At what Ankle-Brachial Index (ABI) are embolic stockings contraindicated?

Contraindications for Compression Stockings Based on ABI

Compression stockings are absolutely contraindicated when the ABI is less than 0.50, and require modified compression with careful monitoring when the ABI is between 0.50 and 0.80. 1

ABI Thresholds for Compression Therapy

The decision to use compression therapy must be guided by specific ABI cutoffs that reflect the severity of arterial insufficiency:

Absolute Contraindication

• ABI < 0.50: This represents severe peripheral arterial disease and is an absolute contraindication for any compression therapy due to the high risk of tissue necrosis and limb loss 1
• At this level of arterial compromise, compression would further reduce already critically impaired blood flow, potentially causing irreversible tissue damage

Relative Contraindication/Modified Compression Required

• ABI 0.50-0.80: Compression therapy requires significant modification and careful monitoring in this range 1
• Standard compression pressures must be reduced, and patients need close vascular surveillance
• This range indicates moderate arterial obstruction (ABI 0.40-0.59) to mild obstruction (ABI 0.60-0.89), both requiring caution 1

Safe for Standard Compression

• ABI > 0.80: Generally indicates safe application of standard compression therapy 1
• However, even with ABI > 0.80, patients with abnormal ABI should still be referred for vascular assessment before initiating compression 1

Critical Clinical Pitfalls

The most dangerous error is applying compression therapy without first measuring ABI in patients with lower extremity wounds or edema. 1 This can lead to catastrophic outcomes including:

• Tissue necrosis in patients with unrecognized severe PAD
• Limb loss from compression-induced ischemia
• Delayed recognition of arterial insufficiency

Never rely solely on palpable pulses to assess arterial circulation - this is insufficient for determining safety of compression therapy 1. Pulses may be palpable even with significant arterial disease, particularly in patients with diabetes or calcified vessels.

Special Populations Requiring Extra Caution

Patients with diabetes mellitus or end-stage renal disease may have falsely elevated ABI values (>1.40) due to arterial calcification, making vessels non-compressible 2. In these patients:

• Consider toe-brachial index (TBI) as an alternative measure 2
• Do not assume normal arterial flow based on elevated ABI alone
• Obtain vascular consultation before applying compression if clinical suspicion of PAD exists

Mandatory Pre-Compression Assessment

Before initiating any compression therapy, the Wound, Ostomy, and Continence Nurses Society recommends performing ABI measurement to identify patients with peripheral arterial disease who may be at risk for complications 1. This is not optional - it is a safety imperative that directly impacts patient morbidity and potential limb loss.