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Meta-Analysis
. 2018 Nov 3;11(11):CD001484.
doi: 10.1002/14651858.CD001484.pub4.

Graduated compression stockings for prevention of deep vein thrombosis

Ashwin Sachdeva  1 , Mark Dalton, Timothy Lees
Affiliations
Meta-Analysis

Graduated compression stockings for prevention of deep vein thrombosis

Ashwin Sachdeva et al. Cochrane Database Syst Rev. .

Abstract

Background: Hospitalised patients are at increased risk of developing deep vein thrombosis (DVT) in the lower limb and pelvic veins, on a background of prolonged immobilisation associated with their medical or surgical illness. Patients with DVT are at increased risk of developing a pulmonary embolism (PE). The use of graduated compression stockings (GCS) in hospitalised patients has been proposed to decrease the risk of DVT. This is an update of a Cochrane Review first published in 2000, and last updated in 2014.

Objectives: To evaluate the effectiveness and safety of graduated compression stockings in preventing deep vein thrombosis in various groups of hospitalised patients.

Search methods: For this review the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), and trials registries on 21 March 2017; and the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE Ovid, Embase Ovid, CINAHL Ebsco, AMED Ovid , and trials registries on 12 June 2018.

Selection criteria: Randomised controlled trials (RCTs) involving GCS alone, or GCS used on a background of any other DVT prophylactic method. We combined results from both of these groups of trials.

Data collection and analysis: Two review authors (AS, MD) assessed potentially eligible trials for inclusion. One review author (AS) extracted the data, which a second review author (MD) cross-checked and authenticated. Two review authors (AS, MD) assessed the methodological quality of trials with the Cochrane 'Risk of bias' tool. Any disagreements were resolved by discussion with the senior review author (TL). For dichotomous outcomes, we calculated the Peto odds ratio and corresponding 95% confidence interval. We pooled data using a fixed-effect model. We used the GRADE system to evaluate the overall quality of the evidence supporting the outcomes assessed in this review.

Main results: We included 20 RCTs involving a total of 1681 individual participants and 1172 individual legs (2853 analytic units). Of these 20 trials, 10 included patients undergoing general surgery; six included patients undergoing orthopaedic surgery; three individual trials included patients undergoing neurosurgery, cardiac surgery, and gynaecological surgery, respectively; and only one trial included medical patients. Graduated compression stockings were applied on the day before surgery or on the day of surgery and were worn up until discharge or until the participants were fully mobile. In the majority of the included studies DVT was identified by the radioactive I125 uptake test. Duration of follow-up ranged from seven to 14 days. The included studies were at an overall low risk of bias.We were able to pool the data from 20 studies reporting the incidence of DVT. In the GCS group, 134 of 1445 units developed DVT (9%) in comparison to the control group (without GCS), in which 290 of 1408 units developed DVT (21%). The Peto odds ratio (OR) was 0.35 (95% confidence interval (CI) 0.28 to 0.43; 20 studies; 2853 units; high-quality evidence), showing an overall effect favouring treatment with GCS (P < 0.001).Based on results from eight included studies, the incidence of proximal DVT was 7 of 517 (1%) units in the GCS group and 28 of 518 (5%) units in the control group. The Peto OR was 0.26 (95% CI 0.13 to 0.53; 8 studies; 1035 units; moderate-quality evidence) with an overall effect favouring treatment with GCS (P < 0.001). Combining results from five studies, all based on surgical patients, the incidence of PE was 5 of 283 (2%) participants in the GCS group and 14 of 286 (5%) in the control group. The Peto OR was 0.38 (95% CI 0.15 to 0.96; 5 studies; 569 participants; low-quality evidence) with an overall effect favouring treatment with GCS (P = 0.04). We downgraded the quality of the evidence for proximal DVT and PE due to low event rate (imprecision) and lack of routine screening for PE (inconsistency).We carried out subgroup analysis by speciality (surgical or medical patients). Combining results from 19 trials focusing on surgical patients, 134 of 1365 (9.8%) units developed DVT in the GCS group compared to 282 of 1328 (21.2%) units in the control group. The Peto OR was 0.35 (95% CI 0.28 to 0.44; high-quality evidence), with an overall effect favouring treatment with GCS (P < 0.001). Based on results from seven included studies, the incidence of proximal DVT was 7 of 437 units (1.6%) in the GCS group and 28 of 438 (6.4%) in the control group. The Peto OR was 0.26 (95% CI 0.13 to 0.53; 875 units; moderate-quality evidence) with an overall effect favouring treatment with GCS (P < 0.001). We downgraded the evidence for proximal DVT due to low event rate (imprecision).Based on the results from one trial focusing on medical patients admitted following acute myocardial infarction, 0 of 80 (0%) legs developed DVT in the GCS group and 8 of 80 (10%) legs developed DVT in the control group. The Peto OR was 0.12 (95% CI 0.03 to 0.51; low-quality evidence) with an overall effect favouring treatment with GCS (P = 0.004). None of the medical patients in either group developed a proximal DVT, and the incidence of PE was not reported.Limited data were available to accurately assess the incidence of adverse effects and complications with the use of GCS as these were not routinely quantitatively reported in the included studies.

Authors' conclusions: There is high-quality evidence that GCS are effective in reducing the risk of DVT in hospitalised patients who have undergone general and orthopaedic surgery, with or without other methods of background thromboprophylaxis, where clinically appropriate. There is moderate-quality evidence that GCS probably reduce the risk of proximal DVT, and low-quality evidence that GCS may reduce the risk of PE. However, there remains a paucity of evidence to assess the effectiveness of GCS in diminishing the risk of DVT in medical patients.

PubMed Disclaimer

Conflict of interest statement

AS: has declared that travel and accommodation expenses were covered by the conference organisers to present the findings of the 2014 version of this review at the 21st European Vascular Course in Maastricht. He has also previously received funding from the following organisations for an unrelated project: National Institute for Health Research, Cancer Research UK, The Urology Foundation, Rosetrees Trust, and JGW Patterson Foundation.

MD: none known

TL: has declared that he is entitled to royalties from Venous Disease Simplified, which are donated to charity. He receives expenses for travel between places of work as part of his normal job and has no known conflicts of interest.

Figures

1
1
Study flow diagram.
2
2
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
3
3
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
4
4
Funnel plot of comparison: Incidence of DVT with stockings and without stockings (all specialties).
5
5
Number of analytic units from each specialty included in the meta‐analysis.
6
6
Funnel plot of comparison: Incidence of proximal DVT with stockings and without stockings (all specialties).
7
7
Funnel plot of comparison: Incidence of PE with stockings and without stockings (all specialties).
1.1
1.1. Analysis
Comparison 1 Incidence of DVT with stockings and without stockings, Outcome 1 All specialties.
1.2
1.2. Analysis
Comparison 1 Incidence of DVT with stockings and without stockings, Outcome 2 All specialties ‐ surgical vs medical.
2.1
2.1. Analysis
Comparison 2 Incidence of proximal DVT with stockings and without stockings, Outcome 1 All specialties.
2.2
2.2. Analysis
Comparison 2 Incidence of proximal DVT with stockings and without stockings, Outcome 2 All specialties ‐ surgical vs medical.
3.1
3.1. Analysis
Comparison 3 Incidence of PE with stockings and without stockings, Outcome 1 All specialties.
3.2
3.2. Analysis
Comparison 3 Incidence of PE with stockings and without stockings, Outcome 2 All specialties ‐ surgical vs medical.
4.1
4.1. Analysis
Comparison 4 Sensitivity analysis, Outcome 1 Method of randomisation.
4.2
4.2. Analysis
Comparison 4 Sensitivity analysis, Outcome 2 Unit of analysis for randomisation.
4.3
4.3. Analysis
Comparison 4 Sensitivity analysis, Outcome 3 Use of background method of thromboprophylaxis.
4.4
4.4. Analysis
Comparison 4 Sensitivity analysis, Outcome 4 Method of diagnosis.
See this image and copyright information in PMC

Update of

Comment in

References

References to studies included in this review

Allan 1983 {published data only}
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Ayhan 2013 {published data only}
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Silbersack 2004 {published data only}
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Sobieraj‐Teague 2012 {published data only}
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References to studies awaiting assessment

Celebi 2001 {published data only}
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References to ongoing studies

ChiCTR1800014257 {published data only}
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GAPS {published data only}
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References to other published versions of this review

Amaragiri 2000
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