cardiovascular disorders
Deep Venous Thrombosis (DVT) Prevention
Treatment in DVT Prevention
DVT prophylaxis can involve one or more of the following: Mechanical therapy (eg, compression devices or stockings, venous filters) Pharmacologic therapy (including low-dose unfractionatedheparin, low molecular weight heparins,warfarin,fondaparinux, direct oral anticoagulants) Choice depends on patient’s risk level, type of surgery (if applicable), projected duration of preventive treatment, contraindications, adverse effects, relative cost, ease of use, and local practice. After surgery, elevating the legs and avoiding prolonged immobility, which places the legs in a dependent position thereby impeding venous return, can help. The benefit of graded compression stockings is questionable except for low-risk surgical patients and selected hospitalized medical patients. However, combining stockings with other preventive measures may be more protective than any single approach. Intermittent pneumatic compression (IPC) uses a pump to cyclically inflate and deflate hollow plastic leggings, providing external compression to the lower legs and sometimes thighs. IPC may be used instead of or in combination with anticoagulants after surgery. IPC is recommended for patients undergoing surgery associated with a high risk of bleeding in whom anticoagulant use may be contraindicated. IPC is probably more effective for preventing calf DVT than proximal DVT. IPC is contraindicated in some patients who have obesity and may be unable to apply the devices properly. For patients who are at very high risk of DVT and bleeding (eg, after major trauma), IPC is recommended until the bleeding risk subsides and anticoagulants can be given. The use of inferior vena cava filters should be avoided unless DVT has been confirmed, except in highly selected patients. Pharmacologic thromboprophylaxis involves use of Anticoagulants . for DVT prophylaxis is largely limited to patients undergoing total hip or knee replacement surgery ( Treatment references ). Low-dose unfractionatedheparin(UFH) 5000 units subcutaneously is given 2 hours before surgery and every 8 to 12 hours thereafter for 7 to 10 days or until patients are fully ambulatory. Patients who bedbound but are not undergoing surgery are given 5000 units subcutaneously every 12 hours until risk factors are reversed. LMWHs are more effective than low-dose UFH for preventing DVT and PE ( Treatment references ), but widespread use is limited by cost. Warfarin, using a target international normalized ratio (INR) of 2.0 to 3.0, is proven to be effective in orthopedic surgery but is being used less frequently because alternative anticoagulants such as LMWHs and direct oral anticoagulants are easier to administer. , and their cost-effectiveness requires further study ( Treatment references ). With DVT prophylaxis, there is always a risk of Bleeding During Use of Anticoagulants . 2.5 mg subcutaneously once a day appears to be more effective to prevent DVT than LMWH for patients undergoing orthopedic surgery but may be associated with an increased risk of bleeding ( Treatment references ). For elective neurosurgery, spinal cord injury, or multiple trauma, low-dose LMWH, as the first option, or low-dose UFH is recommended. For patients undergoing neurosurgery, physical measures (IPC, elastic stockings) have been used because intracranial bleeding is a concern; however, LMWH appears to be an acceptable alternative. Limited data support the combination of IPC, elastic stockings, and LMWH in patients with spinal cord injury or multiple trauma. Preventive treatment is also indicated for patients who have a major medical illnesses that require bed rest (eg, Acute Myocardial Infarction (MI) , In patients with symptomatic DVT who develop symptoms of Chronic Venous Insufficiency and Post-Thrombotic Syndrome (eg, leg swelling, pain, aching), the use of knee-high compression stockings providing 30 to 40 mm Hg pressure is recommended, although stockings with lower tension (20 to 30 mm Hg) can be considered if patients are unable to tolerate the higher tension stockings. However, the routine use of stockings in all patients who have had a DVT has been questioned by data from a meta-analysis of randomized trials, in which the use of compression stockings compared with placebo (none or sham-compression stockings) did not show a significant decrease in post-thrombotic syndrome) ( 1.Ludwick L, Shohat N, Van Nest D, Paladino J, Ledesma J, Parvizi J:AspirinMay Be a Suitable Prophylaxis for Patients with a History of Venous Thromboembolism Undergoing Total Joint Arthroplasty.J Bone Joint Surg Am104(16):1438–1446, 2022. doi:10.2106/JBJS.21.00601 2.McGarry LJ, Stokes ME, Thompson D: Outcomes of thromboprophylaxis withenoxaparinvs. unfractionatedheparinin medical inpatients.Thromb J4:17, 2006. doi:10.1186/1477-9560-4-17 3.Laporte S, Liotier J, Bertoletti L, et al: Individual patient data meta-analysis ofenoxaparinvs. unfractionatedheparinfor venous thromboembolism prevention in medical patients.J Thromb Haemost9(3):464–472, 2011. doi:10.1111/j.1538-7836.2011.04182.x 4.Neumann I, Rada G, Claro JC, et al: Oral directFactor Xainhibitors versus low-molecular-weightheparinto prevent venous thromboembolism in patients undergoing total hip or knee replacement: a systematic review and meta-analysis.Ann Intern Med156(10):710–719, 2012. doi:10.7326/0003-4819-156-10-201205150-00421 5.Dong K, Song Y, Li X, et al: Pentasaccharides for the prevention of venous thromboembolism.Cochrane Database Syst Rev10(10):CD005134, 2016. doi:10.1002/14651858.CD005134.pub3 6.Carrier M, Abou-Nassar K, Mallick R, et al:Apixabanto prevent venous thromboembolism in patients with cancer.N Engl J Med380:711–719, 2019. doi: 10.1056/NEJMoa1814468 7.Farge D, Frere C, Connors JM, et al: 2019 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer.Lancet Oncol20 (10): e566–e581, 2019. doi: 10.1016/S1470-2045(19)30336-5 8.Key NS, Khorana AA, Kuderer NM, et al: Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO Clinical Practice Guideline Update.J Clin Oncol38:496–520, 2020. doi: 10.1200/JCO.19.01461 9.Khorana AA, Soff GA, Kakkar AK, et al:Rivaroxabanfor thromboprophylaxis in high-risk ambulatory patients with cancer.N Engl J Med380:720–728, 2019. doi: 10.1056/NEJMoa1814630 10.Subbiah R, Aggarwal V, Zhao H, Kolluri R, Chatterjee S, Bashir R: Effect of compression stockings on post thrombotic syndrome in patients with deep vein thrombosis: a meta-analysis of randomised controlled trials.Lancet Haematol3(6):e293–e300, 2016. doi:10.1016/S2352-3026(16)30017-5 