We have known for decades that gravity makes varicose veins worse. As far back as 1956, a study of 3,000 factory workers with varicose veins determined that 65 percent had a job standing still while only 6 percent walked frequently on the job. Even in ancient times Roman soldiers used to bind their legs with straps before long marches to prevent leg swelling and fatigue.

Today, the widest use of compression stockings is post-treatment for varicose and spider veins, after endovenous catheter ablation, ambulatory phlebectomy, and sclerotherapy.

Post-treatment compression decreases pain, swelling, inflammation and phlebitis. Compression should also be used for all cases of phlebitis, either superficial or deep, but especially after deep venous thrombosis (DVT). Use of compression after DVT will reduce the incidence of post-phlebitic syndrome by 50 percent.

As a preventive, compression stockings should be worn for prolonged travel to prevent DVT, the so called “economy class syndrome.”

It should be noted here that many insurance companies, including Medicare, require patients to wear compression stockings for several weeks or months prior to varicose vein surgery, but no studies are available to support this particular use. Additionally, a study in Europe several years ago showed a tendency for women who wore compression stockings during pregnancy to have less saphenous vein reflux.

Reasons for Non-compliance
Reasons for non-compliance with compression products are many. Old wives’ tales are still prevalent that knee-length compression will “cut off the circulation.”

Several of my patients have pointed out that their knee length stockings “make my knee and upper leg swell” when in fact they are noticing the opposite effect: The stocking prevents the lower leg from swelling, but the knee and upper leg swell, giving the patient the false impression that the upper limb is swollen.

Firm compression stockings are difficult to don and remove, especially for the frail elderly. Multiple tricks and devices are available to assist these patients in stocking use, including metal stocking butlers, sailcloth slips and foot covers, rubber gloves, and even special “mouse pads” that the patient puts on the floor and rubs their foot on to move the stocking up or down the leg. Careful instruction and teaching will ensure that these patients can take the stockings off and on.

Cost is also a concern. Many pharmacies will sell inexpensive stockings that either wear out quickly or that don’t have a silicone top to keep them up.

Patients often state that they have tried stockings in the past without benefit, but on further questioning they rarely wore the stockings for most of any one day and a few hours in a stocking is not enough time to see consistent benefit.  
In southern climates, many patients flat out refuse to wear stockings when it’s hot outside, even though hot weather will exacerbate venous edema and pain.

Cost of Non-compliance
Non-compliance with stockings after vein treatment will lead to suboptimal results. After endovenous catheter ablation, failure to wear compression stockings will lead to increased pain, swelling, and bruising and may in some cases lead to early failure of vein sclerosis if high intravenous pressures are not alleviated to some degree with compression.
A patient with increased pain, swelling and bruising post operatively will not be happy and may not return for treatment of the contralateral leg or worse yet may negatively influence other potential patients to get their legs done.

For patients with chronic venous insufficiency manifested by edema and skin changes, failure to wear compression stockings will almost certainly lead to worsening symptoms and eventually to ulceration. And for patients with venous ulcers that are not candidates for short stretch bandages, such as non ambulatory patients, failure to wear compression stockings will prevent the ulcers from healing.

Improving Adherence
Consistent and effective teaching and demonstration for patients will assist them in learning how to don and remove stockings. Butlers or other assist devices should be used when available. Patients should be encouraged to wear the stockings consistently or they will not see symptomatic improvement and will stop wearing them.

Good quality stockings should be used because cheaply made, inexpensive stockings will not last and will not fit or wear properly. Doctors should look for brands such as AmesWalkerProfessional.com that are ISO 9001 Certified, and that have a reputation for consistently providing high quality and reasonably priced products.

Finally, it is also helpful if the doctor shows the patient that they themselves wear a knee-high compression stocking daily. Patients are very impressed if the doctor himself has compression hose on.

Compression Level Standards
Most patients with moderately severe varicose veins will require Class II, 30-40 mmHg compression after vein treatment. Class I, 20-30mmHg stockings are usually used for elderly patients or patients with peripheral arterial disease. Class III, 40 mmHg + compression levels are restricted to patients with severe edema or lymphedema.
An ankle brachial index (ABI) should be determined before prescribing compression stockings for these patients. Compression should be avoided in any patient with an ABI less than 0.7.

Studies have shown that even light compression will improve venous symptoms in most patients.

Patients must be instructed to remove their stockings immediately if they begin having persistent aching discomfort or paresthesias in the legs. Patients with borderline arterial disease will complain of leg aching if they wear their stockings to bed. The discomfort usually abates shortly after sitting or standing but if it does not, the compression level is probably too high for that particular patient.

Compression Products, Surgery
Studies are showing that the higher the risk for DVT in any particular hospitalized patient the more aggressive the DVT prophylaxis should be.

•    For patients of average risk this starts with subcutaneous low molecular weight heparin dosed once daily.
•    For high-risk patients, pharmacologic prophylaxis should also be supplemented with mechanical prophylaxis, either with compression stockings or intermittent pneumatic compression devices.
•    Class I compression is probably sufficient for most patients, but patients with borderline arterial insufficiency may need a lighter compression of 15-20 mmHg.

James Altizer, MD, FACPh, RVT, RPVI, of the Vein Center of Charlotte, N.C., is a Fellow in the American College of Phlebology (ACP) of only 30 in the United States. This honor was given to him in recognition for his dedication and efforts on behalf on the College in teaching doctors from all over the country about vein disease and its treatment. He has been with the Vein Center in Charlotte, NC since 2001 and can be contacted at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it