Graded Compression Stockings Research Articles

Advances in the use of neuromuscular electrical stimulation in the prevention of venous thromboembolism

Pharmacologic prophylaxis is the most commonly used prophylaxis for venous thromboembolism (VTE), but the pharmacologic prophylaxis is limited in patients at high risk of bleeding. Mechanical prophylaxis alone or in combination is an important method of VTE prophylaxis in patients at high risk of bleeding, but the current mainstream mechanical prophylaxis, which includes graded compression stockings, intermittent inflatable compression pumps and plantar venous compression pumps, has some limitations, leading to discomfort for patients wearing them due to the large contact area, and even affecting ability to perform daily activities. Many clinical studies have found that NMES combined with pharmacological prophylaxis has better efficacy and safety than pharmacological prophylaxis alone in preventing VTE in medical and surgical patients, and the preventive effect of NMES alone is not inferior to other mechanical prophylaxis. Besides, it also has the advantages of ease of wear and patient compliance. Currently, clinicians have limited experience and knowledge of NMES. We aimed to present the rationale, progress in clinical research and future perspective of NMES in VTE prophylaxis.

Overlap of histological features of pigmented purpuric dermatosis and kaposi sarcoma – pseudo kaposi sarcoma

Pseudokaposi sarcoma can be congenital or acquired. Due to prolonged venous stasis, leads to peripheral tissue hypoxemia, which results in neovascularisation and fibroblast proliferation. Treatment includes rectification of the underlying pathology such as graded compression stockings or compression pumps for venous stasis and ulcer management with regular wound care. Medical management includes oral antibiotics, along with compression therapy with good results. Our patient presented mild lower limb pitting edema unilaterally with erythematous barely elevated plaque over the anterior aspect of the lower limb.

Klippel-trenaunay syndrome: A rare case presenting in a 5-year-old girl

A 5-year-old child presented with progressive right calf swelling for 4 years and a year history of pain at the same site. There was no skin discoloration. Doppler ultrasound scan and venography of the affected leg showed soft-tissue gigantism and anomalous venous drainage of the right leg with multiple tortuous varicose veins and venous aneurysm. The deep right calf veins were anomalous but ipsilateral popliteal and femoral veins were preserved. The arterial system of the right lower limb was preserved; no arteriovenous malformation was seen, and no limb length discrepancy or evidence of bone involvement was observed. The diagnosis of Klippel-Trenaunay syndrome was made based on the above clinical and radiological features. After due consultations with the pediatrician and orthopedic surgeon, she was commenced on analgesic and application of graded compression stockings, and she's doing well.

Graded compression stockings and deep vein thrombosis

Die Wirkung der Kompressionstherapie bei tiefer Bein- und Beckenvenenthrombose (TVT) ist vielschichtig. Sie reicht von der Odemreduktion uber die Schmerzlinderung bis zur Verhinderung eines postthrombotischen Syndroms. Auf was mussen Sie bei der Verordnung achten?

The management of secondary lower limb lymphoedema in cancer patients: A systematic review

Background: Lower limb lymphoedema is a recognised complication of cancer commonly encountered in palliative care, associated with reduced mobility and poor quality of life. Aim: To evaluate the available evidence for the treatment of secondary lower limb lymphoedema in patients with malignancies. Design: A systematic review of the literature. Data sources: The MEDLINE, Embase, LILACS, Science Citation Index, Cochrane Databases and conference proceedings for published data from date of inception to July 2014 were searched. Relevant unpublished studies via relevant databases, Internet searches and hand-searches of the bibliographies of relevant papers were performed. Results: From 1617 citations, 32 papers were selected for full-text assessment. Two randomised trials and five observational studies were identified. The two randomised controlled trials evaluated graded compression stockings and Coumarin capsules, respectively. The five observational studies evaluated lymphovenous microsurgical shunts, pneumatic compression devices, compression bandages alone, manual lymphatic drainage with compression and a herbal remedy combining Coumarin, Ginkgo and Melitoto (with or without manual lymphatic drainage), respectively. The extracted studies showed substantial heterogeneity. Hence, a meta-analysis was inappropriate and not performed. Conclusion: Few studies have evaluated the clinical effectiveness and potential side effects of treatments for lower limb lymphoedema. Moreover, symptoms and quality-of-life assessments were inconsistently reported. All included studies report lower limb volume reduction after treatment, which includes complex decongestion therapy, graded compression stockings and lymphovenous microsurgical shunts. Adequately powered randomised controlled trials of these interventions are recommended. Effort should be made to establish standardised outcomes, to minimise bias and to improve reporting quality in future trials of treatment for lower limb lymphoedema.

8:27 AM Abstract No. 23 - Same day endovascular therapy for lower extremity deep venous thrombosis: technique and initial results

Treatment of deep venous thrombosis(DVT) using catheter-directed thrombolysis (CDT) has been limited by long procedure time and associated high costs, high doses of thrombolytics, and increased utilization of intensive ICU monitoring. The purpose of this study is to describe a single center technique of same day pharmacomechanical catheter-directed thrombolysis (PCDT) for lower extremity DVT. A single center retrospective review was performed on 39 consecutive patients (25 males and 14 females; mean age 51; range 18-84) treated with PDCT in a single day without ICU admission. Technique included power pulse spray with Angioget (Bayer Healthcare, Warrendale, PA) thrombectomy followed by short duration CDT and second session venoplasty and stenting. All patients received at least 6 months of anticoagulation and graded compression stockings post procedure. Data collected included: patient demographics, procedural technical success (defined as 1- the ability to successfully cross the occlusion and 2- restoration of flow to the IVC), major and minor adverse events up to 30 days, freedom from reintervention (FFR) as well as 1 and 6 month follow-up with ultrasound or clinical examination. 15 patients with acute DVT (<14 days), 8 patients with subacute DVT (14-28 days) and 17 patients with chronic DVT (>28 days) were treated. DVT location included: iliocaval (n=10), iliofemoral (n=23) and femoropopliteal (n=6). Technical success was achieved in all cases. FFR was 76%. Reintervention was successfully performed in 10/10 patients (100%). One and six month follow-up was obtained for 32/39 patients (82%) with 72% (23/32) and 56% (18/32) patency at 1 and 6 months, respectively. Adverse events were noted in 5 patients (13%) including breast hematoma, groin hematoma, rapid atrial fibrillation, contrast-induced nephropathy, and death (unrelated to the procedure). Same day PDCT without ICU admission for lower extremity DVT is feasible with high technical success and FFR. Adverse events are rare. Further studies are needed to demonstrate long-term vessel patency as well as reduction in the incidence of post-thrombotic syndrome.

EPA-1006 - An audit into venous thromboembolism (VTE) risk assessment. a potential silent killer in old age psychiatry

Introduction It is estimated that 25,000 people in the UK die from preventable hospital-acquired venous thromboembolism (VTE) every year. Patients admitted to Old Age Psychiatric units clearly posses numerous risk factors relating to developing VTE. Aim/Objective The aim was to study inpatients admitted to the old age psychiatric unit and see if NICE and Department Of Health guidelines are being followed in relation to VTE (Venous thromboembolism) risk assessment and prophylaxis. Methods A prospective opportunistic sample of all the inpatients in the old age psychiatric unit during a 2 week period was audited. Standards were based on the NICE and Department Of Health guidelines. Results 13% of patients developed a deep vein thrombosis during the admission period audited. No patients had a VTE risk assessment completed on admission. Every patient had at least one risk factor for developing DVT (deep vein thromboembolism) due to being over 65 years old. 93% had at least 2 risk factors and 63% had at least 3 risk factors. Despite this no patients were treated prophylactically with graded compression stockings or enoxaparin. Conclusions It was evident that VTE risk assessment and prophylaxis was not something that was being considered for patients admitted to the old age psychiatric inpatient unit. However due to the risk factors this group of patients possess it is something vitally important. As a consequence of presenting the audit across the trust a service change was recommended with a VTE risk assessment planned to be introduced across the trust.

Compliance with thromboprophylaxis – a patient satisfaction survey

Pulmonary embolism accounts for 11% of maternal deaths in the UK; frequently risk factors for venous thromboembolism (VTE) were identified. The RCOG now recommends that all pregnant women be appropriately...

Venous Thromboembolism in Abdominoplasty: A Comprehensive Approach to Lower Procedural Risk

Venous thromboembolism (VTE) is a serious and potentially life-threatening surgical complication. However, there is little consensus regarding appropriate VTE prophylaxis for plastic surgery patients. Risk factors as they apply to plastic surgery patients are unclear, and recent recommendations for chemoprophylaxis in these patients may expose them to other additional risks. The authors examine perioperative and intraoperative measures, specifically those that have enabled a large number of patients to undergo outpatient abdominoplasty safely, with a reduced risk of VTE. A retrospective review was performed of 404 consecutive abdominoplasty patients who were treated at a single outpatient surgery center between 2000 and 2010. Graded compression stockings and intermittent pneumatic compression devices were placed on all patients, and perioperative and intraoperative warming was strictly applied. Progressive tension suturing technique was performed in all cases and drains were eliminated. All patients received pain pumps, ambulated within one hour of surgery, and were discharged home the same day. Patient VTE risk factors were scored with the Caprini/Davison risk assessment model (RAM). Perioperative and intraoperative measures were taken to reduce factors that may increase VTE risk in abdominoplasty. Complications were recorded, including VTE events, seromas, hematomas, and infections. In this series, 247 abdominoplasty procedures were performed alone and 157 were combined with additional procedures. Under the RAM, 297 patients were considered "high risk" and 17 "highest risk." Abdominoplasty operative time was 100 ± 29 minutes. Only one case of deep vein thrombosis (DVT) occurred, in the calf. A comprehensive approach to perioperative and intraoperative patient care has allowed outpatient abdominoplasty to be safely performed without VTE chemoprophylaxis in patients with fewer than six risk factors.

Prevention of Venous Thromboembolic Events After Gynecologic Surgery

Venous thromboembolic events (deep vein thrombosis [DVT] and pulmonary embolism) are serious preventable complications associated with gynecologic surgery. Preoperative risk assessment of the individual patient will provide insight into the level of risk and the potential benefits of prophylaxis. Common risks include a history of venous thromboembolism, age, major surgery, cancer, use of oral contraceptives or hormone therapy, and obesity. Based on the presence of risk factors, the patient should be categorized into one of four risk groups and appropriate thromboprophylaxis prescribed. Randomized clinical trials in gynecologic surgery and general surgery have established the significant value of thromboprophylaxis. For moderate- and high-risk patients undergoing surgery for benign gynecologic conditions, low-dose unfractionated heparin, low molecular weight (LMW) heparins, intermittent pneumatic leg compression, and graded compression stockings all have demonstrated benefit. If using low-dose unfractionated heparin in high-risk patients, the heparin should be administered 5,000 units every 8 hours. Because DVT often begins in the perioperative period, it is important to initiate low-dose unfractionated heparin or administer the first LMW heparin dose either 2 hours preoperatively or 6 hours after the surgical procedure. Low molecular weight heparin has the advantage of being administered once daily but is more expensive than low-dose unfractionated heparin. In addition, LMW heparin has not been shown to be more effective and has similar risk of bleeding complications when compared with low-dose unfractionated heparin. In the very high-risk patient, a combination of two prophylactic methods may be advisable and continuing LMW heparin for 28 days postoperatively appears to be of added benefit.

A study of thromboprophylactic practices of Scottish orthopaedic surgeons in patients undergoing total hip replacements. Should practice change with new guidelines?

Despite increasing scientific investigation, the best method for preventing postoperative thromboembolism in patients undergoing a total hip replacement (THR) remains unclear. National Institute for Health and Clinical Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN) guidelines on the prevention of thromboembolism have caused much controversy. We surveyed Scottish surgeons regarding their thromboprophylaxis prescribing after THR. Questionnaires were sent to all Scottish orthopaedic consultants. They were asked about routine pharmacological and mechanical prophylaxis in patients undergoing a THR. Comparison was made with a previous survey done in 2003. The response rate was 75%. The survey showed an increased use of pharmacological prophylaxis from 93% to 100%. This was due to the increased use of aspirin from 51% to 64%. The use of low molecular weight heparin has remained constant at 51%. No surgeons routinely use warfarin, un-fractionated heparin or fondaparinux. Use of graded compression stockings has increased from 59% to 70%. In conclusion, there is increasing evidence that patients undergoing THR should receive extended prophylaxis for up to 35 days. Oral agents such as dabigatran and rivaroxaban have offered a new option for oral extended prescribing. The results in change of practice must be closely audited.

Prevention of Venous Thromboembolism: Focus on Mechanical Prophylaxis

Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, is a leading health-care problem whose pathogenesis is usually related to the so-called Virchow's triad and involves a variety of factors classified as inherited or acquired, predisposing, or triggers. The main goal of thromboprophylaxis is to reduce mortality and morbidity associated with VTE risk factors. Although striking evidence now indicates that the various pharmacological anticoagulant therapies can substantially lower the risk, this benefit might be offset by a small but definite risk of hemorrhage in some circumstances. Mechanical prophylaxis methods have been suggested because they counteract most of the components of the Virchow's triad and are not associated with any bleeding risk. Although early and frequent ambulation has been historically advised for preventing VTE, this measure is inadequate per se and frequently not feasible as the sole means of mechanical thromboprophylaxis. Accordingly, additional measures are being used in clinical practice, including graded compression stockings, intermittent pneumatic compression devices, and venous foot pumps. Although the efficiency of these measures has been extensively assessed in several clinical studies, there remain unanswered questions, including their suboptimal use and the lack of unequivocal clinical evidence supporting real benefits for preventing VTE. Overall, mechanical compression methods can reduce the risk of VTE by nearly two thirds when used as the only form of thromboprophylaxis and by about half when combined with a pharmacological approach. The main mechanism of action appears to be related to a milking (wavelike) effect to evacuate leg veins and reduce venous stasis because an effect on the enhancement of fibrinolysis remains unproven. Although the biological and clinical evidence suggests that graduate compression stockings are an effective, relatively cheap, and more comfortable thromboprophylactic measure, they appear less effective overall than intermittent pneumatic compression. In conclusion, although the preventive benefits of mechanical prophylaxis on VTE might be circumscribed to select medical and surgical settings, there appears to exist no clinical reason to discourage adoption of these measures when indicated.

Splanchnic Compression Improves the Efficacy of Compression Stockings to Prevent Orthostatic Intolerance

Purpose: Post-spaceflight orthostatic intolerance (OI) is observed in 20-30% of astronauts. Previous data from our laboratory suggests that this is largely a result of decreased venous return. Currently, NASA astronauts wear an anti-gravity suit (AGS) which consists of inflatable air bladders over the calves, thighs and abdomen, typically pressurized from 26 to 78 mmHg. We recently determined that, thigh-high graded compression stockings (JOBST , 55 mmHg at ankle, 6 mmHg at top of thigh) were effective, though to a lesser degree than the AGS. The purpose of this study was to evaluate the addition of splanchnic compression to prevent orthostatic intolerance. Methods: Ten healthy volunteers (6M, 4F) participated in three 80 head-up tilts on separate days while (1) normovolemic (2) hypovolemic w/ breast-high compression stockings (BS)(JOBST(R), 55 mmHg at the ankle, 6 mmHg at top of thigh, 12 mmHg over abdomen) (3) hypovolemic w/o stockings. Hypovolemia was induced by IV infusion of furosemide (0.5 mg/kg) and 48 hrs of a low salt diet to simulate plasma volume loss following space flight. Hypovolemic testing occurred 24 and 48 hrs after furosemide. One-way repeated measures ANOVA, with Bonferroni corrections, was used to test for differences in blood pressure and heart rate responses to head-up tilt, stand times were compared using a Kaplan-Meyer survival analysis. Results: BS were effective in preventing OI and presyncope in hypovolemic test subjects ( p = 0.015). BS prevented the decrease in systolic blood pressure seen during tilt in normovolemia (p < 0.001) and hypovolemia w/o countermeasure (p = 0.005). BS also prevented the decrease in diastolic blood pressure seen during tilt in normovolemia (p = 0.006) and hypovolemia w/o countermeasure (p = 0.041). Hypovolemia w/o countermeasure showed a higher tilt-induced heart rate increase (p = 0.022) than seen in normovolemia; heart rate while wearing BS was not different than normovolemia (p = 0.353). Conclusion: BS may be an effective countermeasure to post-space flight OI. The addition of splanchnic compression is more effective than the previous thigh-high garments. These stockings are readily available, inexpensive, and can be worn for days following landing as astronauts re-adapt to Earth gravity.

Graded Compression Stockings Prevent Post-spaceflight Orthostatic Hypotension

Post-spaceflight orthostatic intolerance is characterized by hypotension and presyncope in 20-30% of returning astronauts. Previous data from our laboratory suggests that this is largely a result of decreased venous return. Currently, NASA astronauts wear an anti-gravity suit (AGS) which consists of inflatable air bladders over the calves, thighs and abdomen, which are typically pressurized from 0.5 to 1.5 PSI (~27 to 78 mmHg). ISS crew members sometimes wear Russian Kentavr suits which consist of laced compression shorts and gaiters, providing ~30 mmHg nominally. While these garments are effective during reentry, there are a number of drawbacks that make them impractical for postflight use. We studied the ability of commercially available, custom fit, graded compression stockings (Jobst, 55 mmHg at ankle to 6 mmHg at top of thigh, 25 mmHg mean compression) to prevent postflight orthostatic intolerance, hypothesizing that these garments would prevent orthostatic intolerance following short duration space flight. Crew members from a single Space Shuttle flight were tilted to 80 degrees for 10 min while wearing the stockings (n=5 males) upon arrival at the clinic (~2 hrs after landing). Hemodynamic data were compared to data from all crewmembers tilted (without countermeasures) since return to flight (n=9). Two-way, repeated measures ANOVA, using the entire tilt time curve (0-10 min) show that systolic blood pressure (SBP, group effect p=0.008), stroke volume (SV, group effect p=0.003), and cardiac output (CO, group effect p=0.004) were higher in crewmembers who wore the Jobst stockings. A one-way ANOVA comparing the last minute standing also showed that SV (p=0.001) and CO (p less than 0.001) were higher and SBP tended to be higher (p=0.06) in Jobst subjects compared to controls. Control subjects had a higher rate of presyncope than Jobst subjects (3/9 vs 0/5) during the tilt on landing day. Orthostatic hypotension continues to present following spaceflight, despite fluid loading and other countermeasures. This preliminary study shows that commercially available compression stockings may ameliorate this problem. These stockings are readily available, inexpensive, and can be worn for days following landing. We have observed similar protection against orthostatic intolerance in ground-based studies of hypovolemic test subjects. Further refinements to the design and compression of the stockings are in progress.

Thromboprophylaxis following Surgery for Colorectal Cancer — Is it Worthwhile after Hospital Discharge?

The efficacy of low-molecular-weight heparin (LMWH) in preventing venous thromboembolism (VTE) after surgery for colorectal cancer is well documented, but the optimal duration of postoperative thromboprophylaxis is not known. The aim of this retrospective study was to assess the occurrence of symptomatic VTE after surgery for colorectal cancer in patients in whom LMWH was continued only until hospital discharge. During 2003-2006 a total of 494 patients underwent abdominal surgery for colorectal cancer at our institution. Enoxaparin (Klexane 40mg s.c.) prophylaxis was started 12 hours before surgery and continued once a day until hospital discharge. The median duration of thromboprophylaxis was 11 days. The follow-up data were collected retrospectively from electronic archives and analyzed up to three months after the operation. Only three (0.6%) symptomatic VTEs occurred during the follow-up period. One patient presented with pulmonary embolism, while the remaining two had proximal deep-vein thrombosis. The 30-day-mortality was 1.6%. None of the deaths were obviously associated with VTE. LMWH given for a median of 11 days until hospital discharge seems to provide sufficient thromboprophylaxis after surgery for colorectal cancer combined with the use of graded compression stockings and early mobilization.

Treatment of chronic venous insufficiency

Chronic venous insufficiency (CVI) results from venous hypertension secondary to superficial or deep venous valvular reflux. Treatment modalities are aimed at reducing venous valvular reflux, thereby inhibiting the ensuing pathologic inflammatory process. Compression therapy using pumps, bandaging, and/or graded compression stockings is the mainstay of treatment for CVI. Compression therapy has been shown to be effective in reducing venous hypertension retarding the development of inflammation and pathologic skin changes. Pharmacologic agents such as diuretics and topical steroid creams reduce swelling and pain short term but offer no long-term treatment advantage. Herbal supplements may reduce the inflammatory response to venous hypertension, but are not licensed by the US Food and Drug Administration, and vary in their efficacy, quality, and safety. However, several randomized controlled trials using the herbal horse chestnut seed extract containing aescin have shown short-term improvement in signs and symptoms of CVI. Endovascular and surgical techniques aimed at treatment of primary and secondary venous valvular reflux have been shown to improve venous hemodynamics promoting healing of venous ulcers and improving quality of life. The newer endovascular treatments of varicose veins using laser, radiofrequency ablation, and chemical foam sclerotherapy show some promise.

Catheter-Directed Thrombolysis for the Management of Postpartum Deep Venous Thrombosis

Women are at their highest risk of developing venous thromboembolism, still the most important cause of maternal mortality in developed countries, during the postpartum period. Acute deep venous thrombosis (DVT) causes significant morbidity, chiefly as a result of postthrombotic syndrome. Heparin anticoagulation can prevent pulmonary embolism but leads to thrombolysis in fewer than 15% of patients with DVT and does not protect against postthrombotic syndrome. Catheter-directed thrombolysis, combined with angioplasty and stent placement when indicated, removes thrombus and restores venous patency. This treatment has, however, been avoided during and after pregnancy because of an increased risk of placental abruption and bleeding complications as well as fetal exposure to radiation. The investigators performed this procedure in 5 women having acute postpartum DVT within 6 weeks of delivery and for less than 3 weeks. The diagnosis was confirmed by color Doppler ultrasound and/or venography. Patients received low-molecular-weight heparin when diagnosed as having DVT. With the patient prone on an angiography table, the ipsilateral popliteal vein was entered with a 6-F microaccess set under ultrasound guidance using a 21-G needle and a guidewire 0.46 mm in diameter. Ascending venography was performed and, using a sidearm sheath and 5-F angled endhole catheter, a 0.89-mm hydrophilic guidewire was passed into the inferior vena cava. The endhole catheter than was replaced with a 5-F multisideholed catheter that was embedded in the thrombus. A recombinant human tissue plasminogen activator, alteplase, was infused for up to 24 hours. Unfractionated heparin also was infused. Doses were adjusted to maintain a fibrinogen level above 1 g/L and cephotest of 50s to 70s. Venography was repeated after 20–24 hours of thrombolytic treatment. If stenosis was found, angioplasty was carried out with or without a stent. Lysis was considered complete if the remaining luminal-area narrowing was less than 5%. Catheter-directed thrombolysis was carried out in 4 women with iliofemoral DVT and 1 with renal and ovarian vein thrombus. Two women had a positive thrombophilia screen for protein S deficiency, but none had recognized risk factors during or after pregnancy. One woman received low-molecular-weight heparin postoperatively after cesarean delivery. Two patients had a stent placed. Thrombolysis succeeded in all 4 patients with iliofemoral DVT. Partial lysis was achieved in the patient with renal and ovarian vein thrombosis, but kidney function was absent a month later. Symptoms resolved completely in all 5 patients. In women with acute postpartum DVT, early endovascular catheter-directed thrombolytic therapy—combined with thrombectomy, angioplasty, and/or stenting when indicated—may preserve function of the venous vales and prevent later venous occlusive disease. Evidence of safety remains insufficient. The authors recommend the use of graded compression stockings after thrombolysis to lessen the risk of postthrombotic syndrome.

Effective Prophylaxis for Deep Vein Thrombosis After Stroke

Approximately 5% of hospitalized stroke patients have a clinically apparent deep vein thrombosis (DVT) and ≈2% will have a pulmonary embolus (PE) confirmed.1 However, prospective studies that systematically screen for DVT with, for example compression Doppler ultrasound or magnetic resonance imaging, identified DVT in up to 50% of patients.2 Some patients who are breathless because of aspiration pneumonia, chest infection, or heart failure may actually have had an undiagnosed pulmonary embolus. Autopsies often identify clinically unrecognized PEs that probably contributed to the patient’s death. Therefore, it seems sensible to offer patients prophylaxis against venous thromboembolism. However, a brief discussion with colleagues is likely to reveal wide variation in the approaches taken to prophylaxis. In our unit, we aim to treat all patients with ischemic stroke with aspirin within 48 hours, because this has been shown to improve long-term outcomes and probably also reduces the risk of venous thromboembolism to some extent.3 In addition, we …

Venous thromboembolism after acute ischemic stroke: a prospective study using magnetic resonance direct thrombus imaging.

We prospectively evaluated the prevalence and clinical risk factors for venous thromboembolism (VTE) after acute ischemic stroke using magnetic resonance direct thrombus imaging, a highly accurate noninvasive technique that directly visualizes thrombus.Method-102 unselected patients with AIS receiving standard prophylaxis with aspirin and graded compression stockings (GCS) were sequentially recruited, underwent regular clinical assessments, and were screened for VTE. The prevalence of all VTE, proximal deep vein thrombosis (PDVT), and pulmonary embolism (PE) after 21 days were 40%, 18%, and 12%, increasing to 63%, 30%, and 20% in patients with Barthel indices (BI) of < or =9 2 days after stroke (BI-2< or =9). Clinical deep vein thrombosis and PE occurred in 3% and 5% overall; half these events were overlooked by the attending team. The true incidence of clinical events is probably higher because the natural history of subclinical PDVT was modified by screening and anticoagulation. BI-2< or =9 or nonambulatory status 2 days after stroke were the clinical factors most strongly associated with subsequent VTE on univariate analysis. Odds ratios for any VTE and PDVT for BI-2< or =9 versus >9 were 8.3 (95% CI, 2.7 to 25.2) and 8.1 (95% CI, 1.7 to 38.3) on multivariable analysis. BI < or =9 or nonambulatory status around the time of admission identifies a subgroup of acute ischemic stroke patients at very high risk for VTE in whom the current strategy of thromboprophylaxis may be inadequate. Future thromboprophylactic studies should focus on the patients at high risk defined in this study.

Screening for proximal deep vein thrombosis after acute ischemic stroke: a prospective study using clinical factors and plasma d‐dimers

Deep vein thrombosis (DVT) remains common in patients with acute ischemic stroke (AIS) receiving aspirin and graded compression stockings (considered standard thromboprophylaxis in the UK), most events occurring in patients with Barthel indices (BI) of <9 ('severe stroke') around the time of admission. In the absence of data indicating improved clinical outcomes with use of low-dose anticoagulant thromboprophylaxis, we evaluated the hypothesis that plasma D-dimers (D-d) might be a valuable initial screening test for proximal DVT (PDVT), facilitating selective use of imaging. One hundred and two unselected AIS-patients receiving aspirin/graded compression stockings thromboprophylaxis were screened for DVT using magnetic resonance direct thrombus imaging, a highly accurate non-invasive technique which directly visualizes thrombus. D-d (VIDAS and IL test D-d assays) were measured on recruitment and at weekly intervals. Median D-d were significantly higher throughout the study in patients with severe stroke who developed PDVT vs. those with severe stroke not developing PDVT, differences being most marked around day 9. Depending on the discriminatory threshold used, a single D-d measurement at this time in patients with severe-AIS allowed identification of a subgroup with ~50% prevalence of PDVT. Sensitivity of these strategies for PDVT was 67-83%, at a cost of imaging 22-30% of the entire cohort of patients. A single measurement of BI around the time of admission and D-d level at day 9 in AIS-patients receiving aspirin/graded compression stockings thromboprophylaxis allows identification of a subgroup containing a substantial proportion of all PDVTs who could be selectively imaged.