Prophylaxis for venous thromboembolism: guidelines translated for the clinician

Primary thromboprophylaxis in cancer outpatients - real-world evidence

INTRODUCTION

Cancer-associated thrombosis (CAT) is a significant concern among patients with malignant diseases, leading to increased mortality. While current guidelines recommend primary thromboprophylaxis for venous thromboembolism (VTE) in medium-to-high-risk outpatients, this practice remains controversial. A better understanding of primary thromboprophylaxis is crucial, yet there is a lack of Real-World Evidence (RWE) in Portugal.

AIMS

This RWE study aimed to elucidate primary thromboprophylaxis practices among cancer outpatients in Portugal.

METHODS

A five-year observational multicentric study in eight Portuguese health institutions enrolled 124 adult cancer outpatients under primary thromboprophylaxis for VTE. The endpoints were CAT, bleeding, cancer progression and death.

RESULTS

High thrombotic risk tumours were prevalent, with 57% (71) of the patients presenting with pancreatic and gastric cancers. Regarding primary thromboprophylaxis, 55% (68) received Low-Molecular-Weight Heparin (LMWH). VTE was presented in 11% (14) of the patients and major bleeding in 2% (2). Vascular compression, elevated D-dimer and previous VTE were significantly associated with VTE occurrence under primary thromboprophylaxis. The Onkotev model was shown to be the best risk assessment model (RAM) in this population (p = 0.007). CAT patients exhibited a lower progression-free survival than non-CAT patients (p = 0.021), while thrombosis did not influence overall survival (p = 0.542).

CONCLUSION

Primary thromboprophylaxis in medium-to-high-risk cancer outpatients is a safe and effective practice in real-world settings. This study is the first Portuguese RWE on primary thromboprophylaxis, highlighting evidence for improving prophylactic strategies in this population.

Unfractionated heparin versus enoxaparin for venous thromboembolism prophylaxis in intensive care units: a propensity score adjusted analysis

Venous thromboembolism (VTE) is a common complication in hospitalized patients. Pharmacologic prophylaxis is used in order to reduce the risk of VTE events. The main purpose of this study is to compare the prevalence of deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients admitted to the intensive care unit (ICU) who received unfractionated heparin (UFH) versus enoxaparin as VTE prophylaxis. Mortality was evaluated as a secondary outcome. This was a Propensity Score Adjusted Analysis. Patients admitted to neurology, surgical, or medical ICUs and screened with venous doppler ultrasonography or computed tomography angiography for detection of VTE were included in the analysis. We identified 2228 patients in the cohort, 1836 (82.4%) patients received UFH and 392 (17.6%) patients received enoxaparin. Propensity score matching yielded a well-balanced cohort of 950 (74% UFH, 26% enoxaparin) patients. After matching, there was no difference in prevalence of DVT (RR 1.05; 95% CI 0.67-1.64, p = 0.85) and PE (RR 0.76; 95% CI, 0.44-1.30, p = 0.31). No significant differences in location and severity of DVT and PE between the two groups were detected. Hospital and intensive care unit stay was similar between the two groups. Unfractionated heparin was associated with a higher rate of mortality, (HR 2.04; 95% CI, 1.13-3.70; p = 0.019). The use of UFH as VTE prophylaxis in ICU patients was associated with a similar prevalence of DVT and PE compared with enoxaparin, and the site and degree of occlusion were similar. However, a higher mortality rate was seen in the UFH group.

Comparison of efficiency and safety of rivaroxaban, apixaban and enoxaparin for thromboprophylaxis after arthroplastic surgery: a meta-analysis

OBJECTIVE

To compare the efficacy and safety of rivaroxaban, apixaban and enoxaparin for thromboprophylaxis after arthroplastic surgery.

METHODS

We conducted a meta-analysis containing a wide range of randomized controlled trials about efficiency and safety of rivaroxaban, apixaban and enoxaparin for thromboprophylaxis after arthroplastic surgery in the recent decade from January 2006 to June 2018. The present study separately analyzed the following key components: the different efficiency and safety for rivaroxaban and enoxaparin; apixaban and enoxaparin; and enoxaparin and other new developed anticoagulants.

RESULTS

Sixteen studies containing 58885 patients were included. In results of efficacy outcomes, total events occurred in 4.89% patients of rivaroxaban group and 9.55% patients of the control group; however, no significant difference was observed in apixaban groups of their efficacy outcomes. Primary events didn't show significant difference when comparing apixaban with the control or comparing enoxaparin with the control. In analysis of safety outcomes, bleeding events occurred in 3.41% patients of rivaroxaban group compared with 2.84% patients of the control groups; bleeding events in apixaban groups were 4.09% compared with the control groups 4.64%. Bleeding events occurred in 3.51% patients of enoxaparin group, slightly lower than 5.82% of the control group.

CONCLUSION

Direct oral anticoagulant, rivaroxaban might have better efficacy outcomes in thromboprophylaxis after arthroplastic surgery; however, apixaban showed no significantly different efficacy outcomes compared with enoxaparin, and enoxaparin may have equal or even better safety outcomes compared with direct oral anticoagulants.

Bedside implantation of a new temporary vena cava inferior filter - Safety and efficacy results of the European ANGEL-Registry

PURPOSE

Pulmonary embolism (PE) is a frequently occurring complication in critically ill patients. Simultaneous occurrence of PE and life-threatening bleeding, may render medical anticoagulation impossible. For these patients, inferior vena cava filters (IVCF) present a valuable therapeutic alternative. The Angel® catheter is a novel IVCF that provides temporary protection from PE and is implanted at bedside. The primary objective of the European Angel® catheter registry is to evaluate the safety and efficacy of this IVCF.

MATERIAL AND METHODS

The European Angel® catheter registry is an observational, multi-centre registry. Patients from four countries and eight sites that have undergone Angel® catheter implantation between March 2013 and February 2017 were enrolled.

RESULTS

A total of 114 critically ill patients were included. The main indication for implantation was a high-risk for PE in combination with contraindications for anticoagulation (69.3%). One clinically non-significant PE (0.9%) occurred in a patient with an indwelling Angel® catheter. No cases of catheter associated serious complications were observed.

CONCLUSION

Data shows that the Angel® catheter is a safe and effective approach to overcome the acute phase of critically ill patients with a high risk for the development of PE or an established PE, when an anticoagulation therapy is contraindicated.

[Bedside implantation of a new temporary vena cava inferior filter : German results from the European ANGEL registry]

BACKGROUND

Pulmonary embolism (PE) is a frequently occurring complication in critically ill patients, and the simultaneous occurrence of PE and life-threatening bleeding is a therapeutic dilemma. Inferior vena cava filters (IVCF) may represent an important therapeutic alternative in these cases. The Angel® catheter (Bio2 Medical Inc., San Antonio, TX, USA) is a novel IVCF that provides temporary protection from PE and is implanted at bedside without fluoroscopy.

MATERIAL AND METHODS

The European Angel® Catheter Registry is an observational, multicenter study. In our German substudy, we investigated patients from three German hospitals and four intensive care units, who underwent Angel® catheter implantation between February 2016 and December 2016.

RESULTS

A total of 23 critically ill patients (68 ± 9 years, 43% male) were included. The main indication for implantation was a high risk for or an established PE, combined with contraindications for prophylactic or therapeutic anticoagulation due to either an increased risk of bleeding (81%) or active bleeding (13%). The Angel® catheter was successfully inserted in all patients at bedside. No PE occurred in patients with an indwelling Angel® catheter. Clots with a diameter larger the 20 mm, indicating clot migration, were detected in 5% of the patients by cavography before filter retrieval. Filter retrieval was uneventful in all of our cases, while filter dislocation occurred in 3% of the patients.

CONCLUSION

The German data from the multicenter European Angel® Catheter Registry show that the Angel® catheter is a safe and effective approach for critically ill patients with a high risk for the development of PE or an established PE, when an anticoagulation therapy is contraindicated.

Post-operative pharmacologic thromboprophylaxis after major hepatectomy: does peripheral venous thromboembolism prevention outweigh bleeding risks?

BACKGROUND

Although standard of care after most abdominal surgeries, post-operative pharmacologic thromboprophylaxis after major hepatectomy is commonly withheld due to bleeding risks. The objective of this retrospective study is to evaluate the benefits and risks of post-operative pharmacologic thromboprophylaxis after major hepatectomy at two high volume academic centers.

METHODS

Demographics, clinicopathologic data, treatments, and post-operative outcomes from patients who underwent major hepatectomy were reviewed.

RESULTS

From 2005 to 2010, 419 patients underwent major hepatectomy; 275 (65.6%) were treated with pharmacologicthromboprophylaxis beginning a median of 1 day after resection. Post-operative symptomatic venous thromboembolism (VTE) occurred in 15 (3.6%) patients. Patients treated with pharmacologic thromboprophylaxis had lower rates of symptomatic VTE (2.2% vs. 6.3%, p = 0.03) and post-operative red blood cell (RBC) transfusion (16.7% vs. 26.4%, p = 0.02) with similar rates of overall RBC transfusion (35.0% vs. 30.6%, p = 0.36) compared to untreated patients. Specifically, isolated deep venous thrombosis (0% vs. 2.1%, p = 0.04) and pulmonary embolism (2.2% vs. 4.2%, p = 0.35) occurred less often in treated patients. Analysis of demographics, clinicopathologic data, and treatment factors revealed that pharmacologic thromboprophylaxis was the only variable associated with post-operative VTE.

CONCLUSIONS

Post-operative pharmacologic thromboprophylaxis lowers the incidence of symptomatic VTE after major hepatectomy without increasing the rate of RBC transfusion.