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Study flow diagram.
Figuras y tablas -
Figure 1

Study flow diagram.

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figuras y tablas -
Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figuras y tablas -
Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Comparison 1 IPC plus pharmacological prophylaxis versus IPC alone, Outcome 1 Incidence of PE.
Figuras y tablas -
Analysis 1.1

Comparison 1 IPC plus pharmacological prophylaxis versus IPC alone, Outcome 1 Incidence of PE.

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Comparison 1 IPC plus pharmacological prophylaxis versus IPC alone, Outcome 2 Incidence of DVT.
Figuras y tablas -
Analysis 1.2

Comparison 1 IPC plus pharmacological prophylaxis versus IPC alone, Outcome 2 Incidence of DVT.

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Comparison 1 IPC plus pharmacological prophylaxis versus IPC alone, Outcome 3 Incidence of symptomatic DVT.
Figuras y tablas -
Analysis 1.3

Comparison 1 IPC plus pharmacological prophylaxis versus IPC alone, Outcome 3 Incidence of symptomatic DVT.

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Comparison 1 IPC plus pharmacological prophylaxis versus IPC alone, Outcome 4 Incidence of DVT by foot IPC or other IPC.
Figuras y tablas -
Analysis 1.4

Comparison 1 IPC plus pharmacological prophylaxis versus IPC alone, Outcome 4 Incidence of DVT by foot IPC or other IPC.

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Comparison 1 IPC plus pharmacological prophylaxis versus IPC alone, Outcome 5 Incidence of bleeding.
Figuras y tablas -
Analysis 1.5

Comparison 1 IPC plus pharmacological prophylaxis versus IPC alone, Outcome 5 Incidence of bleeding.

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Comparison 1 IPC plus pharmacological prophylaxis versus IPC alone, Outcome 6 Incidence of major bleeding.
Figuras y tablas -
Analysis 1.6

Comparison 1 IPC plus pharmacological prophylaxis versus IPC alone, Outcome 6 Incidence of major bleeding.

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Comparison 2 IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone, Outcome 1 Incidence of PE.
Figuras y tablas -
Analysis 2.1

Comparison 2 IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone, Outcome 1 Incidence of PE.

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Comparison 2 IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone, Outcome 2 Incidence of DVT.
Figuras y tablas -
Analysis 2.2

Comparison 2 IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone, Outcome 2 Incidence of DVT.

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Comparison 2 IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone, Outcome 3 Incidence of symptomatic DVT.
Figuras y tablas -
Analysis 2.3

Comparison 2 IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone, Outcome 3 Incidence of symptomatic DVT.

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Comparison 2 IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone, Outcome 4 Incidence of DVT by foot IPC or other IPC.
Figuras y tablas -
Analysis 2.4

Comparison 2 IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone, Outcome 4 Incidence of DVT by foot IPC or other IPC.

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Comparison 2 IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone, Outcome 5 Incidence of bleeding.
Figuras y tablas -
Analysis 2.5

Comparison 2 IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone, Outcome 5 Incidence of bleeding.

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Comparison 2 IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone, Outcome 6 Incidence of major bleeding.
Figuras y tablas -
Analysis 2.6

Comparison 2 IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone, Outcome 6 Incidence of major bleeding.

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Comparison 3 IPC plus pharmacological prophylaxis versus IPC plus aspirin, Outcome 1 Incidence of PE.
Figuras y tablas -
Analysis 3.1

Comparison 3 IPC plus pharmacological prophylaxis versus IPC plus aspirin, Outcome 1 Incidence of PE.

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Comparison 3 IPC plus pharmacological prophylaxis versus IPC plus aspirin, Outcome 2 Incidence of DVT.
Figuras y tablas -
Analysis 3.2

Comparison 3 IPC plus pharmacological prophylaxis versus IPC plus aspirin, Outcome 2 Incidence of DVT.

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Comparison 3 IPC plus pharmacological prophylaxis versus IPC plus aspirin, Outcome 3 Incidence of symptomatic DVT.
Figuras y tablas -
Analysis 3.3

Comparison 3 IPC plus pharmacological prophylaxis versus IPC plus aspirin, Outcome 3 Incidence of symptomatic DVT.

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Comparison 3 IPC plus pharmacological prophylaxis versus IPC plus aspirin, Outcome 4 Incidence of bleeding.
Figuras y tablas -
Analysis 3.4

Comparison 3 IPC plus pharmacological prophylaxis versus IPC plus aspirin, Outcome 4 Incidence of bleeding.

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Comparison 3 IPC plus pharmacological prophylaxis versus IPC plus aspirin, Outcome 5 Incidence of major bleeding.
Figuras y tablas -
Analysis 3.5

Comparison 3 IPC plus pharmacological prophylaxis versus IPC plus aspirin, Outcome 5 Incidence of major bleeding.

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Comparison 4 IPC plus pharmacological prophylaxis versus IPC alone ‐ subgroups, Outcome 1 Incidence of PE.
Figuras y tablas -
Analysis 4.1

Comparison 4 IPC plus pharmacological prophylaxis versus IPC alone ‐ subgroups, Outcome 1 Incidence of PE.

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Comparison 4 IPC plus pharmacological prophylaxis versus IPC alone ‐ subgroups, Outcome 2 Incidence of DVT.
Figuras y tablas -
Analysis 4.2

Comparison 4 IPC plus pharmacological prophylaxis versus IPC alone ‐ subgroups, Outcome 2 Incidence of DVT.

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Comparison 5 IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone ‐ subgroups, Outcome 1 Incidence of PE.
Figuras y tablas -
Analysis 5.1

Comparison 5 IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone ‐ subgroups, Outcome 1 Incidence of PE.

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Comparison 5 IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone ‐ subgroups, Outcome 2 Incidence of DVT.
Figuras y tablas -
Analysis 5.2

Comparison 5 IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone ‐ subgroups, Outcome 2 Incidence of DVT.

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Comparison 6 IPC plus pharmacological prophylaxis versus IPC alone ‐ RCTs only, Outcome 1 Incidence of PE.
Figuras y tablas -
Analysis 6.1

Comparison 6 IPC plus pharmacological prophylaxis versus IPC alone ‐ RCTs only, Outcome 1 Incidence of PE.

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Comparison 6 IPC plus pharmacological prophylaxis versus IPC alone ‐ RCTs only, Outcome 2 Incidence of DVT.
Figuras y tablas -
Analysis 6.2

Comparison 6 IPC plus pharmacological prophylaxis versus IPC alone ‐ RCTs only, Outcome 2 Incidence of DVT.

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Comparison 7 IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone ‐ RCTs only, Outcome 1 Incidence of PE.
Figuras y tablas -
Analysis 7.1

Comparison 7 IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone ‐ RCTs only, Outcome 1 Incidence of PE.

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Comparison 7 IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone ‐ RCTs only, Outcome 2 Incidence of DVT.
Figuras y tablas -
Analysis 7.2

Comparison 7 IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone ‐ RCTs only, Outcome 2 Incidence of DVT.

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Comparison 8 IPC plus pharmacological prophylaxis versus IPC plus aspirin ‐ RCTs only, Outcome 1 Incidence of PE.
Figuras y tablas -
Analysis 8.1

Comparison 8 IPC plus pharmacological prophylaxis versus IPC plus aspirin ‐ RCTs only, Outcome 1 Incidence of PE.

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Comparison 8 IPC plus pharmacological prophylaxis versus IPC plus aspirin ‐ RCTs only, Outcome 2 Incidence of DVT.
Figuras y tablas -
Analysis 8.2

Comparison 8 IPC plus pharmacological prophylaxis versus IPC plus aspirin ‐ RCTs only, Outcome 2 Incidence of DVT.

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Summary of findings for the main comparison. IPC plus pharmacological prophylaxis versus IPC alone

Does combined intermittent pneumatic compression (IPC) plus pharmacological prophylaxis increase prevention of venous thromboembolism compared with IPC alone?

Patient or population: patients undergoing surgery or at risk of developing VTE because of other reasons (e.g. trauma)

Settings: hospital (surgery, trauma or ICU stay)

Intervention: combined IPC plus pharmacological prophylaxis

Comparison: IPC alone

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Single modalities

Combined modalities

Incidence of PEa

8 per 1000

4 per 1000 (1 to 10)

OR 0.49 (0.18 to 1.34)

3017 (12)

⊕⊕⊕⊝
moderate1

Incidence of DVTb

41 per 1000

22 per 1000 (14 to 34)

OR 0.52 (0.33 to 0.82)

2934 (11)

⊕⊕⊕⊝
moderate2

Incidence of bleedingc

7 per 1000

33 per 1000 (16 to 67)

OR 5.04 (2.36 to 10.77)

2155 (7)

⊕⊕⊕⊝

moderate3

Incidence of major bleedingd

1 per 1000

6 per 1000 (2 to 22)

OR 6.81 (1.99 to 23.28)

2155 (7)

⊕⊕⊕⊝

moderate3

* The basis for the assumed risk was the average risk in the single modalities group (i.e. the number of participants with events divided by total number of participants of the single modalities group included in the meta‐analysis). The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)
CI: confidence interval;DVT: deep vein thrombosis;IPC: intermittent pneumatic compression; OR: odds ratio; PE: pulmonary embolism; VTE: venous thromboembolism

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

a PE assessed by pulmonary angiography or scintigraphy, computed tomography (CT), angiography, or autopsy
b DVT assessed by ascending venography, I‐125 fibrinogen uptake test, and ultrasound scanning
c any type of bleeding as described by the study authors
d major bleeding as defined by the study authors, but usually located at the surgical site or in a critical organ or site, requiring intervention or transfusion of at least units of blood, or leading to death

1 Downgraded by one level due to imprecision likely due to a type II error (few events and 4/12 studies contributing to effect estimate)
2 Downgraded by one level, due to risk of attrition bias, affecting effect estimate as shown by sensitivity analysis
3 Downgraded by one level due to indirectness (reporting of bleeding outcomes (major and minor bleeding) was not uniform across the studies, with some studies reporting on blood loss during the procedures or through the drains or providing rates for postoperative bleeding. Definitions used were also not uniform)
Bleeding events may be affected by bias due to blinding. Only two out of seven studies are double blind. These are also the two largest studies in the analysis. When pooled they show a similar direction of effect (increased bleeding for combined modalities) as the overall effect for the seven studies in this comparison indicating that any potential risk of risk of performance or detection bias does not affect the results therefore not downgraded for risk of bias
Wide confidence interval but upper and lower limits of corresponding risk and 95% confidence interval of effect both show the same message i.e. an increased risk of bleeding for combined modalities therefore not downgraded for imprecision

Figuras y tablas -
Summary of findings for the main comparison. IPC plus pharmacological prophylaxis versus IPC alone
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Summary of findings 2. IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone

Does combined intermittent pneumatic compression (IPC) plus pharmacological prophylaxis increase prevention of venous thromboembolism compared with pharmacological prophylaxis alone?

Patient or population: patients undergoing surgery or at risk of developing VTE because of other reasons (e.g. trauma)

Settings: hospital (surgery, trauma or ICU stay)

Intervention: combined IPC plus pharmacological prophylaxis

Comparison: pharmacological prophylaxis alone

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Single modalities

Combined modalities

Incidence of PEa

29 per 1000

12 per 1000 (7 to 19)

OR 0.39 (0.23 to 0.64)

3544 (10)

⊕⊕⊕⊝
moderate1

Incidence of DVTb

62 per 1000

27 per 1000 (12 to 64)

OR 0.42 (0.18 to 1.03)

2866 (11)

⊕⊕⊕⊝
moderate2

Incidence of bleedingc

81 per 1000

66 per 1000 (26 to 159)

OR 0.8 (0.3 to 2.14

244 (3)

⊕⊝⊝⊝

very low3

Incidence of major bleedingd

41 per 1000

49 per 1000 (15 to 150)

OR 1.21 (0.35 to 4.18)

244 (3)

⊕⊝⊝⊝

very low3

*The basis for the assumed risk was the average risk in the single modalities group (i.e. the number of participants with events divided by total number of participants of the single modalities group included in the meta‐analysis). The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)
CI: confidence interval;DVT: deep vein thrombosis;IPC: intermittent pneumatic compression; OR: odds ratio; PE: pulmonary embolism; VTE: venous thromboembolism

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

a PE assessed by pulmonary angiography or scintigraphy, computed tomography (CT), angiography, or autopsy
b DVT assessed by ascending venography, I‐125 fibrinogen uptake test, and ultrasound scanning
c any type of bleeding as described by the study authors
d major bleeding as defined by the study authors, but usually located at the surgical site or in a critical organ or site, requiring intervention or transfusion of at least units of blood, or leading to death

1 Downgraded by one level due to risk of detection and attrition bias affecting effect estimate as shown by sensitivity analysis
2 Downgraded by one level, due to risk of selection, detection and other bias affecting effect estimate as shown by sensitivity analysis. Heterogeneity explained by detection and other bias
3 Downgraded by three levels due to risk of bias due to blinding (none of the studies in this comparison are double blind), indirectness (reporting of bleeding outcomes (major and minor bleeding) was not uniform across the studies, with some studies reporting on blood loss during the procedures or through the drains or providing rates for postoperative bleeding and definitions used were not uniform) and imprecision (small number of participants and relatively few events

Figuras y tablas -
Summary of findings 2. IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone
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Comparison 1. IPC plus pharmacological prophylaxis versus IPC alone

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Incidence of PE Show forest plot

12

3017

Odds Ratio (M‐H, Fixed, 95% CI)

0.49 [0.18, 1.34]

2 Incidence of DVT Show forest plot

11

2934

Odds Ratio (M‐H, Fixed, 95% CI)

0.52 [0.33, 0.82]

3 Incidence of symptomatic DVT Show forest plot

6

2526

Odds Ratio (M‐H, Fixed, 95% CI)

0.49 [0.16, 1.47]

4 Incidence of DVT by foot IPC or other IPC Show forest plot

11

2934

Odds Ratio (M‐H, Fixed, 95% CI)

0.52 [0.33, 0.82]

4.1 foot IPC

1

50

Odds Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

4.2 other IPC

10

2884

Odds Ratio (M‐H, Fixed, 95% CI)

0.52 [0.33, 0.82]

5 Incidence of bleeding Show forest plot

7

2155

Odds Ratio (M‐H, Fixed, 95% CI)

5.04 [2.36, 10.77]

6 Incidence of major bleeding Show forest plot

7

2155

Odds Ratio (M‐H, Fixed, 95% CI)

6.81 [1.99, 23.28]
Figuras y tablas -
Comparison 1. IPC plus pharmacological prophylaxis versus IPC alone
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Comparison 2. IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Incidence of PE Show forest plot

10

3544

Odds Ratio (M‐H, Fixed, 95% CI)

0.39 [0.23, 0.64]

2 Incidence of DVT Show forest plot

11

2866

Odds Ratio (M‐H, Random, 95% CI)

0.42 [0.18, 1.03]

3 Incidence of symptomatic DVT Show forest plot

5

2312

Odds Ratio (M‐H, Fixed, 95% CI)

1.02 [0.29, 3.54]

4 Incidence of DVT by foot IPC or other IPC Show forest plot

11

2866

Odds Ratio (M‐H, Random, 95% CI)

0.42 [0.18, 1.03]

4.1 foot IPC

4

324

Odds Ratio (M‐H, Random, 95% CI)

0.40 [0.05, 3.47]

4.2 other IPC

7

2542

Odds Ratio (M‐H, Random, 95% CI)

0.39 [0.16, 0.96]

5 Incidence of bleeding Show forest plot

3

244

Odds Ratio (M‐H, Fixed, 95% CI)

0.80 [0.30, 2.14]

6 Incidence of major bleeding Show forest plot

3

244

Odds Ratio (M‐H, Fixed, 95% CI)

1.21 [0.35, 4.18]
Figuras y tablas -
Comparison 2. IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone
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Comparison 3. IPC plus pharmacological prophylaxis versus IPC plus aspirin

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Incidence of PE Show forest plot

3

605

Odds Ratio (M‐H, Fixed, 95% CI)

0.33 [0.03, 3.19]

2 Incidence of DVT Show forest plot

3

605

Odds Ratio (M‐H, Fixed, 95% CI)

0.83 [0.48, 1.42]

3 Incidence of symptomatic DVT Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected

4 Incidence of bleeding Show forest plot

3

616

Odds Ratio (M‐H, Fixed, 95% CI)

1.23 [0.27, 5.53]

5 Incidence of major bleeding Show forest plot

3

616

Odds Ratio (M‐H, Fixed, 95% CI)

0.80 [0.15, 4.17]
Figuras y tablas -
Comparison 3. IPC plus pharmacological prophylaxis versus IPC plus aspirin
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Comparison 4. IPC plus pharmacological prophylaxis versus IPC alone ‐ subgroups

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Incidence of PE Show forest plot

12

3017

Odds Ratio (M‐H, Fixed, 95% CI)

0.49 [0.18, 1.34]

1.1 Orthopedic patients

3

445

Odds Ratio (M‐H, Fixed, 95% CI)

0.0 [0.0, 0.0]

1.2 Non‐orthopedic patients

9

2572

Odds Ratio (M‐H, Fixed, 95% CI)

0.49 [0.18, 1.34]

2 Incidence of DVT Show forest plot

11

2934

Odds Ratio (M‐H, Fixed, 95% CI)

0.52 [0.33, 0.82]

2.1 Orthopedic patients

3

445

Odds Ratio (M‐H, Fixed, 95% CI)

0.80 [0.38, 1.69]

2.2 Non‐orthopedic patients

8

2489

Odds Ratio (M‐H, Fixed, 95% CI)

0.41 [0.23, 0.73]
Figuras y tablas -
Comparison 4. IPC plus pharmacological prophylaxis versus IPC alone ‐ subgroups
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Comparison 5. IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone ‐ subgroups

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Incidence of PE Show forest plot

10

3544

Odds Ratio (M‐H, Fixed, 95% CI)

0.39 [0.23, 0.64]

1.1 Orthopedic patients

6

732

Odds Ratio (M‐H, Fixed, 95% CI)

0.58 [0.08, 4.49]

1.2 Non‐orthopedic patients

4

2812

Odds Ratio (M‐H, Fixed, 95% CI)

0.38 [0.22, 0.63]

2 Incidence of DVT Show forest plot

11

2866

Odds Ratio (M‐H, Random, 95% CI)

0.42 [0.18, 1.03]

2.1 Orthopedic patients

8

2605

Odds Ratio (M‐H, Random, 95% CI)

0.32 [0.12, 0.86]

2.2 Non‐orthopedic patients

3

261

Odds Ratio (M‐H, Random, 95% CI)

1.77 [0.30, 10.58]
Figuras y tablas -
Comparison 5. IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone ‐ subgroups
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Comparison 6. IPC plus pharmacological prophylaxis versus IPC alone ‐ RCTs only

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Incidence of PE Show forest plot

7

2023

Risk Ratio (M‐H, Fixed, 95% CI)

0.51 [0.09, 2.76]

2 Incidence of DVT Show forest plot

7

2008

Risk Ratio (M‐H, Fixed, 95% CI)

0.56 [0.35, 0.90]
Figuras y tablas -
Comparison 6. IPC plus pharmacological prophylaxis versus IPC alone ‐ RCTs only
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Comparison 7. IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone ‐ RCTs only

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Incidence of PE Show forest plot

8

3285

Risk Ratio (M‐H, Fixed, 95% CI)

0.40 [0.24, 0.65]

2 Incidence of DVT Show forest plot

9

2607

Risk Ratio (M‐H, Random, 95% CI)

0.49 [0.19, 1.26]
Figuras y tablas -
Comparison 7. IPC plus pharmacological prophylaxis versus pharmacological prophylaxis alone ‐ RCTs only
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Comparison 8. IPC plus pharmacological prophylaxis versus IPC plus aspirin ‐ RCTs only

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Incidence of PE Show forest plot

2

405

Risk Ratio (M‐H, Fixed, 95% CI)

0.33 [0.03, 3.17]

2 Incidence of DVT Show forest plot

2

405

Risk Ratio (M‐H, Fixed, 95% CI)

0.81 [0.50, 1.33]
Figuras y tablas -
Comparison 8. IPC plus pharmacological prophylaxis versus IPC plus aspirin ‐ RCTs only
Ir a la tabla de la revisión