Compression stockings attenuate the expression of proteins

associated with vascular damage in human varicose veins

Guillermo Moñux, MD, PhD,a Mariano de la Serna-Soto, MSc,b Ferrán Plá-Sanchez, MD,c
José J. Zamorano-León, PhD,d Antonio Segura, MD,e Rodrigo Rial, MD, PhD,a Gala Freixer, MSc,b
Khaoula Zekri-Nechar, MSc,b Carlos Hugo-Martínez, MD, PhD,b Javier Serrano, MD, PhD,c and
Antonio López-Farré, PhD,b Madrid and Toledo, Spain

ABSTRACT
Objective: The objective of this study was to analyze whether compression stocking therapy in the human varicose vein
wall may change the levels of biomarkers associated with vein insufficiency.
Methods: Dilated collateral varicose vein samples were obtained from patients showing chronic venous disease (class 2 of
the Clinical, Etiology, Anatomy, and Pathophysiology classification). Before elective surgery, 12 patients underwent
compression stocking therapy (for 1 month) and 9 patients did not (control group). Expression levels of biomarkers
associated with endothelial functionality (nitric oxide synthase 3), inflammation (interleukin-6, interleukin-10), oxidative
stress (Gp91phox subunit of NADPH oxidase), and coagulation (factor Xa) were determined. P-selectin, an inflammatory
and thrombosis-related biomarker, was also measured.
Results: Compression stockings increased the content of nitric oxide synthase 3 (control, 16.48 [16.04-17.40] AU;
compression, 83.71 [67.70-91.85] AU; P < .001) in the varicose vein wall that was accompanied by reduction of both
interleukin-6 levels (control, 38.72 [33.48-48.52] pg/mg protein; compression, 14.49 [11.05-17.41] pg/mg protein; P ¼ .001) and
the expression of Gp91phox subunit of NADPH oxidase (control, 63.24 [53.79-77.03] AU; compression, 36.85 [35.66-52.27] AU;
P < .010). P-selectin (control, 77.37 [61.86-85.00] AU; compression, 54.31 [49.60-67.50] AU; P ¼ .017) and factor Xa (control,
90.78 [75.02-100.00] AU; compression, 14.50 [13.77-36.20] AU; P < .001) were also reduced in the varicose vein wall of
compression stocking-treated patients. However, P-selectin lost its statistical significance after adjustment by
dyslipidemia.
Conclusions: In the varicose vein wall, compression stocking therapy improved the content levels of biomarkers asso-
ciated with endothelial functionality, inflammation, oxidative stress, and coagulation. (J Vasc Surg: Venous and Lym Dis
2021;9:428-34.)
Clinical Relevance: The study revealed that compression stocking therapy increased the content of nitric oxide
synthase 3 in the varicose vein and reduced expression levels of biomarkers associated with endothelial func-
tionality, inflammation, oxidative stress, and coagulation. It suggests that a better understanding of the molecular
mechanisms modified by stocking compression may open new approaches for the use of this noninvasive
therapy.
Keywords: Compression stocking; Endothelium; Inflammation; Thrombosis; Varicose veins

Varicose veins are a common venous disease of

From the Department of Angiology and Vascular Surgery, Hospital Universitario
HM Torrelodones, Madrida; the Department of Medicine,b and Department of
Public Health and Maternal and Child Health,d School of Medicine, Universi-
dad Complutense, Madrid; the Vascular Surgery Department, Hospital Clínico
San Carlos, Madridc; and the Health Science Institute, Talavera de la Reina,
Toledo.e
This work was funded by GenObIA Consortium (S2017/BMD-3773) of the Com-
munity of Madrid, Spain.
Author conflict of interest: none.
Correspondence: Antonio J. López-Farré, PhD, Department of Medicine, School
of Medicine, Universidad Complutense, Plaza Ramón y Cajal/sn, Madrid
28040, Spain (e-mail: ajlf@telefonica.net).
The editors and reviewers of this article have no relevant financial relationships to
disclose per the Journal policy that requires reviewers to decline review of any
manuscript for which they may have a conflict of interest.
2213-333X
Copyright Ó 2020 by the Society for Vascular Surgery. Published by Elsevier Inc.
https://doi.org/10.1016/j.jvsv.2020.05.020
the lower limbs.1 In varicose veins, there is blood
reflux and incompetent valves as well as vein wall
dilation.2 In most of the cases, the disease takes a
benign course. However, advanced stages are
frequently associated with ulcerations and throm-
botic complications, especially superficial and deep
venous thrombosis.3
Researchers in experimental animal models and clin-
ical studies have postulated some possible mechanisms
to explain the development of varicosities in limb veins,
but the determinants are not clearly defined.4 In this re-
gard, inflammatory mechanisms mediated by increased
circulating levels of cytokines and expression of blood
cell adhesion molecules also include prothrombotic
molecules such as P-selectin, proteases, and stimulation
of oxidative stress and seem to contribute to venous

428
Journal of Vascular Surgery: Venous and Lymphatic Disorders
Volume 9, Number 2
endothelial dysfunction and disease progression.5,6
Indeed, reduced circulating nitric oxide (NO) levels
were reported in patients with varicose veins.7 These
diminished NO levels may result from downexpression
of endothelial NO synthase (NOS3) in the damaged vari-
cose vein endothelium or are a consequence of higher
catabolism of NO by the superoxide anion generated in
the damaged vein’s endothelial cells.2,8 Indeed, venous
endothelial dysfunctionality may participate, along with
a slow blood flow, in causing superficial blood clots.9,10
These superficial clots associated with varicose veins
can cause leg swelling, redness, pain, and tenderness in
the affected limb or around the affected vein.11
Compression stocking therapy remains the cornerstone
of varicose vein management for patients. Graduated
compression therapy has been associated with reversal
of venous hypertension, augmentation of the skeletal-
muscle pump, facilitation of venous return, and improve-
ment of lymphatic drainage.12,13 However, the physiologic
effect of compression stockings on varicose veins has
been the subject of different studies.14,15 The possible
modulating effects in the varicose vein wall of the expres-
sion of molecular biomarkers associated with disease
progression, such as inflammatory, oxidative stress, and
coagulation biomarkers, are less well known.
Therefore, the aim of this work was to analyze whether
compression stocking therapy before surgery in the vari-
cose vein wall may modify the level of expression of bio-
markers associated with venous insufficiency.
METHODS
Varicose vein sample collections. Varicose vein sam-
ples were obtained from 24 consecutive patients
showing truncal varices secondary to insufficiency of
the saphenofemoral junction vein (class C2 of the Inter-
national Consensus Committee reporting standards on
venous disease [Clinical, Etiology, Anatomy, and Patho-
physiology classification]).16 All the patients included
were selected for elective surgery. Color flow duplex ul-
trasound was used to examine the lower limb venous
system and to determine the sites of reflux excluding
occlusive vein thrombosis. Ultrasound was performed
with the patient in the standing position using a 7.5-
10 MHz linear probe. Venous insufficiency was consid-
ered when venous reflow duration was >0.5 second.
Eligible patients had to fulfill inclusion and exclusion
criteria. Patients were excluded from the study if they
had suffered deep venous thrombosis, post-thrombotic
syndrome, reflux in the deep venous system, active skin
ulcers or local skin inflammatory changes, Klippel-Tré-
naunay syndrome, May-Turner syndrome, recent infec-
tion, neoplastic disease, and chronic systemic
inflammatory disease or had been subjected to any sur-
gical procedure within the last 6 months before inclu-
sion. Patients with body mass index >29.9 kg/m2 were
also excluded from the study. As an inclusion criterion,
Moñux et al 429
all recruited patients had to show reflux at the sapheno-
femoral junction and great saphenous vein causing su-
perficial varicosities. There was no reflux in the small
saphenous vein, perforating veins, or deep venous sys-
tem. Patients had to sign an informed consent to be
included in the study.
The included patients were randomized into two
experimental groups by random start: with compression
stocking therapy during the months before surgery
(n ¼ 12); and without compression stocking therapy
(n ¼ 12). The compression therapy was followed for
1 month before the surgical intervention. Three samples
from the nontreated group were discarded because of
damage in the vein wall during the isolation and storage
procedure. Therefore, nine patients were finally consid-
ered in the control group. The study was blinded for
the basic researchers who performed the measurements
of the molecular parameters.
During the elective surgery based on endovenous laser
ablation and phlebectomy, 2 cm of dilated collateral vari-
cose vein from the leg was obtained from each patient of
both experimental groups. The section of dilated collat-
eral varicose vein was specifically obtained from a region
that had been subjected to compression stocking ther-
apy during the month preceding the surgical procedure.
The samples obtained from the control group were from
a region equal to that of the patients treated with
compression stocking therapy.
The compression therapy was carried out with the
thigh-length elastic compression stocking Farmalastic
Novum Intelligent Plus (CINFA Laboratory, Navarra,
Spain) with compression degree 2 (23-32 mm Hg). The
compression stockings had a length from the toes to
the upper thigh. Patients subjected to compression ther-
apy were instructed by the vascular surgeon’s group to
wear the elastic compression stocking through the day
and to take it off at night. The medical group monitored
adequate compression stocking therapy through weekly
phone calls. All the patients claimed to use the stockings
as recommended by the physician.
The work was performed according to the principles
outlined in the Declaration of Helsinki. The Institu-
tional Ethics Committee approved the study
(code C.I. 19/041-E).
After extraction, all vein samples were immediately
blood cleaned by washing them in isotonic saline. No pa-
tients from either of the experimental groups had super-
ficial venous thrombosis involving the analyzed veins.
Vein samples were quickly frozen at 80 C until molec-
ular determinations.
Interleukin (IL) 6 and IL-10 determinations. IL-6 and IL-
10 content in the varicose veins was determined by
commercial enzyme-linked immunosorbent assay
(ELISA) kits. As previously reported,17 ELISA kits for IL-6
(Human IL-6 Quantikine ELISA kit; D6050; R&D Systems,
430 Moñux et al Journal of Vascular Surgery: Venous and Lymphatic Disorders
March 2021

Abingdon, Oxfordshire, United Kingdom) and IL-10 (Hu- influence of dyslipidemia on the observed results, a linear
man IL-10 Quantikine ELISA kit; D1000B; R&D Systems) regression analysis was performed. The dependent variable
were performed according to the manufacturer’s was the different molecular parameters, and dyslipidemia
instructions. was used as a covariant. SPSS 25.0 software (IBM Corp,
The sensitivity of the IL-6 and IL-10 ELISA kits was 0.7 pg/ Armonk, NY) was used to perform the statistical analysis,
mL and 3.9 pg/mL, respectively. The intra-assay and inter- and a P value <.05 was considered statistically significant.
assay variation coefficients were 1.7% to 4.4% and 2.0% to
RESULTS
3.7% for IL-6 and 2.5% to 6.6% and 5.6% to 7.6% for IL-10.
Table I shows the clinical characteristics of the patients
All samples were measured within the same ELISA kit.
with varicose veins. Nine patients were finally included in
Protein content of NOS3, P-selectin, factor Xa, and the group not treated with compression stockings (con-
Gp91phox subunit of NADPH oxidase in the varicose trol group), and 12 patients were in the compression
veins. Varicose vein samples were homogenized with an stocking treatment group. The clinical features showed
Ultra-Turrax T8 (IKA-Werke; GmbH & Co, Staufen, Ger- greater number of both patients with dyslipidemia and
many) in a buffer containing 8 mol/L urea, 2% CHAPS w/ statin-treated patients in the control group with respect
v, and 40 mmol/L dithiothreitol. The homogenates were to those in the compression stocking-treated group.
then centrifuged at 10.500g for 10 minutes and the su- However, it did not reach statistical significance. Con-
pernatants recovered.18 Protein quantitation was done cerning other clinical characteristics, there were no sta-
using a bicinchoninic acid kit (Pierce, Rockford, Ill). tistical differences between patients.
As previously reported,19 protein electrophoresis was per- IL-6 and IL-10 content in the varicose vein wall. As
formed loading an equal amount of protein (40 mg/lane) shown in Table II, IL-6 content in the varicose vein wall
from each varicose vein homogenate onto denaturing so- was significantly higher in the control group than in the
dium dodecyl sulfate-polyacrylamide gel electrophoresis patients who underwent compression stocking therapy
12% (w/v) polyacrylamide gels. After electrophoresis, gels during 1 month before surgery. The level of IL-10 content
were blotted onto nitrocellulose membranes, which were in the varicose vein wall was almost undetectable in both
then incubated with 5% (w/v) bovine serum albumin. Nitro-
groups of patients, being similar between them.
cellulose membranes were then incubated with mono-
clonal antibodies against NOS3 (sc-653, dilution 1:1000; Expression levels of NOS3, P-selectin, factor Xa, and
Santa Cruz Biotechnology, Santa Cruz, Calif), mitochondrial Gp91phox subunit of NADPH oxidase in the varicose
Gp91phox subunit NADPH oxidase (Sc-5827, dilution 1:800; vein. In the varicose vein wall, the content of NOS3 pro-
Santa Cruz Biotechnology), and P-selectin (SC-8419, dilu- tein was significantly lower in the control group than in
tion 1:1000; Santa Cruz Biotechnology) and a polyclonal the patients who underwent compression stocking
antibody against factor Xa (12255e05021, dilution 1:800;
AssayPro, St. Charles, Mo). Nitrocellulose was also incu- Table I. Clinical features and drug treatment of patients
bated with a monoclonal anti-b-actin antibody (A-5441, with and without compression stocking therapy
dilution 1:1000; Sigma-Aldrich, St. Louis, Mo) used as Compression
loading control. Parameters Control (n ¼ 9) (n ¼ 12) P value
Nitrocellulose membranes were revealed using
Age, years 46 (42-58) 44.5 (33-52) .247
peroxidase-conjugated anti-rabbit immunoglobulin G
Sex
(IgG; 1:2000 for factor Xa and 1:2500 for NOS3 and
Male 5 6 .801
b-actin), peroxidase-conjugated anti-mouse IgG (1:2500
for P-selectin), and peroxidase-conjugated anti-goat IgG Female 4 6
(1:2000 for Gp91phox subunit NADPH oxidase). The pro- Risk factors
tein signal was obtained using chemiluminescence re- Hypertension 3/9 (33.3) 3/12 (25) .676
agents (ECL; GE Healthcare, Little Chalfont, Dyslipidemia 4/9 (44.4) 2/12 (16.7) .163
Buckinghamshire, United Kingdom) and densitometri- Diabetes 1/9 (11.1) 0/12 (0) .237
cally measured by a transilluminator (iBright FL100; Ther- mellitus
moFisher Scientific, Waltham, Mass). Drug treatment
ARBs 1/9 (11.1) 1/12 (8.3) .830
Statistical analysis. Results are represented as medians ACE inhibitors 2/9 (22.2) 2/12 (16.7) .748
(25th-75th percentiles) and frequency (percentage). The
Statins 4/9 (44.4) 2/12 (16.7) .163
c2 test was used to compare categorical variables between
Diuretics 1/9 (11.1) 0/12 (0) .237
the control and compression groups. Nonparametric
ACE, Angiotensin-converting enzyme; ARBs, angiotensin II receptor
Mann-Whitney tests were used to determine the differ- blockers.
ences in the vein protein content of patients treated and Categorical variables are presented as n/N (%). Age is represented as
median (25th-75th percentile).
not treated with compression stockings. To analyze the
Journal of Vascular Surgery: Venous and Lymphatic Disorders
Volume 9, Number 2
Table II. Inflammatory interleukin (IL) expression levels in veins of patients with and without compression stocking therapy
Biomarkers Control (n ¼ 9)
IL-6, pg/mg protein 38.72 (33.48-48.52)
IL-10, pg/mg protein 1.26 (0.0-9.86)
Interleukin levels are expressed as median (25th-75th percentile).
therapy before surgery. The expression levels of P-selectin
and factor Xa were also determined in the varicose vein
wall. P-selectin content in the varicose vein wall was
significantly higher in the control group than in the pa-
tients treated with compression stockings. The content
of factor Xa was also higher in the varicose vein wall of
controls than of patients with compression stocking
treatment. In addition, the vein wall content of Gp91phox
subunit of NADPH oxidase was significantly higher in
controls than in the compression stocking-treated pa-
tients (Fig; Table III).
Possible influence of dyslipidemia. In the control
group, more patients showed dyslipidemia compared
with the patients treated with compression stockings.
However, although the number of dyslipidemic patients
was not statistically different between the two experi-
mental groups, a linear regression analysis was per-
formed using dyslipidemia as a covariant. As shown in
Tables II and III, after adjustment by dyslipidemia, the
content of IL-6, NOS3, Gp91phox NADPH oxidase, and
factor Xa in the varicose vein walls remained statistically
different between the controls and the patients with
compression stocking treatment. Only the P-selectin
content in the varicose vein wall lost statistical signifi-
cance between the experimental groups when dyslipi-
demia was used as a covariant (Table III).
DISCUSSION
This work shows, for the first time, that patients using
compression stockings during the month before elective
varicose vein surgery had a higher level of NOS3 protein
Fig. Representative Western blots showing the expression levels of nitric oxidase synthase 3 (NOS3), Gp91phox
subunit of NADPH oxidase, P-selectin, and activated coagulation factor X (FXa) in the varicose vein wall of patients
with and without compression stocking therapy. b-Actin was used as loading control.
Moñux et al 431
P value adjusted
Compression (n ¼ 12) P value by dyslipidemia
14.49 (11.05-17.41) .001 .001
2.85 (1.42-10.26) .955 .697
in the varicose vein wall than the patients without
compression stocking therapy. Moreover, the patients
with compression stockings also had reduced content
of proteins associated with inflammation and oxidative
stress in the varicose vein wall. In addition, compression
stocking-treated patients also had reduced content of
proteins associated with the thrombosis and coagulation
processes (ie, P-selectin and factor Xa) in the varicose
vein wall, although the statistical differences in P-selectin
expression were lost after adjustment by dyslipidemia.
Compression stockings remain the first-line treatment
of varicose veins.20 Stockings work by exerting the great-
est degree of compression at the ankle, with the level of
compression gradually decreasing upward. This pressure
gradient ensures that blood flows up toward the heart
instead of refluxing down to the foot or laterally into
the superficial veins, reducing the incidence of hema-
tomas and thrombophlebitis.21-24
It is well recognized that reduction of endothelial shear
stress, as in the varicose vein wall, is directly sensed by
endothelial cells, promoting endothelial dysfunctional-
ity.25,26 Accordingly, it was reported that von Willebrand
factor, an indicator of endothelial damage, was signifi-
cantly increased in the blood from varicose veins
compared with the levels found in systemic blood taken
from the cubital vein.27
In the study, the varicose vein wall of the compression
stocking group contained a higher level of NOS3 protein
than that of the control group. It may suggest that endo-
thelial functionality may be improved after compression
stocking therapy. It is well documented that the endo-
thelium, through NOS3 protein, modulates endothelial
432 Moñux et al
Table III. Expression levels of different biomarkers involved in platelet activation, coagulation, and oxidative stress in veins of
patients with and without compression stocking therapy
Biomarkers Control (n ¼ 9)
NOS3, AU 16.48 (16.04-17.40)
Gp91phox NADPH oxidase, AU 63.24 (53.79-77.03)
P-selectin, AU 77.37 (61.86-85.00)
Factor Xa, AU 90.78 (75.02-100.00)
AU, Arbitrary densitometric units; NOS3, nitric oxide synthase.
Biomarker levels are expressed as median (25th-75th percentile).
homeostasis that additionally regulates the blood flow,
inducing a vasodilation response and preventing both
leukocyte and platelet adhesion to the vascular wall.28,29
It is generally agreed that laminar shear stress induces
the release of factors that suppress inflammation and
reactive free radical production, whereas low shear stress,
turbulent flow, and stasis promote the production of in-
flammatory, oxidative stress, and thrombotic mediators.9
In this regard, Poredos et al27 demonstrated increased
IL-6 levels in blood taken from varicose veins. Interest-
ingly, in the vascular wall, inflammatory process-related
molecules by themselves are triggers for the downex-
pression of NOS3 protein.
In the study, the increased content of NOS3 protein in
the varicose vein undergoing compression stocking
treatment was accompanied by significant reduction of
both IL-6 and the mitochondrial Gp91phox subunit of
NADPH oxidase compared with those observed in the
varicose vein wall obtained from the control group.
It is also noteworthy that the anti-inflammatory cyto-
kine IL-10 was almost undetectable in the varicose vein
wall and was not significantly modified after compres-
sion stocking therapy. This observation may suggest
different regulation of IL-6 and IL-10. Indeed, we have
also observed, as other authors also did, different levels
of expression of IL-6 and IL-10 in other inflammatory
process-related pathologic situations.17,30
An important fact that could influence the relevance of
these findings is that dyslipidemia was more frequent in
the control patients than in the patients with compres-
sion stocking therapy, although it did not reach statistical
significance between the two experimental groups. In
this regard, it was reported that dyslipidemia may by it-
self modify either inflammatory parameters or the
expression of NOS3 protein.31 After adjustment by dyslipi-
demia, the content in varicose vein wall of both IL-6 and
Gp91phox NADPH oxidase remained statistically higher in
the control group than in patients who underwent
compression stocking therapy. Moreover, after dyslipide-
mia was used as a covariant, the content of NOS3 protein
also remained higher in the varicose vein wall of patients
with compression stocking therapy than in the controls.
In addition, all the dyslipidemic patients were receiving
statin treatment. Statin treatment has been reported
Journal of Vascular Surgery: Venous and Lymphatic Disorders
March 2021
P value adjusted
Compression (n ¼ 12) P value by dyslipidemia
83.71 (67.70-91.85) <.001 .021
36.85 (35.66 -52.27) .010 .019
54.31 (49.60-67.50) .017 .064
14.50 (13.77-36.20) <.001 .001
to improve NOS3 expression and to reduce inflamma-
tion.32,33 Therefore, taken together, these results appar-
ently indicate that the effect of dyslipidemia should be
diminished.
To our knowledge, this is the first report showing a
direct effect on the varicose vein wall of compression
stockings on mechanisms involved in endothelial func-
tionality. In the same line of evidence, Okamoto et al34
have previously demonstrated that graduated compres-
sion stockings improved both brachial artery flow-
mediated dilation (a measure to evaluate endothelial
functionality) and the biologic antioxidant potential in
briskly walking healthy individuals.
Endothelial dysfunction is a main player in the link be-
tween varicose veins and deep venous thrombosis.35
Endothelial dysfunctionality causes an imbalance be-
tween procoagulant activity and anticoagulant activity,
increasing the release of prothrombotic and procoagu-
lant factors.36 It is remarkable that varicose veins repre-
sent one of the most important risk factors in the
development of superficial and deep venous throm-
bosis.37 Therefore, graduated compression stockings are
the most widely used mechanical antithrombotic
agent.38
In the experiments, the content of two proteins associ-
ated with the coagulation process, namely, P-selectin
and factor Xa, was significantly reduced in the varicose
vein wall obtained from the patients who underwent
compression stocking treatment with respect to those
patients who did not undergo this therapy. P-selectin
has been demonstrated to be not only an inflammatory
biomarker but also a predictor of platelet activation,
deep venous thrombosis, and venous thromboembo-
lism.39,40 Factor Xa is a serine protease that catalyzes
the proteolytic conversion of prothrombin to active
thrombin, being both the vessel wall and platelet source
to release it. However, the results demonstrated that af-
ter adjustment by dyslipidemia, only factor Xa content
in the varicose vein wall remained different between
the control patients and patients treated with compres-
sion stockings. After use of dyslipidemia as a covariant,
P-selectin expression lost statistical difference between
the two experimental groups. It may be interesting
because the results then suggest that dyslipidemia
Journal of Vascular Surgery: Venous and Lymphatic Disorders
Volume 9, Number 2
seems to have more influence on a marker of platelet ac-
tivity than on a coagulating marker such as factor Xa.
Indeed, it is also important to point out that none of
the included patients showed deep venous thrombosis.
Taken together, the results suggest that compression
stocking treatment of varicose veins achieves wall bene-
ficial effects on the expression of biomarkers associated
with some classic etiologic risk factors for varicose vein
included in the Virchow triad (1856), namely, inflamma-
tion, hypercoagulability, and endothelial functionality.
Comments and study limitations. One of the most
relevant limitations of this work is the small sample
size. Therefore, the study should be considered a pilot
observational study, but the results obtained were
consistent. In this regard, the results observed warrant
future studies to determine additional molecular mech-
anisms that may contribute to the beneficial effects of
compression stocking therapy in patients with varicose
veins, and therefore additional studies with larger sam-
ple size are needed to confirm our results.
A limitation of the study is that we cannot know
whether compression stocking therapy returns protein
expression levels to normal values. To know this fact,
additional future experiments should be performed us-
ing veins from patients who did not have varicose vein
disease, that is, patients undergoing peripheral or coro-
nary bypass.
In this study, we have not determined the severity of
venous dysfunctionality after compression stocking ther-
apy, although it is probable that the molecular changes
occur long before they can be reflected in functional
changes in the varicose vein. In this regard, with these re-
sults, it cannot be elucidated whether the observed mo-
lecular changes after compression stocking therapy
could be occurring on the reported infiltrated leukocytes
or in the cells forming the venous wall structure, that is,
endothelial and smooth muscle cells.
CONCLUSIONS
In the varicose vein wall, compression stockings
improved the level of molecular biomarkers associated
with endothelial functionality, inflammation, oxidative
stress, and coagulation. The better understanding of
the molecular mechanisms modified by stocking
compression may open new approaches for the use of
this noninvasive therapy.
The authors thank CINFA Laboratory, Navarra, Spain, for
donating the elastic compression stockings. We thank
Begoña Larrea for her editorial assistance.
AUTHOR CONTRIBUTIONS
Conception and design: GM, ALF
Analysis and interpretation: FPS, JZL, AS, RR, GF, KZN,
CHM, JS
Data collection: MSS, JZL, GF, KZN, CHM
Moñux et al 433
Writing the article: GM, ALF
Critical revision of the article: MSS, FPS, JZL, AS, RR, GF,
KZN, CHM, JS
Final approval of the article: GM, MSS, FPS, JZL, AS, RR, GF,
KZN, CHM, JS, ALF
Statistical analysis: MSS, AS
Obtained funding: ALF
Overall responsibility: ALF
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Submitted Feb 11, 2020; accepted May 1, 2020.