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 mortality1-4. 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 triad3,5.
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 studies1,2. 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 patients6-8.
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 dissolution1,4. 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 other10-14. 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 strategy15-19.
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 anticoagulation25-27. 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 PTS20,26,32. 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.
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.
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.
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.
16. Warwick, D., et al., Comparison of the use of a foot pump with the use of low-molecular-weight heparin for the prevention of deep-vein thrombosis after total hip replacement. A prospective, randomized trial. J Bone Joint Surg Am, 1998. 80(8): p. 1158-66.
17. Edwards, J.Z., et al., Portable compression device and low-molecular-weight heparin compared with low-molecular-weight heparin for thromboprophylaxis after total joint arthroplasty. J Arthroplasty, 2008. 23(8): p. 1122-7.
18. Silbersack, Y., et al., Prevention of deep-vein thrombosis after total hip and knee replacement. Low-molecular-weight heparin in combination with intermittent pneumatic compression. J Bone Joint Surg Br, 2004. 86(6): p. 809-12.
21. Siddiqui, A.U., T.G. Buchman, and R.S. Hotchkiss, Pulmonary embolism as a consequence of applying sequential compression device on legs in a patient asymptomatic of deep vein thrombosis. Anesthesiology, 2000. 92(3): p. 880-2.
28. Boehler, K., et al., Therapeutic effect of compression stockings versus no compression on isolated superficial vein thrombosis of the legs: a randomized clinical trial. Eur J Vasc Endovasc Surg, 2014. 48(4): p. 465-71.