Veins and Lymphatics 2018; volume 7:7636

Compression stockings after (VTE).5 It is recommended to offer below- deep vein : knee graduated compression stockings with Correspondence: Jan Schuren, Grotestraat 34, an ankle pressure greater than 23 mmHg to 6067 BR Linne, The Netherlands. Where is the evidence? patients with proximal DVT a week after E-mail: [email protected] diagnosis or when swelling is reduced suffi- Conflicts of interest: JS is a retired 3M Jan Schuren ciently and if there are no contraindications. employee and invented and co-developed the Retired from 3M Health Care, Neuss, Patients should be advised to continue 3M Coban 2 Layer compression systems and wearing the stockings for at least two years. Germany holds a master’s degree in evidence-based In 2015 the NICE guidelines are updated health care from the University of Oxford. and now it is recommended that elastic graduated compression stockings should Conference presentation: International Introduction not be offered to prevent post-thrombotic Compression Club (ICC) Meeting, Paris, syndrome or VTE recurrence after a proxi- 2017. This work is licensed under a Creative In 2014, the results were published of a mal DVT.6 Shortly after that, also the 2012 Commons Attribution 4.0 License (by-nc 4.0). randomised placebo-controlled trial to eval- US-guidelines are updated.7 For patients uate the effects of compression stockings with acute DVT of the leg, it is now sug- ©Copyright J. Schuren, 2018 after deep (DVT to pre- gested that compression stockings to pre- Licensee PAGEPress, Italy vent a post thrombotic syndrome (PTS). vent PTS should not be routinely used. In Veins and Lymphatics 2018; 7:7636 806 patients were randomly assigned. other countries, like Australia, New doi:10.4081/vl.2018.7636 Treatment allocation was masked from Zealand, Germany, France and the patients, health-care providers, study per- Netherlands, guidelines still recommend the sonnel and study statisticians. The outcome use of graduated compression stockings confirm these findings because of current 8-11 was clearly defined and the surveillance after DVT to prevent PTS. lack of high quality evidence and consider- was active and of clinically appropriate able heterogeneity.16 duration. The authors conclude that the Burgstaller et al. summarise their find- findings of this study do not support routine ings with the statement that there is evi- wearing of elastic compression stockings Compression stockings after dence favouring compression stockings, but after deep venous thrombosis. This study is 1 DVT to prevent PTS: systematic that there is also evidence showing no ben- generally referred to as the SOX-trial. efit of compression stockings.15 Shortly after its publication, this study was reviews and meta-analyses analysed and, on behalf of the German After the publication of the SOX-trial, Society of Phlebology, the authors state that five systematic reviews with meta-analyses wearing compression stockings after deep were published in which the SOX-trial was Discussion venous thrombosis of the leg is still advis- included.12-16 This high number of reviews 2 able. An expert opinion, based on many not only illustrates the increasing recogni- The conclusions of the presented years of experience and the result of two tion of PTS as a long-term complication of reviews are obvious; more research on com- systematic reviews and meta-analyses, DVT, it also demonstrates a clear need for pression to prevent PTS is needed. states that the long term use of compression evidence-based information on the best However, after the SOX-trial with over 800 stockings may reduce the incidence and treatment. In addition, the number of patients included, it can be questioned how 3 severity of a post-thrombotic syndrome. reviews demonstrates the confusion among realistic the expectation is that in the near This article reviews the literature and tries clinicians on this complication with a sig- future a similar large double-blinded ran- to answer the question: where is the evi- nificant impact on quality of life and major domised controlled trial will be executed dence? health economic implications. Baldwin et that fulfils all needs. In a journal editorial in al. state that up to half of the patients with the issue in which one of the mentioned proximal DVT will develop PTS despite reviews was published,15 Ten Cate-Hoek optimal anticoagulant therapy.17 Although states that, besides compression therapy, Compression stockings after much has been published to date, the more therapeutic options are needed for DVT to prevent PTS: Guidelines reviews of the recent literature are very uni- prevention and treatment of PTS. She sug- form in their conclusions. They can best be gests to take action and to assess the possi- In 2012 a paper was published in Chest, summarised with some of them, which are bilities ahead of us, instead of trying to the journal of the American College of listed below: i) the findings should be inter- solve the current conundrum around elastic Chest Physicians, in which evidence-based preted with caution and hence more large- compression therapy.18 For the time-being, clinical practice guidelines on antithrom- scale and well-designed RCT’s are still war- the only reasonable and unfortunately not 12 botic therapy and the prevention of throm- ranted; ii) the evidence is too weak to evidence-based direction lies in a quote 4 bosis are provided. The authors suggest the draw a reliable conclusion and further ran- from the Christian author Elisabeth Elliot- use of compression stockings in patients domised, double-blind, placebo-controlled Howard (1926-2015): don’t dig up in doubt with acute symptomatic DVT of the leg. In multicentre trials with larger sample size what you planted in faith. addition, it is suggested that compression are needed;13 iii) use of elastic compression stockings should be worn for two years and stockings does not significantly reduce the beyond that if patients have developed PTS development of post thrombotic syndrome, 14 and find the stockings helpful. Also in 2012, but more study is needed; iv) low-quality References the UK National Institute for Health and evidence suggests that elastic compression Care Excellence (NICE) published guide- stockings may reduce the occurrence of PTS 1. Kahn SR, Shapiro S, Wells PS, et al. for lines on venous thromboembolic diseases after DVT but large RCT’s are needed to the SOX trial investigators.

[Veins and Lymphatics 2018; 7:7636] [page 83] Conference Presentation

Compression stockings to prevent post- 7. Kearon C, Akl EA, Ornelas J, et al. botic syndrome: a systematic review thrombotic syndrome: a randomized Antithrombotic therapy for VTE dis- and meta-analysis. Vasc Endovasc Surg placebo-controlled trial. Lancet ease: CHEST Guidelines and expert 2016;50:328-34. 2014;379:31-8. panel report. Chest 2016;149:315-52. 14. Subbiah R, Aggarwal V, Zhao H, et al. 2. Schwahn-Schreiber C, Marshall M, 8. Australian and New Zealand Society for Effect of compression stockings on Wienert V, et al. Wearing compression Vasular Surgery. Guidelines deep post-thrombotic syndrome in patients stockings after deep venous thrombosis venous thrombosis; 2015. Available with : a meta- of the leg is still advisable: analysis of a from: www.anzsvs.org.au analysis of randomised controlled trials. publication in The Lancet, December 9. AWMF, Arbeitsgemeinschaft der Lancet Haematol 2016;3:293-300. 2013. Phlebologie 2014;43:144-7. Wissenschaftlichen Medizinischen 3. Partsch H. Compression and deep vein Fachgesellschaften e.V. S2-Leitlinie: 15. Burgstaller JM, Steurer J, Held U, thrombosis. Veins and Lymphatics Diagnostik und Therapie der Amann-Vesti B. Efficacy of compres- 2016;5:22-3. Venenthrombose und der sion stockings in preventing post- 4. Kearon C, Akl EA, Comerota AJ, et al. Lungenembolie. AWMF Leitlinien- thrombotic syndrome in patients with Antithrombotic therapy for VTE dis- Register Nr. 065/002; 2015. deep venous thrombosis: a systematic ease. Chest 2012;141:e419S-94S. 10. Haute Autorité de Santé (HAS). La review and metaanalysis. Vasa 5. National Institute for Health and Care compression médicale dans le traite- 2016;45:141-7. Excellence (NICE). Venous throm- ment de la maladie thrombo-embolique 16. Appelen D, van Loo E, Prins MH, et al. boembolic diseases: the management of veineuse; Décembre 2010. Compression therapy for prevention of venous thromboembolic diseases and 11. NHG-werkgroep diepe veneuze trom- post-thrombotic syndrome. Cochrane the role of thrombophilia testing. bose en longembolie. NHG Standaard: Database Syst Rev 2017;9:CD004174. Clinical guideline [CG144]: published diepe veneuze trombose en longem- 17. Baldwin MJ, Moore HM, June 2012. bolie. Huisarts Wet 2015;58:26-35. Rudarakanchana N, et al. Post-throm- 6. National Institute for Health and Care 12. Tie HT, Luo MZ, Luo MJ, et al. Excellence (NICE). Venous throm- Compression therapy in the prevention botic syndrome: a clinical review. J boembolic diseases: the management of of postthrombotic syndrome: a system- Thromb Haemost 2013;11:795-805. venous thromboembolic diseases and atic review and meta-analysis. 18. Ten Cate-Hoek A. Efficacy of compres- the role of thrombophilia testing. Medicine 2015;94:1-8. sion for the prevention of post-throm- Clinical guideline [CG144]: published 13. Jin YW, Ye H, Li FY, et al. Compression botic syndrome: an unsolved clinical June 2012, updated November 2015. stockings for prevention of postthrom- conundrum. Vasa 2016;45:85-6.

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