Management of DVT by Compression Stockings

February 24, 2017
Rajath Bappanad, Johns Creek High School, Johns Creek, GA and Nupur Dandavate, (Northview High School Johns Creek, GA)

Introduction

In GTF, we have been routinely conducting research in different fields of medicine, in areas connected with venous thromboembolism.   I got the idea to conduct an exhaustive research on compression stockings when I was given an assignment from NATF during my summer internship in 2016. I started researching the topic of the use of compression stockings and DVT.

A compression stocking is a device that uses pressure to help prevent and ease symptoms of various thrombotic conditions such as deep vein thrombosis (DVT) and Post Thrombotic Syndrome (PTS).

Compression stockings are specially made, snug-fitting, stretchy stockings that gently squeeze the leg.

Graduated compression or pressure stockings are tighter around the ankle and exert less compression as they move up the leg. Compression sleeves are just the tube part, without the foot.

 

Graduated compression hosiery is used to improve circulation and aid in leg health. When circulation is constricted, it can cause venous disorders, circulatory conditions, edema and skin changes such as hyperpigmentation, stasis dermatitis, lipodermatosclerosis, or venous stasis ulcers; some of these can be extremely serious.

 

The stockings are recommended for use in DVT, edema, lymphedema, varicose veins, and PTS  to  improve circulation and aid in leg health in patients who have suffered from DVT and PTS.

 

It is the intention of the authors that the readers will use this guide as a Course 101 for the use of compression stockings.

 

Types of stockings

There are different types of stockings: Support stockings and Compression stockings The terms support, compression, and gradient or graduated compression are often used interchangeably.  Although they are related, they are very different and come in several different forms.

The term support hose smooths out bumps and bulges in the abdominal area for a cosmetically more flattering look, but it does not provide any compression or support to the legs or feet.

Gradient or graduated compression stockings provides tightest compression at the ankle and the pressure decreases gradually as it moves up the garment.  Gradient compression helps to promote circulation, energize tired, achy legs and helps to prevent and reduce swelling. Graduated compression does offer the wearer support, which may be where the confusion lies between support hose and gradient compression. Not all support hose have gradient compression, but all gradient compression offers support.

When circulation is impaired, blood tends to pool in the lower extremities, causing circulatory problems. The graduated compression helps move blood through veins towards the heart.

Unlike traditional dress or athletic stockings and socks, compression stockings use a stronger elastic to create significant pressure on the legs, ankles and feet.

The terms “antiembolism stockings” and “graduated compression hosiery” are often used interchangeably, both types of stockings offer graduated compression. However, they have different levels of compression and indications.

Compression hosiery is available in several styles, including socks, stockings, knee-highs, thigh-highs and pantyhose for both men and women. The high thighs, the stockings with a very high pressure are uncomfortable to wear.

 

TED Hose

A TED hose may be prescribed to patients who are non-ambulatory, meaning they are not up and moving around on their own. For these patients, the risk of a blood

clot developing in their legs is a main concern for health care providers, as clots can form and break free and travel through the bloodstream to the lungs, causing a pulmonary embolism. TED hose help reduce this risk by administering pressure on the lower part of the leg and feet – with the most compression occurring at the calf muscle. As patients lay in bed, blood is more likely to pool in the calf, creating the right environment for a clot to form.

TED hose compression levels are measured in mmHg, or millimeters of Mercury, just as we measure our blood pressure. TED hose compression levels are 20 mmHg or below. Patients may wear TED hose for up to three weeks, at which time they are mobile once again or have been prescribed a different treatment to reduce the risk of blood clots.

What are compression socks?

Whereas TED hose are prescribed for non-ambulatory patients, compression socks are best suited for patients who are able to move around. Generally, compression socks are for patients with circulatory problems such as venous insufficiency, lymphedema, and varicose veins. For some patients, this can be a temporary condition during pregnancy, for example. Compression levels range from 15 to 20 mmHg all the way up to 60 mmHg (above 20 mmHg is considered prescription strength). Compression socks help keep blood from pooling in the ankles, where the pressure is the greatest. They can be worn for up to six months or more.

Anti-embolism stockings are constructed with graduated compression to improve circulation and reduce the risk of blood clots. They can also reduce excess fluid build-up in your legs and relieve swelling. Medically accepted graduated compression can go a long way toward maximizing leg health.

 

The valves in veins get weaker with age, and need some support to make sure that blood flows in one direction. Clots which tend to form around valves make them weaker, and thus need support, which is provided by stockings.

Pressure levels of compression applied in the stockings

 

When we talk about the pressure levels of compression, one consideration is age and as one grows older, one needs more pressure to make the blood flow to the heart. The downside of wearing compression stockings is that the more pressure you use, the more discomfort you feel.

 

It is basically a trial and error technique, a balancing act. The doctor tries to find the best pressure that will effectively provide relief to the patient without causing any adverse effects.

 

The needs for pressure may change over time: sometimes the patient can stabilize on a particular pressure, in some cases, we may have to increase the pressure as the patient gets older, or in some cases the doctor may have to decrease the pressure as the wearing time increases.

 

Degrees of Pressure

 

  1. 8-15 mmHg (mild support) provides very light compression. Can provide relief from tired aching legs, possibly help control minor swelling. With that little pressure, in some cases, you do not even need to wear anything at all, or the patient may just learn to live with the little swelling.

 

  1. 15-20 mmHg (medium support) is used to help for long periods of standing and sitting. This is great for travel, standing or sitting for long periods of time. This offers relief from minor swelling and varicose veins, often recommended during pregnancy. People may use this for temporary conditions.
  2. 20-30 mmHg (firm compression). This is the most frequently prescribed compression level. These are beneficial for venous thrombosis prevention during extended travel, relief from moderate to severe varicose veins and swelling, lymphedema, venous insufficiency, superficial thrombophlebitis. These are often prescribed post-sclerotherapy and to prevent venous stasis ulcers.

 

  1. 30-40 mmHg (extra firm compression) is used to help relieve edema, severe varicose veins and lymphedema. These stockings are also used in patients following an episode of deep venous thrombosis, for severe chronic venous insufficiency or post-thrombotic syndrome . These should only be worn under a physician’s supervision.

 

  1. 40 -50 mmHg is used for venous insufficiency.

These stockings should only be worn when recommended by the physician or other health care provider. Indications are for the management of severe chronic venous insufficiency or post-thrombotic syndrome (PTS) which may result in significant edema and skin changes, such as, hyperpigmentation, stasis dermatitis, lipodermatosclerosis, or venous stasis ulcers.

 

The higher the number, the greater the support. While prescribing these types of stockings, one has to make sure that the patient does not have peripheral arterial disease in which higher level of compression can further decrease blood flow and increase the chance for ulcers. The Ankle Brachial Index (ABI)should be used to make sure the blood pressure is not very low in the legs. Mostly patients use stockings during the day time, and rarely at night. As a rule of thumb, stockings which offer the lowest compression necessary to do the job are good to start with. If the patient wears compression stockings to control swelling in the legs, ankles should be measured first thing in the morning when they are normal, and again at the end of the day when there may be a noticeable swelling. If there is more than ½ inch difference by evening, then 20-30 mmHg pressure is most likely what the patient need.  If there is only minimal swelling noted, the patient may get by with less compression (15-20mmHg). If a patient wears a properly fitted 20-30 mm Hg compression garment and notices that fluid accumulates during the day, then consider increasing the compression. If a patient has never worn compression stockings before, it is not  recommended going straight to a 30-40 mm Hg compression stocking. Remember, the higher the compression, the more difficult the stocking will be to get on. People with severe arthritis, limited hand strength, or limited flexibility may have difficulty getting the stockings on.

The cost of specific types of stockings

Compression stockings come in a variety of “gradients” or compression levels

Typically, lighter compression stockings are less expensive than higher compression stockings.

There is generally a considerable price difference between stockings with compression of less than 20 mm Hg (8-15 mmHg and 15-20 mmHg) and stockings with compression of greater than 20 mmHg (20-30 mmHg and 30-40 mmHg).  The differences in price has to do with the increased amount of thread and the manufacturing process necessary to make the higher compression.

Stockings in the 8-15 or 15-20 mmHg range, (the less expensive option), help only those people with minor vein problems, such as aching legs from pregnancy or people in careers that have them on their feet a lot.

People with significant vein problems or suffer with edema (swelling) in the legs, will generally need at least 20-30 mm/Hg of compression to enjoy the true benefit of the stocking. If your doctor recommends firmer compression, you may be putting your health at risk if you try to skimp on cost by using a lighter compression than you need. If you need compression stockings in the 20-30 mm/Hg or higher range, expect to pay $60 – $75 or more per pair.

 

Frequency of visits for patients with compression stockings

 

The patients are advised to see the physician around once every 2-3 months. The decision to use a higher pressure is made by the physician in close consultation with the patient.

 

How much compression does the patient need ?

Generally, the lowest compression necessary to do the job is what the physician recommends. If there is only minimal swelling noted, one may use lesser compression (15-20mmHg).  If the patient wears a properly fitted stocking at 20-30 mmHg and notices that fluid accumulates during the day, then increasing the compression to the next level (30-40 mmHg) should be considered.

 

How do compression stockings work?

Compression stockings produce external pressure to help increase blood flow, so that there is no stagnation of blood that results from various varicose vein  conditions. Compression stockings tend to relieve aching and heavy feeling in legs, swelling in legs, preventing blood clots, especially after surgery or injury when you are less active. In the long term use, they decrease the risk of various thrombotic conditions by a huge percentage.

 

The pressure these stockings put on the legs helps blood vessels work better. The arteries that take oxygen-rich blood to the muscles can relax, so blood flows freely. The veins get a boost pushing blood back to the heart. They can also  help prevent and treat spider and varicose veins. They may even prevent feeling light-headed or dizzy when standing.

Because the blood keeps moving, it’s harder for it to pool in the veins and make a clot. If one happens to form and breaks free, it can travel with the blood and get stuck somewhere dangerous, such as in the lungs. Clots also are obstructive, reducing blood flow that can  cause swelling, discolored skin, and other problems.

Who Should Wear Compression Stockings

These vary from person to person. Some of the most prevalent symptoms or conditions that benefit from compression therapy are:

.       Pregnancy related swelling and vein problems

  •       Varicose or spider veins
  •       Lymphedema
  •       Swelling, pain or blood clots in the lower legs, DVT
  •       Poor circulation from sitting for long periods
  •       Post-surgical and post-sclerotherapy treatment

.  Patients who had with DVT and Post Thrombotic Syndrome (PTS).

 

Is there any age range that would find compression stockings more beneficial than others?

 

The stockings are equally beneficial to all ages, although older patients use them more often.  

Older patients can use it more because as you age the valves in the veins become less competent, so the older person would have more damage and swelling due to a blood clot than a younger person.

 

How does one find if the compression stockings are working correctly?

 

The best way is to make sure that the measurements are taken correctly. For knee high compression stockings, one must measure the circumference of the ankle, the circumference of the calf, the length of the calf. For thigh high compression stockings, one needs to measure the circumference of the ankle, circumference of the calf, circumference of the thigh and also the length of the legs.

 

Where do we take the measurements?

Measurements are obtained at the following places

 

  1. Ankle Measurement

Measurements taken around the ankle. A measuring tape is put at the narrowest part of the ankle, above the ankle bone.

  1. Calf Measurement

Measurement of the circumference of the calf taken at its widest part.

  1. Calf Length

The patient sits on a chair with legs at a 90-degree angle. The distance from the bend in the knee to the floor is taken.

If measurements are not taken correctly, the patient will not get the full benefit of the stockings.

 

Some tips for getting the stockings on

 

The patient should Make sure the skin is dry. Use rubber gloves to put the stockings on. Don’t bunch the stocking up.

Sometimes the patients can have skin breakdowns so not bunching them and using gloves are very useful in getting them on

 

Precautions that need to be followed for optimal effect of compression stockings

 

Every patient using compression stockings needs to follow some guidelines and precautions. Proper and adequate compression is of critical importance. Excessive compression can lead to edema and skin changes such as hyperpigmentation, stasis dermatitis, lipodermatosclerosis, or venous stasis ulcers. Inadequate compression will not produce the desired results. The pulse should be checked after wearing the stockings. Discoloration of skin or pain may occur if proper stockings are not used.

 

The patients are advised to put the stockings on as soon as possible in the morning when swelling is minimal and they will be easier to put on then.

 

Make sure once again that the patient does not have peripheral arterial disease.

What if the patient feels discomfort wearing stockings?

 

The patients, in general, dislike wearing them because of the discomfort they produce;    this often causes noncompliance. The comfort or discomfort depends upon what grade of the stocking the patient is wearing, and how experienced is the patient in wearing  stockings. As the patients wear stockings for a time, they get accustomed to it  and the discomfort may decrease.

 

How often should the compression stockings be replaced?

 

It is recommended that stockings be replaced every 6 months, so that the patient can always get adequate compression.

The decision is individualized for each patient.

Cons of using compression stockings

 

There are several challenges for patients wearing compression stockings. The compression stockings are rather costly. It is not comfortable walking while the stockings are on. They need to be replaced every 6 months. The patient who is wearing the stockings is susceptible to yeast infections, or can get blisters. It is often hot and moist while wearing them. Skin rashes may appear while wearing them. The cleaning process of the stockings could be annoying.

Discomfort to the patient and the patients who have PAD may have worsened blood flow.

 

The discomfort by the stockings causes more stress in doing normal day to day jobs. Some patients feel fine wearing them, but for most people, it has restricted movement in calf, it’s hot, and causes discomfort, so can cause more stress. We need to balance with the problems that come with not wearing them- pain, ulcers, and other wounds.

 

When the patients wears stockings, they may think that they do not need to take anticoagulants any more as the stockings are good enough. The patients should be warned that anticoagulants are used for prevention and treatment, and that the anticoagulants and stockings are not interchangeable; they must be used together, since they are both needed for treatment.

Difference between gradient compression and uniform compression  

 

Support garments are different than slimming garments in that they give the wearer gentle shaping, as well as support.  Another type of allover compression is the popular athletic compression, which gives an athlete extra stability and support.  The level of compression is the same throughout each garment and can include any type of garment, such as socks, pants, shirts, or sleeves.

Gradient or graduated compression is tightest at the ankle and the pressure decreases gradually as it moves up the garment.  Gradient compression helps to promote circulation, energize tired, achy legs and helps to prevent and reduce swelling.  All of Preggers legwear products are examples of graduated compression.  Graduated compression does offer the wearer support, which may be where the confusion lies between support hose and gradient compression. Just remember that not all support hose have gradient compression, but all gradient compression offers support. The longer the hose is used, the more likely you will have a gradient one.

 

Compliance of the patients wearing stockings

Unfortunately, compression stockings are often not worn because they are deemed unsightly or are uncomfortable. Patients should know that stockings come in various skin-tone and fashion colors, different shapes, sizes and materials, and from a variety of companies. It is worthwhile to make inquiries to find the right stocking that fits well, is relatively comfortable, and is acceptable in appearance. If stockings tend to roll down, you may want to choose a stocking that has a rubber strip at the upper end or wear a garter belt or compression pantyhose. Stockings should be worn during the day, while standing; stockings do not need to be worn at night. They should be worn for weeks, months, or for years, to control symptoms. For example, if swelling has disappeared a few weeks or months after the acute DVT with the use of the stockings, the patient may stop wearing the stocking. If swelling recurs, then the stocking should be worn again. If there is no more swelling, one might assume that stockings are not needed any more.

So-called “Anti Embolism Stockings” or “TED hose” are often given to patients who are hospitalized and have had surgery. They put mild pressure on the legs to prevent blood from clotting and can, to some degree, prevent blood clots in the legs (DVT). However, due to their low compression pressures they are not useful to prevent or treat the postthrombotic syndrome.

Are Anti Embolism stockings and Medical Compression Stockings interchangeable in terms of helping aid the condition the patient has?

When patients hear the terms TED hose (Thrombo-Embolic Deterrent) Hose, and compression stockings, they may think the two are interchangeable. They are in fact, two different types of compression garments for two different types of patients. In general, patients are prescribed one of the two for the treatment of various conditions, of which the most common are edema (fluid retention) and DVT (Deep Vein Thrombosis). Having the right compression garment for the right condition can not only expedite healing, but also help to keep the patient safe.

Any compression stocking will have some decrease in prevention but the medical compression stockings are more for treating PTS. Compression stockings are more for treatment.

How long should the patient wear compression stockings to improve  circulation?

If you’ve been prescribed compression stockings, you may need to wear them for several years and, in some cases, for the rest of your life. The best thing to do is to follow your doctor’s instructions.

Gradient intermediate level 20-30 mmHg is what most people would use because it’s more compression than just a little bit but not so much that its so discomforting to the patient and you can increase/decrease from there.

       Helpful Hints

  1. Wear your compression stockings when you are going to be sitting and/or standing for long periods of time (i.e. at work – sitting or standing). Put your stockings on as soon as you can in the morning when swelling is minimal and they will be easier to put on then.
  2. You do not need to wear your compression stockings when you go to bed or if you are going to be lying flat. Blood flow is optimized when you are lying down, so the stockings are not needed. The body needs a break from compression at some point and nighttime is the perfect time to take one.
  3. Wearing compression stockings may be damaging to your self-esteem, because unless you wear pants and closed-toe shoes, they are not easy to hide.

Be sure to follow the packaging instructions for washing your stockings. Contrary to what you may think, many types actually suggest machine washing and drying to extend the life of the stocking.

  1. Many medical supply stores offer additional products to assist you in getting compression stockings on, for example, if you are struggling or do not have a lot of strength to pull them up.
  2. Join a Patient Support Group of NATF (www.natfonline.org), or GTF (gtfonline.net). They are free, fun, and full of information.
  3. Remember, you are not alone IN this journey!

Summary and conclusions

First, the author’s impressions of the project. Nupur and I feel that we have achieved our goal in researching this complex topic of compression stockings. The research was not easy, but clearly gave us a peek at how to plan and conduct research.

Second, we hope that the readers will use this guide as a 101 for the use of compression stockings. The article should be a “one stop information guide” to the patients, instead of going from place to place to get information.

Acknowledgements

Rajath wants to thank Ms. Kathryn Mikkelsen, Executive Director at NATF for the continuous encouragement on this project.

Thanks to Michael McDaniel, MD from Emory University for agreeing to be interviewed by the authors and giving excellent suggestions throughout the research.

Thanks to Atul Laddu, MD, PhD for mentoring and guiding us at every step of the way us in this area.

@ An abridged version of this article was published in one of the recent issue of The Beat.

## This was a part of an interview with Michael McDaniel, MD from Emory University on February 18, 2017 at the 4th Anniversary event of GTF