Why and how should graduated compression stockings be used to prevent deep‑vein thrombosis in immobilized adult patients (e.g., postoperative or bedridden >24 hours)?

Graduated Compression Stockings for DVT Prevention in Immobilized Patients

Graduated compression stockings should NOT be routinely used for DVT prevention in immobilized hospitalized medical patients (including postoperative and bedridden patients) due to lack of proven benefit for symptomatic DVT/PE and significant risk of skin complications; instead, use intermittent pneumatic compression (IPC) devices combined with early pharmacological prophylaxis when bleeding risk permits. 1

Why Compression Stockings Are Not Recommended

Evidence Against Routine Use in Medical Patients

• The American College of Chest Physicians (2012) found that graduated compression stockings in hospitalized medical patients failed to demonstrate benefit for symptomatic DVT (RR 0.91,95% CI 0.63-1.29) or pulmonary embolism (RR 0.65,95% CI 0.33-1.31), with only moderate to low quality evidence. 1

• Compression stockings significantly increased skin complications, causing 38 additional skin breaks, ulcers, blisters, or skin necrosis per 1,000 patients treated (RR 4.02,95% CI 2.34-6.91). 1, 2

• The European Stroke Organisation (2014) explicitly recommends against both short and long graduated compression stockings for DVT prevention in immobile patients, citing the CLOTS-1 trial where thigh-length stockings increased skin defects without preventing DVT. 1

• The European trauma guidelines (2023) state there is no evidence that graduated compression stockings reduce death from PE in any hospitalized patients and recommend against their use for thromboprophylaxis. 1

Mechanism of Action (Why They Were Theorized to Work)

• Graduated compression stockings theoretically reduce venous stasis by displacing blood from superficial to deep venous systems via perforating veins, thereby increasing velocity and volume of flow in the deep system. 1

• They reduce the overall cross-sectional area of the limb, increase linear velocity of venous flow, reduce venous wall distension, and improve valvular function. 3

• Research shows properly fitted stockings can increase popliteal vein peak systolic velocity by 24% and reduce ankle/calf swelling during immobility. 4

Critical Safety Concerns

Improper Fitting Creates Tourniquet Effect

• Improperly fitted stockings that are too tight around the knee create a tourniquet effect, preventing venous return and paradoxically increasing DVT risk by causing blood pooling. 2

• Stockings must be professionally sized to individual leg measurements to prevent skin complications including ulceration and breakdown. 2

• In standing positions, stockings with 20-30 mmHg may not effectively compress deep or superficial calf veins, limiting their efficacy. 5

What SHOULD Be Used Instead

Intermittent Pneumatic Compression (IPC)

• The European trauma guidelines (2023) recommend early initiation of mechanical thromboprophylaxis with IPC while the patient is immobile and has bleeding risk (Grade 1C), followed by combined pharmacological and IPC thromboprophylaxis within 24 hours after bleeding is controlled. 1

• The CLOTS-3 trial demonstrated IPC was superior for preventing proximal DVT within 30 days (8.5% vs 12.1%; OR 0.65,95% CI 0.51-0.84; P=0.001) and may reduce six-month mortality (adjusted HR 0.86,95% CI 0.74-0.99; P=0.042). 1

• IPC combined with elastic stockings was superior to elastic stockings alone in the VICTORIA trial (4% vs 16.9% asymptomatic DVT; RR 0.29,95% CI 0.08-1.00; P=0.03). 1

• A Cochrane review showed combining IPC with pharmacological prophylaxis reduces both PE (low-certainty evidence) and DVT (high-certainty evidence) compared to pharmacological prophylaxis alone. 1

Pharmacological Prophylaxis

• Low-molecular-weight heparin (LMWH) is more efficacious than twice-daily unfractionated heparin and decreases both overall and symptomatic PE rates in critically ill medical and surgical patients. 1

• Weight-adjusted LMWH is widely used, though definitive RCTs comparing standard versus weight-adjusted dosing are still awaited. 1

• Pharmacological prophylaxis should be initiated within 24 hours after bleeding has been controlled and continued until the patient is fully mobile. 1

Limited Contexts Where Stockings May Have a Role

Surgical Patients (Historical Data)

• Older evidence from surgical populations showed graduated compression stockings reduced relative risk of DVT by 64% in general surgical patients and 57% following total hip replacement, though these data predate modern guidelines. 3

• However, the 2023 GAPS study in over 2,000 surgical patients with moderate VTE risk failed to show any benefit with graduated compression stockings. 1

Post-Thrombotic Syndrome Prevention

• For patients with established proximal DVT, knee-length compression stockings worn for 2 years may help prevent post-thrombotic syndrome and reduce leg edema/discomfort from venous insufficiency. 2, 5

• This indication is for treatment of existing DVT complications, not primary prevention in immobilized patients. 2

Common Pitfalls to Avoid

• Do not reflexively order compression stockings for all immobilized patients based on outdated protocols; current evidence does not support this practice. 1, 2

• Do not assume thigh-length stockings are superior to knee-length; the CLOTS-2 trial showed proximal DVT occurred more often with below-knee stockings than thigh-length, but neither should be used routinely for prevention. 1

• Do not use compression stockings as a substitute for pharmacological prophylaxis in patients without bleeding contraindications; the combination of IPC plus pharmacological prophylaxis is superior. 1

• Do not continue using stockings if skin complications develop; the harm from skin breaks/ulcers outweighs any theoretical benefit. 1, 2

Practical Algorithm for DVT Prophylaxis in Immobilized Patients

1. Assess bleeding risk immediately upon admission or postoperatively. 1

2. If bleeding risk is present:

   • Initiate IPC immediately while patient is immobile 1
   • Do NOT use graduated compression stockings 1
   • Reassess bleeding risk every 24 hours 1

3. Once bleeding is controlled (typically within 24 hours):

   • Continue IPC 1
   • Add pharmacological prophylaxis (LMWH preferred) 1
   • Maintain combined prophylaxis until patient is fully mobile 1

4. If patient cannot tolerate IPC or has contraindications:

   • Use pharmacological prophylaxis alone if no bleeding risk 1
   • Consider aspirin only if both IPC and anticoagulation are contraindicated (though evidence is weak) 1

5. Monitor for complications:

   • Skin integrity if any mechanical device is used 1, 2
   • Bleeding if pharmacological prophylaxis is used 1
   • Thromboprophylaxis failure risk factors (elevated BMI, personal/family VTE history, vasopressor use) 1