Should patients with peripheral arterial disease (PAD) wear compression stockings?

Compression Stockings in Peripheral Arterial Disease

Patients with peripheral arterial disease (PAD) should NOT wear compression stockings as they are contraindicated in severe peripheral arterial disease and may worsen symptoms. 1

Rationale and Evidence

Compression stockings, while beneficial for certain vascular conditions, pose significant risks for patients with PAD:

• Compression stockings are explicitly contraindicated in patients with severe peripheral arterial disease as they may worsen symptoms by further reducing arterial blood flow to the extremities 1
• The primary guidelines for venous thromboembolism (VTE) management from both the American Society of Hematology and American College of Chest Physicians do not recommend compression stockings for patients with PAD 2
• While compression stockings are commonly used for chronic venous insufficiency (CVI), their use must be carefully considered when arterial disease is present

Special Considerations for Mixed Arterial-Venous Disease

In rare cases where patients have both PAD and chronic venous insufficiency, specialized approaches may be considered:

• For patients with mild-to-moderate PAD (ankle-brachial index ≥ 0.5) and coexisting venous insufficiency, specially designed progressive compression stockings might be considered under close supervision 3, 4
• These specialized stockings provide higher compression at the calf than at the ankle level (reverse gradient compared to traditional stockings) 4
• A 2020 study showed that specially designed compression stockings (German compression class 1 with high stiffness) may be safe for individuals with an ankle-brachial index ≥ 0.5, but this is not standard practice 3

Risk Assessment and Monitoring

Before considering any compression therapy in patients with suspected or known PAD:

• Measure ankle-brachial index (ABI) to assess PAD severity (ABI < 0.9 indicates PAD) 5
• Patients with severe PAD (ABI < 0.5) should avoid compression stockings entirely
• If compression is deemed necessary for coexisting venous disease in patients with mild PAD, close monitoring is essential, including:
  • Regular assessment of peripheral pulses
  • Monitoring for worsening pain, coldness, or discoloration of extremities
  • Immediate discontinuation if symptoms worsen

Appropriate Management for PAD

Instead of compression stockings, PAD management should focus on:

• Lifestyle modifications including smoking cessation and supervised exercise therapy 6, 7, 5
• Secondary prevention medications including:
  • Antiplatelet therapy (aspirin or clopidogrel)
  • Angiotensin-converting enzyme inhibitors or angiotensin receptor blockers
  • Statin therapy 6, 7, 5
• Consideration of cilostazol for claudication symptoms in patients without heart failure 7
• Surgical revascularization for patients with lifestyle-limiting claudication that doesn't respond to medical therapy 7, 5

Key Pitfalls to Avoid

• Never prescribe standard compression stockings for patients with known PAD without thorough vascular assessment
• Don't assume that compression stockings that help with venous symptoms are safe for patients with arterial disease
• Avoid delaying appropriate PAD management by focusing on venous symptoms alone
• Remember that many PAD patients (approximately 40%) have no leg symptoms, making assessment before compression therapy crucial 5