Kang-Il Kim, Jun-Ho Kim, and Paul F. Lachiewicz.

Response/Recommendation: The current evidence does not demonstrate notable differences in the clinical outcomes between different types of intermittent pneumatic compression devices (IPCD). However, devices with patient monitoring sensors and sequential compression may improve patient compliance.

Strength of Recommendation: Moderate.

Rationale: There are numerous types of IPCD currently available^1-3. These devices can be categorized into anatomical locations of application, such as thigh-calf compression, calf compression only, and foot compression. In addition, these devices can be subdivided into providing sequential or uniform pressure, gradual or rapid inflation, and portable (outpatient) or stationary (in-hospital) devices^2,3. The assessment of efficacy for IPCD is complicated by the inclusion of various types and doses of anticoagulant and antithrombotic medications in the published studies. The outcomes evaluated included: venous thromboembolism (VTE), (deep venous thrombosis [DVT], and pulmonary embolism [PE]), adverse events, such as postoperative bleeding and swelling, ease of application and use, and patient compliance with the device^2-8.

Determining differences in the efficacy and other outcomes between the numerous IPCD on the market is not possible, because these devices have been evaluated in small number of randomized controlled trials (RCT) that were underpowered^3,9. The influence of the amount of pressure, inflation rate, timing of initiation, and duration of prophylaxis for maximum benefit are still unclear^10,11. There is little evidence for the comparison of efficacy of IPCD between different orthopaedic procedures, although the benefits have been generally accepted in total knee arthroplasty (TKA), total hip arthroplasty (THA), and hip fracture surgery^2,3,9,11.

In a systematic review, Zhang et al.³, noted one RCT comparing patients with thigh-calf-compression (n=58) and foot compression (n=63) in first 3 weeks after THA³. There were no cases of symptomatic DVT or PE in either group^3,12. Postoperative swelling of the thigh, as measured by thigh circumference, was significantly milder in thigh-calf compression group (1.22%) than in foot compression group (3.19%)^3,12. This study was underpowered, with a high risk of bias. One recent meta-analysis noted that venous foot pumps decreased the rate of VTE after THA and TKA compared to chemical prophylaxis¹³. One comprehensive review of IPCD in orthopaedic surgery made recommendations based on the levels of evidence and adherence to established guidelines¹⁴. Compression stockings alone were the lowest-rated, and venous phasic flow-regulated below-knee sequential IPCD were the highest rated in each grading category¹⁴. However, this review included studies with heterogeneous low level of evidence. The superiority of IPCD depending on anatomical location is uncertain, and high-quality studies with large numbers of patients would be required to determine this.

A sequential compression device (SCD) would seem more hemodynamically effective due to the increase in blood flow and prevention of venous stasis, one factor in the initiation of DVT^4,15. One retrospective comparative study reported that a SCD had lower rate of VTE, better compliance, and shorter length of hospital day than a uniform IPCD in 1,577 cases after total joint arthroplasty (TJA)¹⁶. Other clinical studies have not reported significant differences in the incidence of VTE, comparing sequential to uniform IPCD^15,17. There are no high-quality, adequately powered comparative studies on the type of compression.

Pavon et al.², performed comprehensive systematic review of 14 RCT with 2,633 cases and 3 observational studies with 1,724 cases to evaluate effectiveness of IPCD in patients after TJA. Only 3 RCT directly compared different types of IPCD for VTE events^9,18,19. One adequately powered RCT study (moderate risk of bias) of 423 patients having TKA compared a rapid-inflation calf SCD (VenaFlow [Aircast, Summit, NJ]) and a slow-inflation calf SCD (Kendall SCD [Kendall, Mansfield, MA]). The rate of DVT was significantly lower in rapid inflation group than the slow compression group⁹. Another likely underpowered RCT (high risk of bias) compared Kendall SCD to a rapid-inflation IPCD (PlexiPulse [NuTech, San Antonio, TX]) in 107 patients having pelvic fracture surgery and reported no difference in the rate of VTE events between the two groups¹⁸. A third likely underpowered RCT (moderate risk of bias) also compared Kendall SCD with PlexiPulse in 136 patients having spinal surgery and reported no significant differences¹⁹. There were no major bleeding events in these three RCT^9,18,19. This systematic review concluded that current evidence-based to guide selection of a specific device or type of device is limited². With one more caveat, some of the evaluated devices in these studies are no longer available today.

Despite the benefits of IPCD, research has shown considerable variability in adherence to IPCD use ranging from 40% – 89%²⁰ and a systematic review identified several factors affecting the adherence such as patient discomfort and mobilisation²¹. In evaluating the adherence to different IPCD, a systematic review included three RCT^18,19,22 including 308 patients, and 3 observational studies^17,23,24 including 1,724 patients². Two studies compared PlexiPulse foot device and Kendall SCD calf-thigh device regarding ease of use. One moderate-sized RCT¹⁹ reported no difference in comfort ratings. One larger observational study noted that PlexiPulse device was more comfortable²⁴. Another small RCT²², comparing the ease of use between Kendall intermittent slow calf device and Flowtron (Huntleigh, Manalapan, NJ) uniform slow compression calf device, reported that Flowtron device was more comfortable for patients and more convenient for hospital staff²². An observational study compared five different devices, with multiple different sleeve types, and noted no significant difference in ease of use¹⁷. Comparing in-hospital patient compliance, there were no consistent associations between specific manufacturers ’ devices or location of sleeve and patient compliance². The addition of patient sensing technology, such as the one seen in Kendell SCD, is believed to improve patient compliance and ability of health staff to track patient therapy.

Portable devices for IPCD after surgery and for use at home have been developed recently and potentially allow better compliance, patient satisfaction, and continuation of mechanical VTE prophylaxis after discharge^25-27. Although portable IPCD has shown effective mechanical prophylaxis for VTE after THA and TKA¹⁶, the evidence is limited due to confounding variables. One observational study reported that a portable (mobile) IPCD had significantly better compliance, lower rate of DVT, reduction in symptomatic PE, and shorter length of hospital stay than a stationary IPCD¹⁶. However, all patients were also given pharmacologic prophylaxis with low-molecular-weight heparin¹⁶.

Although there are important differences between various IPCD in anatomical sleeve location, inflation pattern, and device portability, the available evidence is limited to recommend a certain IPCD type for patients having a specific surgical procedure.

References:

1.         Kohro S, Yamakage M, Sato K, Sato JI, Namiki A. Intermittent pneumatic foot compression can activate blood fibrinolysis without changes in blood coagulability and platelet activation. Acta Anaesthesiol Scand. 2005 May;49(5):660-4.

2.         Pavon JM, Adam SS, Razouki ZA, McDuffie JR, Lachiewicz PF, Kosinski AS, Beadles CA, Ortel TL, Nagi A, Williams JW, Jr. Effectiveness of Intermittent Pneumatic Compression Devices for Venous Thromboembolism Prophylaxis in High-Risk Surgical Patients: A Systematic Review. J Arthroplasty. 2016 Feb;31(2):524-32.

3.         Zhao JM, He ML, Xiao ZM, Li TS, Wu H, Jiang H. Different types of intermittent pneumatic compression devices for preventing venous thromboembolism in patients after total hip replacement. Cochrane Database Syst Rev. 2014 Dec 22(12):CD009543.

4.         Tamowicz B, Mikstacki A, Urbanek T, Zawilska K. Mechanical methods of venous thromboembolism prevention: from guidelines to clinical practice. Pol Arch Intern Med. 2019 May 31;129(5):335-41.

5.         Kim KI, Kim DK, Song SJ, Hong SJ, Bae DK. Pneumatic compression device does not show effective thromboprophylaxis following total knee arthroplasty in a low incidence population. Orthop Traumatol Surg Res. 2019 Feb;105(1):71-5.

6.         Ngarmukos S, Kim KI, Wongsak S, Chotanaphuti T, Inaba Y, Chen CF, Liu D. Asia-Pacific venous thromboembolism consensus in knee and hip arthroplasty and hip fracture surgery: Part 1. Diagnosis and risk factors. Knee Surg Relat Res. 2021 Jun 19;33(1):18.

7.         Flevas DA, Megaloikonomos PD, Dimopoulos L, Mitsiokapa E, Koulouvaris P, Mavrogenis AF. Thromboembolism prophylaxis in orthopaedics: an update. EFORT Open Rev. 2018 Apr;3(4):136-48.

8.         Lau BD, Haut ER. Practices to prevent venous thromboembolism: a brief review. BMJ Qual Saf. 2014 Mar;23(3):187-95.

9.         Lachiewicz PF, Kelley SS, Haden LR. Two mechanical devices for prophylaxis of thromboembolism after total knee arthroplasty. A prospective, randomised study. J Bone Joint Surg Br. 2004 Nov;86(8):1137-41.

10.       Kearon C. Duration of venous thromboembolism prophylaxis after surgery. Chest. 2003 Dec;124(6 Suppl):386s-92s.

11.       Lieberman JR, Pensak MJ. Prevention of venous thromboembolic disease after total hip and knee arthroplasty. J Bone Joint Surg Am. 2013 Oct 2;95(19):1801-11.

12.       Fujisawa M, Naito M, Asayama I, Kambe T, Koga K. Effect of calf-thigh intermittent pneumatic compression device after total hip arthroplasty: comparative analysis with plantar compression on the effectiveness of reducing thrombogenesis and leg swelling. J Orthop Sci. 2003;8(6):807-11.

13.       Pour AE, Keshavarzi NR, Purtill JJ, Sharkey PF, Parvizi J. Is venous foot pump effective in prevention of thromboembolic disease after joint arthroplasty: a meta-analysis. J Arthroplasty. 2013 Mar;28(3):410-7.

14.       Pierce TP, Cherian JJ, Jauregui JJ, Elmallah RK, Lieberman JR, Mont MA. A Current Review of Mechanical Compression and Its Role in Venous Thromboembolic Prophylaxis in Total Knee and Total Hip Arthroplasty. J Arthroplasty. 2015 Dec;30(12):2279-84.

15.       MacLellan DG, Fletcher JP. Mechanical compression in the prophylaxis of venous thromboembolism. ANZ J Surg. 2007 Jun;77(6):418-23.

16.       Froimson MI, Murray TG, Fazekas AF. Venous thromboembolic disease reduction with a portable pneumatic compression device. J Arthroplasty. 2009 Feb;24(2):310-6.

17.       Proctor MC, Greenfield LJ, Wakefield TW, Zajkowski PJ. A clinical comparison of pneumatic compression devices: the basis for selection. J Vasc Surg. 2001 Sep;34(3):459-63; discussion 63-4.

18.       Stannard JP, Riley RS, McClenney MD, Lopez-Ben RR, Volgas DA, Alonso JE. Mechanical prophylaxis against deep-vein thrombosis after pelvic and acetabular fractures. J Bone Joint Surg Am. 2001 Jul;83(7):1047-51.

19.       Wood KB, Kos PB, Abnet JK, Ista C. Prevention of deep-vein thrombosis after major spinal surgery: a comparison study of external devices. J Spinal Disord. 1997 Jun;10(3):209-14.

20.       Craigie S, Tsui JF, Agarwal A, Sandset PM, Guyatt GH, Tikkinen KA. Adherence to mechanical thromboprophylaxis after surgery: A systematic review and meta-analysis. Thromb Res. 2015 Oct;136(4):723-6.

21.       Greenall R, Davis RE. Intermittent pneumatic compression for venous thromboembolism prevention: a systematic review on factors affecting adherence. BMJ Open. 2020 Sep 3;10(9):e037036.

22.       Pagella P, Cipolle M, Sacco E, Matula P, Karoly E, Bokovoy J. A randomized trial to evaluate compliance in terms of patient comfort and satisfaction of two pneumatic compression devices. Orthop Nurs. 2007 May-Jun;26(3):169-74.

23.       Bockheim HM, McAllen KJ, Baker R, Barletta JF. Mechanical prophylaxis to prevent venous thromboembolism in surgical patients: a prospective trial evaluating compliance. J Crit Care. 2009 Jun;24(2):192-6.

24.       Robertson KA, Bertot AJ, Wolfe MW, Barrack RL. Patient compliance and satisfaction with mechanical devices for preventing deep venous thrombosis after joint replacement. J South Orthop Assoc. 2000 Fall;9(3):182-6.

25.       Colwell CW, Jr., Froimson MI, Anseth SD, Giori NJ, Hamilton WG, Barrack RL, Buehler KC, Mont MA, Padgett DE, Pulido PA, Barnes CL. A mobile compression device for thrombosis prevention in hip and knee arthroplasty. J Bone Joint Surg Am. 2014 Feb 5;96(3):177-83.

26.       Colwell CW, Jr., Froimson MI, Mont MA, Ritter MA, Trousdale RT, Buehler KC, Spitzer A, Donaldson TK, Padgett DE. Thrombosis prevention after total hip arthroplasty: a prospective, randomized trial comparing a mobile compression device with low-molecular-weight heparin. J Bone Joint Surg Am. 2010 Mar;92(3):527-35.

27.       Takahashi Y, Takahira N, Shibuya M, Uchiyama K, Fukushima K, Iwase D, Kawamura T, Miyagi M, Higashiyama R, Moriya M, Sakai K, Tsuda K, Sakamoto M, Akamine A, Takaso M. A portable pneumatic compression device to prevent venous thromboembolism in orthopedic patients with the highest risks of both venous thrombosis and bleeding: A case series study. J Orthop Surg (Hong Kong). 2020 Jan-Apr;28(1):2309499020905711.