Compression Bulletin 40 special edition
Risks and Contraindications of Medical Compression Treatment – A Critical Reappraisal. An International Consensus Statement.
Risks and contraindications of medical compression treatment – A critical reappraisal. An international consensus statement.
Eberhard Rabe: Department of Dermatology, University of Bonn, Bonn, Germany
Hugo Partsch: Emeritus, Department of Dermatology, Medical University of Vienna, Vienna, Austria
Nick Morrison: Center for Vein Restoration, Mesa, AZ, USA
Mark Meissner: Department of Surgery, Harborview Medical Center, Seattle, WA, USA
Giovanni Mosti: Angiology Department, Clinica MD, Barbantini, Lucca, Italy
Christopher Lattimer: Josef Pflug Vascular Laboratory, West London Vascular and Interventional Centre, Ealing Hospital & Imperial College, London, UK
Patrick Carpentier: Centre de Recherche Universitaire de La Lechere, Equipe THEMAS, Universite Joseph Fourier, Grenoble, France
Sylvain Gaillard: SIGVARIS Management AG, Winterthur, Switzerland
Michael Jünger: Department of Dermatology, University of Greifswald, Greifswald, Germany
Tomasz Urbanek: Department of General Surgery, Vascular Surgery, Angiology and Phlebology, Medical University of Silesia, Katowice, Poland
Jürg Hafner: Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
Malay Patel: First Choice Vascular, Swastik Society, Ahmedabad, India
Stephanie Wu: Department of Podiatric Surgery & Applied Biomechanics, Rosalind, Franklin University of Medicine and Science, North Chicago, IL, USA
Joseph Caprini: Department of Vascular Surgery, The University of Chicago, Chicago, IL, USA
Fedor Lurie: Department of Vascular Surgery, University of Michigan, Ann Arbor, MI, USA
Tobias Hirsch: Practice for Internal Medicine and Vascular Diseases, Halle, Germany
Article open access link:
Medical compression (MC) therapy is used for non-invasive treatment of venous and lymphatic diseases. MC therapy-associated adverse events and contraindications have been reported, although some contraindications are theoretically based. This consensus statement reviews the available literature and provides recommendations on medical compression therapy risks and contraindications.
A systematic literature search of medical compression therapy publications reporting adverse events up until November 2017 was performed. Papers on intermittent pneumatic compression were excluded from the analysis. A consensus panel comprising 15 international experts critically reviewed the publications and consented recommendations.
62 publications reporting adverse events of medical compression therapy were identified. The consensus panel issued 21 recommendations on medical compression therapy contraindications and adverse risk mitigation, in addition to reviewing medical compression therapy use in borderline indications. The most frequently reported non-severe medical compression therapy-associated adverse events included skin irritation, discomfort and pain. Very rare but severe adverse events, including soft tissue and nerve injury were included.
This consensus statement summarises published medical compression therapy-associated adverse events and contraindications, and provides guidance on medical compression therapy. Severe medical compression therapy-associated events are very rarely encountered if compression is used correctly and contraindications are considered.
Flow diagram of the relevant literature
Initial search performed on PubMed (n=3419)
Refined search performed on Pubmed (n=2427)
(Reviews were not evaluated. Duplicates were removed.)
Included articles (n=89) based on the following criteria:
- Observational human studies
- Guidelines for compression use
- Use of compression stockings reported
Publications as evidence base for review and critical appraisal (n=62)
Primary search terms & cross-matching terms
Primary search term:
compression bandages, medical compression stockings, graduated elastic compression, adjustable compression, thrombo-prophylactic stockings, TPS
complications, adverse events, contraindications, side effects, risks
ABI, Ankle brachial index; ABPI, Ankle brachial pressure index; ACW, Adjustable compression wraps; CB, Compression bandages; CT, Compression therapy; DVT, Deep vein thrombosis; EPD, Erosive pustular dermatosis; IPC, Intermittent pneumatic compression; MC, Medical compression; MCS, Medical compression stockings; PAOD, Peripheral arterial occlusive disease; PU, Pulmonary embolism; RCT, Randomized controlled trial; SVT, Superficial vein thrombosis; TPS, Thromboprophylactic stockings; VLU, Venous leg ulcer.
Results: General statement
1 We recommend that every patient receiving compression therapy should be screened for conditions that increase the risk of complications, and every compression device should be checked for appropriate fit and application. Contraindications for compression treatment must be considered to limit the risk of side effects.
Results: Risks & complications of compression therapy
2 We recommend adequate skin care to prevent irritation in patients with sensitive skin.
Allergic skin reactions
3 To prevent allergic skin reactions due to compression devices, we suggest avoiding potentially allergenic substances and dyes in compression materials.
Discomfort & pain
4 In patients with discomfort and/or pain below compression garments, we recommend checking the correct indication pressure level, material, fitting or bandage techniques as well as the correct donning and doffing.
Forefoot edema / lymphedema
5 In patients with, or in those developing, forefoot or toe edema when wearing compression, we suggest considering forefoot and toe bandaging or forefoot and toe compression pieces in addition to leg compression with a foot piece.
Bacterial & fungal infections
6 In patients with bacterial or fungal infection beneath the compression device, we recommend considering treatment with topical antiseptics or topical anti-microbiological medication. In patients with systemic symptoms (fever, chills), erysipelas or cellulitis, we recommend that systemic treatment should be given. In other cases of systemic symptoms and severe local wound and tissue infection, the decision on further treatment, including also MC, should be individualized on the basis of the local and general patient condition evaluation.
7 If the compression application or material is suspected to contribute to the infection (e.g. lateral pressure on toes with interdigital maceration), we suggest a modification of compression.
Mechanical tissue & nerve damage
8 We suggest considering that, according to the Law of Laplace, the local pressure below the compression material may be higher than expected at bony and tendinous prominences such as above ankles, the tibia, the fibular head or above tendons such as the Achilles tendon, and to check those locations for skin lesions due to pressure.
9 To prevent tissue damage or necrosis and nerve damage in regions with a small radius, we suggest protecting these regions (tendons, nerves and bones) from inappropriate high pressure, particularly in patients with sensitive skin, by:
- Decreasing the local pressure by inserting soft padding material
- Using low overall pressure
- Taking appropriate circumference measurements so that the compression devices fit properly.
Soft tissue damage & necrosis
10 We suggest specific precaution (padding, special care of fit, low pressure) and close controls at the initial stages of compression therapy in patients with polyneuropathy and elderly patients with frail, atrophic skin (dermatoporosis).
11 We suggest considering that pressure-induced nerve damage may occur at specific points of the leg (e.g. fibular head) mainly in cases with excessive local compression pressure, e.g. due to ill-fitting MCS, TPS or CB. Numbness and nerve palsy may occur. We suggest preventing high or continuous local pressure in regions with a risk of nerve compression as well as correct sizing
and application of compression. Patients at higher risk for nerve damage (e.g. patients with diabetes, patients with neuropathy) should be treated with special caution to prevent nerve damage.
Peripheral arterial occlusive disease (PAOD)
12 We 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 MC therapy.
13 Severe PAOD (systolic ankle pressure <60mmHg, toe pressure <30mmHg) is a contraindication against compression therapy with MCS. In CB, the applied pressure and the elasticity of the material are important. This contraindication does not apply to IPC and to patients with non-critical leg ischaemia treated with inelastic material applied with low resting pressure.
14 In every patient with impaired perfusion of the lower limb (ABI >0.9), the clinical effect of the MCS on leg blood supply should be carefully monitored. If the situation is not recognized, there is a possibility of developing non-healing skin breaks even under low pressure MCS.
Bypass surgery or stenting
15 After bypass surgery with improved peripheral arterial pressures, MC treatment may be performed if there is no direct compression effect on the bypass itself. We suggest avoiding the compression of epifascial bypass conduits. As for all patients with chronic leg ischemia, the recommendations regarding the use of MC treatment should be followed (see recommendations 12-14).
16 Because of a tourniquet effect, improper compression can cause local SVT, especially in combination with prolonged sitting (long-haul flights). To prevent thromboembolic complications, we recommend avoiding a tourniquet effect and strangulation by inappropriate application of MCS, TPS and bandages.
17 We recommend against applying compression in severe cases of cardiac insufficiency (NYHA IV). We also suggest against routine applications of MCS in NYHA III cases. When needed, careful use of compression therapy in this patient group may be considered if there is a strict indication, with clinical and hemodynamic monitoring. In less severe cases, cautious increase of compression pressure only leads to very short phases of increased cardiac load and may lead to a substantial reduction of peripheral edema.
Results: Borderline indications
Deep & superficial vein thrombosis
18 We recommend considering that, in contrast to previous concepts, compression is not contraindicated in acute thrombotic events, but results in favourable clinical outcomes when applied with caution. In the hands of experts, proper compression leads to an immediate improvement of pain and edema.
Edema in different pathological conditions
19 In patients with heart failure, diabetes, mixed pathology CVI or lymphedema and/or PAOD and after arterial bypass surgery or stenting, the use of compression to treat edema is not a contraindication but must be carefully considered.
Inflammatory diseases & infections
20 We suggest additional compression in purpura due to leucocytoclastic vasculitis and in leg erysipelas or cellulitis, to reduce inflammation, pain and edema. In infectious inflammation, we suggest compression only in combination with antibacterial treatment.
21 Special precautions have to be taken if MC treatment is considered in patients with “borderline indications”. Treatment decisions should be taken on a case-by-case basis and under consideration of a careful benefit-risk assessment. In case of a favourable assessment, we suggest the use of low-pressure compression, the use of modified-compression strategies (compression materials) and the use of padding to reduce pressure peaks.
22 We recommend considering the following contraindications for sustained compression with TPS, ACW, MCS and elastic CB:
- In patients with severe PAOD with any of the following: ABPI
< 0.6; ankle pressure <60mmHg; toe pressure <30mmHg;
transcutaneous oxygen pressure <20mmHg.
- Suspected compression of an existing epifascial arterial bypass.
- Severe cardiac insufficiency (NYHA IV).
- Routine application of MC in NYHA III without strict indication,
and clinical and hemodynamic monitoring.
- Confirmed allergy to compression material.
- Severe diabetic neuropathy with sensory loss or microangiopathy with the risk of skin necrosis (this may not apply to inelastic compression exerting low levels of sustained compression pressure (modified compression).
Conclusion & comments of the editors
Compression therapy is a very effective treatment modality, frequently applied by staff members or patients without deeper insight or special skills, which increases the rate of side effects. Also, several reviews report compression therapy "contraindications" that are based on theoretical assumptions, but are rarely proven by clinical data.
Thanks to both an extensive literature review and to a broad selection of medical experts in the field of compression therapy who strongly contributed through their personal experience, our group was able to reduce the list of strict contraindications to only a few situations. We commented on risky conditions and how to avoid side effects. In addition, we defined some conditions, formerly being listed as contraindications, for which even beneficial effects have been reported, as "borderline indications", emphasizing that there are conditions in which proper compression therapy causes more benefit than harm (examples: edema reduction and increase of nutritional flow in diabetic feet, mixed arterial-venous ulcers, erysipelas). It is to the merit of our sponsor SIGVARIS GROUP that we succeeded in bringing together this outstanding faculty.
At this occasion we thank the sponsor and our faculty for their enthusiastic cooperation and hope that this consensus will be useful for everyone involved in compression therapy.
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