Risks and contraindications of medical compression treatment
Felizitas PANNIER, MD2
1Private practice, Helmholtzstr. 4, Bonn, Germany
2Private practice, Helmholtzstr. 4, Bonn,
Germany and Department of
Dermatology, University of Cologne, Germany
Medical compression treatment with medical compression stockings (MCS), compression bandages (CB), or intermittent pneumatic compression (IPC) belongs to the basic treatment options in acute and chronic venous diseases and in lymphedema. In a recent international consensus paper, well-known experts in the field reviewed the recent literature on reported risks and recommended contraindications for elastic compression treatment. Results: Reported nonsevere adverse events (AEs) included skin irritation, allergic skin reaction, discomfort and pain, forefoot edema and lymphedema, and bacterial or fungal infections. Only skin irritations and discomfort and pain were reported commonly with an incidence between 1% and 10%. All reported severe AEs such as soft tissue damage and necrosis, nerve damage, arterial impairment, venous thromboembolism, and cardiac decompensation were reported very rarely with an incidence below 0.01%. The contraindications for compression treatment are: severe peripheral arterial occlusive disease (PAOD) with ankle brachial pressure index (ABPI) <0.6, ankle pressure <60 mm Hg, toe pressure <30 mm Hg, or transcutaneous oxygen pressure < 20 mm Hg; suspected compression of an existing epifascial arterial bypass; severe cardiac insufficiency (New York Heart Association [NYHA] class IV); routine application of MC in NYHA III without strict indication, and clinical and hemodynamic monitoring; confirmed allergy to compression material; and severe diabetic neuropathy with sensory loss or microangiopathy with the risk of skin necrosis. Conclusions: Compression treatment is a standard treatment in venous and lymphatic diseases. Most of the published AEs are caused by incorrect indication or application of the compression material. The contraindications must be respected to avoid severe complications.
Medical compression treatment by medical compression stockings (MCS), compression bandages (CB), or intermittent pneumatic compression (IPC) is a basic treatment option in acute and chronic venous diseases and in lymphedema.1 However, despite widespread acceptance in patients, there are conflicting reports in the literature about risks and contraindications. In a recent international consensus paper, well-known experts in the field reviewed the recent literature on reported risks and recommended contraindications for elastic compression treatment.2
The experts identified 62 publications reporting adverse events (AEs) of medical compression treatment in PubMed.2 The reported risks were critically reevaluated, and recommendations were given on how to prevent and manage AEs.
Nonsevere reported AEs included skin irritation, allergic skin reaction, discomfort and pain, forefoot edema and lymphedema, and bacterial or fungal infections (Table I). Only skin irritations and discomfort and pain were reported commonly with an incidence between 1% and 10%.3,4 All reported severe AEs such as soft tissue damage and necrosis, nerve damage, arterial impairment, venous thromboembolism, and cardiac decompensation were reported very rarely with an incidence below 0.01%.
To prevent itching or dry skin below compression garments, adequate skin care in sensitive patients was recommended.2 Discomfort and pain may be due to inadequate fit and application of compression devices or incorrect indication. Inflammatory skin reactions may be due to occlusive effects and dry skin below compression material. Real allergic reactions to compression material are very rare as modern devices no longer contain allergizing colors but may still be caused by rubber-based materials.5,6
In rare cases, forefoot edema has been described after compression. In those patients with a tendency to foot edema or in lymphedema patients, adequate compression of this region is required. This may include specific foot or toe compression parts.
Bacterial or fungal colonization of the skin may be present in patients with venous ulcers, lymphedema, or other skin diseases in which compression is indicated. Occlusive effects between the toes, promoting fungal infection, may be avoided by toe-free compression devices.7 Erosive pustular dermatosis (EPD) has been described as a rare event below long-term, permanent compression with four-layer bandages.8 In at-risk patients, long-term permanent compression should be avoided. Consideration of topical antiseptics is recommended if local infection beneath compression occurs, and systemic antimicrobiologic treatment is recommended for systemic symptoms.2
More-severe complications of compression treatment are mechanical tissue and nerve damage, which have been described in rare cases below compression bandages, stockings, and for intermittent pneumatic compression.9-26 According to the Law of Laplace, areas with a smaller radius are subject to higher pressure beneath compression material.27 On the leg, this appears in the ankle region, in the lateral aspect of the foot, and above other bony or tendinous prominences such as the tibia head and the Achilles tendon.2 Local pressure that is too high may cause tissue necrosis and ulceration or nerve damage in regions where the nerve is compressed, such as the fibular head. Additional risk factors are reduced ankle brachial pressure index (ABPI), sensory loss as in diabetic neuropathy, frail skin, or strangulation by wrongly applied compression material. To prevent tissue damage or necrosis and nerve damage in regions with a small radius, the authors of the consensus suggest protecting these regions from inappropriately high pressure, particularly in sensitive patients, via decreasing the local pressure by inserting soft padding material, by using low overall pressure, and by taking appropriate circumference measurements so that the compression devices fit properly.2 As peripheral arterial occlusive disease (PAOD) is a risk factor for tissue necrosis below compression, ankle pressure and ABPI or toe pressure should be measured and calculated before compression treatment is initiated. The authors recommend checking the arterial circulation status before any kind of compression therapy is initiated. If foot pulse and/or ankle pulse is weak or not palpable, ABPI should be measured and calculated prior to initiating medical compression (MC) therapy.2 In severe PAOD, sustained compression is contraindicated if the systolic ankle pressure is <60 mm Hg or the toe pressure is <30 mm Hg.2
After bypass surgery with improved peripheral arterial pressure, compression may be indicated if edema is present. In most of the cases, there is no direct compression effect on the bypass itself. However, it is recommended to avoid external compression in epifascial bypasses.2
Previously, it was discussed that compression may not be indicated in acute deep venous thrombosis (DVT). Today, there is a clear recommendation for early compression in acute DVT as part of the standard therapy.28-30 A tourniquet effect on varicose veins should be avoided as it may cause superficial venous thrombosis, as Scurr has shown in prolonged sitting on long-haul flights.31
In recent guidelines, compression is contraindicated in decompensated cardiac insufficiency.32 According to the published data, cardiac insufficiency per se does not constitute a contraindication for compression therapy today.2 In the disease stages New York Heart Association (NYHA) I and II, appropriate compression is possible.2 In the disease stages NYHA III and IV, careful use of compression therapy is possible to a limited extent if there is a strict indication and clinical and hemodynamic monitoring.2
In former times, compression was contraindicated in several situations that are today considered good indications. Among these are deep and superficial vein thrombosis, and different kinds of edema and inflammatory diseases and infections.2
DVT and SVT
The avoidance of compression in DVT or SVT appears to be based only on the fear that compression might promote the dislodgment of clots and cause pulmonary embolism (PE).2 This theory is not supported by published data.28,29 In a study comparing patients with acute DVT treated with either low-molecular-weight heparin (LMWH) plus compression and walking or LMWH plus bed rest, new PEs occurred in less than 7.4% in both groups.33
Compression treatment is effective in the treatment of edema caused by different reasons.
In patients with venous or lymphatic edema and compensated heart failure (NYHA I or II), compression is not contraindicated but should start at the lower legs before being extended to the thigh.2,34 In patients with venous leg ulcers and/or venous or lymphatic edema and PAOD, the ABPI must be measured. An ABPI below 0.6 is a contraindication, but in less severe cases, compression therapy may be beneficial for ulcer healing and edema reduction.2
Edema after bypass graft surgery and post-reconstructive edema after arterial revascularization are both improved with mild compression for edema reduction.35-39
Inflammatory diseases and infections
Compression used to be contraindicated in acute infections of the skin because compression may facilitate bacteria transfer into the circulation. However, compression can reduce inflammatory reactions of the skin and thus have a beneficial effect in addition to standard antibiotic or anti-inflammatory treatment.40 In several centers, compression is used routinely in the management of erysipelas and vasculitis.41-43 Recently, a retrospective study by Eder et al showed that compression is not contraindicated in acute leg erysipelas.44 Compression is also able to prevent recurrent cellulitis in edema patients.45,46 Compression is widely used in vasculitis of the skin, but prospective comparative studies are missing.47
Table II lists recommended contraindications for elastic compression garments based on the available literature.2
Prospective randomized studies investigating for AEs in compression treatment are rare or nonexistent. Most of the data we have comes from occasionally reported single AE cases. Most of these AEs are due to incorrect indication, application, or use of compression material. Another reason is the disregard of contraindications, such as severe PAOD. Main contraindications are severe PAOD, severe cardiac insufficiency, and severe diabetic neuropathy and microangiopathy. In addition to the described contraindications and risks of compression treatment, a limitation of the method is patient adherence to compression. Even in strong indications, such as venous leg ulcers, complete adherence to compression was described to be as low as 40%.48
If contraindications are respected and correct indications, application, and use is guaranteed, treatment with elastic compression is safe and effective in venous and lymphatic diseases.
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