Appropriate treatment methods for varicose veins include drug therapy, surgical treatment, and conservative treatment. Among these, the representative compressive therapy among conservative treatment methods is elastic compression stockings (ECS). ECS usually uses compression hosiery, compression socks, or compression garments. ECS are designed to support the hemodynamic function of calf muscles.

Medical care experts around the world have been using ECS as a primary therapy for their patients with the venous and lymphatic diseases and chronic venous symptoms as well, including lower leg edema. Several major academic societies and experts have been steadily revising and publishing guidelines and evidences on the indications and effectiveness of this method for a long time. Therefore, it is important to find a compelling summary of this large body of literature.

As early as 2018, an evidence-based consensus statement was published by experts [1]. Recently, the Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society announced new guidelines based on the achievements to date [2]. The European Society for Vascular Surgery (ESVS) published the 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs [3]. The ESVS authors reviewed 501 articles and compiled them to make the guidelines updated. Compared to that of 2015’s, this guideline provided more than a dozen of ECS issues that had been changed, unchanged, and newly recommended.

Based on the ESVS 2022 guideline, this review aimed to focus on the effective and efficient use of ECS to enhance patients’ compliance to the primary therapy by convincing them through evidence-based facts.

The ESVS updated ECS issues and they are summarized below into five aspects.

Remommendations numbers correspond to the numbers of recommendations in the guideline document.

Each recommendation follows the European Society of Cardiology system for grading levels of evidence and classes of recommendations.

1. Part I: Recommendations unchanged

Recommendation 9: IB

ECS exerting a pressure of at least 15 mmHg at the ankle are recommended to reduce venous symptoms for the patients with symptomatic chronic venous disease [4,5].

Recommendation 10: IB

Compression treatment exerting a pressure of 20–40 mmHg at the ankle using below knee elastic compression stockings, inelastic bandages or adjustable compression garments is recommended to reduce edema for patients with chronic venous disease and edema (CEAP clinical class C3) [6-8].

Recommendation 23: IA

Immediate postprocedural compression treatment is recommended for patients with superficial venous incompetence undergoing stripping and/or extensive phlebectomies [9,10].

Recommendation 73: IIaB

Intermittent pneumatic compression should be considered for patients with active venous leg ulceration when other compression options are not available, cannot be used, or have failed to promote ulcer healing [11,12].

2. Part II: Recommendations changed

Recommendation 70: IIaB → IA, upgraded

Multilayer or inelastic bandages or adjustable compression garments exerting a target pressure of at least 40 mmHg at the ankle are recommended to improve ulcer healing for patients with active venous leg ulceration [11,13,14].

(2015 recommendation 26: IIaB

The use of high compression pressure of at least 40 mmHg at the ankle level should be considered to promote ulcer healing)

Recommendation 22: IA → IIaA, downgraded

Post-procedural compression treatment should be considered for patients with superficial venous incompetence undergoing ultrasound guided foam sclerotherapy or endovenous thermal ablation of a saphenous trunk [10,15-19].

(2015 recommendation 30: IA

Post-procedural compression is recommended after superficial venous surgery, endovenous truncal ablation, and sclerotherapy)

3. Part III: New recommendations

Recommendation 11: IB

Below knee elastic compression stockings exerting a pressure of 20–40 mmHg at the ankle is reommended to reduce skin induration for patients with chronic stocking venous disease and lipodermatosclerosis and/or atrophie blanche (CEAP clinical class C4b) [20].

Recommendation 24: IA

The duration of post-intervention compression used to minimize post-operative local complication should be decided on an individual basis [9,18].

Recommendation 93: IB

The use of elastic compression hosiery is recommended for patient women presenting with symptoms and/or signs of chronic venous disease [21-23].

Recommendation 12: IIaB

Below knee elastic compression stockings exerting a pressure of 20–40 mmHg at the ankle for patients with post-thrombotic syndrome should be considered to reduce severity [24].

Recommendation 71: IIaB

Superimposed elastic compression stockings exerting a target pressure up to 40 mmHg at the ankle for patients with active venous leg ulceration should be considered for small and recent onset ulcers [25,26].

Recommended 75: IIaB

Long term compression therapy for patients with healed venous leg ulceration should be considered to reduce the risk of ulcer reccurrence [27,28].

Recommendation 13: IIbB

Adjuvant intermittent pneumatic compression for patients with post-thrombotic syndrome may be considered to reduce its severity [24].

Recommendation 74: IIbC

Modified compression therapy under close clinical supervision with a compression pressure less than 40 mmHg for patients with a mixed ulcer caused by coexisting arterial and venous disease may be considered when the ankle pressure is higher than 60 mmHg [29,30].

Recommendation 72: IIIC

Sustained compression therapy is not recommended for patients with active venous leg ulceration with ankle pressure less than 60 mmHg, toe pressure less than 30 mmHg, or ankle brachial index lower than 0.6 (consensus).

4. Part IV: Contraindications to compression treatment

As listed below, only a few contraindications for sustained compression therapy would be considered [31].

1. Severe lower extremity atherosclerotic disease with ABI* <0.6 and/or ankle pressure <60 mmHg.

2. Extra anatomic or superficially tunnelled arterial bypass at the site of intended compression.

3. Severe hear failure, NYHA* Class IV

4. Heart failure NYHA Class III and routine application of compression devices without clinical and hemodynamic monitoring.

5. Severe diabetic neuropathy with sensory loss or microangiopathy with the risk of skin necrosis*.

6. Confirmed allergy to compression material.

*ABI=ankle brachial index

*NYHA=New York Heart Association

NYHA Class IV: fatigue, palpitations, dyspnea and/or angina at rest

NYHA Class III: ordinary physical activity causes undue fatigue, palpitations, dyspnea and/or angina-comfortable at rest

*May not apply to inelastic compression exerting low level of sustained compression pressure (modified compression)

5. Part V: Conservative modality

Patients with symptomatic chronic venous disease C0s–C5 who are not undergoing interventional treatment, awaiting intervention, or have persisting symptoms after intervention should be candidates for conservative therapy.

Conservative management consists of exercise with lifestyle adaptations, compression treatment, and pharmacotherapy with venoactive drugs.

Among these, elastic compression treatment is known to be more effective than others when the patient has venous symptom (IB), CEAP clinical class C3 (IB), and CEAP clinical class C4b (IB), respectively.

Wearing elastic compression stockings usually make the patient uncomfortable.

Patients may experience various discomforts so that physicians should acknowledge those discomforts and try to ease them off (Table 1).

Table 1 . Patients’ subjective and considerable aspects of elastic stockings.

Patients’ subjective	Aspects of elastic stockings
Itchy, I got blisters It’s hard to take them off (donning & doffing) They’re too tight and roll down, the tight area hurts It’s too hot to wear It’s annoying to put them on and I keep forgetting They’re not suitable for the work environment	Material of fabrics (elastic, silicon) Body shape (hip, thigh circumference) Medical condition (arthropathy, neuropathy, ischemic conditions)

Close follow-up is imperative and a physician should be able to modify in response to the individual. If ECS is essential for the management of chronic venous disease, physicians should recommend that the patient make sure to wear it.

In addition, we can choose more comfortable compression stockings, considering the following (Table 1): material of fabrics (elastic, silicon), body shape (hip, thigh circumference), and other medical conditions (arthropathy, neuropathy, ischemic vasculopathy, or complicated diabetic conditions).

It may be inconvenient to wear ECS but physicians should contact patients to check if they are wearing it properly and re-educate them about the need for ECS.

ECS could be essential for quite a few conditions. However, there still remain some inevitable technical problems with ECS, which can preclude patients from wearing ECS thus eventually decreasing compliance. In the setting of the patients with chronic venous disease and the ECS is a requisite for the management of their symptom, we need to assure them that wearing ECS is not merely helpful for alleviating chronic venous symptoms but also cost-effective and efficient for the improvement of lower leg circulation. We would be able to increase the patient’s compliance through applying the recommendations appropriate to the occasion and providing our close medical assistance as well.

The author declares no conflicts of interest.

This report was presented under the title of things we can do to help patients wear compression stockings more faithfully, at the 47th annual academic meeting of The Korean Society for Phlebology.