Decreased Risk Of Venous Thromboembolism Research Articles

Weight-based enoxaparin thromboprophylaxis in young trauma patients: analysis of the CLOTT-1 registry

IntroductionOptimal venous thromboembolism (VTE) enoxaparin prophylaxis dosing remains elusive. Weight-based (WB) dosing safely increases anti-factor Xa levels without the need for routine monitoring but it is unclear if it leads...

Venous Thromboembolism in Patients Hospitalized for COVID-19 in a Non-Intensive Care Unit.

Coronavirus Disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) may contribute to venous thromboembolism (VTE) with adverse effects on the course of COVID-19. The purpose of this study was to investigate an incidence and risk factors for VTE in patients hospitalized for COVID-19 in a non-intensive care unit (non-ICU). Consecutive adult patients with COVID-19 hospitalized from November 2021 to March 2022 in the isolation non-ICU at our center were included in the study. Incidence of VTE including pulmonary embolism (PE) and deep vein thrombosis (DVT), clinical characteristics, and D-dimer plasma levels during the hospitalization were retrospectively evaluated. Among the 181 patients (aged 68.8 ± 16.2 years, 44% females, 39% Delta SARS-CoV-2 variant, 61% Omicron SARS-CoV-2 variant), VTE occurred in 29 patients (VTE group, 16% of the entire cohort). Of them, PE and DVT were diagnosed in 15 (8.3% of the entire cohort) and 14 (7.7%) patients, respectively. No significant differences in clinical characteristics were observed between the VTE and non-VTE groups. On admission, median D-dimer was elevated in both groups, more for VTE group (1549 ng/mL in VTE vs. 1111 ng/mL in non-VTE, p = 0.09). Median maximum D-dimer was higher in the VTE than in the non-VTE group (5724 ng/mL vs. 2200 ng/mL, p < 0.005). In the univariate analysis, systemic arterial hypertension and the need for oxygen therapy were predictors of VTE during hospitalization for COVID-19 (odds ratio 2.59 and 2.43, respectively, p < 0.05). No significant associations were found between VTE risk and other analyzed factors; however, VTE was more likely to occur in patients with a history of VTE, neurological disorders, chronic pulmonary or kidney disease, atrial fibrillation, obesity, and Delta variant infection. Thromboprophylaxis (83.4% of the entire cohort) and anticoagulant treatment (16.6%) were not associated with a decreased VTE risk. The incidence of VTE in patients hospitalized in non-ICU for COVID-19 was high despite the common use of thromboprophylaxis or anticoagulant treatment. A diagnosis of arterial hypertension and the need for oxygen therapy were associated with an increased VTE risk. Continuous D-dimer monitoring is required for the early detection of VTE.

Venous Thromboembolic Risk of Estradiol Valerate-Dienogest Compared with Ethinyl Estradiol-Levonorgestrel Combined Oral Contraceptives.

This pooled analysis compared the risk of venous thromboembolism (VTE) associated with combined oral contraceptives (COCs) containing estradiol (E2) valerate-dienogest with those containing ethinyl E2-levonorgestrel. Data were retrieved from two large, prospective, observational cohort studies. Propensity score subclassification was applied to balance baseline parameters between the COC user cohorts. Crude and adjusted hazard ratios (HRs) were calculated based on the extended Cox model. The pooled data set included 11,616 E2 valerate-dienogest users and 18,681 ethinyl E2-levonorgestrel users, contributing 17,932 and 29,140 women-years of observation, respectively. A significantly decreased VTE risk in E2 valerate-dienogest COCs compared with ethinyl E2-levonorgestrel COCs was observed (propensity score-stratified HR 0.46, 95% CI, 0.22-0.98). This pooled analysis expands data from a previous postauthorization safety study and provides valuable real-world safety information on the relative safety of current COCs.

Tobacco smoking and binge alcohol use are associated with incident venous thromboembolism in an HIV cohort.

People with HIV (PWH) are at increased risk of cardiovascular comorbidities and substance use is a potential predisposing factor. We evaluated associations of tobacco smoking and alcohol use with venous thromboembolism (VTE) in PWH. We assessed incident, centrally adjudicated VTE among 12957 PWH within the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort between January 2009 and December 2018. Using separate Cox proportional hazards models, we evaluated associations of time-updated alcohol and cigarette use with VTE, adjusting for demographic and clinical characteristics. Smoking was evaluated as pack-years and never, former, or current use with current cigarettes per day. Alcohol use was parameterized using categorical and continuous alcohol use score, frequency of use, and binge frequency. During a median of 3.6years of follow-up, 213 PWH developed a VTE. One-third of PWH reported binge drinking and 40% reported currently smoking. In adjusted analyses, risk of VTE was increased among both current (HR: 1.44, 95% CI: 1.02-2.03) and former (HR: 1.44, 95% CI: 0.99-2.07) smokers compared to PWH who never smoked. Additionally, total pack-years among ever-smokers (HR: 1.10 per 5 pack-years; 95% CI: 1.03-1.18) was associated with incident VTE in a dose-dependent manner. Frequency of binge drinking was associated with incident VTE (HR: 1.30 per 7days/month, 95% CI: 1.11-1.52); however, alcohol use frequency was not. Severity of alcohol use was not significantly associated with VTE. Current smoking and pack-year smoking history were dose-dependently associated with incident VTE among PWH in CNICS. Binge drinking was also associated with VTE. Interventions for smoking and binge drinking may decrease VTE risk among PWH.

Risk Factors for Venous Thromboembolism in Severe COVID-19: A Study-Level Meta-Analysis of 21 Studies.

Venous thromboembolism (VTE) in patients with COVID-19 in intensive care units (ICU) is frequent, but risk factors (RF) remain unidentified. In this meta-analysis (CRD42020188764) we searched for observational studies from ICUs reporting the association between VTE and RF in Medline/Embase up to 15 April 2021. Reviewers independently extracted data in duplicate and assessed the certainty of the evidence using the GRADE approach. Analyses were conducted using the random-effects model and produced a non-adjusted odds ratio (OR). We analysed 83 RF from 21 studies (5296 patients). We found moderate-certainty evidence for an association between VTE and the D-dimer peak (OR 5.83, 95%CI 3.18–10.70), and length of hospitalization (OR 7.09, 95%CI 3.41–14.73) and intubation (OR 2.61, 95%CI 1.94–3.51). We identified low-certainty evidence for an association between VTE and CRP (OR 1.83, 95% CI 1.32–2.53), D-dimer (OR 4.58, 95% CI 2.52–8.50), troponin T (OR 8.64, 95% CI 3.25–22.97), and the requirement for inotropic drugs (OR 1.67, 95% CI 1.15–2.43). Traditional VTE RF (i.e., history of cancer, previous VTE events, obesity) were not found to be associated to VTE in COVID-19. Anticoagulation was not associated with a decreased VTE risk. VTE RF in severe COVID-19 correspond to individual illness severity, and inflammatory and coagulation parameters.

Socioeconomic status and risk of incident venous thromboembolism

BackgroundAlthough venous thromboembolism (VTE) is a leading cause of morbidity and mortality, and socioeconomic status (SES) affects human health and health behavior, few studies have examined the association between SES and VTE. ObjectivesWe aimed to investigate the association between SES, assessed individually and in a composite score by levels of education, income, and employment status, and incident VTE. MethodsWe used Danish national registries to identify 51 350 persons aged 25–65 years with incident VTE during 1995–2016. For each case, we used incidence density sampling to select five age‐, sex‐, and index‐year‐matched controls from the general Danish population (n = 256 750). SES indicators, including education, income, and employment status, were assessed 1 and 5 years before the VTE. We used conditional logistic regression to compute odds ratios (ORs) with 95% confidence intervals (CIs) for VTE according to individual SES indicators and a composite SES score in analyses adjusted for age, sex, and comorbidities. ResultsCompared with low levels, high educational level (OR 0.74; 95% CI 0.71–0.77), high income (OR 0.70; 95% CI 0.68–0.72), and high employment status (OR 0.66; 95% CI 0.64–0.68) were associated with decreased risk of VTE, even after adjusting for comorbidities. A composite SES score was superior to the individual indicators in assessing VTE risk (OR for high vs. low score: 0.61; 95% CI 0.59–0.63). In sensitivity analysis with SES indicators measured 5 years before the VTE, the risk estimates remained essentially the same. ConclusionHigh levels of both individual SES indicators and a composite SES score were associated with decreased VTE risk.

Clinical Characteristics Associated With Higher Enoxaparin Dosing Requirements for Venous Thromboembolism Prophylaxis in Trauma Patients.

Enoxaparin dosed by an anti-Xa trough level is effective at reducing venous thromboembolism (VTE) in trauma patients. We identified the patient characteristics associated with higher enoxaparin dosing based on anti-Xa trough levels. A retrospective review was conducted on trauma patients admitted between August 2014 and February 2018 who received enoxaparin dosed by the anti-Xa trough level. Patients who received enoxaparin < 50mg every 12hours were compared to those who required ≥ 50mg every 12hours. Of the 246 patients included, 32 (13.0%) required enoxaparin ≥ 50mg every 12hours to achieve the prophylactic trough level. Factors associated with a higher dose of enoxaparin were male (96.8% vs. 3.2%, P < .01), younger age (39.5 vs. 52.7years, P < .01), higher creatinine clearance (CrCl) (125.9 vs. 93.7mL/min, P < .01), higher body surface area (2m2 vs. 1.8m2, P < .01), and higher injury severity score (18.4 vs. 10.8, P < .01). Height, weight, and body mass index were not significant factors. On regression analysis, CrCl was the only independent predictor for higher enoxaparin dose. There was an increased deep venous thrombosis rate in the higher dose cohort (12.5% vs. 0, P < .01) but no significant differences in transfusion rates. Trauma patients who require higher enoxaparin doses to achieve prophylactic anti-Xa trough levels have a higher CrCl. Patients with high CrCl may benefit from an initial higher dose of enoxaparin to achieve a target anti-Xa level in a shorter time interval to decrease VTE risk.

Risk Assessment and Management of Venous Thromboembolism in Cancer Patients: A Population-Based Cohort Study

Introduction: The risk of venous thromboembolism (VTE) is increased in cancer patients, compared to subjects without cancer. The Khorana score (KS) is used to stratify VTE risk in cancer outpatients and recent society guidelines recommend thromboprophylaxis for patients with KS≥2. The burden of VTE in cancer, current use of thromboprophylaxis and performance of the KS in the Israeli setting are lacking. This data is needed to drive health-care policies regarding risk stratification and thromboprophylaxis. Aim: Define the clinical need for thromboprophylaxis in an Israeli population of cancer outpatients by determining the cumulative VTE incidence, VTE risk factors and anticoagulation (AC) use. Methods: This retrospective cohort study was conducted using the comprehensive computerized patient-level databases of Maccabi Healthcare Services (MHS), a nationwide healthcare insurer-provider organization for a quarter of the population in Israel, including 2.4 million members. All newly diagnosed cancer patients aged ≥18 years identified from the MHS cancer registry (excluding non-melanoma skin cancer) who initiated systemic anti-cancer treatment between 2010 and 2018 were included in the study. The cancer registry includes patients with cancer diagnostic codes from the Israel Ministry of Health, linked to cancer medication approvals and pathology reports. Subjects with prior VTE or AC within 3 months prior index were excluded. Patients were indexed on the first day of anti-cancer treatment and baseline variables were extracted, as well as data on AC post-index. The KS was used to stratify VTE risk as low (0-1) or high (≥2) at index. The main outcome was VTE at any site, defined using a validated algorithm based on diagnostic codes and AC prescription data (Sanfilippo et al, Thrombosis Research 135 (2015)). Cumulative incidence of VTE (95% confidence intervals [CI]) at 12 months was calculated and stratified for KS risk group. Univariate and multivariate analysis identified associations between baseline variables and VTE within 12 months. Results: The study cohort included 15,388 cancer patients of whom 35% were female with a mean age 58.8 (SD 13.6) years, 85% had a solid tumor, and 46% received chemotherapy as the index anti-cancer therapy. Of these, 338 (2.2%) had a VTE within one year after cancer diagnosis (24% pulmonary embolism with or without deep vein thrombosis [DVT], 76% DVT). Table 1 shows baseline characteristics according to VTE status at 12 months. The 12-month cumulative incidence of VTE (95% CI) was 2.3% (2.1%-2.6%) overall, 1.6% (1.3%-1.8%) in the low-risk KS group and 5.6% (4.7%-6.4%) in the high-risk KS group, as shown in Figure 1. A multivariate model considered baseline variables shown in Table 1, as well as socioeconomic status, year of diagnosis, district and use of granulocyte colony stimulating factors. In this multivariate model, the following variables were associated with increased risk of VTE in the first year since index date: females, subjects living in the south of Israel, older age, increasing co-morbidity, and high KS. All non-chemotherapy anti-cancer treatments were associated with decreased VTE risk, compared to chemotherapy. Table 2 shows the hazard ratios with 95% CI. A total of 2896 patients (19%) initiated prophylactic AC after index date (LMWH/unfractionated heparin (UFH) in 2452 (85%)). Among patients with a VTE at any time post-index, 574 (90%) started AC within a median of 2 days (IQR: 0,7) after VTE diagnosis. AC used to treat cancer-associated VTE (defined as AC class 30-days post VTE diagnosis) included LMWH/UFH in 341(74%), direct oral anticoagulant in 74 (16%) and vitamin K antagonists in 43 (9%). Median time on AC after index VTE was 22.1 months (95% CI 17.2-38.4). Conclusion: This study confirms that the Khorana score identifies a population of cancer outpatients at higher risk of VTE, and that patients receiving chemotherapy are at highest risk. The association between VTE risk and geographical location in Israel suggests possible health care disparities. The majority of cancer patients with VTE received long term therapy with LMWH. Funding: This research was sponsored by Pfizer Conflict of Interest Statement: A. Leader is an employee of Rabin Medical Center who was paid as a consultant to Pfizer in connection with this study. O. Friedman-Mazursky &amp; M. Tirosh are employees of Pfizer Israel. The remaining authors declare no conflict of interest. Disclosures Friedman: Pfizer Pharmaceuticals Israel Ltd.: Current Employment. Tirosh:Pfizer Pharmaceuticals Israel Ltd.: Current Employment. Chodick:Novartis Pharma AG: Other: Institutional grant. Leader:Bayer Healthcare: Other: personal fees ; Pfizer Pharmaceuticals Israel Ltd.: Consultancy, Honoraria, Other: personal fees .

Venous thromboembolism following 672,495 primary total shoulder and elbow replacements: Meta-analyses of incidence, temporal trends and potential risk factors

BackgroundThere is wide variability in reported venous thromboembolism (VTE) incidence following total shoulder replacement (TSR) or total elbow replacement (TER). It is uncertain which risk factors influence the risk of VTE following TSR or TER. We conducted a PRISMA compliant meta-analysis to evaluate the incidence, temporal trends and potential risk factors for VTE following primary TSR and TER. MethodsMEDLINE, Embase, Web of Science, and Cochrane Library were searched to September 2019 for longitudinal studies reporting VTE outcomes after TSR or TER. Incidence and relative risks (RR) (95% confidence intervals) were estimated. ResultsWe identified 43 articles with data on 672,495 TSRs and TERs (668,699 TSRs and 3796 TERs). The overall pooled 3-month VTE incidence following TSR was 0.85% (0.39–1.46). For TER, the 3-month incidence of VTE was 0.23% (0.08–0.44). Older age, body mass index (BMI) ≥25 kg/m2, and alcohol abuse were each associated with increased VTE risk following TSR. Comorbidities associated with increased VTE risk following TSR were chronic pulmonary disease, previous VTE, heart failure, anaemia, coagulopathy, arrhythmia, epilepsy, urinary tract infection, sleep apnoea, and fluid & electrolyte imbalance. Anatomic and outpatient TSR were each associated with decreased VTE risk. ConclusionsThe average 3-month incidence of VTE following TSR or TER is <1%. High risk groups such as older patients, those with a previous VTE history and those undergoing reverse or inpatient TSR may need close monitoring. Modifiable factors such as high BMI, alcohol abuse, and comorbidities could be identified and addressed prior to surgery. Systematic review registrationPROSPERO 2019: CRD42019134096.

Association of statins, aspirin, and venous thromboembolism in women with endometrial cancer

ObjectiveThe anti-thrombogenic effects of statins and aspirin have been reported in various malignancies but have not been well examined in endometrial cancer. This study examined the association between statin and/or aspirin use and venous thromboembolism (VTE) risk in endometrial cancer. MethodsThis is a multi-center retrospective study examining 2527 women with endometrial cancer between 2000 and 2015. Statin and aspirin use at diagnosis was correlated to VTE risk during follow-up on multivariable analysis. ResultsThere were 132 VTE events with a 5-year cumulative incidence rate of 6.1%. There were 392 (15.5%) statin users and 219 (8.7%) aspirin users, respectively. On multivariable analysis, statin use was associated with an approximately 60% decreased risk of VTE when compared to non-users (5-year cumulative rates 2.5% versus 6.7%, adjusted-hazard ratio [HR] 0.42, 95% confidence interval [CI] 0.19–0.92, P = 0.030) whereas aspirin did not demonstrate statistical significance (2.0% versus 6.5%, adjusted-HR 0.54, 95%CI 0.19–1.51, P = 0.24). There was a trend of joint effect between statin and aspirin although it did not demonstrate statistical significance: VTE risks for dual statin/aspirin user (adjusted-HR 0.27, 95%CI 0.04–2.07), statin alone (adjusted-HR 0.40, 95%CI 0.18–0.93), and aspirin alone (adjusted-HR 0.51, 95%CI 0.16–1.64) compared to non-use after adjusting for patient characteristics, tumor factors, treatment types, and survival events (P-interaction = 0.090). When stratified by statin type, simvastatin demonstrated the largest reduction of VTE risk (5-year cumulative rates 1.1% versus 6.7%, adjusted-HR 0.17, 95%CI 0.02–1.30, P = 0.088). Obesity, absence of diabetes mellitus, type II histology, and recurrent disease were the factors associated with decreased VTE risk with statin use (all, P-interaction<0.05). ConclusionOur study suggests that statin use may be associated with decreased risk of VTE in women with endometrial cancer.

Interaction of a genetic risk score with physical activity, physical inactivity, and body mass index in relation to venous thromboembolism risk.

Venous thromboembolism (VTE) is highly heritable. Physical activity, physical inactivity and body mass index (BMI) are also risk factors, but evidence of interaction between genetic and environmental risk factors is limited. Data on 2,134 VTE cases and 3,890 matched controls were obtained from the Nurses' Health Study (NHS), Nurses' Health Study II (NHS II), and Health Professionals Follow-up Study (HPFS). We calculated a weighted genetic risk score (wGRS) using 16 single nucleotide polymorphisms associated with VTE risk in published genome-wide association studies (GWAS). Data on three risk factors, physical activity (metabolic equivalent [MET] hours per week), physical inactivity (sitting hours per week) and BMI, were obtained from biennial questionnaires. VTE cases were incident since cohort inception; controls were matched to cases on age, cohort, and genotype array. Using conditional logistic regression, we assessed joint effects and interaction effects on both additive and multiplicative scales. We also ran models using continuous wGRS stratified by risk-factor categories. We observed a supra-additive interaction between wGRS and BMI. Having both high wGRS and high BMI was associated with a 3.4-fold greater risk of VTE (relative excess risk due to interaction=0.69, p=0.046). However, we did not find evidence for a multiplicative interaction with BMI. No interactions were observed for physical activity or inactivity. We found a synergetic effect between a genetic risk score and high BMI on the risk of VTE. Intervention efforts lowering BMI to decrease VTE risk may have particularly large beneficial effects among individuals with high genetic risk.

Surgical Duration Impacts Venous Thromboembolism Risk in Microsurgical Breast Reconstruction.

Increased surgical duration can impact patient outcomes and operative efficiency metrics. In particular, there are studies suggesting that increased surgical duration can increase the risk of venous thromboembolism (VTE). One of the longer duration plastic surgery procedures commonly performed is microsurgical breast reconstruction. With the widening indications for multiple and "stacked" free flaps to reconstruct breasts, we endeavored to assess (1) the relationship between duration of microsurgical breast reconstruction and VTE; and (2) determine if a threshold operative time exists that connotes VTE higher risk. Patients from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) between 2005 and 2014 who underwent microsurgical breast reconstruction were identified by Current Procedural Terminology code. Three models of multivariate logistic regression were used to characterize the adjusted risk for VTE by operative duration, bilaterality, the length of stay, and patient demographics. A total of 4,782 patients who underwent microsurgical breast reconstruction were identified. Overall VTE incidence was 1.13%. The mean operative duration was 8:31 hours:minutes (standard deviation: 2:59). Operative duration was statistically associated with VTE in continuous, quintile, and dichotomized risk models. Beyond an operative duration of 11 hours, adjusted VTE risk increases fourfold corresponding to a number needed to harm of 45.8. Increasing surgical duration heightens the risk of VTE in microsurgical breast reconstruction. Increasing body mass index and age enhances this VTE risk. Moreover, limiting surgical duration to 11 hours or less can decrease VTE risk by fourfold vis-à-vis baseline. Risk, II.

Prophylaxis of venous thromboembolism in knee replacement surgery

Venous thromboembolism (VTE) is still a frequent and sometimes severe complication after knee replacement surgery. Both pharmacological and non-pharmacological measures have been widely used to decrease VTE risk. Non pharmacological treatment include measures directed to decrease the effects of blood stasis, intermittent pneumatic compression device (IPCD) and graduated compression stockings, and mechanical devices. Pharmacological prophylaxis of venous thromboembolism (VTE) is associated with a more significant decrease in the incidence of deep venous thrombosis (DVT) and related complications after knee arthroplasty however anticoagulation may increase the risk of postoperative bleeding and related complications, in particular the need for re-intervention. Aim of present review was to suggest practical approach to DVT prophylaxis in patients undergoing knee arthroplasty

Association of Nonalcoholic Fatty Liver Disease and Venous Thromboembolism in Women With Endometrial Cancer

Recent studies have demonstrated that surgical menopause results in a significantly increased risk of nonalcoholic fatty liver disease (NAFLD) in women with endometrial cancer. In addition, venous thromboembolism (VTE) is known to be one of the major prognostic factors for decreased survival in endometrial cancer. Given the fact that coagulation factors are produced in the liver, the correlation between NAFLD and VTE was examined in endometrial cancer. A retrospective study was conducted to examine patients with endometrial cancer who underwent surgical staging including oophorectomy between 2000 and 2013 (n = 714). Cumulative risk of VTE was examined based on the NAFLD status. A Cox proportional hazard regression model was used to determine the independent risk predictors of VTE. Venous thromboembolism and NAFLD were seen in 57 (8.0%) and 181 (25.4%) cases, respectively. Two-year cumulative risks of VTE and NAFLD were 7.9% and 19.3%, respectively. In univariate analysis, VTE was significantly associated with decreased disease-free survival (2-year rate, 43.6% vs 91.4%, P < .001) and overall survival (65.8% vs 96.8%, P < .001), whereas NAFLD was associated with decreased risk of VTE (1.7% vs 10.4%, P < .001). In multivariate analysis controlling for clinicopathological factors, NAFLD remained an independent predictor of decreased risk of VTE (hazard ratio [HR]: 0.24, 95% confidence interval [CI]: 0.07-0.79, P = .02). Thrombocytosis (HR: 2.30, 95% CI: 1.22-4.35, P = .01), cancer antigen 125 ≥ 35 (HR: 3.81, 95% CI: 1.78-8.17, P < .001), and recurrent disease (HR: 4.57, 95% CI: 1.97-10.6, P < .001) remained as independent predictors of increased risk of VTE. Our results suggest that NAFLD may be associated with decreased VTE risk in women with endometrial cancer.

Quality improvement program reduces venous thromboembolism in infants and children with long-gap esophageal atresia (LGEA).

Patients with long-gap esophageal atresia (LGEA) treated with the Foker process are at increased risk of venous thromboembolism (VTE). An institutional quality improvement program to decrease VTE risk factor exposure and utilize prophylactic anticoagulation was implemented. We aim to evaluate the efficacy and safety of a VTE risk-reduction program in patients with LGEA. Implementation and evaluation of a VTE risk-reduction program in patients with LGEA from 2012 to 2015 was performed. Symptomatic VTE with radiographic confirmation were defined as events. Post-program characteristics were evaluated and compared to a historical cohort. Sixty-seven patients were identified. Two developed VTE (7%) post-program implementation; compared to 13/40 (33%) VTE incidence in the historical cohort (p=0.018). Baseline demographics were similar, including age, esophageal atresia type and gap length. Post-protocol patients had fewer paralysis episodes (p=0.004), paralysis days (p=0.003), central venous catheters (p=0.003), thoracotomies (p<0.001), ventilator hours (p=0.02), and decreased hospital (p<0.001) and ICU stay (p<0.001). All patients in the VTE risk-reduction program were exposed to prophylactic anticoagulation. No bleeding complications and/or thrombosis-related mortality occurred. VTE risk-reduction program implementation decreased symptomatic VTE incidence with associated decreases in ICU and hospital length of stay. Prophylactic anticoagulation can be utilized safely in a complicated pediatric surgical population.

PROPHYLAXIS OF VENOUS THROMBOEMBOLISM IN KNEE REPLACEMENT SURGERY

Venous thromboembolism (VTE) is still a frequent and sometimes severe complication after knee replacement surgery. Both pharmacological and non-pharmacological measures have been widely used to decrease VTE risk. Non pharmacological treatment include measures directed to decrease the effects of blood stasis, intermittent pneumatic compression device (IPCD) and graduated compression stockings, and mechanical devices. Pharmacological prophylaxis of venous thromboembolism (VTE) is associated with a more significant decrease in the incidence of deep venous thrombosis (DVT) and related complications after knee arthroplasty however anticoagulation may increase the risk of postoperative bleeding and related complications, in particular the need for re-intervention. Aim of present review was to suggest practical approach to DVT prophylaxis in patients undergoing knee arthroplasty. Although parenteral drugs (low dose unfractionated heparin, low molecular weight heparin and fondaparinux) are the more frequently employed agents, limited compliance may be a concern. Recent studies suggest that direct oral anticoagulants, antithrombin and anti Xa agent, might be a useful alternative although safety may limited by an higher rate of local bleeding.

Alcohol consumption and venous thromboembolism: friend or foe?

A light to moderate consumption of certain types of alcoholic beverages may exert a favorable effect on cardiovascular risk, but no conclusive information is available on the putative relationship between alcohol intake and the risk of venous thromboembolism (VTE). We performed an electronic search on Medline and Scopus, using the keywords "venous thromboembolism", "venous thrombosis" and "alcohol", to identify clinical studies linking alcohol intake and VTE risk. The literature search generated 16 studies, 4 of which are case-control, 1 cross-sectional and 11 prospective. Significant reduction of VTE associated with alcohol intake is observed in only 4/16 studies, and in all these the association is only meaningful for a moderate amount of alcohol (i.e., 2-4 glasses). Unlike these trials, two other studies observe that alcohol intake is associated with an increased risk of VTE, whereas the association is insignificant in the remainder. Binge drinking increases the VTE risk in one study but not in another. The consumption of beer is associated with a decreased VTE risk in one study but not in two others. We hence conclude that the relationship between intake of alcoholic beverages and increased or decreased risk of VTE is largely elusive.

Is lipid lowering therapy an independent risk factor for venous thromboembolism? A population-based case–control study

IntroductionThe independent effect of lipid lowering therapy (LLT) on venous thromboembolism (VTE) risk is uncertain. ObjectiveTo test statin and non-statin LLT as potential VTE risk factors. MethodsUsing Rochester Epidemiology Project resources, we identified all Olmsted County, MN residents with objectively diagnosed incident VTE (cases) over the 13-year period, 1988–2000 (n=1340), and one to two matched controls (n=1538). We reviewed their complete medical records for baseline characteristics previously identified as independent VTE risk factors, and for statin and non-statin LLT. Using conditional logistic regression, we tested the overall effect of LLT on VTE risk and also separately explored the role of statin versus that of non-statin LLT, adjusting for other baseline characteristics. ResultsAmong cases and controls, 74 and 111 received statin LLT, and 32 and 50 received non-statin LLT, respectively. Univariately, and after individually controlling for other potential VTE risk factors (i.e., BMI, trauma/fracture, leg paresis, hospitalization for surgery or medical illness, nursing home residence, active cancer, central venous catheter, varicose veins, prior superficial vein thrombosis, diabetes, congestive heart failure, angina/myocardial infarction, stroke, peripheral vascular disease, smoking, anticoagulation), LLT was associated with decreased odds of VTE (unadjusted OR=0.73; p=0.03). When considered separately, statin and non-statin LLT were each associated with moderate, non-significant lower odds of VTE. After adjusting for angina/myocardial infarction, each was significantly associated with decreased odds of VTE (OR=0.63, p<0.01 and OR=0.61, p=0.04, respectively). ConclusionsLLT is associated with decreased VTE risk after adjusting for known risk factors.

A prediction model for surgical mortality and serious morbidity after primary debulking surgery

Objectives: The objective of this study was to determine the frequency of venous thromboembolism (VTE) in surgical gynecologic oncology patients, stratified by origin of malignancy. Methods: Using the American College of Surgeons National Surgical Quality Improvement Program database, 104,368 gynecologic surgeries were identified from 2006 to 2012. Patient demographics, 30day postoperative complications, and operative diagnosis were abstracted. Patients were stratified by origin of gynecologic malignancy. The primary outcome was the frequency of VTE. Institutional Board Review exemption was obtained. Results: A total of 104,368 gynecologic surgeries were identified and found to have a frequency of deep venous thrombosis (DVT) of 2.3 in 1000 (n= 242) and a frequency of pulmonary embolism (PE) of 2.9 in 1000 (n= 299). One-fifth (n= 49) of patients with DVT had a simultaneous PE. Of all gynecologic surgeries, 1.6% (n= 1657) were performed for ovarian cancer; 3.8% (3941) for uterine cancer; 0.6% (n= 619) for cervical cancer; and 0.3% (n= 310) for vulvar cancer. The rate of DVT observedwithin the ovarian cancer groupwas 1.9% (n= 32) compared to 0.9% (n= 37) in the uterine cancer group; and for PE was 1.3% (n= 21) and 1.1% (n= 42), respectively. The odds ratio (OR) of postoperative DVT in ovarian cancer compared to all gynecologic surgeries was 9.41 (CI, 6.25–13.73). When comparing ovarian cancer to uterine cancer, the adjusted OR of postoperative DVT was 1.899 (CI, 1.12–3.22, P=0.017), while the OR of PE was 9.31 (CI 6.54–12.96). In contrast, there were only three DVTs and two PEs within the cervical cancer group and no DVTs or PEs within the vulvar cancer group. Conclusions: The incidence of VTE among postoperative gynecologic patients is higher for ovarian cancer patients compared to other gynecologic malignancies in current clinical practice, based on this nationally representative cohort. This surgical sentinel event may not be able to be completely eliminated in this higher-risk population. However, continued attention must be directed to decrease VTE risk and to develop feasible benchmarks and clinical practice guidelines in conjunction with national organizations such as the Joint Commission.

Vasculopathy Associated with the Antiphospholipid Antibody Syndrome

Antiphospholipid antibodies including the false-positive serologic test for syphilis, the lupus circulating anticoagulant, and the anticardiolipin antibody can be associated with recurrent thrombotic events, recurrent fetal loss, and thrombocytopenia. A range of other possible clinical associations also exists, including neurologic events, skin lesions, and cardiac lesions. The pathology of these lesions and the pathophysiology are discussed. Treatment is controversial but when indicated is directed toward prevention of recurrent episodes using anticoagulants including antiplatelet agents, warfarin, and heparin as well as occasionally prednisone with or without immunosuppressive agents.