Incidence Of Symptomatic Pulmonary Embolism Research Articles

Symptomatic pulmonary embolus after catheter removal in children with catheter related thrombosis: A report from the CHAT Consortium

BackgroundAppropriate timing of central venous catheter (CVC) removal, in relation to start of anticoagulation, in children after the diagnosis of a CVC‐related thrombosis (CRT) is not well established. ObjectivesThis retrospective cohort study evaluated the incidence of symptomatic pulmonary embolism (PE) after CVC removal using data from the multi‐institutional Children’s Hospital‐Acquired Thrombosis (CHAT) Consortium Registry. Patients/MethodsThe CHAT Registry consists of data from children aged 0–21 years with a hospital‐acquired venous thromboembolism. Eligible subjects were those with CRT diagnosed <3 days after CVC removal. Subjects were excluded if the CRT was due to a failed CVC insertion. Subjects were divided into three groups: those with CVC removal without anticoagulation, those with CVC removal <48 h after starting anticoagulation, and those with CVC removal ≥48 h after starting anticoagulation. ResultsA total of 687 CRT events from 663 subjects were included. A majority of CRT events were in subjects with peripherally inserted central catheters (62.3%, n = 428). For the 611 CRT events in which the CVC was removed, there was only one case of symptomatic PE (0.16%), which occurred <48 h after initiation of anticoagulation. ConclusionsWhile current guidelines suggest anticoagulation before CVC removal in the setting of a CRT to prevent embolization, CVC removal is not associated with symptomatic PE regardless of duration of anticoagulation before CVC removal.

Incidence of Pulmonary Embolus after Catheter Removal in Children with Central Venous Catheter Related Venous Thromboembolism: A Report from the CHAT Consortium

Introduction: Appropriate timing of central venous Catheter (CVC) removal in children after the diagnosis of a CVC-related thrombosis (CRT) is poorly characterized. Due to the risk of embolization, ASH guidelines recommend initiating anticoagulation before CVC removal, but without a specified treatment period before CVC removal. An abstract from the 2019 ASH meeting did not find an increase in embolization rates when comparing anticoagulation treatment &amp;lt; or &amp;gt;48 hours prior to removal (Houghton et al, Blood 2019) in adult cancer patients with upper extremity CRT. This current study aimed to use data within the multi-institutional Children's Hospital-Acquired Thrombosis (CHAT) Consortium Registry to evaluate the incidence of symptomatic pulmonary embolism (PE) after CVC removal. Methods: The CHAT Registry is a retrospective cohort study which consists of detailed data from children aged 0-21 years with a hospital-acquired venous thromboembolism (HA-VTE) from eight U.S. centers. Eligible participants were those with a CRT. Participants were excluded if the diagnosis of thrombosis was &amp;gt;/= 3 days after CVC removal or if the CRT was due to a failed attempt at inserting a CVC. CHAT included details on demographics, medical history, CVC insertion and removal dates, anticoagulation start and stop dates and secondary outcomes, such as PE were extracted for analysis. Participants were divided into three groups, those in which (1) CVC removal occurred without anticoagulation initiation, (2) CVC removal occurred &amp;lt;48 hours after starting anticoagulation, and (3) CVC removal occurred ≥48 hours after starting anticoagulation (Figure 1). Results: A total of 687 CRT events from 663 participants were included. The median age at hospital admission was 1.4 years (IQR 0.1, 11.3) The majority of participants were male, 57% (378), 54% were non-Hispanic (359) and 46% were White (307). The most common past medical history for all participants with a CRT was congenital heart disease (22%, n=148) followed by cancer (11%, n=71), metabolic or mitochondrial disorder (3%, n=22) and inflammatory bowel disease (3%, n=21). For 76 CRT events the CVC was not removed during the participant's hospitalization or the removal date was unknown, therefore these events were excluded from further analysis. Anticoagulation was not initiated for 72 CRT events and for these events the median time from VTE diagnosis to CVC removal was one day (range 0-5.5). For the events that received anticoagulation there were 311 with CVC removal &amp;lt;48 hours and 228 events with CVC removal ≥48 hours (Table 1). Most of the CRT events with CVC removal &amp;lt;48 hours were in the lower extremity (52%, n=161) compared to CRT events with CVC removal ≥48 hours, which were mostly in the upper extremity (56%, n=127). A peripherally inserted central catheter was the most common CVC type regardless of group, followed by a temporary femoral line (Table 1). For all 611 CRT events in which the CVC was removed, there was only one case of PE (0.16%), which occurred &amp;lt;48 hours after CVC removal and initiation of anticoagulation (Figure 1). Conclusions: While current guidelines suggest anticoagulation before removal of CVCs in the setting of CRT to prevent embolization and PE, removal appears safe regardless of duration of anticoagulation before CVC removal in this pediatric cohort. These findings support need to substantiate the findings our CHAT consortium's ongoing prospective cohort study, but while waiting for these results, potential PEs should not weigh heavily in providers clinical decision making on timing of CVC removal. Disclosures Jaffray: CSL Behring: Research Funding; Octapharma: Other: Unrestricted funds for physician education. Baumann Kreuziger:CSL Behring: Consultancy; Quercegen pharmaceuticals: Consultancy. Mahajerin:Spark Therapeutics, Alexion, Genentech, Inc.: Speakers Bureau. Croteau:Hemophilia Federation of America: Honoraria; National Hemophilia Foundation: Honoraria; Sigilon Therapeutics: Consultancy; ATHN: Research Funding; Spark Therapeutics: Research Funding; CSL-Behring: Consultancy; Novo Nordisk: Research Funding; Pfizer: Consultancy; Genentech: Consultancy; Bayer: Consultancy. Young:BioMarin, Freeline, Genentech/Roche, Grifols, Kedrion, Novo Nordisk, Sanofi Genzyme, Spark, Takeda, and UniQure: Honoraria; Bayer, CSL Behring, Freeline, UniQure: Consultancy; Genentech/Roche, Grifols, and Takeda: Research Funding. Goldenberg:Academic Research Organization CPC Clinical Research: Consultancy; Daiici Sankyo: Consultancy; Novartis: Consultancy; Chiesi: Consultancy; Roshan Pharmaceuticals: Consultancy.

Perioperative symptomatic venous thromboembolism after immediate chemoprophylaxis in patients with pelvic and lower-extremity fractures

The purpose of this study was to investigate the incidence of symptomatic venous thromboembolism (VTE) after chemoprophylaxis in patients with pelvic and lower-extremity fractures, and to identify risk factors for VTEs in this subgroup of patients. To detect VTE, multi-detector computed tomography (CT) angiography was performed. Of 363 patients assessed, the incidence of symptomatic VTE was 12.4% (45 patients), and the incidence of symptomatic PE was 5.2% (19 patients). For the risk-factor analysis, a higher Charlson comorbidity index (p = 0.037), and a history of external fixator application (p = 0.007) were associated with increased VTE risk. Among patients who had VTE, male sex (p = 0.017), and above-the-knee fractures (p = 0.035) were associated with increased pulmonary embolism (PE) risk. In conclusions, the incidence of VTE in post-traumatic patients is not low after chemoprophylaxis. Risk factors for VTE and PE are different among patients with pelvic and lower-extremity fractures.

A Multicenter Trial of Vena Cava Filters in Severely Injured Patients

BackgroundWhether early placement of an inferior vena cava filter reduces the risk of pulmonary embolism or death in severely injured patients who have a contraindication to prophylactic anticoagulation is not known.MethodsIn this multicenter, randomized, controlled trial, we assigned 240 severely injured patients (Injury Severity Score >15 [scores range from 0 to 75, with higher scores indicating more severe injury]) who had a contraindication to anticoagulant agents to have a vena cava filter placed within the first 72 hours after admission for the injury or to have no filter placed. The primary end point was a composite of symptomatic pulmonary embolism or death from any cause at 90 days after enrollment; a secondary end point was symptomatic pulmonary embolism between day 8 and day 90 in the subgroup of patients who survived at least 7 days and did not receive prophylactic anticoagulation within 7 days after injury. All patients underwent ultrasonography of the legs at 2 weeks; patients also underwent mandatory computed tomographic pulmonary angiography when prespecified criteria were met.ResultsThe median age of the patients was 39 years, and the median Injury Severity Score was 27. Early placement of a vena cava filter did not result in a significantly lower incidence of symptomatic pulmonary embolism or death than no placement of a filter (13.9% in the vena cava filter group and 14.4% in the control group; hazard ratio, 0.99; 95% confidence interval [CI], 0.51 to 1.94; P=0.98). Among the 46 patients in the vena cava filter group and the 34 patients in the control group who did not receive prophylactic anticoagulation within 7 days after injury, pulmonary embolism developed in none of those in the vena cava filter group and in 5 (14.7%) in the control group, including 1 patient who died (relative risk of pulmonary embolism, 0; 95% CI, 0.00 to 0.55). An entrapped thrombus was found in the filter in 6 patients.ConclusionsEarly prophylactic placement of a vena cava filter after major trauma did not result in a lower incidence of symptomatic pulmonary embolism or death at 90 days than no placement of a filter. (Funded by the Medical Research Foundation of Royal Perth Hospital and others; Australian New Zealand Clinical Trials Registry number, ACTRN12614000963628.)

Symptomatic pulmonary embolism following hip fracture: A nationwide study

IntroductionThis study evaluated the incidence of symptomatic pulmonary embolism (PE), subsequent mortality, risk factors, and the effects of pharmacological thromboprophylactic intervention following hip fracture surgery in Taiwan. Materials and methodsA nationwide study was conducted from February 2004 to September 2013. Hip fracture patients were placed into two groups: without symptomatic PE (control group) and with symptomatic PE (PE group). We analyzed the incidence of and risk factors for symptomatic PE, post-operative mortality rate, and effects of pharmacological thromboprophylactic intervention. ResultsWe identified 165,748 hip fracture patients. The 3-month cumulative incidence of post-operative symptomatic PE was 0.24% (n = 392). The cumulative 1-, 3-, and 6-month mortality rates were significantly higher in the PE group (16.1%, 23.0%, and 28.6%, respectively) than in the controls (3.3%, 6.7%, and 10.2%, respectively). Increased risk of post-operative symptomatic PE was associated with prior history of PE (adjusted odds ratio [OR], 40.00; 95% CI, 24.75–64.67; P < 0.001), female sex (adjusted OR, 1.33; 95% CI, 1.07–1.65; P = 0.009), older age (>75 years) (adjusted OR, 1.51; 95% CI, 1.20–1.91; P < 0.001), and hemiarthroplasty (adjusted OR, 1.23; 95% CI, 1.01–1.51; P < 0.043). Pharmacological thromboprophylaxis significantly reduced the incidence of post-operative PE (adjusted hazard ratio, 4.54; 95% CI, 2.08–9.88; P < 0.001). ConclusionsThe incidence of symptomatic PE after hip fracture surgery was not low in Asian patients, and PE significantly decreased patient survival rates. Some groups were at higher risk for PE; in these instances, thromboprophylaxis, prompt diagnosis, and subsequent intervention are advised.

Pulmonary thromboembolic events in patients with congenital lipomatous overgrowth, vascular malformations, epidermal nevi, and spinal/skeletal abnormalities and Klippel-Trénaunay syndrome

ObjectivePatients with Klippel-Trénaunay syndrome (KTS) and congenital lipomatous overgrowth, vascular malformations, epidermal nevi, and spinal/skeletal abnormalities (CLOVES) syndrome have central phlebectasia and enlarged persistent embryonic veins that are often incompetent and prone to thromboembolism. The purpose of the study was to determine the presence of phlebectasia and the incidence of symptomatic pulmonary embolism (PE). MethodsA retrospective review was conducted of patients referred to the Vascular Anomalies Center at our institution during a 21-year period who were diagnosed with KTS and CLOVES syndrome. Of these, the patients who had PE were screened for thromboembolic risk factors in addition to phlebectasia and the presence of persistent embryonic veins. Treatment outcomes following subsequent endovascular and medical therapies were reported. ResultsA total of 12 KTS patients of 96 (12.5%) and 10 CLOVES syndrome patients of 110 (9%) suffered PE. Fourteen patients (64%) developed PE after surgery or sclerotherapy. All of the patients had abnormally dilated central or persistent embryonic veins; 20 patients were treated with anticoagulation (1 died at the time of presentation, and no information was available for 1) after PE, and 14 (66%) patients underwent subsequent endovascular treatment. Five patients developed recurrent PE despite anticoagulation. Two of the patients died of PE. No patients treated with endovascular closure of dilated veins had subsequent evidence of PE. ConclusionsPatients with KTS and CLOVES syndrome are at high risk for PE, particularly in the postoperative period.

Perioperative incidence and locations of deep vein thrombosis following specific isolated lower extremity fractures

PurposeTo determine perioperative incidence and locations of deep vein thrombosis (DVT) in injured and uninjured lower extremities following isolated lower extremity fractures (ILEFs). MethodsRetrospective analysis of a prospectively collected data of a consecutive patient series with ILEFs who underwent surgical treatment between September 2014 and September 2017 was performed. Patients’ bilateral lower extremities were screened for DVT with duplex ultrasonography (DUS) before and after surgery. DVT occurrence was analyzed by location of DVT and fracture site. All patients received pharmacologic thromboprophylaxis while hospitalized. Data on demographics, time to surgery, time of DUS examinations, length of hospital stay and symptomatic pulmonary embolism (PE) was collected. Results1825 patients were included in the study. The incidence of symptomatic PE was 1.6%. All patients were screened with DUS of the bilateral lower extremities in a mean of 3.5 days (range: 0–18 days) after injury, and a mean of 3.6 days (range: 1–11 days) after surgery. Preoperative DUS detected DVT in 547 patients (30.0%), including 3.7% of patients with proximal DVT. 792 patients (43.4%) were found to have a DVT postoperatively, but only 6.2% of patients with proximal DVT. Proximal DVT was detected postoperatively of the represented fractures: 6.5% of the hip, 14.5% of the femoral shaft, 4.5% of the tibial plateau, 4.6% of the tibial shaft, 1.7% of the patellar, and 2.0% of the peri-ankle. Interestingly, the rate of DVT in an uninjured lower limb was significantly higher postoperatively compared to preoperatively (16.4% vs. 4.9%), however, only 0.2% of patients had proximal DVT. ConclusionsWhile the perioperative incidence of overall DVT is high following ILEFs, the majority were distal DVT, and the rate of symptomatic PE was low. Femoral shaft fractures were associated with the highest incidence for proximal DVT. The incidence was lower in more distal fractures. The majority of patients diagnosed with DVT postoperatively had already shown symptoms of DVT prior to surgery. DVT can occur in both the injured and uninjured leg, with an obviously higher incidence in the injured leg. The incidence of proximal DVT in an uninjured leg is rare.

Analysis of risk factors and complications in postpartum lower extremity deep vein thrombosis patients at a single center

Objective: The objective of this study is to elucidate circumstances surrounding postpartum patients with lower extremity deep vein thrombosis (DVT) including demographics, risk factors, comorbidities, clinical presentation, and outcomes presenting to our tertiary care center. Introduction: Postpartum is a period of increased risk of venous thromboembolism (VTE). Several risk factors such as previous history of VTE, increased maternal age, varicose veins, mode of delivery, and family history of VTE have been suggested, but data supporting these are inconsistent. In this study, we have described circumstances surrounding postpartum lower extremity DVT including demographics, risk factors, comorbidities, and clinical presentation. Materials and Methods: In this retrospective study, all women with lower extremity duplex confirmed DVT during postpartum period, presented at Jain Institute of Vascular Sciences (JIVAS), Bengaluru, from January 2010 to December 2016 were enrolled. Baseline characteristics recorded were age of the patient, index lower extremity involved, segment of the vein involved and comorbidities. Risk factor evaluated were mode of delivery, history of varicose veins, previous history of thrombophilia, VTE, abortions/miscarriages, and tobacco use. Complications and treatments received in the hospital were documented. Results: Postpartum DVT was seen in 42 out of 1276 DVT patients (497 female patients) treated at JIVAS. The average age was 25.57 ± 5.73 years and left side (29 [69.04%]) being more commonly involved. Risk factors associated in patients were anemia 16 (38.09%), postlower segment cesarean section (LSCS) delivery 16 (38.09%) while tobacco use was seen in 2 (4.76%) patients, and varicose vein in 1 (2.38%). There were no patients with history of VTE, abortions, or thrombophilia. None of the patients had symptomatic pulmonary embolism (PE). All patients were treated with low-molecular-weight heparin and bridged to Vitamin K antagonists. Conclusion: The most common risk factors were anemia and post-LSCS delivery. There was no incidence of symptomatic PE or mortality.

Does preoperative mechanical prophylaxis have additional effectiveness in preventing postoperative venous thromboembolism in elderly patients with hip fracture?-Retrospective case-control study.

BackgroundElderly patients undergoing hip fracture surgery (HFS) are at increased risk of postoperative venous thromboembolism (VTE). To reduce this risk, combined postoperative mechanical and chemical thromboprophylaxis has been routinely performed after HFS in these patients. This retrospective case-control study was conducted to evaluate the additional effectiveness of preoperative mechanical thromboprophylaxis for the prevention of VTE following HFS in elderly patients.MethodsOf 539 consecutive patients aged 70 years or older undergoing HFS, 404 (control group) did not receive preoperative mechanical thromboprophylaxis, while 135 (study group) received mechanical thromboprophylaxis using an intermittent pneumatic compression device and graduated compression stockings from the time of admission until surgery. All patients received combined postoperative mechanical and chemical thromboprophylaxis following HFS in accordance with the same protocol. The incidence of symptomatic VTE confirmed based on clinical symptoms and 3-dimensional CT angiography within one month of surgery was investigated in both groups.ResultsThe American Society of Anesthesiologists grade was higher (p = 0.016) in the study group and more patients in this group had concomitant cardiovascular and neurologic diseases (p = 0.005 and p = 0.009, respectively). In addition, more patients in the study group had received anticoagulant medication preinjury owing to comorbidities (39% vs 28%, p = 0.025). The overall incidences of symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) were 7.4% and 3.7%, and 2.2% and 1.5% in the control and study groups, respectively. According to multiple logistic regression, symptomatic DVT significantly reduced in the study group (OR 0.28, p = 0.042), while there was no significant difference in the incidence of symptomatic PE between the two groups (p = 0.223).ConclusionsPreoperative mechanical thromboprophylaxis may confer an additional benefit by preventing postoperative VTE without adding more risk of perioperative bleeding in elderly patients with hip fracture.

Safety and efficacy of postoperative pharmacologic thromboprophylaxis with enoxaparin after pancreatic surgery.

Pharmacologic thromboprophylaxis is recommended for preventing pulmonary embolism according to some abdominal surgery guidelines. However, few reports have so far described pharmacologic thromboprophylaxis after pancreatic surgery. In addition, concern remains regarding postoperative bleeding due to pharmacologic thromboprophylaxis. We investigated the safety and efficacy of enoxaparin, a low-molecular-weight heparin, as postoperative pharmacologic thromboprophylaxis after pancreatic surgery. In this record-based retrospective study, the sample population comprised 151 consecutive patients who underwent pancreatic surgery and received enoxaparin postsurgery at our institute between November 2009 and March 2014. The primary outcome was the incidence of symptomatic pulmonary embolism after surgery, and the secondary outcome was the incidence of bleeding as an adverse effect of enoxaparin injection. No symptomatic pulmonary embolism events occurred during the study. Major and minor bleeding events were experienced in 5 (3.3%) cases each. Four of these major events were caused by the rupture of a pseudoaneurysm with a pancreatic fistula not related to enoxaparin, and all events were treated safely with no mortalities in the study period. We found no factors related to minor bleeding with enoxaparin injection in a statistical comparison. The use of enoxaparin is considered to be safe and effective for pulmonary embolism prophylaxis after pancreatic surgery.

The Incidence of Peripherally Inserted Central Catheter Symptomatic Pulmonary Embolism after Line Removal: A Retrospective Analysis

Background: To date, there are no recommendations regarding the timing of removal of peripherally inserted central catheters (PICC) in the presence of confirmed upper extremity deep vein thrombosis (UEDVT).Objective: We aimed to determine the incidence of symptomatic pulmonary embolism (PE) post line removal in patients with PICC-associated UEDVT according to treatment strategy.Patients/Methods: We conducted a retrospective study in adult patients who received a PICC with documented UEDVT or superficial thrombosis (UESVT) by vascular ultrasound. Patients’ demographic characteristics, co-morbid diseases, medications, ultrasound findings, treatment strategy for UEDVT/SVT and occurrence of symptomatic PE after PICC removal was documented.Results: 124 patients had PICC-associated UEDVT or UESVT; 69 males and 55 females with mean age 52.2 years. Of 81 patients meeting study criteria, 57 patients had UEDVT and 24 patients UESVT. No episodes of symptomatic PE after PICC removal were documented. Regarding timing of removal, 20 patients had their PICC removed within 24 hours after UEDVT diagnosis, 15 within 1 week, 7 within 2 weeks, 11 within 1 month and 4 at more than a month after diagnosis of UEDVT. No patients had objectively confirmed PE during the follow up period.Conclusion: This retrospective analysis revealed no symptomatic PE with removal of PICC in the presence of UEDVT or UESVT if performed within 24 hours, and an overall low rate of PE events regardless of treatment strategy and duration of PICC insertion. These findings are hypothesis generating and should be confirmed in a prospective trial.

A Phase IV Study of Thromboembolic and Bleeding Events Following Hip and Knee Arthroplasty Using Oral Factor Xa Inhibitor

BackgroundMultiple randomized controlled trials have documented the effectiveness of rivaroxaban in the prevention of venous thromboembolism up to 1-month following total joint arthroplasty. However, the effectiveness and safety of rivaroxaban in the real-world setting, outside of the strict protocols used by randomized clinical trials, are unknown. MethodsThis was a prospective, observational, noninterventional, phase IV study of 3914 consecutive patients who underwent total joint arthroplasty from June 2010 to December 2012. Patients were treated with rivaroxaban 10 mg by mouth daily starting postoperative day 1 and continued for 15 days. Participants were followed up in clinic at 6 weeks and contacted by telephone at 12 weeks. The primary outcome of interest was symptomatic venous thromboembolism; secondary outcomes included bleeding events, transfusion requirements, and death. ResultsThe incidence of symptomatic deep venous thrombosis at 3 months was 0.5% (n = 18). Only 1 deep venous thrombosis event occurred within 7 days of surgery. The incidence of symptomatic pulmonary embolism (PE) at 3 months was 0.7% (n = 28). Thirteen PEs (46%) occurred within 7 days of surgery. The rate of major bleeding while on prophylaxis was 0.1%. Only 5% of patients received a blood transfusion. No deaths were attributed to thromboembolic events. ConclusionThis prospective, observational, phase IV study demonstrates that rivaroxaban appears to protect patients against symptomatic PE and is not associated with major bleeding events when used in a real-world setting as described.

Current incidence of venous thromboembolism and comparison with 1998: a community-based study in Western France.

In 1998 we estimated the incidence of venous thromboembolism (VTE) to be 1.8/1,000 per year. The aim of this study was to compare current VTE incidence to that observed in 1998. We prospectively recorded all cases of symptomatic pulmonary embolism (PE) and deep vein thrombosis (DVT) of the lower limbs diagnosed between March 1, 2013 and February 28, 2014 in hospitals and in the community, using the same method and geographic area than in 1998. The 2013 incidence rates of VTE were computed and compared with those of 1998 using age- and sex-specific standardised incidence ratios (SIRs). In 2013, we recorded 576 VTE cases (279 isolated DVT and 297 PE ± DVT). Among 367,911 inhabitants, the overall incidence of VTE was 1.57/1,000 (95 % CI 1.44-1.69). The overall VTE incidence was significantly lower in 2013 as compared with 1998: SIR 0.72 (95 % CI 0.67-0.79) as well as the incidence of isolated DVT: SIR 0.53 (95 % CI 0.47-0.60); conversely, the overall incidence of PE was unchanged: SIR 1.10 (95 % CI, 0.98-1.23) despite an increase in the incidence of isolated PE: SIR 1.29 (95 % CI, 1.10-1.52). In 1998, 4.4 % of PE cases were diagnosed using CTPA as compared with 73.7 % in 2013 (p < 0.001). In conclusion, between 1998 and 2013, the incidence of symptomatic DVT decreased. Conversely, we found no similar reduction in the incidence of symptomatic PE; whether this is due to changes in diagnostic tests and algorithms in the management of suspected PE requires further investigations.

Does intermittent pneumatic compression increase the risk of pulmonary embolism in deep venous thrombosis after joint surgery?

The present study aimed to identify the incidence and risk factors of symptomatic pulmonary embolism and evaluate the safety of early intermittent pneumatic compression application in patients with deep venous thrombosis (DVT) after joint surgery. A total of 144 patients with DVT undergoing joint surgery were divided into two groups according to the appearance of symptomatic pulmonary embolism. Venography and computed tomographic pulmonary angiography were utilized as the assessment methods. The total incidence of symptomatic pulmonary embolism was 0.39% after joint surgery. However, the prevalence increased to 3.5% when computed in patients with DVT. Patients with symptomatic pulmonary embolism were older than those without symptomatic pulmonary embolism (69 ± 4 versus 61 ± 15 years, P = 0.04). The occurrence rate of symptomatic pulmonary embolism in patients with diabetes mellitus was much higher than that in the patients without diabetes mellitus (40.0% versus 8.6%, respectively, P = 0.02). The prevalence of symptomatic pulmonary embolism after joint surgery in patients with DVT was not distinctive. Increased age and diabetes mellitus put patients with DVT at risk of suffering symptomatic pulmonary embolism after joint surgery. In addition, early postoperative application of intermittent pneumatic compression was safe in these patients.

Role of Extended Thromboprophylaxis After Abdominal and Pelvic Surgery in Cancer Patients: A Systematic Review and Meta-Analysis.

Abdominopelvic cancer surgery increases the risk of postoperative venous thromboembolism (VTE). Low-molecular-weight heparin (LMWH) thromboprophylaxis is recommended, and the role of extended thromboprophylaxis (ETP) is controversial. We performed a systematic review to determine the effect of ETP on deep vein thrombosis (DVT), pulmonary embolism (PE), major bleeding, and all-cause mortality after abdominal or pelvic cancer surgery. A search of the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials was undertaken, and studies were included if they compared extended duration (2-6weeks) with conventional duration of thromboprophylaxis (2weeks or less) after cancer surgery. Pooled relative risk (RR) was estimated using a random effects model. Seven randomized and prospective studies were included, comprising 4807 adult patients. ETP was associated with a significantly reduced incidence of all VTEs [2.6 vs. 5.6%; RR 0.44, 95% confidence interval (CI) 0.28-0.70, number needed to treat (NNT)=39] and proximal DVT (1.4 vs. 2.8%; RR0.46, 95% CI 0.23-0.91, NNT=71). There was no statistically significant difference in the incidence of symptomatic PE (0.8 vs. 1.3%; RR0.56, 95% CI 0.23-1.40), major bleeding (1.8 vs. 1.0%; RR1.19, 95% CI 0.47-2.97), and all-cause mortality (4.2 vs. 3.6%; RR0.79, 95% CI 0.47-1.33). None of the outcomes differed if randomized trials were analyzed independently. ETP after abdominal or pelvic surgery for cancer significantly decreased the incidence of all VTEs and proximal DVTs, but had no impact on symptomatic PE, major bleeding, or 3-month mortality. ETP should be routinely considered in the setting of abdominal and pelvic surgery for cancer patients.

Role of Extended Thromboprophylaxis after Abdominal and Pelvic Surgery in Cancer Patients: A Systematic Review and Meta-Analysis

IntroductionAbdominal or pelvic surgery for cancer increases the risk of postoperative venous thromboembolism (VTE) by 2- to 3-fold. The use of low-molecular weight heparin (LMWH) to prevent post-operative thrombotic events is recommended in high VTE-risk patients; however, the role of extended thromboprophylaxis in this setting is controversial. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) and prospective observational studies to determine the effect of extended LMWH thromboprophylaxis on all VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), major bleeding, and all-cause mortality after abdominal or pelvic surgery for cancer.MethodsWe searched MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials, conference abstracts, and trial registries with no language restriction. Studies were included if they compared extended duration (i.e., administration of prophylactic doses of LMWH for more than 2 weeks, up to 6 weeks) versus conventional duration of thromboprophylaxis (i.e., administration of LMWH for two weeks or less) after cancer surgery. Two reviewers independently performed study selection, data extraction, and quality assessment. Studies were evaluated according to a priori inclusion criteria and critically appraised using the Newcastle-Ottawa Quality Assessment Scale (NOQA). Pooled relative risk was estimated using a random effects model.ResultsThree RCTs and 4 observational studies were included, comprising 4807 adult patients who underwent open or laparoscopic abdominal or pelvic surgery for gastrointestinal, gynecological or urological cancers. The 3 RCTs employed screening for asymptomatic DVT using bilateral lower limb compression ultrasound or venography after 4 weeks of surgery. Most of studies were of good quality (NOQA higher or equal to 6). The extended thromboprophylaxis regimen was associated with a significantly reduced incidence of all VTE (2.6% [59/2292] vs 5.6% [124/2209]; RR=0.44 [95% CI 0.28-0.70]) and proximal DVT (1.4% [14/966] vs 2.8% [24/862]; RR=0.33 [95% CI 0.15-0.73]). No data were available for symptomatic DVT. There was no statistically significant difference in the incidence of symptomatic PE between the two groups (0.8% [8/966] vs 1.3% [11/862]; RR= 0.56 [95% CI 0.23-1.40]). We found no significant difference in major bleeding at 1.8% (14/787) in the extended thromboprophylaxis group vs 1.0% (7/713) in the short thromboprophylaxis group (RR=1.19 [95% CI 0.47-2.97]). There was no significant difference in all-cause mortality at 3 months (4.2% [30/720] vs 3.6% [23/643], respectively; RR= 0.79 [95% CI 0.47-1.33]). There was minor heterogeneity between the studies in all extracted outcomes.ConclusionExtended thromboprophylaxis with LMWH after abdominal or pelvic surgery for cancer significantly decreased the incidence of all VTE and proximal DVT, but had no impact on symptomatic PE, major bleeding or 3-month mortality. [Display omitted] DisclosuresLee:Pfizer: Consultancy, Honoraria; LEO Pharma: Consultancy, Honoraria; BMS: Research Funding; Bayer: Consultancy. Wu:Leo Pharma: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees.

Acute Arteriovenous Access Failure: Long-Term Outcomes of Endovascular Salvage and Assessment of Co-Variates Affecting Patency

Aims: This study reports long-term outcomes after endovascular salvage (EVS) for acute dialysis fistula/graft dysfunction. Methods: All patients presenting with acute fistula or graft dysfunction, excluding primary failures, referred for endovascular salvage were included in this single-centre prospective study. Results: Altogether, 410 procedures were carried out in 232 patients. Overall, the incidence of thrombosis/occlusion (per patient-year) was 0.12 for fistulae and 0.9 for grafts. The anatomical success rate for EVS was 94% for fistulae and 92% for grafts. Primary patency rates for fistulae at 1, 6, 12, 24 and 36 months were 82, 64, 44, 34 and 26%, respectively, whereas secondary patency rates were 88, 84, 74, 69 and 61%, respectively. Primary patency rates for grafts at 1, 6 and 12 months were 50, 14 and 8%. The overall rate of complications was 6% with no incidence of symptomatic pulmonary embolism. In a Cox regression model, upper-arm location of fistula (HR 1.9, p = 0.04, n = 144) was associated with lower primary patency, whereas the presence of thrombosis was associated lower primary (HR 1.9, p = 0.004, n = 144) and secondary patency (HR 3.7, p < 0.001, n = 144). Aspirin therapy was associated with longer primary patency (HR 0.6, p = 0.02, n = 144) and secondary patency (HR 0.58, p = 0.08, n = 144). Conclusion: EVS is effective but longer-term outcomes are poor. Presence of thrombosis portends poor fistula survival and strategies for prevention need attention. Balloon maceration, our preferred declotting technique, is safe and the most cost-effective method. Aspirin therapy for patients presenting with failure of fistulae deserves further investigation.

Aspirin: An Alternative for Pulmonary Embolism Prophylaxis After Arthroplasty?

The most effective agent for prophylaxis against venous thromboembolic disease after total joint arthroplasty (TJA) remains unknown. The paucity of literature comparing different methods of pulmonary embolism (PE) prophylaxis and fear of litigation make it difficult for surgeons to abandon the use of aggressive chemical prophylaxis. We compared the (1) overall frequency of symptomatic PE, (2) risk of symptomatic PE after propensity matching that adjusted for potentially confounding variables, and (3) other complications and length of stay before and after propensity matching in patients undergoing TJA at our institution who received either aspirin or warfarin prophylaxis. A total of 28,923 patients underwent TJA between January 2000 and June 2012 at our institution, had either aspirin (325 mg twice daily; 2800 patients) or warfarin prophylaxis (26,123 patients), and were registered in our institutional electronic database. The incidence of symptomatic PE, symptomatic deep vein thrombosis (DVT), hematoma formation, infection, wound complications, and mortality up to 90 days postoperatively was collected from the database. We performed multivariate analysis and 3:1 and 5:1 propensity score matching for comorbid and demographic variables. The overall symptomatic PE rate was lower (p < 0.001) in patients receiving aspirin (0.14%) than in the patients receiving warfarin (1.07%). This difference did not change after matching. The aspirin group also had significantly fewer symptomatic DVTs and wound-related problems and shorter hospital stays, which did not change after matching. After publication of the American Academy of Orthopaedic Surgeons' guidelines, some surgeons have utilized aspirin as thromboprophylaxis after TJA. Based on our findings from a large institutional database, aspirin offers suitable prophylaxis against symptomatic PE in selected patients.

The use of a low dose hydrocortisone to prevent pulmonary embolism in patients with multiple trauma

Venous thromboembolism events are common in trauma patients. Immediate acute inflammation following injury triggers coagulation cascade and may increase the risk of pulmonary embolism (PE) in this population. We aimed to evaluate whether early low-dose steroids prevent symptomatic PE onset in multiple trauma patients. The medical surgical intensive care unit of Habib Bourguiba University Hospital (Sfax--Tunisia). Comparative study of two cohorts: a retrospective cohort of patients who didn't receive early low-dose steroids (steroid (-) group) and a prospective cohort of patients who received hydrocortisone with a dose of 100 mg/8 h for a scheduled period of 7 days (steroid (+) group). All adult patients admitted in our intensive care unit (ICU) for multiple trauma with predicted duration of mechanical ventilation over 48 h were included. Evaluation of the impact of low-dose steroids on the incidence of symptomatic PE. We included 175 patients: 92 in the steroids (-) group and 83 in the steroids (+) group. PE was diagnosed in 15 patients (8.5 %). The incidence of PE was significantly lower in steroid (+) group (3.6 vs 13 %; p = 0.013). In multivariate analysis, independent factors predicting PE onset were meningeal hemorrhage [OR = 14.7; 95 % CI (2.2-96.3); p = 0.013] and pelvic ring trauma [OR = 8; 95 % CI (1.8-36.4); p = 0.007] whereas low-dose steroids were significantly associated with a protective effect [OR = 0.2; 95 % CI (0.05-0.77); p = 0.019]. There was no significant difference between steroids (+) and steroids (-) groups neither in terms of mean ICU length of stay (LOS) (respectively 11 ± 9.7 and 12.3 ± 10.7 days; p = 0.372) nor in terms of ICU mortality (respectively 29.3 and 24.1 %; p = 0.434). Steroids are effective in reducing the incidence of PE in multiple trauma patients. However, no significant benefice was found on ICU mortality.

The Incidence of Pulmonary Embolism and Deep Vein Thrombosis After Knee Arthroplasty in Asians Remains Low: A Meta-analysis

While Western literature has mostly reported the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) after TKA with chemoprophylaxis, the Asian literature still has mostly reported the incidence without chemoprophylaxis. This may reflect a low incidence of DVT and PE in Asian patients, although some recent studies suggest the incidence after TKA in Asian patients is increasing. Moreover, it is unclear whether the incidence of DVT and PE after TKA is similarly low among different Asian countries. We therefore determined the overall incidence of symptomatic PE and DVT without chemoprophylaxis after TKA in the Asian population, determined whether the incidence had a tendency to increase over time in Asia, and compared the incidence of symptomatic PE and DVT among Asian countries through a meta-analysis. We searched the PubMed, Embase, Cochrane Library, Web of Science, and Google Scholar websites for prospective studies published between 1996 and 2011. A total of 1947 patients from 18 studies were reviewed for meta-analysis. The incidence of symptomatic PE was 0.01%. The incidences of overall DVT, proximal DVT, and symptomatic DVT were 40.4%, 5.8% and 1.9%, respectively. We found no difference in incidence of symptomatic PE among Asian countries and no trends in changes of the incidence over time. The incidence of symptomatic PE and DVT after TKA without prophylaxis is low in Asian countries and has not changed over time, despite Westernizing lifestyles and an aging populace. Further investigation with large randomized studies is necessary to confirm our findings and identify risk factors predisposing to DVT.