What is the recommended treatment for leg edema using compression stockings?

Compression Stockings for Leg Edema

Compression stockings are not recommended for routine use in preventing post-thrombotic syndrome (PTS), but they may help reduce edema and pain associated with deep vein thrombosis (DVT) in selected patients. 1

Compression Therapy Recommendations

For DVT-Related Edema:

• The American Society of Hematology (ASH) 2020 guidelines suggest against routine use of compression stockings for prevention of PTS in patients with DVT (conditional recommendation based on very low certainty evidence) 1
• However, compression stockings may still be beneficial for symptom management in selected patients with DVT-related edema and pain 1

For Chronic Venous Disease and Non-DVT Edema:

• For venous leg ulcers (VLU) and chronic venous insufficiency:
  • A minimum pressure of 20-30 mmHg is recommended for initial treatment 1
  • Higher pressures of 30-40 mmHg are advised for more severe disease 1
  • For ankle-brachial indices between 0.6-0.9, reduced compression to 20-30 mmHg is effective and safe 1

Pressure Recommendations by Indication:

• For occupational/evening edema: 11-21 mmHg stockings can reduce or prevent edema in people who sit or stand for long periods 2
• For chronic leg edema: Compression stockings exerting pressure of around 30 mmHg are nearly as effective as high-pressure bandages (>60 mmHg) 3
• For elderly patients (≥65 years): Lower pressure stockings (18-21 mmHg) may provide better wearing comfort than higher pressure stockings (23-32 mmHg), especially in those with foot deformities, arthritis, or rheumatism 4

Application and Duration Guidelines

• For acute symptomatic DVT of the leg, if compression stockings are used:

  • The 2012 ACCP guidelines suggested wearing compression stockings for 2 years 1
  • However, newer evidence (ASH 2020) does not support routine use 1

• For chronic venous disease:

  • Compression therapy should involve proper fitting, education, and detailed instructions to improve adherence 1
  • Improved ejection fraction in refluxing vessels is achieved when higher pressures are exerted at the calf over the distal ankle (negative graduated compression) 1

Special Considerations

• For patients with post-thrombotic syndrome (PTS):

  • A trial of compression stockings is suggested for symptom management 1
  • For severe PTS not adequately relieved by compression stockings, a trial of an intermittent compression device may be beneficial 1

• For patients with venous leg ulcers:

  • 30-40 mmHg inelastic compression is better than elastic bandaging for wound healing 1
  • Velcro inelastic compression is as effective as 3- or 4-layer inelastic bandages 1

Cautions and Contraindications

• Avoid compression therapy when ankle-brachial index is <0.6 as it indicates arterial anomaly requiring revascularization 1
• Potential adverse effects include discomfort, skin breakdown, and allergic reactions 1
• For elderly patients with arthritis, hallux valgus, and/or digitus flexus (claw toe), lower pressure stockings (18-21 mmHg) are recommended for better compliance 4

Alternative Approaches

• For initial therapy of venous edema, a kit consisting of a liner (20 mmHg) and outer stocking (20 mmHg) may be equally effective as traditional bandaging followed by stockings 5
• For chronic extremity swelling, there appears to be an upper pressure limit beyond which further compression is counterproductive (approximately 50-60 mmHg for lower extremities) 6