Why do healthcare providers apply compression wraps to patients with a history of venous insufficiency or vascular disease without knowing their ankle-brachial pressure index (ABPI)?

Why Healthcare Providers Apply Compression Without Knowing ABPI

Healthcare providers should never apply compression therapy to lower legs without first assessing the ankle-brachial pressure index (ABPI), as this represents the most dangerous error in compression therapy and can cause limb-threatening ischemia in patients with unrecognized peripheral arterial disease. 1, 2

The Critical Safety Issue

The practice of applying compression without ABPI assessment is fundamentally unsafe because:

• Approximately 16% of venous leg ulcer patients have unrecognized concomitant arterial disease that would make standard compression dangerous 1, 2
• When ABPI is <0.6, compression is absolutely contraindicated as it indicates arterial disease requiring revascularization first 1, 3
• Peripheral arterial disease (PAD) is present in 15-20% of patients presenting with venous leg ulcers 4

Why This Dangerous Practice Occurs

Lack of Equipment and Training

• Many providers lack access to handheld Doppler equipment needed for ABPI measurement 5
• Insufficient clinician education on proper ABPI technique and interpretation contributes to assessment gaps 5
• Time constraints in clinical settings lead to shortcuts in comprehensive vascular assessment 5

Misunderstanding of Risk

• Providers may incorrectly assume that palpable pedal pulses exclude significant arterial disease 6
• The clinical presentation of venous insufficiency can mask underlying arterial compromise 4

Role Definition Issues

• Unclear responsibility for who should perform ABPI assessment (nursing vs. physician) creates gaps in care 5
• Lack of standardized protocols in some healthcare settings 5

Proper Assessment Protocol Before Compression

Mandatory ABPI Measurement

The ACC/AHA guidelines mandate ABPI measurement in all patients with suspected lower extremity PAD, defined as those with: 6

• Exertional leg symptoms
• Nonhealing wounds
• Age ≥65 years
• Age ≥50 years with history of smoking or diabetes

ABPI Interpretation for Compression Safety

• ABPI >1.40: Noncompressible vessels from arterial calcification; use toe-brachial index instead 6
• ABPI 1.00-1.40: Normal; full compression therapy safe 6
• ABPI 0.6-0.9: Mild-moderate arterial disease; reduced compression of 20-30 mmHg is both safe and effective 1, 2, 7
• ABPI <0.6: Severe arterial obstruction; compression absolutely contraindicated 6, 1

Alternative Assessment When ABPI Unavailable

• Pulse oximetry index (Lanarkshire Oximetry Index) can be used as a simpler alternative screening tool 8
• This method can obtain measurements in some legs where Doppler ABPI cannot be recorded 8
• Shows fair agreement with ABPI (kappa=0.303) and linear association (p<0.001) 8

Proper Compression Application After ABPI Assessment

For Normal ABPI (≥0.9)

• Start with 20-30 mmHg compression as minimum effective pressure for chronic venous insufficiency 1, 2
• Escalate to 30-40 mmHg inelastic compression for venous ulcers (C6 disease) or ulcer prevention (C5 disease) 1

For Borderline ABPI (0.6-0.9)

• Use reduced compression of 20-30 mmHg, which remains both safe and effective 1, 2
• Research demonstrates successful healing even with moderate PAD (ABPI 0.5-0.8) using modified compression ≤40 mmHg 4
• One study showed compression stockings actually increased systolic arterial pressure in the big toe (from 83.3 to 90.8 mmHg, p=0.026) in patients with ABPI ≥0.5 7

Monitoring Requirements

Ongoing ABPI Surveillance

• Patients in compression hosiery require regular ABPI monitoring as arterial status can deteriorate over time 9
• Those with ABPI <0.9, diabetes, reduced mobility, or claudication symptoms need at least 3-monthly Doppler assessment 9
• Patients without complications who can self-report should have yearly vascular assessment 9

Common Pitfalls to Avoid

• Never assume venous disease alone based on clinical appearance—always rule out arterial compromise 1, 2
• Don't rely solely on pedal pulse palpation—ABPI is essential for quantifying arterial perfusion 6
• Avoid applying compression "just to try it" without proper vascular assessment—this can cause irreversible ischemic damage 1
• Don't skip ABPI in elderly or diabetic patients who are at highest risk for both venous and arterial disease 6