Clinical UM Guideline

This document addresses the use of lower extremity pressure gradient compression stockings (GCS) used to exert external compression on the lower extremities to prevent or reduce swelling, improve venous circulation, or prevent venous pooling and venous hypertension in individuals with incompetent venous circulation (for example, varicose veins). GCS may also be used to prevent venous thrombosis or to improve healing of extremity wounds by reducing venous pressure and edema. Silicone compression garments may be prescribed to minimize scarring in victims of deep burns. Compression stockings may also be used for the treatment of lymphedema or lipedema. Lymphedema is a condition characterized by the pooling of extracellular fluid in the extremities due to a variety of etiologies. Lipedema is a painful, chronic, incurable condition characterized by abnormal bilateral enlargement of subcutaneous adipose tissue of the legs or arms. The use of GCS for these conditions is intended to apply external pressure to the limbs with the goal of decreasing the pooling of blood lymph fluid, thus relieving the conditions related to such pooling.

Note: This document only addresses pressure gradient compression stockings for the lower extremities. Pressure gradient compression sleeves intended for the upper extremities are not addressed.

Note: For other information regarding compression therapy, please see:

• ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities
• CG-DME-06 Compression Devices for Lymphedema
• CG-DME-46 Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting

Medically Necessary:

An initial purchase of two (2) pairs of individually fitted prescription lower extremity gradient compression stockings are considered medically necessary for individuals who require treatment for any of the following conditions:

1. Edema, stasis, varicose veins, or any other disorder of the lower extremity circulation; or 
2. Lipedema; or
3. Lipodermatosclerosis; or
4. Lymphedema; or
5. Postural hypotension; or
6. Prevention or treatment of thrombosis.

Two (2) pairs of replacement individually fitted prescription gradient compression stockings (for a total of 4 sets per 12 month period) are considered medically necessary when either of the following criteria have been met:

1. The medically necessary criteria for initial purchase above have been met; and
2. There is documentation of continued benefit derived from use of the device.

Additional replacement of individually fitted prescription gradient compression stockings is considered medically necessary when the following criteria have been met:

1. The medically necessary criteria for initial purchase above have been met; and
2. The stockings are no longer providing adequate compression*.

* See Discussion section.

Not Medically Necessary:

The initial purchase of individually fitted prescription gradient compression stockings are considered not medically necessary when the criteria above have not been met.

Replacement of individually fitted prescription gradient compression stockings is considered not medically necessary when the criteria above have not been met, including more than four (4) pairs per 12 month period.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.

Compression therapy is a frequently used therapy for conditions involving venous and lymphatic insufficiency in the lower limbs. These conditions include varicosities, lymphedema, venous eczema and ulceration, deep vein thrombosis, and post-thrombotic syndrome. Many forms of therapeutic leg compression therapy exist including elastic and non-elastic bandages, compression boots, elastic stockings and tights, and pneumatic devices. Medical-grade GCS require a prescription and have the advantage of being relatively easier to put on and less cumbersome than bandaging and pneumatic devices. However, not all individuals tolerate GCS and nonadherence to therapy instructions is relatively common.

GCS apply the highest degree of pressure at the ankle, with the level of compression gradually decreasing in proximal stocking sections. This helps blood flow toward the heart instead of refluxing laterally into the superficial veins or downward to the foot. The application of adequate graduated compression decreases the diameter of major veins, which increases the velocity and volume of blood flow. Adequate graduated compression can aid in the reversal of venous hypertension, improve skeletal-muscle pump function, assist venous blood return, and aid lymphatic drainage. It also initiates complex physiologic and biochemical effects involving the venous, arterial, and lymphatic systems.

GCS are categorized according to the sub-bandage compression pressure applied by the garment at the ankle level. The manufacturers determine the pressures based on laboratory measurements. The degree of pressure is classified into several standards, although there is no single standard used worldwide. Low compression (class 1) refers to a maximum pressure of less than 20 mm Hg; medium compression (class 2) refers to a maximum pressure of 20–30 mm Hg; and high compression (class 3) refers to a maximum pressure of greater than 30 mm Hg. The total pressure is affected by factors such as the elasticity and stiffness of stocking material, the size and shape of the wearer’s legs, and the movements and activities of the wearer.

Types of Compression Stockings

While the phrases “graduated compression hosiery” and “antiembolism stockings” are frequently used interchangeably, the terms are not synonymous. Both types of stockings provide graduated compression, but they offer different levels of compression and are indicated for the treatment of different conditions.

GCS exert the highest degree of compression at the ankle, and the level of compression gradually diminishes up the garment. This type of stocking is designed for ambulatory individuals and may be used to treat edema and chronic venous disease. GCS are made under strict medical and technical specifications, including durability and consistency, to provide a specified level of ankle pressure and graduation of compression.

Similar to graduated compression stockings, antiembolism stockings provide gradient compression and are used to reduce the risk of deep vein thrombosis. Designed for bedridden individuals, these stockings do not meet the technical specifications for use by ambulatory individuals (Lim, 2014).

Nonmedical support hose is a third type of hosiery sometimes used in treatment. This includes elastic support stockings and ‘flight socks.’ Such stockings are often used to provide relief for fatigued, heavy, and aching legs. This type of hosiery is available without a prescription and exerts considerably less compression than graduated compression stockings. The compression from such stockings is uniform and not graduated. This type of hosiery does not meet the medical and technical specifications as those of GCS (Lim, 2014).

High compression support stockings, socks, and hosiery provide increased support for relief from:

• Moderate-to-severe varicosities (varicose veins)
• Moderate edema (swelling) of legs, ankles, and feet
• Moderate-to-severe varicose veins during pregnancy
• Severe edema and lymphedema

They may also be used for:

• Management of active venous ulcerations
• Preventing recurrence of venous ulcerations
• Preventing post-thrombotic syndrome. This is a complication that may follow a deep vein thrombosis and includes symptoms such as edema, purpura, increased skin pigmentation, itchiness, rash, ulceration and cellulitis.

Conservative management of varicose veins frequently includes leg elevation, avoidance of prolonged periods of standing, analgesia for symptom relief, and compression therapy. Custom-fit gradient compression stockings are often used prior to more invasive treatments. The stockings should be donned upon arising in the morning, preferably prior to getting out of bed.

GCS require proper fitting and, to remain effective, should be replaced at intervals of 3 to 4 months, in accordance with the manufacturers’ instructions. Presuming conditions of normal wear and tear, durability for at least 6 months should be assured. When prematurely worn out or a replacement is needed due to the disease or in cases of change in leg conformation due to the disease, a renewed prescription of a medical compression stocking is necessary (Wienert, 2008; Wittens, 2015). 

The adherence rate for graduated compression stocking use has been reported to be highly variable, but is generally recognized to be poor to moderate (Knight, 2021). Commonly cited reasons for nonadherence include pain, discomfort, difficulty putting them on, perceived ineffectiveness, excessive heat, skin irritation, cost and appearance. Clinicians are encouraged to ask their patients why stockings are not being used because many of these factors are easily managed by simple methods such as changing the stocking material, lowering the degree of compression, or providing adequate information and reassurance to patients (Lim, 2014).

Clinical Indications

As noted above, GCS may be used for the prevention or treatment of a wide variety of conditions, including those associated with impaired lower extremity circulation including the venous and lymphatic systems. Such conditions  result in pooling of blood and extracellular fluid in the lower extremities and place individuals at risk of or result in conditions such as venous stasis ulcers, stasis dermatitis, lymphedema, and varicose veins. The use of GCS for such conditions decreases fluid pooling and increase fluid return to the trunk. It should be noted that GCS are not used or effective for the treatment of  telangiectasias, also known as spider veins. Other populations are also at increased risk of lower extremity pooling and edema, including those who are pregnant and individuals with paraplegia, quadriplegia, or other conditions resulting in immobility and the use of GCS may be warranted for such individuals.

GCS has been used as standard therapy for the treatment of individuals at risk for or who have a history of thrombosis. This may include individuals who have undergone surgery or sclerotherapy, have a lower limb fracture or other trauma, or are immobilized due to surgery, trauma, or general debilitation. Individuals with conditions such as atrophie blanche and post-thrombotic syndrome (also known as post-phlebitic syndrome) should also be considered for GCS therapy.

CGS has been used for the treatment of other conditions affecting the lower extremities not specifically caused by circulatory issues, including lipedema and lipodermatosclerosis. For both conditions, compression therapy with GCS is intended to alleviate the accumulation of fluid that can exacerbate the condition and result in increased severity of symptoms and complications.

Finally, GCS is a standard therapeutic modality for the individuals with postural hypotension. The use of GCS increases lower extremity blood return and improves the ability of the rest of the body to respond appropriately to orthostatic changes in blood pressure.

Chronic Venous Insufficiency

Chronic venous insufficiency is the most common cause of lower extremity ulceration, accounting for up to 80 percent of cases of leg ulcerations in the United States. Individuals with chronic venous insufficiency may present with symptoms and signs of leg pain, heaviness, itchiness, edema, eczema, lipodermatosclerosis (LDS), thrombophlebitis and ulceration. Chronic venous disease is often classified using the CEAP (clinical, etiologic, anatomic and pathophysiologic) system, which grades venous disease based on the presence of edema, dilated veins, skin changes, or ulceration. In the CEAP system the severity of venous disease may be categorized from the most benign form of the disease, for example telangiectasia and reticular veins (C1 classification), through LDS (C4 classification) to the most debilitating form of the disease, chronic venous ulceration (C6 classification). Chronic venous insufficiency is defined as CEAP grades 3 to 6 and signifies advanced venous disease. Studies report that the average venous ulcer requires as long as 6 to 12 months to heal completely and as many as 70% will recur within 5 years of closure. These ulcers are often painful and cause a national loss of an estimated 2 million workdays because of disability (Gillespie, 2010).

Venous leg ulcers (VLU) are a major clinical challenge. These result from chronic venous insufficiency and venous hypertension. They represent between 60% and 80% of all leg ulcerations. Their three-month healing rate is estimated at 40%. Once healed, up to 80% of individuals develop a recurrence within 3 months. The prevalence of VLUs is reported to be around 1.08% with the incidence being up to 1.33%. The latter numbers are primarily based on estimates due to of the lack of clinical registries for VLU. The prevalence and incidence of VLU increase with age. Advancing age negatively affects healing and recurrence as well as treatment adherence. People with VLUs often report having reduced health-related quality of life because these wounds can be painful, malodorous, and exuding (Probst, 2023)

The use of compression is a conservative measure which aims to reduce discomfort and pain, severity and extent of edema, improve skin changes, and heal associated ulcers. While it does not cure varicosities, it remains a cornerstone of chronic venous insufficiency management to relieve symptoms and prevent deterioration. Compression therapy involves the use of garments or devices that provide static or dynamic mechanical compression to a body region. For the treatment of lower extremity chronic venous insufficiency, static compression includes compression hosiery and compression bandages. Dynamic (intermittent) compression therapy in the form of intermittent pneumatic compression pumps and sleeves may be useful under select circumstances. For patients with venous ulceration, the benefits of long-term compression therapy (stockings or bandages) have been repeatedly demonstrated in randomized trials (Beidler, 2009; Nelson, 2014; O’Donnell, 2014; Probst, 2023).

Many studies that have investigated the effectiveness of GCS in individuals in all CEAP classes reported improvement in symptoms such as pain and swelling, activity levels, and well-being. A multicenter randomized controlled trial (RCT) assessing the efficacy of GCS (pressure 10–15 mm Hg) in 125 female participants with CEAP class C1–C3 reported a significant improvement in relief of global discomfort and improved quality-of-life with use of medical GCS compared with placebo stockings (Benigni, 2003). However, these findings were limited by the recruitment of a heterogeneous group of participants, and no subgroup analysis was performed.

Uncomplicated varicose veins 

The evidence for the benefit of GCS in uncomplicated varicose veins is equivocal. Published results have often been contradictory and the available studies limited by significant methodologic flaws.

A Cochrane systematic review of GCS for the initial treatment of varicosities in individuals without venous ulceration (CEAP class C2–C4) included seven RCTs with a total of 356 participants (Shingler, 2011). Although the participants’ symptoms and physiologic measures subjectively improved in all of the studies when GCS were worn, there was a risk of bias because the assessments were not made by comparing one randomized arm with a control arm. Another systematic review of GCS for uncomplicated varicosities identified 25 studies (Palfreyman. 2009). This review found that wearing stockings improved symptom management, but the findings may have been confounded by the exclusion of a high number of nonadherent patients within the trials. The review also found no evidence that wearing the stockings slowed progression or prevented the recurrence of varicose veins.

In 2011, a joint consensus statement from the Society for Vascular Surgery/American Venous Forum (SVS/AVF) Guideline Committee recommended the use of GCS for the treatment of varicose veins. However, the authors stated that the evidence supporting this recommendation was limited (Gloviczki, 2011).

Some studies reported that low-pressure compression stockings are as effective as high-pressure compression stockings and have a higher adherence rate (Benigni, 2003). A meta-analysis by Amsler in 2008 involving 11 RCTs reported that compression of 15–20 mm Hg demonstrated significant improvement on edema and symptoms when compared to compression of less than 10 mm Hg or no compression. However, no differences were reported between compression of 10–20 mm Hg and compression greater than 20 mm Hg. At this time there is insufficient evidence addressing the benefits of different lengths of graduated compression stocking (for instance, below knee vs. thigh length) (Shingler, 2011).

Chronic venous insufficiency 

Individuals with venous ulcers are often treated with compression bandages; however, there is some evidence that GCS are equally effective. The Amsler study noted above (2008) reported that the proportion of ulcers that healed was significantly higher with GCS than with bandages (62.7% vs. 46.6%). The average time to ulcer healing was also 3 weeks shorter with stockings. GCS may also be associated with less pain. There is evidence that high-pressure compression (30–40 mm Hg) stockings are more effective than medium- and low-pressure compression stockings in promoting venous ulcer healing and preventing recurrence (Nelson, 2012; Partsch, 2008). A Cochrane systematic review of four RCTs (n=979) concluded that there is weak evidence that GCS may prevent recurrence of venous ulcers and that high-pressure compression stockings may be more efficacious than moderate-pressure compression stockings. (Lim, 2014).

Postsurgical or interventional treatment of varicose veins

Compression therapy in the form of bandages or stockings is widely used immediately after surgical or interventional treatment of varicose veins, although few RCTs have assessed this. While some studies have shown compression after sclerotherapy reduces the formation of thrombi and may prevent pigmentation and matting by minimizing inflammation and angiogenesis, other trials comparing GCS to no compression found no difference in efficacy, adverse effects, satisfaction scores, symptoms and quality of life between the two groups (Hamel-Desnos, 2010; Kern, 2007).

Prevention of venous thromboembolism (VTE) in Hospitalized patients 

A Cochrane Library systematic review of GCS alone or in combination with another form of prophylaxis for the prevention of deep vein thrombosis in hospitalized individuals with conditions other than stroke identified 18 RCTs (Sachdeva, 2010). The authors reported that deep vein thrombosis developed in 13% of individuals given graduated compression stockings, as compared with 26% of those with no stockings. In the trials in which stockings were used in combination with another prophylactic method, deep vein thrombosis developed in 4% of individuals using stockings with another method, as compared with 16% of those using the other method alone. The authors concluded that GCS reduced the risk of deep vein thrombosis among hospitalized individuals, especially when used in combination with other methods of prophylaxis.

However, a large-scale, evaluator-blinded trial of hospitalized individuals with stroke, RCT CLOTS trial 1 (Dennis, 2009), compared the use of standard of care plus GCS to standard of care alone. The results indicated symptomatic and asymptomatic deep vein thrombosis occurred in 126 (10.0%) stocking group participants compared to 133 (10.5%) in the control group, which was a nonsignificant absolute reduction in risk of 0.5%.

Travel-related venous thromboembolism/VTE

Long travel duration is associated with a significant increase in risk of VTE. The use of GCS was evaluated in one RCT involving 231 airline passengers aged over 50 years with no history of VTE. Participants were assigned class 1 below-knee GCS or no stockings during journeys lasting more than 8 hours. The results showed that none of the stocking group participants had deep vein thrombosis, whereas 12 of 116 control group participants had asymptomatic deep calf vein thrombosis (Scurr, 2001).

A Cochrane Library systematic review of 10 RCTs involving 2856 participants assigned to wearing GCS or not concluded that wearing GCS may reduce the incidence of asymptomatic deep vein thrombosis and leg edema in airline passengers (Clarke, 2006). However, they also concluded that none of included the trials was large enough alone to assess the effect of GCS on death, pulmonary embolus, or symptomatic deep vein thrombosis.

Postthrombotic Syndrome Prevention 

Postthrombotic syndrome is a common complication of deep vein thrombosis and is characterized by leg pain, swelling, and skin changes ranging from erythema to severe ulceration. A meta-analysis of five RCTs showed that severe postthrombotic syndrome occurred in 5% of individuals given GCS and 12% of individuals with no compression (relative risk [RR], 0.38, 95% confidence interval [CI], 0.22 to 0.68) (Saedon, 2010). This study also reported that postthrombotic syndrome of any severity occurred in 26% of study participants using stockings compared to 46% without stockings (RR, 0.54, 95% CI, 0.44 to 0.67).

Kahn (2014) reported the results of a double-blind multicenter RCT (the SOX trial) involving 806 participants with first proximal DVT comparing the effectiveness of compression stocking to the effectiveness of placebo stockings over the course of 2 years. The authors reported that GCS did not prevent the occurrence of or influence the severity of postthrombotic syndrome after a first proximal deep vein thrombosis. The cumulative incidence of the syndrome by 750 days was similar between the intervention and control groups (14.2% vs. 12.7%, p=0.58). The authors concluded that the use of compression stockings did not prevent postthrombotic syndrome after a first proximal DVT and that their findings did not support routine wearing of compression stockings after DVT.

Postthrombotic Syndrome Treatment 

The use of GCS for treatment of postthrombotic syndrome was reported in two RCTs. In the first study, 35 participants 1 year post symptomatic postthrombotic syndrome following proximal deep vein thrombosis were randomly assigned to wear GCS (30–40 mm Hg) or a matched placebo stocking (Ginsberg, 2001). The rate of treatment failure was not significantly different between the two groups (61% and 59%, respectively, p=0.10). In a second study, participants with postthrombotic syndrome were randomly assigned to wear below-knee GCS (30–40 mm Hg) on the affected leg, to treatment with hydroxyethylrutoside, or both interventions, for 12 months (Prandoni, 2005). The study included 40 participants in each group. No clear differences were found in improvement or worsening of the postthrombotic syndrome between the groups (Hazard Ratio [HR], 1.18 and 1.29, respectively).

Lymphedema and chronic leg edema

Lymphedema is a condition in which impaired lymphatic drainage causes chronic build-up of fluid and swelling in the limbs. Treatment of lymphedema often includes complex decongestive therapy and generally involves a two-phase approach. The first phase is intensive reduction of swelling with skin care, manual massage or lymph drainage, exercises and compression typically with multilayered bandages. The second phase is the long-term maintenance of volume, which includes skin care, exercises, compression therapy, self-lymph drainage and, in some individuals, pneumatic lymph drainage (Lim, 2014).

The International Society of Lymphology published their recommendations regarding the use of compression garments in 2020. In that document they state:

• … patients with chronic venous insufficiency require lifelong external compression therapy to minimize edema, lipodermatosclerosis and skin ulceration (treatments may be preventative if initiated early)
• Preferably, a physician (sometimes with assistance of highly-skilled specialists) should prescribe the compression garment to avoid inappropriate usage in a patient with medical contraindications such as arterial disease, painful postphlebitic syndrome, occult neoplasia, and acute infections and some skin disorders.

Superficial thrombophlebitis

GCS may be used as part of the management of superficial thrombophlebitis either alone or in conjunction with other treatment modalities, including anticoagulation, nonsteroidal anti-inflammatory drugs, and surgery. GCS help to relieve local symptoms and may prevent extension of venous thrombosis. A Cochrane Library systematic review reported that the combination of surgical treatment and use of GCS was associated with a lower rate of VTE and progression of superficial thrombophlebitis compared with stockings alone (Di Nisio, 2012).

Pregnancy

Thaler (2001) published the results of a prospective randomized controlled study involving 42 participants with uncomplicated pregnancies to evaluate the impact of GCS in preventing emergent varicose veins in pregnancy. The authors reported that graduated compression stockings, “do not prevent the emergence of gestational varicose veins, they significantly decrease the incidence of long saphenous vein reflux at the sapheno-femoral junction and improve leg symptoms.”

Contraindications and Complications

The use of compression stockings is contraindicated in individuals with any of the following:

• Individual has been diagnosed with or is suspected of having:
  • peripheral arterial disease (including those with a history of peripheral arterial bypass grafting);
  • septic phlebitis
• Individual has severe peripheral neuropathy or other condition which causes sensory impairment;
• Individuals with severe edema of the leg or pulmonary edema caused by congestive cardiac failure;
• Individuals with a localized skin or soft tissue condition, including but not necessarily limited to recent skin graft, fragile “tissue paper” skin, oozing dermatitis, severe cellulitis or gangrene;
• Individuals with unusual leg shape or size that prevents achieving a correct fit;
• Individual who is allergic to stocking material.

Professional and Medical Society Guidelines and Recommendations

The Society for Vascular Surgery (SVS) and the American Venous Forum (AVF) published guidelines addressing the care of individuals with varicose veins and associated chronic venous diseases (Gloviczki, 2011). Their recommendations for this indication were:

We suggest compression therapy using moderate pressure (20 to 30 mm Hg) for patients with symptomatic varicose veins. Grade 2 Level of Evidence C
9.2 We recommend against compression therapy as the primary treatment of symptomatic varicose veins in patients who are candidates for saphenous vein ablation. Grade 1 Level of Evidence B
9.3 We recommend compression as the primary therapeutic modality for healing venous ulcers. Grade 1 Level of Evidence B
9.4 We recommend compression as an adjuvant treatment to superficial vein ablation for the prevention of ulcer recurrence. Grade1 Level of Evidence A

The VSV and AVF published guidelines for the management of venous leg ulcers which included the following recommendations (O'Donnell, 2014):

Guideline 5.4: Compression- Arterial Insufficiency: In a patient with a venous leg ulcer and underlying arterial disease, we do not suggest compression bandages or stockings if the ankle-brachial index is 0.5 or less or if absolute ankle pressure is less than 60 mm Hg. [GRADE - 2; LEVEL OF EVIDENCE - C]
Guideline 8.1: Primary Prevention- Clinical CEAP C3-4 Primary Venous Disease: In patients with clinical CEAP C3-4 disease due to primary valvular reflux, we recommend compression, 20 to 30 mm Hg, knee or thigh high. [GRADE - 2; LEVEL OF EVIDENCE - C]
Guideline 8.2: Primary Prevention- Clinical CEAP C1-4 Post-thrombotic Venous Disease: In patients with clinical CEAP C1-4 disease related to prior deep venous thrombosis (DVT), we recommend compression, 30 to 40 mm Hg, knee or thigh high. [GRADE - 1; LEVEL OF EVIDENCE - B]

The American Academy of Family Practitioners (AAFP) published recommendations for the diagnosis and treatment of venous ulcers (Bonkemeyer Millan, 2019), where they stated the following:

Compression therapy is beneficial for venous ulcer treatment and is the standard of care. Evidence rating: A (= consistent, good-quality patient-oriented evidence)

Regarding the frequency of replacement, they state that:

Compression stockings are removed at night and should be replaced every six months because of loss of compression with regular washing. Once the ulcer has healed, continued use of compression stockings is recommended indefinitely.

In 2019, the AVF, SVS, American College of Phlebology (ACP), Society for Vascular Medicine (SVM), and International Union of Phlebology (IUP) published clinical practice guidelines for the use of compression therapy after invasive treatment of superficial veins of the lower extremities (Lurie, 2019). Their recommendations for the use of compression stockings were:

Guideline 1.2: Dose of compression after thermal ablation or stripping of the varicose veins: If compression dressings are to be used postprocedurally in patients undergoing ablation or surgical procedures on the saphenous veins, those providing pressures >20 mm Hg together with eccentric pads placed directly over the vein ablated or operated on provide the greatest reduction in postoperative pain. [GRADE - 2; LEVEL OF EVIDENCE - B]
Guideline 2.1: Duration of compression therapy after thermal ablation or stripping of the saphenous veins: In the absence of convincing evidence, we recommend best clinical judgment to determine the duration of compression therapy after treatment. [BEST PRACTICE]
Guideline 3.2: Duration of compression therapy after sclerotherapy: In the absence of convincing evidence, we recommend best clinical judgment to determine the duration of compression therapy after sclerotherapy. [BEST PRACTICE]
Guideline 4.2: Compression after superficial vein treatment in patients with a mixed arterial and venous leg ulcer: In a patient with a venous leg ulcer and underlying arterial disease, we suggest limiting the use of compression to patients with ankle-brachial index exceeding 0.5 or if absolute ankle pressure is >60 mm Hg. [GRADE - 2; LEVEL OF EVIDENCE - C]

The American College of Chest Physicians (ACCP) 2021 guidelines for prevention of VTE recommend:

29. In patients with acute DVT of the leg, we suggest against using compression stockings routinely to prevent post-thrombotic syndrome (PTS) (weak recommendation, low-certainty evidence).

The ACCP also published recommendations for management of antithrombotic therapy for VTE disease (Stevens, 2021). That document states:

29. In patients with acute DVT of the leg, we suggest against using compression stockings routinely to prevent post-thrombotic syndrome (PTS) (weak recommendation, low-certainty evidence).

In 2020 the American Society of Hematology (ASH) published guidelines for management of VTE (Ortel, 2020). In that document they state the following:

Recommendations 27 and 28. For patients with DVT, with (Recommendation 27) or without (Recommendation 28) an increased risk for PTS, the ASH guideline panel suggests against the routine use of compression stockings (conditional recommendations based on very low certainty in the evidence of effects ⊕◯◯◯).

They follow this recommendation with, “Although the majority of patients may not benefit from the use of stockings to reduce the risk of PTS, stockings may help to reduce edema and pain associated with acute DVT in selected patients.”

In another publication from the ASH addressing prophylaxis of VTE in hospitalized and nonhospitalized medical patients, they provide these additional recommendations (Schünemann, 2018)

Recommendation 10. In acutely or critically ill medical patients who are receiving mechanical VTE prophylaxis, the ASH guideline panel suggests using pneumatic compression devices or graduated compression stockings for VTE prophylaxis (conditional recommendation, very low certainty in the evidence of effects ⊕◯◯◯).
Recommendation 17. In long-distance (>4 hours) travelers without risk factors for VTE, the ASH guideline panel suggests not using graduated compression stockings, LMWH, or aspirin for VTE prophylaxis (conditional recommendation, very low certainty in the evidence of effects ⊕◯◯◯).
Recommendation 18. In people who are at substantially increased VTE risk (eg, recent surgery, prior history of VTE, postpartum women, active malignancy, or >2 risk factors, including combinations of the above with hormone replacement therapy, obesity, or pregnancy), the ASH guideline panel suggests using graduated compression stockings or prophylactic LMWH for long-distance (.4 hours) travel (conditional recommendation, very low certainty in the evidence of effects ⊕◯◯◯).

The Society of Obstetrician and Gynaecologists of Canada (SOGC) published the following recommendations on the prevention of venous thromboembolic disease in gynecological surgery in 2022 (Tafler, 2022):

4. Intermittent compression stockings, when available, are preferred to graduated compression stockings (strong, moderate).
11. When patients are both at high risk of venous thromboembolism and at high risk for major bleeding complications, a team approach including consultation with the department of medicine is recommended (strong, moderate). There may be benefits to combining intermittent pneumatic compression and graduated compression stockings in this population (conditional, low)

Additionally, they say, “Contraindications to the use of GCS include peripheral artery disease and severe leg edema.” and “For patients at low risk of VTE… Evidence does support the use of mechanical prophylaxis, either IPC or GCS. For this group, mechanical prophylaxis is recommended, with IPC preferred over GCS.”

The European Society for Vascular Surgery (ESVS) published clinical practice guidelines on the management of chronic venous disease of the lower limbs (De Maeseneer, 2022). The provided the following recommendations:

Recommendation 9: For patients with symptomatic chronic venous disease, elastic compression stockings, exerting a pressure of at least 15 mmHg at the ankle, are recommended to reduce venous symptoms. (Class I, Level B)
Recommendation 10: For patients with chronic venous disease and oedema (CEAP clinical class C3), compression treatment, using below knee elastic compression stockings, inelastic bandages or adjustable compression garments, exerting a pressure of 20-40 mmHg at the ankle, is recommended to reduce oedema(Class I, Level B)
Recommendation 11: For patients with chronic venous disease and lipodermatosclerosis and/or atrophie blanche (CEAP clinical class C4b), using below knee elastic compression stockings, exerting a pressure of 20-40 mmHg at the ankle, is recommended to reduce skin induration. (Class I, Level B)
Recommendation 12: For patients with post-thrombotic syndrome, below knee elastic compression stockings, exerting a pressure of 20-40 mmHg at the ankle, should be considered to reduce severity. (Class IIa, Level B)

Additionally, they provided the following list of contraindications to compression treatment:

• Severe lower extremity atherosclerotic disease with ABI < 0.6 and/or ankle pressure < 60 mmHg
• Extra-anatomic or superficially tunnelled arterial bypass at the site of intended compression
• Severe heart failure, NYHA Class IV
• Heart failure NYHA Class III and routine application of compression devices without clinical and haemodynamic monitoring
• Confirmed allergy to compression material
• Severe diabetic neuropathy with sensory loss or microangiopathy with the risk of skin necrosis

This list is based on a consensus statement published by Rabe and colleagues in 2020.

The National Comprehensive Cancer Networks Clinical (NCCN) practice guideline for cancer-associated venous thromboembolic disease (NCCN, 2024) includes information regarding contraindications to mechanical prophylaxis, with absolute contraindications to GCS being acute DVT and severe arterial insufficiency and relative contraindications to GCS being the presence of large hematomas, skin ulcerations or wounds, mild arterial insufficiency, and peripheral neuropathy.

They provide the following analysis and recommendation for the use of GCS in this population:

GCS is an alternative mechanical prophylactic method that might provide benefit in VTE reduction, especially when combined with other therapies.²¹⁷ However, similar to IPC, it should not be relied upon as the sole method of VTE prophylaxis. First, many studies demonstrating its efficacy were conducted more than a decade ago and used fibrinogen uptake scans as a primary outcome measure—a now antiquated diagnostic method.²¹⁸ Additionally, a randomized controlled trial in patients undergoing hip surgery found that GCS did not provide significant additive protection against VTE in patients receiving fondaparinux.²¹⁹ Similarly, results from the CLOTS1 trial in patients with stroke found that GCS did not reduce the incidence of DVT and was associated with a 4-fold increase in the frequency of skin ulcers and necrosis.²¹⁴ In addition, the GAPS study noted that pharmacologic VTE prophylaxis was non-inferior to pharmacologic prophylaxis combined with GCS; therefore, GCS may be unnecessary in patients undergoing surgery who are receiving pharmacologic thromboprophylaxis.²²⁰ Most of these trials either did not include patients with cancer or only included a small number of patients with cancer. Thus, IPC or GCS should only be used when prophylactic anticoagulants are contraindicated.

The American College of Obstetricians and Gynecologists (ACOG) published a practice bulletin addressing the prevention of VTE in gynecologic surgery in 2021 (ACOG, 2021). In that document they provide the following recommendation:

For gynecologic surgery patients at low risk of VTE, mechanical thromboprophylaxis (preferably with intermittent pneumatic compression) is recommended. Graduated compression stockings are a reasonable alternative if intermittent pneumatic compression is not available or is not preferred by the patient.

Finally, the ACCP clinical practice guidelines on the prevention of VTE in nonorthopedic surgical patients includes the following recommendations and commentary (Gould, 2012).

3.6.5. For general and abdominal-pelvic surgery patients at high risk for VTE ( 6.0%; Caprini score,  5) who are not at high risk for major bleeding complications, we recommend pharmacologic prophylaxis with LMWH  Grade 1B) or LDUH (Grade 1B) over no prophylaxis. We suggest that mechanical prophylaxis with elastic stockings (ES) or IPC should be added to pharmacologic prophylaxis (Grade 2C).

Proper fit and adherence with ES is necessary to ensure efficacy. The correct pressure at the ankle level for primary prophylaxis is 18 to 23 mm Hg, which is lower than for therapeutic stockings used to treat postthrombotic syndrome (30-40 mm Hg). Based on indirect evidence from patients with stroke, ²⁹ we favor thigh-high elastic stockings over calf-high stockings.

Summary

Generally speaking, compression stockings are safe to use with relatively few complications. Many complications associated with the use of GCS are preventable if individuals are assessed, measured, and properly fitted. Skin breakdown and frank necrosis has been reported following incorrectly measured or applied garments. At a minimum, poorly fitting stockings can cause discomfort and, at worst, pressure necrosis. The use of GCS on legs with impaired arterial flow can exacerbate ischemia. Stockings worn by individuals who are allergic to the stocking material may result in contact dermatitis, skin discoloration and blistering. Complications can frequently be managed by one or more of the following: refitting the stockings, using a stocking that is made of a different material, applying an emollient and reducing the degree of compression. Accurate measurement of the limb diameter that conforms to the stocking manufacturer’s guidelines should be performed by a trained health care professional (Lim, 2014).

Although there remain unanswered questions about the use of GCS, high-quality evidence supports their use by individuals with chronic venous insufficiency, especially those with ulcers, and such use has become widely accepted practice in the clinical community.

Chronic venous insufficiency (CVI): A condition in which the veins in the legs fail to pump blood back to the heart efficiently. As a result, blood flows backwards and pools in the legs. CVI is also referred to as chronic venous stasis, phlebitis, post-thrombotic syndrome, and venous valvular reflux.

Peer Reviewed Publications:

1. Amsler F, Blättler W. Compression therapy for occupational leg symptoms and chronic venous disorders - a meta-analysis of randomised controlled trials. Eur J Vasc Endovasc Surg. 2008; 35(3):366-372.
2. Beidler SK, Douillet CD, Berndt DF, et al. Inflammatory cytokine levels in chronic venous insufficiency ulcer tissue before and after compression therapy. J Vasc Surg 2009; 49:1013–1020.
3. Benigni JP, Sadoun S, Allaert FA, et al. Efficacy of class 1 elastic compression stockings in the early stages of chronic venous disease. A comparative study. Int Angiol 2003; 22:383-392
4. Dennis M, Sandercock PA, Reid J, et al.; CLOTS Trials Collaboration. Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial. Lancet. 2009; 373(9679):1958-1965.
5. Ginsberg JS, Hirsh J, Julian J, Vander LaandeVries M, et al. Prevention and treatment of postphlebitic syndrome: results of a 3-part study. Arch Intern Med. 2001; 161(17):2105-2109.
6. Hamel-Desnos CM, Guias BJ, et al. Foam sclerotherapy of the saphenous veins: randomised controlled trial with or without compression. Eur J Vasc Endovasc Surg. 2010; 39(4):500-507.
7. Kahn SR, Shapiro S, Wells PS, et al.; SOX trial investigators. Compression stockings to prevent post-thrombotic syndrome: a randomised placebo-controlled trial. Lancet. 2014; 383(9920):880-888.
8. Kern P, Ramelet AA, Wütschert R, Hayoz D. Compression after sclerotherapy for telangiectasias and reticular leg veins: a randomized controlled study. J Vasc Surg. 2007; 45(6):1212-1216.
9. Lim CS, Davies AH. Graduated compression stockings. CMAJ. 2014; 186(10):E391-E398.
10. Motykie GD, Caprini JA, Arcelus JI, et al. Evaluation of therapeutic compression stockings in the treatment of chronic venous insufficiency. Dermatol Surg 1999; 25:116-120.
11. Palfreyman SJ, Michaels JA. A systematic review of compression hosiery for uncomplicated varicose veins. Phlebology. 2009; 24 Suppl 1:13-33.
12. Probst S, Saini C, Gschwind G, et al. Prevalence and incidence of venous leg ulcers- a systematic review and meta-analysis. Int Wound J. 2023; 20(9):3906-3921.
13. Saedon M, Stansby G. Post-thrombotic syndrome: prevention is better than cure. Phlebology. 2010; 25(Suppl 1):14-19.
14. Scurr JH, Machin SJ, Bailey-King S, et al. Frequency and prevention of symptomless deep-vein thrombosis in long-haul flights: a randomised trial. Lancet. 2001; 357(9267):1485-1489.
15. Thaler E, Huch R, Huch A, Zimmermann R. Compression stockings prophylaxis of emergent varicose veins in pregnancy: a prospective randomised controlled study. Swiss Med Wkly. 2001; 131(45-46): 659-662.
16. Wienert V, Gerlach H, Gallenkemper G, et al. Medical compression stocking (MCS). J Dtsch Dermatol Ges. 2008; 6(5):410-415.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology. Prevention of Venous Thromboembolism in Gynecologic Surgery: ACOG Practice Bulletin, Number 232. Obstet Gynecol. 2021; 138(1):e1-e15.
2. Bonkemeyer Millan S, Gan R, Townsend PE. Venous ulcers: diagnosis and treatment. Am Fam Physician. 2019; 100(5):298-305.
3. Clarke M, Hopewell S, Juszczak E, Eisinga A, Kjeldstrøm M. Compression stockings for preventing deep vein thrombosis in airline passengers. Cochrane Database Syst Rev. 2006 Apr 19; (2):CD004002.
4. Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Database Syst Rev. 2012 Mar 14; (3):CD004982.
5. Geerts WH, et al. Prevention of venous thromboembolism -American College of Chest Physicians evidence-based clinical practice guidelines (8th Edition). Chest 2008; 133(6 Suppl):3815-4513.
6. Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011; 53(5 Suppl):2S-48S.
7. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines Chest 2012; 141(suppl 2):e227S–277S. Published erratum appears in Chest 2012;141:1369.
8. Knight Nee Shingler SL, Robertson L, Stewart M. Graduated compression stockings for the initial treatment of varicose veins in people without venous ulceration. Cochrane Database Syst Rev. 2021 Jul 16; 7(7):CD008819.
9. Lurie F, Lal BK, Antignani PL, et al. Compression therapy after invasive treatment of superficial veins of the lower extremities: Clinical practice guidelines of the American Venous Forum, Society for Vascular Surgery, American College of Phlebology, Society for Vascular Medicine, and International Union of Phlebology. J Vasc Surg Venous Lymphat Disord. 2019; 7(1):17-28.
10. NCCN Clinical Practice Guidelines in Oncology^®: 2025 National Comprehensive Cancer Network, Inc. For additional information visit the NCCN website: http://www.nccn.org/index.asp. Accessed on January 28, 2025.
    • Cancer-Associated Venous Thromboembolic Disease (V2.2024). July 22 2024.
11. Nelson EA, Bell-Syer SE. Compression for preventing recurrence of venous ulcers. Cochrane Database Syst Rev. 2014 Sep 09; (9):CD002303.
12. O'Donnell TF Jr, Passman MA, Marston WA, et al.; Society for Vascular Surgery; American Venous Forum. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery^® and the American Venous Forum. J Vasc Surg. 2014; 60(2 Suppl):3S-59S.
13. Ortel TL, Neumann I, Ageno W, et al. American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. Blood Adv. 2020; 4(19):4693-4738.
14. Partsch H, Flour M, Smith PC; International Compression Club. Indications for compression therapy in venous and lymphatic disease consensus based on experimental data and scientific evidence. Under the auspices of the IUP. Int Angiol. 2008; 27(3):193-219.
15. Prandoni P. Elastic stockings, hydroxyethylrutosides or both for the treatment of post-thrombotic syndrome. Thromb Haemost. 2005; 93(1):183-185.
16. Rabe E, Partsch H, Morrison N, et al. Risks and contraindications of medical compression treatment - a critical reappraisal. An international consensus statement. Phlebology. 2020; 35(7):447-460.
17. Schünemann HJ, Cushman M, Burnett AE, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients. Blood Adv. 2018; 2(22):3198-3225.
18. Shingler S, Robertson L, Boghossian S, Stewart M. Compression stockings for the initial treatment of varicose veins in patients without venous ulceration. Cochrane Database Syst Rev. 2011 Nov 9; (11):CD008819.
19. Stevens SM, Woller SC, Kreuziger LB, et al. Antithrombotic therapy for VTE disease: Second update of the CHEST guideline and expert panel report. Chest. 2021; 160(6):e545-e608.
20. Tafler K, Kuriya A, Gervais N, Leyland N. Guideline No. 417: Prevention of Venous Thromboembolic Disease in Gynaecological Surgery. J Obstet Gynaecol Can. 2022; 44(1):82-96.e1.
21. Wittens C, Davies AH, Baekgaard N, et al. Editor’s choice – management of chronic venous disease: clinical practice guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2015; 49:678-737.

Pressure gradient compression stockings
Compression hose

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.