Mechanical Thromboprophylaxis Research Articles

[Translated article] Thrombotic Event Prevention in Patients Undergoing Posterior Lumbar Arthrodesis: our experiencie. A retrospective case series study

There is no generalized consensus regarding perioperative prophylaxis of venous thromboembolism (VTE), either on using or timing it in patients undergoing spine surgery. VTE is a current concern because, even though being an uncommon event, it can cause serious complications. The aim of the present study is to propose guidelines for the prevention of thrombotic events in posterior spinal surgery, either as deep vein thrombosis or pulmonary thromboembolism. If the number of patients getting prophylaxis drugs is reduced a subsequent reduction of the incidence of epidural hematoma can be expected. A number of 235 patients who had undergone posterior spinal arthrodesis in the previous five years were studied. Mechanical thromboprophylaxis measures consisting of compression stockings were applied in all of them. Anticoagulant drugs were also applied whenever risk factors for thrombosis were observed. Early weight-bearing was resumed immediately after surgery. Demographic, clinical, and surgical variables were collected, as well as complications appearing during the follow-up period, that was scheduled at one, two, four, six and twelve months after the surgery. Thrombotic events, if present, were diagnosed by clinical and imaging tests such as ultrasound and CT angiography. From the total 235 patients of this series, one hundred and fifty-three cases met the study inclusion criteria. A total of four thrombotic events appeared, one in the form of deep vein thrombosis and other three in the form of pulmonary thromboembolism. These last patients suffering an embolism died because of it. None of the variables studied had statistical significance for the occurrence of a thrombotic event. All four patients who suffered thrombotic events were receiving anticoagulant drugs, in addition to mechanical compression stockings, because of the presence of risk factors for thrombosis. By applying the fore mentioned protocol, adequate prevention of thromboembolic events was achieved in this study population of patients undergoing posterior spinal surgery.

Mechanical Thromboprophylaxis and Hospital-Acquired Venous Thromboembolism Among Critically Ill Adolescents: A U.S. Pediatric Health Information Systems Registry Study, 2016-2023.

To estimate the rate of mechanical thromboprophylaxis (mTP) prescription among critically ill adolescents using a multicenter administrative database and determine whether mTP prescription is inversely associated with hospital-acquired venous thromboembolism. Multicenter, observational, retrospective study of the Pediatric Health Information Systems (PHIS) Registry cohort, January 2016 to December 2023. Thirty PICUs located within quaternary pediatric referral centers in the United States. Critically ill children 12-17 years old, excluding encounters with a principal diagnosis at admission of venous thromboembolism. mTP prescription within the first 24 hours of hospitalization. A total of 107,804 children met the study criteria, of which 21,124 (19.6%) were prescribed mTP. Hospital center prescribing rates ranged from 1.4% to 65.4% and decreased by 1.6% per year from 28.2% in 2016 to 17.1% in 2023. As compared with those without mTP, those with mTP more frequently had a concurrent central venous catheter (17.2% vs. 9.4%, p < 0.001), underwent invasive mechanical ventilation (37.4% vs. 24.8%, p < 0.001), were admitted for a primary surgical indication (30.9% vs. 12.7%, p < 0.001), and experienced a longer median duration of hospitalization (7 [interquartile range (IQR): 4-15] vs. 4 [IQR: 2-9] d, p < 0.001). Hospital-acquired venous thromboembolism occurred in 2.7% of the study sample and was more common among those with, as compared with without, prescription of mTP (4% vs. 2.4%, p < 0.001). In multivariable logistic regression models for hospital-acquired venous thromboembolism adjusting for salient prothrombotic risk factors, we failed to identify an association between mTP and greater odds of hospital-acquired venous thromboembolism (HA-VTE) among low-, moderate-, and high-risk tiers. However, we cannot exclude the possibility of 17-50% greater odds of HA-VTE in this population. In the multicenter PHIS cohort, 2016-2023, the prescribing patterns for mTP among critically ill adolescents showed a low rate of mTP prescription (19.6%) that varied widely across institutions, decreased annually over the study period by 1.6%/year, and was not independently associated with HA-VTE risk reduction.

Incidence and Risk Factors for Deep Venous Thrombosis and Its Impact on Outcome in Patients Admitted to Medical Critical Care.

This study evaluated the incidence and risk factors for deep venous thrombosis (DVT) while on thromboprophylaxis, in patients admitted to the medical intensive care unit (MICU), and to assess its impact on outcomes. Consecutive patients admitted to the MICU underwent compression ultrasound of the jugular, axillary, femoral, and popliteal veins at admission, day 3 and 7 to screen for DVT. All patients were on pharmacological and/or mechanical thromboprophylaxis as per protocol. The primary outcome was the incidence of DVT (defined as occurrence on day 3 or 7). Secondary outcomes were death and duration of hospitalization. Risk factors for DVT were explored using bivariate and multivariable logistic regression analysis and expressed as risk ratio (RR) with 95% confidence intervals (CIs). The incidence of DVT was 17.2% (95% CI 12.0, 22.3) (n = 35/203); two-thirds were catheter associated (23/35). There was no difference in mortality between those with and without incident DVT (9/35 vs 40/168, p = 0.81). The mean (SD) duration of hospitalization was longer in the DVT group (20.1 (17) vs 12.9 (8.5) days, p = 0.007). Although day 3 INR (RR 2.1, 95% CI 0.9-5.3), age >40 years (2.1, 0.8-5.3), vasopressor use (1.0, 0.4-2.9) and SOFA score (0.9, 0.85-1.1) were associated with the development of DVT on bivariate analysis, only central venous catheters (15.97, 1.9-135.8) was independently associated with DVT on multivariable analysis. Despite thromboprophylaxis, 17% of ICU patients develop DVT. The central venous catheter is the main risk factor. DVT is not associated with increased mortality in the setting of prophylaxis. Krishnamoorthy A, Hansdak SG, Peter JV, Pichamuthu K, Rajan SJ, Sudarsan TI, et al. Incidence and Risk Factors for Deep Venous Thrombosis and Its Impact on Outcome in Patients Admitted to Medical Critical Care. Indian J Crit Care Med 2024;28(6):607-613.

Prevención de eventos trombóticos en pacientes sometidos a cirugía de artrodesis lumbar por vía posterior: experiencia en nuestro centro. Estudio retrospectivo de casos

There is no generalized consensus regarding perioperative prophylaxis of venous thromboembolism (VTE), either on using or timing it in patients undergoing spine surgery. VTE is a current concern because, even though being an uncommon event, it can cause serious complications. The aim of the present study is to propose guidelines for the prevention of thrombotic events in posterior spinal surgery, either as deep vein thrombosis or pulmonary thromboembolism. If the number of patients getting prophylaxis drugs is reduced a subsequent reduction of the incidence of epidural hematoma can be expected. A number of 235 patients who had undergone posterior spinal arthrodesis in the previous five years were studied. Mechanical thromboprophylaxis measures consisting of compression stockings were applied in all of them. Anticoagulant drugs were also applied whenever risk factors for thrombosis were observed. Early weight-bearing was resumed immediately after surgery. Demographic, clinical, and surgical variables were collected, as well as complications appearing during the follow-up period, that was scheduled at one, two, four, six and twelve months after the surgery. Thrombotic events, if present, were diagnosed by clinical and imaging tests such as ultrasound and CT angiography. From the total 235 patients of this series, one hundred and fifty-three cases met the study inclusion criteria. A total of four thrombotic events appeared, one in the form of deep vein thrombosis and other three in the form of pulmonary thromboembolism. These last patients suffering an embolism died because of it. None of the variables studied had statistical significance for the occurrence of a thrombotic event. All four patients who suffered thrombotic events were receiving anticoagulant drugs, in addition to mechanical compression stockings, because of the presence of risk factors for thrombosis. By applying the fore mentioned protocol, adequate prevention of thromboembolic events was achieved in this study population of patients undergoing posterior spinal surgery.

Incidence of deep venous thrombosis in patients with hemophilia undergoing bilateral simultaneous total knee arthroplasty: a retrospective cohort study

BackgroundHemophilic arthropathy usually affects the knees bilaterally. In order to reduce costs and improve rehabilitation, bilateral simultaneous total knee arthroplasty (TKA) can be performed. However, pharmacological prophylaxis for deep venous thrombosis (DVT) remains controversial in patients with severe hemophilia. The purpose of this study was to establish the incidence of DVT in severe hemophilia A patients undergoing bilateral simultaneous TKA without pharmacological thromboprophylaxis.MethodsConsecutive patients with severe hemophilia A undergoing bilateral simultaneous TKA at a single center between January 2015 and December 2020 were retrospectively reviewed. All patients received a modified coagulation factor substitution regimen. Tranexamic acid (TXA) was used for hemostasis in all patients during surgery. All patients followed a standardized postoperative protocol with routine mechanical thromboprophylaxis, and none received anticoagulation. D-dimer was measured preoperatively, on the day of the operation and on postoperative days 1, 7 and 14. Ultrasound (US) of the lower extremities was performed before (within 3 days of hospitalization) and after surgery (days 3 and 14) to detect asymptomatic DVT. Patients were followed up until 2 years after surgery for the development of symptomatic DVT or pulmonary embolism (PE).Results38 male patients with severe hemophilia A underwent 76 simultaneous TKAs. Mean (± standard deviation) age at the time of operation was 41.7 (± 17.1) years. Overall, 47.3% of patients had D-dimer concentrations above the threshold 10 µg/mL on day 7 and 39.5% on day 14. However, none of the patients had DVT detected on postoperative US, nor developed symptomatic DVT or PE during the 2-year follow-up.ConclusionsThe risk of DVT in patients with severe hemophilia A after bilateral simultaneous TKA is relatively low, and routine pharmacological thromboprophylaxis may not be needed.

Advances and current research in primary thromboprophylaxis to prevent hospital-associated venous thromboembolism.

Hospital-associated venous thromboembolism (VTE) is defined as any case of VTE occurring during hospital admission and for up to 90 days post discharge. It accounts for over 50% of all cases of VTE internationally; indeed, there are an estimated 10 million cases of hospital-associated VTE annually. Over the last decade, there has been increasing interest in improving VTE risk assessment and thromboprophylaxis. This review summarises all the recent and ongoing major research studies and future challenges in the different areas, including medical, surgical and obstetric patients, as well as special areas such as lower limb immobilisation. We include sections on both pharmacological and mechanical thromboprophylaxis.

Evaluation of venous thromboembolism risk assessment models for hospital inpatients: the VTEAM evidence synthesis.

Pharmacological prophylaxis during hospital admission can reduce the risk of acquired blood clots (venous thromboembolism) but may cause complications, such as bleeding. Using a risk assessment model to predict the risk of blood clots could facilitate selection of patients for prophylaxis and optimise the balance of benefits, risks and costs. We aimed to identify validated risk assessment models and estimate their prognostic accuracy, evaluate the cost-effectiveness of different strategies for selecting hospitalised patients for prophylaxis, assess the feasibility of using efficient research methods and estimate key parameters for future research. We undertook a systematic review, decision-analytic modelling and observational cohort study conducted in accordance with Enhancing the QUAlity and Transparency Of health Research (EQUATOR) guidelines. NHS hospitals, with primary data collection at four sites. Medical and surgical hospital inpatients, excluding paediatric, critical care and pregnancy-related admissions. Prophylaxis for all patients, none and according to selected risk assessment models. Model accuracy for predicting blood clots, lifetime costs and quality-adjusted life-years associated with alternative strategies, accuracy of efficient methods for identifying key outcomes and proportion of inpatients recommended prophylaxis using different models. We identified 24 validated risk assessment models, but low-quality heterogeneous data suggested weak accuracy for prediction of blood clots and generally high risk of bias in all studies. Decision-analytic modelling showed that pharmacological prophylaxis for all eligible is generally more cost-effective than model-based strategies for both medical and surgical inpatients, when valuing a quality-adjusted life-year at £20,000. The findings were more sensitive to uncertainties in the surgical population; strategies using risk assessment models were more cost-effective if the model was assumed to have a very high sensitivity, or the long-term risks of post-thrombotic complications were lower. Efficient methods using routine data did not accurately identify blood clots or bleeding events and several pre-specified feasibility criteria were not met. Theoretical prophylaxis rates across an inpatient cohort based on existing risk assessment models ranged from 13% to 91%. Existing studies may underestimate the accuracy of risk assessment models, leading to underestimation of their cost-effectiveness. The cost-effectiveness findings do not apply to patients with an increased risk of bleeding. Mechanical thromboprophylaxis options were excluded from the modelling. Primary data collection was predominately retrospective, risking case ascertainment bias. Thromboprophylaxis for all patients appears to be generally more cost-effective than using a risk assessment model, in hospitalised patients at low risk of bleeding. To be cost-effective, any risk assessment model would need to be highly sensitive. Current evidence on risk assessment models is at high risk of bias and our findings should be interpreted in this context. We were unable to demonstrate the feasibility of using efficient methods to accurately detect relevant outcomes for future research. Further research should evaluate routine prophylaxis strategies for all eligible hospitalised patients. Models that could accurately identify individuals at very low risk of blood clots (who could discontinue prophylaxis) warrant further evaluation. This study is registered as PROSPERO CRD42020165778 and Researchregistry5216. This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127454) and will be published in full in Health Technology Assessment; Vol. 28, No. 20. See the NIHR Funding and Awards website for further award information.

Seek and ye shall find: The utility of perioperative VTE screening in high-risk oncologic patients undergoing abdominopelvic surgery.

The aim of this study was to evaluate the prevalence and risk factors associated with perioperative venous thromboembolism (VTE) in patients undergoing major oncologic surgery using an epidural catheter (EC) for postoperative analgesia with mechanical prophylaxis and without chemoprophylaxis. Six hundred and twenty-sixpatients undergoing major oncologic surgery from 2009 to 2023 were evaluated. VTE was defined as deep vein thrombosis above the level of the knee. Lower extremity venous duplexes (LEVDs) were done preoperatively and postoperatively after the EC was removed. All patients received mechanical thromboprophylaxis, but not chemical prophylaxis, while the EC was in place. A generalized linear multivariable model was constructed to identify risk factors that predict pre and postoperative VTE. 29/626 patients (4.6%) were found to have preoperative VTE. 16/626 (2.6%) were found to have a postoperative VTE when their preoperative LEVD was negative. In comparison to patients without preoperative VTE, those with VTE were more likely to be male, anticoagulated, and have a history of coronary artery disease.Patients in the postoperative VTE group were older, male, anticoagulated, and had a history of VTE. On multivariable analysis, previous history of VTE was the risk factor most strongly associated with both pre and postoperative VTE. Oncologic patients undergoing elective abdominopelvic surgery with epidural analgesia should be screened in the perioperative setting with LEVD to identify VTE and possibly prevent PE.

Inflammation Sub-Group Analysis in Pediatric HA-VTE Cases: A Report from the Children's Hospital Acquired Thrombosis Registry (CHAT) Registry

Introduction: Hospital-Acquired venous thromboembolism (HA-VTE) is becoming an increasingly more common complication in children that may result in mortality, short- and long-term morbidity, and increased healthcare costs. To inform HA-VTE risk mitigation strategies, clinical research efforts have been undertaken to determine the precipitating causes of pediatric HA-VTE. Many of these studies have identified inflammation as an important underlying risk factor. We aimed to determine the association between HA-VTE and any clinical inflammatory state among a hospitalized pediatric patient population within the Children's Hospital Acquired Thrombosis (CHAT) Registry, with the hypothesis that inflammation increases the risk of HA-VTE among hospitalized children. Methods: Institutional review boards at all centers approved the protocol. Children aged 0-21 years admitted to a hospital at one of 8 U.S. pediatric healthcare institutions centers were enrolled in the study. Participants with VTE at admission were excluded. Electronic health records for enrolled subjects were reviewed for the development of a HA-VTE throughout their hospitalization and up to 30 days post discharge to identify cases. Control subjects were hospitalized patients without VTE on admission, during their hospital stay, or within 30 days of discharge. Controls were matched to cases by admission year and admitting institution. Acute inflammation was defined as notation of an inflammatory disease diagnosis (as defined by consensus of the physicians on the study team) as an admitting or discharge diagnosis but not in past medical history (PMH). Inflammatory disease diagnosis in PMH but not in admission/discharge diagnosis was denoted as chronic inflammation. Acute on chronic inflammation was identified in subjects having inflammatory disease diagnoses in both the PMH and admission/discharge diagnosis, while subjects without inflammation had no inflammatory diseases in either PMH or admission/discharge diagnoses. Inflammation was further categorized by consensus of the physicians on the study team as either systemic, regional, or local based on degree of organ system involvement. Results: From January 1, 2012 to December 31, 2021, 2164 subjects were enrolled. Complete data were available for 1218 HA-VTE cases and 946 controls. Median age for HA-VTE cases was 2.1 years compared to 5.8 years for controls without HA-VTE, with 56% of cases and 51% of controls being males. Cases were more likely than controls to have had surgery, ICU admission/transfer, intubation with mechanical ventilation, and central venous catheter placement, as well as to have received mechanical, pharmacological, or combined thromboprophylaxis while hospitalized. Among controls, 24 (2.5%) carried PMH diagnoses of inflammatory diseases, while 47 (3.9%) of the HA-VTE cases did (p=0.087). Among cases, 643 (52.8%) had infections either present on admission or develop while hospitalized, compared to 178 (18.8%) of controls (p&amp;lt;0.01). Steroids were administered to 677 (55.6%) of cases compared to 276 (29.2%) of controls (p&amp;lt;0.01). Interestingly, 42.5% of cases and 55.6% of controls were noted to exhibit any type of inflammation (p&amp;lt;0.01), while 39.2% of cases demonstrated systemic inflammation compared to only 26.5% of controls (p&amp;lt;0.01). Of the 1043 children with inflammation, systemic inflammation yielded an odds ratio (OR) of 1.78 (95% confidence interval [CI], 1.37-2.32) for HA-VTE development in univariate analysis. Four hundred eighty-six (39.9%) HA-VTE cases exhibited acute inflammation, 16 (1.3%) had chronic, 31 (2.6%) had acute-on-chronic, and 685 (56.2%) had no inflammation, compared to 513 (54.2%), 11 (1.2%), 13 (1.4%), and 409 (43.2%) for controls, respectively. Compared to no inflammation, acute-on-chronic inflammation demonstrated increased risk for HA-VTE development with OR 1.42 (95% CI 0.74-2.75). Conclusion: The present work demonstrates the importance of clinical inflammation subcategories when determining HA-VTE risk. Initial analysis of these data demonstrated that systemic inflammation, especially of the acute-on-chronic variety, conveys the highest risk for HA-VTE in children. Ongoing work will determine how to incorporate these concepts into clinical practice as well as clinical trials of HA-VTE prevention in children.

Incidence of deep vein thrombosis and symptomatic pulmonary embolism in Taiwanese patients with pelvic and/or acetabular fractures: a retrospective study

Venous thromboembolism (VTE) is common in patients with trauma, and thromboprophylaxis has been advocated. However, conflicting results regarding VTE rates in the Asian population following orthopaedic procedures have been presented. We aimed to investigate the VTE incidence in Taiwanese patients with pelvic and/or acetabular fractures and identify the associated risk factors. We included 402 patients who underwent surgery for pelvic and/or acetabular fractures. All patients received mechanical thromboprophylaxis with graduated compression stockings. Duplex scanning was performed postoperatively or during follow-up when signs or symptoms of deep vein thrombosis (DVT) developed. Variables with a significance level of ≤ 0.1 in the univariate analyses were introduced into the multivariate logistic regression analysis to identify DVT risk factors. The overall DVT and symptomatic pulmonary embolism (PE) rate was 3.48% (14/402 patients). Among patients with DVT, 46.1% were asymptomatic. Patients with VTE were significantly older than those without. Multivariate logistic regression analysis revealed that age was a VTE risk factor. The incidence of DVT and symptomatic PE in our cohort was low. Advanced age was a risk factor for VTE. These findings could help clinicians develop appropriate prevention and treatment strategies for VTE in Taiwanese patients with pelvic and/or acetabular fractures.

Venous thromboembolism prophylaxis practices for patients with sickle cell disease prior to and during the COVID-19 pandemic.

Patients with sickle cell disease (SCD) are predisposed to a hypercoagulable state due to alterations in the coagulation system. Despite concern for the development of venous thromboembolism (VTE) in this population, there are no standardized guidelines for routine thromboprophylaxis. The objective of this study was to assess thromboprophylaxis practices of adult and pediatric treaters of SCD before and during the coronavirus disease of 2019 (COVID-19) pandemic. A cross-sectional electronic survey was distributed to pediatric and adult hematology oncology practitioners through seven SCD-specific interest groups between May 29, 2020, and July 13, 2020. Of 93 total responses, 14% ( N = 13) reported they only treat patients more than 21 years old; 38.7% ( N = 36) only treat patients 0-21 years old and 47.3% ( N = 44) reported they treat both. Our study showed that before the COVID-19 pandemic, 96% of adult practitioners would recommend pharmacologic thromboprophylaxis, mechanical thromboprophylaxis or both for hospitalized adults with thromboprophylaxis, but only 76% of pediatric treaters would recommend any thromboprophylaxis in hospitalized children ( P < 0.0001), with 24% of pediatric treaters choosing no thromboprophylaxis at all. During the COVID-19 pandemic, pharmacologic thromboprophylaxis specifically was recommended for adults by 94% of treaters and for pediatric patients by 76% of treaters. These findings suggest that despite the lack of evidence-based thromboprophylaxis guidelines in adults and children with thromboprophylaxis, subspecialty treaters routinely provide pharmacologic thromboprophylaxis in their adult patients and will modify their practice in pediatric patients who are considered at a high risk for VTE.

Cost-effectiveness of mechanical thromboprophylaxis for cesarean deliveries in Brazil.

To evaluate the cost-effectiveness of using mechanical thromboprophylaxis for patients undergoing a cesarean delivery in Brazil. A decision-analytic model built in TreeAge software was used to compare the cost and effectiveness of intermittent pneumatic compression to prophylaxis with low-molecular-weight heparin or no prophylaxis from the perspective of the hospital. Related adverse events were venous thromboembolism, minor bleeding, and major bleeding. Model data were sourced from peer-reviewed studies through a structured literature search. A willingness-to-pay threshold of R$15,000 per avoided adverse event was adopted. Scenario, one-way, and probabilistic sensitivity analyses were performed to evaluate the impact of uncertainties on the results. The costs of care related to venous thromboembolism prophylaxis and associated adverse events ranged from R$914 for no prophylaxis to R$1,301 for low-molecular-weight heparin. With an incremental cost-effectiveness ratio of R$7,843 per adverse event avoided. Intermittent pneumatic compression was cost-effective compared to no prophylaxis. With lower costs and improved effectiveness, intermittent pneumatic compression dominated low-molecular-weight heparin. The probabilistic sensitivity analyses showed that the probability of being cost-effective was comparable for intermittent pneumatic compression and no prophylaxis, with low-molecular-weight heparin unlikely to be considered cost-effective (0.07). Intermittent pneumatic compression could be a cost-effective option and is likely to be more appropriate than low-molecular-weight heparin when used for venous thromboembolism prophylaxis for cesarean delivery in Brazil. Use of thromboprophylaxis should be a risk-stratified, individualized approach.

Mechanical prophylaxis to prevent venous thromboembolism on stroke patient: a Literature Review

Prevention of Venous Thromboembolism (VTE) is important in the treatment of stroke, including pharmacological and mechanical thromboprophylaxis. One of the post-stroke complications is Deep vein thrombosis (DVT), DVT can lead to pulmonary embolism (PE), and Venous thromboembolism (VTE) is manifested as DVT and PE. Stroke patients are at increased risk of developing DVT. This review aims to assess the clinical efficacy of mechanical prophylaxis for preventing venous thromboembolism in stroke patients. The articles were searched through PubMed, ScienceDirect, Sage Journals and ProQuest database. Keywords: "Stroke", "Prevention", "Deep Vein Thrombosis", “Venous Thromboembolism”, “Intermittent Pneumatic Compression”, and “Stocking Compression” combined using the Boolean operators AND or OR. The articles were full text, written in English, published in the last 10 years, and provided information about mechanical prophylaxis for preventing VTE in stroke patients. This review provides important information on VTE prevention in stroke patients. The use of IPC significantly reduces the risk of DVT and the addition of IPC in pharmacological prophylaxis provides moderate benefits in VTE, whereas the use of graduated compression stocking is less clinically significant in the prevention of VTE. The use of IPC is an effective method to reduce the risk of VTE in post-stroke immobilized patients, with fewer skin side effects compared to stocking compression.

Perioperative Management of Incidental Pulmonary Embolisms on Trauma CT Scans: A Narrative Review.

Unsuspected pulmonary embolism (PE) may be identified on an initial traumacomputed tomography (CT) scan. The clinical importance of these incidental PEs remains to be elucidated.In patients who require surgery, careful management is needed.We sought to investigate the optimal perioperative management of such patients, including the use of pharmacological and mechanical thromboprophylaxis, possible thrombolytic therapy, and inferior vena cava (IVC) filters. A literature search was conducted, and all relevant articles were identified, investigated, and included. Medical guidelines were also consulted where appropriate.Pharmacological thromboprophylaxis is the mainstay of preoperative treatment, and low-molecular-weight heparins, fondaparinux, and unfractionated heparin may all be used. It has been suggested that prophylaxis should be administered as soon as possible after trauma. Such agents may be contraindicated in patients with significant bleeding, and mechanical prophylaxis and inferior vena cava filters may be favoured in these patients. Therapeutic anticoagulation and thrombolytic therapies may be consideredbut are associated with an increased risk of haemorrhage. Delaying surgery might help to minimise the risk of recurrent venous thromboembolism, and any interruption of prophylaxis must be strategically planned. Recommendations for postoperative care include a continuation of prophylaxis and therapeutic anticoagulation, with follow-up clinical evaluation within six months. Incidental PE is a common finding on trauma CT scans. Although the clinical significance is unknown, careful management of the balance between anticoagulation and bleeding is needed, especially in trauma patients and even more so in trauma patients requiring surgery.

A Retrospective Analysis of Thromboprophylaxis in Hospitalized Patients with Cancer

Venous thromboembolism (VTE) is a known complication of hospitalization for acute medical illness; hospitalized patients with cancer represent a particularly high thrombotic risk population. However, there is significant underuse of thromboprophylaxis in medical inpatients with cancer. The objective of this study is to characterize the use of thromboprophylaxis in hospitalized patients with cancer at Windsor Regional Hospital (WRH), a large, community-based hospital in Ontario, Canada. Specifically, we investigated use of both pharmacologic and mechanical thromboprophylaxis, along with clinical determinants underlying lack of VTE prophylaxis to better understand our local practice patterns. This study is a retrospective, single center cohort study of 120 adult patients admitted to WRH with a primary solid tumor diagnosis (n=57) and hematologic cancer diagnosis (n=63) over a 3-month period. Chart review was performed for the first ten days of admission or until discharge. Multi-variate analyses were employed to determine clinical predictors of thromboprophylaxis use. Sixty-one (51%) medical inpatients with cancer received pharmacologic thromboprophylaxis during their hospitalization. The majority of patients (n=39; 68.4%) with a solid tumor malignancy received prophylaxis, while only twenty-two (34.9%) patients with a hematologic malignancy were provided pharmacologic VTE prophylaxis. In the subgroup of patients without contraindications to pharmacologic prophylaxis, 60% of patients with a primary hematologic diagnosis and 75% of patients with a primary solid tumor diagnosis received pharmacologic prophylaxis (Figure 1). 4 of 58 patients who did not receive pharmacologic prophylaxis received mechanical prophylaxis during admission (6.9%). Risk of VTE stratified by Khorana score >2 or ≤2 was not associated with use of pharmacologic prophylaxis (p=0.255). Platelet nadir <25x109/L (OR=0.12, 95% CI 0.0256-0.4087), active hormonal therapy (OR=0.11, 95% CI 0.0055-0.6707) and pulmonary disease at baseline (OR=4, 95% CI 1.0031-22.9064) were the only patient variables significantly related to the odds of pharmacologic prophylaxis. Given the limited number of patients in the study with pulmonary disease and maintained on hormonal therapy at baseline, the statistical significance may not correlate to clinical significance. In conclusion, thromboprophylaxis is an integral adjunct to the management of medical inpatients with active cancer yet is often neglected in clinical practice. In our population, nearly half of patients were not provided VTE prophylaxis. Severe thrombocytopenia and active hormonal therapy were negative predictors of pharmacologic thromboprophylaxis use while the presence of pulmonary disease favored prescription of prophylaxis on admission. Further studies are needed to better understand the rationale underlying omission of VTE prophylaxis in medical inpatients with cancer, and raise awareness of measures to prevent VTE in this patient population. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Thromboprophylaxis with unilateral pneumatic device led to less edema and blood loss compared to enoxaparin after knee arthroplasty: randomized trial

BackgroundPharmacological and mechanical thromboprophylaxis are frequently used together after total knee arthroplasty (TKA). Most studies in this context compare anticoagulants versus a combination of these drugs with an intermittent pneumatic compression device (IPCD). However, there is uncertainty about the need for the combination of both and whether a unilateral IPCD would alone affect other important clinical outcomes: edema and blood loss. We compared the effects of enoxaparin versus unilateral portable IPCD after TKA on edema and blood loss. We hypothesised that unilateral IPCD would cause the same level of edema and the same blood loss as enoxaparin.MethodsIn this open, randomized trial (1:1), adults with no history of coagulation disorders, anticoagulant use, venous thromboembolism, liver or malignant diseases underwent TKA. For 10 days, participants received the IPCD, used 24 h/day on the operated leg from the end of surgery, or 40 mg of enoxaparin, starting 12 h after surgery. All underwent the same rehabilitation and were encouraged to walk on the same day of surgery. We measured edema (thigh, leg and ankle circumference) before and on the third postoperative day. Blood loss (volume accumulated in the suction drain and drop of hemoglobin and hematocrit in 48 h) was a secondary outcome.ResultsWe randomized 150 patients and lost 3 to follow-up with enoxaparin and 2 with IPCD. There was no case of symptomatic venous thromboembolism. Four patients needed transfusions (three receiving enoxaparin), one had infection and one hemarthrosis (both in the enoxaparin group). Leg circumference increased by approximately 2 cm for enoxaparin group and 1.5 cm in IPCD (p < 0.001). The increase in ankle circumference was about 1.5 cm in the enoxaparin group (p < 0.001), and almost zero in IPCD (p = 0.447). Enoxaparin group lost 566.1 ml (standard deviation, SD, 174.5) of blood in the first 48 h, versus 420.8 ml (SD 142.5) in the IPCD.ConclusionsExclusively mechanical prophylaxis after TKA with portable IPCD only on the operated leg reduces leg and ankle swelling and post-operative blood loss compared to exclusively pharmacological prophylaxis with enoxaparin. Portable devices that can prevent deep vein thrombosis and pulmonary embolism without increasing blood loss or other risks should be further investigated.Trial registrationREBEC RBR-8k2vpx. Registration date: 06/04/2019.

Systematic Review and Meta-analysis of the Additional Benefit of Pharmacological Thromboprophylaxis for Endovenous Varicose Vein Interventions.

The primary objective of this systematic review and meta-analysis was to elucidate the rate of venous thromboembolism (VTE) after endovenous interventions for varicose veins in the presence of pharmacological and mechanical thromboprophylaxis versus mechanical thromboprophylaxis alone. The VTE rate after endovenous procedures for varicose veins is higher than other day-case procedures and could be reduced with pharmacological thromboprophylaxis. The review followed Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines with a registered protocol (PROSPERO: CRD42021274963). Studies of endovenous intervention for superficial venous incompetence reporting the predefined outcomes with at least 30 patients were eligible. Data were pooled with a fixed effects model. There were 221 trials included in the review (47 randomized trial arms, 105 prospective cohort studies, and 69 retrospective studies). In randomized trial arms, the rate of deep venous thrombosis with additional pharmacological thromboprophylaxis was 0.52% (95% CI, 0.23%-1.19%) (9 studies, 1095 patients, 2 events) versus 2.26% (95% CI, 1.81%-2.82%) (38 studies, 6951 patients, 69 events) with mechanical thromboprophylaxis alone. The rate of pulmonary embolism in randomized trial arms with additional pharmacological thromboprophylaxis was 0.45% (95% CI, 0.09-2.35) (5 studies, 460 participants, 1 event) versus 0.23% (95% CI, 0.1%-0.52%) (28 studies, 4834 participants, 3 events) for mechanical measures alone. The rate of EHIT grade III to IV was 0.35% (95% CI, 0.09-1.40) versus 0.88% (95% CI, 0.28%-2.70%). There was 1 VTE-related mortality and 1 instance of major bleeding, with low rates of minor bleeding. There is a significant reduction in the rate of DVT with additional pharmacological thromboprophylaxis and routine prescription of anticoagulation after endovenous varicose vein intervention should be considered. VTE risk for individual study participants is heterogeneous and risk stratification in future randomized interventional studies is critical to establish the clinical effectiveness and safety of additional pharmacological thromboprophylaxis.

Preferences and Practices of Brazilian Orthopedists for Thromboprophylaxis Techniques in Total Knee Arthroplasty: Survey Among Members of the Brazilian Society of Knee Surgery (SBCJ).

Objective The present study describes the preferences and current practices of a sample of knee surgeons in Brazil regarding thromboprophylaxis in total knee arthroplasty (TKA). Method In the present internet survey, surgeons from the Brazilian Knee Surgery Society (SBCJ, in the Portuguese acronym) voluntarily answered an anonymous questionnaire including time of personal surgical experience, perceptions about the best thromboprophylaxis options, and actual practices in their work environment. Results From December 2020 to January 2021, 243 participants answered the questionnaire. All, except for 3 (1.2%), reported using thromboprophylaxis, and most (76%) combined pharmacological and mechanical techniques. The most prescribed drug was enoxaparin (87%), which changed to rivaroxaban (65%) after discharge. The time of thromboprophylaxis initiation varied according to the length of training of the knee surgeon ( p ≤ 0.03), and their preferences and practices differed according to the Brazilian region ( p < 0.05) and the health system in which the surgeons work (public or private sector; p = 0.024). The option for mechanical thromboprophylaxis also depended on the training time of the surgeon. Conclusion Thromboprophylaxis preferences and practices in TKA are diverse across Brazilian regions and health systems (public or private sectors). Given the lack of a national clinical guideline, most orthopedists follow either their hospital guidelines or none. The mechanical prophylaxis method and the little use of aspirin are the points that most diverge from international guidelines and practices.

Post-hepatectomy venous thromboembolism: a systematic review with meta-analysis exploring the role of pharmacological thromboprophylaxis

PurposePatients undergoing hepatectomy are at moderate-to-high risk of venous thromboembolism (VTE). This study critically examines the efficacy of combining pharmacological (PTP) and mechanical thromboprophylaxis (MTP) versus only MTP in reducing VTE events against the risk of hemorrhagic complications.MethodsA systematic review of major reference databases was undertaken, and a meta-analysis was performed using common-effects model. Risk of bias assessment was performed using Newcastle–Ottawa scale. Trial sequential analysis (TSA) was used to assess the precision and conclusiveness of the results.Results8 studies (n = 4238 patients) meeting inclusion criteria were included in the analysis. Use of PTP + MTP was found to be associated with significantly lower VTE rates compared to only MTP (2.5% vs 5.3%; pooled RR 0.50, p = 0.03, I2 = 46%) with minimal type I error. PTP + MTP was not associated with an increased risk of hemorrhagic complications (3.04% vs 1.9%; pooled RR 1.54, p = 0.11, I2 = 0%) and had no significant impact on post-operative length of stay (12.1 vs 10.8 days; pooled MD − 0.66, p = 0.98, I2 = 0%) and mortality (2.9% vs 3.7%; pooled RR 0.73, p = 0.33, I2 = 0%).ConclusionDespite differences in the baseline patient characteristics, extent of hepatectomy, PTP regimens, and heterogeneity in the pooled analysis, the current study supports the use of PTP in post-hepatectomy patients (grade of recommendation: strong) as the combination of PTP + MTP is associated with a significantly lower incidence of VTE (level of evidence, moderate), without an increased risk of post-hepatectomy hemorrhage (level of evidence, low).

Mechanical thromboprophylaxis is effective in reducing postoperative venous thromboembolism.

Venous thromboembolism (VTE) is a result of factors described by Virchow’s triad: venous stasis, hypercoagulability, and endothelial injury. Clinically manifested as pulmonary embolism (PE), deep vein thrombosis (DVT) or both, VTE is a major cause of postoperative morbidity and mortality, frequently occurring early after discharge from hospital. Venous stasis in surgical patients is multifactorial. Leg immobility during surgery under general or regional anaesthesia is usually followed by reduced mobility of variable magnitude and duration during the postoperative phase. Specific types of surgery such as bariatric surgery, or operations requiring high-pressure pneumoperitoneum, reverse Trendelenburg or lithotomy positions are likely to exaggerate venous stasis. During operative recovery, reduction in leg mobility may be the result of the waning effects of regional anaesthesia, pain (particularly when the procedure was performed on a leg), sedation for intubated patients or cognitive impairment, unilateral or bilateral leg oedema, or physician orders. Development of complications may also adversely affect patient mobility. Under-recognized causes of venous stasis include vein compression or infiltration by a pelvic tumour, and venous ligation because of injury during procedures such as excision of a pelvic tumour. Furthermore, operative venodilatation may cause endothelial injury to the leg veins.