Thromboprophylaxis can be omitted in selected patients undergoing varicose vein surgery and hernia repair

Chemothromboprophylaxis in varicose vein surgery. A systematic review

INTRODUCTION

Venous Thromboembolism (VTE) is a possible complication after varicose vein surgery, reported after both open and endovascular interventions. Nonetheless, there are no internationally accepted recommendations regarding postoperative VTE prevention strategies, with some authors advocating for its use, while others recommend against it. This study aims to systematically review current evidence on the efficacy and safety of chemothromboprophylactic strategies after varicose vein surgery.

EVIDENCE ACQUISITION

A literature search was performed on the MEDLINE, Scopus, SciELO and Web of Science databases, which returned 532 studies. Ten studies were included. Data were extracted using piloted forms.

EVIDENCE SYNTHESIS

A total of 6929 patients were included for analysis, out of which 70.4% were treated by open surgery (n=4878) and 29.6% by endovenous procedures (n=2051; 79.1% EVLA; 20.9% RFA). VTE chemothromboprophylaxis was performed in 76.3% of the patients (n=5284), from which 62.5% were treated by open surgery (n=3301) and 37.5% by endovenous interventions (n=1983). Among those treated by open surgery, reported deep venous thrombosis (DVT) rates ranged between 0-6.25%, while pulmonary embolism (PE) was reported in 0-0.07% of the cases. Regarding endovenous interventions, EHIT and DVT rates ranged between 0-2.5% and 0-0.9%, respectively, with no cases of PE described. The remaining 23.7% of the patients did not underwent VTE chemothromboprophylaxis (n=1645), with DVT and PE rates after open surgery ranging between 0-5.17% and 0-1.48%, respectively. Only one study reported thrombotic complications after endovenous interventions in this subgroup of patients, with post-operative EHIT rates of 7.3%, and no information regarding PE or DVT. Bleeding complications were higher in patients undergoing chemothromboprophylaxis (0-10.2%) when compared to those who did not (0-0.18%), and were more frequent after endovenous interventions (0-10.2% versus 0-0.75% after open surgery).

CONCLUSIONS

VTE is a possible complication after both open and endovascular varicose vein procedures, although overall VTE complications occur less frequently after endovascular interventions. There's a clear heterogeneity regarding peri and postoperative chemoprophylaxis regimens used. Further studies are required to stratify risk factors and indications for chemothromboprophylaxis after varicose vein surgery.

A narrative review on the epidemiology, prevention, and treatment of venous thromboembolic events in the context of chronic venous disease

OBJECTIVE

Chronic venous disease (CVD) describes a spectrum of conditions associated with venous hypertension. The association between various CVD etiologies and the subsequent risk of venous thromboembolism (VTE), such as deep vein thrombosis or pulmonary embolism, is a topic of considerable clinical interest. The aims of the present review were to characterize the risk of VTE according to the CVD etiology and to determine the optimal anticoagulation strategy for the treatment or prevention of VTE in patients with CVD.

METHODS

An extensive search of the available surgical and medical data was conducted in PubMed and Google Scholar. We searched for the following terms and other related terms to identify relevant studies: CVD, chronic venous insufficiency, varicose veins, post-thrombotic syndrome (PTS), anticoagulation, venous thromboembolism, and venous disease scoring systems (eg, CEAP [clinical, etiology, anatomic, pathophysiology], Villalta, Ginsberg, venous clinical severity score). The identified studies included randomized control trials, retrospective and prospective observational studies, narrative and systematic reviews, case reports, and case series that contributed to the proposed aims. The ClinicalTrials.gov database was also queried to identify any relevant ongoing clinical trials.

RESULTS

Congenital CVD carries a heightened risk of VTE, although few higher level studies are available to inform on this topic or on the appropriate anticoagulation strategies for these patients. Noncongenital CVD seems to carry a heightened risk of VTE, although few studies have adequately differentiated between primary and secondary etiologies. Varicose veins are a risk factor for primary VTE but might not be associated with an increased risk of recurrent VTE. In the hospital setting, patients with varicosities should be provided thromboprophylaxis. In the setting of varicose vein intervention, high-risk patients should be identified using risk assessment models and receive thromboprophylaxis. The risk of recurrent VTE in the setting of PTS is unclear but indefinite anticoagulation is not currently indicated. For patients with PTS, residual vein thrombosis might be an indicator of when anticoagulation can be safely stopped, although practical limitations to its application exist.

CONCLUSIONS

CVD is associated with an increased risk of VTE. Few studies have differentiated between classes of CVD using a standardized method and have assessed the efficacy of anticoagulation prophylaxis against or treatment of VTE. Additional studies are needed to determine the optimal therapy for preventing and treating VTE in patients with active concurrent CVD.

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

BACKGROUND

Despite guidelines recommending perioperative thromboprophylaxis for patients undergoing general surgery, we have observed significant variations in its practice. This may compromise patient safety. Here, we quantify the heterogeneity of perioperative thromboprophylaxis across all major general surgical operations, and place them in relation to their risk of bleeding and venous thromboembolism.

METHODS

Retrospective review of all elective major general surgeries performed between 1 January 2018 and 30 June 2019 across seven Victorian hospitals was conducted.

RESULTS

A total of 5912 patients who underwent 6628 procedures were reviewed. Significant heterogeneity was found in the use of chemoprophylaxis, timing of its initiation, type of anticoagulant administered and application of extended chemoprophylaxis. These variations were observed within the same procedure, and between different surgeries and subspecialties. Contrastingly, there was minimal heterogeneity with the use of mechanical thromboprophylaxis. Oesophago-gastric, liver and colorectal cancer resections had the highest thromboembolic risk. Breast, oesophago-gastric, liver, pancreas and colon cancer resections had the highest bleeding risk.

CONCLUSION

Perioperative chemoprophylaxis across general surgery is highly variable. This study has highlighted key areas of variance. Our findings also enable surgeons to compare their practices, and provide baseline data to inform future efforts towards optimizing thromboprophylaxis for general surgical patients.

The contribution of specific enhanced recovery after surgery (ERAS) protocol elements to reduced length of hospital stay after ventral hernia repair

BACKGROUND

Ventral hernia repair (VHR) is a commonly performed procedure that may be associated with prolonged hospitalization. Enhanced recovery after surgery (ERAS) protocols are intended to decrease hospital length of stay (LOS) and improve outcomes. This study evaluated the impact of compliance with individual VHR ERAS elements on LOS.

METHODS

With IRB approval, a medical record review (perioperative characteristics, clinical outcomes, compliance with ERAS elements) was conducted of open VHR consecutive cases performed in August 2013-July 2017. The ERAS protocol was implemented in August 2015; elements in place prior to implementation were accounted for in compliance review. Clinical predictors of LOS were determined through forward regression of log-transformed LOS. The effects of specific ERAS elements on LOS were assessed by adding them to the model in the presence of the clinical predictors.

RESULTS

Two-hundred and thirty-four patients underwent VHR (109 ERAS, 125 pre-ERAS). Across all patients, the mean LOS was 5.4 days (SD = 3.3). Independent perioperative predictors (P's < 0.05) of increased LOS were CDC Wound Class III/IV (38% increase above the mean), COPD (35%), prior infected mesh (21%), concomitant procedure (14%), mesh size (3% per 100 cm²), and age (8% increase per 10 years from mean age). Formal ERAS implementation was associated with a 15% or about 0.7 days (95% CI 6%-24%) reduction in mean LOS after adjustment. Compliance with acceleration of intestinal recovery was low (25.6%) as many patients were not eligible for alvimopan use due to preoperative opioids, yet when achieved, provided the greatest reduction in LOS (- 36%).

CONCLUSIONS

Implementation of an ERAS protocol for VHR results in decreased hospital LOS. Evaluation of the impact of specific ERAS element compliance to LOS is unique to this study. Compliance with acceleration of intestinal recovery, early postoperative mobilization, and multimodal pain management standards provided the greatest LOS reduction.

Current prevalence of perioperative early venous thromboembolism and risk factors in Chinese adult patients with inguinal hernia (CHAT-1)

Venous thromboembolism (VTE) is an important postoperative complication. We investigated and analyzed the current inguinal hernia treatment methods and occurrence of early postoperative VTE in Chinese adults. This study involved data for patients with inguinal hernia hospitalized in 58 general hospitals in mainland China from January 1st, 2017 to December 31st, 2017. Data were retrospectively analyzed using a questionnaire. After data inputting and cleaning, we stratified and statistically analyzed patients' data using Caprini scores to create a high-, middle-, and low-risk group. A total of 14,322 patients with inguinal hernia were admitted to the 58 participating hospitals. After data collation and cleaning, 13,886 patients (97.0%) met our inclusion and exclusion criteria. The percentages of laparoscopic surgery and open surgery were 51.2% and 48.8%, respectively. 16 VTEs occurred during the hospitalization, accounting for 0.1% of all adverse events (95% confidence interval (CI) 0.11-0.13). The incidence of VTE was 0.2% (95% CI 0.18-0.2) in the high-risk group and 0.02% (95% CI 0.01-0.03) in the middle-risk group, based on Caprini scoring, with a significant difference (p < 0.0001). No VTE occurred in the low-risk group. Only 3,250 (23.4%) patients underwent Caprini risk assessment regarding treatment, with 13.2% receiving any prevention and only 1.2% receiving appropriate prevention. The treatment of inguinal hernia in Chinese adults has progressed somewhat; however, the evaluation and prevention of perioperative VTE was seriously neglected, in our study, and the incidence of postoperative VTE was underestimated postoperatively. Risk factors continue to be inadequately considered.

A meta-analysis and systematic review of venous thromboembolism prophylaxis in patients undergoing vascular surgery procedures

OBJECTIVE

Perioperative venous thromboembolism (VTE) is generally considered preventable. Whereas the non-vascular surgery literature is rich in providing data about the impact of VTE prophylaxis on VTE outcomes, vascular surgery data are relatively sparse on this topic. This study sought to evaluate the evidence for VTE prophylaxis specifically for the population of vascular surgery patients.

METHODS

A systematic search was conducted in MEDLINE, Cochrane, and Embase databases in December 2018. Included were studies reporting primary and secondary outcomes for common vascular surgery procedures (open aortic operation, endovascular aneurysm repair [EVAR], peripheral artery bypass, amputation, venous reflux operation). A meta-analysis was performed comparing the patients who did not receive VTE prophylaxis and had VTE complications with patients who developed VTE despite receiving prophylaxis.

RESULTS

From 3757 uniquely identified articles, 42 publications met the criteria for inclusion in this review (1 for the category of all vascular operations, 5 for open aortic reconstructions, 2 for EVAR, 1 for open aortic surgery or EVAR, 3 for abdominal or bypass surgery, 2 for peripheral bypass surgery, 2 for amputations, 1 for vascular trauma, and 25 for surgical treatment of superficial venous disease). Five studies met the criteria for inclusion in the meta-analysis. The results demonstrated slightly lower relative risk for development of VTE among patients receiving VTE prophylaxis (relative risk, 0.70; 95% confidence interval, 0.26-1.87). After open aortic reconstruction, the risk of VTE is 13% to 18% and is not reduced by VTE prophylaxis. For EVAR patients, the risk of VTE without prophylaxis is 6%. For patients undergoing peripheral bypass surgery and not receiving therapeutic or prophylactic anticoagulation, the risk of VTE is <2%. For patients undergoing amputations, VTE prophylaxis reduces the risk of VTE. For patients undergoing surgical treatment of superficial venous disease, there is an abundance of literature exploring the utility of VTE prophylaxis, but the evidence is conflicting; some studies demonstrated a benefit, whereas others showed no reduction of VTE with prophylaxis.

CONCLUSIONS

Overall, there is a paucity of literature that addresses the effectiveness of VTE prophylaxis specifically in the population of vascular surgery patients. Our meta-analysis of the literature does not demonstrate a statistically significant benefit of VTE prophylaxis among the vascular surgery patients evaluated; however, it does suggest a low incidence of VTE among patients who receive VTE prophylaxis. Clinicians should identify the patients at high risk for development of postoperative VTE as the risk-benefit ratio may favor VTE prophylaxis in a selected group of patients. Clinicians should use their judgment and established VTE risk prediction models to assess VTE risk for patients. Vascular surgeons should consider reporting VTE incidence as a secondary outcome in publications.

Thromboprophylaxis for varicose vein procedures – A national survey

Background

Venous thromboembolism is rare following varicose vein ablation procedures, but uncertainty about its incidence combined with a lack of evidence-based clinical guidelines regarding thromboprophylaxis has led to debate about best practice. We conducted a national survey to investigate current practice among Irish vascular surgeons.

Methods

An anonymous online questionnaire was emailed to all members of the Irish Association of Vascular Surgeons and the Northern Ireland Vascular Society.

Results

Response rate was 60%. With regard to procedure type, 36.7% of respondents use only endovenous techniques and 53% use a combination of open and endovenous. Formal duplex imaging on all patients is obtained by 53.3%. With regard to VTE prevention, 73.3% always give thromboprophylaxis. For those who give it selectively, a variety of factors were considered as risks. Pharmacological agents used are enoxaparin in 73.3% of cases or tinzaparin, and 71.4% use a single dose (either 20/40 mg or 3500/4500 IU respectively). If patients are already taking anticoagulation, this is continued by 46.7% of respondents. Routine post procedure duplex imaging is carried out by 23.1% of recipients, either by the surgeon or formally and 80% review patients clinically. Moreover, 43.3% of respondents claim to know their post-operative VTE rate and this varies from 0 to 1% with one mortality reported.

Conclusions

The majority of respondents use single-dose thromboprophylaxis periprocedurally for varicose vein ablation procedures. VTE rates are low but the true incidence may be unknown.

Coagulation and deep vein flow changes following laparoscopic total extraperitoneal inguinal hernia repair: a single-center, prospective cohort study

BACKGROUND AND PURPOSE

Venous thromboembolism (VTE) is a serious complication encountered in surgical practice. The purpose of this study was to identify changes in coagulation status and deep vein flow parameters, within 24 h postoperatively, for patients undergoing laparoscopic total extraperitoneal inguinal hernia repair (TEP).

METHODS

For 144 patients undergoing TEP, coagulation markers including prothrombin time (PT), partial thromboplastin time, thrombin time, D-dimer, fibrinogen, fibrin degradation products (FDP), and international normalized ratio (INR) were monitored preoperatively and in the first morning postoperatively. Echo-Doppler recordings preoperatively and again within 24 h postoperatively were completed for 23 patients to monitor lower extremity deep vein flow parameters including speed of flow (cm/s), diameter (cm), and cross-sectional area (cm²). Clinically significant VTE and other complications were recorded.

RESULTS

No significant VTE were diagnosed. Significant increases were seen in the first morning postoperatively for PT, D-dimer, FDP, and INR (P < 0.05). Stratified by age, except for those < 50 years, the ratio of value-outside-the-normal-range (VONR) for D-dimer and FDP increased significantly postoperatively for all age groups. Stratified by operation duration, a significant difference in the ratio of VONR in D-dimer was identified postoperatively between those with an operation duration < 60 min and ≥ 60 min. There were significant decreases in the iliac and common femoral vein flow velocity of the ipsilateral extremity postoperatively (P < 0.05).

CONCLUSIONS

Activated hypercoagulability and hampered lower extremity deep vein flow were observed immediately after TEP. DVT formation was more pronounced in older patients and for those with operation duration ≥ 60 min. Proper VTE risk stratification for laparoscopic inguinal hernia repair (LIHR) and prophylaxis early after LIHR should be important clinical considerations.

28 day post-operative persisted hypercoagulability after surgery for benign diseases: a prospective cohort study

BACKGROUND

Surgery for benign disease is associated with a low-risk of developing venous thromboembolism (VTE). Despite a relatively low incidence of postoperative VTE in patients after elective cholecystectomy and abdominal hernia repair there are data proving hypercoagulability in the early postoperative period. We focused on assessment of the systemic inflammatory response and coagulation status in these surgical patients after hospital discharge.

METHODS

Prospectively, patients who underwent surgery for benign disease were included. Two hundred sixteen patients were enrolled - 90 patients in laparoscopic cholecystectomy (LC) group and 126 patients in hernia surgery (HS) group. Risk assessment of VTE according to the Caprini risk assessment model was performed in all patients. Prevalence of VTE in postoperative period was observed. Markers of systemic inflammatory response (IL-6, CRP, α-1-acid glycoprotein, transferrin) and coagulation markers (PLT, fibrinogen, prothrombin fragment F1 + 2 and D-dimer) were measured before surgery, on 7-10th postoperative day and on 28-30th postoperative day.

RESULTS

Clinically apparent deep vein thrombosis was diagnosed in only one patient - 0.46%. Statistically significant elevation of inflammatory markers IL-6, CRP and α-1-acid glycoprotein (p < 0.001; all) were proved in both groups of patients on 7-10th postoperative day. Statistically significant elevation of coagulation markers PLT, fibrinogen, prothrombin fragment F1 + 2 and D-dimer (p < 0.001; all) were proved in LC and HS groups on 7-10th postoperative day. No statistical difference was observed in IL-6, CRP and α-1-acid glycoprotein levels a month after surgery as compared with preoperative levels within each group. Statistically significant elevation of fibrinogen and prothrombin fragment F1 + 2 levels (p < 0.001; both) persisted on 28-30th postoperative day in both groups. Persisted elevation of D-dimer levels was proved only in HS group (p < 0.001), not in LC group (p = 0.138), a month after surgery.

CONCLUSIONS

Activated systemic inflammatory response and hypercoagulable condition were verified in patients after laparoscopic cholecystectomy and hernia surgery after their hospital discharge. Hypercoagulability persisted even a month after surgery. Nevertheless, we observed very low prevalence of clinically apparent VTE in patients with in-hospital postoperative VTE prophylaxis.

TRIAL REGISTRATION

Trials of the Czech Ministry of Health No. RVO-VFN64165 and NT 13251-4 .

Slow femoral venous flow and venous thromboembolism following inguinal hernioplasty in patients without or with low molecular weight heparin prophylaxis

BACKGROUND

Prosthetic material (mesh) is commonly used to repair inguinal hernias. Its implantation close to the common femoral vein (CFV) can induce slow flow and favor the appearance of venous thromboembolism (VTE) events.

AIM

To investigate the speed of flow, diameter and area of the CFV after inguinal hernioplasty.

METHODS

Two hundred and fifty patients receiving open hernioplasty with a non-resorbable mesh for the repair of a unilateral, primary, simple inguinal hernia were prospectively investigated. Patients were stratified, by consensus, into a low or a moderate risk of VTE group. The moderate-risk group (n = 163) received low molecular weight heparin. On day 10 post-operation a blinded Echo-Doppler was carried out, and repeated 7 days later in patients with a venous flow of <15 cm/s. The speed of flow (cm/s), diameter (cm), and area (cm(2)) of the ipsilateral and contralateral CFV of the groin operated upon were measured.

RESULTS

No event symptomatic of VTE was documented. One case of asymptomatic deep vein thrombosis (1/163, 0.6%) was found in the moderate-risk group. In 29 patients (2 and 27 in the low- and moderate-risk groups, respectively; p < 0.001) a maximum blood flow velocity of <15 cm/s was found in the ipsilateral CFV; these flows were close to normal in the second measurement. Taking the entire sample into account, the maximum venous blood flow found in the ipsilateral CFV of the operated groin was less than that measured in the contralateral CFV (20.88 vs. 24.01 cm/s; p < 0.001); this difference was significant in both VTE risk groups. The diameter and area of the CFV were both greater in the ipsilateral than the contralateral CFV (p < 0.01); this finding proved to be significant only in hernias of the left groin (p < 0.001).

CONCLUSIONS

In the immediate postoperative period, inguinal hernioplasty with mesh induces a temporarily slow venous flow in the ipsilateral CFV. However, this does not lead to an increase in the incidence of VTE.

Prevention of venous thromboembolism in patients undergoing surgical treatment of varicose veins

Introduction:

There is no consensus among surgeons with regard to prevention of venous thromboembolism (VTE) in patients undergoing surgical treatment of varicose veins. We performed a systematic review of the available literature.

Methods:

We systematically searched the online database from PubMed for studies about the incidence of VTE and thromboprophylaxis in varicose vein surgery. We included 13 papers for review.

Results:

The incidence of VTE after varicose vein surgery remains unclear. Most retrospective case series report an incidence of deep venous thrombosis (DVT) of approximately 1%, based on a clinical diagnosis. However, three prospective studies have systematically detected DVT by means of duplex ultrasound and showed that the true incidence might be 5–10 times higher than expected on a clinical basis.

Discussion:

More data on the incidence of VTE, and the need for postoperative thromboprophylaxis are necessary to formulate evidence-based clinical guidelines. Therefore, high-quality randomised clinical trials, with high numbers of included patients, and ideally comparing prophylaxis to placebo are warranted.

Epidemiology, risk factors and sequelae of venous thromboembolism

The aim of this review was to discuss the epidemiology, risk factors and sequelae of venous thromboembolism (VTE). VTE has an incidence of 1-2 per 1000 people annually. The risk of VTE increases with age and is highest in Caucasians and African Americans. Combined oral contraceptives (COC), especially the third-generation COCs, have been strongly implicated in VTE. Hospitalized patients, especially patients with underlying malignancy and undergoing surgery, have a host of risk factors for VTE. Thrombophilia can predispose an individual to VTE but indiscriminate testing for thrombophilia in patients presenting with VTE is not indicated. VTE can have serious chronic sequelae in the form of post-thrombotic syndrome (PTS) and chronic thromboembolic pulmonary hypertension (CTPH). The risk of PTS and CTPH is increased with recurrent deep vein thrombosis and pulmonary embolism, respectively. Mortality from VTE can be as high as 21.6% at one year. Patients who had an episode of VTE have a high risk of subsequent VTE and this risk is highest in patients who had a first VTE event associated with malignancy. A good understanding of the epidemiology and risk factors of VTE will enable the treating medical practitioners to identify patients at risk and administer appropriate VTE prophylaxis to prevent the long-term consequences of VTE.

Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

BACKGROUND

VTE is a common cause of preventable death in surgical patients.

METHODS

We developed recommendations for thromboprophylaxis in nonorthopedic surgical patients by using systematic methods as described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement.

RESULTS

We describe several alternatives for stratifying the risk of VTE in general and abdominal-pelvic surgical patients. When the risk for VTE is very low (< 0.5%), we recommend that no specific pharmacologic (Grade 1B) or mechanical (Grade 2C) prophylaxis be used other than early ambulation. For patients at low risk for VTE (∼1.5%), we suggest mechanical prophylaxis, preferably with intermittent pneumatic compression (IPC), over no prophylaxis (Grade 2C). For patients at moderate risk for VTE (∼3%) who are not at high risk for major bleeding complications, we suggest low-molecular-weight heparin (LMWH) (Grade 2B), low-dose unfractionated heparin (Grade 2B), or mechanical prophylaxis with IPC (Grade 2C) over no prophylaxis. For patients at high risk for VTE (∼6%) who are not at high risk for major bleeding complications, we recommend pharmacologic prophylaxis with LMWH (Grade 1B) or low-dose unfractionated heparin (Grade 1B) over no prophylaxis. In these patients, we suggest adding mechanical prophylaxis with elastic stockings or IPC to pharmacologic prophylaxis (Grade 2C). For patients at high risk for VTE undergoing abdominal or pelvic surgery for cancer, we recommend extended-duration, postoperative, pharmacologic prophylaxis (4 weeks) with LMWH over limited-duration prophylaxis (Grade 1B). For patients at moderate to high risk for VTE who are at high risk for major bleeding complications or those in whom the consequences of bleeding are believed to be particularly severe, we suggest use of mechanical prophylaxis, preferably with IPC, over no prophylaxis until the risk of bleeding diminishes and pharmacologic prophylaxis may be initiated (Grade 2C). For patients in all risk groups, we suggest that an inferior vena cava filter not be used for primary VTE prevention (Grade 2C) and that surveillance with venous compression ultrasonography should not be performed (Grade 2C). We developed similar recommendations for other nonorthopedic surgical populations.

CONCLUSIONS

Optimal thromboprophylaxis in nonorthopedic surgical patients will consider the risks of VTE and bleeding complications as well as the values and preferences of individual patients.

Can bilateral varicose vein surgery be performed safely in an ambulatory setting?

OBJECTIVES

Surgery for varicose veins is still the method of choice worldwide. When varicose veins require bilateral surgery, a single procedure often is the preferred choice by the patient. Today, unilateral varicose vein surgery is frequently performed as an outpatient procedure, while in many institutions bilateral surgery is done as an in-hospital procedure.

DESIGN

Retrospective comparative study.

METHODS

Between 1 October 2004 and 31 October 2006, 433 patients underwent surgery for the great saphenous vein as in-patient procedure (303 unilateral and 130 bilateral), period 1. From 1 November 2006 until 31 December 2009, 825 patients had ambulatory great saphenous vein surgery (550 unilateral and 275 bilateral), period 2. We have compared unilateral and bilateral varicose vein surgery (high ligation and stripping of the great saphenous vein) and in-hospital procedures with ambulatory surgery, with regard to postoperative complications, postoperative pain and midterm follow-up.

RESULTS

Operation time and total length of stay in the institution following varicose vein surgery were significantly shorter for period 2 compared with period 1 for both unilateral and bilateral surgery, without other differences between the groups. There were few postoperative complications without differences between periods, and between unilateral and bilateral surgery (wound infection 0.5%, haematoma requiring drainage 0.2%, transient paraesthesia 1.1%, superficial localised thrombophlebitis 0.6% and deep vein thrombosis in one unilaterally operated case only).

CONCLUSIONS

Bilateral varicose vein surgery can be safely performed as an outpatient procedure, without increased risk of postoperative complications, increased postoperative discomfort or midterm adverse effects compared with unilateral surgery.

[Prophylaxis of thromboembolic events in surgery. DVT prophylaxis: a comparison of out-patient and hospitalized patients]

BACKGROUND

The aim of this study was to compare the efficacy and tolerability of enoxaparin for preventing thromboembolism after surgery in the out-patient and in-hospital settings.

MATERIALS AND METHODS

A total of 2,005 out-patient and 1,360 hospitalized patients were included in the study. Prophylaxis was carried out with 20 or 40 mg enoxaparin and follow-up examination after 4-6 weeks.

RESULTS

Out-patients were younger (mean 48.4 vs. 58.5 years, p<0.01), had less cardiovascular comorbid diseases (7.1 vs. 20.8%, p<0.01) and underwent less complex interventions (arthroscopy 33.6 vs. 7.5%, p<0.01). Out-patients also received 20 instead of 40 mg enoxaparin more frequently (60.7 vs. 38.3%, p<0.01). The mean duration of thromboprophylaxis was reduced (12.6 vs. 15.3 days). For patients treated with 20 and 40 mg minor bleeding was observed in 1.8 and 3.4%, respectively (4.7 with 20 mg and 4.5% with 40 mg in hospital), major bleeding was 0.1% for both doses in out-patients and 0.0% with 20 mg and 0.3% with 40 mg in-hospital. Deep vein thrombosis (DVT) occurred in 0.4% of out-patients receiving 20 mg enoxaparin and 0.6% with 40 mg (0.0% with 20 mg and 0.9% with 40 mg in-hospital). There were no cases of pulmonary embolism (PE) in out-patients but PE was observed in 0.2% and 0.5% with 20 mg and 40 mg in-hospital patients, respectively.

CONCLUSIONS

Thromboprophylaxis with enoxaparin is well tolerated under clinical conditions as well as under out-patient treatment and severe bleeding complications are rare.

Venous thromboembolism prophylaxis in a general hospital

OBJECTIVE

To evaluate the use of venous thromboembolism (VTE) prophylaxis in a general hospital.

METHODS

A cross-sectional cohort study at the Hospital Nossa Senhora da Conceição, located in the city of Porto Alegre, Brazil, involving a random sample of patients admitted between October of 2008 and February of 2009. We included patients over 18 years of age and hospitalized for more than 48 h. The exclusion criteria were anticoagulant use, pregnancy, puerperium, and a history of thromboembolic disease. The adequacy of prophylaxis was evaluated in accordance with a protocol created by the Hospital and principally based on the American College of Chest Physicians guidelines, eighth edition.

RESULTS

We included 262 patients. The mean age was 59.1 ± 16.6 years. The most common risk factors were immobilization (in 70.6%), infection (in 44.3%), cancer (in 27.5%), obesity (in 23.3%), and major surgery (in 14.1%). The risk of VTE was classified as high and moderate in 143 (54.6%) and 117 (44.7%) of the patients, respectively. Overall, 46.2% of the patients received adequate prophylaxis, 25% of those with > three risk factors for VTE and 18% of those with cancer, the differences between these last two groups and their counterparts (patients with < three risk factors and those without cancer) being statistically significant (p < 0.001 for both).

CONCLUSIONS

Our data reveal that nearly all patients at our hospital were at risk for VTE, and that less than half received adequate VTE prophylaxis, which is in agreement with the literature. It is surprising that inadequate prophylaxis is more common in high-risk patients.

Prophylaxis for venous thromboembolism: guidelines translated for the clinician

Venous thromboembolism is a major cause of morbidity and mortality worldwide and most often affects hospitalized postoperative surgical and medical patients. Venous thromboembolism prophylaxis undoubtedly improves the care of these patients, as demonstrated by the current literature and guidelines. Failure to prescribe prophylaxis when indicated, however, remains a vital health care concern. The American College of Chest Physicians (ACCP) published their most recent guidelines regarding venous thromboembolism prophylaxis in 2008. In this review, we aim to summarize the most recent ACCP prophylaxis guidelines with practical application and interpretation for the practicing physician. Here we present the most practical information from these guidelines and summarize essential recommendations in key tables. We will briefly review the grading system used in the guidelines for the level of evidence and the strength of the recommendation. We will then discuss the recommendations for prophylaxis in the various patient populations described in these guidelines including general and orthopedic surgery, gynecologic surgery, urologic surgery, thoracic surgery, neurosurgery, trauma, medical conditions, cancer patients, and critical care. In addition, we will discuss recent clinical trials regarding novel anticoagulants for venous thromboembolism prophylaxis and share some conclusions.

[Thromboembolism and its prevention in one-day surgery]

Perioperative antithrombotic prophylaxis as well as surgical and invasive procedures done in anticoagulated patients ("bridging") have primary importance as regards prevention of venous thromboembolism (VTE) and reducing haemorrhagic complications. It is understandable that overwhelming majority of publications are dealing with major surgery (when usually several days hospitalization is required) while much less papers focus on one-day surgery cases. In this paper a brief survey on VTE epidemiology and prevention is carried out based on the new international and the 4th Hungarian Antithrombotic Guideline. The new protocols suggest that beside general measures a perioperative pharmaceutical antithrombotic prophylaxis is necessary if concomittant inherited and/or acquired thrombophilia is present.

[Risk of venous thromboembolic disease in general surgery]

Despite preventive efforts, venous thromboembolic disease (VTED) is still a major problem for surgeons due to its frequency and the morbidity, mortality and enormous resource consumption caused by this entity. However, the most important feature of VTED is that it is one of the most easily preventable complications and causes of death. To take appropriate prophylactic decisions (indication, method, initiation, duration, etc.), familiarity with the epidemiology of VTED in general surgery and some of its most significant populations (oncologic, laparoscopic, bariatric, ambulatory and short-stay) is essential. These factors must also be known to determine the distinct risk factors in these settings with a view to stratifying preoperative risk.

[Prevention of venous thromboembolic disease in general surgery]

Postoperative venous thromboembolic disease (VTED) affects approximately one in four general surgery patients who do not receive preventive measures. In addition to the risk of pulmonary embolism, which is often fatal, patients with VTED may develop long-term complications such as post-thrombotic syndrome or chronic pulmonary hypertension. In addition, postoperative VTED is usually asymptomatic or produces clinical manifestations that are attributed to other processes and consequently this complication is often unnoticed by the surgeon who performed the procedure. Thus, the most effective strategy consists of effective prevention of VTED using the most appropriate prophylactic measures against the patient's thromboembolic risk. There is sufficient evidence that VTED can be prevented by pharmacological methods, especially heparin and its derivatives and with mechanical methods such as support tights or intermittent pneumatic compression of the lower extremities. To reduce the incidence of VTED as far as possible, strategies have been proposed that include a combination of drugs and mechanical methods, new antithrombotic drugs, or prolonging the duration of prophylaxis in patients at very high risk, such as those who have undergone surgery for cancer. Another important aspect is the optimal moment to initiate prophylaxis with anticoagulant drugs with the aim of achieving an adequate equilibrium between antithrombotic efficacy and the risk of hemorrhagic complications. The present article reviews the available evidence to attempt to optimize prevention of VTED in general surgery and in some special groups, such as laparoscopic surgery, short-stay surgery and obesity.

Should all patients undergo postoperative duplex imaging to detect a deep vein thrombosis after varicose vein surgery?

OBJECTIVES

Deep vein thrombosis (DVT) is a serious complication of varicose vein surgery, with attendant risks of pulmonary embolization. Prospective duplex screening identifies DVT in 5% of patients compared to clinical incidence of approximately 1%. Universal duplex screening is costly, and the benefits of diagnosing subclinical DVT are unproven. This study evaluates whether a policy of using clinical indications (leg swelling) to determine the need for duplex imaging is safe after varicose vein surgery.

METHODS

Patients undergoing varicose vein surgery over a 4-year period were studied. Postoperative venous duplex imaging was performed if leg swelling occurred within 6 weeks of surgery. Long-term follow-up was performed to detect any missed occurrence of clinical DVT or pulmonary embolism.

RESULTS

A total of 411 patients had 491 leg operations with 80 bilateral procedures (27%); 29 patients with leg swelling underwent duplex imaging, 5 of whom had duplex-proven DVT. No patient without early clinical signs went on to develop clinical DVT on long-term follow-up.

CONCLUSION

A policy of using clinical signs as a triage for duplex imaging detected all clinically significant DVTs and generated manageable workloads for our vascular laboratory.

Technical review of endovenous laser therapy for varicose veins

BACKGROUND

In the last decade, several new treatments of truncal varicose veins have been introduced. Of these new therapies, endovenous laser therapy (EVLT) is one of the most widely accepted and used treatment options for incompetent greater and lesser saphenous veins.

OBJECTIVE

The objective of this report is to inform clinicians about the EVLT procedure and to review its efficacy and safety in treatment of truncal varicose veins. Also, we discuss some of the underlying theoretical principles and laser parameters that affect EVLT.

METHODS

We carried out a literature review of EVLT;s efficacy and safety. We included reports that included 100 or more limbs with a follow-up of at least 3 months. The principals and procedure of EVLT are described. Of the laser parameters, mode of administration, wavelength, fluence, wattage and pullback speed are discussed.

CONCLUSION

EVLT appears to be a very effective and safe option in the treatment of varicose veins but large randomized comparative studies are needed.

Current treatment of varicose veins

Varicose veins (VVs) of the lower limbs are a common complaint that can take many forms, ranging from a nonpathologic condition to an invalidating chronic disorder. When they have not been neglected, uncomplicated VVs have often been treated by sclerotherapy or surgery, with variably successful results. Currently, the best way of assessing VVs has been to carry out routine ultrasound investigations. The approach to VVs has changed due to recent awareness of cosmetic considerations and the way they can affect quality of life, as well as the development of new treatments (ie, echo-guided sclerotherapy, foam sclerotherapy, endovascular obliteration) and ambulatory care practices. In some cases, the evolution of the disease can be disconcerting, if not entirely hopeless. However, in most cases, poor results have been obtained because of perfunctory assessment, inappropriate treatment, and lack of follow-up. The treatment of complicated VVs has been improved by combining clinical and ultrasound examinations, which make for a quick, accurate diagnosis, pointing the way to the right treatment. Venous ulcers resulting from primary saphenous vein insufficiency, which account for 50% of all venous ulcers, and recurrent venous ulcers should all be a thing of the past, apart from those associated with deep valvular insufficiency disease. The quality of care and the scientific standard of clinical studies on chronic venous insufficiency and VVs have both increased considerably. Although there is still a need to set up scales for assessing symptoms and quality of life, progress is being made in clinical studies that now meet the standards of evidence-based medicine.

Extension of saphenous thrombus into the femoral vein: A potential complication of new endovenous ablation techniques

Endovenous techniques such as radiofrequency ablation (RFA) and endovenous laser therapy (ELT) have emerged as percutaneous minimally invasive procedures for ablation of incompetent great saphenous veins in patients with varicosity and venous insufficiency. Early reports showed safety and efficacy of both techniques, with excellent technical success rates and few major complications, such as deep vein thrombosis or pulmonary embolism. During our initial experience with ELT in 56 limbs of 41 patients, 39 underwent postoperative duplex scanning. We encountered three cases (7.7%) with thrombus extension into the common femoral vein. All three patients were anticoagulated, and a temporary inferior vena cava filter was placed in one. All remained asymptomatic. The thrombus resolved by 1 month in all three patients. Review of the literature revealed that the incidence of thrombus extension into the common femoral vein or deep vein thrombosis in published clinical series is 0.3% after ELT and 2.1% after RFA. This possibility warrants routine postoperative duplex scanning, more alertness during these procedures, and patient education on this possible complication.