Are sequential compression devices (SCDs) used in patients with active deep vein thrombosis (DVT)?

Sequential Compression Devices Should Not Be Used in Patients with Active DVT

Sequential compression devices (SCDs) should not be used in patients with active deep vein thrombosis (DVT) as they may potentially dislodge existing clots and increase the risk of pulmonary embolism. 1

Rationale for Avoiding SCDs in Active DVT

• SCDs work by artificially replicating the "pumping mechanism" of the soleus muscle to enhance venous return and reduce stasis, which could potentially mobilize existing clots in patients with active DVT 2
• The American Society of Hematology (ASH) 2020 guidelines do not recommend mechanical compression for patients with established DVT, focusing instead on appropriate anticoagulation as the primary treatment 1
• External compression on a limb with active thrombosis could theoretically dislodge the thrombus and increase the risk of pulmonary embolism 3

Recommended Management for Active DVT

• Anticoagulation is the primary treatment for active DVT to control symptoms, prevent progression, and reduce the risk of post-thrombotic syndrome and pulmonary embolism 3
• Direct oral anticoagulants (DOACs) are preferred over warfarin for most patients with DVT due to their effectiveness, safety profile, and convenience 3
• For patients with cancer-associated thrombosis, low molecular weight heparin or specific DOACs (edoxaban or rivaroxaban) may be considered 3

Role of Compression Therapy in DVT Management

• While SCDs are contraindicated in active DVT, graduated compression stockings may be used selectively for symptom management after initial treatment 1
• The ASH 2020 guidelines suggest against the routine use of compression stockings for prevention of post-thrombotic syndrome in patients with DVT (conditional recommendation based on very low certainty evidence) 1
• However, compression stockings may help reduce edema and pain associated with DVT in selected patients 1, 4

Appropriate Use of SCDs

• SCDs are indicated for DVT prophylaxis in high-risk patients without active DVT 5, 2
• They are particularly valuable for patients with contraindications to pharmacological prophylaxis 5
• In trauma patients with lower extremity injuries that preclude the use of standard SCDs, foot pumps may be a reasonable alternative for DVT prophylaxis 5

Clinical Considerations and Pitfalls

• A common clinical pitfall is continuing mechanical compression in patients who develop DVT while on prophylactic SCDs - these devices should be discontinued once DVT is diagnosed 1
• For patients with established post-thrombotic syndrome not adequately relieved by compression stockings, intermittent pneumatic compression devices may be considered, but only after the acute DVT has been adequately treated 4
• The effectiveness of SCDs for VTE prevention in medically ill patients has been questioned, with one retrospective study showing no significant difference in VTE incidence compared to no prophylaxis 6

Special Situations

• For patients with iliofemoral DVT, the American Heart Association suggests daily use of 30-40 mm Hg knee-high graduated elastic compression stockings for at least 2 years after diagnosis, but only after initial anticoagulation therapy 1
• In patients with venous leg ulcers resulting from previous DVT, compression therapy with 30-40 mmHg pressure is recommended, but only after ensuring adequate arterial flow 4