Venous thromboembolism (VTE) is one of the most common preventable cause of morbidity and mortality after trauma. Though most of the western countries have their guidelines for thromboprophylaxis in these patients, India still does not have these. The increasing detection of VTE among Indian population, lack of awareness, underestimation of the risk, and fear of bleeding complications after chemical prophylaxis have made deep vein thrombosis (DVT) a serious problem, hence a standard guideline for thromboprophylaxis after trauma is essential. The present review article discusses the incidence of DVT and role of thromboprophylaxis in Indian patients who have sustained major orthopedic trauma. A thorough search of ‘PubMed’ and ‘Google Scholar’ revealed 10 studies regarding venous thromboembolism in Indian patients after major orthopedic trauma surgery (hip or proximal femur fracture and spine injury). Most of these studies have evaluated venous thromboembolism in patients of arthroplasty and trauma. The incidence, risk factors, diagnosis and management of VTE in the subgroup of trauma patients (1049 patients) were separately evaluated after segregating them from the arthroplasty patients. Except two studies, which were based on spinal injury, all other studies recommended screening/ thromboprophylaxis in posttraumatic conditions in the Indian population. Color Doppler was used as common diagnostic or screening tool in most of the studies (eight studies, 722 patients). The incidence of VTE among thromboprophylaxis-receiving group was found to be 8% (10/125), whereas it was much higher (14.49%, 40/276) in patients not receiving any form of prophylaxis. Indian patients have definite risk of venous thromboembolism after major orthopedic trauma (except spinal injury), and thromboprophylaxis either by chemical or mechanical methods seems to be justified in them.
Thromboprophylaxis; trauma; venous thromboembolism
Postoperative deep vein thrombosis (DVT) occurs most often in the large veins of the legs in patients undergoing major joint arthroplasty and major surgical procedures. These patients remain at high risk for venous thromboembolic events. In patients undergoing total hip or total knee arthroplasty (THA or TKA, respectively), different patterns of altered venous hemodynamics and hypercoagulability have been found, thus the rate of distal DVT is higher than that of proximal DVT after TKA. In addition, symptomatic venous thromboembolism (VTE) occurs earlier after TKA than THA; however, most of those events occur after hospital discharge. Consequently, extended thromboprophylaxis after discharge should be considered and is particularly important after THA owing to the prolonged risk period for VTE. Evidence-based guideline recommendations for the prevention of VTE in these patients have not been fully implemented. This is partly owing to the limitations of traditional anticoagulants, such as the parenteral route of administration or frequent coagulation monitoring and dose adjustment, as well as concerns about bleeding risks. The introduction of new oral agents (e.g., dabigatran etexilate and rivaroxaban) may facilitate guideline adherence, particularly in the outpatient setting, owing to their oral administration without the need for routine coagulation monitoring. Furthermore, the direct Factor Xa inhibitor rivaroxaban has been shown to be more effective than enoxaparin in preventing VTE.
Little information exists on the presentation of symptomatic venous thromboembolism (VTE) in orthopaedic surgery when a defined protocol for thromboprophylaxis is used. The objective with this study was to establish the VTE rate and mortality rate in orthopaedic surgery.
We performed a prospective, single centre observational cohort study of 45 968 consecutive procedures in 36 388 patients over a 10 year period. Follow-up was successful in 99.3%. The primary study outcome was the incidence of symptomatic deep vein thrombosis (DVT), symptomatic pulmonary embolism (PE) and mortality at 6 weeks, specified for different surgical procedures. The secondary outcome was to describe the DVT distribution in proximal and distal veins and the proportion of VTEs diagnosed after hospital discharge. For validation purposes, a retrospective review of VTEs diagnosed 7–12 weeks postoperatively was also performed.
In total, 514 VTEs were diagnosed (1.1%; 95% CI: 1.10-1.14), the majority (84%) after hospital discharge (432 out of 514).With thromboprophylaxis, high incidence of VTE was found after internal fixation (IF) of pelvic fracture (12%; 95% CI: 5–26), knee replacement surgery (3.7%; 95% CI: 2.8-5.0), after internal fixation (IF) of proximal tibia fracture (3.8%; 95% CI: 2.3-6.3) and after IF of ankle fracture (3.6%; 95% CI: 2.9-4.4). Without thromboprophylaxis, high incidence of VTE was found after Achilles tendon repair (7.2%; 95% CI: 5.5-9.4). In total 1094 patients deceased (2.4%; 95% confidence interval (CI): 2.33- 2.44) within 6 weeks of surgery. Highest mortality was seen after lower limb amputation (16.3%, CI: 13.8-19.1) and after hip hemiarthroplasty due to hip fracture (9.6%, CI; 7.6-12.1).
The overall incidence of VTE is low after orthopaedic surgery but our study highlights surgical procedures after which the risk for VTE remains high and improved thromboprophylaxis is needed.
Deep vein thrombosis; Mortality; Operation; Orthopaedic surgery; Prophylaxis; Pulmonary embolism; Thrombosis; Venous thromboembolism
Venous thromboembolism, presenting as deep vein thrombosis or pulmonary embolism, is a major challenge for health care systems. It is the third most common vascular disease after coronary heart disease and stroke, and many hospitalized patients have at least one risk factor. In particular, patients undergoing hip or knee replacement are at risk, with an incidence of asymptomatic deep vein thrombosis of 40%–60% without thromboprophylaxis. Venous thromboembolism is associated with significant mortality and morbidity, with patients being at risk of recurrence, post-thrombotic syndrome, and chronic thromboembolic pulmonary hypertension. Arterial thromboembolism is even more frequent, and atrial fibrillation, the most common embolic source (cardiac arrhythmia), is associated with a five-fold increase in the risk of stroke. Strokes due to atrial fibrillation tend to be more severe and disabling and are more often fatal than strokes due to other causes. Currently, recommended management of both venous and arterial thromboembolism involves the use of anticoagulants such as coumarin and heparin derivatives. These agents are effective, although have characteristics that prevent them from providing optimal anticoagulation and convenience. Hence, new improved oral anticoagulants are being investigated. Dabigatran is a reversible, direct thrombin inhibitor, which is administered as dabigatran etexilate, the oral prodrug. Because it is the first new oral anticoagulant that has been licensed in many countries worldwide for thromboprophylaxis following orthopedic surgery and for stroke prevention in patients with atrial fibrillation, this compound will be the main focus of this review. Dabigatran has been investigated for the treatment of established venous thromboembolism and prevention of recurrence in patients undergoing hip or knee replacement, as well as for stroke prevention in atrial fibrillation patients with a moderate and high risk of stroke.
dabigatran etexilate; venous thromboembolism; stroke; prevention; treatment
Multimodal thromboprophylaxis includes preoperative thromboembolic risk stratification and autologous blood donation, surgery performed under regional anaesthesia, postoperative rapid mobilisation, use of pneumatic compression devices and chemoprophylaxis tailored to the patient’s individual risk. We determined the 90-day rate of venous thromboembolism (VTE), other complications and mortality in patients who underwent primary elective hip and knee replacement surgery with multimodal thromboprophylaxis.
A total of 1,568 consecutive patients undergoing hip and knee replacement surgery received multimodal thromboprophylaxis: 1,115 received aspirin, 426 received warfarin and 27 patients received low molecular weight heparin and warfarin with or without a vena cava filter.
The rate of VTE, pulmonary embolism, proximal deep vein thrombosis (DVT) and distal DVT was 1.2, 0.36, 0.45 and 0.36 %, respectively, in patients who received aspirin. The rates in those who received warfarin were 1.4, 0.9, 0.47 and 0.47 %, respectively. The overall 90-day mortality rate was 0.2 %.
Multimodal thromboprophylaxis in which aspirin is administered to low-risk patients is safe and effective following primary total joint replacement.
Patients undergoing major orthopedic surgery, total hip arthroplasty (THA) and total knee arthroplasty (TKA) are at high risk of venous thromboembolism, manifesting as deep vein thrombosis or pulmonary embolism. The recommended pharmacologic treatment options for thromboprophylaxis after major orthopedic surgery include the vitamin K antagonists (VKAs eg, warfarin), low molecular weight heparins (LMWHs; eg, enoxaparin) and the synthetic pentasaccharide fondaparinux. Most clinics use some kind of thromboprophylaxis routinely. However, due to the frequent need for coagulation monitoring (VKAs) and subcutaneous injections (LMWHs and fondaparinux) barriers exist to prescribing prophylaxis after discharge from hospital. Targeting specific components of the coagulation cascade has yielded several new antithrombotic agents for use as thromboprophylaxis after THA or TKA. Two of these, dabigatran etexilate and rivaroxaban, have already reached the markets in the European Union member states and Canada. Both are administered by the oral route, once-daily fixed dose and without the need to monitor the anticoagulant effect. Whether these new drugs facilitate guideline adherence, particularly in the outpatient settings and thereby improve the overall clinical outcomes remains to be shown.
dabigatran etexilate; rivaroxaban; thromboprophylaxis; total joint arthroplasty; venous thromboembolism
Deep vein thrombosis (DVT) and pulmonary embolism (PE) are known collectively as venous thromboembolism (VTE). Venous thromboembolic events are common and potentially life-threatening complications following trauma with an incidence of 5 to 63%. DVT prophylaxis is essential in the management of trauma patients. Currently, the optimal VTE prophylaxis strategy for trauma patients is unknown. Traditionally, pelvic and lower extremity fractures, head injury, and prolonged immobilization have been considered risk factors for VTE; however it is unclear which combination of risk factors defines a high-risk group. Modalities available for trauma patient thromboprophylaxis are classified into pharmacologic anticoagulation, mechanical prophylaxis, and inferior vena cava (IVC) filters. The available pharmacologic agents include low-dose heparin (LDH), low molecular weight heparin (LMWH), and factor Xa inhibitors. Mechanical prophylaxis methods include graduated compression stockings (GCSs), pneumatic compression devices (PCDs), and A-V foot pumps. IVCs are traditionally used in high risk patients in whom pharmacological prophylaxis is contraindicated. Both EAST and ACCP guidelines recommend primary use of LMWHs in trauma patients; however there are still controversies regarding the definitive VTE prophylaxis in trauma patients. Large randomized prospective clinical studies would be required to provide level I evidence to define the optimal VTE prophylaxis in trauma patients.
Most surgeons believe that Asians have a low risk of developing venous thromboembolism (VTE) and routine thromboprophylaxis therapy is not required after major orthopaedic trauma. This study evaluates the postoperative risk of VTE in Indian patients sustaining pelvi-acetabular injury. Fifty-six patients with pelvi-acetabular injury, who underwent open reduction and internal fixation, were prospectively evaluated for VTE in the postoperative period. They were evaluated, both clinically and radiologically (pulmonary CT angiography and indirect venography of lower limb and pelvis veins), until six weeks after surgery. A total of 16 patients developed VTE, of which 12 had proximal deep vein thrombosis (DVT), ten had pulmonary embolism (PE) and only two had distal DVT. Six patients with proximal DVT had associated PE. The risk of development of VTE among Indian patients after pelvi-acetabular injury is high (28.6%) with increasing chances of proximal DVT and PE; hence, administration of routine thromboprophylaxis is fully justified in them.
In Western countries, deep vein thrombosis (DVT) and pulmonary embolism (PE), are relatively common after THA and many surgeons recommend routine pharmacologic thromboprophylaxis. There is some suggestion in the literature that the incidences of DVT and PE may be lower in East Asian patients. Therefore, it would be important to establish the incidences in a large number of East Asian patients who did not receive pharmacologic thromboprophylaxis.
We therefore determined the incidence of DVT and PE and evaluated the associated risk factors in a series of East Asian patients who underwent primary THA without pharmacologic prophylaxis.
We retrospectively evaluated all 861 patients who underwent 992 elective primary THAs from May 2003 to December 2009. We identified patients with symptomatic DVT, symptomatic PE, and fatal PE. For potential risk factors we considered age, gender, body mass index (BMI), administration of aspirin, type of anesthesia, operation time, approach, simultaneous bilateral THAs, and duration of immobilization between symptomatic and asymptomatic patients.
We identified eight patients with symptomatic DVT, one of whom also had a symptomatic PE; there were no cases of fatal PE. The incidences of fatal PE, symptomatic PE, and symptomatic DVT were 0 %, 0.1 %, and 0.8 %, respectively. Longer duration of immobilization predicted symptomatic DVT or PE.
East Asian patients have a low incidence of symptomatic DVT and PE and virtually no fatal PEs after primary THA. The incidences and risk factors should be taken into consideration when deciding whether to prophylactically treat these patients with pharmacologic agents.
Level of Evidence
Level IV, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
There is high incidence of venous thromboembolism, comprising of deep vein thrombosis and pulmonary embolism, in hospitalized patients. The need for systemic thromboprophylaxis is essential, especially in patients with inherited or acquired patient-specific risk factors or in patients undergoing surgeries associated with high incidence of postoperative deep vein thrombosis and pulmonary embolism. These patients, on prophylactic or therapeutic doses of anticoagulants, may present for surgery. General or regional anaesthesia may be considered depending on the type and urgency of surgery and degree of anticoagulation as judged by investigations. The dilemma regarding the type of anaesthesia can be solved if the anaesthesiologist is aware of the pharmacokinetics of drugs affecting haemostasis. The anaesthesiologist must keep abreast with the latest developments of methods and drugs used in the prevention and management of venous thromboembolism and their implications in the conduct of anaesthesia.
Anaesthetic considerations; deep vein thrombosis; pulmonary embolism; thromboprophylaxis; venous thromboembolism
The majority of epidemiological studies demonstrate an increased risk of venous thromboembolism among diabetic patients. Our aim was to compare clinical characteristics, prophylaxis, treatment, and outcomes of venous thromboembolism in patients with and without previously diagnosed diabetes.
We studied diabetic patients in the population-based Worcester Venous Thromboembolism Study of 2488 consecutive patients with validated venous thromboembolism.
Of 2488 venous thromboembolism patients, 476 (19.1%) had a clinical history of diabetes. Thromboprophylaxis was omitted in more than one third of diabetic patients who had been hospitalized for non-venous-thromboembolism-related illness or had undergone major surgery within 3 months before diagnosis. Patients with diabetes were more likely than nondiabetic patients to have a complicated course after venous thromboembolism. Patients with diabetes were more likely than patients without diabetes to suffer recurrent deep vein thrombosis (14.9% vs 10.7%) and long-term major bleeding complications (16.4% vs 11.7%) (all P = .01). Diabetes was associated with a significant increase in the risk of recurrent deep vein thrombosis (adjusted odds ratio [AOR] 1.74; 95% confidence interval [CI], 1.21–2.51). Aspirin therapy at discharge (AOR 1.59; 95% CI, 1.1–2.3) and chronic kidney disease (AOR 2.19; 95% CI, 1.44–3.35) were independent predictors of long-term major bleeding.
Patients with diabetes who developed venous thromboembolism were more likely to suffer a complicated clinical course. Diabetes was an independent predictor of recurrent deep vein thrombosis. We observed a low rate of thromboprophylaxis in diabetic patients. Further studies should focus on venous thromboembolism prevention in this vulnerable population.
Deep vein thrombosis; Diabetes mellitus; Prophylaxis; Pulmonary embolism; Treatment; Venous thromboembolism
This is a literature review of the frequency of venous thromboembolism in hospitalized patients with cancer and of the available evidence supporting the use of thromboprophylaxis. Patients with cancer are at particularly high risk of venous thromboembolism and account for almost 20% of patients in the population. Hospitalization is an important risk factor in patients with cancer, with rates reported between 0.6% and 7.8%. The incidence has been increasing over the past decade. Three randomized controlled trials and meta-analyses indicate that prophylaxis with low molecular weight heparin, heparin, or fondaparinux significantly reduces the rate of venous thromboembolism in hospitalized medical patients who are at high risk. Patients with cancer were included in these studies, but prospective trials specifically focused on patients with cancer are not available. Evidence indicates that appropriate thromboprophylaxis is provided to a minority of hospitalized patients with cancer and that targeted educational efforts and computerized prompt systems can increase appropriate use. Guidelines developed by both oncology and thrombosis organizations support the use of thromboprophylaxis in hospitalized patients with cancer. In conclusion, most patients hospitalized with cancer are at high risk of venous thromboembolism, and thromboprophylaxis should be provided in the absence of active bleeding or a high bleeding risk.
A retrospective study of the morbidity and mortality from deep vein thrombosis (DVT) and pulmonary embolus (PE) in 490 consecutive patients undergoing uncemented total hip replacement was carried out in a district general hospital. Special diagnostic tests for DVT and PE were not available. Patients were followed up for one year. There were three deaths in hospital and eight further deaths during the first year, all unrelated to DVT and PE. The clinical incidence of venous thromboembolism was 2.04%. While clinical diagnosis of venous thromboembolic disease probably underestimates its incidence, the figures for mortality are accurate. With every patient accounted for one year after operation, there were no deaths attributable to PE in this series.
We prospectively assessed the implementation of venous thromboembolism (VTE) prophylaxis guidelines and the impact of grand round presentation of the datain changing clinical practice. Two NHS teaching hospitals were studied for 24 months from January 2003. Patients were risk stratified according to the THRIFT (thromboembolic risk factor) consensus group guidelines and compared with the recommendations of the THRIFT and ACCP (American College of Chest Physicians) consensus groups. Six months following presentation of the initial results, a further analysis was made to assess changes in clinical practice.
1128 patients were assessed of whom 1062 satisfied the inclusion criteria for thromboprophylaxis. 89% of all patients were stratified as having high or moderate riskof developing VTE. Of these only 28% were prescribed some form of thromboprophylaxis—4% received the THRIFT-recommended and 22% received the ACCP-recommended thromboprophylaxis. The vast majority (72%) received no thromboprophylaxis at all. Reassessment, following data presentation at grandrounds, showed a significant increase to 31% inpatients receiving THRIFT (P<0.0001) and ACCP (P=0.002) recommended thromboprophylaxis. However,the proportion of patients receiving no form of prophylaxis barely changed (72% to 69%: P=0.59).
We found a gross underutilization of thromboprophylaxis in hospitalized medical patients. A simple grand-round presentation of the data and recommended guidelines to clinicians significantly increased the proportion of patients receiving recommended thromboprophylaxis but did not increasethe overall proportion of patients receiving it. Wetherefore conclude that a single presentation of guidelines is not enough to achieve the desired levels. Such presentations may only serve to make DVT (deepvenous thromboembolism) aware clinicians prescribe prophylaxis more accurately.
Venous thromboembolism is the most common preventable cause of death in surgical patients. Thromboprophylaxis, using mechanical methods to promote venous outflow from the legs and antithrombotic drugs, provides the most effective means of reducing morbidity and mortality in these patients. Despite the evidence supporting thromboprophylaxis, it remains underused because surgeons perceive that the risk of venous thromboembolism is not high enough to justify the potential hemorrhagic complications of anticoagulant use. The risk of venous thromboembolism is determined by patient characteristics and by the type of surgery that is performed. In this paper we identify the risk factors for venous thromboembolism and provide a scheme for stratifying surgical patients according to their risk. We describe the mechanism of action of the various forms of thromboprophylaxis and outline the evidence supporting thromboprophylaxis in different surgical settings. Finally, we recommend optimal forms of thromboprophylaxis in patients who undergo various types of surgery. Intermittent pneumatic compression, with or without elastic stockings, can be used for thromboprophylaxis in patients who undergo neurosurgical procedures; for patients who undergo vascular or cardiovascular procedures, long-term acetylsalicylic acid should be used for thromboprophylaxis. Low-molecular-weight heparin (LMWH) or warfarin is the choice for patients with spinal cord operations and all patients with major trauma who do not have contraindications to anticoagulation should receive thromboprophylaxis with LMWH.
Venous thromboembolism (VTE) is a frequent complication among acutely ill medical patients hospitalized for congestive heart failure, acute respiratory insufficiency, rheumatologic disorders, and acute infectious and/or inflammatory diseases. Based on robust data from randomized controlled studies and meta-analyses showing a reduced incidence of VTE by 40% to about 60% with pharmacologic thromboprophylaxis, prevention of VTE with low molecular weight heparin (LMWH), unfractionated heparin (UFH), or fondaparinux is currently recommended in all at-risk hospitalized acutely ill medical patients. In patients who are bleeding or are at high risk for major bleeding, mechanical prophylaxis with graduated compression stockings or intermittent pneumatic compression may be suggested. Thromboprophylaxis is generally continued for 6 to 14 days or for the duration of hospitalization. Selected cases could benefit from extended thromboprophylaxis beyond this period, although the risk of major bleeding remains a concern, and additional studies are needed to identify patients who may benefit from prolonged prophylaxis. For hospitalized acutely ill medical patients with renal insufficiency, a low dose (1.5 mg once daily) of fondaparinux or prophylactic LMWH subcutaneously appears to have a safe profile, although proper evaluation in randomized studies is lacking. The evidence on the use of prophylaxis for VTE in this latter group of patients, as well as in those at higher risk of bleeding complications, such as patients with thrombocytopenia, remains scarce. For critically ill patients hospitalized in intensive care units with no contraindications, LMWH or UFH are recommended, with frequent and careful assessment of the risk of bleeding. In this review, we discuss the evidence for use of thromboprophylaxis for VTE in acutely ill hospitalized medical patients, with a focus on (low-dose) fondaparinux.
venous thromboembolism; medical patient; hospitalization; fondaparinux; heparin
Over the last 15 years, low-molecular-weight heparins (LMWHs) have been accepted as the “gold standard” for pharmaceutical thromboprophylaxis in patients at high risk of venous thromboembolism (VTE) in most countries around the world. Patients undergoing major orthopedic surgery (MOS) represent a population with high risk of VTE, which may remain asymptomatic or become symptomatic as deep vein thrombosis or pulmonary embolism. Numerous trials have investigated LMWH thromboprophylaxis in this population and demonstrated high efficacy and safety of these substances. However, LMWHs have a number of disadvantages, which limit the acceptance of patients and physicians, especially in prolonged prophylaxis up to 35 days after MOS. Consequently, new oral anticoagulants (NOACs) were developed that are of synthetic origin and act as direct and very specific inhibitors of different factors in the coagulation cascade. The most developed NOACs are dabigatran, rivaroxaban, and apixaban, all of which are approved for thromboprophylaxis in MOS in a number of countries around the world. This review is focused on the pharmacological characteristics of apixaban in comparison with other NOACs, on the impact of NOAC on VTE prophylaxis in daily care, and on the management of specific situations such as bleeding complications during NOAC therapy.
major orthopedic surgery; apixaban; dabigatran; edoxaban; rivaroxaban; deep vein thrombosis; venous thromboembolism; VTE prophylaxis
Deep vein thrombosis (DVT), and its most feared complication, pulmonary embolism (PE), still have a high incidence with high risk for patients’ health. Proven prophylactic measures are available but are generally underused, and DVT is still considered the most common cause of preventable death among hospitalized patients. The rationale for prophylaxis of venous thromboembolism is based on the clinically silent nature of the disease, the relatively high prevalence among hospitalized patients and the potentially tragic consequences of a missed diagnosis. During the last 15–20 years, spine surgery has changed radically, developing into a well-defined area of specialist surgery, and some attention is now being given to DVT events in spine surgery. The incidence of DVT during spine surgery is not documented in the literature, because only case reports or retrospective studies are reported. It would therefore be very helpful to initiate a multicenter study in order to understand this problem better and to develop, if possible, some guidelines on prophylactic measures in spine surgery. In doing so, we need to consider each patient’s pattern, any risk factors and every kind of surgical technique related to DVT, in order to improve the outcome of the patient and to reduce any medicolegal problems that could arise from a thrombotic complication or an epidural hematoma, with its high potential for irreversible consequences.
Deep vein thrombosis; Pulmonary embolism; Prophylaxis; Spinal surgery
The western literature on deep vein thrombosis (DVT) and pulmonary embolism (PE) following spinal cord injury (SCI) report an alarmingly high incidence, necessitating thromboprophylaxis. The literature on incidence from the Asian subcontinent is scanty and from India is almost nonexistent.
Materials and Methods:
Seventy hospitalized acute SCI patients presenting within five days of the injury were included in the present analysis. Forty-two cases were subjected to color Doppler studies and 28 cases had to be subjected to venography due to lack of facility at some point of time. The clinical course of the patients was closely observed during the period of hospitalization. All except 14 were managed nonoperatively. Thromboprophylaxis was not given to any patient at any stage; however, treatment was instituted in those showing the features of DVT on investigations.
Twelve patients died during the period of hospitalization. Deep vein thrombosis could be detected in seven patients only, three in the proximal and four in the distal segment of the lower limb and of these three died. Based on the clinical course and positive investigation report in favor of DVT, we presumed that the cause of death in these three patients was pulmonary embolism. In the other nine, in the absence of an autopsy report, the cause of deaths was considered as pulmonary infection, asphyxia, diaphragmatic paralysis, hematemesis, cervicomedullary paralysis etc. Clinical features to diagnose DVT were of little help.
There is a much lower incidence (10%) of DVT and PE following spinal cord injury (SCI) in India than what is reported from the western countries. Higher age group and quadriplegia were the only factors which could be correlated. Deep vein thrombosis extending proximal to the knee was significant. In the absence of autopsy and other screening tests like D-dimer test or 125I fibrogen uptake study, the true incidence of venous thromboembolism remains uncertain. Noninvasive screening of all patients for the detection of deep vein thrombosis in SCI patients is strongly recommended.
Deep vein thrombosis; pulmonary embolism; spinal cord injury
Venous thromboembolism (VTE) often occurs after surgery and can even occur before surgery in patients with gynaecological malignancies. We investigated the incidence of VTE before treatment of endometrial cancer and associated risk factors. Plasma D-dimer (DD) levels before initial treatment were examined in 171 consecutive patients with endometrial cancer. Venous ultrasound imaging (VUI) of the lower extremities was performed in patients with DD ⩾1.5 μg ml−1, as the negative predictive value of DD for VTE is extremely high. For patients with deep vein thrombosis (DVT), pulmonary scintigraphy was performed to ascertain the presence of pulmonary thromboembolism (PTE). Risk factors for VTE were analysed using univariate and multivariate analyses for 171 patients. Of these, 37 patients (21.6%) showed DD ⩾1.5 μg ml−1, 17 (9.9%) displayed DVT by VUI and 8 (4.7%) showed PTE on pulmonary scintigraphy. All patients with VTE were asymptomatic. Univariate analysis for various risk factors revealed older age, non-endometrioid histology and several variables of advanced disease as significantly associated with VTE before treatment. Obesity, smoking and diabetes mellitus were not risk factors. Multivariate analysis confirmed extrauterine spread and non-endometrioid histology as independently and significantly associated with risk of VTE. These data suggest that silent or subclinical VTE occurs before treatment in at least around 10% of patients with endometrial cancer. Risk factors for VTE before treatment might not be identical to those after starting treatment.
endometrial adenocarcinoma; deep vein thrombosis; pulmonary thromboembolism; plasma D-dimer
There is no clear evidence in the literature regarding the incidence of deep vein thrombosis (DVT) in patients undergoing arthroscopic anterior cruciate ligament (ACL) reconstruction. Literature also lacks on the recommendations on thromboprophylaxis in patients undergoing elective arthroscopic ACL reconstruction. We conducted a prospective analysis to assess incidence of DVT in patients undergoing arthroscopic ACL reconstruction.
Materials and Methods:
120 consecutive patients with MRI proven ACL injury who were operated for arthroscopic ACL reconstruction were enrolled in this prospective study. None of the patients had risk factors (on history) for DVT, and all were below the age of 45 years. All cases were operated upon by a single surgeon and a standard rehabilitation regime was followed. The patients underwent clinical examination and screening (Doppler ultrasonography/venous scan) for any DVT, on the day prior to surgery, day of discharge (Day 3) and at 4 weeks postsurgery. None of the patients received any form of thromboprophylaxis against DVT.
One hundred and twelve patients (61 males and 51 females) completed the study. The average age was 31.6 years (range 24-42 years). All patients underwent arthroscopic assisted ACL reconstruction surgery within 3 weeks of the injury. Two patients (males) in the series had Doppler venous scan proven DVT. One patient was asymptomatic but the screening Doppler picked up the DVT on the third postoperative day. The other patient was symptomatic at 12 weeks with pain and swelling in the leg and had ultrasound -proven DVT.
In our study the incidence of deep vein thrombosis in patients undergoing arthroscopic ACL reconstruction is 1.78%. We do not recommend routine thromboprophylaxis in patients, who are not high risk candidates for thrombosis and are of less than 45 years, in patients undergoing arthroscopic ACL reconstruction, with early postoperative rehabilitation.
Anterior cruciate ligament; deep vein thrombosis; reconstruction; arthroscopy; thromboprophylaxis
Two hundred admissions to a general surgical ward were audited prospectively before and after the introduction of a thromboembolic risk score. This was based on the Thromboembolic Risk Factors (THRIFT) Consensus Group guidelines for thrombo-prophylaxis. The results showed an overall improvement in compliance from 65% to 79%. High risk patients formed 24% of the patients studied. In this group, compliance improved significantly from 14% to 58%. The overall prevalence of important thromboembolic risk factors was calculated. Of the patients, 26.5% had a Body Mass Index (BMI) of > 25, and 10% gave a past or family history of thromboembolism. Of female patients, 24% were taking oestrogens. We conclude that quantitative assessment of all patients for thromboembolic risk can improve the implementation of thromboprophylaxis, particularly in high risk patients.
Postoperative venous thromboembolism is one of the most serious complications following total joint arthroplasty. Pharmacological and mechanical prophylaxis methods are used to reduce the risk of postoperative symptomatic deep vein thrombosis and pulmonary embolism. Use of pharmacological prophylaxis requires a fine balance between the efficacy of the drug in preventing deep vein thrombosis and the adverse effects associated with the use of these drugs. In regions with a low prevalence of deep vein thrombosis such as Korea, there might be a question whether the benefits of using pharmacological prophylaxis outweigh the risks involved. The current article reviews the need for thromboprophylaxis, guidelines, problems with the guidelines, pharmacological prophylaxis use, and the current scenario of deep vein thrombosis, and discusses whether the use of pharmacological prophylaxis should be mandatory in low incidence populations.
Total joint arthroplasty; Deep vein thrombosis; Pulmonary embolism; Thromboprophylaxis
Background: Deep vein thrombosis (DVT) is one of the most common complications of total hip (THA) and total knee arthroplasty (TKA). Though the reported incidence of DVT is very high, that of proximal DVT is low and that of fatal thromboembolism is very low. Hence the issue of prophylaxis for DVT remains controversial.
The incidence of DVT is based on various studies in European and American populations. The Asian population is genetically and socially quite different from American and European populations, and the incidence of DVT can be quite different. Therefore a prospective study was initiated at our centre to determine incidence of DVT after THA and TKA in Indian patients.
Methods: A prospective study was conducted on 60 hips in 45 patients and 46 knees in 26 patients who underwent THA and TKA respectively, without any known risk factors for thromboembolic disease. DVT was studied by preoperative and postoperative serial colour Doppler ultrasonography. No prophylaxis was given to any of the patients.
Results: DVT was found in two patients who had undergone THA. No case of DVT was detected in any patient who had undergone TKA.
Conclusion: These results suggest that the incidence of DVT in Indian patients is very low and is not comparable with American and European populations. It is therefore not cost effective to advise prophylaxis in Indian patients undergoing THA/TKA who have no known risk factors for DVT.
Venous thromboembolism (VTE) is a common and important complication of stroke. The CLOTS 3 trial aims to determine whether, compared with best medical care, best medical care plus intermittent pneumatic compression (IPC) in immobile stroke patients reduces the risk of proximal deep vein thrombosis (DVT).
The CLOTS 3 trial is a multicenter, parallel group trial with centralized randomization (minimization) to ensure allocation concealment. The protocol has been published (Trials 2012, 13:26) and is available in full at: http://www.clotstrial.com. Between December 2008 and September 2012, 105 centers in the UK recruited 2,876 immobile stroke patients within the first 3 days of their hospital admission. Patients were allocated to best medical care or best medical care plus IPC. Ultrasonographers performed a compression Doppler ultrasound scan to detect DVT in each treatment group at 7 to 10 days and 25 to 30 days. The primary outcome cluster includes symptomatic or asymptomatic DVT in the popliteal or femoral veins detected on either scan. Patients will be followed up by postal or telephone questionnaire at 6 months from randomization to detect later symptomatic DVT and pulmonary embolism (PE), and to measure functional outcome (Oxford Handicap Scale) and quality of life (EQ-5D-3L). The ultrasonographers performing the scans are blinded to treatment allocation, whereas the patients and caregivers are not. The trial has more than 90% power to detect a 4% absolute difference (12% versus 8%) in risk of the primary outcome and includes a health economic analysis.
Follow-up will be completed in April 2013 and the results reported in May 2013. In this update, we describe the statistical analysis plan.
Stroke; Deep vein thrombosis; Prevention; Intermittent pneumatic compression; Statistical analysis plan