stiffness (inelastic) compression devices may be more effective than elastic stockings for severe disease 2

Measurement and Fitting

Proper fitting is essential—stockings that are too tight at the knee paradoxically worsen venous return and increase DVT risk. 2, 3

• Measure at the smallest circumference at the ankle (B-area) 6
• Be aware that actual delivered pressure may vary: Class II stockings (labeled 25-35 mmHg) often deliver mean pressures of only 24.7 mmHg, with lowest pressures at the medial ankle (18.3 mmHg, only 74% of mean) 6
• The medial ankle site is the critical target area for venous insufficiency—inadequate pressure here may explain high ulcer recurrence rates despite stocking use 6

Application Considerations

For bandaging (alternative to stockings):

• Apply "negative graduated compression" with higher pressure at the calf rather than distal ankle—this achieves improved ejection fraction in refluxing vessels 1, 3
• Place compression over the calf rather than just the distal leg for improved pressure distribution 1, 3

Optimizing Adherence

Treatment failure most commonly results from non-compliance rather than inadequate compression. 1, 2, 3

• Provide detailed application and removal instructions 2, 3, 4
• Ensure proper measurement and fitting, as ill-fitting stockings cause skin breakdown, discomfort, and non-adherence 2
• Compliance decreases with higher pressures—don't start with maximum compression (30-40 mmHg) in all patients unless clinically indicated 2
• Consider that lighter pressures (18-21 mmHg) may be more suitable for patients requiring long-term inactive standing or sitting 7

Common Pitfalls to Avoid

• Never prescribe compression without assessing arterial circulation first 2, 3
• Don't assume palpable pedal pulses exclude significant arterial disease—quantitative ABI is essential 3
• Avoid traditional graduated compression (higher at ankle) for severe venous disease—negative graduated approach (higher at calf) is biomechanically superior 1, 3
• Don't rely on labeled compression class alone—actual delivered pressure varies significantly by anatomical location 6
• Consider using Class III stockings or foam pads/pelotes more often, as Class II stockings may deliver subtherapeutic pressure at critical medial ankle sites 6