Incidence Of Symptomatic Venous Thromboembolic Events Research Articles

Clinical Outcome of Different Post-operative Prophylactic Strategies on Symptomatic Venous Thromboembolism after Total Knee Arthroplasty

IntroductionThe objective of this study was to evaluate the use of different post-operative prophylactic strategies on the rates of symptomatic venous thromboembolic events (VTE) incidence after primary total knee arthroplasty (TKA).MethodsA retrospective study of patients who underwent primary TKA procedure was performed from January 2015 through July 2020. Outcomes examined prophylaxis medication used during inpatient and outpatient care, amount of medication, length of medication, complications occurring within 90 days post-operatively, including symptomatic VTE (deep venous thrombosis (DVT), and pulmonary embolism (PE)), gastrointestinal (GI) bleeding requiring medical attention, change in management protocols after post-operative complications, and mortality.ResultsIn total, 5,663 cases were included (mean age 66 ± 10 years, mean BMI 34.1 ± 7.1kg/m2). The overall post-operative complication rate was 0.9% (DVT: 0.5%, PE: 0.3%, VTE: 0.04%, and GI bleeding: 0.09%). Enoxaparin use as inpatient anticoagulation medication was reduced significantly (67% vs. 13%, p < 0.001), and apixaban was increased significantly (6% vs. 49%, p < 0.001). Average hospital stays were reduced significantly among the years (3 ± 2 days vs. 2 ± 1 days, p < 0.001), and complication rates were not significantly different between the five years (~1%, p < 0.001). Most post-operative complications occurred on either aspirin 325 mg (36%) or apixaban (26%). However, the relative risk ratio results indicating that utilization of warfarin, rivaroxaban, and aspirin 81 mg as outpatient anticoagulation medication were more likely to increase the risk of symptomatic VTE incidence compared to other anticoagulants. The average time of complication detected was 21 ± 21 days (range: 1 – 87 days). More than 54% of complication events occurred after the patient had completed their medication (enoxaparin, rivaroxaban, and apixaban).ConclusionsThe observed incidence of symptomatic VTE in this study was similar to previous studies regardless of the type of post-operative inpatient or outpatient prophylaxis prescribed. The ultimate choice of prophylaxis should remain with the treating physician and their knowledge of a particular patient’s medical history.

Risk of Venous Thromboembolism in Glioblastoma Patients.

BackgroundPatients with cancer are at increased risk of venous thromboembolic events (VTE) with a particularly high prevalence in patients with glioblastoma (GB). We designed this current study to determine the incidence of symptomatic VTE in patients with GB undergoing first-line chemoradiotherapy and to develop a clinical score to help physicians identify those who are at the highest risk of VTE.MethodsA retrospective study cohort included patients diagnosed with GBM treated with radical concurrent chemoradiotherapy between 2005 and 2010 in Southern Alberta. Descriptive statistics were used to characterize the patient population. A predictive value for VTE was assessed by comparing logistic models and using the area under the receiver operating characteristic curve.ResultsTwenty-three out of 115 patients (20%) experienced a symptomatic VTE. This complication was not associated with overall survival at two years (p=0.06, heart rate (HR)=1.61). Hypertension and smoking were associated with VTE (p-values 0.034 and 0.048, respectively). A scoring system with the following variables was developed to predict the likelihood of developing VTE: (1) Karnofsky performance status (KPS) - 70, 1 point; KPS < 70, 2 points; (2) Age – 45 to 60, 1 point; 61 to 70, 2 points; (3) Current smoking, 1 point; (4) Hypertension, 1 point. Patients with >3 points were 5 times more likely to develop a VTE.ConclusionsIn our population, our simple scoring system allows the identification of patients with GB receiving first-line therapy, who are at the highest risk of VTE. These results require validation in an independent series.

A Prospective Cohort Study of Symptomatic Venous Thromboembolic Events in Foot and Ankle Trauma: The Need for Stratification in Thromboprophylaxis?

The incidence of venous thromboembolic (VTE) events (deep vein thrombophlebitis [DVT] or pulmonary embolism [PE]) in foot and ankle trauma has been low, and the risk/benefit ratio associated with chemoprophylaxis is controversial. We compared the 90-day incidence of VTE events in 3 cohorts: group 1, tendo-Achillis (TA) ruptures managed with full weightbearing in a walker boot; group 2, ankle fractures immobilized non-weightbearing in a below-the-knee cast; and group 3, ankle fractures managed surgically, followed by non-weightbearing in a below-the-knee cast. Data were extracted from 2 prospectively collected trust databases for acute TA ruptures and ankle fractures. VTE risk was assessed using a U.K. national assessment tool. Chemoprophylaxis was prescribed for high-risk patients. The 90-day incidence of symptomatic VTE events was drawn from a trust-wide radiology database. In group 1 (n = 291), the incidence of VTE events was 4.8% (11 [3.8%] DVT, 3 [1.0%] PE) at a mean of 16.1 ± 6.8 days. In group 2 (n = 227), the incidence of VTE events was 2.2% (5 [2.2%] DVT) at a mean of 33.4 ± 11.3 days. In group 3 (n = 199), the incidence of VTE events was 3.0% (5 [2.5%] DVT, 1 [0.5%] PE) at a mean of 37.2 ± 14.2 days. Patients with symptomatic VTE events presented significantly earlier after acute TA rupture compared with after ankle fracture (p = .002). We found the overall incidence of VTE events in foot and ankle trauma was low, with a relatively greater incidence of symptomatic VTE events, which occurred earlier, in acute TA ruptures compared with ankle fractures.

Dabigatran etexilate for thromboprophylaxis in over 5000 hip or knee replacement patients in a real-world clinical setting.

BackgroundThromboprophylaxis is recommended for patients undergoing total hip or total knee replacement (THR, TKR). An international, open-label, prospective, observational, single-arm study in a routine clinical setting was performed to assess the safety and efficacy of dabigatran etexilate 220 mg once daily in patients undergoing THR or TKR, and in subgroups of patients with potentially increased risk of bleeding or venous thromboembolism (VTE).Materials and methodsPatients were ≥18 years and required to be eligible to receive dabigatran 220 mg once daily (first dose 110 mg 1–4 h after THR/TKR surgery) according to the European Summary of Product Characteristics. The primary safety and efficacy outcomes were incidence of major bleeding events (MBEs), and the composite incidence of symptomatic VTE events and all-cause mortality, respectively.ResultsIn total, 5292 patients (median age 64 years) were enrolled and received dabigatran (2734 THR and 2558 TKR). Median drug exposure was 31 days (THR 34 days; TKR 27 days). Overall incidence of MBEs was 0.72 % (95 % confidence interval [CI] 0.51, 0.98), and this rate was comparable between types of surgery and was not significantly affected by protocol-defined risk factors. The overall incidence of symptomatic VTE and all-cause mortality was 1.04 % (95 % CI 0.78, 1.35); the only significant risk factor was history of VTE events (odds ratio 5.59; 95 % CI 2.53, 11.08). A post-hoc analysis showed that the incidence of MBEs in this observational study was similar to or lower than those reported in previous phase 3 trials.ConclusionsResults from this observational study of dabigatran etexilate administered to patients undergoing THR or TKR surgery are reassuring and supportive of those obtained in dabigatran phase 3 trials.Trial registrationClinicalTrials.gov identifier: NCT00846807.Electronic supplementary materialThe online version of this article (doi:10.1186/s12959-016-0082-4) contains supplementary material, which is available to authorized users.

Aspirin Can Be Used as Prophylaxis for Prevention of Venous Thromboembolism After Revision Hip and Knee Arthroplasty

BackgroundThe optimal prophylaxis for prevention of venous thromboembolic events (VTEs) after revision total joint arthroplasty (TJA) remains unknown. The objective of this study was to evaluate whether aspirin, known to be effective for prevention of VTEs after primary arthroplasty, is also effective after revision TJA. MethodsWe studied 2997 consecutive patients who underwent revision TJA between 2005 and 2013 and were treated with intermittent pneumatic compression devices and either aspirin (534 patients) or warfarin (2463 patients) for VTE prophylaxis. Pertinent data including the incidence of symptomatic VTEs, bleeding events, infection, and mortality were retrieved from our prospectively collected database. ResultsThe incidence of symptomatic VTEs was significantly higher in the warfarin group at 1.75% (43 of 2463) compared with 0.56% (3 of 534) in the aspirin group (odds ratio: 3.2; 95% CI: 1.03-16.3; P = .03). There was a higher rate of bleeding events with administration of warfarin (1.5%) compared with aspirin (0.4%; P = .02; odds ratio: 4.1; 95% CI: 1.2-34.0). The rate of surgical site infection was similar between the aspirin group and the warfarin group (1.61% and 1.70%, respectively). ConclusionAdministration of aspirin as prophylaxis against VTEs after revision arthroplasty may be a viable option as it appears to be more effective than warfarin in prevention of symptomatic VTEs and is associated with a lower rate of complications.

Low incidence of symptomatic thromboembolic events after total ankle arthroplasty without routine use of chemoprophylaxis.

There is little evidence regarding the incidence of symptomatic venous thromboembolism (VTE) following total ankle arthroplasty (TAA) to allow formulation of treatment recommendations. The purpose of this study was to determine the incidence of symptomatic VTE events after TAA without use of chemoprophylaxis and to identify risk factors contributing to the occurrence of VTEs. We conducted a retrospective chart review of 637 patients (664 ankles) who received a TAA between May 2007 and January 2014 and had a minimum follow-up of 3 months. Chemoprophylaxis was prescribed only in the setting of a history of VTE or active coagulopathy. Patients were continued on chemoprophylactic agents if they were taking these medications preoperatively. A VTE event was defined when clinical signs and symptoms of deep venous thrombosis (DVT) were confirmed with use of Doppler ultrasonography or pulmonary embolism was confirmed with the use of a computed tomography scan. Routine screening for VTE was not performed. The overall incidence of clinically detected VTE events was 0.60% (4/664), with 0.45% (3 patients) developing a DVT and 0.15% (1 patient) developing a nonfatal pulmonary embolism. Moreover, we identified a subset of 434 patients without identifiable preoperative risk factors who were not taking chemoprophylaxis preoperatively and were not prescribed chemoprophylaxis postoperatively. Two of these patients developed a DVT postoperatively (0.46%). Given the low incidence of clinically detected VTE, no significant correlation could be identified between the occurrence of VTE events and risk factors. Our results suggest that clinically detectable VTE after TAA is uncommon. Patients without identifiable risk factors do not appear to require chemoprophylaxis following TAA. We recommend continuation of antiplatelet or anticoagulation therapy in patients who are taking these medications preoperatively and the initiation of chemoprophylaxis postoperatively in patients with known risk factors for VTE. Level IV, case series.

High incidence of catheter-associated venous thromboembolic events in patients with long gap esophageal atresia treated with the Foker process

PurposeTo determine the incidence of catheter-associated venous thromboembolic events (VTE) in long gap esophageal atresia (LGEA) patients treated at Boston Children's Hospital (BCH) and to identify possible risk factors associated with their development. MethodsWe performed a retrospective analysis of LGEA patients from 2005 to 2012. Symptomatic VTEs with radiographic confirmation were defined as events. Potential risk factors were assessed by univariate analysis and multivariate logistic regression. Covariates included age, weight, initial gap length, cumulative days of pharmacologic paralysis and paralytic episodes, number and type of central venous catheters (CVCs), and number of operations. ResultsForty-four LGEA patients were identified. The incidence of CVC associated VTE was 34%. Univariate analysis identified age at Foker 1 (P=.03), paralysis duration (P=.01), episodes of paralysis (P=.001), cumulative number of CVC (P=.007) and length of stay (P=.03) as significant. Multivariate logistic regression identified the number of paralytic episodes as the only significant independent risk factor for VTE (P<.0001). ConclusionsThe incidence of symptomatic VTE was 34%, significantly higher than the VTE incidence of 4.5% reported for our other hospitalized children. These data have led to multidisciplinary discussions regarding thromboprophylaxis and development of a consensus-driven protocol. Since the initiation of this protocol, no VTEs have been identified.

Systemic treatments for the prevention of venous thrombo-embolic events in paediatric cancer patients with tunnelled central venous catheters

Children with cancer are at higher risk of thrombosis than children without cancer. This is a result of the disease itself but also of the cancer treatment and the presence of a central venous catheter. In this review, we investigated whether systemic treatments can prevent thrombosis. We identified six studies; two studies investigated low molecular weight heparins, one antithrombin supplementation and one cryoprecipitate and/or fresh frozen plasma supplementation; one study compared antithrombin supplementation with low molecular weight heparin and antithrombin supplementation, and another investigated warfarin. The addition of low molecular weight heparins to antithrombin supplementation did result in a lower number of symptomatic thromboses. This was statistically significant. We could not detect an effect of systemic preventive treatments in comparison with no treatment, and no difference was noted in the number of participants who suffered from major or minor bleeding. However, the overall number of participants was very small; a similar study with a larger population of participants might yield different results.

Is Thromboprophylaxis After Knee Arthroscopy Warranted?

The management of venous thrombophlebitis and thromboembolic disease has challenged the medical community for decades. The diagnosis can be elusive because of absent or mild clinical symptoms, and the potential outcome can be catastrophic. Major venous thromboembolic events (VTEs) are uncommon after outpatient knee arthroscopy, although many orthopaedic surgeons are aware of cases of fatal pulmonary embolism (PE) after this “low risk” surgery. In their paper, Maletis et al. use a large administrative database from the Kaiser Permanente Health Maintenance Organization to analyze the incidence of symptomatic VTE after knee arthroscopy. The records of almost 22,000 patients were retrospectively reviewed to identify ICD-9-CM procedure codes associated with symptomatic deep venous thrombosis (DVT) or PE during a ninety-day postoperative period. The incidence of symptomatic DVT during this period …

Evaluation of a Thromboprophylaxis Quality Improvement Project in a Palliative Care Unit

Context The benefits of anticoagulation treatment for primary prophylaxis in patients with advanced progressive diseases are unclear. Moreover, there are no empirically based guidelines on thromboprophylaxis for palliative care patients. Objectives To prospectively evaluate a quality improvement protocol on the use of thromboprophylaxis on a 36-bed palliative care unit (PCU). Methods A protocol was developed to guide and standardize practice related to venous thromboembolic events (VTE) and anticoagulation medication use on the PCU in patients with a life expectancy of less than six months. Through a prospective audit, data were collected for consecutively admitted patients over a period of four months. Results Of the 127 patients admitted to the PCU, 41 (32.3%) were on thromboprophylaxis on admission. All but one of these patients had come from an acute care hospital. Thromboprophylaxis was discontinued in 36 (87.8%) of these patients; one patient went on to develop a VTE. Of the 71 patients admitted without thromboprophylaxis, none of the patients were started on thromboprophylaxis and six went on to develop a VTE. Conclusion In this quality improvement study of patients admitted to a PCU largely for end-of-life care, thromboprophylaxis was discontinued in most patients without a significant increase in the incidence of symptomatic VTE. The validity of recommendations extrapolated from the general hospitalized cancer population supporting routine thromboprophylaxis and applied to these patients can be challenged. A policy that requires thromboprophylaxis in all hospitalized cancer patients may run the risk of indiscriminately including patients who are in the terminal phase of their lives.

Venous thromboembolism in 9,489 patients with glioma

1538 Background: Venous thromboembolic events (VTE) are a commonly reported complication of brain tumors. The objective of this study was to define the incidence, risk factors, and outcomes associated with VTE in a population-based cohort. Methods: This was a retrospective analysis of all glioma cases diagnosed in California between 1993–1995 and 1997–1999. Glioma cases in the California Cancer Registry were linked to the California Patient Discharge Database to identify incident VTE. Cox models were generated to analyze the association of pre-specified risk factors with VTE or death within one year of the cancer diagnosis. Results: There were 9489 cases: 76% were Caucasians and 56% were men. The 1-year cumulative incidence of VTE was 663 (7%) with an incidence rate during the first year of 11.1 events per 100 person-years. Sixty-six percent of all VTE diagnosed in the first year occurred within 3 months of the cancer diagnosis with a corresponding incidence rate of 21.6 events per 100 person-years. Of 663 first year VTE, 405 (61%) occurred &lt;2 months after an invasive neurosurgical procedure. Glioblastoma multiforme (GBM) was associated with an increased risk of VTE (HR=1.6, CI: 1.3–2.0) compared to other gliomas. The risk of VTE was strongly associated with the number of chronic co-morbidities (HR=4.0, CI: 3.1–5.0 for ≥3 chronic co-morbidities). Asian race was associated with significantly lower risk of VTE (HR=0.3, CI: 0.2–0.6) and female gender conferred a modestly lower risk (HR=0.8, CI: 0.7–0.9). A VTE in the first year was associated with slightly lower risk of death (HR = 0.8; CI: 0.8–0.9), whereas increasing age (HR=6.3, CI: 5.6–7.0 for age≥75), number of co-morbidities (HR=1.9, CI: 1.7–2.0 for ≥3 chronic co-morbidities), and GBM (HR=2.2, CI: 2.0–2.4) or anaplastic astrocytoma (HR=1.5, CI: 1.3–1.7) histology were associated with a higher risk of death within 1 year. Conclusions: In this large glioma cohort, the incidence of symptomatic VTE was very high. Two-thirds of all VTE occurred early after the diagnosis of glioma, and most of these occurred within 2 months of an invasive neurosurgical procedure. The presence of chronic medical co-morbidities and GBM histology were strong predictors of VTE. A diagnosis of VTE was not associated with an increased risk of death within 1 year. No significant financial relationships to disclose.

Incidence of symptomatic venous thromboembolism after different elective or urgent surgical procedures.

There have been no comprehensive studies that have compared the incidence of symptomatic VTE over a spectrum of different urgent or elective surgical procedures. In this study we determined the incidence of symptomatic venous thromboembolic events (VTE) within a 3 month period after 76 different surgical procedures. Using a large administrative data-base, we analyzed 1,653,275 cases that underwent one of 76 selected surgical procedures between January 1, 1992 and September 30, 1996. The principal outcomes were venous thrombosis or pulmonary embolism, during either the initial hospitalization or a re-hospitalization for VTE within 91 days of the date of surgery. Predictors of VTE were analyzed using logistic regression. Overall, VTE was diagnosed in 13,533 cases (0.8%, 95% CI = 0.7-0.9%) and of these, 5049 (37%, 95% CI = 36-38%) had pulmonary embolism. Predictors of VTE included: advancing age (OR=1.1 per 5 year increment in age, 95% CI =1.1-1.1), Latino ethnicity (OR = 0.9, 95% CI = 0.8-0.9), Asian/Pacific Islander ethnicity (OR = 0.5, 95% CI = 0.4-0.6), presence of a malignancy (OR = 1.7, 95% CI = 1.6-1.8) and prior VTE (OR = 6.2, 95% CI = 5.5-7.0). High-risk procedures that had an incidence of symptomatic VTE of approximately 2 to 3% included invasive neurosurgery, total hip arthroplasty, major vascular surgery and radical cystectomy. Fifty-six percent of all VTE events diagnosed within 91 days of surgery occurred after discharge. The findings of this study provide a basis for categorizing different surgical procedures as low, intermediate, high and very high risk for VTE. Because of the high incidence of VTE diagnosed after hospital discharge, further studies of extended thromboprophylaxis appear warranted.

Risk factors for venous thromboembolism after total hip and knee replacement surgery.

Elective total hip and total knee arthroplasty surgeries are associated with an extraordinarily high incidence of asymptomatic venous thromboembolism (VTE). Symptomatic deep vein thrombosis (DVT) or pulmonary embolism (PE) is diagnosed in only 2%-4% of these patients. A number of studies have defined the incidence and time course of symptomatic thromboembolism after these procedures. Knee arthroplasty is associated with a very high incidence of asymptomatic calf vein thrombosis, with almost all symptomatic VTE events diagnosed in the first 21 days after surgery. Hip arthroplasty, however, is associated with a higher incidence of asymptomatic proximal thrombi and a modestly higher incidence of symptomatic VTE events, many diagnosed up to 6 or 8 weeks after hospital discharge. Extended medical thromboprophylaxis has been shown to reduce the incidence of symptomatic and asymptomatic VTE among hip arthroplasty patients but not among knee arthroplasty patients. Risk factors for VTE after knee arthroplasty are not well defined. Important risk factors that have been shown to be associated with the development of VTE after hip surgery include (1) a history of prior VTE, (2) obesity (body mass index > 25), (3) delay in ambulation after surgery, and (4) female sex. Factors associated with lower risk include (1) Asian/Pacific Islander ethnicity, (2) use of pneumatic compression among non-obese patients after surgery, and (3) extended thromboprophylaxis after hospital discharge.