Dangers of Compression Stockings in Peripheral Arterial Disease (PAD)
Compression stockings are contraindicated in patients with severe peripheral arterial disease (PAD) as they may worsen arterial blood flow and potentially lead to critical limb ischemia. 1
Pathophysiological Concerns
Compression stockings work by applying external pressure to the limbs, which can have significant implications for patients with PAD:
- Reduced arterial blood flow: The primary concern is that external compression may further compromise already limited arterial circulation in PAD patients
- Risk of tissue hypoxia: Decreased perfusion can lead to worsening tissue oxygenation, particularly in distal extremities
- Potential for tissue damage: In severe cases, inappropriate compression could accelerate tissue damage and potentially lead to ulceration or necrosis
Risk Stratification
The danger of compression stockings varies based on PAD severity:
- Severe PAD (ABI < 0.5): High risk - compression stockings are absolutely contraindicated
- Moderate PAD (ABI 0.5-0.8): Moderate risk - traditional compression stockings should be used with extreme caution
- Mild PAD (ABI > 0.8): Lower risk - may tolerate mild compression with careful monitoring
Evidence-Based Considerations
Recent research provides some nuanced insights:
A 2023 pilot study found that class I compression stockings did not significantly affect microperfusion parameters in patients with advanced PAD (Fontaine stage IIb and higher), suggesting potential safety in carefully selected cases 2
A 2019 study demonstrated high tolerance of progressive elastic compression stockings (18±2 mmHg at calf and 8±2 mmHg at ankle) in patients with symptomatic PAD with ABI > 0.60 3
A 2020 study found that medical compression therapy did not impair microperfusion in patients with PAD in physiologic body positions, though perfusion decreased in elevated leg positions 4
Special Considerations
Body Position Impact
- Elevated leg position: Significantly decreases perfusion in PAD patients when using compression stockings 4
- Sitting/standing positions: Generally better tolerated with compression 4
Alternative Approaches
For patients with mixed arterial and venous disease:
- Progressive compression stockings: Higher pressure at calf (18±2 mmHg) than ankle (8±2 mmHg) may be better tolerated in selected PAD patients 3
- Intermittent pneumatic compression (IPC): May be considered as an alternative in some cases 5
Clinical Assessment Before Compression Use
Before considering compression stockings in any patient with suspected PAD:
- Measure ABI: Essential to quantify PAD severity
- Assess pedal pulses: Diminished or absent pulses indicate higher risk
- Evaluate skin integrity: Pre-existing tissue damage increases risk
- Consider toe pressure measurements: Particularly valuable in patients with calcified vessels where ABI may be unreliable
Monitoring Protocol
If compression is deemed necessary despite PAD (e.g., in mixed arterial-venous disease):
- Start with lowest effective compression class
- Monitor skin color, temperature, and sensation frequently
- Instruct patient to remove stockings immediately if pain, numbness, or color changes occur
- Schedule frequent follow-up assessments
- Consider alternative body positions that optimize perfusion
Conclusion
While recent research suggests that carefully selected compression approaches may be tolerated in some PAD patients, the potential risks remain significant. The decision to use compression stockings in PAD requires careful risk assessment, appropriate patient selection, and vigilant monitoring to prevent potentially serious complications.