Compression Stockings No Longer Recommended After DVT

SEPTEMBER 15, 2016
The 2012 CHEST guidelines recommended that all patients with acute, symptomatic deep vein thrombosis (DVT) of the leg should use graduated compression stockings for 2 years to prevent the occurrence of post-thrombotic syndrome (PTS).1 In the 2016 CHEST guidelines update, however, this recommendation has been reversed, as graduated compression stockings are no longer recommended for PTS prevention.2

What’s PTS?
It’s a type of chronic venous insufficiency caused after DVT of the leg.1 It’s characterized by chronic swelling, pain, discomfort while walking, and skin discoloration. In more severe cases, patients may even experience skin ulcerations. Because up to half of patients with acute proximal DVTs (occurring in a vein above the knee) will experience PTS, there’s always been considerable interest in reducing PTS risk after DVT.

What Are Graduated Compression Stockings?
Also called elastic compression stockings, they’re tight-fitting hosiery worn on the legs, applying pressure that gradually decreases up the garment.3 Because compression stockings are tight -fitting, patients must be measured and fitted to ensure proper use. The compression applied by these stockings is thought to increase venous return, reduce blood stasis and venous pressure, and improve lower extremity edema.

Prior Evidence Supporting Compression Stockings
The previous CHEST guideline recommendation was based on findings from 2 randomized trials showing a dramatic 50% relative risk reduction in PTS among patients randomized to receive compression stockings for 2 years. At the time, the guidelines assigned this a grade 2B recommendation (weak recommendation based on moderate evidence) because the 2 trials were single center and unblinded, and they only included 421 patients between them. Because the assessment of PTS is partially based on subjective symptoms by the patient, there was a large risk of bias without a blinded trial.

The SOX Trial Changed Everything
In 2014, the efficacy of compression stockings was put to the test in the large, randomized, multicenter SOX trial with blinding of both the investigators and the patients.4 After enrolling 806 patients, the study authors demonstrated no difference in PTS at 6 months between those receiving compression stockings (14.2%) and placebo (12.7%). Although the incidence of PTS was much lower than other trials, the nature of this study compared with previous publications makes it the highest-quality data to date regarding the efficacy of compression stockings to prevent PTS following DVT.

New Compression Stocking Recommendations
Based on the SOX trial, the updated CHEST guidelines don’t recommend the routine use of compression stockings after DVT to prevent PTS.2 Given the discrepant data regarding this recommendation, the guidelines assign this a grade 2B recommendation (weak recommendation, moderate evidence).
 
Importantly, compression stockings may still be effective for pain associated with DVT or symptomatic management of PTS. In fact, the guidelines state that “for patients with acute or chronic symptoms, a trial of graduated compression stockings is often justified,” emphasizing they may play a role in the treatment (but not prevention) of PTS.

References
  1. Kearon C, et al. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 Suppl):e419S-494S.
  2. Kearon C, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016 Feb;149(2):315-352.
  3. Lim CS, et al. Graduated compression stockings. CMAJ. 2014 Jul 8;186(10):E391-398.
  4. Kahn SR, et al. Compression stockings to prevent post-thrombotic syndrome: a randomised placebo-controlled trial. Lancet. 2014 Mar 8;383(9920):880-888. 


Sean Kane, PharmD
Sean Kane, PharmD
Sean Kane, PharmD, BCPS, is an Assistant Professor at Rosalind Franklin University of Medicine and Science in North Chicago, Illinois, and a Critical Care Pharmacist at Advocate Condell Medical Center in Libertyville, Illinois. Dr. Kane received his Doctor of Pharmacy degree at Butler University in 2010 and completed 2 years of residency, specializing in critical care at the University of Illinois at Chicago. Dr. Kane is the creator of ClinCalc.com, an evidence-based clinical decision support website with educational tools for health care students and professionals. In addition, Dr. Kane is the creator and co-host of HelixTalk, Rosalind Franklin University's College of Pharmacy Podcast.
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