Guidelines for Using Compression Stockings to Prevent Deep Vein Thrombosis (DVT)
Current guidelines do not recommend routine use of compression stockings for prevention of post-thrombotic syndrome (PTS) in patients with DVT, based on the most recent evidence from the American Society of Hematology 2020 guidelines. 1
Prevention of DVT in High-Risk Populations
Hospitalized Medical Patients
- Mechanical prophylaxis with intermittent pneumatic compression is preferred over graduated compression stockings when pharmacological prophylaxis is contraindicated 2
- For ischemic or hemorrhagic stroke patients with unacceptable anticoagulant risks, a combination of graduated compression stockings and intermittent pneumatic compression is recommended 2
Long-Distance Travelers
- For long-distance (>4 hours) travelers without risk factors for VTE, compression stockings are not routinely recommended 1
- For travelers at substantially increased VTE risk (recent surgery, history of VTE, postpartum women, active malignancy, or ≥2 risk factors including combinations with hormone replacement therapy, obesity, or pregnancy), properly fitted below-knee graduated compression stockings providing 15-30 mmHg of pressure at the ankle are recommended 1
- Below-knee compression stockings are preferred as they are as effective as thigh-length stockings and better tolerated 3
Management After DVT Diagnosis
Post-Thrombotic Syndrome Prevention
- The American Society of Hematology 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
- This represents a change from earlier guidelines (2007) that recommended compression stockings beginning within 1 month of diagnosis of proximal DVT and continuing for a minimum of 1 year 1
- The change in recommendation is based on newer evidence showing inconsistent benefits in preventing PTS 1, 4
Symptom Management
- Despite not being routinely recommended for PTS prevention, compression stockings may still be beneficial for symptom management in selected patients with DVT-related edema and pain 2, 5
- For patients with established post-thrombotic syndrome symptoms, a trial of compression stockings may be considered 2, 6
Compression Pressure Recommendations
- 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, 6
- 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, 2
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 6
- The American College of Chest Physicians previously suggested wearing compression stockings for 2 years after acute symptomatic DVT, but newer evidence does not support this routine practice 1, 2
Contraindications and Cautions
- Avoid compression therapy when ankle-brachial index is <0.6 as it indicates arterial anomaly requiring revascularization 2, 6
- Potential adverse effects include discomfort, skin breakdown, and allergic reactions 1, 2
- Compression stockings should not be used in patients with active DVT who are receiving sequential compression devices as prophylaxis; these devices should be discontinued once DVT is diagnosed 5
Mechanism of Action
- Graduated compression stockings reduce the overall cross-sectional area of the limb, increase linear velocity of venous flow, reduce venous wall distension, and improve valvular function 7
- Compression stockings reduce edema by decreasing capillary filtration and improving lymphatic drainage 2
- They enhance microcirculation through transient increases in shear stress, releasing anti-inflammatory, vasodilating, and antithrombotic mediators 2