What is the recommended use of compression socks for patients with Deep Vein Thrombosis (DVT)?

Compression Stockings for Deep Vein Thrombosis (DVT)

Current guidelines suggest against the routine use of compression stockings for prevention of post-thrombotic syndrome (PTS) in patients with DVT, but they may be beneficial for symptom relief in selected patients with pain and edema. 1

Evidence Evolution on Compression Stockings

The recommendations regarding compression stockings for DVT patients have evolved significantly over time:

Earlier Guidelines (2007-2012)

• The 2007 American College of Physicians and American Academy of Family Physicians guideline recommended routine use of compression stockings beginning within 1 month of DVT diagnosis and continuing for at least 1 year to prevent PTS 1
• The 2011 American Heart Association recommended daily use of 30-40 mmHg knee-high graduated elastic compression stockings (ECS) for at least 2 years after diagnosis of proximal DVT 1
• The 2012 American College of Chest Physicians suggested compression stockings for acute symptomatic DVT, to be worn for 2 years 1

Current Guideline (2020)

• The 2020 American Society of Hematology (ASH) guidelines now suggest against the routine use of compression stockings for patients with DVT, regardless of their risk for PTS 1
• This recommendation is based on more recent evidence, particularly the SOX trial, which was larger and better designed than previous studies
• The recommendation is conditional, based on very low certainty in the evidence

Rationale for Current Recommendation

The shift in recommendations is based on:

1. Inconsistent evidence of benefit:

   • When considering only trials with low risk of bias, compression stockings showed no significant reduction in PTS (RR 1.01; 95% CI 0.76-1.33) 1
   • Earlier positive studies had methodological limitations including lack of placebo control and blinding 1

2. Limited effect on key outcomes:

   • Negligible effect on mortality (RR 0.99; 95% CI 0.72-1.36) 1
   • Non-significant reduction in pulmonary embolism risk 1
   • Non-significant reduction in DVT recurrence 1

When Compression Stockings May Be Appropriate

Despite not being routinely recommended, compression stockings may be beneficial in specific situations:

• For symptom relief in patients with pain and edema associated with DVT 1
• For patients with established PTS who find stockings helpful for symptom management 1
• For patients with severe edema, where intermittent sequential pneumatic compression followed by daily use of 30-40 mmHg knee-high graduated ECS may be considered 1

Practical Considerations

If compression stockings are used:

• Pressure gradient: 30-40 mmHg at the ankle is the recommended pressure 1
• Length: Knee-high stockings are generally recommended and as effective as thigh-high stockings 1, 2
• Duration: If used for PTS prevention, they were traditionally recommended for at least 2 years after DVT diagnosis 1
• Patient factors: Consider patient comfort, ability to apply stockings, and cost 1

Common Pitfalls and Caveats

1. Patient compliance: Many patients find compression stockings difficult to apply and uncomfortable to wear, leading to poor adherence 1

2. Cost considerations: Maintaining stockings for a long period represents a moderate cost to patients 1

3. Proper fitting: Ill-fitting stockings may not provide therapeutic benefit and could potentially cause harm

4. Contraindications: Avoid compression stockings in patients with severe peripheral arterial disease or skin conditions that could be exacerbated by compression

Summary

While earlier guidelines recommended routine use of compression stockings after DVT, current evidence suggests they may not provide significant benefit for most patients in preventing PTS. However, they may still have a role in symptom management for selected patients with pain, edema, or established PTS. The decision to use compression stockings should consider the individual patient's symptoms, preferences, and ability to use them properly.