Are compression stockings recommended for a limb with Deep Vein Thrombosis (DVT)?

Compression Stockings for DVT: Not Recommended Routinely

I recommend against the routine use of compression stockings for prevention of post-thrombotic syndrome (PTS) in patients with acute DVT of the leg, but they may be offered selectively for symptom management of acute leg pain and swelling. 1

Current Evidence-Based Recommendations

The most recent high-quality guidelines have shifted away from routine compression stocking use:

• The 2021 CHEST guidelines suggest against using compression stockings routinely to prevent PTS (weak recommendation, low-certainty evidence), representing a major change from earlier practice. 1

• The 2020 American Society of Hematology guidelines similarly recommend against routine use for PTS prevention, based on very low certainty evidence. 1

• The 2020 NICE guidelines recommend against offering graduated compression stockings for PTS prevention, though they can be offered to manage leg symptoms after DVT. 1

Why the Change in Practice?

The shift in recommendations is driven by the 2014 SOX trial, the largest and only placebo-controlled study with 806 patients:

• This rigorous trial found no benefit of active compression stockings (30-40 mmHg) versus placebo stockings for preventing PTS (14.2% vs 12.7%, p=0.58). 2

• The cumulative incidence of PTS showed a hazard ratio of 1.13 (95% CI 0.73-1.76), meaning compression stockings provided no protective effect. 2

• Earlier positive trials from 1997-2004 were smaller, single-center, and unblinded, making them susceptible to bias. 1, 3

When Compression May Still Be Appropriate

For Acute Symptom Relief

• Compression stockings can be offered to manage acute leg symptoms (pain, swelling, edema) after DVT diagnosis, but should not be prescribed with the expectation of preventing PTS. 1, 3

For Established Post-Thrombotic Syndrome

• If PTS has already developed, a trial of compression stockings (30-40 mmHg) is suggested to reduce chronic symptoms. 1

• For severe PTS not adequately relieved by stockings, intermittent pneumatic compression devices may be considered. 1

Special Case: Iliofemoral DVT

• For patients with iliofemoral DVT specifically, some guidelines suggest daily use of 30-40 mmHg knee-high graduated elastic compression stockings for at least 2 years, but only after initial anticoagulation therapy is established. 3, 4

Critical Safety Considerations

Absolute Requirements Before Prescribing

• Adequate anticoagulation must be established first - compression should never substitute for or delay appropriate anticoagulation therapy. 3, 4

• Assess for peripheral arterial disease before prescribing - avoid compression when ankle-brachial index is <0.6, as it indicates arterial insufficiency requiring revascularization. 5, 3

Contraindications

• Sequential compression devices (SCDs) must be discontinued immediately upon DVT diagnosis - they are contraindicated in active DVT. 3, 4

• Active peripheral arterial disease with ABI <0.6. 5

Common Clinical Pitfalls to Avoid

1. Prescribing stockings with the expectation of PTS prevention - this is not supported by the highest quality evidence from the SOX trial. 1, 3

2. Continuing mechanical compression devices after DVT diagnosis - SCDs must be stopped once DVT is confirmed. 4

3. Using compression without adequate anticoagulation - anticoagulation is the primary treatment; compression is only adjunctive at best. 3

4. Ignoring arterial status - always check for peripheral arterial disease before prescribing compression. 3

If You Do Prescribe Compression Stockings

When used for symptom management (not PTS prevention):

• Pressure specification: 30-40 mmHg at the ankle for DVT-related symptoms. 5, 3

• Knee-high stockings are sufficient - thigh-length stockings provide no additional benefit. 3

• Proper fitting is essential - stockings must be measured and fitted to the individual patient. 5

• Patient education on application technique improves adherence and effectiveness. 5

• Potential adverse effects include discomfort, skin breakdown, and allergic reactions. 1, 5

The Bottom Line

The evidence has evolved significantly. The landmark SOX trial definitively showed no benefit for PTS prevention, contradicting earlier smaller studies. 2 While compression stockings may provide symptomatic relief for some patients with acute DVT symptoms or established PTS, they should not be routinely prescribed with the expectation of preventing post-thrombotic syndrome. 1