Are Ankle Brachial Index (ABI) tests required before prescribing compression stockings?

Ankle Brachial Index Testing Before Prescribing Compression Stockings

ABI testing is required before prescribing compression stockings to identify patients with peripheral arterial disease (PAD) who may be at risk for complications from compression therapy.

Rationale for ABI Testing

The American College of Cardiology/American Heart Association guidelines clearly establish the importance of vascular assessment before compression therapy:

• Compression therapy can potentially worsen tissue perfusion in patients with significant PAD
• An ABI ≤0.90 indicates abnormal arterial flow that may contraindicate standard compression
• Patients with noncompressible vessels (ABI >1.40) require alternative assessment methods

Assessment Algorithm Before Compression Stocking Prescription

1. Perform resting ABI measurement

   • Interpret results according to standardized criteria 1:
     • Normal: ABI 1.00-1.40
     • Borderline: ABI 0.91-0.99
     • Abnormal: ABI ≤0.90
     • Noncompressible: ABI >1.40

2. For patients with noncompressible vessels (ABI >1.40)

   • Perform toe-brachial index (TBI) with waveforms 1
   • TBI ≤0.70 indicates PAD
   • Toe pressure <30 mm Hg indicates severe ischemia with poor wound healing potential 2

3. For patients with borderline ABI (0.91-0.99)

   • Consider exercise treadmill ABI testing to evaluate for PAD 1

Compression Recommendations Based on Vascular Assessment

• ABI >0.9: Safe to use standard compression stockings
• ABI 0.5-0.9: Modified compression may be considered with careful monitoring
  • Research shows progressive elastic compression stockings (higher at calf than ankle) may be tolerated in patients with ABI >0.6 3
  • A study demonstrated safety of specialized compression stockings (German compression class 1) in patients with ABI between 0.5-0.9 4
• ABI <0.5: Compression is contraindicated due to high risk of tissue damage

Monitoring Requirements

• Patients with normal ABI and no risk factors: Annual reassessment of ABI 5
• Patients with borderline ABI or risk factors (diabetes, reduced mobility, claudication): ABI reassessment every 3 months 5
• Any patient reporting new or worsening symptoms: Immediate reassessment

Common Pitfalls to Avoid

1. Relying solely on ABI in patients with diabetes or renal disease

   • These patients often have noncompressible vessels (ABI >1.40)
   • TBI is essential in these populations 2

2. Assuming stable vascular status over time

   • ABI can change, particularly in patients with PAD 5
   • Regular monitoring is essential for patients in compression therapy

3. Overlooking mild PAD

   • Even borderline ABI (0.91-0.99) may indicate early PAD
   • Exercise ABI testing can reveal PAD not detected at rest 1

By following this evidence-based approach to vascular assessment before prescribing compression stockings, clinicians can minimize the risk of adverse events and optimize outcomes for patients requiring compression therapy.