Introduction

Acute deep vein thrombosis (DVT) is seen with a frequency of 1/1,000 in the general population and is an important cause of mortality and morbidity, especially in the hospitalized patients, when evaluated in terms of the complications it may cause (pulmonary embolism, post thrombotic syndrome) (1). Today, in the treatment of acute DVT with lower extremity proximal involvement (common femoral vein and/or iliac venous involvement), new catheter-based interventions (2) and accompanying medical treatments are important steps in the prevention of post thrombotic syndrome (PTS), which is the most frightening long-term complication of the disease. has been recorded. However, PTS can still develop in 30-50% of all patients (3). In addition to these treatments; compression stocking (CS) is used in acute DVT in order to relieve edema due to stasis and venous hypertension and the associated pain, and to prevent the development of PTS. When current guidelines are examined, routine use of CS is not recommended in preventing the development of PTS after acute DVT (4). Although CS contains difficulties in terms of patient compliance, it is still used in routine practice because it regresses patients’ symptoms.

A visual analogue scale (VAS) can be used to numerically express the satisfaction of the patients with DVT with symptomatic acute proximal involvement who used CS in addition to medical treatment, in terms of the reduction of pain in the follow-up (5). VAS is a method that provides patient-based measurement between “no pain” and “the most severe pain” in vertical or horizontal plane of 10 cm length divided into equal parts. In this study, the effectiveness of CS added to the medical treatment of patients with acute proximal DVT on the development of PTS in the early period and the effectiveness of evaluating patient satisfaction with VAS method in the same patient group who were given symptomatic treatment for pain were investigated.

Method

Between January 2016 and August 2018, 151 patients who were admitted to our clinic with a diagnosis of acute DVT and were treated with CS in addition to medical treatment were retrospectively analyzed and 92 were included in the study who met the inclusion criteria. Three patients with active cancer, 10 patients who underwent percutaneous interventional procedure, 14 patients with popliteal and/or distal segment involvement, 4 patients with recurrent DVT, 4 patients who were pregnant, 8 patients below 20 years of age or over 70 years of age, and 16 patients whose follow-up records could not be accessed were excluded from the study. Medium pressure (23-32 mmHg) below-knee CS was given to the patients. Thirty-seven patients who could not comply with CS in the 1st week outpatient controls were followed up with only medical treatment and were identified as Group I. Fifty-five patients who were compliant with the use of CS were named as Group II. The VAS scores of the patients were calculated before the treatment, in the 3^rd month and 6^th month of the treatment (Figure 1). The Villalta (Figure 2) score and the venous clinical severity score (VCSS) (Figure 3) of the patients in the beginning of the treatment and in the 6^th month were calculated. In medical treatment, subcutaneous enoxaparin treatment at a dose of 1 mg/kg/12 hours was started in all patients, followed by oral warfarin at a dose that would provide the effective INR (2-2.5) level, on a patient-based basis. The study was approved by the local ethics committee and all data were evaluated retrospectively before and after treatment. The patients were informed about the treatment to be applied to them, and their consent was obtained.

Statistical Analysis

Baseline, 3^rd month and 6^th month VAS scores and baseline, 6^th month Villalta and VCSS measurements were expressed as mean ± standard deviation. Independent sample t-test was used to compare VAS, Villalta, VCSS scores between Group I and Group II. Descriptive data were presented as mean standard deviation, median (minimum, maximum) or frequency (%). Independent samples t-test and χ² test were used to compare groups according to normality test results. SPSS (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) package program was used for statistical analysis and p<0.05 was considered statistically significant.

Results

Ninety-two patients who were planned to use CS in the medical treatment of acute DVT were included in the study. The demographic characteristics of all patients are shown in Table 1. The basal, 3^rd month and 6^th month average VAS scores of the patients before CS treatment were 7, 7 and 5 in Group I, and 7, 6 and 5 in Group II, respectively (Table 2). When the VAS scores ​​at baseline and 3^rd month follow-up were compared, no significant difference was observed between the two groups, while a statistically significant difference was found in favor of Group II, which used CS, in terms of VAS values ​​at the 6^th month follow-up (p<0.05). Basal and 6^th month average Villalta scores of the patients before compression therapy were 8 and 6 in Group I, and 7 and 6 in Group II, respectively (Table 2). The basal and 6^th month average VCSS scores of the patients before compression therapy were; 6 and 5 in Group I, and 6 and 5 in Group II, respectively. There was no statistically significant difference in terms of the baseline and 6^th month Villalta and VCSS scores between the groups.

Discussion

In this study, the early results of the use of medium pressure CS in patients with symptomatic DVT with acute proximal involvement were examined. While CS had no effect on the development of PTS, it was found to have a reducing effect on the pain as assessed by VAS. In the follow-up of patients with DVT, many evaluation systems have been used to evaluate both the development of PTS and the regression of symptoms, and VCSS and Villalta scores are the most accepted, valid and up-to-date methods (6).

There are studies showing that the use of CS prevents the development of PTS, which is a long-term complication of acute proximal DVT, as well as there are studies showing that it has no effect on PTS (7,8). In our study, the early 6^th month Villalta score results in patients using CS were compared with patients not using CS, and no significant difference was found in terms of preventing the development of PTS.        

It has not yet been clarified in the literature whether choosing a higher pressure and high level CS is effective in the development of PTS or in reducing symptoms. Ten Cate-Hoek et al. (9) found no significant difference between different CS pressures and levels in terms of the efficacy, and a regression in symptoms was observed regardless of the pressure and level of CS. Similar results were obtained in studies in which only low-pressure or high-pressure CS was used and the venous filling index was measured (10,11). In our study, we preferred the use of below-knee and medium-pressure CS for each patient in order to increase patient compliance, we did not use higher pressure and high-level stockings.

Study Limitations

When the results of studies using VAS scoring were examined to investigate the effect of CS use on pain symptoms in patients with DVT, it was found that CS especially used in the early period, had positive effects on reducing pain (12). Similarly, in our study, a statistically significant difference was found between the 6^th month VAS scores of the patients who used CS and those who did not. In the evaluation of pain satisfaction, VAS can be preferred as a valuable measurement method in DVT with acute proximal involvement. Although it is an advantage that this scoring system is easy to understand and re-applicable, it is a disadvantage that difficulties ocur due to declining cognitive functions, especially in older age groups.

Conclusion

Considering the early results of CS in the treatment of patients with proximal lower extremity DVT, no significant effect was found on the development of PTS. However, in daily practice, they can still be used in symptomatic treatment. Studies that evaluate more patients and include long-term results are needed for efficacy analysis.

Ethics

Ethics Committee Approval: The study was approved by the local ethics committee and all data were evaluated retrospectively before and after treatment.

Informed Consent: The patients were informed about the treatment to be applied to them, and their consent was obtained.

Peer-review: Externally peer reviewed.

Authorship Contributions

Surgical and Medical Practices: C.K., M.Ş.B.,  Concept: C.K., M.Ş.B., E.A.,  Design: C.K., M.Ş.B., E.A., Data Collection or Processing: C.K., M.Ş.B., A.Ö., E.Ş.D.Y., F.B.,  Analysis or Interpretation: C.K., M.Ş.B., A.Ö., E.Ş.D.Y., F.B., E.A.,  Literature Search: C.K., M.Ş.B., Writing: C.K., M.Ş.B.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.