Compression has demonstrated effectiveness in preventing both superficial and deep vein thrombosis following various venous procedures, including surgery, endovascular laser therapy, and foam sclerotherapy. Additionally, it has been shown to reduce bruising, hematomas, and bleeding, as well as to minimize inflammation and pain. Compression therapy also plays a crucial role in preventing revascularization and neovascularization. Furthermore, it appears to accelerate recovery time, making it an integral component of postoperative management in venous treatments [1].

Although compression therapy offers numerous anticipated benefits, there is a paucity of clinical studies that directly validate these effects. Moreover, individual variability in symptoms and the discomfort associated with wearing compression stockings should not be overlooked. Notably, above-knee compression stockings are often equipped with silicone bands to prevent slipping; however, silicone-induced skin allergies represent a significant concern. Additionally, rising global temperatures associated with climate change contribute to decreased compliance, as the use of compression stockings becomes increasingly uncomfortable in warmer weather conditions.

This article aims to critically evaluate the practical necessity of using compression stockings, which are widely regarded as effective.

The primary objective of postoperative compression is to narrow or occlude the treated vein segment following endovenous treatment, thereby reducing the risk of luminal thrombosis. Additionally, compression is applied to the surrounding tissue of the excised vein to prevent hematoma formation. Achieving effective compression of the treated vein lumen requires the applied compression pressure to exceed the intravenous pressure. Generally, compression pressure increases during muscle contraction in standing or walking positions, ensuring that the vein lumen is adequately narrowed or occluded [2].

Dr. Mosti [3] has elucidated the hemodynamic effects of thigh compression, specifically addressing the pressure required to compress the thigh veins and questioning whether compression stockings can achieve the necessary levels of pressure. Vein wall dilatation in patients with varicose veins is primarily induced by the force exerted by increased hydrostatic pressure, which is directly responsible for venous dilatation [4]. Hemodynamically, in patients with varicose veins, venous pressure in the lower leg corresponds to the weight of the blood column extending from the right atrium to the lower leg. Assuming the specific gravity of blood is equivalent to that of water, a 100 cm blood column between the calf and the heart would generate a venous pressure of approximately 73.5 mmHg at mid-calf. Similarly, with a 50 cm distance between the mid-thigh and the heart, the venous pressure in the mid-thigh femoral vein in the standing position is estimated to be approximately 37 mmHg.

Thigh-length elastic stockings, which exert 20–30 mmHg of pressure at the lower leg, provide only 10–15 mmHg of pressure at the thigh level. While these stockings slightly reduce the venous lumen in the supine position, they do not effectively reduce the venous diameter at the thigh level in the upright position. According to Dr. Mosti’s [3] analysis, this pressure is insufficient to significantly reduce the diameter of the saphenous or femoral veins at the thigh level.

Magnetic resonance imaging (MRI) has demonstrated that pressures below 10 mmHg are sufficient to occlude the great saphenous vein (GSV) in the supine position. However, substantially higher pressures are required in the sitting or standing position to achieve effective vein restriction. Observations from MRI and duplex ultrasound (DUS) indicate that, in the standing position, compression pressures should exceed 50 mmHg at the lower leg and reach 30–40 mmHg or higher at the thigh level to ensure optimal vein occlusion [5,6].

In a study conducted by Benigni et al. [7], 53 patients who underwent ligation and stripping of the great saphenous vein were provided with postoperative elastic stockings, either with or without rigid pads along the venous course. The addition of rigid pads significantly increased the compression pressure, from approximately 14 mmHg in the supine position without pads to about 49 mmHg when pads were applied. The primary outcome of the study, pain reduction, showed that patients using firm pads experienced a 50% decrease in pain compared to those without pads.

In a study by Mosti et al. [8], 54 patients who underwent flush ligation and stripping were randomly assigned to three groups: one group wore elastic stockings that applied minimal pressure (~10 mmHg) to the thigh postoperatively, a second group was treated with an inelastic adhesive bandage tightly fixed to the skin over the venous course with a plaster to locally increase pressure (>60 mmHg), and a third group received an inelastic adhesive bandage applying approximately 40 mmHg. The primary outcomes assessed were pain, bleeding, hematoma, and the incidence of superficial and deep vein thrombosis. Patients who wore stockings over the inelastic adhesive bandage or the inelastic device demonstrated significantly better outcomes in terms of pain, bleeding, and hematoma compared to those wearing elastic stockings alone.

In the study by Lugli et al. [9], 200 patients undergoing endovenous laser ablation were randomly assigned to receive either an elastic stocking applying 35 mmHg of pressure at the ankle or the same stocking placed over a self-made cotton swab firmly fixed to the skin along the venous course with a plaster cast. Although the compression pressure was not directly measured, it is likely that the addition of the cotton swab increased localized pressure along the vein under the same stocking. The primary outcome of the study was post-procedure pain, which was significantly lower in the group receiving the higher compression, achieved through the addition of the cotton swab under the stocking.

The recently published multicenter society guidelines recommend a compression dressing with a pressure greater than 20 mmHg (equivalent to class II compression stockings), applied with eccentric pads over the ablation point, for patients undergoing vein ablation. This approach is advised for achieving the greatest reduction in postoperative pain [10].

The 2019 guidelines from the American Venous Forum (AVF), Society for Vascular Surgery (SVS), and American College of Phlebology (ACP) recommend compression after thermal ablation or stripping of the saphenous veins. When possible, the guidelines suggest the use of compression (elastic stockings or wraps) following surgical or thermal procedures to treat varicose veins. [GRADE - 2; LEVEL OF EVIDENCE - C]. Regarding the dosage of compression after thermal ablation or stripping, the guidelines indicate that compression dressings providing pressures greater than 20 mmHg, in combination with eccentric pads placed directly over the ablated or surgically treated vein, offer the most significant reduction in postoperative pain. [GRADE - 2; LEVEL OF EVIDENCE - B] [10].

Thigh-length compression stockings are unlikely to provide sufficient pressure to effectively compress the veins in the thigh. Additionally, the silicone band used to prevent slippage often causes various skin issues, which is a primary reason many individuals avoid wearing compression stockings. If the goal is to improve blood flow and reduce swelling following surgery, lower-knee compression stockings alone may be adequate. However, if thigh-length compression stockings are desired postoperatively, the addition of a pad appears to enhance compression and may provide more effective therapeutic benefits.

The author declares no conflicts of interest.