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Veins and Lymphatics 2012; volume 1:e3

[Veins and Lymphatics 2012; 1:e3] [page 7]

Unexpected venous diameter
reduction by compression
stocking of deep, but not
of superficial veins
Hugo Partsch,1 Giovanni Mosti,2
Jean-Fran�ois Uhl3
1Dermatology, Medical University of
Vienna, Austria; 2Angiology Department,
Clinica MD Barbantini, Lucca, Italy;
3URDIA research unit - EA4465 -
University Paris Descartes, France

Abstract 

Morphological studies on the effect of com-
pression on the leg veins are rare and mostly
performed in the supine position. The aim of
this study was to investigate the influence of
compression applied with different pressures
on the venous calibre in the standing position.
Standing magnetic resonance imaging was
used to measure the venous diameters of
superficial and deep leg veins in a patient with
massive varicose veins without and with dif-
ferent levels of compression and realistic 3D
vectorial models were built. In the standing
position compression stockings with a pres-
sure of 22 mmHg were able to reduce the cali-
bre of deep calf veins, but not of superficial
varices. These were compressed only by band-
ages exerting pressures between 51 and 83
mmHg. Compression stockings may reduce the
diameter of deep calf veins in the standing
position. To empty a varicose vein after venous
ablation much higher pressures are required. 

Introduction

Following the conventional concept com-
pression devices will compress a leg vein
when the external pressure is higher than the
intravenous pressure. In the standing position
of an adult person this intravenous pressure is
around 80-100 mmHg in a dorsal foot vein and
around 60 mmHg at knee level corresponding
to the weight of the blood column between the
right heart and the measuring point on the
leg. Measurements of venous occlusion pres-
sure by Duplex in connection with a sphygmo-
manometer containing a transparent window
in different body positions were in agreement
with this concept.1

The following observations demonstrate
that superficial and deep veins may respond to
compression in a different manner which has
therapeutic consequences.

Case Report

A 42-year-old male presenting with massive
varicose veins in connection with a dilated
and completely incompetent great saphenous
vein (C2EpAsPr) gave his consent to take part
in a magnetic resonance imaging (MRI)
investigation without contrast medium in the
laboratory of Esaote, Genova, Italy.2 Using the
G-scan® machine (Esaote, Genova) with a
0.25 Tesla field and a hydraulic tilting table
transversal scans of the lower extremity were
gained in supine and standing position, with-
out compression, with a round knitted com-
pression stocking (German compression class
II, 23-32 mmHg at B) and after application of a
moderate and a strong multi-component
inelastic compression bandage (Rosidal sys®,
Lohmann & Rauscher, Rengsdorf, Germany).
The interface pressures of these compression
devices were measured at mid-calf level in the
supine and standing position using the
Picopress® probe (Microlab Italia).3 In order to
demonstrate that the venous diameter reduc-
tions observed under compression were not
restricted to a small segmental slice only, a
3D-reconstruction using manual drawing of
the T2 weighted slices and a computer soft-
ware (Winsurf®) was performed by JF Uhl and
his team in Paris.4

Quantitative assessment of the results was
done by planimetry of the venous cross-sec-
tions and by volume calculations in the 3D
model.
The procedures were in accordance with

the ethical standards of the responsible com-
mittee on human experimentation in Italy and
with the Helsinki Declaration of 1975 (as
revised in 2008).

Results

The pressures measured at mid-calf in
supine/ standing position were 18/22 mmHg
under the stocking, 39/51 mmHg under the
first and 60/83 mmHg under the second band-
age.
In the supine position (Figure 1A) large

dilated varicose veins are seen (arrow), which
collapse under a compression stocking exert-
ing a pressure of 18 mmHg (Figure 1B). At the
same time the enlarged soleus vein and the
deep leg veins are only slightly compressed. 
During standing (Figure 2A) superficial

and deep veins are slightly larger than in the
lying position, a compression stocking (22
mmHg) closes the soleus veins and narrows
the deep leg veins, while the diameter of the
superficial varicose veins remains unchanged
(Figure 2B).
This can also be shown in the 3D-recon-

struction (Figure 3, A without and B with the
stocking). Quantitative volumetric results are
demonstrated in Figure 4 in absolute terms
(A) and in percent changes (B). It is clearly
shown that the most intense compression
effect involves the deep veins while the super-
ficial veins stay nearly untouched. 
Only a strong compression with a pressure

of 51 mmHg using an inelastic bandage leads
to a narrowing not only of the deep but also of
the superficial veins (Figure 5A). Under a
pressure of 83 mmHg in standing, both, super-
ficial and deep veins are totally compressed
(Figure 5B).

Discussion

This case is reported because of the instruc-
tive documentation obtained by MRI in the
standing position in a patient with large vari-
cose veins. Three normal individuals without
varicose veins showed a similar pattern, espe-
cially concerning non-compressibility of the
superficial veins by compression stockings
during standing. 
Compression of the leg leads to a shift of the

muscle compartments which can clearly be

Correspondence: Hugo Partsch, Steinhäusl 126,
Altlengbach, 3033 Austria.
Tel. +43.664.1437.274.
E-mail: hugo.partsch@meduniwien.ac.at

Key words: compression, magnetic resonance
imaging, varicose veins, stockings, bandages.

Acknowledgements: we would like to thank Dr. E.
Fracchia, Genova, for sending the patient. The
research was carried out at the MRI research lab-
oratory of Esaote, Genova, Italy and at the URDIA
research unit of the University Paris Descartes,
France.

Contributions: HP, outcome analysis, manuscript
writing; GM, MRI (in the standing position) per-
forming, manuscript writing; J-FU, 3D recon-
struction and quantitative evaluation, manu-
script writing.

Conflict of interests: the authors declare no
potential conflict of interests.

Received for publication: 11 March 2012.
Revision received: 21 May 2012.
Accepted for publication: 31 May 2012.

This work is licensed under a Creative Commons
Attribution 3.0 License (by-nc 3.0).

©Copyright H. Partsch et al., 2012
Licensee PAGEPress, Italy
Veins and Lymphatics 2012; 1:e3
doi:10.4081/vl.2012.e3

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Case Report

[page 8] [Veins and Lymphatics 2012; 1:e3]

seen by the change of the configuration of the
MRI cross-section, especially in the standing
position. This happens already with low pres-
sure as demonstrated in Figure 2 and is obvi-
ously associated with an occlusion of the
enlarged soleus vein and with considerable
narrowing of the deep veins. In contrary the
superficial varicose veins do not change its
calibre. Using MRI in the lying position
Downie et al. reported a greater cross-section-
al area reduction under compression stockings
in the deep veins (64%) than in superficial
veins (39%).5 Analyzing our own data with MRI
we found this surprising feature in the prone
and in the standing position, but not in the
supine position.2 Actually Downie’s investiga-
tions were done in the prone position. 
The described narrowing of deep veins in the

standing and prone position, but not in the
supine position points to the fact that the config-
uration of the muscle compartments which
change in every body position plays a major role
on the embedded veins. As visible result of these
compartment-shifts the contour of the cross-sec-
tion through the leg is getting more circular with
in comparison without compression (Figures 2B
and 5B versus Figures 2A and 5A).
To narrow or to occlude superficial varicose

veins in the standing position much higher
pressures are needed as demonstrated in
Figure 5. The same was demonstrated on
superficial veins of three healthy individuals
by MRI, in agreement with previous Duplex
findings on individuals without varicose
veins.1

The fact that superficial leg veins are barely
compressed by compression stockings in the
upright position has practical implications. If
we want to achieve an empty vein after any
ablative intervention of varicose veins, e.g.
after sclerotherapy, endovenous treatment or
surgery, much higher pressure is needed in the
ambulant patient than that exerted by a com-
pression stocking. This is the most likely expla-
nation that some authors using compression
stockings with a pressure below 20 mmHg were
unable to demonstrate any benefit after scle-
rotherapy6 or after surgery7 while others using
very strong bandages8 or eccentric compression
pads in order to increase local pressure9-12

showed a much better outcome, especially con-
cerning pain and haematoma-formation.

Conclusions

At the time being MRI in the lying and
standing position with and without compres-
sion is certainly the best method to demon-
strate diameter reductions in clearly defined
veins of the lower extremity.
This short report using MRI in the standing

position showed surprisingly stronger com-

Figure 1. A) Magnetic resonance imaging cross - section at mid-calf level in the supine
position without compression. B) The same with compression stocking (18 mmHg). The
arrows point to the enlarged varicose veins on the medial lower leg. Opposite are the
markers attached to the skin in order to evaluate identical segments 

Figure 2. A, B) Same arrangement as in Figure 1, standing position.

Figure 3. A) 3D reconstruction in the standing position without compression. B) With
compression stocking, reducing the calibre of the deep, but not of the superficial veins.

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[Veins and Lymphatics 2012; 1:e3] [page 9]

pression effects on the deep than on superfi-
cial veins. This is in complete contrast to the
traditional concept that compression would
affect more the superficial than the deep veins.
To narrow superficial varicose leg-veins in

the upright position in the demonstrated case
(e.g. after endovenous procedures) a pressure
of more than 50 mmHg would be needed. 

References

1. Partsch B, Partsch H. Calf compression
pressure required to achieve venous clo-
sure from supine to standing positions. J
Vasc Surg 2005;42:734-8.

2. Partsch H, Mosti G, Mosti F. Narrowing of

leg veins under compression demonstrat-
ed by magnetic resonance imaging (MRI).
Int Angiol 2010;29:408-10.

3. Partsch H, Mosti G. Comparison of three
portable instruments to measure compres-
sion pressure. Int Angiol 2010;29:426-30.

4. Uhl JF. 3D multislice CT to demonstrate
the effects of compression therapy. Int
Angiol 2010;29:411-5.

5. Downie SP, Firmin DN, Wood NB, et al.
Role of MRI in investigating the effects
of elastic compression stockings on the
deformation of the superficial and deep
veins in the lower leg. J Magn Imaging
2007;26:80-5.

6. Hamel-Desnos CM, Guias BJ, Desnos PR,
Mesgard A. Foam sclerotherapy of the
saphenous veins: randomised controlled
trial with or without compression. Eur J
Vasc Endovasc Surg 2010;39:500-7.

7. Biswas S, Clark A, Shields DA.
Randomised clinical trial of the duration
of compression therapy after varicose
vein surgery. Eur J Vasc Endovasc Surg
2007;33:631-7.

8. Mosti G, Mattaliano V, Arleo S, Partsch H.
Thigh compression after great saphenous
surgery is more effective with high pres-
sure. Int Angiol 2009;28:274-80. 

9. Lugli M, Cogo A, Guerzoni S, et al. Effects
of eccentric compression by a crossed-tape
technique after endovenous laser ablation
of the great saphenous vein: a randomized
study. Phlebology 2009;24:151-6.

10. Benigni JP. Interface pressure measure-
ments at the thigh under eccentric com-
pression (Mediven Post Op Kit). Int Angiol
2009;28:334-5.

11. Benigni JP, Allaert FA, Desoutter P, et al.
The efficiency of pain control using a
thigh pad under the elastic stocking in
patients following venous stripping:
results of a case-control study. Perspect
Vasc Surg Endovasc Ther 2011;23:238-
43.

12. Partsch B, Partsch H. Which pressure do
we need to compress the great saphenous
vein on the thigh? Dermatol Surg 2008;34:
1726-8.

Figure 4. A) Calculation of vein volume. B) Its percent changes under the stocking based
on the 3D reconstruction. AT, anterior tibial vein; PT, posterior tibial vein; Fib, fibular
vein; MG, medial gastrocnemius vein; VAR, superficial varicose vein.

Figure 5. A) Standing position with inelastic bandage exerting 51 mmHg. B) Standing
with very strong inelastic bandage (pressure 83 mmHg).

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