Support hose and varicose veins

Graduated compression stockings for the initial treatment of varicose veins in people without venous ulceration

BACKGROUND

Compression hosiery or stockings are often the first line of treatment for varicose veins in people without either healed or active venous ulceration. Evidence is required to determine whether the use of compression stockings can effectively manage and treat varicose veins in the early stages. This is the second update of a review first published in 2011.

OBJECTIVES

To assess the effectiveness of compression stockings for the only and initial treatment of varicose veins in people without healed or active venous ulceration.

SEARCH METHODS

For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and AMED databases and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 12 May 2020. We also checked references of studies identified from the literature searches.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) involving people diagnosed with primary trunk varicose veins without healed or active venous ulceration (Clinical, Etiology, Anatomy, Pathophysiology (CEAP) classification C2 to C4). Included trials assessed compression stockings versus no treatment or placebo stockings, or compression stockings plus drug intervention versus drug intervention alone. We also included trials comparing different lengths and pressures of stockings. We excluded trials involving other types of treatment for varicose veins (either as a comparator to stockings or as an initial non-randomised treatment), including sclerotherapy and surgery.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology. Two review authors independently assessed trials for inclusion, extracted data, assessed risk of bias and assessed the certainty of the evidence using GRADE. Outcomes of interest were change in symptoms; physiological measures; complications; compliance; comfort, tolerance and acceptability of wearing stockings; and quality of life.

MAIN RESULTS

We included 13 studies with 1021 participants with varicose veins without healed or active venous ulceration. One study included pregnant women while other studies included participants who had sought medical intervention for their varicose veins by being on surgical waiting lists, or attending vascular surgery or dermatology clinics or outpatient departments. The stockings used in the studies exerted different levels of pressure, ranging from 10 mmHg to 50 mmHg. Five studies assessed compression stockings versus no compression stockings or placebo stockings. Three of these studies used knee-length stockings, one used full-length stockings and one used full tights. Eight studies compared different types or pressures of knee-length stockings. The risk of bias of many included trials was unclear, mainly because of inadequate reporting. We were unable to pool studies as they did not report the same outcomes or used different ways to assess them. Many studies were small and there were differences in the populations studied. The certainty of the evidence was therefore low to very low. Compression stockings compared with no treatment or placebo stockings All four studies that reported change in symptoms found a subjective improvement by the end of the study. However, change in symptoms was not always analysed by comparing the randomised arms of the studies and was therefore subject to bias. Two studies assessed physiological measures using either ankle circumference or duplex sonography to measure oedema. Ankle circumference showed no clear difference between baseline and follow-up while oedema was reduced in the stocking group compared with the placebo stocking group. Three studies reported complications or side effects with itching and irritation the main side effects reported. None of the trials reported severe side effects. Reports of compliance varied between studies. One study reported a high dropout rate with low levels of compliance due to discomfort, application and appearance; two studies reported generally good levels of compliance in the stocking group compared to placebo/no treatment. Two studies reported comfort, tolerance and acceptability with outcomes affected by the study population. Compression tights were increasingly rejected by pregnant women as their pregnancy progressed, while in one study of non-pregnant women, the stockings group showed no more hindrance of normal activities and daytime discomfort when compared with placebo stockings. One study reported quality of life showing no clear differences between the stocking and placebo stocking groups. Compression stockings compared with different compression stockings All five studies that reported change in symptoms found a subjective improvement in symptoms by the end of the study. Change in symptoms was not always analysed comparing the randomised arms of the trials and was therefore subject to bias. Five studies reported a variety of physiological measures such as foot volumetry, volume reduction and change in diameter. Generally, there were no clear differences between study arms. Four studies reported complications or side effects, including sweating, itching, skin dryness, and constriction and tightness. None of the trials reported severe side effects. Two studies reported compliance showing no difference in compliance rates between stockings groups, although one study reported high initial levels of dropout due to discomfort, appearance, non-effectiveness and irritation. Four studies reported comfort, tolerance and acceptability. Two studies reported similar levels of tolerance and discomfort between groups. Discomfort was the main reason for indicating a preference for one type of stocking over another. None of the studies assessed quality of life. No conclusions regarding the optimum length or pressure of compression stockings could be made as there were no conclusive results from the included studies.

AUTHORS' CONCLUSIONS

There is insufficient high-certainty evidence to determine whether or not compression stockings are effective as the sole and initial treatment of varicose veins in people without healed or active venous ulceration, or whether any type of stocking is superior to any other type. Future research should consist of large RCTs of participants with trunk varices either wearing or not wearing compression stockings to assess the efficacy of this intervention. If compression stockings are found to be beneficial, further studies assessing which length and pressure is the most efficacious could then take place.

Long-Term Prevention of Sequelae of Chronic Venous Disease with Graduated-Compression Stockings

Chronic venous insufficiency (CVI) with associated venous hypertension may lead to stasis dermatitis and ulceration. This sixty-month study determined whether compliance with the use of below-the-knee graduated-compression hosiery affected long-term clinical manifestations.

At one year, 105 patients of 284 (37%) were compliant and 179 (63%) were not. At 2 years, of the available compliant patients (89), none had skin changes; 28% of the available (51) noncompliant patients had skin changes; and 13 of this group (51) had ulceration. At sixty months, of 79 compliant patients available, none had ulceration and 11 had stasis changes. Of noncompliant patients (119) available for assessment, 63 (53%) have chronic skin changes.

Compliance with the use of gradient compression below-the-knee stockings reduces the incidence of venous stasis disease and ulceration.

The effects of short-term use of compression stockings on health related quality of life in patients with chronic venous insufficiency

[Purpose] This study was aimed to analyse the effects of short-term use of compression stockings (CS) on symptoms and QoL in patients with Chronic Venous Insufficiency (CVI). [Subjects and Methods] Based on the CEAP classification C2 and C3, 117 patients with CVI were enrolled in this study. The participants were divided into two groups. The control group refused to use CS, however, was advised to do exercises and take skin care whereas the CS group used CS and performed exercise. The data were collected by using Nottingham Health Profile (NHP), Venous Insufficiency Epidemiological and Economic Study (VEINES-QoL/Sym) and Beck Depression Inventory (BDI) at baseline and after four weeks of treatment and compared within and in between groups. [Results] The comparison of pre- and post-treatment differences between groups was statistically significant for all parameters. In the study group, pre- and post-treatment scores for each parameter were significantly different. However, elevated scores in the control group suggested worsening of the illness. [Conclusion] This study established that short-term use of CS in patients with CVI significantly improved disease specific and general QoL by reducing venous symptoms. Further studies with larger sample size are necessary to confirm these findings.

Paroven and Graduated Compression Hosiery for Superficial Venous Insufficiency

The effects of Sigvaris graduated compression hosiery and Paroven on symptoms of superficial venous insufficiency were assessed in a prospective, randomized, crossover study. Seventy-two patients awaiting surgery for non-cosmetic symptoms associated with varicose veins received 4-week treatments in random order, namely; placebo, Paroven alone, Sigvaris graduated compression hosiery and placebo, Sigvaris graduated compression hosiery and Paroven. Symptoms were assessed before and after each treatment using linear analogue scales. No statistically significant effects were observed, but there was a consistent trend for both Paroven alone and hosiery alone to produce modest improvements in symptoms. The relief of symptoms associated with a combination of Paroven and Sigvaris graduated compression hosiery was greater than that produced by either treatment on its own.

Support Stockings in Practical Management of Varicose Veins

Sixty six patients were studied in a randomized trial comparing two types of pressure graduated stockings. The variables studied were age, sex, grip strength and stocking type. These variables were correlated with the patient's willingness to wear support hose (compliance with treatment as judged by random home visit). Of the 66 patients prescribed stockings, 40 patients (18 Medi Plus and 22 Sigvaris) completed the study. Overall compliance with treatment was only 32%. Increasing age correlated positively with usage of stockings. Other variables (including grip strength) had no significant effect in determining likelihood of compliance. Willingness to comply with treatment proved to be a greater problem than ability to do so.

Compression Stockings and their Effect on the Venous Pump — A Comparative Study

A prospective study of 45 patients with venous insufficiency. The patients were divided into four different groups that were comparable in venous function, age and sex distribution. The effect of four different conventional compression stockings was evaluated by their clinical effect and the effect upon the musculo-venous pump as assessed by ambulatory strain-gauge plethysmography, over a 6-week treatment period. In this patient category, there could not be demonstrated any additional benefit of increasing compression, and patient acceptability was concomitantly reduced with increasing pressure. The pressure exerted by the stockings was assessed by the Borgnis Medical Stocking Tester, and pressures were found to increase in the upright position with an increase in the concomitant pressure gradient between ankle and knee.

A Prospective Study of the Long-Term Efficacy of Two Different Venoactive Drugs in Patients with Post-Thrombotic Syndrome

Objective:

In an open cross-over study, the effect of two different venoactive drugs was prospectively studied in a series of patients with post-thrombotic syndrome.

Design:

Prospective, open cross-over study.

Patients:

Twenty-nine patients with established unilateral deep venous insufficiency of at least 12 months duration, and a history of venography-proven deep venous thrombosis in the affected leg.

Interventions:

On entering the study, patients were randomly assigned to receive either Hidrosmina (Venosmil, FAES SA, Spain) 600 mg daily, or 0-(β-hydroxyethyl)-rutosides (Venoruton, Zyma SA, Switzerland) 900 mg daily. The drugs were taken for 6 months. At the end of this period, the drug was discontinued, and patients taking Hidrosmina changed to rutosides, or vice versa, for a further 6-month period. Finally, both drugs were discontinued, and patients were re-examined 3 and 6 months later.

Results:

During the first 6-month period, 12 out of 29 patients showed reduced tiredness and/or pain in the leg in comparison to the control visit. Furthermore, a slight reduction was found in mean circumferences of both the ankle and calf during this study period. During the second 6-month period of therapy, six additional patients improved their subjective symptoms, but there were three patients in whom these symptoms had increased. Six months after discontinuation of therapy, subjective symptoms increased in 10 out of 29 patients, and mean circumferences of both the ankle and calf returned to baseline values.

Conclusions:

In this pilot study our findings demonstrate that venoactive drugs may improve both objective and subjective symptoms in patients with post-thrombotic syndrome, and that these effects disappear after drug therapy is discontinued.

Low Compression, High Gradient Stockings in Patients with Venous Insufficiency: Effect on the Musculo-Venous Pump, Evaluated by Strain Gauge Plethysmography

In a prospective study 17 patients with superficial venous insufficiency were treated with a high gradient low compression stocking for a period of 6 weeks. The effect upon the musculo-venous pump was evaluated by ambulatory calf strain gauge plethysmography and compared to improvements in symptoms and clinical findings. The immediate effect of the stockings was a significant 22% reduction in venous reflux and 43% increase of the expelled volume. Moreover, an effect after 6 weeks (with the stockings applied during all daytime hours) was found even after the stockings were removed. This reduction of venous reflux of 30% and increase in expelled volume of 29% were statistically significant. Symptoms and objective findings were simultaneously improved. Finally the stockings were found to increase the maximal venous outflow by 27%.

Compression stockings for the initial treatment of varicose veins in patients without venous ulceration

BACKGROUND

Compression hosiery or stockings are often the first line of treatment for varicose veins in people without either healed or active venous ulceration. Evidence is required to determine whether the use of compression stockings can effectively manage and treat varicose veins in the early stages. This is an update of a review first published in 2011.

OBJECTIVES

To assess the effectiveness of compression stockings for the only and initial treatment of varicose veins in patients without healed or active venous ulceration.

SEARCH METHODS

For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched August 2013) and CENTRAL (2013, Issue 5).

SELECTION CRITERIA

Randomised controlled trials (RCTs) were included if they involved participants diagnosed with primary trunk varicose veins without healed or active venous ulceration (Clinical, Etiology, Anatomy, Pathophysiology (CEAP) classification C2 to C4). Included trials assessed compression stockings versus no treatment, compression versus placebo stockings, or compression stockings plus drug intervention versus drug intervention alone. Trials comparing different lengths and pressures of stockings were also included. Trials involving other types of treatment for varicose veins (either as a comparator to stockings or as an initial non-randomised treatment), including sclerotherapy and surgery, were excluded.

DATA COLLECTION AND ANALYSIS

Two authors assessed the trials for inclusion and quality (SS and LR). SS extracted the data, which were checked by LR. Attempts were made to contact trial authors where missing or unclear data were present.

MAIN RESULTS

Seven studies involving 356 participants with varicose veins without healed or active venous ulceration were included. Different levels of pressure were exerted by the stockings in the studies, ranging from 10 to 50 mmHg. One study assessed compression hosiery versus no compression hosiery. The other six compared different types or pressures of stockings. The methodological quality of all included trials was unclear, mainly because of inadequate reporting.The symptoms subjectively improved with the wearing of stockings across trials that assessed this outcome, but these assessments were not made by comparing one randomised arm of a trial with a control arm and are therefore subject to bias.Meta-analyses were not undertaken due to inadequate reporting and actual or suspected high levels of heterogeneity.

AUTHORS' CONCLUSIONS

There is insufficient, high quality evidence to determine whether or not compression stockings are effective as the sole and initial treatment of varicose veins in people without healed or active venous ulceration, or whether any type of stocking is superior to any other type. Future research should consist of a large RCT of participants with trunk varices either wearing or not wearing compression stockings to assess the efficacy of this intervention. If compression stockings are found to be beneficial, further studies assessing which length and pressure is the most efficacious could then take place.

Compression stockings for the initial treatment of varicose veins in patients without venous ulceration

BACKGROUND

Compression hosiery or stockings are often the first line of treatment for varicose veins in people without either healed or active venous ulceration. Evidence is required to determine whether the use of compression stockings can effectively manage and treat varicose veins in the early stages.

OBJECTIVES

To assess the effectiveness of compression stockings for the initial treatment of varicose veins in patients without healed or active venous ulceration.

SEARCH METHODS

The Cochrane Peripheral Vascular Disease Group searched their Specialised Register (last searched 31 May 2011) and CENTRAL (2011, Issue 2). In addition, the reference lists of relevant articles were searched. Authors of ongoing and current trials were contacted. There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) were included if they involved participants diagnosed with primary trunk varicose veins without healed or active venous ulceration (Clinical, Etiology, Anatomy, Pathophysiology (CEAP) classification C2 to C4). Included trials assessed compression stockings versus no treatment, compression versus placebo stockings, or compression stockings + drug intervention versus drug intervention alone. Trials comparing different lengths and pressures of stockings were also included. Trials involving other types of treatment for varicose veins (either as a comparator to stockings or as an initial non-randomised treatment), including sclerotherapy and surgery, were excluded.

DATA COLLECTION AND ANALYSIS

Two authors assessed the trials for inclusion and quality (SS and LR). SS extracted the data, which were checked by LR. Attempts were made to contact trial authors where missing or unclear data were present.

MAIN RESULTS

Seven studies involving 356 participants with varicose veins without healed or active venous ulceration were included. Different levels of pressure were exerted by the stockings in the studies, ranging from 10 to 50 mmHg. One study assessed compression hosiery versus no compression hosiery. The other six compared different types or pressures of stockings. The methodological quality of all included trials was unclear, mainly because of inadequate reporting.The symptoms subjectively improved with the wearing of stockings across trials that assessed this outcome, but these assessments were not made by comparing one randomised arm of a trial with a control arm and are therefore subject to bias.Meta-analyses were not undertaken due to inadequate reporting and actual or suspected high levels of heterogeneity.

AUTHORS' CONCLUSIONS

There is insufficient, high quality evidence to determine whether or not compression stockings are effective as the sole and initial treatment of varicose veins in people without healed or active venous ulceration, or whether any type of stocking is superior to any other type. Future research should consist of a large RCT of participants with trunk varices either wearing or not wearing compression stockings to assess the efficacy of this intervention. If compression stockings are found to be beneficial, further studies assessing which length and pressure is the most efficacious could then take place.

A systematic review of compression hosiery for uncomplicated varicose veins

OBJECTIVE

Compression hosiery is widely used in the prevention and management of symptoms related to varicose veins. However, there are still gaps and questions in relation to its benefit. This review seeks to examine the current evidence regarding the effectiveness of compression hosiery in the treatment of varicose veins.

METHOD

Prospective, randomized controlled trials (RCTs) evaluating compression hosiery in the treatment of varicose veins were sought. Where RCTs were unavailable other evidence was included. Studies were included if they evaluated the application of compression to patients with a diagnosis of varicose veins. Twelve electronic bibliographic databases and 18 internet-based research resources were searched. Inclusion or exclusion of trials was decided by two reviewers acting independently.

RESULTS

The search strategy identified 25 studies. Eleven were RCTs or systematic reviews, 12 non-randomized studies and two guidelines. No consensus was found regarding the class of compression needed for the effective management of varicose veins. Wearing compression improved symptom management, but could be confounded by the exclusion of high number of non-compliant patients within the trials. Wearing compression to slow the progression, or prevent the reoccurrence of varicose veins could not be supported by the current published evidence.

CONCLUSION

The evidence for the benefit of compression hosiery for varicose veins was equivocal. The published literature was often contradictory and had methodological flaws.

Postoperative limb compression in reduction of haemorrhage after varicose vein surgery

In varicose vein surgery, significant postoperative morbidity results from subcutaneous haematoma formation and limb swelling after saphenous vein stripping. We investigated the effectiveness of a high-compression short-stretch adhesive bandage compared with non-adhesive crêpe in reducing haemorrhage after stripping of varicose veins. Using 99mTc-labelled red blood cells, the degree of postoperative bleeding was assessed in 10 patients with bilateral varicose veins allocated for stripping and ligation. High-compression adhesive bandaging was applied to the experimental limb and a non-adhesive bandage to the contralateral control limb. Results show that adequate compression bandaging can decrease subcutaneous haematoma formation after stripping of varicose veins.

The varicose vein waiting list: results of a validation exercise

A lengthening waiting list for treatment of varicose veins in a busy teaching hospital prompted a careful review. Patients were sent a detailed questionnaire which addressed current symptoms, progression of the complaint and the desire for surgical treatment. Of 519 patients on the waiting list, replies were received from 471 (91%). Forty-eight patients could not be traced after two questionnaires had been sent and enquiries made with their last known local GP. A further 87 (17%) patients were removed from the waiting list because they no longer desired treatment or had had treatment in the private sector. The remaining 384 patients were sent appointments for specially organised Saturday morning assessment clinics attended by consultants and senior registrars. Eighty patients failed to attend without giving a reason and were removed from the waiting list. Of 304 patients reviewed, surgical treatment was considered necessary for 219, of whom 182 were suitable for day-case surgery, leaving only 37 patients of the original 519 who required inpatient surgical care. This study has shown how careful assessment and the increased provision of day-case facilities can relieve pressure on inpatient care.

Varicose veins: optimum compression after surgery and sclerotherapy

Graduated compression stockings are used in both surgical and non-surgical treatment of varicose veins. In a trial of high versus low compression stockings (40 mmHg vs 15 mmHg at ankle) after varicose vein surgery, both were equally effective in controlling bruising and thrombophlebitis, but low compression stockings proved to be more comfortable. In a further trial after sclerotherapy, high compression stockings alone produced comparable results to Elastocrepe bandages with stockings. It is concluded that after varicose vein surgery low compression stockings provide adequate support for the leg and that after sclerotherapy, bandaging is not required if a high compression stocking is used.