The role of compression

hosiery in the prevention

of post thrombotic
syndrome

Lynda Bonner,
Consultant Nurse for
Thrombosis & AC

Kumal Rajpaul MSc, BSc

(Hons), Dip HE, RN
CNS-Tissue Viability

What is Post Thrombotic Syndrome?

PTS is a severe and common chronic complication
of DVT of the lower extremity
1 in 3 people with DVT will develop postthrombotic complications within five years
(Kolbach, 2008)
It is postulated that PTS occurs as a result of
chronic venous hypertension that develops due to
valvular reflex and residual thrombus

PTS; QOL issues

Prevention of PTS; NICE CG144 2012

In patients with Prox DVT and PE, offer belowknee GCS with ankle pressure >23mmHg a week
after diagnosis or when swelling is reduced
significantly and if there are no contraindications
wear stockings for at least 2 years
replace stockings 2 or 3 times per year
wear only on the affected leg or legs

Review of literature (Kanaan et al 2012)

First
author/year
published

No. of pt per
Stocking characteristics
group
(Stocking/Contr
ol)

Stocking
duration

Followup

Brandjes et al. 96/98

1997

Graduate compression stocking

below knee
40 mm Hg at ankle
36 mm Hg at lower calf
21 mm Hg at upper calf

2 years

5 years in
both group

Partsch and
Blattler 2000

30/15

Inelastic compression bandages

[Unna boots on the lower leg,
adhesive bandages on the thigh]
(n=15) or Thigh length
compression stockings (n=15)

9 days

None

Ginsberg et al. 42/40

2001

Elastic compression stocking

below knee (n=38) or thigh (n=4)
(i) 20-30 mmHg

1.4-4.6
years

1.4-4.6 years
in stocking
group; 1.8-4.9
years in
control group

Review of literature (Kanaan et al 2012)

First
author/year
published

No. of pt per
Stocking characteristics
group
(Stocking/Contr
ol)

Stocking
duration

Followup

Partsch et al.
2004

26/11

Thigh length elastic compression

stockings (n=13) or Gauze zinc oxide
and calamine impregnated bandages
on lower leg and firm thigh adhesive
bandage (n=13)

2 years

2 years in
both
group

Prandoni et
al. 2004

90/90

Graduate below-knee compression

elastic stocking
(i) 30 to 40 mm Hg at the ankle

2 years

3-5 years
in both
groups

Aschwanden
et al. 2008

84/85

Compression stockings below knee

(i) 26.3-36.1 mm Hg at ankle

3.2 years

3.2 years in
stocking
group; 2.9
years in
control
group

Cochrane Library Review

Selected 3 studies;
1997 Brandjes (40mmHg ankle)
2001 Ginsberg (20-30mmHg ankle)
2004 Prandoni (30-40mmHg ankle)
There is substantial evidence that elastic compression
stockings reduce the occurrence of PTS after DVT. No
serious adverse effects were mentioned in the studies.
Hence, elastic compression stockings should be added to the
treatment of DVT to prevent the development of postthrombotic syndrome.
Non-pharmaceutical measures for prevention of post-thrombotic
syndrome (Kolbach et al 2008)

Types of Compression Stockings

Anti-embolism stockings, are indicated for the
prevention of DVT
Class I, II, III compression hosiery:
indicated for the treatment of varying degrees
of venous disorders, or in the prevention of
post-thrombotic syndrome

Usually ordered and fitted by specialist

department/clinician
Higher compression levels than AES
Require careful assessment of arterial flow
(Ankle Brachial Index)

Medical Compression Stockings;

Norms and Standards

British Standard

French Standard

German Standard

Testing method

HATRA

IFTH

HOSY

Class l

14-17 mmHg

10-15 mmHg

18-21 mmHg

Class ll

18-24 mmHg

15-20 mmHg

23-32 mmHg

Class lll

25-35 mmHg

20-36 mmHg

34-46 mmHg

Class lV

Not reported

>36 mmHg

>49 mmHg

British Standards
BS 7672: 1993 (in vitro)
Specification for compression, stiffness
and labelling of anti-embolism
stockings (AES)

BS 6612: 1985 (in vitro)

Specification for graduated
compression hosiery/stockings (GCS)

HATRA (picture supplied by SMTL)

Instron/Tensiometer
(picture supplied by SMTL)

Check for suitability for compression hosiery

ABPI calculation can safely be undertaken as soon as
the patient starts to mobilise and is fully anticoagulated
(Vowden & Vowden, 2007)
It is important to remember that if the limb is significantly
swollen or large it is necessary to adjust the cuff size and
possibly use a 5MHz rather than an 8MHz Doppler probe
Best Practice Statement: Compression Hosiery;
http://www.wounds-uk.com/pdf/content_8953.pdf

Points to discuss
Length of time before ABPI can be
performed once a DVT is diagnosed?

Which standard are your stockings

measured against (British, French or
German Standards)?

Conclusion
Studies have identified risk factors for developing
this syndrome including obesity, older age, and
poor quality of anticoagulation therapy

Modalities such as compression stockings are

evidence based in reducing the incidence of PTS
The role of compression stockings including use
and duration of use will be further clarified with
ongoing research

Further research
Official Title: CELEST
Evaluation of the Efficacy of Elastic Compression in
Preventing Post-thrombotic Syndrome. Randomised
Non-inferiority Study for Ankle Pressure Targeted at 25
mm Hg Versus 35 mmHg

http://clinicaltrials.gov/ct2/show/NCT01578122

CELEST 20-30mmHg v 30-40mmHg

PTS is a frequent and burdensome complication of proximal deep-vein thrombosis. Therapeutic

options for PTS are limited and mainly rely on its prevention. Therapeutic trials evidenced that
elastic compression stockings (ECS) applying 30-40mmHg of pressure at the ankle reduced the
rate of PTS by 50%. Although ECS are unlikely to cause harm, in clinical practice, compliance to
this treatment appears to be low as ECS may be difficult to apply and to wear

ECS with a lighter compression strength (20-30mmHg) might be easier to apply and be more
comfortable. This could favour a better compliance.

CELEST is a randomized, multicentre, double-blind trial which aims to determine whether ECS
applying 25mmHg of targeted pressure at the ankle are non inferior to ECS applying 35mmHg of
targeted pressure at the ankle

Condition Intervention Phase Deep Vein Thrombosis

Post-thrombotic Syndrome
Device: compression stockings 25mm Hg
Device: compression stockings 35 mm Hg
Phase 3
Study Type: Interventional Study Design: Allocation: Randomized
Endpoint Classification: Safety/Efficacy Study
Intervention Model: Parallel Assignment
Masking: Double Blind (Subject, Investigator)
Primary Purpose: Treatment Official Title: Evaluation of the Efficacy of Elastic Compression in
Preventing Post-thrombotic Syndrome. Randomised Non-inferiority Study for Ankle Pressure
Targeted at 25 mm Hg Versus 35 mm Hg

References
Vazquez, S.R. and Kahn, S.R. (2010) Postthrombotic
Syndrome. Circulation: Journal of the American Heart
Association
Vowden, P. and Vowden K. (2007) How should
compression hosiery be used for patients who have
had deep venous thrombosis? CorrespondenceWound UK. Vol 3, No 1.
Kanaan A.O., Lepage, J.E., Djazayeri, S. and
Donovan, L. (2012). Evaluating the role of
compression stockings in preventing postthrombotic
syndrome: A review of the literature