Should a patient at high risk for Deep Vein Thrombosis (DVT) wear compression stockings 24 hours a day?

Compression Stockings Should Not Be Worn 24 Hours Daily for DVT Prophylaxis

Compression stockings for DVT prophylaxis should be worn during waking hours only (approximately 18 hours daily), not continuously for 24 hours, and must be removed at night to prevent complications and ensure proper skin care. 1

Duration and Timing of Wear

• Compression stockings should be applied for at least 18 hours per day during periods of immobility or increased DVT risk, but removed at bedtime. 1
• Stockings were applied 2-3 hours before flights in most clinical trials demonstrating efficacy, not worn continuously. 1
• Continuous 24-hour wear increases risk of skin complications, including ulceration, dermatitis, and impaired venous return if stockings bunch or roll at the knee. 1

Proper Application and Fit

• Compression strength should be 20-30 mm Hg at the ankle for DVT prophylaxis (not the 30-40 mm Hg used for post-thrombotic syndrome treatment). 1
• Knee-high stockings are as effective as thigh-high stockings and should be the preferred option. 2
• A stocking that is too tight around the knee can paradoxically prevent venous return, causing blood pooling and potentially increasing DVT risk rather than reducing it. 1
• Proper fitting is essential—stockings should be worn around the house before travel or prolonged use to ensure comfortable fit and identify sizing issues. 1

Clinical Context for Use

For hospitalized medical patients at increased DVT risk:

• Compression stockings (graduated compression stockings, GCS) are suggested only when pharmacologic prophylaxis is contraindicated due to bleeding risk. 1
• When bleeding risk decreases, pharmacologic prophylaxis should replace mechanical prophylaxis. 1
• Intermittent pneumatic compression (IPC) is preferred over graduated compression stockings alone, with IPC reducing DVT risk by 35% in immobile patients. 3

For long-distance travelers (>4 hours):

• Those at substantially increased VTE risk (recent surgery, history of VTE, active malignancy, or ≥2 risk factors) should use graduated compression stockings during travel only. 1
• Low-risk travelers without risk factors do not require compression stockings. 1

Critical Safety Considerations

Absolute contraindications to compression stockings include: 1, 3

• Dermatitis or skin breakdown
• Lower-extremity ulceration
• Severe peripheral vascular disease
• Recent lower-extremity bypass procedure
• Acute DVT (confirmed)
• Severe leg edema or gangrene

Daily skin assessment is mandatory during compression stocking use to identify early complications including skin damage, which occurred at 4 times the rate in patients wearing compression stockings in stroke trials (39 additional events per 1000 patients). 1

Evidence Limitations

• One large trial (n=2,518) in acute stroke patients showed compression stockings provided no benefit for mortality, symptomatic DVT, or PE, while significantly increasing lower-extremity skin damage (RR 4.02,95% CI 2.34-6.91). 1
• The evidence supporting compression stockings is of very low to moderate quality, with most recommendations being conditional rather than strong. 1

Practical Implementation

Adherence monitoring is essential as compliance with compression devices is often suboptimal in clinical practice. 1

• Address specific barriers to compliance including comfort, proper fitting, and application technique before prescribing. 4
• Patients should remove stockings at night for skin inspection and to prevent complications from continuous compression. 1
• Consider starting with 15-20 mm Hg compression to establish tolerance before progressing to therapeutic 20-30 mm Hg compression. 4