Treatment of Lower Extremity Superficial Thrombophlebitis

Diagnosis, Management of, and Return to Play Guidance for Venous Thromboembolism in Athletes

ABSTRACT

Venous thromboembolism (VTE) is not rare and is becoming more recognized in our athletic population. This diagnosis can be elusive. A provider must have a high clinical suspicion and use pretest probabilities to order the appropriate studies and accurately diagnose a VTE. Treatment using direct oral anticoagulants for 3 months is recommended in most cases. Gradual return to play can be achieved after treatment is complete. Some athletes, however, may require lifelong anticoagulation. Return to collision sports may be possible using a timed dose strategy if long-term anticoagulation is needed. The management of an athlete with a VTE should include an individualized treatment plan and involve shared decision making with the athlete, team physicians, and hematologic specialists.

The Impact of a Multifaceted Pharmacist-Led Antimicrobial Stewardship Program on Antibiotic Use: Evidence From a Quasi-Experimental Study in the Department of Vascular and Interventional Radiology in a Chinese Tertiary Hospital

Objective: The objective of the study was to assess the impact of multifaceted clinical pharmacist-led antimicrobial stewardship (AMS) program on the rational use of antibiotics for patients who receive vascular and interventional radiology therapies. Methods: A quasi-experimental retrospective intervention design with a comparison group was applied to the practice of antibiotic use in the department of vascular and interventional radiology in a Chinese tertiary hospital. We used difference-in-differences (DID) analysis to compare outcomes before and after the AMS intervention between the intervention group and control group, to determine whether intervention would lead to changes in irrationality of antibiotic prescribing, antibiotic utilization, cost of antibiotics, and length of hospital stay. Results: The DID results showed that the intervention group was associated with a reduction in the average consumption of antibiotics (p = 0.017) and cost of antibiotics (p = 0.006) and cost per defined daily dose (DDD) (p = 0.000). There were no significant differences in the mean change of total costs and length of stay between the two groups (p > 0.05). The average inappropriate score of perioperative antimicrobial prophylaxis in the intervention group declined by 0.23, while it decreased by 0.02 in the control group [0.21 (95% CI, -0.271 to -0.143); p = 0.000]. The average inappropriate score of non-surgical antimicrobial prophylaxis in the intervention group declined by 0.14, while it increased by 0.02 in the control group [0.16 (95% CI, -0.288 to -0.035); p = 0.010]. The average inappropriate score of the therapeutic use of antibiotics in the intervention group declined by 0.07, while it decreased by 0.01 in the control group [0.06 (95% CI, -0.115 to -0.022); p = 0.003]. Conclusions: This study provides evidence that implementation of AMS interventions was associated with a marked reduction of antibiotic use, cost of antibiotics, and irrationality of antibiotic prescribing in China.

Position Paper on the Management of Pregnancy-Associated Superficial Venous Thrombosis. Balkan Working Group for Prevention and Treatment of Venous Thromboembolism

Venous thromboembolism (VTE) is a multifactorial disease that can possibly affect any part of venous circulation. The risk of VTE increases by about 2 fold in pregnant women and VTE is one of the major causes of maternal morbidity and mortality. For decades superficial vein thrombosis (SVT) has been considered as benign, self-limiting condition, primarily local event consequently being out of scope of well conducted epidemiological and clinical studies. Recently, the approach on SVT has significantly changed considering that prevalence of lower limb SVT is twice higher than both deep vein thrombosis (DVT) and pulmonary embolism (PE). The clinical severity of SVT largely depends on the localization of thrombosis, when it concerns the major superficial vein vessels of the lower limb and particularly the great saphenous vein. If untreated or inadequately treated, SVT can potentially cause DVT or PE. The purpose of this review is to discuss the complex interconnection between SVT and risk factors in pregnancy and to provide evidence-based considerations, suggestions, and recommendations for the diagnosis and treatment of this precarious and delicate clinical entity.

Updated recommendations for the treatment of venous thromboembolism

Venous thromboembolism (VTE), which includes pulmonary embolism and deep vein thrombosis, is a condition characterized by abnormal blood clot formation in the pulmonary arteries and the deep venous vasculature. It is often serious and sometimes even fatal if not promptly and appropriately treated. Moreover, the later consequences of VTE may result in reduced quality of life. The treatment of VTE depends on various factors, including the type, cause, and patient comorbidities. Furthermore, bleeding may occur as a side effect of VTE treatment. Thus, it is necessary to carefully weigh the benefits versus the risks of VTE treatment and to actively monitor patients undergoing treatment. Asian populations are known to have lower VTE incidences than Western populations, but recent studies have shown an increase in the incidence of VTE in Asia. A variety of treatment options are currently available owing to the introduction of direct oral anticoagulants. The current VTE treatment recommendation is based on evidence from previous studies, but it should be applied with careful consideration of the racial, genetic, and social characteristics in the Korean population.

Management of superficial venous thrombosis in unevaluated situations: Cancer, severe renal impairment, pregnancy and post-partum

BACKGROUND

Information is lacking as to the management of patients with superficial venous thrombosis (SVT) whose profile has been excluded from trials, such as patients with active cancer, severe renal impairment, or pregnancy.

OBJECTIVES

To describe the frequency and management of SVT occurring in these situations.

METHODS

We retrospectively analyzed the frequency, management and evolution of all patients with isolated SVT associated with either active cancer, severe renal impairment, or pregnant or postpartum women, diagnosed in 2 university hospital between January 1st, 2015 and December 31st, 2016.

RESULTS

Of the 594 isolated SVTs individualized from the 7941 reports screened, 149 SVTs (105 in the upper extremity, 44 in the lower extremity) were analyzed: 94 (63%) associated with active cancer, 27 (18%) with severe renal impairment and 30 (20%) pregnant or postpartum women. SVT was treated with anticoagulant in 34 (36%) patients with cancer, 3 (11%) patients with severe renal impairment and 19 (63%) pregnant or postpartum women. At 3-month, 16 patients (10.8%) had a further venous thromboembolic event, 8 (5.4%) major bleeding, and 9 (6.1%) died.

CONCLUSION

SVT in patients with active cancer, severe renal impairment and pregnant or postpartum women represents a quarter of isolated SVTs diagnosed. Heterogeneity of treatment patterns mainly affects patients with cancer and severe renal impairment. Poor outcomes, although probably linked to morbidity, call for dedicated research in these specific situations.

Diagnosis and Treatment of Lower Extremity Venous Thromboembolism: A Review

IMPORTANCE

Incidence rates for lower extremity deep vein thrombosis (DVT) range from 88 to 112 per 100 000 person-years and increase with age. Rates of recurrent VTE range from 20% to 36% during the 10 years after an initial event.

OBSERVATIONS

PubMed and Cochrane databases were searched for English-language studies published from January 2015 through June 2020 for randomized clinical trials, meta-analyses, systematic reviews, and observational studies. Risk factors for venous thromboembolism (VTE), such as older age, malignancy (cumulative incidence of 7.4% after a median of 19 months), inflammatory disorders (VTE risk is 4.7% in patients with rheumatoid arthritis and 2.5% in those without), and inherited thrombophilia (factor V Leiden carriers with a 10-year cumulative incidence of 10.9%), are associated with higher risk of VTE. Patients with signs or symptoms of lower extremity DVT, such as swelling (71%) or a cramping or pulling discomfort in the thigh or calf (53%), should undergo assessment of pretest probability followed by D-dimer testing and imaging with venous ultrasonography. A normal D-dimer level (ie, D-dimer <500 ng/mL) excludes acute VTE when combined with a low pretest probability (ie, Wells DVT score ≤1). In patients with a high pretest probability, the negative predictive value of a D-dimer less than 500 ng/mL is 92%. Consequently, D-dimer cannot be used to exclude DVT without an assessment of pretest probability. Postthrombotic syndrome, defined as persistent symptoms, signs of chronic venous insufficiency, or both, occurs in 25% to 50% of patients 3 to 6 months after DVT diagnosis. Catheter-directed fibrinolysis with or without mechanical thrombectomy is appropriate in those with iliofemoral obstruction, severe symptoms, and a low risk of bleeding. The efficacy of direct oral anticoagulants-rivaroxaban, apixaban, dabigatran, and edoxaban-is noninferior to warfarin (absolute rate of recurrent VTE or VTE-related death, 2.0% vs 2.2%). Major bleeding occurs in 1.1% of patients treated with direct oral anticoagulants vs 1.8% treated with warfarin.

CONCLUSIONS AND RELEVANCE

Greater recognition of VTE risk factors and advances in anticoagulation have facilitated the clinical evaluation and treatment of patients with DVT. Direct oral anticoagulants are noninferior to warfarin with regard to efficacy and are associated with lower rates of bleeding, but costs limit use for some patients.