Compression stockings have been a standard treatment for varicose veins for many decades, and are still prescribed today as a first-line therapy to manage symptoms and prevent the progression of chronic venous insufficiency (CVI).
While compression stockings can provide effective symptom relief for some, many patients find them uncomfortable and have a hard time staying compliant with their treatment plan. Even when patients strictly adhere to their compression therapy, stockings are unlikely to be a curative treatment for vein disease. These limitations can lead physicians to believe that they’re effectively managing their patients’ vein problems with a simple compression therapy prescription when in reality, vein disease may be progressing as it would without any prescription at all.
To help explain the role of compression therapy versus more effective vein treatments, we take a look at why compression stockings are prescribed, their limitations, and what the clinical evidence has taught us about their efficacy.
In this Article
How compression stockings may help manage varicose veins
The challenges and limitations of compression stockings for varicose veins
The comparative data between compression stockings and curative vein treatments
In a healthy vein, tiny valves along the course of the vein open and close to prevent backflow. As a person ages, the veins are subjected to stresses that can cause the valves to weaken and stop working, causing blood to flow backwards and pool in the veins. This phenomenon is called venous reflux, and leads to a variety of symptoms like bulging varicose veins, spider veins, swelling, and cramping.
Compression stockings work by applying external pressure on the veins. This external pressure is meant to ease blood flow through the veins by creating a more favorable pressure gradient across the vein.¹ This mode of action may alleviate symptoms and may prevent further worsening of vein disease.²
Compression stockings are only effective while they are worn. Because swelling increases when sitting or walking, stockings must be worn throughout the entire day to have maximum benefit. Most physicians recommend wearing them throughout the day and only taking them off at night before sleeping. Care must be taken to not get them wet, and any open sores or ulcers that may be present on the legs must be cleaned and bandaged before putting on the stockings.
Many patients find that keeping up with compression therapy for varicose veins is difficult. A literature review published by the European Society of Vascular Surgery in 2017 found that patient compliance with compression stockings was only 66%, and patients were more likely to be compliant when prescribed lower degrees of compression. ³ The investigators of this review cited a number of reasons why patients have a hard time keeping up with compression therapy. Challenges include:
Forgetting to wear stockings
Difficulty putting stockings on
Dissatisfaction with stocking appearance
Discomfort wearing stockings on warm days
Another study found that compression stockings can cause a number of uncomfortable side effects,² including:
Itchiness
Numbness in the legs
Sweating
Pain related to stocking use
Skin breakdown if the stockings are too tight
Fungal infections if the skin is not cleaned properly or if an open wound is present
Contact dermatitis if allergic to stocking material
Studies examining both compression stocking therapy and venous surgery have demonstrated the differences in efficacy between passive management (compression) and proactive vein treatment (surgery). One such study done over two years in Finland showed that patients who underwent surgery had a significant reduction in symptoms and improvement in quality of life measures such as itching, appearance, ability to perform daily activities and swelling. And of the patients who underwent compression therapy alone, 36% of patients had opted to undergo vein surgery after the trial ended.⁴
Another way to look at the long-term effects of compression therapy is to examine their effect on venous stasis ulceration, the ‘end-stage’ complication of vein disease. One such randomized controlled trial published by The Lancet in 2004 compared compression stockings alone versus surgery and compression stockings. This trial, popularly called the ESCHAR trial, found no difference between the two therapies for ulcer healing within 24 weeks. However, patients who had gone though both superficial venous surgery and compression therapy had a 19-20% reduction of ulcer recurrence compared to compression therapy alone.⁵
While these studies looked at surgical vein treatment compared to compression stockings, these findings certainly apply to minimally invasive treatments like thermal vein ablation, VenaSeal, and ultrasound-guided foam sclerotherapy as well.⁶
Compression stockings may provide symptom relief and help prevent vein disease from worsening, but they require continuous use to be effective and do not address the underlying source of vein disease. Clinical studies have demonstrated that more proactive vein treatments are more effective than simple compression therapy. Taken together, these facts point to compression therapy as a very conservative treatment approach with a high likelihood of failure. And while the risks of compression therapy are minimal, the real risk is that effective vein treatment is delayed when we rely too heavily on compression stockings to provide effective long-term vein disease management.
At the Dallas Vein Institute, we tend to say that vein problems are very common and very treatable. Minimally invasive treatments like thermal vein ablation are more than 95% effective in treating varicose veins and resolving vein-related symptoms. ⁷ If you’ve had enough of compression stockings, it may be time to see a vein specialist.
About the Author
Dr. Dev Batra, M.D. is a vein specialist and founding partner of Dallas Vein Institute. Holding board certifications in radiology and vascular & interventional radiology, he is well-versed in vein issues and has been voted one of D-Magazine’s best doctors in Dallas for three years running.
This blog post was written with research and editorial assistance from OnChart.
References
[1] Rohan, C.P-Y., Badel, P., Lun, B., Rastel, D. & Avril, S. (2013). Biomechanical response of varicose veins to elastic compression: A numerical study. Journal of Biomechanics, 46:599-603.
[2] Motykie, G.D., Caprini, J.A., Arcelus, J.I., Reyna, J.J., Overom, E. & Mokhtee, D. (1999). Evaluation of therapeutic compression stockings in the treatment of chronic venous insufficiency. Dermatol Surgery, 25:116-120.
[3] Kankam, H.K.N., Lim, C.S., Fiorentino, F., Davies, A.H. & Gohel, M.S. (2017). A summation analysis of compliance and complications of compression hosiery for patients with chronic venous disease or post-thrombotic syndrome. European Journal of Vascular and Endovascular Surgery, 55:406-416.
[4] Sell, H., Vikatmaa, P., Albäck, A., Lepäntalo, M., Malmivaara, A., Mahmoud, O. & Venermo, M. (2014) Compression therapy versus surgery in the treatment of patients with varicose veins: A RCT. European Journal of Vascular and Endovascular Surgery, 47(6):670-677.
[5] Barwell, J.R., Davies, C.E., Deacon, J., Harvey, K., Minor, J., Sassano, A., Taylor, M., Usher, J., Wakely, C., Earnshaw, J.J., Heather, B.P., Mitchell, D.C., Whyman, M.R. & Poskitt, K.R. (2004). Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomized controlled trial. Lancet, 363:1854-59.
[6] Lohr, J., & Kulwicki, A. (2010). Radiofrequency Ablation: Evolution of a Treatment. Seminars in Vascular Surgery, 23(2), 90–100.
[7] Morrison, N., Gibson, K., Vasquez, M., Weiss, R., Cher, D., Madsen, M., & Jones, A. (2017). VeClose trial 12-month outcomes of cyanoacrylate closure versus radiofrequency ablation for incompetent great saphenous veins. Journal of Vascular Surgery: Venous and Lymphatic Disorders, 5(3), 321–330.
Medical Disclaimer
The Materials available in the Dallas Vein Institute blog are for informational and educational purposes only and are not a substitute for the professional judgment of a health care professional in diagnosing and treating patients.
