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Preventing Venous Thrombosis by Wearing Elastic Compression Stocking

The elastic compression stocking is often recommended for patients with deep vein thrombosis (DVT). Several new studies discuss the advantages and disadvantages of wearing the compression stocking and it's effectiveness.

Preventing Venous Thrombosis use Elastic Compression Stocking


Thrombosis can occur in the venous circulation, including deep vein thrombosis (DVT) in the lower limb, pelvis, and pulmonary embolism. DVT can heal on its own without complications. But, the complication of pulmonary embolism causes 300,000 deaths each year in the United States. The cause of thrombosis is multifactorial and often involves a combination of acquired and congenital factors. Most common causes are temporary immobilization (for example during long flights or general anesthesia surgery), and also long-term immobilization (for example in hospitalized, stroke, or paraplegic patients)

Venous thrombosis is estimated to occur as much as 104-183 per 100,000 people per year in European ethnicities, and the incidence rate is lower in Asian ethnicities. Thrombosis also often recurs, where around 30% of patients will experience a thrombosis again within 10 years.


Action Mechanism of Elastic Compression Stocking

The elastic compression stocking are therapeutic options besides elastic and non-elastic bandages, boots, hosiery, and pneumatic tools. The action mechanism of the elastic compression stocking is to provide the highest pressure at the ankle, and the pressure level decreases progressively at the top of the garment. This garment ensures that blood flow goes upward, toward the heart — not down or to other superficial veins. Compression reduces the major venous diameter, thereby increasing the speed and volume of blood flow.


Effectiveness of Elastic compression stockings

Clinical indications for wearing the compression stocking are: 
  • primary chronic venous disease, 
  • postoperative patients, 
  • or interventional varicose vein management, 
  • prevention of venous thromboembolism, 
  • post-thrombotic syndrome, 
  • lymphatic edema, and chronic leg edema, 
  • superficial thrombophlebitis, 
  • and pregnancy.



Prevention of Venous Thromboembolism
Prevention of venous thromboembolism is often recommended for patients hospitalized (especially those who will undergo surgery) as well as patients who plan to travel long distances on flights. Some postoperative patients are immobilized due to various causes and need the prevention of thromboembolism. Blood-thinning drugs should be avoided in postoperative patients, so it is considered wearing the elastic compression stocking.

A systematic review published by Cochrane at the end of 2014 analyzed 19 randomized controlled trials (RCTs). From the results of the analysis, it was concluded that wearing the elastic compression stocking singly could be beneficial in reducing the risk of DVT. However, the effectiveness is reportedly increased when accompanied by pharmacological prevention.

However, it should be noted that wearing the compression stocking coupled with the drug thromboprophylaxis analyzed in this study is concluded from a heterogeneous study where the drugs used to differ.

Another 2009 study looked at the effects of using compression stockings for immobilized stroke patients. In this RCT, 2518 patients were analyzed, and the result found was an insignificant reduction in risk of 0.5%. Also, other side effects such as ulcers, sores, bullae, and skin necrosis are more in patients who use stockings than those who do not.

The 2009 meta-analysis analyzed 1560 abstracts and 14 studies and found that the relative risk for thromboembolism increased 2.8-fold in people who traveled than those who did not. The meta-analysis also found a correlation between 'dose' and an increased risk of thrombosis. 

A systematic review study by Cochrane in 2016 compared DVT rates in aircraft passengers (over 5 hours) who were asked to wear stockings with those who did not. None of the study participants had symptomatic DVT but found asymptomatic DVT.

The incidence of asymptomatic DVT decreased from about 10 per 1000 passengers to 2-3 per 1000 passengers in patients wearing stockings. The study also states that only a few patients complained that they were uncomfortable with stockings. 


Postthrombotic Syndrome (PTS)
Complications of post-thrombotic syndrome increase morbidity and burden the patient even more socioeconomically. Symptoms include skin disorders such as mild erythema and local induration to swelling.  Symptoms can also occur months to years after the occurrence of DVT. Post-thrombotic syndrome is a complication often experienced by DVT patients, where one in every 3-4 patients with symptomatic proximal DVT will experience these complications.

The RCT study by Prandoni et al. found that wearing compression stockings for 2 years reduced the percentage of DVT patients who experienced PTS from 49% (not using stockings) to 26% (using stockings).

A recommendation from the American College of Chest Physicians in 2012 states that patients with acute DVT are advised to use compression stockings for 2 years and even longer if PTS occurs. Stockings are also recommended for stroke patients, patients at risk of thromboembolism during pregnancy, and several other conditions. However, the latest guidelines from these organizations state that compression stockings should not be used routinely for PTS prevention.

The Cochrane review in 2017 regarding the use of compression stockings for the prevention of PTS examined 10 randomized controlled trials. It stated that overall the use of stockings reduced the incidence of PTS even though the evidence was still weak (low-quality evidence). However, wearing stockings did not reduce the number of severe or severe PTS, and there were no precise results regarding the DVT recurrence rate.


Disadvantages of The Compression Stocking

Wearing the compression stocking can cause several side effects that adversely affect patients' quality of life, especially elderly patients or malnutrition. Compression stockings that are too tight or uneven distribution of pressure can cause sores on the skin and be ulcerated.

Other side effects of wearing the elastic compression stocking are dry skin, sweating, and itching. Comfort disorders that can be felt by patients include tingling, burning, movement disorders, constrictions, or pain. These complaints can reduce patient compliance in stockings, and now optimal manufacturing and research of stockings are still under development.


Conclusion
Compression stockings are a tool that is often used in the prevention of DVT, post-thrombotic syndrome, and several other conditions. There is some clinical evidence that the use of compression stockings effectively reduces the risk of DVT. However, the risk reduction is relatively small.

The use of compression stockings is also reported to reduce the incidence of complications from DVT, namely Post-thrombotic Syndrome, but the clinical evidence is still low-quality evidence. Like other health therapies, compression stockings have side effects, and their use can interfere with patient comfort.

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