Minor Project

Background of Deep Vein Thrombosis

Deep vein thrombosis is one of the main causes of morbidity in the population. it is, however, a preventable condition. The number of deaths that are reported from Deep vein thrombosis is usually the one that goes undetected in the initial stages of manifestations.

The manifestation of this condition in an individual mainly begins with the development of, a single clot or multiple clots in the deep veins of the extremities. Rarely the clot is formed in the pelvis region. These sites are the most common sites for inflammation to take place (Watson, 2016). Due to prolonged inflammation or severe inflammation in these areas, there is a reduced or hampered blood flow to the structure. This reduced circulation leads to the development of a clot in the affected region. However, there have been certain incidences where there was no presence of swelling in the extremity still the musculature tends to develop a clot. The patient might not be experiencing any pain or limitation of movement and still develop deep vein thrombosis. Multiple risk factors contribute to the formation of deep vein thrombosis in an individual. These risk factors are inclusive of prolonged immobility, major surgeries, dehydration for prolonged hours, personal habits such as smoking and drinking and so on. Some of the other risk factors and complications are inclusive of patient developing pulmonary embolism (Di Nisio, 2016). This mainly manifests in patients due to the development of deep vein thrombosis in the lower extremity of the patient.

Another complication associated with people having deep vein thrombosis is the development of post-thrombotic syndrome (PTS) (Hemmati, 2020). It is another complication that might manifest in patients due to the chronic presence of deep vein thrombosis. In this syndrome, the patient might be having a clinical presentation of erythema, swelling, pain and even reduced mobility due to severe pain barrier. However, the condition is considered severe, the same can be treated conservatively as well. The use of compression stockings is found to be effective in maintaining the condition and even resolving the blood clot that might be hampering with the daily activity of the individual.

Compression therapy or compression modalities are one of the most common and primary choices of treatment for deep vein thrombosis. These are an effective method of preventing the development of deep vein thrombosis in the patient. Graduated or compartment stockings are also used to promote adequate blood flow in the deep veins of the lower extremities (Appelen, 2017). This helps in the prevention of blood clotting and also provides the extremity with a gradient through which smooth blood circulation can be promoted. It helps in relieving the pressure on the affected extremity. It also helps in promoting backflow of the blood and thus, helps in promoting and enhancing blood circulation in the extremities. These support stockings are applied as per the affected veins in the extremity. The stocking is ideally provided to support till the knee length or up to the upper end of the thing, depending upon the severity of the condition of the patient. However, the tourniquet used in the pressure stockings is bound to leave certain marks in the skin. In few cases, especially requiring prolonged use of pressure stockings the tourniquet is bound to leave marks on the skin and sometimes disturbing the skin integrity as well. Some patients might also get allergic reactions by the application of the same, due to excessive sweating or due to skin irritation. Despite all of these limitations, compressions stockings are the best feasible option to help in the treatment of deep vein thrombosis and prevention of the same.

Objectives of Compression Stockings

The main objective of this review is to evaluate the effectiveness of the compression stocking in the treatment and prevention of deep vein thrombosis. This is also crucial from reducing the rate of hospitalization of the patients suffering from the deep vein thrombosis.

Review question

Are compression stockings effective enough to manage DVT and post-thrombotic syndrome?

Criteria for Considering Studies for This Review

Types of studies

For analysis of this topic, systemic review studies will be taken into consideration. This review was conducted by taking into consideration the systemic review based on concluding the effectiveness of pressure stocking for the treatment of deep vein thrombosis. The main studies were based on the patients present in hospital settings. The patients who were considered for analysis were all having a set diagnosis of deep vein thrombosis. The patients were also provided with pressure stockings for the treatment purpose.

Types of participants

The patients that were considered for this review purpose included both males and females patients. The patients were also high-risk patients having several other complications such as cardiac, renal and so and also having personal histories such as smoking and alcoholism. The patients that underwent surgical correction for deep vein thrombosis were also taken into consideration for the review purpose.

Type of interventions

The main intervention taken into due consideration was compression stocking to help in preventing deep vein thrombosis as well as post-thrombotic syndrome. Studies that highlighted the positive impact of the use of pressure stockings in the treatment of deep vein thrombosis were dully reviewed and included in the analysis. The studies that included medication as the main treatment modality were excluded for review.

Types of outcomes

The main primary outcomes were based on the patient having an incidence of deep vein thrombosis and post-thrombosis syndrome. The secondary outcome in this review was based on the patient’s adherence to the pressure stockings prescribed to them for treatment purpose. The review also took into consideration the complications of deep vein thrombosis that might arise from the prolonged use of pressure stockings.

Search strategy

The search strategy was mainly divided into various steps. These steps were based on searching for the results from three different databases that were taken into due consideration. The articles from the last 7years were selected. The articles that fulfilled all of the criteria of the review, were only taken the one after 2013 and onwards. The databases were searched based on a few keywords. These databases were CINAHL, MEDLINE and Cochrane Library (Budhram, 2018). These articles were screened in detail to examine their fulfilling of every criterion. The articles were initially scanned based on abstract and titles of the study. The articles that included social media content, newspaper articles and duplicate results were removed from the data collection to be examined. The full-text articles were only separated and those reviews meeting all of the criteria were taken into final consideration to be analysed. Initially, a total of 600 articles were collected. After looking up for all of the criteria the articles that didn’t comply with the consideration were removed from the final database to be reviewed.

After due examination, a total of 7 review articles were finally evaluated. Papers were not excluded after the quality assessment of the paper, because none of the studies included in the analysis that was weak in methodology (AMSTAR>5). Total of seven articles was included and all of them were based on evaluating the effectiveness of the compression stockings in preventing advancement and treatment of deep vein thrombosis as well as managing the patient in post-discharge settings after being hospitalized with the same diagnosis.

Method of The Review

Assessment of Methodological Quality

For the review, the total number of 7 studies were considered. The quality of these articles was also analyzed with the help of Multiple Systematic Reviews (AMSTAR) tool (Burda, 2016). This questionnaire was mainly made up of 11 important questions helping in examining the reliability and validity of these review articles. Each question is to answer with the help of “yes”, “no”, “Can’t answer” and “not applicable”. The scale also has a final score of 11 and the quality of systemic review of these articles was based on the measurement of three main grades. High quality (8-11), medium quality (5-7) and low quality (0-4). The total score of the analysis was supposed to lie between the score of 5-10. Any scoring of AMSTAR scale having a score of 5 or above was considered to have good quality and all of the studies taken into consideration for this review had a good quality as examined by this scale.

Data extraction

The data was mainly extracted from the summary of these articles. The collected data was input in the data collection forms. These data had the details of the population of the patient, interventions, methods used to conduct the study and the outcomes derived in accordance with the same. The various parameters that were included in the review were the age of the patient, sex of the patient, the severity of the DVT in the patient, type and length of stockings used, duration of the pressure stocking worn by the patients.

Data synthesis

The details of the data synthesis are included in the Appendix section under section-C.

Review results

Description of study

All of the seven studies were retrieved through the authentic process of selection and was duly followed in the step-wise protocol. The tool of AMSTAR was used to check the quality and all of the articles were having a quality index of 6 scores or above (Pollock, 2017). The tool also helped in reflecting as to how some of the parameters were reported less in comparison to another. It helped highlight the shortcomings of these studies which were not a part of the study inclusion criteria.

Graduated compression stocking

The studies included the patients being provided with the intervention of the pressure stockings for managing DVT. The duration and the length of the pressure stocking were also duly noted and considered for the review purpose. Few of the studies compared the patients having intervention management in comparison to the patient having no treatment intervention at all. The patients having the intervention of pressure stocking were found to be having positive results.

Applications of the stockings to the patient

The study also included the application of pressure stockings in the patient in terms of applying correctly. The main consideration was given to the application of the stockings in a correct manner post-discharge. Most of the patients in the studies were wearing stockings with due diligent after being discharged from healthcare settings. Some of the studies also reviewed the complications that were caused due to prolonged use of gradient stocking.

Discussion on Effectiveness of Compression Stockings

Summary of findings

The main aim of the review was to identify for the apt number of systemic reviews that can help review the application of pressure stockings in patients having DVT so that better intervention and treatment plans can be executed for the patients. The review studies were inclusive of criteria like the application of stockings, length of application and duration of application of stockings and so on. Few of the studies, however, reflected upon the severity of the condition and most of them reflected upon improved health care outcomes post-application of the same.

Quality of evidence

The review articles were examined with the help of the AMSTAR tool which provides an insight into the quality of the article. As most of the reviews taken into consideration had a score of 6 and above, the quality factor of the review was up to mark. The data were synthesized with the help of best available evidence and support material.

Potential biases of review

The exclusion of the data was mainly done based on study selection method and quality of the review article. The studies that did not meet the set criteria were dully excluded from the analysis purpose. Only articles after the year of 2013 were taken into consideration. As the criteria of selection were very limited, there is a possible chance of bias in the data collection and review method.

Changes in the project

Main changes were made in the title of the review articles to comply with the inclusion criteria of the review analysis. Since exact articles related to the topic were not that vastly available, the project was concluded with various changes. The criteria of PTS were also included to examine the detailed results and analyze the effectiveness in congruence with the same. Only articles, having full-text were taken so that the data of the research studies selected could be compared with each other, based on statistical data as well.

Conclusion on Effectiveness of Compression Stockings

The study was able to provide and insight into the various intervention that can be provided to the patient in promoting the effectiveness of pressure stocking as a part of the treatment protocol. The parameters that were taken into consideration were also apt for the study purpose. These implementation techniques can be helpful for both the patient as well as healthcare professionals in enhancing the impact of the use of this intervention for the treatment of DVT and preventing the manifestation of the post-thrombotic event.

Implication for practitioners

The study will be able to provide the practitioners with the various intervention techniques that can be used for the patients suffering from deep vein thrombosis. The review was also able to help the clinical practitioners in teaching them how to educate the patients on the effectiveness of the same as well in preventing the complications arising from the same (Weller, 2020). The patient could be taught and prescribed upon the optimal lengths of stockings advised for them following their extent of the disease. These interventions can thus, be applied in congruence with other treatment modalities such as medication therapy.

Implication for researchers

The study can be elaborated in various aspect as follow-

  • The review can also be concluded to evaluate for any other complication that can be manifested with the onset of deep vein thrombosis.
  • The evaluation of the effectiveness of the application of pressure stockings mainly in post-operative cases can be further evaluated. This is also crucial from preventing further complications in the patients (Wade, 2017).
  • The importance of the length of stocking can also be further evaluated so that the aptest vein can be targeted for the treatment purpose.
  • Further studies can also be conducted including studies in which these gradient stockings are worn by the patients for a longer duration.
  • The details on complications also need to be identified so that specific pressure stockings can be prescribed to the patients in accordance with their complications.

References for Effectiveness of Compression Stockings

Appelen, D., van Loo, E., Prins, M. H., Neumann, M. H., & Kolbach, D. N. (2017). Compression therapy for prevention of post‐thrombotic syndrome. Cochrane Database of Systematic Reviews, (9).

Budhram, D., Navarro-Ruan, T., & Haynes, R. B. (2018). The efficiency of database searches for creating systematic reviews was improved by search filters. Journal of Clinical Epidemiology95, 1-6.

Burda, B. U., Holmer, H. K., & Norris, S. L. (2016). Limitations of A Measurement Tool to Assess Systematic Reviews (AMSTAR) and suggestions for improvement. Systematic reviews5(1), 58.

Burgstaller, J. M., Steurer, J., Held, U., & Amann-Vesti, B. (2016). Efficacy of compression stockings in preventing post-thrombotic syndrome in patients with deep venous thrombosis: a systematic review and metaanalysis. Vasa45(2), 141-147.

Di Nisio, M., van Es, N., & Büller, H. R. (2016). Deep vein thrombosis and pulmonary embolism. The Lancet388(10063), 3060-3073.

Heijkoop, B., Nadi, S., Spernat, D., & Kiroff, G. (2020). Extended or Inpatient Thromboprophylaxis with Heparins Following Major Open Pelvic Surgery for Malignancy–A Systematic Review of Efficacy and Safety. European Journal of Surgical Oncology45(11), 2218-2219.

Hemmati, H., Askari, M. R., Haj Reza, P., Balassi, R., Jafaryparvar, Z., & Hemmati, G. (2020). Incidence and Clinical Signs of Post Thrombotic Syndrome in Patients with Deep Vein Thrombosis in a Three-year Follow-up. Journal of Mazandaran University of Medical Sciences29(182), 31-40.

Pollock, M., Fernandes, R. M., & Hartling, L. (2017). Evaluation of AMSTAR to assess the methodological quality of systematic reviews in overviews of reviews of healthcare interventions. BMC Medical Research Methodology17(1), 48.

Sachdeva, A., Dalton, M., & Lees, T. (2018). Graduated compression stockings for prevention of deep vein thrombosis. Cochrane Database of systematic reviews, (11).

Skervin, A. L., Thapar, A., Franchini, A. J., Prandoni, P., Shalhoub, J., & Davies, A. H. (2016). Systematic review and meta-analysis of utility of graduated compression stockings in prevention of post-thrombotic syndrome. European Journal of Vascular and Endovascular Surgery51(6), 838-845.

Wade, R., Paton, F., & Woolacott, N. (2017). Systematic review of patient preference and adherence to the correct use of graduated compression stockings to prevent deep vein thrombosis in surgical patients. Journal of advanced nursing73(2), 336-348.

Wade, R., Sideris, E., Paton, F., Rice, S., Palmer, S., Fox, D., ... & Spackman, E. (2015). Graduated compression stockings for the prevention of deep-vein thrombosis in postoperative surgical patients: a systematic review and economic model with a value of information analysis.

Watson, L., Broderick, C., & Armon, M. P. (2016). Thrombolysis for acute deep vein thrombosis. Cochrane Database of Systematic Reviews, (11).

Weller, C. D., Richards, C., Turnour, L., Patey, A. M., Russell, G., & Team, V. (2020). Barriers and enablers to the use of venous leg ulcer clinical practice guidelines in Australian primary care: A qualitative study using the theoretical domains framework. International Journal of Nursing Studies103, 103-109.

Zhang, H., Tang, H., He, Q., Wei, Q., Tong, D., Wang, C., ... & Li, D. (2015). Surgical versus conservative intervention for acute Achilles tendon rupture: a PRISMA-compliant systematic review of overlapping meta-analyses. Medicine94(45).

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