What is the recommended use of compression socks for inpatients with Deep Vein Thrombosis (DVT) or at risk for DVT?

Compression Therapy for Inpatients with or at Risk for DVT

Do not routinely use compression stockings for DVT prevention in hospitalized patients, and never use sequential compression devices (SCDs) in patients with established DVT. The evidence has evolved significantly, with the most recent high-quality guidelines reversing earlier recommendations.

For Patients with Established DVT

Compression Stockings

• The American Society of Hematology (ASH) 2020 guidelines recommend against routine use of compression stockings to prevent post-thrombotic syndrome (PTS) in patients with DVT (conditional recommendation, very low certainty evidence) 1
• The 2016 CHEST guidelines similarly suggest against routine compression stocking use for PTS prevention (Grade 2B) 1
• This represents a major shift from earlier 2007 recommendations that favored compression stockings, based on the landmark SOX trial which showed no benefit when proper blinding was used 1

When Compression May Be Considered

• Compression stockings may help reduce acute edema and pain in selected patients with symptomatic DVT, though this is for symptom management rather than PTS prevention 1, 2
• For patients with acute leg pain, swelling, or edema, a trial of graduated compression stockings (30-40 mmHg) is often justified for symptomatic relief 1, 2

Critical Contraindication

• Sequential compression devices (SCDs) are absolutely contraindicated in patients with confirmed DVT as they can potentially dislodge clots and cause pulmonary embolism 3, 4
• A common clinical pitfall is continuing mechanical compression in patients who develop DVT while on prophylactic SCDs—these devices must be discontinued immediately once DVT is diagnosed 3

For Patients at Risk for DVT (Prophylaxis)

Mechanical Prophylaxis in Medical Patients

• For acutely or critically ill medical patients, pharmacological VTE prophylaxis is preferred over mechanical prophylaxis alone (conditional recommendation, very low certainty evidence) 1
• If pharmacological prophylaxis is contraindicated, mechanical prophylaxis with pneumatic compression devices or graduated compression stockings should be used over no prophylaxis (conditional recommendation, moderate certainty evidence) 1
• The ASH 2018 guidelines suggest either pneumatic compression devices or graduated compression stockings when mechanical prophylaxis is chosen, with no clear superiority of one over the other 1

Surgical Patients

• In surgical patients, graduated compression stockings are effective in reducing DVT risk (Peto OR 0.35,95% CI 0.28-0.43), representing a reduction from 21% to 9% incidence 5
• GCS also probably reduce proximal DVT (Peto OR 0.26,95% CI 0.13-0.53) and may reduce PE risk (Peto OR 0.38,95% CI 0.15-0.96) in surgical patients 5

Important Contraindications for Mechanical Prophylaxis

• Severe peripheral arterial disease (ankle-brachial index <0.6) is an absolute contraindication 4
• Dermatitis, skin breakdown, gangrene, recent skin grafts, or severe leg edema are contraindications to compression devices 4
• Moderate peripheral arterial disease (ABI 0.6-0.9) requires reduced compression pressure (20-30 mmHg) with caution 4

Evidence Evolution and Quality

The evidence base has fundamentally changed due to the SOX trial, which was the largest and only properly blinded study 1. Earlier unblinded trials from 2007 showed >50% relative risk reduction in PTS 1, but when the SOX trial used placebo stockings with minimal pressure, no benefit was demonstrated (RR 1.01,95% CI 0.76-1.33) 1. This highlights how lack of blinding in earlier studies likely introduced significant bias.

Practical Algorithm

1. Patient has established DVT:

   • Discontinue any SCDs immediately 3, 4
   • Do NOT routinely prescribe compression stockings for PTS prevention 1
   • Consider compression stockings (30-40 mmHg) only if patient has significant acute pain/edema for symptom relief 1, 2
   • Ensure appropriate anticoagulation is primary treatment 3

2. Medical patient at risk for DVT:

   • Prioritize pharmacological prophylaxis (LMWH, UFH, or fondaparinux) 1
   • If anticoagulation contraindicated, use pneumatic compression devices or graduated compression stockings 1
   • Screen for contraindications (peripheral arterial disease, skin breakdown) 4

3. Surgical patient at risk for DVT:

   • Use graduated compression stockings as part of multimodal prophylaxis 5
   • Apply on day before or day of surgery, continue until fully mobile 5
   • Combine with pharmacological prophylaxis when appropriate 5