Stocking in dvt and varicose vein

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compression stockings DVT varicose veins

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Compression Stockings in DVT and Varicose Veins

What Are Compression Stockings?

Compression (elastic/graduated) stockings are external garments that apply graduated pressure - highest at the ankle, decreasing proximally - to improve venous return by narrowing superficial and calf veins and augmenting the calf muscle pump.

Classification of Compression Hosiery

The British classification system (used clinically):

Class	Pressure at Ankle	Use
Class 1	14-17 mmHg	Mild varicose veins, minor ankle swelling
Class 2	18-24 mmHg	Moderate varicose veins, mild post-thrombotic syndrome
Class 3	25-35 mmHg	Severe chronic venous insufficiency, venous ulcers

Therapeutic compression targets 30-40 mmHg at the ankle for post-thrombotic syndrome. Complete occlusion of superficial veins occurs at a median pressure of 70 mmHg - that is NOT the therapeutic goal.

Bailey and Love's Short Practice of Surgery, 28th Ed

Types of Compression

Elastic compression (stockings, long-stretch bandages) - maintains relatively constant pressure at rest and during exercise.
Inelastic compression (Unna's paste boot, short-stretch bandages, four-layer bandage, Velcro devices) - demonstrates a more dramatic pressure increase during exercise (beneficial for venous pump), but pressure decreases when recumbent. Better tolerated overnight and over days.

Key point: Inelastic compression achieves greater venous hemodynamic improvement at equivalent pressures compared to elastic compression, and maintains its effect despite gradual pressure loss over time.

Mulholland and Greenfield's Surgery, 7th Ed

Stockings in DVT

1. DVT Prophylaxis (Prevention)

Compression stockings are used as mechanical thromboprophylaxis, particularly:

During long-haul flights (combined with walking every hour)
Perioperatively in surgical patients

Important caveat: A stocking fitted too tightly can cause skin ulceration and paradoxically increase DVT risk on long flights. Proper fitting is essential.

2. Post-Thrombotic Syndrome (PTS) Prevention

PTS develops in up to 50% of patients with proximal DVT, typically 6 months to 2 years after the event. It is caused by:

Residual venous obstruction
Valvular incompetence leading to venous hypertension

Evidence regarding stockings for PTS is conflicting - they are not routinely recommended for all DVT patients. Current guidance (Goldman-Cecil Medicine):

If symptoms are mild-moderate: elevation, avoiding prolonged standing/sitting, occasional analgesics
If edema is present: lightweight support hose until edema resolves
If severe symptoms: stocking applying 30-40 mmHg at ankle

3. Venous Ulcers (Severe PTS)

The best management is prevention - apply graduated compression stockings when skin changes develop alongside leg swelling. Once an ulcer heals, graduated compression stockings should be prescribed to prevent recurrence. Stockings are the cornerstone of long-term venous ulcer management.

Goldman-Cecil Medicine, International Edition

Stockings in Varicose Veins

Role of Compression Hosiery

Compression hosiery significantly improves varicose vein symptoms (aching, heaviness, throbbing, swelling) - this is well established.
Symptoms are typically worse at end of day and with prolonged standing; they are relieved by elevation or compression hosiery.
A therapeutic trial of hosiery can help confirm whether symptoms are truly venous in origin.

What Compression Does NOT Do

There is no evidence that compression hosiery prevents the occurrence or progression of varicose veins.
Level 1 trial data show that interventional treatment (endothermal ablation, surgery) offers superior quality-of-life improvement and is more cost-effective than compression alone.

Limitations and Risks

Compliance is universally poor - patients find stockings uncomfortable and cosmetically unappealing.
Incorrect application can cause serious harm: pressure necrosis, tourniquet effects.
Assessment, prescription, and fitting should be done by trained personnel only.

Current Position

Compression is to be regarded as an adjunct to assessment or treatment of varicose veins, unless the patient chooses it over intervention.

Bailey and Love's Short Practice of Surgery, 28th Ed

Special Considerations

Arterial Occlusive Disease (Contraindication)

Compression is contraindicated or must be modified in patients with coexisting arterial disease:

ABI ≥ 0.80: standard compression is safe and effective
ABI 0.50-0.80 (or ankle systolic pressure ≥60 mmHg): modified lower-pressure compression can still aid ulcer healing
ABI ≤ 0.50 or ankle pressure <60 mmHg: compression bandages/stockings are not indicated

Stocking Length

Below-knee vs. thigh-length: no evidence that thigh-length stockings are more effective
Below-knee stockings are preferred - easier to apply and have much better patient acceptance

Frequency of Change

Stockings often need to be changed/replaced more frequently during early stages of treatment because significant limb swelling reduction changes the fit.

Summary Table

Indication	Role of Stockings	Pressure	Evidence
DVT prophylaxis (surgical/flight)	Mechanical thromboprophylaxis	Class 1-2	Supported
Post-thrombotic syndrome	Symptom management, ulcer prevention	30-40 mmHg	Conflicting for PTS prevention
Venous ulcer	Healing adjunct, prevent recurrence	Class 3	Supported
Varicose veins (symptoms)	Symptom relief (adjunct only)	Class 1-2	Supported for symptoms only
Varicose vein progression prevention	Not recommended	-	No evidence

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