Which compression stocking (class and length) is appropriate for an adult with uncomplicated varicose veins and no arterial insufficiency, heart failure, or severe peripheral edema?

Compression Stockings for Varicose Veins

For adults with uncomplicated varicose veins, prescribe 20-30 mmHg knee-high graduated compression stockings, but recognize that compression is no longer recommended as first-line therapy and should not delay definitive endovenous treatment if the patient is a candidate for ablation. 1, 2

Current Evidence on Compression Efficacy

The landscape of varicose vein treatment has shifted dramatically over the past decade. There is insufficient evidence to determine if compression stockings are effective for treating varicose veins in the absence of active or healed venous ulcers. 1 The 2013 NICE guidelines recommend offering external compression only if interventional treatment is ineffective, and as first-line therapy only in pregnant women. 1

When Compression IS Appropriate

Compression stockings should be prescribed in these specific scenarios:

• Pregnant women with varicose veins (first-line therapy) 1
• Patients who are not candidates for endovenous or surgical management 1
• Patients who do not desire intervention 1
• Insurance requirement: When a trial of compression is mandated before approval of interventional treatments 1
• Adjunctive therapy after DVT: For symptomatic relief in patients with acute DVT of the leg (though not for routine post-thrombotic syndrome prevention) 1, 3

Specific Compression Recommendations

Pressure Class

• 20-30 mmHg is the standard recommendation for uncomplicated varicose veins 1, 3, 4
• Higher pressures (30-40 mmHg) may be used for more severe venous disease 3, 4
• Even lower pressures (18-21 mmHg, German class I) have shown significant symptom improvement in recent studies 5
• Avoid compression when ankle-brachial index is <0.6, as this indicates arterial disease requiring revascularization 3
• For patients with ankle-brachial indices between 0.6-0.9, reduced compression of 20-30 mmHg is both effective and safe 3, 6

Length

• Knee-high stockings are typically sufficient for most patients with varicose veins 1
• Thigh-length stockings showed no advantage over knee-high stockings in stroke patients, and below-knee stockings actually resulted in more proximal DVT 1

Gradient

• Graduated compression with decreasing pressure from distal to proximal extremity is essential 1

Critical Limitations and Pitfalls

Poor Compliance is the Major Barrier

Only 37% of patients with chronic venous disease actually use compression stockings as prescribed. 7 In a large tertiary referral study:

• 21% used stockings daily
• 63% did not use them at all or abandoned them after trial 7
• Compliance was poor regardless of age, sex, disease severity, or symptom duration 7

Common Reasons for Non-Compliance

• Unable to specify reason (30%)
• Not prescribed by physician (25%)
• Did not help symptoms (14%)
• Binding/"cutting off" circulation sensation (13%)
• Too hot to wear (8%) 7

Ineffectiveness Despite Compliance

Approximately one-third of compliant patients continue to have persistent symptoms despite wearing stockings as prescribed. 7 This underscores why compression should not delay definitive treatment.

Treatment Algorithm

1. Confirm diagnosis with duplex ultrasound showing venous reflux 1, 2

2. Determine if patient is a candidate for endovenous thermal ablation:

   • If YES: Recommend endovenous thermal ablation as first-line treatment; do not delay for compression trial 1, 8, 2
   • If NO (pregnant, refuses intervention, medical contraindications): Prescribe 20-30 mmHg knee-high graduated compression stockings 1

3. If insurance requires compression trial before ablation approval:

   • Prescribe 20-30 mmHg knee-high graduated compression stockings 1
   • Ensure proper fitting and patient education on application 3
   • Document trial duration and symptom response

4. For patients with arterial disease concerns:

   • Obtain ankle-brachial index
   • If ABI <0.6: Do not use compression 3
   • If ABI 0.6-0.9: Use reduced compression (20-30 mmHg) 3, 6

Why Endovenous Ablation is Preferred

Endovenous thermal ablation (radiofrequency or laser) is now first-line treatment for symptomatic varicose veins with documented valvular reflux and need not be delayed for a trial of external compression. 1, 8, 2 This recommendation is based on:

• High occlusion rates (91-100% at 1 year) 8, 2
• Same-day discharge with quick return to activities 1, 8
• Superior long-term outcomes compared to conservative management 8
• Low complication rates (approximately 7% temporary nerve damage) 1, 8