Risk and contraindication medical compression treatment
Dr. Tomasz Urbanek starts the speech by the general recommendation: "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."
Let's dig deeper in the rest of recommendations
suggests this specific precaution such as padding, special care of fit, low pressure and close control at the initial stages of compression therapy in patient with polyneuropathy and elderly patients with atrophic skin (dermatoporosis).
Skin, soft tissue and nerve damage are concerned especially in aged, malnourished or sun-damaged skin with subcutaneous fat.
Factors which should be taken into consideration:
- Law of Laplace
- Reduced ABPI contributes to the risk of tissue damage by compression
- Failure to maintain appropriate MCS position on leg
- Additional risk factors for tissue necrosis: severe PAOD and microangiopathy
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 also we suggest preventing continuous local pressure in regions with a risk of nerve compression as well as correct sizing and application.
Nerve damage: most of the injury is common in perineal nerve at the fibular head.
Causes of nerve damage:
- Incorrect size of medical compression stocking
- Slipping or rolling of MCS
- Sensory loss especially in patients with paraplegia (this patient requires periodic neurological assessment)
Peripheral arterial occlusive disease (PAOD) is a quite common disease especially in old patients, it is asymptomatic in many of them, high prevalence in diabetes, these patients will also have some limitations in mobilization and walking and of course many of them are obese
There are two main issues regarding this compression:
- Increased risk of local soft tissue damage and necrosis
- Increased risk of peripheral ischemia
We have the necrotic changes in the patient with critical ischemia on the fingers and the heel region, if the skin is previously damaged and if we have the ischemic leg there is possibility to have this skin injuries also in other areas of the of the extremity.
The prevalence of PAOD is from 3 to 10 percent of the adult population but significantly increases in the person's over 70 years. This population will really be the target of the treatment. The practical issue to some of the possibilities how to measure this at least ankle brachial index should be available in the patient when we have the doubts to use compression or not and remember about the patients with diabetes when incorrect ankle brachial index measurements can show you the value above 1.4 and this can be really ischemic extremity.
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.
Severe PAOD (systolic ankle pressure < 60mmHg, toe pressure < 30 mmHg) is a contraindication against compression therapy with MCS.
It corresponds to the ankle brachial index below 0.6 but talking about the contraindication to the medical compressions about these values but what about the patients with the value of uncle brachial index from 0.6 to 0.8, will reduce the level of compression anyway in this group of patients but if you have doubts what kind of compression can be applied there is the wonderful paper of Giovanni Mosti and the group showing and documenting that in this group of patients you can successfully use short stretch compression in it means inelastic bandage with modified reduced level of compression below 40 mmHg.
This contraindication does not apply to IPC and to patients with non-critical leg ischemia treated with inelastic material applied with low resting pressure. In Compression bandages, the applied pressure and the elasticity of the material are important.
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.
Leg swelling in the patients after arterial reconstruction (lower leg bypass procedure or local revascularization)
- Previous lymphatic and venous disorder
- Groin incision
- Lymphatic system injury
- Local hematoma and healing process
- Ischemia and re-perfusion
- Post-operative DVT
- Infected complication
The higher risk of bypassing occlusion by compression:
- If superficial bypass location is present
- If the very distal lower leg bypass anastomosis was performed
- If there is a possible tourniquet effect along the bypass course or in the anastomosis region
- If there is a direct very high-grade compression effect on the bypass and peripheral circulation.
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 epifascail bypass conduits. As for all patients with chronic leg ischemia, the recommendations regarding the use of MC treatment should be followed.
Common indications to wear medical compression:
- Deep vein thrombosis prevention and treatment
- Post thrombotic syndrome prevention and treatment
- Superficial venous thrombosis treatment
Contraindication for MC:
Due to tourniquet effect additional venous obstruction can be provoked by MCS or CB (Virchow’s triad).
Because of the tourniquet effect, improper compression can cause local SVT, especially in combination with prolonged sitting. To prevent thromboembolic complications, we recommend avoiding the tourniquet effect and strangulation by inappropriate application of MC, TPS and bandages.
We recommend considering the following contraindication for sustained compression with TPS, ACW, MCS and elastic CB: Severe PAOD, epifacial arterial bypass, presence of confirmed allergy but this is also perhaps not absolute but should be taken into consideration, severe diabetic neuropathy with sensory losses or microangiopathy with the risk of skin necrosis and the next though severe cardiac insufficiency will be discussed.