Tag Archives: Venous Thromboembolism

Bleeding Risk with Apixaban vs. Rivaroxaban in Acute Venous Thromboembolism

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“Direct oral anticoagulants, including rivaroxaban and apixaban, are the most frequently prescribed treatments for acute venous thromboembolism. In randomized clinical trials, rivaroxaban at a dose of 15 mg twice daily for 21 days followed by 20 mg daily and apixaban at a dose of 10 mg twice daily for 7 days followed by 5 mg twice daily were noninferior to vitamin K antagonists regarding efficacy (risk of recurrent venous thromboembolism). These trials showed that clinically relevant bleeding, a composite of major bleeding or clinically relevant nonmajor bleeding, occurred in 4.3% of the patients who received apixaban as
compared with 9.7% of those who received vitamin K antagonists9 and in 8.1% of patients who received rivaroxaban as compared with 8.1% of those who received vitamin K antagonists. The difference between apixaban and rivaroxaban therapy regarding the risk of clinically relevant bleeding was hypothesized to be related to heterogeneity in the patient populations and differences in the trial designs. Owing to a lack of trials that have compared rivaroxaban with apixaban regarding the risk of bleeding, clinical practice guidelines do not recommend one anticoagulant over the other.”

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Anticoagulant treatment for upper extremity deep vein thrombosis

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“Upper extremity DVT may be complicated by recurrent thrombosis in about 7.5% of cases and by post-thrombotic syndrome in 19.4% of cases, with higher rates of recurrence in patients with cancer-associated thrombosis and of post-thrombotic syndrome in patients with unprovoked thrombosis or related to congenital or anatomical abnormalities. The intensity and duration of anticoagulant treatment need to be balanced against the risk of bleeding
complications, especially in high-risk subgroups like patients with cancer in whom major bleeding events were reported in up to 10%.”

FIGURE 2 Recurrent venous thromboembolism and major bleeding in patients with upper extremity deep vein thrombosis, sorted by the proportion of patients with cancer and an indwelling catheter. Recurrent venous thromboembolism and major bleeding occurring during anticoagulant treatment were considered in the analysis. The vertical line indicates the summary estimate. Gray squares indicate individual study estimates of the proportion, whereas the gray horizontal lines indicate 95% confidence intervals of the individual studies. The diamond indicates the summary estimate with 95% confidence intervals. The horizontal black line refers to the prediction intervals which are displayed numerically under the 95% confidence intervals. CI, confidence interval; ES, estimates; PI, prediction interval
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Symptomatic perioperative venous thromboembolism is a frequent complication inpatients with a history of deep vein thrombosis

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“Perioperative venous thromboembolism (VTE) is a frequent complication in patients who undergo major surgical procedures. The risk for thromboembolism is increased in patients with advancing age, malignancy, inherited and acquired thrombophilic conditions, and in those patients who undergo certain higher-risk surgical procedures (for example: total hip arthroplasty, total knee arthroplasty, and abdominal cancer operations). A history of deep vein thrombosis (DVT) or pulmonary embolism (PE) frequently is cited as a risk factor for subsequent recurrence around the time of surgery. However, the incidence of perioperative VTE recurrence in patients with a history of lower extremity deep vein thrombosis is not well studied.”

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Venous Thromboembolism Prevention in Emergency General Surgery

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“Venous thromboembolism (VTE) represents the most preventable cause of morbidity and mortality in hospitalized patients, and the Agency for Healthcare Research and Quality (AHRQ) suggests appropriate VTE prophylaxis as a top patient safety practice. The burden of operative and nonoperative emergency general surgery (EGS) is increasing and represents 7% of all hospital admissions in the United States. The reported rate of VTE among patients undergoing EGS is approximately 2.5%. Numerous observational studies, quality improvement studies, randomized clinical trials, reviews, and practice management guidelines are available to guide acute care surgeons in VTE prevention for patients with trauma. However, little guidance is available for the emergency general surgeon. Patients undergoing EGS represent a challenge regarding VTE prevention. Despite the substantial number of annual EGS admissions, little is known about the risk of VTE or the use of mechanical and/or pharmacologic prophylaxis in EGS patients. Furthermore, although guidelines for VTE prophylaxis are available, they are difficult to interpret in the context of admission to an EGS service for an acute condition, particularly when admissions to such services include as many as 70% of patients who do not require operative intervention.”

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Variations in practice of thromboprophylaxis across general surgical subspecialties: a multicentre (PROTECTinG) study of elective major surgeries

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“General surgical patients who undergo major operations are at risk of venous thromboembolism (VTE). This incurs significant morbidity and healthcare costs. Therefore, the Royal Australasian College of Surgeons and other regulatory bodies recommend routine thromboprophylaxis. Moreover, considerations for thromboprophylaxis is an integral part of theatre timeout performed prior to any operation.”

“In this study, we extend the observations made from our multicentre survey by quantifying the heterogeneity of perioperative thromboprophylaxis across all major general surgical operations, and placing them in context of their bleeding and VTE risk. Findings from this study will highlight areas of practice with the greatest variability, allow surgeons to benchmark their practices against that of their colleagues and focus future research to optimize perioperative thromboprophylaxis.”

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Trends and Risk Factors for Venous Thromboembolism Among Hospitalized Medical Patients

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“Hospital-associated venous thromboembolism (HA-VTE), commonly defined as deep vein thrombosis (DVT), pulmonary embolism (PE), or both occurring during or within 90 days of hospital admission, is a frequent complication of hospitalization, accounting for approximately one-half to two-thirds of VTE incidence worldwide. HA-VTE events are associated with substantial burdens. They are a leading factor associated with hospital mortality and lost disability-adjusted life-years.”

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Phlegmasia alba dolens and phlegmasia cerulea dolens

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Shackford SR. (2018). Venous Disease. In: Abernathy’s Surgical Secrets, 7th ed.: p. 357.

What is the difference between phlegmasia alba dolens and phlegmasia cerulea dolens? 

“These two entities occur following iliofemoral venous thrombosis, 75% of which occur on the left side presumably because of compression of the left common iliac vein by the overlying right common iliac artery (May-Thurner syndrome). Iliofemoral venous thrombosis is characterized by unilateral pain and edema of an entire lower extremity, discoloration, and groin tenderness. In phlegmasia alba dolens (literally, painful white swelling), the leg becomes pale. Arterial pulses remain normal. Progressive thrombosis may occur with propagation proximally or distally and into neighboring tributaries. The entire leg becomes both edematous and mottled or cyanotic. This stage is called phlegmasia cerulea dolens (literally, painful purple swelling). When venous outflow is seriously impeded, arterial inflow may be reduced secondarily by as much as 30%. Limb loss is a serious concern and aggressive management (i.e., venous thrombectomy, catheter-directed lytic therapy, or both) is necessary.”

Chinsakchai K, et al. Trends in management of phlegmasia cerulea dolens. Vasc Endovascular Surg. 2011 Jan;45(1):5-14. Full-text for Emory users.

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