Compression stockings are available in different grades of pressure (Table 5.1). The classification of pressure varies between countries. One international consensus group, for example, categorized “mild” compression as <20 mmHg, “moderate” as =20–40 mmHg, “strong” as =40–60 mmHg, and “very strong” as ≥60 mmHg, at the ankle [16].

Partsch [8] used ultrasound to evaluate the mid-calf small saphenous vein (SSV) and posterior tibial vein in 14 patients (5 with varicose veins). Narrowing was observed at 30–40 mmHg, occlusion at 70 mmHg, when standing. Lord [17] evaluated 30 patients (13 with varicose veins) who wore waist-high 20–30 mmHg compression stockings . The great saphenous vein (GSV) was not compressed when standing. Among the varicose vein patients, the GSV was not compressed even when supine. Additional imaging studies utilizing ultrasound and MRI suggest that in order to compress the GSV while standing, 40–50 mmHg compression pressure is required [18–20].

Accomplishment of vein occlusion or compression, however, may not be the ideal outcome to study. Sarin et al. [21] study using duplex found that cuff pressures required to achieve valve function restoration were lower than pressures to achieve occlusion. Some practitioners choose grades of compression based on severity of disease. The CEAP (clinical-etiology-anatomy-pathophysiology) classification system has been widely adopted to standardize research and dialogue in venous disease [22, 23].

In one study, treatment of patients with predominantly C2–C3 venous disease (varicose veins and edema) with 30–40 mmHg compression led to improved pain, pigmentation, and swelling [24]. High pressure compression (>40 mmHg) is better than low pressure compression for venous ulcer healing [25]. For venous ulcer disease , a systematic review [26] showed that 30–40 mmHg compression hosiery is more effective than lower pressures for healing and lowering recurrence. The Society for Vascular Surgery and the American Venous Forum Guidelines suggest 20–30 mmHg stockings for simple varicose veins (C2 disease) [27].

In a systematic review of stand-alone compression therapy , that is, not after an ablative procedure, in varicose vein patients, symptoms (e.g., pain, discomfort, edema) were improved. However, there was lack of evidence for posttreatment efficacy in reduction of progression or recurrence of varicose veins [28]. A Cochrane review in patients with venous insufficiency (C2–C4 disease) found insufficient high-quality evidence to determine effectiveness of compression [29]. For C5/C6 disease (healed or active venous ulcer), two Cochrane reviews reported lower ulcer recurrence with compression therapy. Furthermore, compression noncompliance is associated with lower ulcer healing and greater recurrence [3, 30]. Various compression lengths are available to adapt to patient needs (Fig. 5.2).

In the 1960s, Fegan described the empty vein technique, where veins would be compressed after sclerotherapy [31]. While the concept sounds logical, evidence for the optimal duration of compression after sclerotherapy or whether it is necessary is scant. Furthermore, there exists a wide variation across the globe on utilization of compression after ablative procedures.

Kern randomized 100 patients undergoing sclerotherapy for lateral thigh reticular and spider veins to no versus 3 weeks of post-procedure compression (23–32 mmHg). Improved clearance was reported in the compression group at 7 weeks [32]. El-Sheika’s [33] systematic review of randomized control trials found seven suitable for analysis. Three studies were surgical; two used sclerotherapy and two endovenous laser ablation (EVLA) . Heterogeneity in study quality and duration of compression was found which made meta-analysis difficult. No specific conclusions could be drawn about efficacy or optimal duration of compression therapy.

Two of the evaluated studies suggested that longer compression resulted in less pain. Bakker et al. [34] prospectively randomized patients undergoing EVLA of the GSV to 2 versus 7 days of compression stockings (35 mmHg). Sixty-nine patients were analyzed. At 1-week follow-up, the 7-day compression group reported less pain and better physical function. At 6 weeks no significant difference was found. Another similarly designed prospective study noted a small but significant reduction in pain scores when compression was worn after EVLA [35]. These studies did not demonstrate any difference in procedural success or efficacy.

Venous ulcers represent the most severe form of venous disease. A 2012 Cochrane systematic review evaluated 48 randomized clinical trials (n = 4321), concluding that compression led to greater ulcer healing compared to no compression. Both ulcer healing and reduction in recurrence are enhanced with compression [3, 26]. Multi-component systems (as opposed to single layer) or those with elastic components appeared to work better. Higher compression pressures appear to heal ulcers better [3]. In another systematic review, Cullum et al. [36] found that multilayered high compression was more effective than moderate compression, in the prevention of ulcer recurrence. Another Cochrane review [30] determined that high pressure compression may work better than medium compression to prevent recurrence. Overall, there was insufficient evidence when comparing types or lengths of compression.

Compression hosiery prevents venous thromboembolism in the perioperative setting. Its mechanism of benefit might be through decreasing venous stasis and stimulating tissue factor pathway inhibitor [37].

A Cochrane database review found 19 randomized controlled trials, 18 evaluating surgical patients, and 1 medical patients [38]. The graduated compression-stocking group developed DVT in 9% compared to 21% among controls (P < 0.00001). The incidence of pulmonary embolism based on 5 included studies was 2% in the treatment group versus 5% in controls (P = 0.04).

Post-thrombotic syndrome (PTS) is a chronic, potentially disabling, disorder that can occur after acute DVT , affecting at least 30% of patients [39]. In the affected leg, skin changes, edema, and ulceration can occur along with pain. It has been postulated that compression may alleviate venous reflux, hypertension, and sequelae, if applied early following a DVT. Subfascial lymphatic function can be reduced with deep vein thrombosis and deep venous incompetence due to a post-thrombotic syndrome but may be treated with compression [40, 41].

Three randomized trials have evaluated compression stockings in the prevention of PTS. Two small randomized trials appear to suggest an approximately 50% reduction in PTS with compression stockings [42, 43]. The SOX trial [44] randomized 410 patients with proximal DVT to 30–40 mmHg below-knee graduated compression stockings versus <5 mmHg placebo stockings. The stockings were mailed to participants within 2 weeks of DVT diagnosis . They were asked to be worn on the affected leg for 2 years, during waking hours. Participants were asked to report frequency of stocking use. At 24 months there was no significant difference in the proportion of patients with PTS. Adherence was recorded as being equivalent.

A number of criticisms have been directed against the study. Compression stockings were not applied immediately upon diagnosis of DVT but rather up to 2 weeks later. In addition, 83% of participants provided a wrong guess or “uncertain” reply as to whether they had been receiving real compression or placebo stockings. This may suggest that a sizeable number had not worn the compression stockings at all. The benefit of compression hosiery post-DVT to prevent PTS is controversial, but in our view, compression hosiery should be applied immediately following DVT, as in the least, it appears to decrease swelling and provide comfort.

A diverse selection of compression modalities exists , from those compressing around the ankle region to those compressing up to the waist. Bandages, stockings, and pneumatic compression devices have been utilized. Single to multilayer bandages have been used. Bandages and stockings can vary in power and elasticity (Fig. 5.3).

Inelastic compression bandages tend to generate lower resting pressures but the pressure increases with walking due to calf muscle expansion [45]. They are therefore not ideal for immobile patients. Inelastic bandages should be reapplied once edema has improved. Increased layers not only augment the pressure applied but also tend to render the compression less elastic.

A small randomized study compared venous ulcer healing rates using five compression modalities: pneumatic compression, multilayer bandages (45–50 mmHg), compression stockings (30–40 mmHg), two-layer bandages (20–30 mmHg), and Unna boots . More patients had superficial than deep reflux. No ablative intervention was performed. At 2 months, ulcer healing rates were best (57–59%) in the groups that received pneumatic compression, 30–40 mmHg compression and multilayer bandages (45–50 mmHg). Ulcer healing rates were lowest in those assigned to Unna boots (20%) and two-layer bandages (17%) [46].

In a randomized trial of 200 patients undergoing EVLA to the GSV , one group wore 23–32 mmHg thigh-high compression stockings . The second group wore the same compression stockings with an added eccentric medial compression band, approximating the GSV location. The group with added medial compression reported significantly less post-EVLA pain. GSV closure rates were not evaluated [47]. A 2009 meta-analysis of eight RCTs found faster ulcer healing with purpose-made compression stockings than “diverse” bandages in venous ulcer disease [48]. There was a greater proportion of healed ulcers (62.7% with stockings vs 46.6% with bandages; P < 0.0001) and stocking use resulted in 3 weeks shorter mean ulcer healing time (n = 535, P = 0.0002) and lower pain scores (P < 0.001) than with bandages [48].

Inelastic compression stockings typically require application by a trained individual. Adjustable devices may present a better future alternative while also being easier to apply. Mosti et al. [49] demonstrated efficacy in edema reduction among C3 patients when comparing an adjustable Velcro compression device to inelastic bandages. They randomly assigned 20 limbs to multi-component multilayer inelastic bandages versus 20 to the Velcro device for 7 days. The Velcro group was instructed to tighten the device if it felt loose, whereas the inelastic bandage group was asked not to adjust theirs. At baseline the inelastic bandage exerted a supine mean pressure of 63 mmHg versus 43 mmHg with the Velcro device. However, the inelastic bandage pressures fell >50% over 7 days whereas remained stable in the Velcro group. Furthermore, there was greater limb volume reduction in the Velcro group (26 versus 19% at 7 days; P < 0.001), without a significant difference in patient discomfort.