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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-
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Article
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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.