79 – In patients with confirmed acute distal DVT, should a mechanical compression device be discontinued in the affected limb?

Pedro Tort-Saade, Antonio Otero-López, Louis M. Kwong, David Beatón-Comulada, Norberto J. Torres-Lugo, Roberto Colón-Miranda, Ruben Tresgallo-Parés.

Response/Recommendation: The practitioner might continue the mechanical compression device in patients with an acute distal deep venous thrombosis (DVT), in combination with the DVT treatment protocol (anticoagulation) recommended in current guidelines.

Strength of Recommendation: Limited.

Rationale: Venous thromboembolism (VTE) constitutes a major interdisciplinary challenge in health care¹. It represents a common complication for hospitalized patients that could prolong hospital stay and significantly cause increased morbidity and mortality^1-4. Critically ill patients and those that underwent major surgical interventions are at a particularly increased risk of VTE, i.e., DVT and pulmonary embolism (PE)^2,5. These events result from the dynamic influence of 3 factors: hypercoagulability, venous stasis, and endovascular injury, commonly recognized as the Virchow’s triad^3,5.

The oldest and simplest VTE prophylactic approach is early mobilization¹. However, this method is not always feasible in some individuals, such as critically ill or traumatic patients. For this reason, significant effort has been placed over the years on studying prophylactic alternatives for VTE, such as chemoprophylaxis and mechanical prophylaxis⁵. Pharmacological methods presented in current guidelines considerably reduce the risk of VTE, as has been evidenced in most clinical situations through all the available studies^1,2. Mechanical compression devices (MCD) are an alternative prophylactic measure that has been recommended in recent guidelines, mainly as a combined approach with chemoprophylaxis in high-risk patients^6-8.

The use of MCD has ranged from intermittent pneumatic compression (IPC), and sequential compression of the calves and thighs to plantar compression pumps and even compression sleeves applied to the upper extremities⁹. These devices exert their prophylactic effect by decreasing peripheral venous stasis and promoting endogenous fibrinolysis, both contributing to a continuous blood flow and potential clot dissolution^1,4. The various types of MCD could vary by the speed of cuff inflation, duration of compression, duration of deflation, as well as fixed cycle vs. physiologically triggered cycling. No mechanical device has been demonstrated to be superior to the other^10-14. These methods have been used in DVT prophylaxis involving a spectrum of patients, including the medically ill, trauma patients, and those undergoing elective total hip and total knee arthroplasty. Studies have demonstrated their effectiveness in the prophylaxis against DVT combined with a pharmacologic agent and singly as a standalone strategy^15-19.

While recognized as an effective thrombophylactic strategy, the role of mechanical compression in the setting of an acute distal DVT remains a debatable issue that has not been well-established in current literature. Most of the conflict around the use of compression strategies in established DVT appears to be based on theoretical grounds, as compression might promote clot dislodgment and cause a PE even when no data supports this idea²⁰. Such is the case by Siddiqui et al., they presented a patient who sustained a PE in an apparent temporal association with the activation of a lower extremity pneumatic compression pump for intraoperative prophylaxis against DVT during surgery for small bowel obstruction. Yet, no causality has been established²¹. Additionally, Parvizi et al., demonstrated through a cross-sectional retrospective study that there is no statistically significant relationship between lower extremity DVT and PE²².

Similarly, a prospective cohort study by Hou et al., assessed the safety of postoperative application of IPC devices in patients with pre-existing DVT who were undergoing joint surgery. Their study suggests that IPC reduces the risk of symptomatic PE in general patients after surgery without an increased rate of postoperative PE in those patients with distal DVT²³. In addition, a systematic review by Rabe et al., evaluated the risks and contraindications of medical compression treatments, including their use in acute DVT²⁰. In this review, they presented a cohort by Partsch et al., that found no significant increase in the percent of PE compared with patients with DVT treated with chemoprophylaxis (low-molecular-weight heparin [LMWH]) and bedrest against chemoprophylaxis, compression, and walking²⁴. In addition, three randomized control trials (RCT) demonstrated that early mobilization does not increase the frequency of PE compared with bed rest in patients with DVT treated with anticoagulation^25-27. Another study consisted of an RCT of patients with isolated superficial venous thrombosis treated with LMWH plus compression stockings that demonstrated faster thrombus regression and no increased risk of PE compared with LMWH alone²⁸. Based on these studies, the review by Rabe et al., provides recommendations in favor of compression therapy (including IPC) in acute thrombotic events, with favorable outcomes when applied with caution²⁰. Compression therapy in the acute phase of DVT has reduced the occurrence of pain on calf compression and the incidence of hyperpigmentation, venectasia, and skin induration, which are irreversible skin signs associated with post-thrombotic syndrome (PTS)^29-31. However, these articles and their foundations consist of diverse populations, inconsistent study designs, and endpoints, providing poor data significance and generalizability.

These findings challenge the common impression and some of the statements that consider the use of MCD in the presence of an acute distal DVT as an unsafe practice or even a contraindication. Currently, there is no data report or comprehensive study that confirmed that the compression of veins with an established clot would lead to an increased risk of PE or PTS^20,26,32. The presented conclusions suggest that continuing this prophylactic measure during an acute distal DVT events may possess some benefits. However, the studies available provide limited evidence with heterogeneous features and modest significance. Therefore, further studies are necessary to provide robust evidence about the role of MCD in the setting of an acute distal DVT. Future research should contemplate a randomized homogenous population, evaluate specific types of MCD, in addition to specific endpoints that demonstrate the benefit of continuous compression therapy in the setting of a distal DVT. Based on the results presented by the aforementioned studies, there is a limited set of evidence supporting the use of mechanical compression in the setting of an acute distal DVT in combination with the DVT treatment approach (anticoagulation) designated in current guidelines. Practitioners might continue the MCD in patients with an acute distal DVT. Their decision should be based on their clinical judgment as this therapy does not substitute the management of acute DVT as per existing guidelines. Physicians should be alert to emerging evidence that might counter the current findings.

References:

1. Tamowicz, B., et al., Mechanical methods of venous thromboembolism prevention: from guidelines to clinical practice. Pol Arch Intern Med, 2019. 129(5): p. 335-341.

2. Vandenbriele, C., et al., Intermittent pneumatic compression on top of pharmacological thromboprophylaxis in intensive care: added value or added cost? J Thorac Dis, 2019. 11(5): p. 1734-1737.

3. Wang, Y., et al., Can Intermittent Pneumatic Compression Reduce the Incidence of Venous Thrombosis in Critically Ill Patients: A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost, 2020. 26: p. 1076029620913942.

4. Pavon, J.M., et al., Effectiveness of Intermittent Pneumatic Compression Devices for Venous Thromboembolism Prophylaxis in High-Risk Surgical Patients: A Systematic Review. J Arthroplasty, 2016. 31(2): p. 524-32.

5. Tyagi, V., et al., The Role of Intraoperative Intermittent Pneumatic Compression Devices in Venous Thromboembolism Prophylaxis in Total Hip and Total Knee Arthroplasty. Orthopedics, 2018. 41(1): p. e98-e103.

6. Kakkos, S.K., et al., Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism. Cochrane Database Syst Rev, 2016. 9: p. CD005258.

7. Kim, Y.H., et al., Mechanical thromboprophylaxis would suffice after total knee arthroplasties in Asian patients? Arch Orthop Trauma Surg, 2019. 139(2): p. 167-171.

8. Zhao, J.M., et al., Different types of intermittent pneumatic compression devices for preventing venous thromboembolism in patients after total hip replacement. Cochrane Database Syst Rev, 2014(12): p. CD009543.

9. Kakkos, S.K., et al., The efficacy of the new SCD response compression system in the prevention of venous stasis. J Vasc Surg, 2000. 32(5): p. 932-40.

10. Lachiewicz, P.F., S.S. Kelley, and L.R. Haden, Two mechanical devices for prophylaxis of thromboembolism after total knee arthroplasty. A prospective, randomised study. J Bone Joint Surg Br, 2004. 86(8): p. 1137-41.

11. Pagella, P., et al., A randomized trial to evaluate compliance in terms of patient comfort and satisfaction of two pneumatic compression devices. Orthop Nurs, 2007. 26(3): p. 169-74.