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up to the giuteal fold
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Fig. 12.6 Sigvaris©
measurement guidelines
for sizing compression
stockings [
17]
M. Machin et al.
1. Ankle circumference
directly above ankle bone
3. Calf length from the floor to
the fibuler head
2. Calf circumference at
fullest part of the calf
4. Widest circumference
of the thigh
5. Leg length from the floor
6. Circumference at the hip
12 Compression Stockings
169
• Thigh circumference
• Leg length
The sizes available from Sigvaris© cater for an ankle circumference of 18cm up
to 36cm.
12.8 Compression Stockings: Fabrics andDesign
Graduated compression stockings are available in a range of fabric compositions
and colors. Stockings are commonly made from a synthetic composite of polyamide
and elastane in a 2 to 1 ratio. Addition of cotton to the composite is often added to
change the properties of the material, making them easier to wear in hotter climates.
Furthermore, some stocking manufacturers such as Sigvaris© add zinc to the sole of
the stocking to combat odor [17].
Stockings are available in a range of colors and designs which is an important
consideration for adherence, particularly in encouraging patients to remain
socially active.
Both closed-toe and open-toe variations are available. Open-toe stockings are
usually preferred by those with arthritic or deformed toes, or fungal infection of the
forefoot or a relatively longer foot size compared with their calf dimeter [13].
Closed-toe stockings prevent the toe swelling that can, for example, trouble those
with lymphedema.
The length of the graduated stocking prescribed will depend on if there is venous
insufciency or lymphoedema in the thigh. Regarding the prevention of PTS, it has
been shown that there is no difference in prevention of PTS after acute proximal
DVT when wearing thigh-length in comparison to knee-length stockings. However,
knee-length stockings are better tolerated [18].
12.8.1 Donning Aids
Donning aids are devices designed to facilitate the application and subsequent
removal of the graduated compression stocking to the upper or lower limb [19].
Donning aids are available in a range of designs including low-friction materials
that allow manipulation of the stockings over it, xed step-in cages which hold the
stocking open as it is applied, and roller devices that apply the stockings as it rolled
up the limb [19]. Figure12.7 demonstrates the step-in Medi Valet frame type donning aid and the Sigvaris© roller ball applicator.
Other readily available aids, such as a plastic bag, can also be used to decrease
friction over the foot.
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M. Machin et al.
a
Fig. 12.7 (a) demonstrates the step-in Medi Valet frame type donning aid which can be held in
place using the metal arms; (b) the Sigvaris© roller ball applicator which is shown as it is used
and alone
b
12.8.2 Indications forCompression Therapy
The clinical indications for graduated compression therapy include:
1. Prevention of thromboembolic events (TEDS), although this benet is mar-
ginal [20].
2. Prevention of post-thrombotic syndrome.
3. Symptomatic relief in post-thrombotic syndrome.
4. Symptomatic relief in chronic venous disease.
5. Management of venous ulceration.
6. Management of lymphedema and lipedema.
See Table 12.3 for summary of American and European clinical practice
guidelines.
12.9 Thromboembolic Deterrent Stockings inthePrevention
ofHospital-Acquired Thrombosis
The CLOTS-1 RCT assessed their use in hospital-acquired thrombosis prevention
for stroke in patients who had a contraindication to low-molecular-weight heparin
and demonstrated no difference in the rate of hospital-acquired thrombosis [16].
They did, however, cause a signicant number of adverse skin events such as ulceration and necrosis. Furthermore, the large multicenter GAPS RCT demonstrated no
additional benet in reduction of hospital-acquired thrombosis when applying graduated compression stockings to surgical inpatients receiving low-molecular-weight
heparin [16]. NICE guidelines currently still recommend their use in the prevention
of hospital-acquired thrombosis [21].
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171
12.10 Prevention ofPost-Thrombotic Syndrome
Current NICE guidelines published in 2018 advise against the use of compression
stockings in the prevention of post-thrombotic syndrome after acute ilio-femoral/
proximal deep vein thrombosis [21]. Previous NICE guidelines had recommended
compression stockings, but subsequent publication of the SOX trial promoted a
change in recommendations [22].The SOX trial was a placebo-controlled doubleblind RCT which assigned 803 participants to receive graduated compression stockings (30–40 mmHg) or placebo stockings. The cumulative incidence of PTS as
dened by the Villalta scale did not differ between the two groups, with 53% in the
graduated compression stocking arm and 52% in the placebo stocking arm (HR
1·00, 95% CI 0·81–1·24, p=0.96).
The American Heart Association guidelines echo this, suggesting that the evidence for compression therapy in reducing post-thrombotic syndrome is uncertain
and hence not recommended [23]. A systematic review and meta-analysis on the use
of graduated compression stockings in prevention of PTS revealed high heterogeneity in the three pooled RCTs, the results of which are illustrated in Table12.4 [24].
Table 12.3 Illustrative summary of American and European clinical practice guidelines
European
Society for
Vascular
Surgery
International
Union of
Phlebology
Recommendation for
compression therapy
To increase venous leg ulcer
healing rate
Against their use for
symptomatic venous reux
disease when other
denitive treatments are
appropriate
Management of symptoms
related to supercial disease
Class of evidence: level I–III
Grade of evidence: A–C
American
Venous
Forum
1A 1A 1A
1B 1A
2C 2C 1B
American
College of
Phlebology
Table 12.4 Cumulative incidence of PTS in the three RCTs comparing graduated compression
stockings to control stockings [24]
First author
(study)
Kahn etal. Villalta 53% 52%
Prandoni
etal.
Brandjes
etal.
System used to
dene PTS
Villalta 26% 49%
Brandjes 31% 70%
Incidence of PTS in graduated
compression stockings arm
Incidence of PTS in
control arm
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M. Machin et al.
However, it did suggest a trend between increased baseline risk of PTS and increasing benet with stockings, for example in those in whom anticoagulation is
ineffective.
12.11 Symptomatic Relief inPost-Thrombotic Syndrome
The use of class II compression stockings for symptomatic relief is widespread.
This is reected in clinical practice guideline recommendations; however, there is
little evidence to support their use [9, 25]. A recent systematic review identied only
two studies investigating the use of graduated compression stockings in the management of established PTS [25]. The rst trial was published by Ginsberg etal.
reporting a double-blind RCT of 35 participants with PTS randomized to either
graduated compression stocking (30 to 40mmHg) or a placebo stocking. At 2years
follow-up, there was no signicant difference in the treatment success between the
two arms.
The second study was a non-randomized prospective trial that allocated 34 consecutive patients with PTS (median Villalta score of 10) to four different compression stockings. Each participant wore each stocking for 60 min and underwent
venous duplex and air plethysmography and subsequently offered a participant preference [26]. The venous volume and time to ll the venous volume signicantly
improved with use of all types of stocking versus no compression.
However, the reported results did not include long-term symptom control or
quality of life, and limited conclusions regarding their efcacy could be drawn.
However, as compression represents a low-risk and low-cost intervention, a trial
of stockings is often considered appropriate. This is mirrored in both the NICE and
American Heart Association guidelines [21, 23].
12.12 Symptomatic Relief inAcute DVT
Kahn etal. undertook a large multicenter RCT investigating the use of graduated
compression stockings in the treatment of acute leg pain in patients suffering from
acute proximal DVT [22]. A total of 803 participants with acute proximal DVT were
randomized to either graduated compression stockings or placebo stockings. There
was no signicant difference in pain score at any point up to the 60-day follow-up,
and it was concluded that compression stockings failed to reduce pain in acute DVT.
12.13 Symptomatic Relief inChronic Venous Disease
Class II compression stockings are often used for symptomatic relief in chronic
venous disease; however, the evidence to support this is lacking. For supercial
varicose veins, three RCTs have investigated the use of compression stockings in
disease/symptom control [27–29]. The pooled analysis from the NICE evidence
summary revealed that compression stockings were associated with a relative
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173
reduction in pain experiences and the feeling of “heavy”/tired legs; however, the
uncertainty in evidence rendered the analysis low quality. UK NICE guidelines recommend endovenous intervention for incompetent varicose veins leading to venous
insufciency. NICE recommend against graduated compression stockings in these
patients unless interventional treatment is unsuitable [30]. However, if there is evidence of skin changes such as lipodermatosclerosis or persistent venous eczema,
these recommendations differ slightly. In addition to treatment of supercial venous
insufciency, NICE recommend class II graduated compression therapy. However,
this is largely based on expert opinion [31].
12.14 Treatment ofVenous Ulceration
The use of compression therapy in the treatment of venous ulceration was examined
by a 2012 Cochrane systematic review. This identied 48 RCTs assessing the use of
compression bandaging/stockings and wound dressings for the management of
venous ulceration [32]. Overall, it was found that compression bandaging reduced
time to ulcer healing. Importantly, pooled analysis from 3 RCTs demonstrated that
three-component systems containing an elastic component, i.e., the Charing Cross
four-layer bandaging healed more ulcers than those without elastic. The VenUS1
trial is known for demonstrating that four-layer bandage (multilayer elastic compression) is superior to the short-stretch bandage (multilayer, inelastic compression)
with signicant improvement in ulcer healing while being more cost-effective [33].
Furthermore, a systematic review assessing the use of four-layer bandaging in
comparison to short-stretch bandaging identied 7 RCTs; pooled analysis revealed
that four-layer bandaging was associated with a signicantly shorter time to venous
ulcer healing [32]. Interestingly, a recent multicenter RCT (the VenUS IV trial)
comparing 4-layer bandaging to two-layer hosiery therapy found no difference in
time to ulcer healing and suggested that two-layer hosiery therapy may be more
cost-effective [34]. However, more research on this comparison is required.
It is important to note the isolated use of compression bandaging in venous ulceration is not recommended. The recent EVRA RCT demonstrated that early endovenous ablation of supercial venous reux at the time of ulceration resulted in faster
healing of venous leg ulcers and was subsequently found to be more cost-effective
than compression alone [35].
Regarding deep venous insufciency, Raju etal. report impressive results from a
prospective cohort study of 504 patients with C2–C6 disease and deep venous
incompetence undergoing intravascular ultrasound-guided iliac vein stent placement [36]. For patients with C5 disease, the rate of limbs with healed active ulcers
and freedom from ulcer recurrence were 54% and 88%, respectively. Improvement
in pain experienced at 5years was reported in 78% of participants with a corresponding signicant increase in quality of life.
Furthermore, Black etal. reported early results that the use of deep venous stent
in chronic iliac vein occlusion may improve the healing of venous ulcers; however,
this is an evolving area of research [37].
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Adjunctive therapies such as pentoxifylline, micronized puried avonoid fraction, skin care, and wound dressing also play an important role but are outside the
scope of this chapter [38]. The UK NICE guidelines recommend multilayer bandaging in the management of venous ulceration [38]. This is also reected in the
Scottish Intercollegiate Guidelines Network publication [39].
12.15 Treatment ofAcute Leg Pain Post-Endovenous Ablation
Graduated compression stockings are commonly used after endovenous ablation or
manual avulsion of varicose veins. The best evidence that graduated compression
stockings are benecial in the reduction of postoperative pain comes from the RCT
Compression After Endovenous Thermal Ablation of Varicose Veins (COMETA
Trial) [40]. A total of 206 participants who underwent endothermal ablation, with or
without concurrent phlebectomies, were allocated to receive either 7days of graduated compression stockings or no stockings at all. Median pain scores in the graduated compression group were signicantly lower within the rst few days after the
procedures suggesting that compression stockings are benecial in the reduction of
postoperative pain. There was also no difference in the degree of ecchymosis.
12.16 Treatment ofLipedema
Lipedema is a symmetrical and abnormal increase of adipose tissue in the gluteal
region, hips, thighs, and calves [41]. This increase in adiposity is disproportional to
the trunk and upper limbs. Nonsurgical treatment consists of manual lymph drainage, physical exercise, and multilayered/multicomponent compression bandaging;
however, very little evidence exists in the literature. A randomized comparative
study of 11 patients allocated participants to complete decongestive physiotherapy
(including multilayered compression bandaging and manual lymph drainage) alone
or combined with intermittent pneumatic compression for 5 days [42]. The reduction in limb diameter was signicant (although relatively small) in the control arm
and the intermittent pneumatic compression arm at 6.2% and 8.9%, respectively.
Further research in this area is required in order to provide evidence-based
recommendations.
12.17 Treatment ofLymphedema
The use of class II/III compression stockings in lymphedema is common practice.
However, there is a lack of evidence to support their use [43, 44]. This could be due
to RCTs using compression therapy as the control arm and then investigating additional treatment modalities as the intervention. Often lymphedema is approached
with a treatment phase using manual lymphatic drainage and multilayer bandaging
to reduce the size of the limb, followed by a maintenance phase using class II/III
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graduated compression stockings. This two-stage approach comes as a result of an
RCT assessing the use of multilayer bandaging followed by stockings in comparison to stockings alone in patients with upper or lower limb lymphedema of any
cause [45]. Greater and sustained limb volume reduction was seen in the two-phase
approach in comparison to compression stockings alone.
12.18 Adherence toCompression Stockings
The adherence to graduated compression stockings varies dramatically. In two large
RCTs investigating the use of graduated compression stockings in the prevention of
PTS, the adherence at 2 years ranged from 56% in the SOX trial to 87% reported by
Prandoni etal. 2014 [22, 46]. There are a variety of factors that inuence adherence
with graduated compression therapy including hot climate, season, belief that they
work, comfort, fashion, and ability to easily don and doff stockings. In a regression
analysis of participants with venous ulceration, there were two factors that were
found to be associated with adherence: a belief that wearing stockings was benecial and the belief that stockings were uncomfortable to wear [47]. Other reports
have highlighted that adherence was better in those with knowledge about their
underlying condition and self-efcacy, with a lower adherence seen in those with
depression [48].
The authors of this chapter have previously undertaken focus groups and online
surveys addressing adherence to graduated compression stockings in patients
with PTS.
When questioned regarding measures to improve adherence the responses were
more choice of stocking colors and fabrics, a custom-tted stocking, stockings that
are easier to get on and off, and more information on the risk of reducing ulceration
by wearing stockings.
Furthermore, other pragmatic issues were identied such as owning two pair of
stockings may increase compliance as when one pair is in the wash, the other pair
can be worn.
Adherence to compression stockings is complex, with a variety of environmental
and patient-related factors. However, a belief that wearing the stockings is worthwhile seems to be key.
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