Are compression stockings effective for patients with Peripheral Artery Disease (PAD)?

Compression Stockings for Peripheral Artery Disease (PAD)

Compression stockings are generally not recommended for patients with Peripheral Artery Disease (PAD) as they may potentially worsen arterial blood flow in an already compromised circulation. 1

Understanding PAD and Compression Therapy

• PAD is a progressive atherosclerotic disease affecting over 8 million Americans, characterized by insufficient arterial blood flow to the lower extremities, resulting in ischemia-induced leg discomfort, especially during walking 1
• Classic claudication presents as pain, aching, cramping, or fatigue in the buttocks, thigh, calf, or foot that occurs during walking and is relieved within approximately 10 minutes of rest 2
• Unlike venous disorders where compression therapy is beneficial, PAD involves arterial insufficiency that may be worsened by external compression 1

Evidence Against Routine Use of Compression Stockings in PAD

• The American Society of Hematology (ASH) 2020 guidelines suggest against the routine use of compression stockings even for venous thromboembolism, noting inconsistent evidence regarding their effectiveness 1
• Compression stockings work by applying external pressure to improve venous return, but this same mechanism could potentially reduce arterial blood flow in patients with compromised arterial circulation 1
• In PAD, the primary concern is insufficient arterial blood flow to tissues, which compression stockings could theoretically worsen by adding external pressure on already narrowed arteries 2

Special Considerations for Mixed Disease (PAD + Venous Insufficiency)

• Some patients develop both chronic venous insufficiency (CVI) and PAD, particularly with increasing age 3
• For patients with both conditions, specially designed compression stockings with lower pressure (Class I) and high stiffness may be considered if:
  • Ankle-brachial index (ABI) is ≥ 0.5 3
  • Absolute ankle systolic pressure is > 60 mmHg 3
• A 2020 study showed that specially designed Class I compression stockings did not impair microperfusion in patients with diabetes or PAD and were safe when used within these parameters 4

Safety Parameters for Compression Use in Select PAD Patients

• If compression therapy is considered for a patient with both PAD and venous disease:
  • Use only Class I (lower pressure) compression stockings 3, 5
  • Ensure the patient has an ankle-brachial index (ABI) ≥ 0.5 3
  • Monitor for any signs of worsening ischemia (increased pain, numbness, color changes) 4
  • Avoid compression therapy in patients with critical limb ischemia or rest pain 2

Alternative Management Approaches for PAD

• The American Heart Association recommends supervised exercise programs as a first-line therapy for PAD with claudication (Class I recommendation, Level of Evidence A) 1
• Supervised exercise treadmill training has been shown to improve claudication onset time, peak walking time, and other functional outcomes 1
• In 2017, the Centers for Medicare & Medicaid Services approved coverage for supervised exercise therapy for Medicare beneficiaries with symptomatic PAD 1
• For patients with limited exercise capacity, intermittent pneumatic compression (IPC) devices may be beneficial, showing increased popliteal artery velocity (49-70%) and flow (49-84%) 6

Clinical Decision Algorithm

1. Assess if patient has pure PAD or mixed disease (PAD + venous insufficiency)
2. For pure PAD:
   • Avoid compression stockings 1
   • Implement supervised exercise program 1
   • Address cardiovascular risk factors 7
3. For mixed disease (PAD + venous insufficiency):
   • Measure ankle-brachial index (ABI)
   • If ABI ≥ 0.5 and ankle systolic pressure > 60 mmHg: Consider Class I compression stockings with monitoring 3, 4
   • If ABI < 0.5 or critical limb ischemia: Avoid compression therapy 2

Pitfalls and Caveats

• Never use standard compression stockings in patients with severe PAD (ABI < 0.5) or critical limb ischemia 2, 3
• Recognize that PAD symptoms worsen with exercise and improve with rest, while venous claudication presents with tight, bursting pain that improves with elevation (opposite to arterial pain) 2
• Be aware that patients with rest pain that worsens when lying flat and improves with dependency suggests more severe PAD (chronic limb-threatening ischemia) rather than simple claudication 2
• Monitor patients with mixed disease using compression therapy closely for signs of worsening ischemia 4, 5