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Compression and deep vein thrombosis

DOI:10.4081/vl.2016.5991
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Hugo Partsch at Medical University of Vienna
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Veins and Lymphatics 2016; volume 5:5991
[page 22] [Veins and Lymphatics 2016; 5:5991]
Compression and deep vein
thrombosis
Hugo Partsch
Department of Dermatology and
Angiology, Medical University of Vienna,
Vienna, Austria
Introduction
Compression may have two beneficial
effects in deep vein thrombosis (DVT): i) long
term use may reduce the incidence and sever-
ity of a post-thrombotic syndrome (PTS); ii) in
the acute stage it alleviates pain and swelling.
Reduction of post-thrombotic
syndrome
Based on meta-analyses wearing of com-
pression stockings after DVT for 2 years
reduces the incidence of PTS.1,2
Also previous American College of Chest
Physicians (ACCP) guidelines have recom-
mended compression after DVT for this indica-
tion.3 This suggestion has recently been
changed, mainly due to the outcome of the
SOX trial, which was unable to find a reduction
of PTS, 2 years after DVT, when compression
stockings were used in comparison to placebo
stockings.4 This publication caused lot of dis-
cussions, in which especially the poor compli-
ance wearing the stockings had been criti-
cized.5
However, the most recent ACCP guideline
states: In patients with acute DVT of the leg, we
suggest not using compression stockings rou-
tinely to prevent PTS (Grade 2B). Remarks: this
recommendation focuses on prevention of the
chronic complication of PTS and not on the
treatment of symptoms. For patients with acute
or chronic symptoms, a trial of graduated com-
pression stockings is often justified.6
It may be assumed that future guidelines
will advocate a tailored regime suggesting
compression for symptomatic patients as soon
as data will be available.7
Reduction of pain and swelling
in the acute stage
Starting compression in the acute stage of
DVT, at the same time as anticoagulation is a
real Cinderella indication, which tends to fall
into oblivion.
The description that strongly applied inelas-
tic Unna boot bandages (zinc paste invented
by Unna) lead to an immediate reduction of
pain dates back more than 100 years ago.8Also
swelling is immediately reduced, so that
mobile patients are able to keep on walking.
Several famous European phlebologists fol-
lowed the recommendation of treating DVT by
compression in addition to anticoagulation (G.
Bauer, Sweden; R. Tournay, France; K. Sigg,
Switzerland; F. Haid-Fischer, Germany).
However, this regime was based on experience
only and not supported by scientific evidence.
The introduction of low molecular heparin
(LMWH) allowing safe and efficient anticoagu-
lation by subcutaneous injections of fixed
doses and avoiding intravenous infusions
opened the possibility for home therapy. In our
hands patients could stay ambulant without
bed-rest due to the pain relieving effect of
simultaneously applied good compression,
without the risk of major pulmonary
embolism.9
A randomized controlled three-arms study
was started comparing bed-rest and no com-
pression with compression stockings and with
inelastic Fischer bandages in patients with
proximal DVT. Since most patients did not
want to take the risk of bed-rest and refused to
sign the consent for the study plan, the study
had to be stopped after 53 patients.10 All
patients were mobile and received therapeutic
doses of LMWH and overlapping vitamin K
antagonists. One group received firmly applied
Unna-boot bandages (Fischer-bandages),8the
second group, thigh-length compression stock-
ings, and the third group had bed-rest and no
compression. Both compression groups were
encouraged to walk. Study duration was 10
days, starting on the day of admission to the
hospital because of verified DVT extending
into the thigh (n=37) or pelvis (n=16).
Pain was assessed by visual analogue scale
and by a modified Lowenberg-test. (Assessing
the tolerability of a pressure applied to both
calves using a blood pressure cuff the differ-
ence between the tolerated pressure on the
non-affected limb minus that on the leg with
DVT gives a quantifiable parameter for pain).
In addition, daily walking distances, quality of
life and differences of leg circumferences were
measured. Repeated lung scans were per-
formed as a safety feature.
The firmly applied zinc paste bandages were
wrapped over by inelastic textile bandages
(Rosidal K®; Lohmann & Rauscher AG, St.
Gallen, Switzerland), and adhesive bandages
were applied over the knee and thigh up to the
groin (Panelast® and Porelast®; Lohmann &
Rauscher AG). The initial resting pressure on
the leg was >50 mmHg. These bandages stayed
overnight and were changed every 2-3 days.
Thigh length compression stockings (23-31
mmHg) (Sigvaris 503; Sigvaris Management
AG, Winterthur, Switzerland) were also worn
during night.
In spite of the low number of recruited
patients the outcome was convincing. There
were statistically significant superior results
for pain, swelling and quality of life favoring
the compression groups in comparison to bed
rest and no compression. Globally, no signifi-
cant difference was found between the efficacy
of stockings and bandages. Pain reduction was
much faster with compression compared to
bed-rest. One day after starting with inelastic
Fischer-bandages the pain level was in the
same range as in the bed rest group after 5
days.
More randomized clinical trials regarding
the value of compression are rare. A study, con-
centrating on the post-thrombotic sequelae,
after one year reported a faster reduction of
clinical symptoms including pain and swelling
if strong bandages were applied for one week
in the acute phase of DVT in contrast to no
compression.11
Recently the authors of the SOX trial have
published a sub-analysis of their data concen-
trating on their findings after one month, con-
cluding that compression stockings do not
reduce leg pain in patients with acute proximal
DVT.12 However, this conclusion is invalid,
since treatment with compression started only
2-3 weeks after the onset of DVT, at which time
acute symptoms have already disappeared.13
In conclusion new data are supporting the
experience that good compression applied
immediately is able to reduce pain and edema
in DVT patients. Future randomized trials
should start in the acute phase of compression
since we know that the clinical outcome in this
acute phase will have a deciding influence on
the development of PTS.
References
1. Musani MH, Matta F, Yaekoub AY, et al.
Venous compression for prevention of
postthrombotic syndrome: a meta-analy-
sis. Am J Med 2010;123:735-40.
2. Tie HT, Luo MZ, Luo MJ, et al.
Correspondence: Hugo Partsch, Department of
Dermatology and Angiology, Medical University of
Vienna, Baumeistergasse 85, A 1160 Vienna,
Austria.
E-mail: Hugo.Partsch@meduniwien.ac.at
This work is licensed under a Creative Commons
Attribution 4.0 License (by-nc 4.0).
©Copyright H. Partsch, 2016
Licensee PAGEPress, Italy
Veins and Lymphatics 2016; 5:5991
doi:10.4081/vl.2016.5991
Non commercial use only
Conference presentation
[Veins and Lymphatics 2016; 5:5991] [page 23]
Compression therapy in the prevention of
postthrombotic syndrome: a systematic
review and meta-analysis. Medicine
(Baltimore) 2015;94:e1318.
3. Kearon C, Akl EA, Comerota AJ, 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;141:e419S-94S.
4. Kahn SR, Shapiro S, Wells PS, et al. SOX
trial investigators. Compression stockings
to prevent post-thrombotic syndrome: a
randomised placebo-controlled trial.
Lancet 2014;383:880-8.
5. Labropoulos N, Gasparis AP, Caprini JA,
Partsch H. Compression stockings topre-
vent post-thrombotic syndrome. Lancet
2014;384:129-30.
6. Kearon C, Akl EA, Omelas E, et al.
Antithrombotic therapy for VTE disease:
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Chest 2016;149:315-52.
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Vasc Surg 2010;52:132-8.
8. Fischer H. Eine neue Therapie der
Phlebitis. Med Klinik 1910;30.
9. Partsch H. Therapy of deep vein thrombo-
sis with low molecular weight heparin, leg
compression and immediate ambulation.
Vasa 2001;30:195-204.
10. Blättler W, Partsch H. Leg compression and
ambulation is better than bed rest for the
treatment of acute deep venous thrombo-
sis. Int Angiol 2000;22:393-400.
11. Roumen-Klappe EM, den Heijer M, van
Rossum J, et al. Multilayer compression
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thrombosis has no effect on the develop-
ment of the post-thrombotic syndrome. J
Thromb Thrombolysis 2009;27:400-5.
12. Kahn SR, Shapiro S, Ducruet T, et al.
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Thromb Haemost 2014;112:1137-41.
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ResearchGate has not been able to resolve any citations for this publication.
Graduated compression stockings to treat acute leg pain associated with proximal DVT. A randomised controlled trial
Article
Full-text available
  • Aug 2014
Acute deep venous thrombosis (DVT) causes leg pain. Elastic compression stockings (ECS) have potential to relieve DVT-related leg pain by diminishing the diameter of distended veins and increasing venous blood flow. It was our objective to determine whether ECS reduce leg pain in patients with acute DVT. We performed a secondary analysis of the SOX Trial, a multicentrerandomised placebo controlled trial of active ECS versus placebo ECS to prevent the post-thrombotic syndrome.The study was performed in24 hospital centres in Canada and the U.S. and included 803 patients with a first episode of acute proximal DVT. We performed active ECS (knee length, 30-40 mm Hg graduated pressure) or placebo ECS (manufactured to look identical to active ECS, but lacking therapeutic compression). Study outcome was leg pain severity assessed on an 11-point numerical pain rating scale (0, no pain; 10, worst possible pain) at baseline, 14, 30 and 60 days after randomisation. Mean age was 55 years and 60% were male. In active ECS patients (n=409), mean (SD) pain severity at baseline and at 60 days were 5.18 (3.29) and 1.39 (2.19), respectively, and in placebo ECS patients (n=394) were 5.38 (3.29) and 1.13 (1.86), respectively. There were no significant differences in pain scores between groups at any assessment point, and no evidence for subgroup interaction by age, sex or anatomical extent of DVT. Results were similar in an analysis restricted to patients who reported wearing stockings every day. In conclusion, ECS do not reduce leg pain in patients with acute proximal DVT.
Leg compression and ambulation is better than bed rest for the treatment of acute deep vein thrombosis
Article
Full-text available
  • Jan 2004
Treatment of acute deep venous thrombosis (DVT) with low-molecular-weight heparin and vitamin K-antagonists reduces the risk of thrombus progression and pulmonary embolism but has no immediate effect on signs and symptoms. We addressed the question whether adding compression and walking would lead to a more rapid clinical improvement than bed rest. Fifty-three symptomatic outpatients with proximal DVT were randomly treated, in addition to dalteparin and phenprocoumon, with either firm inelastic bandages (n=18), elastic compression stockings (n=18), both combined with immediate deliberate ambulation, or bed rest without any compression (n=17). We assessed daily walking distance, well-being, quality of life, pain, swelling and clinical scores over a period of 9 days. Lung scans and ultrasound of the leg were performed on days 0 and 9. In the compression groups the walking distance increased with time to 4 km/day on average. Improvement of well-being and DVT-related quality of life was significantly faster and more pronounced with compression than with bed rest (p<0.05 for stockings, p<0.001 for bandages). Pain monitored by visual analogue scale decreased with time in a linear pattern in all groups (p<0.001). There was a significant difference between the groups (p<0.01), the best effect being achieved with bandages. Pain assessed by a provocation test was reduced by half on day 3 with bed rest but remained constantly present over the subsequent 6 days. With compression it was reduced to near baseline on day 3. Swelling was almost completely removed with compression and clinical scores also improved more than with bed rest (p<0.001). Thrombus progression, as studied with ultrasound, was less frequent and less pronounced in the compression groups than with bed rest. There was no difference of new pulmonary embolism on repeat lung scans. Leg compression combined with walking is the better alternative to bed rest for the treatment of symptomatic outpatients with proximal DVT.
Compression stockings to prevent post-thrombotic syndrome: A randomised placebo-controlled trial
Article
Background: Post-thrombotic syndrome (PTS) is a common and burdensome complication of deep venous thrombosis (DVT). Previous trials suggesting benefit of elastic compression stockings (ECS) to prevent PTS were small, single-centre studies without placebo control. We aimed to assess the efficacy of ECS, compared with placebo stockings, for the prevention of PTS. Methods: We did a multicentre randomised placebo-controlled trial of active versus placebo ECS used for 2 years to prevent PTS after a first proximal DVT in centres in Canada and the USA. Patients were randomly assigned to study groups with a web-based randomisation system. Patients presenting with a first symptomatic, proximal DVT were potentially eligible to participate. They were excluded if the use of compression stockings was contraindicated, they had an expected lifespan of less than 6 months, geographical inaccessibility precluded return for follow-up visits, they were unable to apply stockings, or they received thrombolytic therapy for the initial treatment of acute DVT. The primary outcome was PTS diagnosed at 6 months or later using Ginsberg's criteria (leg pain and swelling of ≥1 month duration). We used a modified intention to treat Cox regression analysis, supplemented by a prespecified per-protocol analysis of patients who reported frequent use of their allocated treatment. This study is registered with ClinicalTrials.gov, number NCT00143598, and Current Controlled Trials, number ISRCTN71334751. Findings: From 2004 to 2010, 410 patients were randomly assigned to receive active ECS and 396 placebo ECS. The cumulative incidence of PTS was 14·2% in active ECS versus 12·7% in placebo ECS (hazard ratio adjusted for centre 1·13, 95% CI 0·73-1·76; p=0·58). Results were similar in a prespecified per-protocol analysis of patients who reported frequent use of stockings. Interpretation: ECS did not prevent PTS after a first proximal DVT, hence our findings do not support routine wearing of ECS after DVT. Funding: Canadian Institutes of Health Research.
Antithrombotic Therapy for VTE Disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines
Article
This article addresses the treatment of VTE disease. We generated strong (Grade 1) and weak (Grade 2) recommendations based on high-quality (Grade A), moderate-quality (Grade B), and low-quality (Grade C) evidence. For acute DVT or pulmonary embolism (PE), we recommend initial parenteral anticoagulant therapy (Grade 1B) or anticoagulation with rivaroxaban. We suggest low-molecular-weight heparin (LMWH) or fondaparinux over IV unfractionated heparin (Grade 2C) or subcutaneous unfractionated heparin (Grade 2B). We suggest thrombolytic therapy for PE with hypotension (Grade 2C). For proximal DVT or PE, we recommend treatment of 3 months over shorter periods (Grade 1B). For a first proximal DVT or PE that is provoked by surgery or by a nonsurgical transient risk factor, we recommend 3 months of therapy (Grade 1B; Grade 2B if provoked by a nonsurgical risk factor and low or moderate bleeding risk); that is unprovoked, we suggest extended therapy if bleeding risk is low or moderate (Grade 2B) and recommend 3 months of therapy if bleeding risk is high (Grade 1B); and that is associated with active cancer, we recommend extended therapy (Grade 1B; Grade 2B if high bleeding risk) and suggest LMWH over vitamin K antagonists (Grade 2B). We suggest vitamin K antagonists or LMWH over dabigatran or rivaroxaban (Grade 2B). We suggest compression stockings to prevent the postthrombotic syndrome (Grade 2B). For extensive superficial vein thrombosis, we suggest prophylactic-dose fondaparinux or LMWH over no anticoagulation (Grade 2B), and suggest fondaparinux over LMWH (Grade 2C). Strong recommendations apply to most patients, whereas weak recommendations are sensitive to differences among patients, including their preferences.
Venous Compression for Prevention of Postthrombotic Syndrome: A Meta-analysis
Article
  • Aug 2010
To determine the effectiveness of venous compression stockings or compression bandages on the reduction of postthrombotic syndrome in patients with deep venous thrombosis. We attempted to identify all published trials in all languages identified by PubMed through June 2009. Meta-analysis was performed. Based on 5 randomized trials of patients with deep venous thrombosis comparing treatment with venous compression to controls, mild-to-moderate postthrombotic syndrome occurred in 64 of 296 (22%) treated with venous compression, compared with 106 of 284 (37%) in controls (relative risk=0.52). Severe postthrombotic syndrome occurred in 14 of 296 (5%) treated, compared with 33 of 284 (12%) controls (relative risk=0.38). Any postthrombotic syndrome occurred in 89 of 338 (26%) treated, compared with 150 of 324 (46%) controls (relative risk=0.54). Venous compression reduced the incidence of postthrombotic syndrome, particularly severe postthrombotic syndrome. Venous compression in patients with deep venous thrombosis would seem to be indicated for this purpose. There was, however, wide variation in the type of stockings used, time interval from diagnosis to application of stockings, and duration of treatment. Further investigation, therefore, is needed.
Individually tailored duration of elastic compression therapy in relation to incidence of the postthrombotic syndrome
Article
  • Apr 2010
We assessed whether individualized shortened duration of elastic compression stocking (ECS) therapy after acute deep venous thrombosis (DVT) is feasible without increasing the incidence of postthrombotic syndrome (PTS). At the outpatient clinic of the Maastricht University Medical Centre, 125 consecutive patients with confirmed proximal DVT were followed for 2 years. Villalta scores were assessed on four consecutive visits; 3, 6, 12, and 24 months after the acute event. Reflux was assessed once by duplex testing. After 6 months, patients with scores <or=4 on the Villalta clinical score and in the absence of reflux were allowed to discontinue ECS therapy. If reflux was present, two consecutive scores <or=4 were needed to discontinue ECS therapy. ECS therapy was discontinued in 17% of patients at 6 months, in 48% at 12 months, and in 50% at 24 months. Reflux on duplex testing was present in 74/101 (73.3%) tested patients and was not associated with the onset of PTS. At the 6-month visit, the cumulative incidence of PTS was 13.3%, at 12 months 17.0%, and at 24 months 21.1%. Varicosities/venous insufficiency (present at baseline) was significantly associated with PTS; hazard ratio 3.2 (1.2-9.1). Patients with a low probability for developing PTS can be identified as early as 6 months after the thrombotic event, and individualized shortened duration of ECS therapy based on Villalta clinical scores may be a safe management option. These findings need to be confirmed in a randomized clinical trial.
Therapy of deep vein thrombosis with low molecular weight heparin, leg compression and immediate ambulation
Article
Traditionally, patients with acute deep vein thrombosis (DVT) are treated with strict bed rest for several days to avoid clots from breaking off and causing pulmonary emboli. The purpose of this study is to give a precise estimate of short term complications like pulmonary embolism, bleeding, heparin-induced thrombocytopenia (HIT) and death in a cohort of consecutive patients who were admitted because of acute symptomatic DVT, all treated by compression and walking exercises instead of conventional bed-rest and nearly all by low-molecular-weight heparin. In 1289 consecutive patients the following five endpoints were registered for the period of hospital-stay: 1. Frequency of pulmonary embolism (PE) at admission (V/Q lung scan), 2. Frequency of new PE's after 10 days (second lung scan), 3. Fatal events (autopsy), 4. Frequency of malignant disease, 5. Bleeding complications and HIT. 1. 190/356 (53.4% of iliofemoral, 355/675 (52.6%) of femoral and 84/239 (35.1%) of lower leg vein thrombosis showed PE (difference iliofemoral and femoral versus lower leg DVT p < 0.001). Two thirds of these PE were asymptomatic. 2. New PE after 10 days in comparison to the baseline scan occurred in 7.4%, 6.4% and 3.4% respectively. 3. Fatal events, all investigated by autopsy, were caused by PE in 3 patients aged over 76 years (0.23%), by malignant diseases in 12 (0.9%) and due to other causes in 2 (0.15%). 4. 232 patients (18%) had associated malignant diseases, from which 33% were detected by our screening. 5. Non-fatal bleeding complications were seen in 3.3%, including 5 patients (0.4%) with major bleeding. Three patients (0.2%) suffered from HIT II. The low incidence of recurrent and fatal pulmonary emboli in this series affirms the value of early ambulation with heavy leg compression in patients with symptomatic acute leg deep venous thrombosis. In addition, the presence of pulmonary emboli in one-third of those with calf vein thrombi emphasizes the importance of fully diagnosing and treating calf clots.