Tailored, shorter wear of compression socks as good as longer wear for DVT
Tailored therapy duration with elastic compression stockings based on a patient’s signs and symptoms was noninferior to the standard therapy duration of 24 months in preventing post-thrombotic syndrome (PTS), according to the IDEAL-DVT* study.
“Elastic compression stockings are commonly viewed as unattractive and uncomfortable … Individualized shortening of the duration of therapy based on the original Villalta scoring method is an effective and safe strategy that might be less demanding for patients … potentially enhancing patients’ wellbeing,” according to the researchers.
The multicentre, single-blind trial enrolled 865 patients with acute proximal deep vein thrombosis (DVT) of the leg without pre-existent venous insufficiency (CEAP** score <C3). They were randomized 1:1 to receive individualized duration of compression therapy (based on symptoms scored on the Villalta scale) or a standard 24-month therapy duration after an initial 6-month treatment with 30–40 mm Hg elastic compression stockings daily. [Lancet Haematol 2018;5:e25-33]
At 24 months, PTS occurred in similar proportion of patients in the individualized vs the standard duration group (29 percent vs 28 percent; odds ratio [OR], 1.06, 95 percent confidence interval [CI], 0.78–1.44), according to the original Villalta scoring. The absolute difference between groups was 1.1 percent, which met the predefined noninferiority margin of 7.5 percent.
Similar findings were seen when PTS was assessed according to ISTH*** scoring (51 percent vs 45 percent, OR, 1.24, 95 percent CI, 0.94–1.64).
Recurrent venous thromboembolic episodes were also similar between both groups (5 percent vs 6 percent for DVT and 3 percent vs 2 percent for pulmonary embolism).
There were no serious adverse events related to the intervention.
“We found that it is possible to select patients based on their Villalta score to stop treatment as early as 6 months without increasing the incidence of PTS at 24 months,” said the researchers.
During the study, patients in the individualized therapy group were advised to stop wearing the stockings when they achieved two consecutive Villalta scores of ≤4 assessed in follow-up visits. Sixty-six percent of the patients could stop wearing the stockings before 24 months, with 55 percent being able to stop at as early as 6 months and an additional 11 percent stopping at 12 months.
Nonetheless, a post hoc analysis using ISTH scoring revealed a higher PTS incidence among early stoppers in the individualized group compared with patients in the standard group (36 percent vs 22 percent, relative risk, 1.6; number-needed-to-treat, 7), although the between-group difference was not significant when using the original scoring method.
“[What this means] could be that compression after around 6 or 12 months benefits mainly patients with mild PTS caused by oedema,” said the researchers.
“Whether it is cost-effective in the long run to provide such patients with elastic compression stockings and thus prevent further damage due to venous hypertension, or whether PTS in these patients is so mild that therapy may be forgone, should be assessed by a formal cost-effectiveness analysis to estimate the long-term costs and effects of this strategy,” they added.
The researchers believed that compression in the subacute phase could be more effective for PTS prevention than later-stage compression, as compression can prevent drastic increase in venous pressure resulting from thrombus obstruction and restore venous flow, which may help thrombus resolution and reduce PTS.