A randomized trial of dalteparin compared with ibuprofen for the treatment of superficial thrombophlebitis

Anticoagulants for the treatment of isolated lower limb superficial vein thrombosis a Bayesian network meta-analysis of randomized controlled trials

OBJECTIVE

Assess the safety and efficacy of anticoagulants in treating isolated superficial vein thrombosis (iSVT).

MATERIALS AND METHODS

A systematic review was conducted according to PRISMA 2020 guidelines, for randomized controlled trials (RCTs) investigating anticoagulants in the treatment of iSVT. The primary endpoint of thrombotic complications encompassed any incident of iSVT progression/recurrence and the development of new-onset (deep vein thrombosis) DVT or (pulmonary embolism) PE.

RESULTS

Eight RCT's and 4721 patients treated once daily with either fondaparinux 2.5 mg, rivaroxaban 10 mg, therapeutic, intermediate, and prophylactic low molecular weight heparin (LMW) were included. While all anticoagulants displayed a statistically significant risk reduction compared to placebo in terms of thrombotic complications and iSVT progression/recurrence, only fondaparinux reduced the risk for DVT/PE. Additionally, fondaparinux exhibited enhanced efficacy in decreasing DVT/PE events relative to prophylactic and therapeutic LMWH. Furthermore, rivaroxaban and fondaparinux demonstrated superior outcomes in terms of preventing thrombotic complications compared to all three dosing regimens of LMWH without significant differences between the two, risk ratio RR 1.00(95%CI:0.51-1.92). SUCRA identified fondaparinux as the most effective treatment regarding thrombotic complications, (SUCRA,91.6) and DVT/PE, (SUCRA,96) and rivaroxaban in terms of iSVT progression/recurrence (SUCRA,94.68). Ultimately and despite certain model limitations, meta-regression analysis suggested a possible trend towards improved outcomes with longer treatment durations for thrombotic complications β = -0.34(95%CI:-16.39to12.23).

CONCLUSIONS

Despite inherent limitations such as variations in treatment durations and follow-up periods, this review displayed the efficacy of fondaparinux, rivaroxaban and LMWH in treating iSVT. The improved efficacy of fondaparinux over therapeutic LMWH in terms of DVT/PE outcomes necessitates cautious interpretation underscoring the need for further investigation through adequately powered RCTs.

A systematic review and meta-analysis for the association between duration of anticoagulation therapy and the risk of venous thromboembolism in patients with lower limb superficial venous thrombosis

OBJECTIVE

The aim of this study was to determine the association between the duration of systemic anticoagulation therapy (ACT) and the risk of further venous thromboembolism (VTE) in patients with superficial venous thrombosis (SVT).

METHODS

A systematic review and meta-analysis were performed using searches of Medline and Cochrane Library databases in September 2023. Papers that provided VTE incidence within mid-term follow-up of ≥45 days in patients who received any ACT were included. Patients were categorized into subgroups according to the course of treatment: (1) no ACT (0 days); (2) ACT of ≤14 days; (3) ACT of 15 to 30 days; (4) ACT of 31 to 45 days; and (5) ACT of >45 days. Reported events were transformed to events per 100 patient-years, and a random-effects model was used to calculate pooled rates for proportions. The primary outcome (VTE) was a combination of SVT progression or recurrence with the occurrence of deep vein thrombosis (DVT) and pulmonary embolism (PE). Secondary outcomes included major and clinically relevant non-major or minor bleeding.

RESULTS

Twenty-four studies (10 randomized controlled trials and 14 cohort studies) combining outcomes in 12,341 patients were included in the quantitative synthesis. Minimum VTE and SVT recurrence or progression rates were observed with the ACT duration of 31 to 45 days of 16.2 (95% confidence interval [CI], 10.4-23.3) and 8.2 (95% CI, 3.1-15.8) events per 100 patient-years, respectively. Minimum DVT and PE rates observed with the treatment duration of 15 to 30 days were 5.5 (95% CI, 2.8-9.1) and 0.9 (95% CI, 0.5-1.3) events per 100 patient-years, respectively. Short-term treatment of ≤14 days was associated with the highest rates of VTE of 59.7 (95% CI, 37.7-86.4), DVT of 13.7 (95% CI, 9.6-18.4), and PE of 3.1 (95% CI, 1.4-5.6) events per 100 patient-years. Major bleeding rates were unrelated to the duration of ACT and did not exceed 0.5 events per 100 patient-years. The highest rate of clinically relevant non-major or minor bleeding was observed with ACT duration of 31 to 45 days of 14.2 (95% CI, 5.5-26.8) events per 100 patient-years. The most common risk factors for VTE included male sex, cancer, personal history of DVT, PE, or SVT, and thrombosis of non-varicose veins.

CONCLUSIONS

Prolonged systemic anticoagulation is associated with the tendency to decrease VTE rates in patients with lower limb SVT.

Three-Month Outcomes in Cancer Patients with Superficial or Deep Vein Thrombosis in the Lower Limbs: Results from the RIETE Registry

Background: The clinical characteristics and outcomes of cancer patients with lower-limb isolated superficial vein thrombosis (SVT) have not been consistently evaluated. Methods: We used data in the RIETE registry to compare the clinical characteristics and 90-day outcomes for patients with: (1) active cancer and lower-limb SVT; (2) active cancer and lower-limb deep vein thrombosis (DVT); (3) lower-limb SVT without cancer. The primary outcomes included subsequent symptomatic SVT, DVT or pulmonary embolism (PE). Secondary outcomes were major bleeding and death. Results: From March 2015 to April 2021, there were 110 patients with cancer and SVT, 1695 with cancer and DVT, and 1030 with SVT but no cancer. Most patients in all subgroups (93%, 99% and 96%, respectively) received anticoagulants, while those with SVT received lower daily doses of low-molecular-weight heparin (114 ± 58, 163 ± 44, and 106 ± 50 IU/kg, respectively). During the first 90 days, 101 patients (3.6%) developed subsequent VTE (PE 47, DVT 41, SVT 13), whereas 72 (2.5%) had major bleeding and 282 (9.9%) died. Among the three groups, 90-day events were, respectively: VTE at rates of 7.3%, 4.0% and 2.4%; major bleeding at rates of 2.7%, 3.9% and 0.3%; mortality at rates of 8.2%, 16% and 0.3%. Between D90 and D180, only one SVT recurrence and one death occurred in SVT cancer patients. In multivariable analysis, cancer was associated with subsequent VTE (HR = 2.04; 1.15–3.62), while initial presentation as SVT or DVT were not associated with a different risk. Conclusions: The risk for subsequent VTE (including symptomatic SVT, DVT or PE) was similar in cancer patients with isolated SVT than in those with isolated DVT.

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.

Effect of low-molecular-weight heparins on anti-Xa peak levels and adverse reactions in Chinese patients with recurrent spontaneous abortion: a single-center, observational study

Objective

To compare three commonly used low-molecular-weight heparins (LWMHs) in the treatment of recurrent spontaneous abortion (RSA) by evaluating the anti-Xa peak levels and adverse reactions.

Methods

In this single-center, observational study, we enrolled 310 patients with RSA in whom anti-Xa levels were measured during pregnancy. Patients were divided into three groups according to the LMWH they used: the nadroparin group, enoxaparin group and dalteparin group. We compared the peak anti-Xa levels and the coagulation status of each group, and analyzed the incidence of adverse reactions, including local allergy, liver and renal dysfunction, and the impact on platelet.

Results

Patients in the enoxaparin group had a higher anti-Xa peak level than those in the nadroparin group (0.80 ± 0.22 IU/ml vs. 0.61 ± 0.24 IU/ml; P <  0.0001), although most patients in the three groups reached the target concentration of anti-Xa. Furthermore, patients in the enoxaparin group had a more stable anti-Xa levels during pregnancy. In addition, patients in the nadroparin group had a higher rate of local allergy than those in the enoxaparin group (60.5% vs. 42.5%; P = 0.004) and those in the dalteparin group (60.5% vs. 33.3%; P = 0.002). Further examination by the type of local allergy indicated a dramatic difference in pruritus and induration between the nadroparin group and the other two groups. No difference was found in the incidence of liver and renal dysfunction and thrombocytopenia.

Conclusion

Compared with nadroparin and daltepatin, enoxaparin showed a better performance regarding anti-Xa levels and the incidence of adverse reactions in the treatment of RSA.

Oberflächliche Venenthrombose der Beinvenen – Eine systematische Übersicht – Teil 2: Therapie

Einleitung Die oberflächliche Venenthrombose (OVT) der Beinvenen ist mit einer Inzidenz von 0,5–1/1000 Einwohner/Jahr ein häufiges und mit einer Frequenz assoziierter thromboembolischer Ereignisse in bis zu 25 % der Fälle ein ernst zu nehmendes Krankheitsbild. In der vorliegenden Übersichtsarbeit sollen alle relevanten Aspekte der OVT basierend auf der aktuellen wissenschaftlichen Literatur behandelt werden.

Methoden Die systematische Übersicht umfasst das Wissen über die OVT basierend auf dem gesamten, systemisch recherchierten Erkenntnismaterial in den Datenbanken PubMed und Google Scholar. Eine Literaturrecherche in PubMed von Publikationen (1968–2018) mit den Suchbegriffen „Superficial vein thrombosis; thrombophlebitis“ ergab 102 aussagekräftige Arbeiten, die nach Vorlage der Originalarbeit ausgewertet wurden. Teil 2 der Arbeit behandelt Aspekte zur Therapie.

Ergebnisse Die Bewertungskriterien der Therapie der OVT sind in den einzelnen Leitlinien und Übersichtsarbeiten z. T. unterschied­lich. Andererseits ist in den letzten Jahren eine zunehmende Stringenz in den Therapieempfehlungen festzustellen, die vom Ausprägungsgrad der OVT abhängig sind. Zu deren Prinzipien gehören die Mobilisation des Patienten und das Tragen eines medizinischen Kompressionsstrumpfes der Kompressionsklasse II. Die medikamentöse Therapie umfasst den Einsatz von Fondaparinux oder niedermolekularen Heparinen. Fondaparinux ist derzeit das einzig zugelassene Medikament für diese Indikation ab einer Thrombusausdehnung von mindestens 5 cm. Rivaroxaban in einer Tagesdosis von 10 mg war gegenüber Fondaparinux in einer randomisierten Studie nicht unterlegen; dies führte jedoch nicht zu einer Zulassung für die Indikation der OVT. Eine therapeutische Antikoagulation hingegen wird empfohlen, sobald sich das proximale Thrombusende 3 cm oder näher zum Übergang in das tiefe Venensystem befindet. Nichtsteroidale Antirheumatika reduzieren das Risiko einer OVT-Extension oder eines Rezidivs und wirken schmerzlindernd. Die Therapie mit Externa bietet nur lokale symptomlindernde Effekte. Eine operative Therapie der OVT kann in bestimmten Situationen erwogen werden, um Varizen, Schmerzen und das Risiko einer Thrombusaszension in einem Behandlungsschritt zu beseitigen.

Schlussfolgerung Aufgrund der Häufigkeit und des Risikos potenziell lebensbedrohender Komplikationen sollte der OVT der Beinvenen eine größere Beachtung zukommen, insbesondere mit Blick auf eine auf den individuellen Befund ausgerichtete Stadien-adaptierte Therapie.

The Anticoagulant and Nonanticoagulant Properties of Heparin

Heparins represent one of the most frequently used pharmacotherapeutics. Discovered around 1926, routine clinical anticoagulant use of heparin was initiated only after the publication of several seminal papers in the early 1970s by the group of Kakkar. It was shown that heparin prevents venous thromboembolism and mortality from pulmonary embolism in patients after surgery. With the subsequent development of low-molecular-weight heparins and synthetic heparin derivatives, a family of related drugs was created that continues to prove its clinical value in thromboprophylaxis and in prevention of clotting in extracorporeal devices. Fundamental and applied research has revealed a complex pharmacodynamic profile of heparins that goes beyond its anticoagulant use. Recognition of the complex multifaceted beneficial effects of heparin underscores its therapeutic potential in various clinical situations. In this review we focus on the anticoagulant and nonanticoagulant activities of heparin and, where possible, discuss the underlying molecular mechanisms that explain the diversity of heparin's biological actions.

Treatment for superficial thrombophlebitis of the leg

BACKGROUND

The optimal treatment of superficial thrombophlebitis (ST) of the legs remains poorly defined. While improving or relieving the local painful symptoms, treatment should aim at preventing venous thromboembolism (VTE), which might complicate the natural history of ST. This is the third update of a review first published in 2007.

OBJECTIVES

To assess the efficacy and safety of topical, medical, and surgical treatments for ST of the leg in improving local symptoms and decreasing thromboembolic complications.

SEARCH METHODS

For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register (March 2017), CENTRAL (2017, Issue 2), and trials registries (March 2017). We handsearched the reference lists of relevant papers and conference proceedings.

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating topical, medical, and surgical treatments for ST of the legs that included people with a clinical diagnosis of ST of the legs or objective diagnosis of a thrombus in a superficial vein.

DATA COLLECTION AND ANALYSIS

Two authors assessed the trials for inclusion in the review, extracted the data, and assessed the quality of the studies. Data were independently extracted from the included studies and any disagreements resolved by consensus. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We identified three additional trials (613 participants), therefore this update considered 33 studies involving 7296 people with ST of the legs. Treatment included fondaparinux; rivaroxaban; low molecular weight heparin (LMWH); unfractionated heparin (UFH); non-steroidal anti-inflammatory drugs (NSAIDs); compression stockings; and topical, intramuscular, or intravenous treatment to surgical interventions such as thrombectomy or ligation. Only a minority of trials compared treatment with placebo rather than an alternative treatment and many studies were small and of poor quality. Pooling of the data was possible for few outcomes, and none were part of a placebo-controlled trial. In one large, placebo-controlled RCT of 3002 participants, subcutaneous fondaparinux was associated with a significant reduction in symptomatic VTE (risk ratio (RR) 0.15, 95% confidence interval (CI) 0.04 to 0.50; moderate-quality evidence), ST extension (RR 0.08, 95% CI 0.03 to 0.22; moderate-quality evidence), and ST recurrence (RR 0.21, 95% CI 0.08 to 0.54; moderate-quality evidence) relative to placebo. Major bleeding was infrequent in both groups with very wide CIs around risk estimate (RR 0.99, 95% CI 0.06 to 15.86; moderate-quality evidence). In one RCT on 472 high-risk participants with ST, fondaparinux was associated with a non-significant reduction of symptomatic VTE compared to rivaroxaban 10 mg (RR 0.33, 95% CI 0.03 to 3.18; low-quality evidence). There were no major bleeding events in either group (low-quality evidence). In another placebo-controlled trial, both prophylactic and therapeutic doses of LMWH (prophylactic: RR 0.44, 95% CI 0.26 to 0.74; therapeutic: RR 0.46, 95% CI 0.27 to 0.77) and NSAIDs (RR 0.46, 95% CI 0.27 to 0.78) reduced the extension (low-quality evidence) and recurrence of ST (low-quality evidence) in comparison to placebo, with no significant effects on symptomatic VTE (low-quality evidence) or major bleeding (low-quality evidence). Overall, topical treatments improved local symptoms compared with placebo, but no data were provided on the effects on VTE and ST extension. Surgical treatment combined with elastic stockings was associated with a lower VTE rate and ST progression compared with elastic stockings alone. However, the majority of studies that compared different oral treatments, topical treatments, or surgery did not report VTE, ST progression, adverse events, or treatment adverse effects.

AUTHORS' CONCLUSIONS

Prophylactic dose fondaparinux given for 45 days appears to be a valid therapeutic option for ST of the legs for most people. The evidence on topical treatment or surgery is too limited and does not inform clinical practice about the effects of these treatments in terms of VTE. Further research is needed to assess the role of rivaroxaban and other direct oral factor-X or thrombin inhibitors, LMWH, and NSAIDs; the optimal doses and duration of treatment in people at various risk of recurrence; and whether a combination therapy may be more effective than single treatment. Adequately designed and conducted studies are required to clarify the role of topical and surgical treatments.

Medical management of acute superficial vein thrombosis of the saphenous vein

OBJECTIVE

Acute superficial vein thrombosis (SVT) of the axial veins, such as the great saphenous vein (GSV), is a common clinical condition that carries with it significant risk of propagation of thrombus, recurrence, and, most concerning, subsequent venous thromboembolism (VTE). Conservative therapy with nonsteroidal anti-inflammatory medication and heat does not prevent extension of thrombus or protect against recurrent or future VTE in patients with extensive SVT (thrombotic segment of at least 5 cm in length). To prevent future thromboembolic events, anticoagulation has become the treatment of choice for extensive acute SVT in the GSV. In spite of this, the dose and duration of anticoagulation in the treatment of SVT vary widely. This review summarizes the evidence from large prospective, randomized clinical trials on the treatment of SVT with anticoagulation (vs placebo or different doses and durations of anticoagulation) with respect to the outcome measures of thrombus extension, SVT recurrence, and future VTE.

METHODS

A systematic search was performed using the MEDLINE database to identify all prospective, randomized controlled trials of treatment with anticoagulation in patients with SVT in the GSV. Six prospective, randomized trials were identified that met the inclusion criteria and were reviewed in detail.

RESULTS

Treatment of acute SVT was most commonly managed in an outpatient setting using either low-molecular-weight heparin (LMWH) in four studies or, alternatively, a factor Xa inhibitor in one large multicenter trial. LMWH was associated with a lower rate of thrombus extension and subsequent recurrence, especially when an intermediate dose (defined as a dose between prophylactic and therapeutic doses) was used for a period of 30 days. The full effect of treatment with LMWH on the risk of subsequent VTE remains unclear, as do the optimal dose and duration of this drug. Prophylactic doses of fondaparinux, a factor Xa inhibitor, were found to be beneficial in reducing the rate of thrombus extension and recurrence as well as in reducing the risk of subsequent VTE both during treatment and after cessation of anticoagulation in the short term.

CONCLUSIONS

These data suggest that treatment of acute SVT of the GSV with anticoagulation, at doses below therapeutic levels, does offer the benefit of decreased risk of thrombus propagation, recurrence, and, at least in one large randomized clinical trial, subsequent VTE. Future studies to refine optimal dose and duration of anticoagulation to lower the rate of subsequent thromboembolic events and SVT recurrence are needed.

Patterns in the management of superficial vein thrombosis

Objective To highlight current practice patterns in management of superficial vein thrombosis. Methods An electronic survey was conducted using the mailing lists of the Mediterranean League of Angiology and Vascular Surgery and European Venous Forum regarding superficial vein thrombosis diagnosis, investigation, and treatment. Results The response rate was 41% (175/430) and the majority of the participants were vascular surgeons practicing in a hospital. More experienced physicians considered superficial vein thrombosis as a medical issue of moderate seriousness and performed duplex ultrasound for confirmation of diagnosis. Elastic stockings were recommended by 87% of the physicians, while 57% prescribed nonsteroidal anti-inflammatory drugs. Eighty six percent advised anticoagulation, although a large disparity was shown regarding regime, dose, and duration. Thrombophilia test was regularly suggested by 19% of the physicians. Ligation of the saphenofemoral junction was the treatment of choice by those who suggested intervention in the acute phase of superficial vein thrombosis. Conclusions A great disparity exists in the management of superficial vein thrombosis. Current guidelines have not been adopted by physicians; more focused training is needed for those involved in the management of venous diseases.

Prevalence of deep vein thrombosis and pulmonary embolism in patients with superficial vein thrombosis: a systematic review and meta-analysis

Essentials The association of superficial vein thrombosis (SVT) with venous thromboembolism (VTE) is variable. We performed a meta-analysis to assess the prevalence of concomitant VTE in patients with SVT. Deep vein thrombosis was found in 18.1%, and pulmonary embolism in 6.9%, of SVT patients. Screening for VTE may be worthy in some SVT patients to plan adequate anticoagulant treatment.

SUMMARY

Background Some studies have suggested that patients with superficial vein thrombosis (SVT) have a non-negligible risk of concomitant deep vein thrombosis (DVT) or pulmonary embolism (PE) at the time of SVT diagnosis. Unfortunately, the available data on this association are widely variable. Objectives To perform a systematic review and meta-analysis of the literature in order to evaluate the prevalence of concomitant DVT/PE in patients with SVT of the lower limbs. Methods Studies reporting on the presence of DVT/PE in SVT patients were systematically searched for in the PubMed, Web of Science, Scopus and EMBASE databases. The weighted mean prevalence (WMP) of DVT and PE was calculated by use of the random effect model. Results Twenty-one studies (4358 patients) evaluated the prevalence of DVT and 11 studies (2484 patients) evaluated the prevalence of PE in patients with SVT. The WMP of DVT at SVT diagnosis was 18.1% (95%CI: 13.9%, 23.3%) and the WMP of PE was 6.9% (95%CI: 3.9%, 11.8%). Heterogeneity among the studies was substantial. Selection of studies including outpatients only gave similar results (WMP of DVT, 18.2%, 95% CI 12.2-26.3%; and WMP of PE, 8.2%, 95% CI 3.3-18.9%). Younger age, female gender, recent trauma and pregnancy were inversely associated with the presence of DVT/PE in SVT patients. Conclusions The results of our large meta-analysis suggest that the prevalence of DVT and PE in patients presenting with SVT is not negligible. Screening for a major thromboembolic event may be worthwhile in some SVT patients, in order to allow adequate anticoagulant treatment to be planned. Other high-quality studies are warranted to confirm our findings.

Treatment for superficial infusion thrombophlebitis of the upper extremity

BACKGROUND

Although superficial thrombophlebitis of the upper extremity represents a frequent complication of intravenous catheters inserted into the peripheral veins of the forearm or hand, no consensus exists on the optimal management of this condition in clinical practice.

OBJECTIVES

To summarise the evidence from randomised clinical trials (RCTs) concerning the efficacy and safety of (topical, oral or parenteral) medical therapy of superficial thrombophlebitis of the upper extremity.

SEARCH METHODS

The Cochrane Vascular Group Trials Search Co-ordinator searched the Specialised Register (last searched April 2015) and the Cochrane Register of Studies (2015, Issue 3). Clinical trials registries were searched up to April 2015.

SELECTION CRITERIA

RCTs comparing any (topical, oral or parenteral) medical treatment to no intervention or placebo, or comparing two different medical interventions (e.g. a different variant scheme or regimen of the same intervention or a different pharmacological type of treatment).

DATA COLLECTION AND ANALYSIS

We extracted data on methodological quality, patient characteristics, interventions and outcomes, including improvement of signs and symptoms as the primary effectiveness outcome, and number of participants experiencing side effects of the study treatments as the primary safety outcome.

MAIN RESULTS

We identified 13 studies (917 participants). The evaluated treatment modalities consisted of a topical treatment (11 studies), an oral treatment (2 studies) and a parenteral treatment (2 studies). Seven studies used a placebo or no intervention control group, whereas all others also or solely compared active treatment groups. No study evaluated the effects of ice or the application of cold or hot bandages. Overall, the risk of bias in individual trials was moderate to high, although poor reporting hampered a full appreciation of the risk in most studies. The overall quality of the evidence for each of the outcomes varied from low to moderate mainly due to risk of bias and imprecision, with only single trials contributing to most comparisons. Data on primary outcomes improvement of signs and symptoms and side effects attributed to the study treatment could not be statistically pooled because of the between-study differences in comparisons, outcomes and type of instruments to measure outcomes.An array of topical treatments, such as heparinoid or diclofenac gels, improved pain compared to placebo or no intervention. Compared to placebo, oral non-steroidal anti-inflammatory drugs reduced signs and symptoms intensity. Safety issues were reported sparsely and were not available for some interventions, such as notoginseny creams, parenteral low-molecular-weight heparin or defibrotide. Although several trials reported on adverse events with topical heparinoid creams, Essaven gel or phlebolan versus control, the trials were underpowered to adequately measure any differences between treatment modalities. Where reported, adverse events with topical treatments consisted mainly of local allergic reactions. Only one study of 15 participants assessed thrombus extension and symptomatic venous thromboembolism with either oral non-steroidal anti-inflammatory drugs or low-molecular-weight heparin, and it reported no cases of either. No study reported on the development of suppurative phlebitis, catheter-related bloodstream infections or quality of life.

AUTHORS' CONCLUSIONS

The evidence about the treatment of acute infusion superficial thrombophlebitis is limited and of low quality. Data appear too preliminary to assess the effectiveness and safety of topical treatments, systemic anticoagulation or oral non-steroidal anti-inflammatory drugs.

Spontaneous acute superficial vein thrombosis of the legs: do we really need to treat?

Spontaneous acute superficial vein thrombosis (SVT) of the leg is now generally recognized as an integral component of venous thromboembolic disease with potentially severe consequences. However, the relatively low grades of some current international recommendations and uncertainty regarding the cost-effectiveness of available therapies may prompt questioning of the real need to treat patients with SVT and explain the persisting heterogeneity of their management in practise. Yet several studies have consistently shown high rates of thromboembolic complications associated with SVT, whether at first presentation or during follow-up. The CALISTO trial established for the first time the clinical benefit of a well-defined anticoagulant regimen for the prevention of serious thromboembolic complications in SVT patients, and we believe that patients such as those included in this trial should receive this regimen as tested. However, several areas of uncertainty remain for categories of SVT patients not evaluated in CALISTO.

Anti-Inflammatory Effects of Heparin and Its Derivatives: A Systematic Review

Background. Heparin, used clinically as an anticoagulant, also has anti-inflammatory properties. The purpose of this systematic review was to provide a comprehensive review regarding the efficacy and safety of heparin and its derivatives as anti-inflammatory agents. Methods. We searched the following databases up to March 2012: Pub Med, Scopus, Web of Science, Ovid, Elsevier, and Google Scholar using combination of Mesh terms. Randomized Clinical Trials (RCTs) and trials with quasi-experimental design in clinical setting published in English were included. Quality assessments of RCTs were performed using Jadad score and Consolidated Standards of Reporting Trials (CONSORT) checklist. Results. A total of 280 relevant studies were reviewed and 57 studies met the inclusion criteria. Among them 48 studies were RCTs. About 65% of articles had score of 3 and higher according to Jadad score. Twelve studies had a quality score > 40% according to CONSORT items. Asthma (n = 7), inflammatory bowel disease (n = 5), cardiopulmonary bypass (n = 8), and cataract surgery (n = 6) were the most studied disease condition. Forty studies use unfractionated heparin (UFH) for intervention; the remaining studies use low molecular weight heparin (LMWH). Conclusion. Despite the conflicting results, heparin seems to be a safe and effective anti-inflammatory agent; although it is shown that heparin can decrease the level of inflammatory biomarkers and improves patient conditions, still more data from larger rigorously designed studies are needed to support use of heparin as an anti-inflammatory agent in clinical setting. However, because of the association between inflammation, atherogenesis, thrombogenesis, and cell proliferation, heparin and related compounds with pleiotropic effects may have greater therapeutic efficacy than compounds acting against a single target.

Risk of venous and arterial thrombotic events in patients diagnosed with superficial vein thrombosis: a nationwide cohort study

Recently, it has become apparent that superficial vein thrombosis (SVT) can have serious complications. However, the magnitude of the risk of subsequent deep venous and arterial thrombotic events remains unknown. We examined this in a nationwide population-based setting during a period when SVT was not treated routinely with anticoagulants. The Danish National Registry of Patients, covering all Danish hospitals, was used to identify 10 973 patients with a first-time diagnosis of SVT between 1980 and 2012. A comparison cohort of 515 067 subjects, matched by age, gender, and calendar year, was selected from the general Danish population. Outcomes were venous thromboembolism, acute myocardial infarction, ischemic stroke, and death. During median follow-up of 7 years, the incidence rate of venous thromboembolism was 18.0/1000 person-years (95% confidence interval [CI], 17.2-18.9). The highest risk occurred in the first 3 months (3.4%; 95% CI, 3.0-3.7). Compared with the general population, the hazard ratio was 71.4 (95% CI, 60.2-84.7) in this period, steadily decreasing to 5.1 (95% CI 4.6-5.5), 5 years after the SVT. The hazard ratios for acute myocardial infarction, stroke, and death were 1.2 (95% CI, 1.1-1.3), 1.3 (95% CI, 1.2-1.4), and 1.3 (95% CI, 1.2-1.3), respectively, with the highest risk also shortly after SVT. These data indicate the prognostic importance of SVT and may form the basis for clinical decision-making regarding anticoagulation.

Therapeutic effect of compression stockings versus no compression on isolated superficial vein thrombosis of the legs: a randomized clinical trial

OBJECTIVE/BACKGROUND

Leg compression is considered basic treatment for superficial vein thrombosis (SVT), although scientific proof for its efficacy is lacking. The aim of the study was to evaluate the therapeutic effect of compression stockings on isolated SVT of the legs.

METHODS

This was a single-center randomized controlled trial. Eighty patients with isolated SVT of the legs were instructed to wear compression stockings (23-32 mmHg) (CG) or no compression (NCG) for 3 weeks. All patients received low molecular weight heparin (LMWH) at prophylactic dosage. Non-steroidal anti-inflammatory drugs (NSAIDs) were allowed. The primary outcome variable was the reduction of pain as assessed by a visual analog scale (VAS) and the Lowenberg test. Secondary outcomes were the consumption of analgesics, thrombus length, skin erythema, D-dimer, and quality of life (QoL).

RESULTS

Seventy-three patients completed the study. Clinical symptoms and QoL significantly improved from baseline to day 21 in both groups (p < .001 for VAS, Lowenberg test, thrombus length, and erythema; p < .006 for QoL), and consumption of analgesics and D-dimer significantly decreased (p < .001). There was no significant difference between the groups for all tested variables. At day 7, patients in the CG revealed a significantly faster thrombus regression (p = .02).

CONCLUSION

Adding compression stockings for 3 weeks to LMWH and NSAIDs does not bring significant additional benefit in the treatment of isolated SVT. When worn for 1 week, compression stockings stimulate significantly faster thrombus regression.

Treatment for superficial thrombophlebitis of the leg

BACKGROUND

The optimal treatment of superficial thrombophlebitis (ST) of the legs remains poorly defined. While improving or relieving the local painful symptoms, treatment should aim at preventing venous thromboembolism (VTE), which might complicate the natural history of ST. This is the second update of a review first published in 2007.

OBJECTIVES

To assess the efficacy and safety of topical, medical, and surgical treatments in patients presenting with ST of the legs.

SEARCH METHODS

For this update, the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched November 2012) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 11). We handsearched the reference lists of relevant papers and conference proceedings.

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating topical, medical, and surgical treatments for ST of the legs that included participants with a clinical diagnosis of ST of the legs or an objective diagnosis of a thrombus in a superficial vein.

DATA COLLECTION AND ANALYSIS

Two authors assessed the trials for inclusion in the review, extracted the data, and assessed the quality of the studies. Data were independently extracted from the included studies and any disagreements resolved by consensus.

MAIN RESULTS

We identified four additional trials (986 patients), so this update considered 30 studies involving 6507 participants with ST of the legs.Treatment ranged from fondaparinux, low molecular weight heparin (LMWH), unfractionated heparin (UFH), non-steroidal anti-inflammatory agents (NSAIDs), topical treatment, oral treatment, intramuscular treatment, and intravenous treatment to surgery. Only a minority of trials compared treatment with placebo rather than an alternative treatment, none evaluated the same treatment comparisons on the same study outcomes (which precluded meta-analysis), and many of the studies were small and of poor quality. In one large, placebo-controlled RCT of about 3000 patients, subcutaneous fondaparinux was associated with a significant reduction in symptomatic VTE (RR 0.15; 95% CI 0.04 to 0.50), ST extension (RR 0.08; 95% CI 0.03 to 0.22), and ST recurrence (RR 0.21; 95% CI 0.08 to 0.54) with comparable rates of major bleeding (RR 0.99; 95% CI 0.06 to 15.86) relative to placebo. In a further placebo-controlled trial, both prophylactic and therapeutic doses of LMWH (RR 0.40; 95% CI 0.22 to 0.72 and RR 0.42; 95% CI 0.23 to 0.75, respectively) and NSAIDs (RR 0.41; 95% CI 0.23 to 0.75) reduced the extension and recurrence of ST in comparison to placebo, with no significant effects on symptomatic VTE nor major bleeding. Overall, topical treatments improved local symptoms compared with placebo but no data were provided on the effects on VTE and ST extension. Surgical treatment combined with elastic stockings was associated with a lower VTE rate and ST progression compared with elastic stockings alone. However, the majority of studies that compared different oral treatment, topical treatment, or surgery did not report VTE, ST progression, adverse events, or treatment side effects.

AUTHORS' CONCLUSIONS

Prophylactic dose fondaparinux given for six weeks appears to be a valid therapeutic option for ST of the legs. The evidence on oral treatments, topical treatment, or surgery is too limited and does not inform clinical practice about the effects of these treatments in terms of VTE and ST progression. Further research is needed to assess the role of the new oral direct thrombin and activated factor-X inhibitors, LMWH, and NSAIDs; the optimal doses and duration of treatment; and whether a combination therapy may be more effective than single treatment. Adequately designed and conducted studies are required to clarify the role of topical and surgical treatments.