Routine Stocking Therapy after Deep Venous Thrombosis: A Clinical Dilemma

The post-thrombotic syndrome is one of the most common and frustrating chronic conditions that physicians encounter. Its clinical presentation varies from mild, painless edema of the leg to painful, incapacitating swelling of the affected limb with or without ulceration. Heit and colleagues (1) recently estimated that the post-thrombotic syndrome and venous ulcers have an annual health care cost of at least $200 million in the United States. Properly fitted graduated compression stockings, which exert pressure that is maximal in the distal calf and decreases in the more proximal part of the leg, have long been the cornerstone of management of affected patients. However, for a variety of reasons, convincing evidence of the efficacy of these stockings in preventing the post-thrombotic syndrome and relieving symptoms in patients with established cases of the disorder is lacking. Few properly designed studies of this issue have been performed, and furthermore, experts have not agreed on an accepted definition of the post-thrombotic syndrome. In addition, until recently, a validated quality-of-life questionnaire that could be used to evaluate the efficacy of therapy over time was unavailable (2). Consequently, although most of us who see patients with the post-thrombotic syndrome believe that stockings have benefit, the proportion of patients who respond and the magnitude of the benefit remain unclear.

Patients with acute venous thrombosis have pain and swelling of the affected extremity caused by a combination of venous outflow obstruction and inflammation. With appropriate antithrombotic therapy, the outflow obstruction usually begins to improve within 2 to 12 weeks by a combination of recanalization (partial or complete) and flow through …