Contracting role of graduated compression stockings in prevention of perioperative venous thromboembolism Joseph Shalhoub* Imperial Vascular Unit, Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, UK *Correspondence to: Joseph Shalhoub, Imperial Vascular Unit, Imperial College Healthcare NHS Trust, St Mary’s Hospital, Praed Street, London W2 1NY, UK (e-mail: j.shalhoub@imperial.ac.uk) There can be no doubt that the prevention of venous thromboembolism (VTE) is a healthcare need and priority 1 . The issue remains in sharp focus in surgery, with the implementation of VTE risk assessment, and the use of mechanical and pharmacological thromboprophylaxis. These measures have been further enhanced through education and dissemination, and have been reinforced through key clinical guidelines 2,3 and incentivization 4 . There was a 15 per cent reduction in hospital-associated VTE deaths (within 90 days of admission) in the UK between 2010 and 2017 5 , with concurrent falls in pulmonary embolism-related mortality among European countries 6 . This is likely to be more impressive considering that improved awareness and imaging are likely to have increased the diagnosis of VTE, resulting in a further reduction in the case fatality rate. The factors responsible for this reduction are likely to be multifactorial. This can be attributed to a long list of varied and important factors, including (but not limited to) prehabilitation, systematic VTE risk assessment (including computer-aided assessment 7 ), enhanced recovery with early mobilization, patient hydration, use of advanced minimally invasive surgical techniques resulting in a reduction in the systemic inflammatory response (both magnitude and duration), and of course thromboprophylaxis. Given the number of relevant factors at play, it is challenging to know which are dominant, and this also applies when considering mechanical and pharmacological thromboprophylaxis. Much of the evidence underpinning perioperative thromboprophylaxis is dated and may not reflect modern surgical practice. Furthermore, these studies, for the most part, used mechanical thromboprophylaxis alone or pharmacological thromboprophylaxis alone, with little evidence relating to the use of both mechanical and pharmacological strategies 8 . Many studies were funded by stocking manufacturers 9 . It was for these and a number of other reasons that doubt was cast over the evidence that formed the basis of recommendations for mechanical thromboprophylaxis, particularly the use of graduated compression stockings (GCS) 9,10 . What should be considered is whether, in individuals receiving pharmacological thromboprophylaxis, GCS further reduce the VTE risk. The first CLOTS trial 11 randomized 2518 patients admitted to hospital following an acute stroke to receive either routine care including thigh-length GCS, or routine care with avoidance of GCS. Not only was there no significant reduction in symptomatic or asymptomatic deep vein thrombosis (DVT), complications of skin breaks, ulcers, blisters, and skin necrosis were significantly more common in the GCS arm of the trial 12 . A subsequent RCT 12 included individuals in critical care who were receiving pharmacological thromboprophylaxis and were randomized to receive either additional intermittent pneumatic compression (991 patients) or no additional intermittent pneumatic compression (1012). The addition of intermittent pneumatic compression did not result in a lower incidence of proximal lower limb DVT than pharmacological thromboprophylaxis alone 12 . These studies generated further uncertainty around the role of mechanical thromboprophylaxis in medical inpatient and critical care settings, respectively. What does this mean for the surgical patient? In 2007, an RCT 13 of individuals undergoing hip surgery was published. This compared postoperative VTE or sudden death between those randomized to a combination of fondaparinux and compression stockings (395 patients, 19 DVT events) or to fondaparinux alone (400 patients, 22 DVT events), and concluded ‘the addition of graduated compression stockings to fondaparinux appears to offer no additional benefit over the use of fondaparinux alone’ 13 . This trial set the scene for the large UK National Institute for Health Research (NIHR)-funded GAPS (Graduated compression stockings as an Adjunct to Pharmacoprophylaxis in Surgery) trial. GAPS aimed to elucidate the role of GCS in individuals undergoing elective surgery who were assessed as being at moderate or high risk of VTE, and who were receiving prophylactic-dose low molecular weight heparin (LMWH) 14 . The primary outcome, imaging-confirmed lower limb DVT with or without symptoms, or pulmonary embolism with symptoms within 90 days of surgery, occurred in 16 of 937 patients (1.7 per cent) in the LMWH-alone group compared with 13 of 921 (1.4 per cent) in the LMWH and GCS group. LMWH alone was confirmed to be statistically non-inferior (non-inferiority margin of 3.5 per cent risk difference) to the combination of LMWH and GCS in this surgical patient group 15,16 . Considering this subgroup of elective surgical patients, removing the cost of purchasing GCS and of the nursing time required to apply them, it has been estimated conservatively that more than £60 million (approximately €70 million [exchange rate date 11th May 2022]) per annum could be liberated from National Health Service budgets in England alone on a recurring basis 14 . This estimate did not consider the costs of treating complications related to GCS such as those reported by the CLOTS Received: April 24, 2022. Accepted: April 27, 2022 © The Author(s) 2022. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com BJS, 2022, 109, 669–670 https://doi.org/10.1093/bjs/znac157 Advance Access Publication Date: 20 May 2022 Gloves Off Downloaded from https://academic.oup.com/bjs/article/109/8/669/6589667 by guest on 18 April 2024