Symptomatic Venous Thromboembolism In Patients Research Articles

Symptomatic Venous Thromboembolism and Major Bleeding After Renal Transplantation: Should We Use Pharmacologic Thromboprophylaxis?

Venous thromboembolism (VTE) is a major health issue that may result in complications such as post-thrombotic syndrome, pulmonary hypertension, and death. Appropriate thromboprophylaxis in individuals undergoing kidney transplantation remains unclear. The aim of this study was to determine the prevalence of symptomatic VTE and major bleeding within 90 days after renal transplantation (RT). This was a retrospective study on consecutive patients undergoing RT at Hospital Privado Córdoba, Argentina, from January 1, 2006, to December 31, 2013. Exclusion criteria were age<18 years and combined organ transplantation. Pharmacologic or mechanical thromboprophylaxis was not used routinely. Symptomatic VTE and major bleeding were documented. A total of 511 RTs were performed; 62 patients received combined organ transplantation, and 8 patients (1.5%) were lost to follow-up. Overall, follow-up was completed on 441 patients, 4 (0.9%) of whom developed deep venous thrombosis and 14 (3%) of whom died. The most frequent causes of death were septic shock and severe hemorrhage. Duration of surgery >4 hours (P= .006) and a history of VTE (P< .001) were associated with VTE. Twenty-three patients (5.2%) had major bleeding, 2 (0.4%) died from bleeding complications, and 17 (3.85%) required a reoperation to control bleeding. This study shows a low prevalence of symptomatic VTE in patients undergoing RT despite not having used thromboprophylaxis routinely. Major bleeding was significant, and despite the high risk of VTE assigned by the Caprini score, which suggests pharmacologic prophylaxis, our data raise questions about the appropriate prophylaxis for these patients.

A Prospective Cohort Study of Symptomatic Venous Thromboembolic Events in Foot and Ankle Trauma

Category: Trauma Introduction/Purpose: The incidence of Venous Thromboembolism (VTE) and the balance of risks and benefits associated with chemical thromboprophylaxis in foot and ankle trauma are controversial, and much less investigated than in hip and knee surgery. A recent systematic review showed a low VTE rate in foot and ankle surgery (0-0.55%), but with an increased incidence in foot and ankle trauma, the highest in TA rupture and surgery. This study compares the 90-day VTE rates of 3 cohorts of patients: Group 1: TA ruptures managed in a full weight bearing (FWB), functional, Vacoped™ protocol over an 8 week period; Group 2: Stable ankle fractures managed in NWB below knee casts for 6 weeks; Group 3: Unstable or displaced ankle fractures managed with surgery and NWB below knee casts for 6 weeks. Methods: The data was extracted from two prospectively collected databases, one for the acute TA ruptures between March 2010 and December 2014, and one for ankle fractures from October 2013 to April 2014. These datasets were cross validated with the hospital VTE database. All patients were risk assessed at the time of presentation to the hospital. Selective chemical thromboprophylaxis was prescribed for patients with the previous history of VTE and patients who were deemed high-risk on VTE assessment. 90-day incidence of symptomatic VTE was drawn from the hospital radiology database. Results: Group 1: Overall VTE rate of 4.9% at a mean of 16.1 days. 3 Pulmonary Embolism (PE) and 11 Deep Vein Thrombosis (DVT). Total number of 283 patients. Group 2: Overall VTE rate of 2.2% at a mean of 33.4 days. 5 DVT. Total number of 227 patients Group 3: Overall VTE rate of 3.0% at a mean of 37.2 days. 1 PE and 5 DVT. Total number of 199 patients. Symptomatic VTE presents significantly earlier in acute TA rupture than ankle fracture patients (p=0.002) Conclusion: Although the overall incidence of VTE in foot and ankle trauma is low., there is a relatively higher incidence of VTE in patients with acute TA ruptures. This is, in spite of recent early weight bearing regimens. This study also shows that occurrence of symptomatic VTE in patients with Acute TA rupture happens much sooner compared to the ankle fracture patients. Although the exact reason for this difference in time of presentation of VTE is unknown, it may be due to de-functioning of the calf muscle pump immediately after the acute TA rupture.

Low rates of symptomatic venous thromboembolism in patients with gastrointestinal cancer: an Iranian study.

e13105Background: Venous thromboembolism (VTE) which is mostly presented by deep venous thrombosis (DVT) and Pulmonary Embolism (PE) is associated with considerable morbidity and mortality in patie...

Thrombophylaxis in Patients Undergoing Bariatric Surgery

Background: Patients undergoing bariatric surgery are at increased risk for symptomatic venous thromboembolism (VTE). Although the incidence of clinical VTE is lower than in other general and orthopedic surgical procedures, pulmonary embolism is an independent predictor of death after gastric bypass surgery. The optimal strategy for postoperative thrombophylaxis in bariatric surgery has yet to be elucidated. In 2010 our institution proposed a guideline for postoperative thrombophylaxis for bariatric surgery based on risk stratification. Patients were considered high risk if they had history of VTE or a BMI >/= 60 kg/m2 or if they had two or more of the following: age > 50, BMI >/= 50 kg/m2, male sex, recent history of smoking, obstructive sleep apnea, varicose veins, or hormone therapy within 30 days. All patients undergoing bariatric surgery received enoxaparin 40 mg SC twice daily in addition to mechanical thrombophylaxis including venodynes and compression stockings during the hospital stay. Prophylactic IVC filter insertion was not recommended. High-risk patients received an extended course of anticoagulation for 10 days after discharge.Methods: We retrospectively reviewed the medical charts of 692 patients who underwent bariatric surgery at Dartmouth-Hitchcock Medical Center from 2009 to 2014. We analyzed the incidence of VTE and bleeding complications under two different institutional thrombophylaxis protocols: an earlier protocol of VTE prophylaxis based on surgeon's preference (n = 62) and our subsequent protocol based on risk stratification (n = 630).Results: Prior to implementing our protocol the incidence of VTE and bleeding complications in patients who underwent bariatric surgery was 1.6% (1 in 62) for each. After 2010, with the implementation of extended VTE prophylaxis for high-risk patients, the incidence of postoperative VTE was 0% (0 in 630) and the incidence of postoperative bleeding was 2.7% (17 in 630). Of 17 patients who developed postoperative bleeding, 14 (82%) developed bleeding before postoperative day 3 during the hospitalization and 3 (18%) experienced delayed bleeding after hospital discharge. Of 3 patients with delayed bleeding, only 1 was on the extended thrombophylaxis protocol. Severe bleeding, defined as the need for packed red blood cell transfusions or re-operation, occurred in 1.6% (10 in 630).Conclusion: Our study demonstrates that a protocol based on risk stratification is effective at reducing the risk of symptomatic VTE in patients undergoing bariatric surgery. Although the incidence of all postoperative bleeding appears to have increased slightly after implementation of the protocol, the incidence of severe bleeding appears unchanged. As most of the post-operative bleeding events occurred during the hospitalization period, extending the length of pharmacologic thromboprophylaxis was not associated with an increase in bleeding. This study is limited by its retrospective design and the small number of patients studied prior to implementing the extended VTE prophylaxis protocol. Nevertheless, the findings are promising with respect to VTE risk reduction after bariatric surgery and suggest that prospective evaluation of the thromboprophylaxis protocol is in order. DisclosuresNo relevant conflicts of interest to declare.

The catheter to vein ratio and rates of symptomatic venous thromboembolism in patients with a peripherally inserted central catheter (PICC): A prospective cohort study

BackgroundPeripherally inserted central catheters (PICCs) are a common vascular access device used in clinical practice. Their use may be complicated by adverse events such as venous thromboembolism (VTE). The size of the vein used for PICC insertion and thus the catheter to vein ratio is thought to be a controllable factor in the reduction of VTE rates in patients who have a PICC. However, an optimal catheter to vein ratio for PICC insertion has not previously been investigated to inform clinical practice. ObjectivesTo determine the effect of the catheter to vein ratio (proportion of the vein measured at the insertion point taken up by the catheter) on rates of symptomatic VTE in patients with a PICC and identify the optimal ratio cut-off point to reduce rates of this adverse event. MethodAdult patients waiting for PICC insertion at a large metropolitan teaching hospital were recruited between May and December 2013. Vein diameter at the PICC insertion site was measured using ultrasound with in-built callipers. Participants were followed up at eight weeks to determine if they developed symptomatic VTE. ResultsData were available for 136 patients (50% cancer; 44% infection; 6% other indication for PICC). Mean age was 57 years with 54% males. There were four cases of confirmed symptomatic VTE (two involving the deep veins, one peripheral vein and one pulmonary embolism). Receiver operator characteristic (ROC) analysis determined that a 45% catheter to vein ratio was the ideal cut off point to maximise sensitivity and specificity (AUC 0.761; 95% CI 0.681–0.830). When a ratio of 46% or above was compared to one that was less than or equal to 45% using a log binomial generalised linear model it was found that participants with a catheter to vein ratio >45% were 13 times more likely to suffer VTE (relative risk 13, p=0.022; CI 1.445–122.788). ConclusionIt was found that a 45% catheter to vein ratio was the optimal cut off with high sensitivity and specificity to reduce the risk of VTE. However, further research is needed to confirm these results as although adequately powered; the number of cases of VTE was comparatively small, resulting in wide confidence intervals.

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.

Oral rivaroxaban versus enoxaparin with vitamin K antagonist for the treatment of symptomatic venous thromboembolism in patients with cancer (EINSTEIN-DVT and EINSTEIN-PE): a pooled subgroup analysis of two randomised controlled trials

Patients with venous thromboembolism and cancer have a substantial risk of recurrent venous thromboembolism and bleeding during anticoagulant therapy. Although monotherapy with low-molecular-weight heparin is recommended in these patients, in clinical practice many patients with venous thromboembolism and cancer do not receive this treatment. We aimed to assess the efficacy and safety of a single-drug regimen with oral rivaroxaban compared with enoxaparin followed by vitamin K antagonists, in the subgroup of patients with cancer enrolled in the EINSTEIN-DVT and EINSTEIN-PE randomised controlled trials. We did a subgroup analysis of patients with active cancer (either at baseline or diagnosed during the study), a history of cancer, or no cancer who were enrolled in the EINSTEIN-DVT and EINSTEIN-PE trials. Eligible patients with deep-vein thrombosis (EINSTEIN-DVT) or pulmonary embolism (EINSTEIN-PE) were randomly assigned in a 1:1 ratio to receive rivaroxaban (15 mg twice daily for 21 days, followed by 20 mg once daily) or standard therapy (enoxaparin 1·0 mg/kg twice daily and warfarin or acenocoumarol; international normalised ratio 2·0-3·0). Randomisation with a computerised voice-response system was stratified according to country and intended treatment duration (3, 6, or 12 months). The prespecified primary efficacy and safety outcomes of both the trials and this subanalysis were symptomatic recurrent venous thromboembolism and clinically relevant bleeding, respectively. We did efficacy and mortality analyses in the intention-to-treat population, and bleeding analyses for time spent receiving treatment plus 2 days in the safety population (all patients who received at least one dose of study drug). The EINSTEIN-DVT and EINSTEIN-PE studies are registered at ClinicalTrials.gov, numbers NCT00440193 and NCT00439777. In patients with active cancer (diagnosed at baseline or during treatment), recurrent venous thromboembolism occurred in 16 (5%) of 354 patients allocated to rivaroxaban and 20 (7%) of 301 patients allocated to enoxaparin and vitamin K antagonist (hazard ratio [HR] 0·67, 95% CI 0·35 to 1·30). Clinically relevant bleeding occurred in 48 (14%) of 353 patients receiving rivaroxaban and in 49 (16%) of 298 patients receiving standard therapy (HR 0·80, 95% CI 0·54 to 1·20). Major bleeding occurred in eight (2%) of 353 patients receiving rivaroxaban and in 15 (5%) of 298 patients receiving standard therapy (HR 0·42, 95% CI 0·18 to 0·99). The overall frequency of recurrent venous thromboembolism in patients with only a history of cancer (five [2%] of 233 patients in the rivaroxaban group vs five [2%] of 236 in the standard therapy group; HR 0·98, 95% CI 0·28-3·43) was similar to that of patients without cancer (65 [2%] of 3563 vs 70 [2%] of 3594, respectively; HR 0·93, 95% CI 0·66-1·30), but the frequency was increased in patients with active cancer at baseline (six [2%] of 258 vs eight [4%] of 204, respectively; HR 0·62, 95% CI 0·21-1·79) and most markedly increased in patients whose diagnosis of cancer was made during the study (ten [10%] of 96 vs 12 [12%] of 97, respectively; HR 0·80, 95% CI 0·34-1·88). The overall frequency of major bleeding in patients with only a history of cancer (one [<1%] patient in the rivaroxaban group vs four [2%] patients in the standard therapy group; HR 0·23, 95% CI 0·03-2·06) was similar to that of patients without cancer (31 [1%] vs 53 [1%], respectively; HR 0·58, 95% CI 0·37-0·91), but was increased in patients with active cancer at baseline (five [2%] vs eight [4%], respectively; HR 0·47, 95% CI 0·15-1·45) and was highest in those with cancer diagnosed during the study (three [3%] vs seven [7%], respectively; HR 0·33, 95% CI 0·08-1·31). In patients with active cancer and venous thromboembolism, rivaroxaban had similar efficacy to prevent recurrence of venous thromboembolism and reduced the number major bleeding events compared with treatment with enoxaparin and a vitamin K antagonist, although there was no difference between groups for clinically relevant bleeding. Based on these results, a head-to-head comparison of rivaroxaban with long-term low-molecular-weight heparin in patients with cancer is warranted. Bayer HealthCare Pharmaceuticals and Janssen Research & Development.

Oral Rivaroxaban Versus Standard Therapy for the Treatment of Symptomatic Venous Thromboembolism in Patients with Cancer

ABSTRACT Objective: To compare the efficacy and safety of oral rivaroxaban with that of enoxaparin/vitamin K antagonist (VKA) in patients with cancer among 8282 patients with acute venous thromboembolism (VTE) enrolled in the EINSTEIN programme. Rationale: Patients with cancer and VTE constitute a medical challenge for physicians because anticoagulant treatment is indicated to prevent recurrent VTE but is associated with a high risk of major bleeding. Methods: EINSTEIN DVT and EINSTEIN PE were randomized, event-driven, non-inferiority, open-label phase III studies. Patients were treated for 3, 6 or 12 months with rivaroxaban (15 mg twice daily for 21 days followed by 20 mg once daily) or enoxaparin/VKA (international normalized ratio 2.0–3.0) and followed for suspected recurrent VTE, bleeding and mortality. Cancer patients were classified as: active cancer at baseline (diagnosis or treatment within 6 months before enrolment or recurrent/metastatic cancer) or diagnosed during the study (n = 655); or a history of cancer (n = 469). Results: Recurrent VTE occurred with a similar incidence in the rivaroxaban and enoxaparin/VKA groups in patients with active cancer (hazard ratio [HR] 0.67; 95% confidence interval [CI] 0.35–1.30) and patients with a history of cancer (HR 0.98; 95% CI 0.28–3.43). In patients with active cancer, the risk of major bleeding was significantly reduced in the rivaroxaban group (HR 0.42; 95% CI 0.18–0.99), whereas it was similar between treatments in patients with a history of cancer (HR 0.23; 95% CI 0.03–2.06). Mortality occurred with a similar incidence between treatments in patients with active cancer (HR 0.93; 95% CI 0.64–1.35) and patients with a history of cancer (HR 1.12; 95% CI 0.30–4.22). Rivaroxaban Enoxaparin/VKA HR (95% CI) Recurrent VTE, n (%) Active cancer 16/354 (4.5) 20/301 (6.6) 0.67 (0.35–1.30) History of cancer 5/233 (2.1) 5/236 (2.1) 0.98 (0.28–3.43) Major bleeding, n (%) Active cancer 8/353 (2.3) 15/298 (5.0) 0.42 (0.18–0.99) History of cancer 1/231 (0.4) 4/236 (1.7) 0.23 (0.03–2.06) Mortality, n (%) Active cancer 58/354 (16.4) 53/301 (17.6) 0.93 (0.64–1.35) History of cancer 5/233 (2.1) 4/236 (1.7) 1.12 (0.30–4.22) Conclusions: Rivaroxaban had similar efficacy to enoxaparin/VKA in patients with VTE and active cancer or a history of cancer, but was associated with a significant reduction in major bleeding in patients with active cancer. Disclosure: M.H. Prins: is a consultant advisor for Bayer HealthCare Pharmaceuticals, Daiichi Sankyo, Pfizer, Sanofi, Boehringer Ingelheim, GlaxoSmithKline (GSK), LEO, and ThromboGenics; T. Lensing, F. Misselwitz, A.F. Pap, M. Trajanovic and S.D. Berkowitz: is an employee of Bayer HealthCare Pharmaceuticals; P. Prandoni: has received consultant fees from Bayer Pharma, Daiichi Sankyo, Pfizer, Boehringer-Ingelheim and Sanofi-Aventis; A.T. Cohen: has received consultancy and clinical trial funding from Astellas, AstraZeneca, Bayer, Boehringer-Ingelheim, BMS, Daiichi, GSK, Johnson & Johnson, Mitsubishi Pharma, Pfizer, Portola, Sanofi-aventis, Schering-Plough & Takeda; B.L. Davidson: has received travel support from Bayer Healthcare, and is a steering committee member for Bayer HealthCare and Daiichi Sankyo;P. Wells: has received research support from Bristol-Myers Squibb, Pfizer; has participated on scientific advisory boards for Bayer Schering Pharma, Pfizer & Boehringer Ingelheim; and has received honoraria from Bayer Schering Pharma, Pfizer & Biomerieux.

Symptomatic venous thromboembolism uncommon without thromboprophylaxis after isolated lower-limb fracture: the knee-to-ankle fracture (KAF) cohort study.

The prevalence of deep vein thrombosis as demonstrated by routine venography in patients with distal lower-extremity injury requiring cast immobilization or surgery is 10% to 40%. These deep vein thromboses are usually asymptomatic and distal, and the need for thromboprophylaxis in these patients is not known. We conducted a multicenter prospective cohort study to define the prevalence of symptomatic venous thromboembolism in patients with a tibial, fibular, or ankle fracture (treated nonoperatively) or a patellar or foot fracture (treated operatively or conservatively). Consecutive patients were enrolled at five Ontario, Canada, hospitals within ninety-six hours after injury, and they were followed with a telephone interview at two, six, and twelve weeks. Thromboprophylaxis was not allowed. Suspected venous thromboembolism was investigated in a standardized manner. From August 2002 to June 2005, 1200 patients were enrolled, and a three-month follow-up was completed for 98% of them. Eighty-two percent of the patients were treated with cast or splint immobilization for an average (and standard deviation) of 42 ± 32 days. Overall, seven patients (0.6%; 95% confidence interval [CI] = 0.2% to 1.2%) had symptomatic, objectively confirmed venous thromboembolism. Two of them had proximal deep vein thrombosis; three, calf deep vein thrombosis; and two, pulmonary embolism. There were no fatal pulmonary emboli. Symptomatic venous thromboembolism is an infrequent complication after fractures of the distal part of the lower limb requiring cast immobilization and managed without thromboprophylaxis. Given these estimates of symptomatic venous thromboembolism, the risk-benefit ratio and cost-effectiveness of routine anticoagulant prophylaxis are unlikely to be favorable for these patients. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The rate of symptomatic venous thromboembolism in patients undergoing elective Ilizarov surgery and the cost of chemical prophylaxis

Recent recommendations by the National Institute for Health and Care Excellence (NICE) suggest that all patients undergoing elective orthopaedic surgery should be assessed for the risk of venous thromboembolism (VTE). Little is known about the incidence of symptomatic VTE after elective external fixation. We studied a consecutive series of adult patients who had undergone elective Ilizarov surgery without routine pharmacological prophylaxis to establish the incidence of symptomatic VTE. A review of a prospectively maintained database of consecutive patients who were treated between October 1998 and February 2011 identified 457 frames in 442 adults whose mean age was 42.6 years (16.0 to 84.6). There were 425 lower limb and 32 upper limb frames. The mean duration of treatment was 25.7 weeks (1.6 to 85.3). According to NICE guidelines all the patients had at least one risk factor for VTE, 246 had two, 172 had three and 31 had four or more. One patient (0.23%) developed a pulmonary embolus after surgery and was later found to have an inherited thrombophilia. There were 27 deaths, all unrelated to VTE. The cost of providing VTE prophylaxis according to NICE guidelines in this group of patients would be £89 493.40 (£195.80 per patient) even if the cheapest recommended medication was used. The rate of symptomatic VTE after Ilizarov surgery was low despite using no pharmacological prophylaxis. This study leads us to question whether NICE guidelines are applicable to these patients.

The necessity of pharmacological prophylaxis against venous thromboembolism in major joint arthroplasty

Venous thromboembolism (VTE) is a recognised post-operative complication of major lower limb joint arthroplasty. Current National Institute for Health and Clinical Excellence (NICE) guidelines suggest the use of both mechanical and pharmacological prophylaxis following hip and knee replacement. Since the introduction of enhanced recovery programmes following hip and knee arthroplasty the requirement for routine pharmacological VTE prophylaxis has been questioned. The purpose of this study was to assess the efficacy of pharmacological prophylaxis against symptomatic VTE in patients undergoing hip and knee arthroplasty under an enhanced recovery programme. Symptomatic VTE incidence was audited in 1,100 patients undergoing primary or revision total hip or knee arthroplasty at the same hospital with only mechanical prophylaxis from 2007 to 2009. Following addition of chemical prophylaxis (enoxaparin) symptomatic VTE incidence in 522 patients undergoing primary or revision total hip or knee arthroplasty from 2011 to 2012 was re-audited. In the mechanical prophylaxis group incidence of DVT was 0.73 % [95 % confidence interval (CI) 0.37-1.43 %] and incidence of pulmonary embolism (PE) 0.91 % (95 % CI 0.49-1.67 %). Following addition of pharmacological prophylaxis incidence of DVT was 0.57 % (95 % CI 0.20-1.68 %) and incidence of PE 1.15 % (95 % CI 0.53-2.48 %). We found no statistically significant difference in symptomatic VTE incidence following the addition of enoxaparin. We question whether routine pharmacological prophylaxis still has a role following total hip and knee arthroplasty. Peri-operative optimisation, including post-operative analgesia and mobility, with current enhanced recovery programmes may be sufficient. As anticoagulants carry increased risk of post-operative bleeding and wound ooze, in addition to significant cost implications, their role remains controversial.

Venous Thromboembolism and Cancer

Case Presentation 1: A 64-year-old man with prostate cancer who recently underwent radical retropubic prostatectomy presented to the emergency department with sudden-onset exertional dyspnea and chest heaviness. On physical examination, he was tachycardic with a heart rate of 110 beats per minute, normotensive with a blood pressure of 100/76 mm Hg, and hypoxemic with an oxygen saturation of 88% on room air. Left lower extremity edema and calf tenderness were noted. Contrast-enhanced chest computed tomography demonstrated bilateral segmental pulmonary embolism (PE) without right ventricular enlargement. A left lower extremity venous ultrasound documented left femoral, popliteal, and calf deep vein thrombosis. Case Presentation 2: A 70-year-old woman with renal cell carcinoma underwent resection of a solitary right upper lobe metastatic pulmonary nodule and was referred to the Vascular Medicine clinic after surveillance chest computed tomography performed 1-month postoperatively demonstrated a right lobar PE. She noted fatigue since her surgery but denied any dyspnea or chest discomfort. On physical examination, her heart rate was 82 beats per minute, blood pressure was 102/66 mm Hg, and oxygenation was 96% on room air. Cardiac and pulmonary examinations were unremarkable. Although the association between cancer and venous thromboembolism (VTE) was first noted in 1823 by Bouillard, Trousseau provided the most detailed early description in 1865. VTE is now recognized as a common cause of morbidity and mortality in patients with cancer. Increasing life expectancy attributable to advances in cancer therapy and greater use of imaging for cancer surveillance have contributed to the growing incidence of VTE in patients with malignancy. The rate of symptomatic VTE in patients with cancer who have been hospitalized approaches 5%.1 VTE, especially when unprovoked, may herald an impending diagnosis of cancer in a subset of patients without known malignancy. Although the frequency of VTE is considered highest among patients with solid …

Incidence Of Symptomatic Venous Thromboembolism In Patients With Hemophilia Undergoing Joint Replacement Surgery: A Retrospective Study

BackgroundHip and knee arthroplasty (THA and TKA), in general, pose a high risk for venous thromboembolism (VTE), and pharmacologic VTE prophylaxis is often strongly recommended. In patients (pt) with hemophilia undergoing THA/TKA, given the underlying bleeding diathesis, the routine use of pharmacologic VTE prophylaxis is controversial. In this study, we report THA/TKA outcomes in pt with hemophilia in our institution. MethodsRetrospective chart review of Mayo Comprehensive hemophilia center pt undergoing THA and TKA. Medical records were reviewed for objectively documented VTE for up to 3 months after surgery. Results42 consecutive pt with hemophilia A (n=38) or B (n=4) underwent 71 operations: THA (n=32) and TKA (n=39) over a period of 39 years. All pt received compression stockings up to 6 weeks after surgery; 6/71 (8.4%) received sequential intermittent compression and 2/71 (2.8%) received postoperative low molecular weight heparin (LMWH). Symptomatic femoral vein DVT occurred in 1/42 pt (2%); (1/71, 1.4% of operations (1.4%)), 10 days after THA for traumatic hip fracture and after the LMWH was discontinued. The patient was subsequently found to be heterozygous for the factor V Leiden gene mutation. For up to 3 months after surgery, there were no additional cases of symptomatic DVT. There was no unexpected bleeding in the 2 patients receiving LMWH. ConclusionIn this this study, routine use of compression stockings without the use of pharmacologic prophylaxis resulted in a low rate of symptomatic VTE in patients with hemophilia. This may be similar to the incidence in the general population receiving LMWH (Heit, JA et al Annals of Internal Medicine 2000) A limited sample size precludes definitive recommendations for practice. For appropriate high risk patients, limited use of pharmacologic prophylaxis may still be important. Disclosures:No relevant conflicts of interest to declare.

Incidence and Outcome of Symptomatic Venous Thromboembolism in Patients With Glioblastoma Multiforme in Southern Alberta

Patients with malignancy, and especially those with Glioblastoma Multiforme (WHO grade IV), have an increased risk of venous thromboembolism (VTE). The incidence of VTE reported in the literature has been highly variable and few studies have carefully investigated the factors related to the development of VTE and its impact on patient outcome in this population. The objective of this study was to determine the incidence of symptomatic VTE, to identify clinical and molecular factors related to VTE formation, and to determine patient outcome in this patient population.

Symptomatic venous thromboembolism after femoral vein harvest

The femoral vein is increasingly utilized as a conduit in major arterial and venous reconstruction. However, perioperative complications, especially venous thromboembolism (VTE) associated with femoral vein harvest (FVH), are not well described. The purpose of this study was to determine the incidence and risk factors for the development of symptomatic VTE in patients who undergo FVH. We conducted a retrospective cohort study of all patients who underwent FVH over a 5-year period at a single institution. Patient clinical characteristics, indications for surgery, postoperative venous duplex scans, and computerized tomography scans of the chest were gathered and reviewed from an electronic medical record query. Statistical analysis was performed to determine which factors correlate with development of perioperative complications after FVH. There were 57 patients (53% male; mean age, 62 years) who underwent 58 FVHs. Of the procedures, 53% were performed for arterial reconstruction and 47% for vascular reconstruction after cancer resection (85% portomesenteric reconstruction). Perioperative VTEs were diagnosed in 17 of 58 (29%) FVH procedures. Sixteen ipsilateral deep vein thromboses (DVTs) occurred distal to the FVH site and five (9%) occurred proximal to the FVH site. The incidence of VTE was significantly greater in patients with malignancy (52% vs 10%; P = .001), and 88% of all VTEs in this series were diagnosed in patients with cancer. All DVTs proximal to the FVH site and all DVTs in the contralateral extremity occurred in patients with malignancy. Pulmonary embolism occurred in two patients. No patients developed compartment syndrome or limb loss. Eight patients (14%) required FVH site wound debridement. VTE after FVH occurs more frequently in patients with malignancy. Aggressive and prolonged thromboprophylaxis and routine venous ultrasound surveillance are warranted after FVH in patients with malignancy.

Abstract 8642: A Randomized Controlled Trial of Physician Alerts to Prevent Symptomatic Venous Thromboembolism after Hospital Discharge

Introduction: Many patients develop venous thromboembolism (VTE) in the months following hospitalization for medical illness. Hypothesis: We assessed the hypothesis that a VTE prophylaxis alert from a hospital staff member to the Attending Physician prior to patient discharge from the hospital will reduce the incidence of symptomatic VTE after discharge. Methods: We enrolled hospitalized Medical Service patients in a large multicenter randomized controlled trial using a validated point score system to identify those at high risk for symptomatic VTE who were not ordered to receive VTE prophylaxis after discharge. Results: Among 2,513 eligible patients randomized from 18 study sites, 1,252 were assigned to the intervention group, and 1,261 were assigned to the control group. Patients in the intervention group were more than twice as likely to receive VTE prophylaxis at discharge as controls (22.0% versus 9.7%, p&lt;0.0001). Symptomatic VTE at 90 days (99.9% follow-up) occurred in 4.5% of patients in the intervention group compared with 4.0% of controls (hazard ratio, 1.12; 95% confidence interval, 0.74 to 1.69). Rates of death at 90 days and major bleeding at 30 days in the intervention group were similar to that of the control group. In an on-treatment analysis, we observed a nearly one-third reduction in 90-day mortality among at-risk medical patients whose physicians were alerted and in whom discharge prophylaxis was prescribed compared with those in whom the alert recommendation was not followed and compared with those for whom an alert was not issued and prophylaxis was not ordered after hospital discharge. Conclusion: We observed no difference in the rate of symptomatic VTE in patients assigned to the alert group compared with controls. The physician alert doubled the rate of VTE prophylaxis ordered at the time of hospital discharge. Further Quality Improvement initiatives to improve VTE prevention after hospital discharge are warranted.

Incidence of Symptomatic Venous Thromboembolism in Oncologic Patients Undergoing Lower-Extremity Endoprosthetic Arthroplasty

As both cancer and major orthopaedic surgery are risk factors for venous thromboembolism, patients undergoing lower-extremity oncologic endoprosthetic arthroplasty for neoplastic processes are at substantial risk of the development of symptomatic venous thromboembolism. Therefore, the primary purpose of this study was to determine the incidence of symptomatic venous thromboembolism in patients undergoing lower-extremity oncologic endoprosthetic arthroplasty. Secondary purposes were to assess whether chemoprophylaxis influenced the incidence of venous thromboembolism, surgical complications, or the incidence of local sarcoma recurrence. We also sought to determine whether any known risk factors for venous thromboembolism could be identified in this patient population. We performed a retrospective comparative review of 423 patients who had undergone mega-endoprosthetic reconstruction following cancer resection. Univariate analysis was used to assess the association between chemoprophylaxis and the incidence of venous thromboembolism, to postulate the surgical complications associated with chemoprophylaxis, and to assess the rate of recurrence of local sarcoma as well the association between risk factors and venous thromboembolism. Seventeen patients (4.0%) (95% confidence interval: 2.5% to 6.3%) had a venous thromboembolic event, ten with deep venous thrombosis and seven with nonfatal pulmonary embolism. Risk factors and chemoprophylactic regimens were not statistically associated with the occurrence of venous thromboembolism. The incidence of symptomatic venous thromboembolism in our group of cancer patients who underwent lower-extremity endoprosthetic arthroplasty was lower than anticipated. A significant difference was not identified between the use of any or no chemoprophylactic agent and the incidence of venous thromboembolism or complication rates. No risk factors were associated with the incidence of symptomatic venous thromboembolism.

Patients Admitted with Acute Abdominal Conditions are at High Risk for Venous Thromboembolism but Often Fail to Receive Adequate Prophylaxis

IntroductionThe aim was to determine the frequency with which thromboprophylaxis is prescribed, factors predicting its prescription, and the frequency of symptomatic venous thromboembolism in patients admitted with acute abdominal conditions. MethodsCharts of patients admitted with acute abdominal conditions that did not have surgery for at least 24 h following admission were audited to identify if thromboprophylaxis was prescribed, if it was prescribed appropriately, factors affecting its prescription, and the rate of symptomatic venous thromboembolism. ResultsOf 350 patients (176 females, mean age 64.9 ± 18.6), 194 (55.4%) were admitted for bowel obstruction, 113 (32.3%) for biliary conditions, 14 (4.0%) for diverticulitis, 8 (2.3%) for pancreatitis, and 21 (6.0%) for other conditions. One hundred forty-two (40.6%) underwent surgery. Two hundred fifty-two (72.0%, 95% CI 67.3–76.7%) received thromboprophylaxis although only 199 (56.9%, 95% CI 51.7–62.1%) received adequate thromboprophylaxis. Hospital site and having surgery were associated with prescription of thromboprophylaxis. Twelve patients (3.4%, 95% CI 1.5–4.3%) developed symptomatic venous thromboembolism (nine deep venous thrombosis, three pulmonary embolism). ConclusionsDespite patients admitted with acute abdominal conditions being at high risk for development of symptomatic venous thromboembolism, many do not receive adequate thromboprophylaxis. Further work is required to decrease this gap in care.

Symptomatic venous thromboembolism following a hip fracture

Background and purpose Venous thromboembolism (VTE) remains a substantial cause of morbidity and mortality following hip fracture. Previous work has not identified any risk factors associated with the type of hip fracture. We report the incidence of and risk factors for development of symptomatic VTE in patients following a hip fracture.Patients and methods In this prospective study, we collected information on 5,300 consecutive patients who were admitted to a single unit with a hip fracture—in terms of their pre-admission status, details of any operation performed, and details of complications in the form of symptomatic venous thromboembolism. All patients received thromboprophylaxis with heparin.Results The incidence of symptomatic VTE was 2.2% (95% CI: 1.8–2.6). 85% of these events occurred within 5 weeks of the fracture. The statistically significant risk factors for symptomatic VTE were better preoperative mobility, living in one's own home, high mental test score, high preoperative hemoglobin, inter-trochanteric fractures, and fixation with a dynamic hip screw. In multivariate analysis adjusting for sex and age, type of residence on admission, type of fracture, and hemoglobin values on admission remained independently significant.Interpretation We found that the rate of symptomatic VTE using thromboprophylaxis with heparin was low but that there were a number of groups that were at a significantly higher risk of developing VTE. The patients who are particularly at risk appear to be those with a subtrochanteric or intertrochanteric hip fracture; here, the incidence of symptomatic VTE was twice that of intracapsular hip fractures.

Treatment of Cancer-Associated Venous Thrombosis

Venous thromboembolism (VTE) is an important complication in cancer patients, which is associated with bad outcome. Increased recurrence rates and bleeding complications as compared to non-cancer patients during the treatment of VTE, require special attention. This review aims to summarize the available evidence on both the anticoagulant and non-anticoagulant treatment of symptomatic VTE in patients with active malignancy.