Risk Factors For VTE Research Articles

Management of Cancer-Associated Upper Extremity Deep Vein Thrombosis with and without Venous Catheters at a Tertiary Care Center

Introduction: Data on management of upper extremity deep vein thrombosis(UEDVT) in patients with cancer is limited. Patients in this subgroup were excluded from the large clinical trials that showed the efficacy of extended duration low-molecular-weight heparin (LMWH) for cancer-associated thrombosis. Furthermore, risk factors for cancer-associated UEDVT in patients who do not have central lines in situ have not been well defined. The goal of our study was to determine the risk factors for cancer-associated UEDVT and to examine the approach to management of these patients in a real-world setting.Methods: We conducted a retrospective review of 200 consecutive patients who were assessed for cancer-associated UEDVT between January 2010 and June 2014 at a tertiary care center. Outcome measures were recurrent VTE, and major and clinically relevant non-major bleeding. Risk factors for recurrent VTE and bleeding were assessed using multivariable analysis.Results: Median duration of follow-up 11 months. Median age was 61.5 years and 55% were male. Cancer subtypes included colorectal (24%), lung (15%), breast (14%), lymphoma (10%), leukemia (5%), esophageal (4%), pancreatic (4%), head & neck (3%), sarcoma (2%), and others 17%. Metastatic disease at the time of diagnosis was present in 37% of patients and 7% of the study population had a previous history of VTE. Of the study population, 138 (69%) had line-associated UEDVT. Risk factors for UEDVT other than presence of a line after univariate analysis were lung cancer, breast cancer and extrinsic compression of vessels by local tumour on diagnostic imaging.The proportion of patients with UEDVT in the absence of a line according to cancer subtype was as follows: lung cancer (83%), pleural mesothelioma (66%), breast cancer (51%) and head & neck cancer (50%). Of these patients, greater than half had evidence of local mass effect on vessels on diagnostic imaging studies. Of the 138 patients with line-associated UEDVT, 20 (15%) had their line removed within one week of diagnosis for reasons unrelated to thrombosis and 107 (84%) had their line removed after completion of at least 3 months of anticoagulant therapy.Recurrent VTE was documented in 35 patients (17.5%), of which 16 (8%) were UEDVT (PE - 10, lower limb DVT-8, other-2). Recurrent VTE while receiving anticoagulants occurred in 23 (65.7%) of all recurrences and in 10 (62.5%)of UEDVT recurrences. Recurrent VTE occurred in 26 patients with a central line and in 9 patients without a central line. All of the patients with recurrent VTE had solid tumours, and 45% had metastatic disease. Multivariant analysis revealed that male gender(OR 2.42, 95% CI;1.1-5.1,p-value=0.02) and active cancer at the end of follow-up (OR 2.47, 95% CI; 0.1-0.9, p-value=0.04) were the only factors significantly associated with recurrent VTE (Figure 1 and 2). None of the following were significant risk factors for recurrence: type of antineoplastic treatment, accompanying PE, white cell count, initial UEDVT while anticoagulated, cancer stage, previous VTE, number of involved venous segments, removal of line during first week after index event or switching to a different anticoagulant. In the group with UEDVT without a venous catheter, the presence of radiologically proven extrinsic compression of vessels was not statistically associated with recurrent VTE.Patients were treated with LMWH for a median duration of 5 months. Six and 8 patients were switched to rivaroxaban and warfarin, respectively. Clinically relevant non-major bleeding occurred in 24 patients (12%), 61% of the bleeds were gastrointestinal and 83% of the bleeds occurred while receiving anticoagulants. On multivariate analysis, bleeding was significantly associated with ongoing anticoagulation (OR 5.6, 95% CI;1.6-19.3, p-value=0.006) and liver metastasis (OR 7.2, 95% CI;0.9-7.2, p-value=0.05). The use of concomitant clopidogrel or aspirin significantly increased the risk of bleeding (OR 6.6 and 5.5, respectively).Conclusions: While the presence of a venous catheter was the primary risk factor for UEDVT for the majority of our cohort, extrinsic compression of vessels by local tumour appeared to be equally important for certain cancer types. Furthermore, our finding that the majority of recurrent events did not occur in the upper limb suggests that UEDVT may be predictive of overall increased thrombogenic risk rather than just a local effect caused by the line. [Display omitted] [Display omitted] DisclosuresLinkins:Bayer: Honoraria, Research Funding; Pfizer: Honoraria.

VTE Incidence and Risk Factors in Patients With Severe Sepsis and Septic Shock

Prospective studies on the incidence of VTE during severe sepsis and septic shock remain absent, hindering efficacy assessments regarding VTE prevention strategies in sepsis. We prospectively studied 113 consecutively enrolled patients in the ICU with severe sepsis and septic shock at three hospitals. All patients provided informed consent. VTE thromboprophylaxis was recorded for all patients. Patients underwent ultrasonography and were followed for VTE prior to ICU discharge. All-cause 28-day mortality was recorded. Variables from univariate analyses that were associated with VTE (including central venous catheter [CVC] insertion, age, length of stay, and mechanical ventilation) were included in a multivariable logistic regression analysis using backward stepwise elimination to determine VTE predictors. Mean APACHE (Acute Physiology and Chronic Health Evaluation) II score was 18.2 ± 7.0, and age was 50 ± 18 years. Despite all patients receiving guideline-recommended thromboprophylaxis, the incidence of VTE was 37.2% (95% CI, 28.3-46.8). Most VTE events were clinically significant (defined as pulmonary embolism, proximal DVT, and/or symptomatic distal DVT) and associated with an increased length of stay (18.2 ± 9.9 days vs 13.4 ± 11.5 days, P < .05). Mortality was higher in patients with acute VTE but did not reach statistical significance. Insertion of a CVC and longer mechanical ventilation duration were significant VTE risk factors. VTE incidence did not differ by thromboprophylaxis type. To our knowledge this is the first multicenter prospective study to identify a high incidence of VTE in patients with severe sepsis and septic shock, despite the use of universal, guideline-recommended thromboprophylaxis. Our findings suggest that the systemic inflammatory milieu of sepsis may uniquely predispose patients with sepsis to VTE. More effective VTE prevention strategies are necessary in patients with sepsis. ClinicalTrials.gov; No.: NCT02353910; URL: www.clinicaltrials.gov.

Incidence of Venous Thromboembolism and Benefits and Risks of Thromboprophylaxis After Cardiac Surgery: A Systematic Review and Meta-Analysis.

BackgroundOptimal thromboprophylaxis after cardiac surgery is uncertain. This systematic review aimed to define the incidence and risk factors for deep vein thrombosis (DVT), fatal and nonfatal pulmonary embolism (PE), and assess whether venous thromboembolism (VTE) prophylaxis was effective in reducing VTE without complications after cardiac surgery.Methods and ResultsTwo reviewers independently searched and assessed the quality and outcomes of randomized, controlled trials (RCTs) and observational studies on VTE after cardiac surgery in the MEDLINE, EMBASE, and Cochrane controlled trial register (1966 to December 2014). Sixty‐eight studies provided data on VTE outcomes or complications related to thromboprophylaxis after cardiac surgery. The majority of the studies were observational studies (n=49), 16 studies were RCTs, and 3 were meta‐analyses. VTE prophylaxis was associated with a reduced risk of PE (relative risk [RR], 0.45; 95% confidence interval [CI], 0.28–0.72; P=0.0008) or symptomatic VTE (RR, 0.44; 95% CI, 0.28–0.71; P=0.0006) compared to the control without significant heterogeneity. Median incidence (interquartile range) of symptomatic DVT, PE, and fatal PE were 3.2% (0.6–8.1), 0.6% (0.3–2.9), and 0.3% (0.08–1.7), respectively. Previous history of VTE, obesity, left or right ventricular failure, and prolonged bed rest, mechanical ventilation, or use of a central venous catheter were common risk factors for VTE. Bleeding or cardiac tamponade requiring reoperation owing to pharmacological VTE prophylaxis alone, without systemic anticoagulation, was not observed.ConclusionsUnless proven otherwise by adequately powered RCTs, initiating pharmacological VTE prophylaxis as soon as possible after cardiac surgery for patients who have no active bleeding is highly recommended.

Incidence and risk factors of venous thromboembolism after pelvic uro-oncologic surgery--a single center experience.

To determine the incidence and assess risk factors for the development of VTE among patients undergoing major pelvic surgery for prostate and bladder cancer in an Australian tertiary referral center. Consecutive patients undergoing major pelvic uro-oncologic surgery, namely radical cystectomy and radical prostatectomy over a five-year period (2009-2013) were identified. Patient variables and types of thromboprophylaxis (pharmacological and/or mechanical) used in this patient cohort were collected for analyses as predictive factors. The overall incidence of VTE was 1.8%. Patients undergoing radical cystectomy were more likely to suffer a VTE event compared to patients having radical prostatectomy. In this cohort, the risk factors for VTE include, prolonged operative time of greater than 4hours (h), lymph node dissection (LND) and patients requiring blood transfusions. Patients undergoing major pelvic uro-oncologic surgery have an approximately 1.8% risk of developing VTE. Risk factors identified in this study should be used to guide the use of early and prolonged thromboprophylaxis.

Inferior Vena Caval Thrombosis in Elderly Patients with Active Pulmonary Tuberculosis: A Case Series with Implications for Therapy

Introduction: Prevalence of tuberculosis continues to remain high worldwide According to 2010 Global Burden of Disease estimates, majority of tuberculosis related deaths occurred in people older than 50. Tuberculosis (TB) is associated with a hypercoagulable state and hence VTE. These can be extensive and potentially life threatening. A variety of factors have been postulated to predispose patients with tuberculosis to venous thrombosis that include local stasis due to venous compression by lymph nodes and relative immobility caused by respiratory dysfunction, alteration in coagulation factors and reactive thrombocytosis. Case series presentation: We report 2 cases of extensive venous thromboembolism associated with pulmonary tuberculosis in the elderly. A 65 year-old Asian female with recently diagnosed tuberculosis presented with a new long deep vein thrombus extending from tibial vein up to right heart chamber and 67 year old Asian male in whom VTE was a presenting feature of tuberculosis (CFV thrombus extending up to IVC). Inferior vena caval thrombosis has been reported only rarely in active pulmonary tuberculosis and only 3 reports exist in English literature Conclusion: Our two cases highlight the risk of deep venous thrombosis in elderly patients with pulmonary tuberculosis even in the absence of any other risk factors for VTE. TB should be considered as a risk factor for VTE and included in thromboembolism risk evaluation especially in first few months of treatment. VTE might be the first presentation of underlying tuberculosis. Also, VTE associated with tuberculosis might be extensive and involve proximal veins hence, may be life threatening due to a higher risk of pulmonary embolism. Physicians must be aware of this for prompt diagnosis and treatment to prevent fatality. Patients on tubercular therapy might require high doses of anticoagulation due to known interaction

Venous thromboembolism in patients with chronic lymphocytic leukemia

IntroductionVenous thromboembolism (VTE) is a major cause of morbidity and mortality in patients (pts) with malignant tumors. Increased risk of VTE is well described in a variety of hematologic malignancies; however, data regarding VTE in chronic lymphocytic leukemia (CLL) is very limited. Patients and methods: We retrospectively analyzed clinical and laboratory data of 346 consecutive pts with CLL followed up at 4th Department of Internal Medicine - Hematology, University Hospital, Hradec Kralove, Czech Republic, diagnosed between 1999 and 2011 (males, 64%; median age, 64years; low/intermediate/high Rai modified risk in 41/47/12%). Results: After a median follow-up of 72months (range, 26-138), at least one episode of VTE occurred in 38 patients (11%). VTE developed after a median of 34months from CLL diagnosis. Incidence of VTE was 1.67% per patient year of follow-up. There was a high proportion of unfavourable prognostic factors (advanced Rai stages, unmutated IgVH genes, unfavourable cytogenetics) in pts with VTE. The presence of 0/1/2/3 additional risk factors for VTE was identified in 2/16/14/6 patients. The most common risk factors for VTE besides age (n=24) were corticosteroid therapy (n=13), other malignancies (n=9) and obesity (n=7). Recurrence of VTE was diagnosed in 7 pts. Performance status≥2 and inherited thrombophilia were significant risk factors for VTE development in univariate and multivariate analysis. VTE was not associated with shorter overall survival. Conclusion: Based on our results, VTE is a relatively frequent complication in patients with CLL. Although most patients had other known risk factors for VTE including CLL treatment, 29% had no risk factors or only age≥60years. These findings demonstrate the possible role of CLL in the development of VTE.

Symptomatic venous thromboembolism following circular frame treatment for tibial fractures

IntroductionVenous thromboembolism (VTE) is a significant cause of morbidity and mortality following tibial fractures. The risk is as high as 77% without prophylaxis and around 10% with prophylaxis. Within the current literature there are no figures reported specifically for those individuals treated with circular frames. Our aim was to evaluate the VTE incidence within a single surgeon series and to evaluate potential risk factors. MethodsWe retrospectively reviewed our consecutive single surgeon series of 177 patients admitted to a major trauma unit with tibial fractures. All patients received standardised care, including chemical thromboprophylaxis within 24h of injury until independent mobility was achieved. We comprehensively reviewed our prospective database and medical records looking at demographics and potential risk factors. ResultsSeven patients (4.0%±2.87%) developed symptomatic VTE during the course of frame treatment; three deep vein thrombosis (DVTs) and four pulmonary embolisms (PEs). Those with a VTE event had significantly increased body mass index (BMI) (p=0.01) when compared to those without symptomatic VTE. No differences (p>0.05) were observed between the groups in age, gender, smoking status, fracture type (anatomical allocation or open/closed), delay to frame treatment, weight bearing status post-frame, inpatient stay or total duration of frame treatment. ConclusionThis study suggests that increased BMI is a statistically significant risk factor for VTE, as reported in current literature. In addition, we calculated the true risk of VTE following circular frame treatment for tibial fracture in our series is from 1.13% to 6.87%, which is at least comparable to other forms of treatment.

Canadian consensus recommendations on the management of venous thromboembolism in patients with cancer. Part 1: prophylaxis.

Patients with cancer are at increased risk of venous thromboembolism (vte). Anticoagulation therapy has been shown to prevent vte; however, unique clinical circumstances in patients with cancer can often complicate the decisions surrounding the administration of prophylactic anticoagulation. No national Canadian guidelines on the prevention of cancer-associated thrombosis have been published. We therefore aimed to develop a consensus-based, evidence-informed guideline on the topic. PubMed was searched for clinical trials and meta-analyses published between 2002 and 2013. Reference lists of key articles were hand-searched for additional publications. Content experts from across Canada were assembled to review the evidence and make recommendations. Low molecular weight heparin can be used prophylactically in cancer patients at high risk of developing vte. Direct oral anticoagulants are not recommended for vte prophylaxis at this time. Specific clinical scenarios, including renal insufficiency, thrombocytopenia, liver disease, and obesity can warrant modifications in the administration of prophylactic anticoagulant therapy. There is no evidence to support the monitoring of anti-factor Xa levels in clinically stable cancer patients receiving prophylactic anticoagulation; however, factor Xa levels could be checked at baseline and periodically in patients with renal insufficiency. The use of anticoagulation therapy to prolong survival in cancer patients without the presence of risk factors for vte is not recommended.

Duration of anticoagulation after venous thromboembolism in real world clinical practice

IntroductionVenous thromboembolism (VTE) carries a considerable risk of recurrence and anticoagulants should be administered for a minimum of three months. Since little is known about real life management of VTE, we aimed to describe current practice in the secondary prevention of VTE. Materials and MethodsUsing the database of an international, prospective registry on patients treated for VTE, RIETE, information was collected on risk factors for VTE and bleeding, anticoagulant treatment, and clinical outcomes during follow up. Multivariate analysis using logistic regression was performed to identify predictors of treatment duration. ResultsOf 6944 patients with a first episode of VTE 41.1% had unprovoked VTE, 31.8% had transient risk factors, 27.1% had cancer. After the exclusion of patients who died during the first year of observation, the rate of patients treated for >12months was 55.1%, 41.9%, and 43.2%, respectively (p<0.001). Pulmonary embolism at presentation, recurrence while on treatment, chronic heart failure and age >65years were independently associated with treatment for >12months. Body weight <75kg, anemia, cancer, and the presence of transient risk factors were associated with treatment for 12months or less. Major bleeding occurred more frequently than recurrent VTE in patients with VTE secondary to transient risk factors and cancer; fatal bleeding was more frequent than fatal recurrent PE in all subgroups. ConclusionsWe observed heterogeneous duration of anticoagulant treatment for the secondary prevention of VTE. A substantial proportion of patients, in particular those with VTE secondary to transient risk factors, may be exposed to a possibly unnecessary risk of bleeding.

Plasminogen activator inhibitor-1 4G/5G polymorphism, factor V Leiden, prothrombin mutations and the risk of VTE recurrence.

Plasminogen-activator inhibitor (PAI)-1 is an important inhibitor of the plasminogen/plasmin system. PAI-1 levels are influenced by the 4G/5G polymorphism in the PAI-1 promoter. We investigated the relationship between the PAI-1 polymorphism and VTE recurrence, and its possible modification by factor V Leiden (FVL) and prothrombin (PTM) mutations. Patients (n=1,069) from the Malmö Thrombophilia Study were followed from discontinuation of anticoagulant treatment until diagnosis of VTE recurrence or the end of the study (maximum follow-up 9.8 years). One hundred twenty-seven patients (11.9 %) had VTE recurrence. PAI-1 was genotyped by TaqMan PCR. Cox regression analysis adjusted for age, sex and acquired risk factors of VTE showed no evidence of an association between PAI-1 genotype and risk of VTE recurrence in the study population as a whole. However, by including an interaction term in the analysis we showed that FVL but not PTM modified the effect of PAI-1 genotype: patients with the 4G allele plus FVL had a higher risk of VTE recurrence [hazard ratio (HR) =2.3, 95 % confidence interval (CI) =1.5-3.3] compared to patients with the 4G allele but no FVL (reference group) or FVL irrespective of PAI-1 genotype (HR=1.8, 95 % CI=1.3-2.5). Compared to reference group, 5G allele irrespective of FVL was associated with lower risk of VTE recurrence only when compared with 4G allele together with FVL. In conclusion, FVL has a modifying effect on PAI-1 polymorphism in relation to risk of VTE recurrence. The role of PAI-1 polymorphism as a risk factor of recurrent VTE may be FVL dependent.

Congestive heart failure is a risk factor for venous thromboembolism in bariatric surgery

BackgroundVenous thromboembolism (VTE) is a major complication of bariatric surgery leading to significant morbidity and mortality. We sought to identify predictive factors that increase the risk of deep venous thrombosis (DVT) and pulmonary embolism (PE) using data from the National Surgical Quality Improvement Program (NSQIP). MethodsPatients undergoing bariatric procedures from 2005–2012 were identified in the NSQIP database. Pretreatment patient characteristics were examined by laparoscopic and open treatment groups using t tests and chi-square regression. Independent associations between patient characteristics and DVT and PE were examined using logistic regression. Logistic regression was also used to examine whether patients who had postprocedure DVT or PE were more likely than those who did not have these events to have additional morbidity and mortality outcomes. Results102,869 patients underwent bariatric surgery (96,085 laparoscopic; 6,784 open) from 2005–2012. Preoperative variables associated with increased risk of DVT in laparoscopic bariatric surgery are male gender, higher BMI, congestive heart failure (CHF), and hypertension (HTN). Preoperative variables associated with increased risk of PE in laparoscopic bariatric surgery are male gender, age greater than or equal to 60, higher BMI, African American race, chronic obstructive pulmonary disease (COPD) and CHF. There are no preoperative variables associated with an increased risk of DVT in open bariatric surgery although there is a trend toward significance with CHF. Finally, higher BMI and CHF is associated with an increased risk of PE in open bariatric surgery. ConclusionsCHF is a significant risk factor for VTE in bariatric surgery. Surgeons should consider aggressive screening and VTE prophylaxis in patients with CHF and other known risk factors to decrease postoperative morbidity from VTE.

Incidence of symptomatic venous thromboembolism in patients with hemophilia undergoing joint replacement surgery: A retrospective study

IntroductionVenous thromboembolism (VTE) is a recognized complication after joint replacement surgery, and prophylaxis is routinely used in patients without bleeding disorders. However, for patients with hemophilia, pharmacologic prophylaxis is highly variable and controversial because of the inherent bleeding risk. AimTo review our institutional experience with outcomes of total knee or hip arthroplasty with regard to symptomatic VTE and use of VTE prophylaxis in patients with hemophilia and without inhibitors. MethodsWe reviewed records of 42 consecutive patients with hemophilia A or B who underwent 71 hip or knee replacements over a 39-year period. We also reviewed the literature to estimate the incidence of VTE after arthroplasty in the hemophilia population. ResultsAll patients used compression stockings for up to 6weeks after surgery; additionally, 6 cases (10.5%; 57 with available data) used sequential intermittent compression devices and 2 (2.8%) postoperatively received low-molecular-weight heparin. One patient (1.4%) who received low-molecular-weight heparin had a symptomatic, lower-extremity, deep venous thrombosis 10days after hip replacement for traumatic fracture. None of the other 70 surgical cases had symptomatic VTE within 3months after the procedure. Analysis of pooled data from published series of hemophilia patients undergoing arthroplasty showed an estimated incidence of symptomatic VTE of 0.5%. ConclusionOur study suggests that in patients with hemophilia, joint replacement surgery can be performed safely without routine pharmacologic VTE prophylaxis and without increasing risk of thromboembolic events. Pharmacologic VTE prophylaxis may be considered in select patients with known additional risk factors for VTE.

What clinical factors predict the incidence of deep venous thrombosis and pulmonary embolism in neurosurgical patients?

Venous thromboembolisms (VTEs) occur frequently in surgical patients and can manifest as pulmonary emboli (PEs) or deep venous thromboses (DVTs). While many medical therapies have been shown to prevent VTEs, neurosurgeons are concerned about the use of anticoagulants in the postoperative setting. To better understand the prevalence of and the patient-level risk factors for VTE, the authors analyzed data from the National Surgical Quality Improvement Program (NSQIP). Retrospective data on 1,777,035 patients for the years from 2006 to 2011 were acquired from the American College of Surgeons NSQIP database. Neurosurgical cases were extracted by querying the data for which the surgical specialty was listed as "neurological surgery." Univariate statistics were calculated using the chi-square test, with 95% confidence intervals used for the resultant risk ratios. Multivariate models were constructed using binary logistic regression with a maximum number of 20 iterations. Venous thromboembolisms were found in 1.7% of neurosurgical patients, with DVTs roughly twice as common as PEs (1.3% vs 0.6%, respectively). Significant independent predictors included ventilator dependence, immobility (that is, quadriparesis, hemiparesis, or paraparesis), chronic steroid use, and sepsis. The risk of VTE was significantly higher in patients who had undergone cranial procedures (3.4%) than in those who had undergone spinal procedures (1.1%). Venous thromboembolism is a common complication in neurosurgical patients, and the frequency has not changed appreciably over the past several years. Many factors were identified as independently predictive of VTEs in this population: ventilator dependence, immobility, and malignancy. Less anticipated predictors included chronic steroid use and sepsis. Venous thromboembolisms appear significantly more likely to occur in patients undergoing cranial procedures than in those undergoing spinal procedures. A better appreciation of the prevalence of and the risk factors for VTEs in neurosurgical patients will allow targeting of interventions and a better understanding of which patients are most at risk.

Venous thromboembolism prophylaxis in acutely ill hospitalized medical patients. A retrospective multicenter study

ObjectiveTo analyze the incidence of VTE in hospitalized medical patients and prophylaxis applied in accordance with the 8th ACCP guidelines and the National PRETEMED guide for thromboprophylaxis. MethodsDischarge lists were reviewed to select the first consecutive 20 patients, aged ≥40years and admitted ≥4days to the Internal Medicine Departments of 79 Spanish hospitals. Exclusion criteria were: admission for diagnostic procedures, VTE or surgical illness, or care during hospitalization provided by the local investigator. ResultsFrom September 2011 to July 2012, 2845 discharge reports were evaluated and 1623 were considered eligible for the study. Overall 930 (57.3%) patients of this group were at risk of VTE according to the ACCP guidelines, 759 (81.6%) received VTE prophylaxis (mechanical or pharmacological) and 159 (17.1%) had at least one risk factor that might contraindicate anticoagulant use. The proportion of patients at VTE risk according to the ACCP and National PRETEMED guidelines with no risk factors of bleeding that did not receive prophylaxis was 16.3% and 17.2%, respectively. During hospitalization, there were 14 (0.9%) episodes of symptomatic VTE, 12 (86%) of which occurred in patients receiving prophylaxis. VTE rate was 1.3% among patients with VTE risk that received prophylaxis and 3.5% in patients that also had one risk factor that might contraindicate anticoagulant use. ConclusionsIn a setting characterized by high thromboprophylaxis compliance most of the episodes occurred in patients receiving pharmacological prophylaxis. Patients with combined VTE and bleeding risk factors showed the highest rate of both symptomatic VTE and prophylaxis failure.

Rethinking Guidelines for VTE Risk Among Nursing Home Residents: A Population-Based Study Merging Medical Record Detail With Standardized Nursing Home Assessments

Nursing home (NH) residents are at increased risk for both VTE and bleeding from pharmacologic prophylaxis. Construction of prophylaxis guidelines is hampered by NH-specific limitations with VTE case identification and characterization of risk. We addressed these limitations by merging detailed provider-linked Rochester Epidemiology Project (REP) medical records with Centers for Medicare and Medicaid Services Minimum Data Set (MDS) NH assessments.This population-based nested case-control study identified all Olmsted County, Minnesota, residents with first-lifetime VTE October 1, 1998, through December 31, 2005, while a resident of an NH (N = 91) and one to two age-, sex-, and calendar year-matched NH non-VTE control subjects. For each NH case without hospitalization 3 months before VTE (n = 23), we additionally identified three to four nonhospitalized NH control subjects. REP and MDS records were reviewed before index date (VTE date for cases; respective REP encounter date for control subjects) for numerous characteristics previously associated with VTE in non-NH populations. Data were modeled using conditional logistic regression.The multivariate model consisting of all cases and control subjects identified only three characteristics independently associated with VTE: respiratory infection vs no infection (OR, 5.9; 95% CI, 2.6-13.1), extensive or total assistance with walking in room (5.6, 2.5-12.6), and general surgery (3.3, 1.0-10.8). In analyses limited to nonhospitalized cases and control subjects, only nonrespiratory infection vs no infection was independently associated with VTE (8.8, 2.7-29.2).Contrary to previous assumptions, most VTE risk factors identified in non-NH populations do not apply to the NH population. NH residents with infection, substantial mobility limitations, or recent general surgery should be considered potential candidates for VTE prophylaxis.

The incidence of postoperative thromboembolic complications following surgical resection of intracranial meningioma. A retrospective study of a large single center patient cohort

BackgroundPatients with meningiomas carry an increased risk for postoperative venous thromboembolic complications (VTE) including deep venous thrombosis (DVT) and pulmonary embolism (PE). ObjectiveIn the present retrospective study we investigated the incidence of VTE and the risk factors involved, in a large cohort of patients surgically treated for an intracranial meningioma at our institution. MethodsDuring the period from January 1997 to January 2009, 581 consecutive patients underwent craniotomy for intracranial meningioma. All patients received low-molecular weight heparins as thromboembolism prophylaxis. Patient demographics and tumor characteristics were gathered via retrospective chart review. Postoperative VTE and hemorrhages were noted. Backward stepwise logistic regression was used to determine the risk factors. Results80.6% of meningiomas were WHO grade 1; 15.1% WHO grade 2; 4.3% WHO grade 3. Postoperative VTE were observed in 41 patients (7.2%). Of these, DVT was seen in 20 (3.5%) and PE in 26 patients (4.6%). The thromboembolic complication appeared on average 21.1±29.2 days post surgery. The 90-day mortality rate after VTE was 11.2% (23.1% for PE and 5.0% for DVT). Postoperative hemorrhages requiring surgical treatment were found in 2.9% of patients. Risk factors for VTE were body mass index (p=0.015) for DVT; weight (p=0.001) and bedridden postoperatively (p=0.001) for PE; and weight (p=0.004) and bedridden postoperatively (p=0.003) for VTE in general. There was no relation between tumor grade and thromboembolic complications. ConclusionThe major risk factors for postoperative VTE found in our single center study are patient weight and a bedridden status postoperatively. Prophylactic intervention for this potentially fatal complication should be evaluated against the relative lower risk of postoperative hemorrhages.

AB0245 Clinical Analysis of Preoperative Deep Vein Thrombosis Risk Factors in Patients with Total Hip Arthroplasty

BackgroundVenous thromboembolism (VTE) is a common complication during and after a hospital admission. That is associated with significant morbility and mortality after orthopedic surgery. The ACCP Guidelines showed that limb...

Maximizing Chemoprophylaxis Against Venous Thromboembolism in Abdominoplasty Patients With the Use of Preoperative Heparin Administration

Abdominoplasty is one of the highest risk plastic surgery procedures for venous thromboembolism complications (VTE). Current recommendations for VTE prophylaxis are sequential compression devices (SCDs) in the OR and optional use of subcutaneous heparin after surgery. Subcutaneous heparin has been shown to be safe in other surgical groups. However, the large raw surface areas and dissection involved in abdominoplasty has been a relative contraindication for preoperative chemoprophylaxis. However, the period while the patient is under general anesthesia and immediately following the procedure is likely the highest risk time period for VTEs. The purpose of this study is to determine if preoperative chemoprophylaxis is safe in these patients. All patients undergoing abdominoplasty by the senior author from January 1, 2005 to January 1, 2012 were retrospectively reviewed. All patients whose operation took place between January 1, 2005 and January 18, 2008 were given SCDs before the induction of anesthesia and heparin (unfractionated) 5000 units s.q. on call to the OR. All patients whose operation took place between January 19, 2008 and January 1, 2012 received enoxaparin (low molecular weight heparin) 40 mg s.q. on call to the OR and then daily for 2 days postoperatively. These groups were evaluated in regards to overall complication rate, incidence of VTE, and bleeding complications. A total of 151 patients underwent abdominoplasty during the study period. One hundred one patients received the SCD/heparin protocol and 50 had the enoxaparin protocol. The groups were similar in regard to pre-morbid conditions and risk factors for VTE. There were no VTEs diagnosed in either group. The overall incidence of any complication was similar between the 2 groups (19% vs. 14%, P = 0.503) and similar to other published series. The most common complications were seroma, cellulitis, and minor wound dehiscence. The incidence of bleeding complications was similar between the 2 groups (1% vs. 0%, P = 1.0). The use of preoperative chemoprophylaxis in patients undergoing abdominoplasty can be done without an increase in bleeding complications or overall complication rate. Furthermore, enoxaparin can also be used preoperatively and continued for 2 more days during the period of time of maximum immobility with easy administration for outpatients via use of a prescription home use kit.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

HIV infection as a permanent, acquired risk factor for VTE

HIV infection as a permanent, acquired risk factor for VTE