Arterial thrombosis associated with graduated pressure antiembolic stockings

Risks and contraindications of medical compression treatment - A critical reappraisal. An international consensus statement

Objectives

Medical compression therapy is used for non-invasive treatment of venous and lymphatic diseases. Medical compression therapy-associated adverse events and contraindications have been reported, although some contraindications are theoretically based. This consensus statement provides recommendations on medical compression therapy risks and contraindications.

Methods

A systematic literature search of medical compression therapy publications reporting adverse events up until November 2017 was performed. A consensus panel comprising 15 international experts critically reviewed the publications and formulated the recommendations.

Results

Sixty-two publications reporting medical compression therapy adverse events were identified. The consensus panel issued 21 recommendations on medical compression therapy contraindications and adverse event risk mitigation, in addition to reviewing medical compression therapy use in borderline indications. The most frequently reported non-severe medical compression therapy-associated adverse events included skin irritation, discomfort and pain. Very rare but severe adverse events, including soft tissue and nerve injury, were also identified.

Conclusion

This consensus statement summarises published medical compression therapy-associated adverse events and contraindications, and provides guidance on medical compression therapy. Severe medical compression therapy-associated adverse events are very rarely encountered if compression is used correctly and contraindications are considered.

The Effect of Graduated Compression Stockings on Lower Limb Venous Haemodynamics

Objectives:

To compare the effect of four types of thigh-length graduated compression stockings (GCS) on lower limb venous blood flow using strain-gauge Plethysmography (SGP).

Design:

A randomized controlled study.

Setting:

Inpatient Orthopaedic Centre.

Patients:

200 preoperative patients admitted for elective lower limb orthopaedic surgery.

Interventions:

Patients were randomized to five groups to wear one of four types of GCS or no stocking (control). Resting venous flow parameters were measured prior to application of GCS and after 20 min bed rest with the stockings in situ.

Main outcome measures:

Effects on resting venous capacitance (Vc) and venous outflow (Vo).

Results:

In the control group 20 min bed rest had no effect on the parameters studied. Both Vc and Vo were significantly increased ( p<0.001) in all the groups wearing stockings. There was a significant variation in the changes in outflow produced by the different stocking types ( p<0.05).

Conclusions:

GCS have a beneficial effect on lower limb venous outflow, preventing venous stasis, an important factor in the development of deep venous thrombosis. This effect varies depending on which type of stocking is used.

Clinical thromboembolic detterrent stockings application: Are thromboembolic detterrent stockings in practice matching manufacturers application guidelines

Background

Thromboembolic detterrent (TED) stockings have been shown to be effective in the reduction of thromboembolic events in post operative patients. These manufactured stockings create graduated compression from ankle to calf.

Aim

To assess whether the manufacturers' recommendations for application were being met in a District general hospital setting and whether this achieved the desired gradient of compression.

Methods

We carried out pressure measurements on 100 legs in post-operative patients and recorded reasons for poorly fitting stockings. Pressure measurements were taken at standard positions around calf and ankle using a pre-calibrated subbandage pressure measuring device.

Results

About 20% of stockings were worn incorrectly by patients. Median pressure applied at the ankle was 13 mmHg (range, 6.5–18.5) compared to the manufacturers' intended compression of 18 mmHg. Only 14% of the stockings showed an acceptable gradation of reduced pressure between ankle and calf. About 23% of the stockings exerted a positive pressure at calf level compared to the ankle.

Conclusion

Most TED stockings do not produce a standardised Siegel profile pressure gradient decrease from ankle to calf. This may be due in part to fluid changes after surgery in combination with the large variation in size of lower limbs. Our District general hospital utilises three of the six sizes of TED stocking, and remeasurement was not taking place every 24 h as per guidance. This as the result show not only negates the benefit of TED stockings but may also exert harm in terms of venous thromboembolism risk. This finding adds further weight to the argument of whether TED stockings may not be having the desired prophylactic effect and may even be resulting in harm in select cases.

Review article: Anti-embolism stockings

The National Institute for Health and Clinical Excellence (NICE) guidelines recommend combined mechanical and pharmacological prophylaxis to reduce the risk of venous thromboembolism (VTE) in patients undergoing orthopaedic surgery. There is increasing evidence that anti-embolic stockings (AES) have little effect on reducing such risk. Articles in the MEDLINE, EMBASE, and Cochrane Library were reviewed. Studies on the use of pharmacological prophylaxis recommended in the 2010 NICE guidelines including low-molecular-weight heparin, unfractionated heparin, rivaroxaban, and dabigatran with and without AES in patients undergoing orthopaedic surgery were included. A total of 1171 trauma and elective orthopaedic patients in 4 studies were included; 587 received pharmacological prophylaxis alone, and 584 received a combination of pharmacological prophylaxis and above- or belowknee AES. Of the respective patients, 44 (7.5%) and 31 (5.3%) developed deep vein thrombosis (p=0.1587) and 7 (1.2%) and 9 (1.5%) developed pulmonary embolism (p=0.8493). The overall VTE rates did not differ significantly (p=0.2864). No death from VTE was reported. Addition of AES did not confer significant benefit in terms of reducing the risk of VTE in orthopaedic patients.

Prevention of venous thromboembolism

Venous thromboembolism (VTE) is a preventable cause of significant morbidity and mortality in hospitalized patients, especially in the perioperative period. After identifying the risk factors, it is possible to stratify patients into groups based on their degree of risk for developing VTE. Methods available for the prevention of VTE vary in degree of intensity, efficacy, and side effects. The type of preventive measure used for each patient is based on matching the degree of risk for VTE with the intensity of prophylaxis, keeping in mind the risk-benefit ratio. This article discusses VTE prophylaxis relevant to oral and maxillofacial surgery patients.

Graduated compression stockings in hospitalized postoperative patients: correctness of usage and size

OBJECTIVE

Graduated compression stockings, when used correctly, have been shown to significantly reduce the risk of deep-vein thrombosis in surgical patients, but they can be harmful to skin and may even increase the risk of thrombosis if the wrong size is used. The authors sought to determine whether nurses correctly size and apply the stockings, whether problems were more common in knee- or thigh-length stockings, and whether nurses adequately educate patients on the usage of the stockings.

METHODS

The researchers used a comparative, descriptive design to study 142 hospitalized postoperative patients; 37 had thigh-length and 105 had knee-length stockings. They assessed usage of the stockings and compared four separate leg measurements against the manufacturer's sizing chart to determine whether stockings that had been applied were the correct size. They also asked patients to rate the comfort of the stockings and to describe their purpose.

RESULTS

The graduated compression stockings were used incorrectly (for example, they were wrinkled or the gusset was in the wrong place) in 29% of the patients and sized incorrectly in 26% of the patients. These problems were more common with the thigh-length stockings and in overweight patients. More patients who had thigh-length stockings found them uncomfortable than did those who had knee-length stockings, and 20% of patients didn't understand the stockings' purpose.

CONCLUSIONS

The authors recommend that nurses ensure that graduated compression stockings are properly sized and used, that the education of both nurses and patients regarding the stockings be improved, and that knee-length stockings be the standard length used.

The use of graduated compression stockings in association with fondaparinux in surgery of the hip

Little is known about the efficacy of graduated compression stockings in preventing venous thromboembolism after hip surgery. We conducted a prospective, randomised single-blind study to determine whether the addition of compression stockings to fondaparinux conferred any additional benefit.

The study included 874 patients, of whom 795 could be evaluated (400 in the fondaparinux group and 395 in the fondaparinux plus compression stocking group). Fondaparinux was given post-operatively for five to nine days, either alone or combined with wearing stockings, which were worn for a mean 42 days (35 to 49).

The study outcomes were venous thromboembolism, or sudden death before day 42. Duplex ultrasonography was scheduled within a week of day 42. Safety outcomes were bleeding and death from venous thromboembolism.

The prevalence of deep-vein thrombosis was similar in the two groups 5.5% (22 of 400) in the fondaparinux group and 4.8 (19 of 395) in the fondaparinux plus stocking group (odds ratio 0.88, 95% confidence interval 0.46 to 1.65, p = 0.69). Major bleeding occurred in only one patient.

The addition of graduated compression stockings to fondaparinux appears to offer no additional benefit over the use of fondaparinux alone.

Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy

This article discusses the prevention of venous thromboembolism (VTE) and is part of the Seventh American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this chapter are the following. We recommend against the use of aspirin alone as thromboprophylaxis for any patient group (Grade 1A). For moderate-risk general surgery patients, we recommend prophylaxis with low-dose unfractionated heparin (LDUH) (5,000 U bid) or low-molecular-weight heparin (LMWH) [< or = 3,400 U once daily] (both Grade 1A). For higher risk general surgery patients, we recommend thromboprophylaxis with LDUH (5,000 U tid) or LMWH (> 3,400 U daily) [both Grade 1A]. For high-risk general surgery patients with multiple risk factors, we recommend combining pharmacologic methods (LDUH three times daily or LMWH, > 3,400 U daily) with the use of graduated compression stockings and/or intermittent pneumatic compression devices (Grade 1C+). We recommend that thromboprophylaxis be used in all patients undergoing major gynecologic surgery (Grade 1A) or major, open urologic procedures, and we recommend prophylaxis with LDUH two times or three times daily (Grade 1A). For patients undergoing elective total hip or knee arthroplasty, we recommend one of the following three anticoagulant agents: LMWH, fondaparinux, or adjusted-dose vitamin K antagonist (VKA) [international normalized ratio (INR) target, 2.5; range, 2.0 to 3.0] (all Grade 1A). For patients undergoing hip fracture surgery (HFS), we recommend the routine use of fondaparinux (Grade 1A), LMWH (Grade 1C+), VKA (target INR, 2.5; range, 2.0 to 3.0) [Grade 2B], or LDUH (Grade 1B). We recommend that patients undergoing hip or knee arthroplasty, or HFS receive thromboprophylaxis for at least 10 days (Grade 1A). We recommend that all trauma patients with at least one risk factor for VTE receive thromboprophylaxis (Grade 1A). In acutely ill medical patients who have been admitted to the hospital with congestive heart failure or severe respiratory disease, or who are confined to bed and have one or more additional risk factors, we recommend prophylaxis with LDUH (Grade 1A) or LMWH (Grade 1A). We recommend, on admission to the intensive care unit, all patients be assessed for their risk of VTE. Accordingly, most patients should receive thromboprophylaxis (Grade 1A).

[Graduated compression stockings in surgery -- optional or obligatory?]

BACKGROUND

Graduated compression stockings (GCS) can effectively reduce postoperative deep vein thrombosis (DVT) and their use is recommended by expert committees. However, it appears that GCS are not frequently used. The objectives of this study are to evaluate the customary use of GCS in surgical settings in the City of Hamburg, Germany, and to present evidence on the effectiveness of GCS.

METHODS

A questionnaire on the use of thromboprophylaxis was sent to 48 surgeons in Hamburg. In addition, a comprehensive search for randomized-controlled trials, reviews, and meta-analyses indexed in MEDLINE (1984-06/2002) and the Cochrane Library (Issue 2, 2002) was conducted to show the effectiveness of GCS compared to nontreatment, other antithrombotic methods, or combined treatment.

RESULTS

Of 48 surgeons 39 responded. Seven surgeons dismissed the use of GCS for thromboprophylaxis, 3 used GCS alone, 25 GCS in combination with heparin, and 4 used GCS only for patients at high risk. The review of the literature revealed the effectiveness of GCS in general and for abdominal surgical patients. Enhanced benefit is suggested when combining GCS with another intervention such as low-dose unfractionated heparin. Single application of GCS in orthopedic surgical or neurosurgical patients using venography showed no effect when compared to combined treatment of GCS and low molecular weight heparin. Trials with patients undergoing gynecological and urological surgeries are rare. There is a lack of trials investigating health-related quality of life and costs associated with the use of GCS. Complications are poorly reported. A determination as to the appropriate length of stockings is presently not possible.

CONCLUSIONS

GCS should be integral part of DVT prophylaxis in surgical departments. Their ineffectiveness is likely in some surgical populations.

Deep vein thrombosis prophylaxis: the effectiveness and implications of using below-knee or thigh-length graduated compression stockings

Potential complications of reduced mobility in both acute and chronically ill patients continue to challenge nurses on a daily basis. Deep vein thrombosis (DVT) is one of the most serious of these complications. Graduated compression stockings, also known as antiembolism stockings, are among the most commonly available and accepted methods of external compression for the prophylaxis of DVT. Currently, there are 2 lengths of graduated compression stockings in common use, thigh-length and below-knee. Although thigh-length stockings are widely perceived to be more effective in prophylaxis, difficulties associated with therapeutic application and maintenance are often encountered in different clinical settings. Below-knee stockings are easier to apply and maintain and appear to be tolerated better by patients. The aim of this article is to examine existing support for both lengths of stockings in terms of their effectiveness in DVT prophylaxis and to discuss the implications for practice.

Deep vein thrombosis prophylaxis: the effectiveness and implications of using below-knee or thigh-length graduated compression stockings

Potential complications of reduced mobility in both acute and chronically ill patients continue to challenge nurses on a daily basis. Deep vein thrombosis (DVT) is one of the most serious of these complications. Graduated compression stockings, also known as antiembolism stockings, are among the most commonly available and accepted methods of external compression for the prophylaxis of DVT. Currently, there are 2 lengths of graduated compression stockings in common use, thigh-length and below-knee. Although thigh-length stockings are widely perceived to be more effective in prophylaxis, difficulties associated with therapeutic application and maintenance are often encountered in different clinical settings. Below-knee stockings are easier to apply and maintain and appear to be tolerated better by patients. The aim of this article is to examine existing support for both lengths of stockings in terms of their effectiveness in DVT prophylaxis and to discuss the implications for practice.

Graduated compression stockings in the prevention of venous thromboembolism

BACKGROUND

Surveys still show a wide variation in routine use of deep vein thrombosis (DVT) prophylaxis despite its established place in current patient management. This article reviews the mechanism of action, efficacy and complications of stockings in preventing DVT.

METHODS

Relevant publications indexed in Medline (1966-1998) and the Cochrane database were identified. Appropriate articles identified from the reference lists of the above searches were also selected and reviewed.

RESULTS AND CONCLUSION

Graduated compression stockings reduce the overall cross-sectional area of the limb, increase the linear velocity of venous flow, reduce venous wall distension and improve valvular function. Fifteen randomized controlled trials of graduated compression stockings alone were reviewed. Stockings reduced the relative risk of DVT by 64 per cent in general surgical patients and 57 per cent following total hip replacement. The effect of stockings was enhanced by combination with pharmacological agents such as heparin; the combination is recommended in patients at moderate or high risk of DVT. Knee-length stockings are as effective and should replace above-knee stockings. Complications are rare and avoidable.

Knee-length versus thigh-length graduated compression stockings in the prevention of deep vein thrombosis

Graduated compression stockings can reduce the incidence of deep vein thrombosis by 60 per cent1, by providing a decreasing compression gradient from the ankle towards the thigh. There is both theoretical and clinical evidence that compression of the thigh as well as the calf does not give extra benefit2,3. Although regarded as safe, improperly used stockings are not without risk. Problems are usually due to areas of localized high pressure, especially under ‘rucked up’ constricting bands of stocking. This is particularly so in the presence of ischaemia; manufacturers state that ischaemia is a contraindication to stocking use. Cases of arterial thrombosis have been reported4, as well as more frequent skin necrosis, when stockings have been used in the presence of reduced arterial blood supply5.

Prophylaxis against venous thromboembolism

Death from venous thromboembolism occurs in the perioperative period at a rate varying between 0.1% and 7.0%. The risk factors and methods of prophylaxis are reviewed and current recommendations presented.

Thigh length versus knee length stockings in the prevention of deep vein thrombosis

Above-knee graduated compression stockings are effective in preventing postoperative deep vein thrombosis, but are more expensive and less acceptable than below-knee stockings. One hundred and fourteen patients undergoing major abdominal surgery were randomly allocated to wear above-knee or below-knee graduated compression stockings. Deep vein thromboses were diagnosed by isotope uptake in three of 56 patients (5.4 per cent) in the above-knee group and one of 58 patients (1.7 per cent) in the below-knee group. These differences are not statistically significant. Results suggest that below-knee stockings are as effective as above-knee in the prevention of postoperative deep vein thrombosis.