Guideline Development Group

Summary of Evidence

The influence of mechanical compression on LE DVT and/or PE prophylaxis was examined in 7 systematic reviews.^44-50 The populations included patients who were in post-operative recovery from a variety of surgical procedures with or without pharmacological prophylaxis. Also included were airline travelers of varying VTE risk levels. These studies supported that graded compression stockings (GCS) used alone significantly decreased the incidence of LE DVT and/or PE and that this mechanical compression method provided additional benefit when combined with other prophylactic methods. Although GCS was the method of mechanical compression in all seven of these publications, the descriptive features of the GCS were inconsistent.

Screening to identify VTE risk is essential and will identify which, if any, mechanical compression method is appropriate to implement. In the CPG of the Japanese Circulation Society (JCS) for PE and LE DVT prevention, elastic stockings or intermittent pneumatic compression (IPC), IPC or anticoagulation, and anticoagulation plus IPC or elastic stockings are recommended for post-operative patients with elevated risk.⁵¹ The Institute for Clinical Systems Improvement (ICSI) guidelines for VTE prophylaxis recommends that if contraindications exist for both low molecular weight heparin (LMWH) and low dose unfractionated heparin (UH or UFH ) and there is high-risk for VTE but not high-risk for bleeding, Fondaparinux or low dose aspirin or IPC be used.⁴² One example would be someone with a Heparin induced thrombocytopenia (HIT) history. Graduated compression stockings or IPC are recommended for acutely or critically ill medical patients who are bleeding or are at high risk for major bleeding, until bleeding risk decreases at which time pharmacological thrombo-prophylactic methods can be substituted.^{37, 52}

A systematic review of 6 RCTs looked at patients at high-risk for VTE who underwent various surgical procedures to assess the effectiveness of IPC combined with pharmacological prophylaxis versus single modality usage.⁵³ Combining IPC with an anti-coagulant (e.g. LMWH) was more effective in VTE prevention than either IPC or anticoagulant use alone which is consistent with the CPG recommendation offered by the JCS.

In summary, there is substantial supportive evidence for the use of mechanical compression methods for medical and surgical patients^{35, 54 55-58} prolonged air-flight travelers^{6, 45, 47} and patients in long- term care facilities.⁴³ For those persons at increased risk for VTE, the use of GCS or IPC, with or without anticoagulation therapy, is considered to be beneficial. The evidence is inconsistent, however, in describing the optimal protocols for use of GCS, elastic stockings, or IPC. Potential for rare circulatory compromise with the use of GCS (i.e. knee- or thigh-length) warrants proper fitting and careful monitoring of skin condition by the patient and physical therapist.