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Turner BR, Machin M, Salih M, Jasionowska S, Lawton R, Siracusa F, Gwozdz AM, Shalhoub J, Davies AH. An Updated Systematic Review and Meta-analysis of the Impact of Graduated Compression Stockings in Addition to Pharmacological Thromboprophylaxis for Prevention of Venous Thromboembolism in Surgical Inpatients. Ann Surg 2024; 279:29-36. [PMID: 37753655 PMCID: PMC10727201 DOI: 10.1097/sla.0000000000006096] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
OBJECTIVE To compare the rate of venous thromboembolism (VTE) in surgical inpatients with pharmacological thromboprophylaxis and additional graduated compression stockings (GCSs) versus pharmacological thromboprophylaxis alone. BACKGROUND Surgical inpatients have elevated VTE risk; recent studies cast doubt on whether GCS confers additional protection against VTE, compared with pharmacological thromboprophylaxis alone. METHODS The review followed "Preferred Reporting Items for Systematic Reviews and Meta-analyses" guidelines using a registered protocol (CRD42017062655). The MEDLINE and Embase databases were searched up to November 2022. Randomized trials reporting VTE rate after surgical procedures, utilizing pharmacological thromboprophylaxis, with or without GCS, were included. The rates of deep venous thrombosis (DVT), pulmonary embolism, and VTE-related mortality were pooled through fixed and random effects. RESULTS In a head-to-head meta-analysis, the risk of DVT for GCS and pharmacological thromboprophylaxis was 0.85 (95% CI: 0.54-1.36) versus for pharmacological thromboprophylaxis alone (2 studies, 70 events, 2653 participants). The risk of DVT in pooled trial arms for GCS and pharmacological thromboprophylaxis was 0.54 (95% CI: 0.23-1.25) versus pharmacological thromboprophylaxis alone (33 trial arms, 1228 events, 14,108 participants). The risk of pulmonary embolism for GCS and pharmacological prophylaxis versus pharmacological prophylaxis alone was 0.71 (95% CI: 0.0-30.0) (27 trial arms, 32 events, 11,472 participants). There were no between-group differences in VTE-related mortality (27 trial arms, 3 events, 12,982 participants). CONCLUSIONS Evidence from head-to-head meta-analysis and pooled trial arms demonstrates no additional benefit for GCS in preventing VTE and VTE-related mortality. GCS confer a risk of skin complications and an economic burden; current evidence does not support their use for surgical inpatients.
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Lawton R, Shalhoub J, Davies AH. Implementation of the graduated compression as an adjunct to pharmaco-thromboprophylaxis in surgery trial results across the UK. Phlebology 2022; 37:540-542. [PMID: 35466796 PMCID: PMC9379381 DOI: 10.1177/02683555221090781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objectives This study aims to examine uptake and dissemination of a National Institute for Health
Research (NIHR) Health Technology Assessment (HTA)–funded trial – Graduated compression
as an Adjunct to Pharmaco-thromboprophylaxis in Surgery (GAPS) (project number:
14/140/61) amongst health professionals in the UK. This study aims to evaluate the
impact of the trial on venous thromboembolism (VTE) prevention policies 7 months after
publication. Method A 12-question online survey emailed to 2750 individuals via several vascular societies,
34 VTE Exemplar Centre leads and 1 charity over a 3-month period. Results In total, 250 responses were received; a 9.1% response rate. Over half of all
respondents (52.4%) had read the GAPS trial results prior to completing the survey.
Precisely, 77.1% said their hospital had not yet made changes or did not intend to make
changes to local hospital VTE policy based on the GAPS trial. Conclusions Findings must be interpreted in the context of the low response rate. Further in-depth
interviews would aid understanding of barriers to implementing change.
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Affiliation(s)
| | | | - Alun H Davies
- Alun H Davies, Section of Vascular Surgery,
Department of Surgery and Cancer, Imperial College London, 4th Floor, East Wing, Charing
Cross Hospital, Fulham Palace Road, London, W6 8RF, UK.
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OUP accepted manuscript. Br J Surg 2022; 109:669-670. [DOI: 10.1093/bjs/znac157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 04/27/2022] [Indexed: 11/14/2022]
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A Review of Current and Future Antithrombotic Strategies in Surgical Patients-Leaving the Graduated Compression Stockings Behind? J Clin Med 2021; 10:jcm10194294. [PMID: 34640311 PMCID: PMC8509226 DOI: 10.3390/jcm10194294] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/15/2021] [Accepted: 09/18/2021] [Indexed: 11/16/2022] Open
Abstract
Venous thromboembolism (VTE) remains an important consideration within surgery, with recent evidence looking to refine clinical guidance. This review provides a contemporary update of existing clinical evidence for antithrombotic regimens for surgical patients, providing future directions for prophylaxis regimens and research. For moderate to high VTE risk patients, existing evidence supports the use of heparins for prophylaxis. Direct oral anticoagulants (DOACs) have been validated within orthopaedic surgery, although there remain few completed randomised controlled trials in other surgical specialties. Recent trials have also cast doubt on the efficacy of mechanical prophylaxis, especially when adjuvant to pharmacological prophylaxis. Despite the ongoing uncertainty in higher VTE risk patients, there remains a lack of evidence for mechanical prophylaxis in low VTE risk patients, with a recent systematic search failing to identify high-quality evidence. Future research on rigorously developed and validated risk assessment models will allow the better stratification of patients for clinical and academic use. Mechanical prophylaxis' role in modern practice remains uncertain, requiring high-quality trials to investigate select populations in which it may hold benefit and to explore whether intermittent pneumatic compression is more effective. The validation of DOACs and aspirin in wider specialties may permit pharmacological thromboprophylactic regimens that are easier to administer.
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Shalhoub J, Lawton R, Hudson J, Baker C, Bradbury A, Dhillon K, Everington T, Gohel MS, Hamady Z, Hunt BJ, Stansby G, Warwick D, Norrie J, Davies AH. Compression stockings in addition to low-molecular-weight heparin to prevent venous thromboembolism in surgical inpatients requiring pharmacoprophylaxis: the GAPS non-inferiority RCT. Health Technol Assess 2020; 24:1-80. [PMID: 33275096 DOI: 10.3310/hta24690] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Patients admitted to hospital for surgery are at an increased risk of venous thromboembolism. Pharmaco-thromboprophylaxis and mechanical prophylaxis (usually graduated compression stockings or intermittent pneumatic compression) have been shown to reduce the incidence of venous thromboembolism. The evidence base supporting the National Institute for Health and Care Excellence's recommendation for the use of graduated compression stockings for venous thromboembolism prevention in the UK has recently been challenged. It is unclear if the risks and costs associated with graduated compression stockings are justified for deep-vein thrombosis prevention in moderate- and high-risk elective surgical inpatients receiving low-dose low-molecular-weight heparin pharmaco-thromboprophylaxis. OBJECTIVES The primary objective was to compare the venous thromboembolism rate in elective surgical inpatients at moderate or high risk of venous thromboembolism who were receiving either graduated compression stockings and low-dose low-molecular-weight heparin (standard care) or low-dose low-molecular-weight heparin alone (intervention). DESIGN This was a pragmatic, multicentre, prospective, non-inferiority, randomised controlled trial. SETTING This took place in secondary care NHS hospitals in the UK. PARTICIPANTS Patients aged ≥ 18 years who were assessed to be at moderate or high risk of venous thromboembolism according to the NHS England venous thromboembolism risk assessment tool (or the trust equivalent based on this form) and who were not contraindicated to low-molecular-weight heparin or graduated compression stockings were deemed eligible to take part. INTERVENTIONS Participants were randomised 1 : 1 to either low-molecular-weight heparin or low-molecular-weight heparin and graduated compression stockings. MAIN OUTCOME MEASURES The primary outcome measure was venous thromboembolism up to 90 days after surgery. A combined end point of duplex ultrasound-proven new lower-limb deep-vein thrombosis (symptomatic or asymptomatic) plus imaging-confirmed symptomatic pulmonary embolism. Secondary outcomes included quality of life, compliance with graduated compression stockings and low-molecular-weight heparin during admission, and all-cause mortality. RESULTS A total of 1905 participants were randomised and 1858 were included in the intention-to-treat analysis. A primary outcome event occurred in 16 out of 937 (1.7%) patients in the low-molecular-weight heparin-alone arm compared with 13 out of 921 (1.4%) patients in the low-molecular-weight heparin plus graduated compression stockings arm. The risk difference between low-molecular-weight heparin and low-molecular-weight heparin plus graduated compression stockings was 0.30% (95% confidence interval -0.65% to 1.26%). As the 95% confidence interval did not cross the non-inferiority margin of 3.5% (p < 0.001 for non-inferiority), the results indicate that non-inferiority of low-molecular-weight heparin alone was shown. LIMITATIONS In total, 13% of patients did not receive a duplex ultrasound scan that could have detected further asymptomatic deep-vein thrombosis. However, missing scans were balanced between both trial arms. The subpopulation of those aged ≥ 65 years assessed as being at a moderate risk of venous thromboembolism was under-represented in the study; however, this reflects that this group is under-represented in the general population. CONCLUSIONS For elective surgical patients at moderate or high risk of venous thromboembolism, administration of pharmaco-thromboprophylaxis alone is non-inferior to a combination of pharmaco-thromboprophylaxis and graduated compression stockings. These findings indicate that graduated compression stockings may be unnecessary for most elective surgical patients. FUTURE WORK Further studies are required to evaluate whether or not adjuvant graduated compression stockings have a role in patients receiving extended thromboprophylaxis, beyond the period of hospital admission, following elective surgery or in patients undergoing emergency surgical procedures. TRIAL REGISTRATION Current Controlled Trials ISRCTN13911492. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 69. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Joseph Shalhoub
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Rebecca Lawton
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Christopher Baker
- Department of Surgery and Cancer, Imperial College Healthcare NHS Trust, London, UK
| | - Andrew Bradbury
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Karen Dhillon
- Department of Surgery and Cancer, Imperial College Healthcare NHS Trust, London, UK
| | - Tamara Everington
- Department of Haematology, Hampshire Hospitals NHS Foundation Trust, Basingstoke, UK
| | - Manjit S Gohel
- Department of Surgery and Cancer, Imperial College London, London, UK.,Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Zaed Hamady
- Southampton HPB Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Beverly J Hunt
- Department of Thrombosis and Haemostasis, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Gerard Stansby
- Northern Vascular Unit, Freeman Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - David Warwick
- Department of Trauma and Orthopaedic Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - John Norrie
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Alun H Davies
- Department of Surgery and Cancer, Imperial College London, London, UK
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Guéroult AM, Machin M, Lawton R, Davies AH, Shalhoub J. What does the future hold for mechanical thromboprophylaxis? Phlebology 2020; 36:257-259. [PMID: 33236672 DOI: 10.1177/0268355520975599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Aurélien M Guéroult
- Department of Surgery & Cancer, Academic Section of Vascular Surgery, 4615Imperial College London, London, UK.,Imperial Vascular Unit, 8946Imperial College Healthcare NHS Trust, London, UK
| | - Matthew Machin
- Department of Surgery & Cancer, Academic Section of Vascular Surgery, 4615Imperial College London, London, UK.,Imperial Vascular Unit, 8946Imperial College Healthcare NHS Trust, London, UK
| | - Rebecca Lawton
- Department of Surgery & Cancer, Academic Section of Vascular Surgery, 4615Imperial College London, London, UK.,Imperial Vascular Unit, 8946Imperial College Healthcare NHS Trust, London, UK
| | - Alun H Davies
- Department of Surgery & Cancer, Academic Section of Vascular Surgery, 4615Imperial College London, London, UK.,Imperial Vascular Unit, 8946Imperial College Healthcare NHS Trust, London, UK
| | - Joseph Shalhoub
- Department of Surgery & Cancer, Academic Section of Vascular Surgery, 4615Imperial College London, London, UK.,Imperial Vascular Unit, 8946Imperial College Healthcare NHS Trust, London, UK
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Suna K, Herrmann E, Kröger K, Schmandra T, Müller E, Hanisch E, Buia A. Graduated compression stockings in the prevention of postoperative pulmonary embolism. A propensity-matched retrospective case-control study of 24 273 patients. Ann Med Surg (Lond) 2020; 56:203-210. [PMID: 32670570 PMCID: PMC7338863 DOI: 10.1016/j.amsu.2020.06.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 06/18/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Recommendations for venous thromboembolism and deep venous thrombosis (DVT) prophylaxis using graduated compression stockings (GCS) is historically based and has been critically examined in current publications. Existing guidelines are inconclusive as to recommend the general use of GCS.Patients/Methods: 24 273 in-patients (general surgery and orthopedic patients) undergoing surgery between 2006 and 2016 were included in a retrospectively analysis from a single center. From January 2006 to January 2011 perioperative GCS was employed additionally to drug prophylaxis and from February 2011 to March 2016 patients received drug prophylaxis alone. According to german guidelines all patients received venous thromboembolism prophylaxis with weight-adapted LMWH. Risk stratification (low risk, moderate risk, high risk) was based on the guideline of the American College of Chest Physicians. Data analysis was performed before and after propensity matching (PM). The defined primary endpoint was the incidence of symptomatic or fatal pulmonary embolism (PE). A secondary endpoint was the incidence of deep venous thromboembolism (DVT). RESULTS After risk stratification (low risk n = 16 483; moderate risk n = 4464; high risk n = 3326) a total of 24 273 patient were analyzed. Before to PM the relative risk for the occurrence of a PE or DVT was not increased by abstaining from GCS. After PM two groups of 11 312 patients each, one with and one without GCS application, were formed. When comparing the two groups, the relative risk (RR) for the occurrence of a pulmonary embolism was: Low Risk 0.99 [CI95% 0.998-1.000]; Moderate Risk 0.999 [CI95% 0.95-1.003]; High Risk 0.996 [CI95% 0.992-1.000] (p > 0.05). The incidence of PE in the total group LMWH alone was 0.1% (n = 16). In the total group using LMWH + GCS, the incidence was 0.3% (n = 29). RR after PM was 0.999 [CI95% 0.998-1.00]. CONCLUSION In comparison to prior studies with only small numbers of patients our trial shows in a large group of patients with moderate and high risk developing VTE we can support the view that abstaining from GCS-use does not increase the incidence of symptomatic or fatal PE and symptomatic DVT.
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Affiliation(s)
- Kenan Suna
- Clinic for General, Visceral and Thoracic-Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe-Universität Frankfurt, Röntgenstr 20, Langen, 63225, Germany
| | - Eva Herrmann
- Institute of Biostatistics und Mathematical Modeling, Klinikum und Fachbereich Medizin der Goethe-Universität Frankfurt, Theodor-Stern-Kai 7, Frankfurt Am Main, 60590, Germany
| | - Knut Kröger
- Clinic for Angiology, Helios Klinikum Krefeld, Lutherplatz 40, Krefeld, 47805, Germany
| | - Thomas Schmandra
- Department of Vascular Surgery, Heart and Vascular Clinic, Bad Neustadt, Salzburger Leite 1, Bad Neustadt a. d. Saale, 97616, Germany
| | - Elisa Müller
- Clinic for General, Visceral and Thoracic-Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe-Universität Frankfurt, Röntgenstr 20, Langen, 63225, Germany
| | - Ernst Hanisch
- Clinic for General, Visceral and Thoracic-Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe-Universität Frankfurt, Röntgenstr 20, Langen, 63225, Germany
| | - Alexander Buia
- Clinic for General, Visceral and Thoracic-Surgery, Asklepios Klinik Langen, Academic Teaching Hospital Goethe-Universität Frankfurt, Röntgenstr 20, Langen, 63225, Germany
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Shalhoub J, Lawton R, Hudson J, Baker C, Bradbury A, Dhillon K, Everington T, Gohel MS, Hamady Z, Hunt BJ, Stansby G, Warwick D, Norrie J, Davies AH. Graduated compression stockings as adjuvant to pharmaco-thromboprophylaxis in elective surgical patients (GAPS study): randomised controlled trial. BMJ 2020; 369:m1309. [PMID: 32404430 PMCID: PMC7219517 DOI: 10.1136/bmj.m1309] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To investigate whether the use of graduated compression stockings (GCS) offers any adjuvant benefit when pharmaco-thromboprophylaxis is used for venous thromboembolism prophylaxis in patients undergoing elective surgery. DESIGN Open, multicentre, randomised, controlled, non-inferiority trial. SETTING Seven National Health Service tertiary hospitals in the United Kingdom. PARTICIPANTS 1905 elective surgical inpatients (≥18 years) assessed as being at moderate or high risk of venous thromboembolism were eligible and consented to participate. INTERVENTION Participants were randomly assigned (1:1) to receive low molecular weight heparin (LMWH) pharmaco-thromboprophylaxis alone or LMWH pharmaco-thromboprophylaxis and GCS. OUTCOME MEASURES The primary outcome was imaging confirmed lower limb deep vein thrombosis with or without symptoms, or pulmonary embolism with symptoms within 90 days of surgery. Secondary outcome measures were quality of life, compliance with stockings and LMWH, lower limb complications related to GCS, bleeding complications, adverse reactions to LMWH, and all cause mortality. RESULTS Between May 2016 and January 2019, 1905 participants were randomised. 1858 were included in the intention to treat analysis (17 were identified as ineligible after randomisation and 30 did not undergo surgery). A primary outcome event occurred in 16 of 937 (1.7%) patients in the LMWH alone group compared with 13 of 921 (1.4%) in the LMWH and GCS group. The risk difference between the two groups was 0.30% (95% confidence interval -0.65% to 1.26%). Because the 95% confidence interval did not cross the non-inferiority margin of 3.5% (P<0.001 for non-inferiority), LMWH alone was confirmed to be non-inferior. CONCLUSIONS For patients who have elective surgery and are at moderate or high risk of venous thromboembolism, administration of pharmaco-thromboprophylaxis alone is non-inferior to a combination of pharmaco-thromboprophylaxis and GCS. These findings indicate that GCS might be unnecessary in most patients undergoing elective surgery. TRIAL REGISTRATION ISRCTN13911492.
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Affiliation(s)
- Joseph Shalhoub
- Department of Surgery and Cancer, Imperial College London & Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London W6 8RF, UK
| | - Rebecca Lawton
- Department of Surgery and Cancer, Imperial College London & Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London W6 8RF, UK
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK
| | - Christopher Baker
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
| | - Andrew Bradbury
- University of Birmingham & University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Karen Dhillon
- Department of Surgery and Cancer, Imperial College London & Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London W6 8RF, UK
| | | | - Manjit S Gohel
- Department of Surgery and Cancer, Imperial College London & Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London W6 8RF, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Zaed Hamady
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Gerrard Stansby
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - David Warwick
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Alun H Davies
- Department of Surgery and Cancer, Imperial College London & Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London W6 8RF, UK
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Milinis K, Shalhoub J, Coupland AP, Salciccioli JD, Thapar A, Davies AH. The effectiveness of graduated compression stockings for prevention of venous thromboembolism in orthopedic and abdominal surgery patients requiring extended pharmacologic thromboprophylaxis. J Vasc Surg Venous Lymphat Disord 2018; 6:766-777.e2. [PMID: 30126797 DOI: 10.1016/j.jvsv.2018.05.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 05/16/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE There is an increasing evidence base to support the use of extended pharmacologic thromboprophylaxis in selected surgical patients to prevent venous thromboembolism (VTE). The benefit of graduated compression stockings (GCS) in addition to extended pharmacologic thromboprophylaxis is unclear. The aim of this study was to systematically review the evidence relating to the effectiveness of using GCS in conjunction with extended pharmacologic thromboprophylaxis to prevent VTE in surgical patients. METHODS A literature search of MEDLINE, Embase, Cochrane Library, and ClinicalTrials.gov databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in April 2017. The review protocol was published on PROSPERO (CRD42017062655). Randomized controlled trials (RCTs) were eligible if one of the study arms included patients receiving extended pharmacologic thromboprophylaxis alone (>21 days) or in conjunction with GCS. Data on deep venous thrombosis (DVT), pulmonary embolism (PE), and VTE-related death were compiled. Pooled proportions of the VTE rates were determined using random-effects meta-analysis. RESULTS The systematic search identified 1291 studies, of which 19 studies were eligible for inclusion. No RCT directly compared extended pharmacologic thromboprophylaxis alone with GCS plus extended pharmacologic thromboprophylaxis. A total of 9824 patients from 16 RCTs were treated with extended pharmacologic thromboprophylaxis, of whom 0.81% (95% confidence interval [CI], 0.5-1.20) were diagnosed with symptomatic DVT and 0.2% (95% CI, 0.12-0.36) with PE. Three trials included 337 patients who received extended pharmacologic thromboprophylaxis in conjunction with GCS. In this group, 1.61% (95% CI, 0.03-5.43) had symptomatic DVT with no reported PE. Similar VTE rates were observed when studies in orthopedic and abdominal surgery were analyzed separately. CONCLUSIONS There is insufficient evidence to recommend GCS in conjunction with extended pharmacologic prophylaxis to prevent VTE in patients undergoing orthopedic and abdominal surgery. A clinical trial directly investigating this important subject is needed.
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Affiliation(s)
- Kristijonas Milinis
- Academic Section of Vascular Surgery, Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, United Kingdom.
| | - Joseph Shalhoub
- Academic Section of Vascular Surgery, Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Alexander P Coupland
- Academic Section of Vascular Surgery, Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Justin D Salciccioli
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, Mass
| | - Ankur Thapar
- Academic Section of Vascular Surgery, Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Alun Huw Davies
- Academic Section of Vascular Surgery, Division of Surgery, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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Rabe E, Partsch H, Hafner J, Lattimer C, Mosti G, Neumann M, Urbanek T, Huebner M, Gaillard S, Carpentier P. Indications for medical compression stockings in venous and lymphatic disorders: An evidence-based consensus statement. Phlebology 2018; 33:163-184. [PMID: 28549402 PMCID: PMC5846867 DOI: 10.1177/0268355516689631] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Objective Medical compression stockings are a standard, non-invasive treatment option for all venous and lymphatic diseases. The aim of this consensus document is to provide up-to-date recommendations and evidence grading on the indications for treatment, based on evidence accumulated during the past decade, under the auspices of the International Compression Club. Methods A systematic literature review was conducted and, using PRISMA guidelines, 51 relevant publications were selected for an evidence-based analysis of an initial 2407 unrefined results. Key search terms included: 'acute', CEAP', 'chronic', 'compression stockings', 'compression therapy', 'lymph', 'lymphatic disease', 'vein' and 'venous disease'. Evidence extracted from the publications was graded initially by the panel members individually and then refined at the consensus meeting. Results Based on the current evidence, 25 recommendations for chronic and acute venous disorders were made. Of these, 24 recommendations were graded as: Grade 1A (n = 4), 1B (n = 13), 1C (n = 2), 2B (n = 4) and 2C (n = 1). The panel members found moderately robust evidence for medical compression stockings in patients with venous symptoms and prevention and treatment of venous oedema. Robust evidence was found for prevention and treatment of venous leg ulcers. Recommendations for stocking-use after great saphenous vein interventions were limited to the first post-interventional week. No randomised clinical trials are available that document a prophylactic effect of medical compression stockings on the progression of chronic venous disease (CVD). In acute deep vein thrombosis, immediate compression is recommended to reduce pain and swelling. Despite conflicting results from a recent study to prevent post-thrombotic syndrome, medical compression stockings are still recommended. In thromboprophylaxis, the role of stockings in addition to anticoagulation is limited. For the maintenance phase of lymphoedema management, compression stockings are the most important intervention. Conclusion The beneficial value of applying compression stockings in the treatment of venous and lymphatic disease is supported by this document, with 19/25 recommendations rated as Grade 1 evidence. For recommendations rated with Grade 2 level of evidence, further studies are needed.
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Affiliation(s)
- Eberhard Rabe
- Department of Dermatology, University of Bonn, Bonn, Germany
| | - Hugo Partsch
- Department of Dermatology, Medical University of Vienna, Austria
| | - Juerg Hafner
- Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
| | - Christopher Lattimer
- Josef Pflug Vascular Laboratory, West London Vascular and Interventional Centre, Ealing Hospital & Imperial College, London, UK
| | - Giovanni Mosti
- Angiology Department, Clinica MD Barbantini, Lucca, Italy
| | - Martino Neumann
- Department of Dermatology, Erasmus University Hospital, Rotterdam, The Netherlands
| | - Tomasz Urbanek
- Medical University of Silesia Department of General Surgery, Vascular Surgery, Angiology and Phlebology, Katowice, Poland
| | | | | | - Patrick Carpentier
- Centre de Recherche Universitaire de La Léchère, Equipe THEMAS, Université Joseph Fourier, Grenoble, France
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Shalhoub J, Norrie J, Baker C, Bradbury A, Dhillon K, Everington T, Gohel M, Hamady Z, Heatley F, Hudson J, Hunt B, Lawton R, Stansby G, Stephens-Boal A, Toh S, Warwick D, Davies A. Graduated Compression Stockings as an Adjunct to Low Dose Low Molecular Weight Heparin in Venous Thromboembolism Prevention in Surgery: A Multicentre Randomised Controlled Trial. Eur J Vasc Endovasc Surg 2017; 53:880-885. [DOI: 10.1016/j.ejvs.2017.02.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 02/08/2017] [Indexed: 11/28/2022]
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