Guidelines for Prescribing Compression Stockings
Compression stockings should be prescribed based on the specific clinical indication, with pressure levels ranging from 15-40 mmHg depending on the condition being treated, and should not be routinely used for post-thrombotic syndrome prevention. 1, 2
Pressure Recommendations by Clinical Indication
- For venous leg ulcers and chronic venous insufficiency, a minimum pressure of 20-30 mmHg is recommended initially, with higher pressures of 30-40 mmHg for more severe disease 2
- For patients with ankle-brachial indices between 0.6-0.9, reduced compression of 20-30 mmHg is both effective and safe 2
- For long-distance travelers at increased risk for VTE, 15-30 mmHg below-knee graduated compression stockings are recommended 1
- For elderly patients (≥65 years) with leg edema, especially those with foot deformities or arthritis, lower pressure stockings (18-21 mmHg) may provide better wearing comfort and compliance than higher pressure options (23-32 mmHg) 3
- For lymphedema management, higher compression levels (30-40 mmHg) are typically required 4
Specific Clinical Scenarios
Deep Vein Thrombosis (DVT)
- Current ASH 2020 guidelines suggest against routine use of compression stockings for prevention of post-thrombotic syndrome in patients with DVT (conditional recommendation based on very low certainty evidence) 1, 2
- However, compression stockings may still be beneficial for symptom management in selected patients with DVT-related edema and pain 1, 2
- If prescribed for post-thrombotic syndrome symptoms, a trial of compression stockings is suggested 1, 2
- For severe post-thrombotic syndrome not adequately relieved by compression stockings, a trial of an intermittent compression device may be beneficial 1, 2
VTE Prophylaxis
- For hospitalized patients at risk of VTE where pharmacological prophylaxis is contraindicated, mechanical prophylaxis with intermittent pneumatic compression is preferred over graduated compression stockings 1
- For ischemic or hemorrhagic stroke patients in whom anticoagulant prophylaxis risks are unacceptable, graduated compression stockings plus intermittent pneumatic compression is recommended 1
- For long-distance travelers at increased risk for VTE, 15-30 mmHg below-knee graduated compression stockings are recommended, along with frequent ambulation and calf muscle exercises 1
Application and Duration Guidelines
- Proper fitting is essential - stockings should be measured and fitted to the individual patient 2
- Patient education on proper application and removal techniques improves adherence 2
- The older 2012 ACCP guidelines suggested wearing compression stockings for 2 years after acute symptomatic DVT 1, but newer evidence does not support this routine practice 1, 2
- For chronic conditions like venous insufficiency, ongoing use may be required as long as symptoms persist 2
Contraindications and Cautions
- Avoid compression therapy when ankle-brachial index is <0.6 as it indicates arterial anomaly requiring revascularization 2
- Potential adverse effects include discomfort, skin breakdown, and allergic reactions 1, 2
- Be aware that 20-30 mmHg compression stockings may not effectively compress leg veins in the standing position, which may limit their effectiveness for some indications 5
- There appears to be an upper limit beyond which further increase of compression pressure becomes counterproductive: approximately 30 mmHg for upper extremities and 50-60 mmHg for lower extremities 6
Dosing Considerations
- For optimal effectiveness, compression pressure should be graduated (highest at ankle, decreasing proximally) 4
- For lymphedema and severe chronic venous insufficiency, higher pressures (30-40 mmHg) are typically required 2, 4
- For elderly patients or those with arthritis, hallux valgus, or digitus flexus, lower pressure stockings (18-21 mmHg) may provide better comfort and compliance 3