Proper treatment requires defining the affliction and its severity and differentiating it from other venous disorders. The term varicose veins loosely refers to a spectrum of symptoms and physical findings ranging from simple dilatation of cutaneous veins to severe, chronic swelling and ulceration of the lower legs. This is due to underlying venous hypertension caused by valvular incompetence in the saphenous veins and/or reflux or obstruction in the deeper veins. These abnormalities cause blood to pool in the lower extremities and adversely affect the surrounding tissues. Chronic venous insufficiency is the resulting state of diseased veins and sequelae that progress over many years, while the term varicose vein should be confined to the dilated and distorted veins. This is an important distinction as the clinical findings of varicose veins add little to the classification of CVI and do not influence its management; it is the impact of venous hypertension on the skin, subcutaneous tissues and muscle that dictates the severity and treatment of this condition.
The overwhelming majority of people who come to our clinic with a diagnosis of chronic venous insufficiency cannot remember when they first noticed the appearance of and symptoms related to their varicose and/or spider veins. Indeed, as this condition is increasingly prevalent in older age, most individuals have lived with venous abnormalities for several decades. As a result, varicose and spider veins have come to be regarded by the general public as little more than a common cosmetic nuisance or a benign aspect of getting old. This is a dangerous misconception. This essay seeks to increase awareness of venous disease and its most important complication by elucidating the pathophysiology, clinical significance, and treatment of varicose veins. In particular, of which is an often overlooked mode of therapy – supportive hosiery and clothing.
Benefits of Supportive Hosiery and Clothing
The reduction in swelling and discomfort from the use of supportive hosiery can significantly improve the daily lives of those who suffer from varicose veins with minimal cost or effort.
Compression therapy has been proven to increase the removal and reduce the production of edema in patients with mild to moderate chronic venous insufficiency. This also applies to decreased discomfort and prevention of a more severe form of skin and tissue changes resulting from chronic venous insufficiency called venous stasis dermatitis, which causes the skin to turn a reddish-brown color near the ankles and a texture that is dry, itchy, and thin. This occurs due to increased pressure in the veins and ambulatory venous hypertension. High pressure in the veins forces red blood cells and fluid to deposit in the skin and surrounding tissues. This also increases the number of white blood cells in the affected area, which can cause inflammation and skin damage.
Swelling of the feet and ankles can often be an unpleasant side effect of varicose veins as well as a symptom that increases the discomfort of vein disease. Edema is the condition in which an area of the body swells due to an excessive accumulation of tissue fluid, and it is a common side effect of slow blood flow in the veins.
In elastic support stockings for varicose veins, the elasticity provides a squeezing action to the legs which can help improve the rate at which the blood is returned to the heart. Improved blood circulation not only helps prevent varicose veins, it can soothe the discomfort of current symptoms, retard the progression of vein disease, and above all, it can decrease the risk of a blood clot forming in the superficial veins (superficial thrombophlebitis) or a deep vein (deep vein thrombosis).
Improved blood circulation can be observed using several different types of supportive hosiery. Graduated compression stockings, the most commonly used hosiery for varicose veins, are tightly fitted stockings most often prescribed by a doctor at a particular compression class level to meet specific medical needs for a patient. Compression levels are differentiated by how tightly the stockings constrict the affected area. This pressure helps the blood flow in the right direction, toward the heart.
Improved Blood Circulation
When varicose veins are caused by larger saphenous vein reflux underneath the skin, compression stockings may not work to relieve the symptoms and an endovenous ablation treatment may be necessary to solve the underlying problem. This is done by a minimally invasive surgical procedure using state-of-the-art ultrasound guidance. Covered by most insurance carriers, this procedure uses heat to seal the faulty vein in its entirety. Once sealed, the unhealthy veins shrink and are absorbed by the body. Compared to traditional vein stripping surgery, this most often successful technique uses a thin catheter to seal and collapse the vein, making recovery and results more rewarding. Following the treatment, a patient will be required to wear the gradient pressure stockings for 1-2 weeks. Your doctor will discuss the specific details of treatment options that are best for you.
For maximum efficacy, compression stockings with the gradient pressure pattern should be worn. General elastic support stockings are not as effective. Gradient pressure stockings are tightest at the ankle and gradually become looser as they work their way up the leg. Because of this construction, compression is greatest at the ankle and decreases as you move up the leg. Custom-made gradient pressure stockings are best, especially if you have a large difference in size between the ankle and calf. Another alternative is adjustable wrap-around style elastic stockings. These may be easier to put on and are often more comfortable to wear, especially if you have large legs with a big difference in size between the ankle and calf. (These can be made most effective with a special sock and stocking donner).
Reduced Swelling and Discomfort
Compression stockings should be worn as the first thing in the morning and taken off before bed at night. This is because the blood has usually accumulated in your legs overnight and by putting the stockings on first thing, they can keep the blood from further pooling in the veins throughout the day. There are different strengths of compression and it is important to consult your doctor to get the appropriate strength. If the stockings are too tight, they can cut off the blood flow to your feet and if they are too loose, they will not be effective. In addition, once the stockings start to lose their elastic, usually after about six months, they will no longer apply the necessary pressure to your legs and will need to be replaced.
Compression or support hose are the mainstay of treatment for varicose veins and have good success. Graduated compression stockings are specially designed to apply pressure to your lower legs. This pressures the stretched vein walls together and improves the overall function of the leg veins. The pressure they provide is strongest at the ankle and then gradually decreases as it moves up the leg. This pressure gradient ensures that the deoxygenated blood gets pushed up the leg to the next valve, ultimately pushing it up out of the leg. Once the blood is removed from the vein, usually the symptoms of aching and swelling of the legs is greatly reduced. The many stocking styles and brands feature different types of materials, colors and styles. A certified fitter will measure you for them and you can purchase them online or at medical supply stores.
Prevention of Varicose Vein Progression
Varicose veins are a common, chronic, and recurrent condition, meaning it occurs over a long period of time and often reoccurs. However, the use of compression stockings can end the progression of the disease, having a substantial impact on the quality of one’s life. Due to the increased pressure in the leg, the walls of the veins become weakened, allowing the valves to stretch. If the valves do not close properly, this allows blood to flow backwards and stay in the vein, increasing pressure and causing further damage to the veins. This downward spiral can eventually cause the skin to break down and an ulcer to form, long after the original cause of the varicose veins. Varicose veins will not go away if left untreated and usually get worse over time. This causes the initial symptoms of aching and fatigue to progress to swelling, leg heaviness, night cramps, and restless legs. As the vein continues to deteriorate under the increased pressure, there is a high risk of phlebitis and clot formation, so it is essential to halt the progression of the disease. Compression stockings have been proven to halt the progression of varicose veins. Patients who wore compression stockings had fewer symptoms and had symptoms for fewer years than those who did not wear compression stockings. Compression stocking use also reduced the risk of a venous ulcer in those with moderate to severe varicose veins. A venous ulcer is a serious complication of varicose veins that has a major impact on a person’s quality of life and can take many months to heal.
Types of Supportive Hosiery and Clothing
Compression leggings are a further development again. These work in the same way as both compression stockings and socks. They are tight fitting elastic leggings, designed to gently press on legs, compressing the veins and helping the blood to move upwards. They provide the same graduated compression as socks and stockings, so there is more pressure at the ankle which decreases going up the leg. These are usually a more expensive option, but provide much better symptom relief.
Compression socks are similar to compression stockings, but are designed with the sole purpose of treating symptoms caused by varicose veins in the feet. Like compression stockings, they use graduated compression to increase blood velocity. However, compression socks rather than decreasing in pressure when going up the leg are tightest around the arch of the foot and the ankle. This increases the velocity of the blood flow in these areas. This in turn will help to eliminate those symptoms caused by blood pooling in the veins, such as leg swelling and edema.
Compression stockings are the most simple intervention for those patients with varicose veins. These are tight elastic stockings which are usually knee length, although thigh length and tights are available. Sometimes these are so tight they require a prescription from a doctor. There is evidence that compression stockings give symptom relief. They exert an external pressure on the veins to reduce their caliber and increase the velocity of blood flow through them. This is achieved by the higher pressure of the stockings at the ankle, which decreases further up the leg. This is known as graduated compression. A more recent development are compression stockings with the added benefit of aloe vera. These moisturize the skin while wearing them to improve dry and damaged skin. This is a common problem in those with a venous disorder.
Compression Stockings
There are several classes of compression stockings available, which offer different levels of compression. The class of stocking required will depend on the severity of the varicose veins as well as other circulatory problems. Your doctor will be able to advise you on the most appropriate class of stocking. Compression stockings can generally only be worn under skirts and long trousers. This may be off-putting to some women, particularly in hot weather. If this is the case, there is the option of using compression knee-high stockings, which can be worn with shorts, skirts, and sandals. Knee-high stockings exert most of their pressure at the ankle and less at the calves. This is often a good option for the treatment of varicose veins in the lower leg.
According to the Circulation Foundation, compression stockings are a mainstay of treatment for varicose veins. If used correctly, they improve symptoms and slow the progression of varicose veins. Compression stockings are tight elastic garments worn around the leg, compressing the limb. This builds up external pressure on the veins, helping to keep them the right size and up so that the blood can be pumped back towards the heart. This provides relief of symptoms and prevents worsening of varicose veins. Compression stockings are a relatively conservative treatment option and may be all that is required to relieve symptoms. They are widely available and relatively inexpensive. Stockings come in a range of colours and styles and can be made to measure.
Compression Socks
It would be natural to assume that there is no difference between compression stockings and compression socks, however, there is a very distinct difference. Compression socks are very similar to their stocking counterparts but the major variance is that they do not constrict the foot. Compression socks are ideal for those with mild vein issues, who feel they don’t require the full compression effect right down to their feet. People such as this often find that compression socks are easier to put on and that there is less chafing due to the absence of a foot component. They are suitable for wear during physical activity or at work, particularly if the wearer sustains posture where the feet swell. The absence of foot compression in this case will generally cause the swelling to accumulate at the end of the sock, but it is still suitable for mild cases. Compression socks come in a variety of styles, ranging from an athletic knee high to a more formal dress sock. Pricing is also very similar to that of compression stockings and can generally be found for a comparative cost. Step into Life Fitness provides an extensive range of compression socks designed for both active and formal use. Compression socks are found to be comfortable for those who travel and who may suffer from swollen and sore feet and legs during or after their trip. In some cases, mild vein sufferers will choose to wear compression socks as a preventative measure aiming to stop the onset of more severe vein issues over time. With specialty lines readily available and no shortage of typical styles and colors, it is easy to make the transition and eradicate the dated notion that compression stockings are the only option available. Step into Life is happy to make recommendations and provide samples of compression socks, to ensure you find the correct product to match your needs.
Compression Leggings
Compression leggings complete the restriction and prevention of the development of varicose veins. They provide graduated compression to assist in moving blood and fluids up the leg towards the heart. When correctly prescribed, they apply the greatest amount of pressure at the ankle and less further up the leg. This external pressure supports venous muscle pumping, prevents reflux, and decreases the likelihood of blood pooling in the veins. The effectiveness of compression stockings in preventing and treating varicose veins is controversial, with some individuals experiencing symptomatic relief and others no change. This is often blamed on poor compliance and/or using a compression stocking with the wrong amount of compression for the individual. Prices and ease of access to compression stockings may only make them a viable option for prevention and individuals on their feet all day (i.e., nurses, teachers).
Supportive Shoes and Footwear
Dr. Chideckel stressed the importance of getting all the information from your doctor before agreeing on treatment. It also may be wise to get multiple opinions about your condition. Make sure you are comfortable with the doctor and that the treatment center is a place you would like to have your procedure. Now armed with all the information, masses of people will surely tell those 50 and older to retire the notion of beauty over comfort, fashion over function, or form over support when it comes to their shoes. This problem is particularly relevant for the large majority of women who have sought surgical treatment for their symptomatic varicose veins. Behind the shoes lies the main dilemma. All those who understood the findings behind support hose have a tough time donning their compression stockings with dress shoes. How then can these patients protect their progress in vein treatment and continue providing the prophylactic maintenance that is needed after recent surgical procedures? For the answer, we must turn back to preventative measures of support that have proven effective for venous symptoms in the run-up to surgical therapy of this condition. A recent study by Dr. Alfred Casale et al has drastically modernized the sanitation of open vein stripping operations. The Chicago-based research group successfully demonstrated that this intricate microsurgical technique can be accomplished with a local anesthetic, frequently sufficient to put the procedure in the realms of office surgery. An earlier Poland-based study had recommended prophylactic use of antiembolism compression for one week post-operative in above knee vein surgery, there being less positive findings on a separate group that had thigh-length compression for a similar duration. These studies bring the vein patient to a familiar crossroads. The minimalist invasive techniques of several new surgical protocols combine with the message that less invasive procedures require less aggressive post-operative management. What is clear is that no matter what form surgical therapy takes, the patient with any history of varicose veins is in greater need of advice and special provisions for what standard medical compression in the form of stockings is expected for varying lower extremity venous symptoms.
Dr. Chideckel performs all his procedures in the Park Avenue Vein Center, which is a treatment center fully staffed with anesthesia. We have anesthesia because some procedures for varicose vein treatments can be complex and time-consuming, and anesthesia is necessary. The other benefit of being in an accredited treatment center is that the nurses are able to focus more on patient care when there are no other duties to attend to. This leads to patients having a more comfortable and enhanced experience during their treatment. With more time for each patient and complete attention from the nursing staff, often painful or difficult procedures can be better tolerated and recovered from. This achieves better results and greater patient satisfaction.
Consider that patients need to know whether the surgery is done in a physician’s office for treatment or at a treatment center. Some centers are uncomfortable places to have procedures and are hard to have done when the patient is awake.
If venous reflux has led to chronic venous insufficiency, pudal and reticular veins, most insurance agencies will cover a percentage of the treatment of varicose veins,” he said. “Because venous insufficiency is considered a medical condition. But patients should be aware that varicose or spider veins that are strictly a cosmetic issue generally aren’t covered by insurance.” This info was taken off of website if venous reflux has led.
Choosing the Right Supportive Hosiery and Clothing
The use of compression stockings with a pressure level of 20-30mmHg is commonly prescribed for those with or at risk for varicose veins. This is the ideal pressure level for those who are still relatively mobile and can effectively aid in management and prevention of further varicosity. A 30-40mmHg pressure is used for more severe cases and after vein treatment, if recommended by a physician. This pressure level requires a doctor’s prescription as it is too strong for those who are still relatively healthy.
Proper sizing and fit of supportive hosiery and clothing is important for patients to gain optimal benefits from their compression gear. A garment that is too loose cannot provide enough support, while a garment that is too constricting is uncomfortable and harder to apply. For these reasons, the use of a measuring guide and sizing chart, preferably supplied by the manufacturer, is essential. Brands often differ in sizing, just as patients do in shape, thus size should not be estimated. Measurements should be taken first thing in the morning, especially for those with some degree of daily swelling, to ensure accuracy. The measuring guide should be followed exactly, as it may contain instructions for taking several measurements at different points on the leg. Garments should be replaced every 3-6 months, as loss of elasticity affects the ability of the garment to apply the necessary amount of pressure.
Proper Sizing and Fit
For accurate sizing, a doctor can get a stocking or sock size from a medical supply store or pharmacy. This may be important in determining the correct size and brand of compression stocking. Consumers must know the precise ankle, calf, thigh, or knee measurement to ensure a perfect fit. Standardized sizing is effective and easy for consumers to find garments that provide the correct amount of pressure. Due to wide variance in brand name hosiery, sizing charts are essential in determining fit and avoiding trial and error purchases.
Long periods of standing and sitting cause blood to pool in the legs, worsening the condition and causing leg swelling. When circulation is constricted, it can cause discomfort and continue to worsen the condition. Ill-fitting hosiery and clothing can cause significant constriction. This uneven pressure on the leg can trigger vein dilation and cause blood to seep into surrounding tissues. The use of properly fitting hosiery can create external pressure on the skin to help keep vein diameter at its normal size and prevent blood from pooling in the veins.
There are several instructions to keep in mind when choosing supportive hosiery and clothing. Clothing should never fit too tight, and it is important to not get items of clothing that are restrictive or binding.
Graduated Compression Levels
Care and attention must be given when putting on compression stockings, as this will stress the material if done incorrectly and may damage its effectiveness. Be sure to keep your fingernails and toenails closely trimmed to prevent snagging the stocking, remove all jewelry, and use rubber gloves to ensure a good grip.
Always listen to your doctor’s advice when selecting compression levels, and have a fitting by a professional fitter to determine which is the most suitable for your condition. It is also best to get a fitting in the morning as this is when the leg size is smallest.
Level 4 (40-50mmHg): This is the highest form of compression and is used to relieve severe symptoms. It is used to treat severe venous stasis, post thrombotic syndrome, moderate lymphedema, and active ulcers.
Level 3 (30-40mmHg): This is used to relieve pronounced symptoms. It is often used to treat pronounced varicose veins, pronounced swelling, and thrombosis.
Level 2 (20-30mmHg): This is used to relieve moderate symptoms. It is commonly used to treat mild varicose veins, and light swelling.
Level 1 (15-20mmHg): This is the mildest form of compression, used to relieve mild symptoms. It is often worn as a preventative measure by patients with varicose veins during pregnancy.
Jobst Compression Stockings are often used to help relieve symptoms of venous conditions and are available in a number of different gradient compression levels. Heavier symptoms require greater restriction and thus higher the level of compression. Percentage compression is calculated at the ankle. Any pressure above the calf or upper thigh is used to increase blood circulation and thus is not included in the percentage compression levels in the stocking.
You should start by trying on a number of different types of compression stockings to see which is most comfortable for you, fits properly, and is compatible with your lifestyle. Gradient stockings come in many designs, colors, and compression levels. They are also available with open-toes and in maternity sizes.
Material and Breathability
Compression hosiery and bandages cannot maintain their therapeutic efficacy unless they provide sufficient stiffness and pressure over a sustained period. This means that a garment must resist gradual deformation over a long period of use. Failure to do so can result in a garment that becomes ‘loose’ and provides less compression than intended, possibly doing more harm than good. Indeed, a study by Moffatt has shown that nearly 50% of nurses working in the UK have difficulty in interpreting whether a bandage provides the correct level of compression, attributing this to the ‘complex and variable properties of bandage systems’.
Material can have a number of different effects on a stocking or bandage. For one, it will affect the garment’s stiffness. Generally, garments made with higher amounts of rubber will be less elastic and provide more resistance. Durability of the garment will also be affected, with garments made with more elastic fibers generally being less durable. Perhaps most importantly, the material of a garment will greatly affect its ability to provide the listed compression over its lifespan, an issue related to the concept of ‘rigidity of materials’ described in the next section.
Garments may be composed of a variety of different types of materials, including natural rubber, synthetic rubber, cotton, and various other fibers. In addition, many hosiery are made with a combination of these materials, adding another level of complexity. As of now, there are no standardized methods to determine the exact composition of different compression hosiery. To add further confusion, it is not uncommon for manufacturers to change the materials used in their garments without any change in labeling or packaging. Online catalogs and sales materials are typically no more helpful, generally offering only a vague description of the material composition or none at all.
Style and Design Options
Overall, patients now have a vast amount of options when choosing supportive hosiery.
If you have been prescribed an mmHg pressure rating, it is important to note that this is the amount of pressure the stocking will provide when properly worn. If you purchase a stocking that is too large or long, the pressure and style may be affected. Long lengths of stockings are also available and can be cut to fit those with longer legs. High-pressure stockings or compression wraps are also available to those with wounds or ulcerations on the leg. Wraps may be the best and only option for those with limb abnormalities or severely fluctuating leg sizes, as custom wraps can be made for almost any leg shape. These wraps are also adjustable, making them easy to apply and remove.
For those fashion-conscious patients, the good news is that there are various options available to fit the personal style of every individual. Today, due to the advancements in technology, patients do not have to sacrifice style for medical effectiveness. There are sheer, thin materials available now and hosiery that looks just like regular stockings and socks. Some brands even offer a free sample program, allowing patients to try different styles to find the right feel and look. This can be a great option, as buying multiple pairs of medical hose that are not returnable can become an expensive trial and error process.
Style and design are two important options when choosing supportive hose. Most medical supportive hose comes with a standard look consisting of a full leg hose that is either an open or closed toe design. This can be unappealing to some, especially those with venous conditions. Most of these patients are already self-conscious about the appearance of their legs, and the thought of wearing medical hose just makes matters worse.