1
|
Fu Y, Pu H, Wang Y, Lu X, Qiu P, Hu M, Cheng Y. Effectiveness, reach, uptake and feasibility of digital health interventions for adults with venous thromboembolism: protocol of a systematic review and meta-analysis. BMJ Open 2024; 14:e074547. [PMID: 38548369 PMCID: PMC10982713 DOI: 10.1136/bmjopen-2023-074547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 02/26/2024] [Indexed: 04/02/2024] Open
Abstract
INTRODUCTION Prevention of recurrence after an episode of venous thromboembolism (VTE), and also the post-thrombotic syndrome (PTS), is still a recognised challenge. In this meta-analysis, we will summarise existing evidence to compare intelligent system follow-up and routine follow-up for patients with VTE. METHODS AND ANALYSIS Relevant randomised controlled trials (RCTs) and cohort studies will be included from the following databases: MEDLINE/PubMed, Web of Science and the Cochrane Library. The last search time will be 31 March 2024. Two reviewers will independently identify RCTs and cohort studies according to eligibility and exclusion criteria. The risk of bias of included cohort studies will be assessed with the Newcastle-Ottawa Scale, Methodological Index of Non-Randomised Studies, and the risk of bias of RCTs will be assessed with and Cochrane Collaboration's tool. The primary outcomes include overall survival rate and PTS incidence rate. The Grades of Recommendations, Assessment, Development and Evaluation tool will be used to assess the level of evidence for outcome from RCTs. RevMan V.5.4 software will be used to pool outcomes. ETHICS AND DISSEMINATION Ethical approval was obtained from Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine Science Research Ethics Committee (SH9H-2023-T466-1). The findings will be disseminated to the public through conference presentations and publication in peer-reviewed scientific journals. PROSPERO REGISTRATION NUMBER CRD42023410644.
Collapse
Affiliation(s)
- Yan Fu
- Department of Nursing, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| | - Hongji Pu
- Department of Vascular and Endovascular Sugery, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| | - Yanjie Wang
- Department of Nursing, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| | - Xinwu Lu
- Department of Vascular and Endovascular Sugery, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| | - Peng Qiu
- Department of Vascular and Endovascular Sugery, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| | - Min Hu
- Department of Nursing, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| | - Yong Cheng
- Department of Nursing, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| |
Collapse
|
2
|
Wang H, Klok FA, Rosendaal FR, Cushman M, van Hylckama Vlieg A. Health-related quality of life after first venous thromboembolism in individuals aged 70 years and older. Res Pract Thromb Haemost 2023; 7:102144. [PMID: 37601012 PMCID: PMC10439441 DOI: 10.1016/j.rpth.2023.102144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/06/2023] [Accepted: 06/21/2023] [Indexed: 08/22/2023] Open
Abstract
Background There is limited information on short- and long-term effects of venous thromboembolism (VTE) on health-related quality of life (HRQoL) in the elderly. Objectives To assess change in generic HRQoL and disease-specific HRQoL in patients 1 year after the VTE. Methods The Age and Thrombosis, Acquired and Genetic risk factors in the elderly (AT-AGE) study is a 2-center case-control study performed in Leiden, the Netherlands, and Vermont, United States, among individuals aged ≥70 years. We measured generic HRQoL using the 36-item Short Form Health Survey (SF-36) and disease-specific HRQoL using the Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms Questionnaire (VEINES-QoL/Sym) and the Pulmonary Embolism-Specific Quality of Life Questionnaire (PEmb-QoL). All patients completed these questionnaires shortly after their VTE and 1 year later, while controls completed the 36-item Short Form Health Survey questionnaire once. Linear regression for change in quality of life scores was performed and adjusted for potential confounders. Results For the current analysis, we included patients who were visited twice (n = 316) and controls (n = 427) with HRQoL information. Mean age of patients and controls was similar (78.8 vs 75.5 years). In patients who survived at least 1 year after the VTE, generic HRQoL improved for both summary scores, but it did not reach the level of the age-matched controls: physical and mental summary scores increased by 5.6 and 5.5 points, respectively, but compared with controls, remained 8.2 and 6.4 points lower. For disease-specific HRQoL, the Pulmonary Embolism-Specific Quality of Life Questionnaire overall score decreased from 21.7% to 15.2%, indicating improved HRQoL. Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms Questionnaire scores did not change over time. Conclusion Overall, the quality of life of patients with VTE was worse than that of controls after 1 year, indicating a long-term impact of VTE diagnosis in the elderly.
Collapse
Affiliation(s)
- Huijie Wang
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Frederikus A. Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Frits R. Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mary Cushman
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | | |
Collapse
|
3
|
Schreurs RHP, Ten Cate-Hoek AJ, Ten Cate H, Joore MA. Budget Impact of Three Improvement Targets for Compression Therapy for Patients with Deep Venous Thrombosis in The Netherlands. PHARMACOECONOMICS - OPEN 2023; 7:479-491. [PMID: 37074590 PMCID: PMC10169940 DOI: 10.1007/s41669-023-00403-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND AND OBJECTIVE Compression therapy following deep venous thrombosis in the Netherlands is suboptimal. We assessed the budget impact of targeted care improvements. METHODS We calculated the per-patient and population healthcare resource use and costs concerning 26,500 new patients each year in the Netherlands for the current pathways in region North Holland (divided into two parts: NH-A and NH-B) and region Limburg. Next, we assessed the impact of three improvement targets: optimizing initial compression therapy, early consultation of an occupational therapist, and tailored duration of elastic compression stocking therapy. Inputs were based on interview (n = 30) and survey data (n = 114), literature, and standard prices. The robustness of the results was tested by sensitivity analyses. RESULTS The current per-patient costs for a 2-year episode were €1046 (NH-A), €947 (NH-B), and €1256 (Limburg). The improvements led to direct savings for region Limburg (€4.7 million). Population costs increased in the first year for NH-A (+ €3.5 million) and NH-B (+ €6.4 million), and decreased in the second and third year resulting in a cost reduction for NH-A (- €2.2 million) but not for NH-B (+ €0.6 million). Workload for occupational therapists and internists in North Holland increased, and workload for home care nurses decreased in all regions. CONCLUSIONS This study provides a detailed insight into current costs and healthcare resource use associated with compression therapy and the potential impact of implementing three improvement targets. We showed that the improvements resulted in considerable cost savings within 3 years after implementation for region NH-A and Limburg.
Collapse
Affiliation(s)
- Rachel H P Schreurs
- Thrombosis Expert Centre Maastricht and Laboratory for Clinical Thrombosis and Haemostasis, Maastricht, The Netherlands.
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands.
- Department of Internal Medicine, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
| | - Arina J Ten Cate-Hoek
- Thrombosis Expert Centre Maastricht and Laboratory for Clinical Thrombosis and Haemostasis, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Hugo Ten Cate
- Thrombosis Expert Centre Maastricht and Laboratory for Clinical Thrombosis and Haemostasis, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Manuela A Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, The Netherlands
- CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| |
Collapse
|
4
|
Asady E, Ghanima W, Jelsness‐Jorgensen L, Klok FA, Kahn SR, Stromme H, Wik HS. Health-related quality-of-life questionnaires for deep vein thrombosis and pulmonary embolism: A systematic review on questionnaire development and methodology. Res Pract Thromb Haemost 2021; 5:e12556. [PMID: 34278190 PMCID: PMC8279125 DOI: 10.1002/rth2.12556] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/19/2021] [Accepted: 05/04/2021] [Indexed: 12/25/2022] Open
Abstract
To improve the quality and accuracy of the patient-reported outcome measures that assess health-related quality of life (HRQoL), guidelines have been developed to standardize the development and validation process. Considering the increasing importance of HRQoL questionnaires in research, we set out to review the literature and evaluate whether existing questionnaires developed for deep vein thrombosis (DVT) and pulmonary embolism (PE) fulfill state-of-the-art requirements. The literature search was conducted in March 2019 and updated in September 2020. Seven databases were searched. No time limit was set for the search to include all available questionnaires. The inclusion criteria were original publications describing the development of disease-specific HRQoL questionnaires specific to DVT or PE in adults and available in English. The questionnaires were assessed to determine whether they fulfill the requirements in the latest guidelines. A total of 3826 references were identified. After the exclusion process, 15 papers were reviewed in full, of which 7 were included. Four questionnaires were developed for chronic venous disease, two were specific to DVT, and one was specific to PE. Most questionnaires we found in this review, fulfilled some but none fulfilled all recommendations in existing guidelines. Because the development of current available HRQoL questionnaires specific to DVT or PE do not fulfil all recommendations of existing guidelines, there is room for improvements within this field. Such improvements could likely enhance the quality associated with the use of these end points in clinical trials and practice.
Collapse
Affiliation(s)
- Elia Asady
- Department of ResearchØstfold Hospital TrustGrålumNorway
- Institute of Clinical MedicineUniversity of OsloOsloNorway
| | - Waleed Ghanima
- Department of ResearchØstfold Hospital TrustGrålumNorway
- Institute of Clinical MedicineUniversity of OsloOsloNorway
- Department of HaematologyOslo University HospitalOsloNorway
| | - Lars‐Petter Jelsness‐Jorgensen
- Department of ResearchØstfold Hospital TrustGrålumNorway
- Department of Health SciencesØstfold University CollegeHaldenNorway
| | - F. A. Klok
- Department of Medicine – Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Susan R. Kahn
- McGill UniversityMontrealQCCanada
- Jewish General HospitalMontrealQCCanada
| | - Hilde Stromme
- Library of Medicine and ScienceUniversity of OsloNorway
| | - Hilde S. Wik
- Department of HaematologyOslo University HospitalOsloNorway
| |
Collapse
|
5
|
Wang Y, Wu XJ, Ma YF, Xu Y, Wang XJ, Zhu C, Cao J, Jiao J, Liu G, Li Z, Liu Y, Zhu LY. Chinese orthopaedic nurses' knowledge, attitude and venous thromboembolic prophylactic practices: A multicentric cross-sectional survey. J Clin Nurs 2021; 30:773-782. [PMID: 33351972 PMCID: PMC8048869 DOI: 10.1111/jocn.15615] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 11/16/2020] [Accepted: 12/13/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Venous thromboembolism is a severe preventable complication among orthopaedic surgical patients. Integrating therapeutic guidelines into clinical practice can help improve patient safety and reduce the burden of this pathology. Improving the quality of patient care is important for bridging the gap between the prophylaxis for venous thromboembolism and therapeutic guidelines. OBJECTIVES This study aimed at evaluating the knowledge, attitude, and venous thromboembolism and prophylaxis practices of Chinese orthopaedic nurses to guide quality care improvements. METHODS The data used in this study are secondary data obtained from a multicentric survey. An anonymous questionnaire was used to measure the attitude and knowledge of venous thromboembolic prophylaxis among orthopaedic nurses. VTE prophylactic practices were extracted from medical records within the electronic case report form immediately after the nurses' investigations. The STROBE statement for observational studies was applied. RESULTS Results indicated that although 94.0% of the responding nurses had attended training courses in their wards, a majority of them (68.9%) achieved a median knowledge score of 7 points or below (range 0-9). Knowledge regarding the proper use of prophylaxis, identification of risk factors, signs and symptoms for pulmonary embolism was limited. Self-reported attitudes underestimate the relationships between venous thromboembolism and low-quality nursing care. Pharmacological prophylaxis was highly used (90.9%), while the utilisation of mechanical prophylaxis and its proper use was relatively low. CONCLUSIONS Chinese orthopaedic nurses demonstrated enthusiasm for venous thromboembolism and prophylaxis. Their knowledge needs to be improved, including the proper use of prophylaxis, identification of risk factors, signs and symptoms. Mechanical prophylaxis practice for VTE prevention after THA and TKA surgical procedures is not optimistic. Further studies should analyse the causes from multiple perspectives, including the availability of resources, the knowledge and attitude of doctors, nurses and patients. RELEVANCE TO CLINICAL PRACTICE The findings from this study can be used to develop and implement interventions for venous thromboembolism after orthopaedic surgery.
Collapse
Affiliation(s)
- Yu Wang
- Department of Nursing, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xin-Juan Wu
- Department of Nursing, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Yu-Fen Ma
- Outpatient Department, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Yuan Xu
- Department of Orthopedic Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xiao-Jie Wang
- Department of Breast Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Chen Zhu
- Department of Nursing, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Jing Cao
- Department of Nursing, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Jing Jiao
- Department of Nursing, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Ge Liu
- Department of Neurological Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Zhen Li
- Intensive Care Unit, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Ying Liu
- Department of Nursing, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Li-Yun Zhu
- Department of Nursing, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| |
Collapse
|
6
|
Azirar S, Appelen D, Prins MH, Neumann MHAM, de Feiter ANP, Kolbach DN. Compression therapy for treating post-thrombotic syndrome. Cochrane Database Syst Rev 2019; 9:CD004177. [PMID: 31531971 PMCID: PMC6749555 DOI: 10.1002/14651858.cd004177.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Post-thrombotic syndrome (PTS) is a long-term complication of deep vein thrombosis (DVT) characterised by chronic complaints such as oedema and skin changes including; venous ectasia, varicose veins, redness, eczema, hyperpigmentation, and in severe cases fibrosis of the subcutaneous adipose in the affected limb. These chronic complaints are the effects of venous outflow restriction that can cause symptoms such as heaviness, itching, pain, cramps, and paraesthesia. Twenty to fifty percent of people with DVT develop post-thrombotic complications. Several non-pharmaceutical measures are used for prevention of PTS during the acute phase of DVT. These include elevation of the legs and compression therapy. There have been limited studies regarding the effectiveness of compression therapy for prevention or treatment of PTS. As a result, clinicians and guidelines differ in their assessment of compression therapy during treatment of DVT and in the treatment of PTS. This is an update of a review first published in 2003. OBJECTIVES To assess the effectiveness of compression therapy for treatment of post-thrombotic syndrome, including elastic compression stockings and mechanical devices compared with no intervention, placebo and with each other. SEARCH METHODS For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registries on 2 July 2018. SELECTION CRITERIA We included trials that evaluated compression therapy for the treatment of PTS. The primary outcomes were severity of PTS and adverse effects. There were no restrictions on date or language. Two review authors (SA, DNK) independently assessed whether potentially relevant studies met the inclusion criteria. DATA COLLECTION AND ANALYSIS One review author extracted and summarised data and one review author (DNK) verified them. We resolved disagreements by discussion. We assessed methodological study quality with the Cochrane 'Risk of bias' tool. We used GRADE to assess the overall certainty of the evidence supporting the outcomes assessed in this review. MAIN RESULTS We identified four trials, with 116 participants, investigating the effectiveness of compression therapy for treatment of PTS. The methodology used by each trial was too heterogeneous to perform a meta-analysis, so we reported our findings narratively.Two trials studied the effect of graduated elastic compression stockings (GECS) on improvement of PTS symptoms. One study reported beneficial haemodynamic effects, while the other found no benefits on PTS severity compared to placebo (very low-certainty evidence). There was very limited evidence available for adverse effects and quality of life (QoL). The two studies did not report on compliance rates during the study period.Two trials studied the effects of intermittent mechanical compression devices. Both reported improvement in PTS severity (low-certainty evidence). Improvement of the severity of PTS was defined by treatment 'success' or 'failure'. Only one study comparing compression devices evaluated adverse effects and QoL. Although 9% of the participants experienced adverse effects such as leg swelling, irritation, superficial bleeding, and skin itching (moderate-certainty evidence), QoL was improved (moderate-certainty evidence). Studies did not assess compliance using intermittent mechanical compression devices.None of the studies evaluated patient satisfaction. AUTHORS' CONCLUSIONS There is very low-certainty evidence regarding the use of GECS for treatment of PTS as assessed by two small studies of short duration. One study reported beneficial haemodynamic effects, while one found no benefits on PTS severity compared to control/placebo stockings. There is very limited evidence for adverse effects, patient satisfaction, QoL, and compliance rates. There is low-certainty evidence favouring use of intermittent pneumatic compression devices compared to a control device for the treatment of severity owing to different measurements used by the studies reporting on this outcome and small studies of short duration. There is moderate-certainty evidence of improved QoL but possible increased adverse effects related to compression device use owing to small studies of short duration. High-certainty evidence to support the use of compression therapy in prevention of PTS is lacking and any conclusions drawn from current evidence should be interpreted with care. Further research is needed to assess whether compression can result in long-term reduction and relief of the symptoms caused by PTS, or prevent deterioration and leg ulceration.
Collapse
Affiliation(s)
- Sara Azirar
- Huidcentrum LimburgDepartment of DermatologyMaastrichtNetherlands
| | - Diebrecht Appelen
- Radboud University Nijmegen Medical CenterDepartment of DermatologyNijmegenNetherlands
| | - Martin H Prins
- CAPHRI Research School, Maastricht UniversityDepartment of EpidemiologyMaastrichtNetherlands6200 MD
| | - Martino HAM Neumann
- Erasmus Medical CenterDepartment of DermatologyPO Box 2040RotterdamNetherlands3000 CA
| | | | | | | |
Collapse
|
7
|
Paz T, Bloom A, Roth B, Kalish Y, Rottenstreich A, Elchalal U, Da'as N, Varon D, Spectre G. Pharmacomechanical catheter thrombolysis for pregnancy-related proximal deep venous thrombosis: prevention of post-thrombotic syndrome. J Matern Fetal Neonatal Med 2019; 34:1441-1447. [PMID: 31257966 DOI: 10.1080/14767058.2019.1638900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The efficacy of pharmacomechanical catheter-directed thrombolysis (PCDT) in preventing post thrombotic syndrome (PTS) for pregnancy related deep vein thrombosis (DVT) is unknown. STUDY DESIGN An observational cross section study of women with pregnancy related proximal (femoral/iliofemoral) DVT who underwent PCDT followed by anticoagulation (study group), and women who were treated with anticoagulation alone (control group). Women were evaluated for PTS using the Villalta scale (primary outcome) and VEINES-QOL/Sym questionnaires. RESULTS Eleven women with iliofemoral DVT underwent PCDT, two during their first trimester and nine postpartum; 18 women were treated with anticoagulation only. There were no significant differences in age, number of previous pregnancies, and duration of anticoagulation or thrombophilia between the groups. The time between DVT diagnosis and study inclusion was longer in the study group [median 50.5 (range 16-120) months] compared to the control group [median 27 (range 11-64) months], p = .4. None of the women in the PCDT group developed PTS, compared to six (33.3%, p = .03) in the control group, four of whom developed severe PTS. One patient in each group developed recurrent DVT, and one patient in the study group developed a calf hematoma. A reduced frequency of lower extremity symptoms was observed in the PCDT group (VEINES-Sym questionnaire), but no differences in quality of life (VEINES-QOL questionnaire) were reported. CONCLUSION This study suggests that PCDT may reduce the incidence of PTS in women with pregnancy related proximal DVT.Bullet pointsDVT involving the iliofemoral veins and development of post thrombotic syndrome is frequent among pregnant or postpartum womenStudies of pharmacomechanical catheter-directed thrombolysis (PCDT) for deep vein thrombosis did not include pregnant or postpartum womenIn our observational cross section study women who underwent PCDT (mainly in the postpartum period) had reduced frequency of post-thrombotic syndrome compared to women who received anticoagulation onlyLarger studies are required to confirm the use of PCDT for prevention of PTS in this population.
Collapse
Affiliation(s)
- Tal Paz
- Department of Ophthalmology, Kaplan Medical Center, Rehovot, Israel
| | - Allan Bloom
- Department of Medical Imaging, Hadassah Medical Center (HMC), Jerusalem, Israel
| | - Batia Roth
- Department of Hematology, HMC, Jerusalem, Israel
| | - Yosef Kalish
- Department of Hematology, HMC, Jerusalem, Israel
| | | | - Uriel Elchalal
- Department of Obstetrics & Gynecology, HMC, Jerusalem, Israel
| | - Nael Da'as
- Department of Internal Medicine, Hematology Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - David Varon
- Department of Hematology, HMC, Jerusalem, Israel.,Department of Hematology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Galia Spectre
- Coagulation Unit, Institute of Hematology, Beilinson Hospital Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
8
|
Xu Y, Wang W, Zhao J, Wang J, Zhao T. Knowledge, attitude, and practice of healthcare professionals toward clinically applying graduated compression stockings: results of a Chinese web-based survey. J Thromb Thrombolysis 2019; 47:102-108. [PMID: 30293224 PMCID: PMC6336747 DOI: 10.1007/s11239-018-1749-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
This study had three objectives: (1) to investigate healthcare professionals’ knowledge, attitude, and practice toward clinically applying graduated compression stockings, (2) to analyze the influencing factors, and (3) to provide data to support departments that develop health policies. A self-administered web-based survey was completed by 1,444 healthcare professionals, including physicians and nurses from 15tertiary hospitals and four secondary hospitals from 10 provinces in China. Reliability analysis and exploratory factor analysis were used to evaluate the researcher-designed questionnaire’s reliability and validity. The formal questionnaire, which included demographic data (eight items), knowledge (ten items), attitudes (four items), and clinical practice patterns (six items), was distributed among healthcare professionals. The relationships and mechanisms among the variables were explored using descriptive statistical analysis, Pearson’s correlation coefficients, and multiple linear regression analysis. Of the 1,444 respondents, 31.2% had good knowledge of clinically applying graduated compression stockings, 83.5% had a positive attitude toward clinically applying them, and 30.4% of respondents exhibited normative behavior when applying them. The multiple linear regression analysis indicated that training was an important factor influencing the knowledge, attitude, and practice toward clinically applying graduated compression stockings. The healthcare professionals’ attitude toward clinically applying graduated compression stockings was positive, but the related knowledge was poor, and the code of behavior was deficient. Medical institutions should improve training for clinically applying graduated compression stockings among healthcare professionals and standardize the use of graduated compression stockings to facilitate the prevention of hospital-acquired venous thromboembolism.
Collapse
Affiliation(s)
- Yaping Xu
- Department of Orthopedics, China-Japan Friendship Hospital, Beijing, China. .,Bone Necrosis and Joint Preservation Reconstruction Center, China-Japan Friendship Hospital, Beijing, China. .,Department of Bone and Joint Surgery, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Hepingli, Chaoyang District, Beijing, 100029, China.
| | - Wei Wang
- Department of Nursing, China-Japan Friendship Hospital, Beijing, China
| | - Jing Zhao
- Department of Nursing, China-Japan Friendship Hospital, Beijing, China
| | - Jiahuan Wang
- Department of Orthopedics, China-Japan Friendship Hospital, Beijing, China.,Bone Necrosis and Joint Preservation Reconstruction Center, China-Japan Friendship Hospital, Beijing, China
| | - Tingting Zhao
- Department of Orthopedics, China-Japan Friendship Hospital, Beijing, China.,Bone Necrosis and Joint Preservation Reconstruction Center, China-Japan Friendship Hospital, Beijing, China
| |
Collapse
|
9
|
Kurstjens RL, de Wolf MA, Konijn HW, Toonder IM, Nelemans PJ, van Laanen JH, de Graaf R, Wittens CH. The Effect of Stenting on Venous Hypertension: Results Using a Treadmill Stress Test with Invasive Pressure Measurements in Patients with Iliofemoral Venous Obstruction. Eur J Vasc Endovasc Surg 2018; 56:247-254. [DOI: 10.1016/j.ejvs.2018.04.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 04/18/2018] [Indexed: 11/27/2022]
|
10
|
Appelen D, van Loo E, Prins MH, Neumann MHAM, Kolbach DN. Compression therapy for prevention of post-thrombotic syndrome. Cochrane Database Syst Rev 2017; 9:CD004174. [PMID: 28950030 PMCID: PMC6483721 DOI: 10.1002/14651858.cd004174.pub3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Post-thrombotic syndrome (PTS) is a long-term complication of deep vein thrombosis (DVT) that is characterised by chronic pain, swelling, and skin changes in the affected limb. One of every three people with DVT will develop post-thrombotic complications within five years. Several non-pharmaceutical measures are used for prevention of post-thrombotic syndrome during the acute phase of DVT. These include elevation of the legs and compression therapy. Clinicians and guidelines differ in their assessment of the utility of compression therapy for treatment of DVT. This is an update of a review first published in 2003. OBJECTIVES To determine relative effectiveness and rate of complications when compression therapy is used in people with deep vein thrombosis (DVT) for prevention of post-thrombotic syndrome (PTS). SEARCH METHODS For this update, the Cochrane Vascular Information Specialist (CIS) searched the Cochrane Vascular Specialised Register (20 March 2017) and CENTRAL (2017, Issue 2). The CIS also searched trial registries for details of ongoing or unpublished studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) and controlled clinical trials (CCTs) of compression therapy, such as bandaging and elastic stockings, in people with clinically confirmed DVT. The primary outcome was the occurrence of PTS. DATA COLLECTION AND ANALYSIS Two review authors (DK and EvL) identified and assessed titles and abstracts for relevance, and a third review author (DA) verified this assessment independently. Review authors imposed no restrictions on date or language of publications. Three review authors (DA, DK, EvL) used data extraction sheets to independently extract study data. We resolved disagreements by discussion. MAIN RESULTS We identified 10 RCTs with a total of 2361 participants that evaluated compression therapy. The overall methodological quality of these trials was low. We used only five studies in meta-analysis owing to differences in intervention types and lack of data. Three studies compared elastic compression stockings (pressure of 30 to 40 mmHg at the ankle) versus no intervention. Two studies compared elastic compression stockings (pressure 20 to 40 mmHg) versus placebo stockings. Overall, use of elastic compression stockings led to a clinically significant reduction in the incidence of PTS (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.38 to 1.01; P = 0.05; 1393 participants; 5 studies; low-quality evidence); no reduction in the incidence of severe PTS (RR 0.78, 95% CI 0.53 to 1.15; P = 0.21; 1224 participants; 4 studies; low-quality evidence); and no clear difference in DVT recurrence (RR 0.94, 95% CI 0.69 to 1.28; 1212 participants; 4 studies; P = 0.69; low-quality evidence). We did not pool data on the incidence of pulmonary embolism because this information was poorly reported, but we observed no differences between groups included in individual studies (low-quality evidence).Two studies evaluated effects of compression in the acute phase versus no compression treatment and found no differences in the incidence of PTS (RR 0.76, 95% CI 0.49 to 1.16; P = 0.2; 101 participants). One study reported that thigh-length stockings did not provide better protection against development of PTS than knee-length stockings (RR 0.92, 95% CI 0.66 to 1.28; P = 0.6; 267 participants). Another trial reported that wearing compression stockings for two years seemed to be superior to wearing them for one year in terms of PTS incidence.Two of the 10 included studies described patient satisfaction and quality of life (moderate-quality evidence), using different measurement systems. The first study showed significant improvement in well-being and DVT-related quality of life with compression treatment (P < 0.05) compared with bed rest, and the second study showed no differences in quality of life scores between compression and placebo groups. Four studies poorly reported side effects (low-quality evidence) that included itching, erythema, and other forms of allergic reaction and described no serious adverse events. Compliance with wearing of compression stockings was generally high but varied across studies. AUTHORS' CONCLUSIONS Low-quality evidence suggests that elastic compression stockings may reduce the occurrence of PTS after DVT. We downgraded the quality of evidence owing to considerable heterogeneity between studies and lack of or unclear risk of blinding due to clinical assessment scores. No serious adverse effects occurred in these studies. Large randomised controlled trials are needed to confirm these findings because of current lack of high-quality evidence and considerable heterogeneity.
Collapse
Affiliation(s)
- Diebrecht Appelen
- Huidcentrum LimburgDepartment of DermatologyReinaartsingel 50MaastrichtNetherlands
| | - Eva van Loo
- Maastricht University Medical CenterDepartment of DermatologyMaastrichtNetherlands
| | - Martin H Prins
- CAPHRI Research School, Maastricht UniversityDepartment of EpidemiologyMaastrichtNetherlands6200 MD
| | - Martino HAM Neumann
- Erasmus Medical CenterDepartment of DermatologyPO Box 2040RotterdamNetherlands3000 CA
| | - Dinanda N Kolbach
- Huidcentrum LimburgDepartment of DermatologyReinaartsingel 50MaastrichtNetherlands
| | | |
Collapse
|
11
|
Ikesaka RT, Kahn SR, Galanaud JP, Vazquez FJ, Roche-Nagle G, Carrier M, Le Gal G, Rodger M, Gandara E. The importance of post thrombotic syndrome as an outcome after deep venous thrombosis: A survey of Canadian thrombosis clinicians. Thromb Res 2017; 159:13-15. [PMID: 28942356 DOI: 10.1016/j.thromres.2017.09.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 09/11/2017] [Accepted: 09/14/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The development of post thrombotic syndrome (PTS) is a major source of morbidity and reduced quality of life. We sought to determine the value assigned by clinicians to post thrombotic syndrome and whether clinicians believe that any post thrombotic syndrome or severe post thrombotic syndrome are important outcomes to assess after deep vein thrombosis (DVT) as compared to other outcomes. DESIGN The design of the study was a self-responded electronic survey. Questions for the online survey were designed by two authors (R.I. and E.G.). METHODS The survey was distributed to 233 members of Thrombosis Canada and the Canadian Society for Vascular Surgery between August 2014 and October 2014. RESULTS There were 84 responses to the survey with complete responses were obtained from 71 respondents for a response rate of 36%. PTS was ranked as a significantly less important outcome after DVT than recurrent DVT, pulmonary embolism during treatment, major bleeding, death, quality of life, venous ulceration and severe post thrombotic syndrome (all comparisons p<0.05 by two sample t-test). CONCLUSIONS Our survey determined that "any post thrombotic syndrome" is perceived by physicians as less important than other DVT outcomes. Thus, "Severe PTS" and not "Any PTS" should be included as an outcome measure in studies investigating acute DVT.
Collapse
Affiliation(s)
| | - Susan R Kahn
- Center for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | | | - Fernando J Vazquez
- Internal Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Gregoire Le Gal
- Hematology, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marc Rodger
- Hematology, The Ottawa Hospital, Ottawa, Canada
| | - Esteban Gandara
- Internal Medicine, Research in Hematology Department, Hospital Privado de la Comunidad, Mar del Plata, Buenos Aires, Argentina
| |
Collapse
|
12
|
Lozano Sánchez F. SOS al SOX. La evidencia puesta en evidencia. ANGIOLOGIA 2016. [DOI: 10.1016/j.angio.2016.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
13
|
Utne KK, Tavoly M, Wik HS, Jelsness-Jørgensen LP, Holst R, Sandset PM, Ghanima W. Health-related quality of life after deep vein thrombosis. SPRINGERPLUS 2016; 5:1278. [PMID: 27547653 PMCID: PMC4977231 DOI: 10.1186/s40064-016-2949-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 07/29/2016] [Indexed: 12/01/2022]
Abstract
Background Health-related quality of life (HRQoL) is known to be impaired in patients who develop post-thrombotic syndrome (PTS) following deep vein thrombosis (DVT). However, there is limited knowledge of the long-term HRQoL after DVT compared to controls without DVT. The objectives of this study were to evaluate long-term HRQoL following DVT and to compare that with age and sex matched control group and to population norms as well as to investigate possible predictors for reduced HRQoL. Methods HRQoL was evaluated in 254 patients with confirmed DVT using the generic EQ-5D and the diseases specific VEINES-QOL/Sym questionnaire, whereas PTS was assessed by the Villalta scale. Patients were asked to give the EQ-5D questionnaire to two friends of same age- (±5 years) and sex (buddy controls). Results Patients scored significantly lower on all dimensions of EQ-5D compared to controls. EQ-5D index value was lower in patients compared with buddy controls; mean 0.79 (SD 0.17; IQR 0.72–1.00) versus 0.9 (SD 0.12; IQR 0.80–1.00), p < 0.001. EQ-5D index value was also significantly lower than age- and sex-adjusted population norms (p < 0.001). PTS and obesity (BMI >30/m2) were significantly associated with impaired HRQoL assessed by EQ-5D index value (odds ratio [OR] 11.0: 95 % confidence interval [CI] 4.6–29.7; and 2.3: 95 % CI 1.1–4.8, respectively) and VEINES-QOL (OR 28.2: 95 % CI 10.6–75.0; and OR 4.1: 95 % CI 1.7–9.7, respectively). Conclusion Long-term HRQoL was significantly impaired in DVT patients compared with buddy controls and population norms. PTS and obesity were independently associated with impaired HRQoL.
Collapse
Affiliation(s)
- Kristin Kornelia Utne
- Department of Medicine, Østfold Hospital Trust, Kalnes, Norway ; Institute of Clinical Medicine, University of Oslo, Oslo, Norway ; Department of Haematology, Østfold Hospital Trust, Postbox 300, 1714 Grålum, Norway
| | - Mazdak Tavoly
- Department of Medicine, Østfold Hospital Trust, Kalnes, Norway ; Institute of Clinical Medicine, University of Oslo, Oslo, Norway ; Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Hilde Skuterud Wik
- Department of Haematology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Lars Petter Jelsness-Jørgensen
- Department of Medicine, Østfold Hospital Trust, Kalnes, Norway ; Department of Health Science, Østfold University College, Fredrikstad, Norway
| | - René Holst
- Department of Medicine, Østfold Hospital Trust, Kalnes, Norway ; Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Per Morten Sandset
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway ; Department of Haematology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Waleed Ghanima
- Department of Medicine, Østfold Hospital Trust, Kalnes, Norway ; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
14
|
ten Cate-Hoek AJ, Henke PK, Wakefield TW. The post thrombotic syndrome: Ignore it and it will come back to bite you. Blood Rev 2015; 30:131-7. [PMID: 26462885 DOI: 10.1016/j.blre.2015.09.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 09/21/2015] [Indexed: 10/22/2022]
Abstract
Post thrombotic syndrome (PTS) is a very common chronic complication of deep venous thrombosis (DVT), as three out of ten patients with lower extremity DVT will develop PTS. The possibility to identify patients at risk is limited. Diagnosis is challenging, because there is no gold standard diagnostic method. Progress in diagnostic options may therefore change future diagnostic strategies. The better understanding of pathophysiologic processes that underlie PTS may stimulate the development of treatment modalities and improve and diversify management options. The quest for adequate preventive strategies and treatment is important because PTS has a detrimental effect on patients' quality of life and is associated with increased healthcare as well as societal costs. The problem of PTS prevention is therefore clearly relevant to patients, doctors as well as policy makers.
Collapse
Affiliation(s)
- Arina J ten Cate-Hoek
- Cardiovascular Center and Laboratory for Clinical Thrombosis and Hemostasis, Maastricht University Medical Center, Maastricht, the Netherlands.
| | - Peter K Henke
- Section of Vascular Surgery and the Jobst Vascular Research Laboratory, Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI, USA.
| | - Thomas W Wakefield
- Section of Vascular Surgery and the Jobst Vascular Research Laboratory, Department of Surgery, University of Michigan School of Medicine, Ann Arbor, MI, USA.
| |
Collapse
|
15
|
Sista AK, Vedantham S, Kaufman JA, Madoff DC. Endovascular Interventions for Acute and Chronic Lower Extremity Deep Venous Disease: State of the Art. Radiology 2015; 276:31-53. [PMID: 26101920 DOI: 10.1148/radiol.2015132603] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The societal and individual burden caused by acute and chronic lower extremity venous disease is considerable. In the past several decades, minimally invasive endovascular interventions have been developed to reduce thrombus burden in the setting of acute deep venous thrombosis to prevent both short- and long-term morbidity and to recanalize chronically occluded or stenosed postthrombotic or nonthrombotic veins in symptomatic patients. This state-of-the-art review provides an overview of the techniques and challenges, rationale, patient selection criteria, complications, postinterventional care, and outcomes data for endovascular intervention in the setting of acute and chronic lower extremity deep venous disease. Online supplemental material is available for this article.
Collapse
Affiliation(s)
- Akhilesh K Sista
- From the Department of Radiology, Weill Cornell Medical College, 525 E 68th St, P-518, New York, NY 10065 (A.K.S., D.C.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (S.V.); and Dotter Interventional Institute, Oregon Health and Science Center, Portland, Ore (J.A.K.)
| | - Suresh Vedantham
- From the Department of Radiology, Weill Cornell Medical College, 525 E 68th St, P-518, New York, NY 10065 (A.K.S., D.C.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (S.V.); and Dotter Interventional Institute, Oregon Health and Science Center, Portland, Ore (J.A.K.)
| | - John A Kaufman
- From the Department of Radiology, Weill Cornell Medical College, 525 E 68th St, P-518, New York, NY 10065 (A.K.S., D.C.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (S.V.); and Dotter Interventional Institute, Oregon Health and Science Center, Portland, Ore (J.A.K.)
| | - David C Madoff
- From the Department of Radiology, Weill Cornell Medical College, 525 E 68th St, P-518, New York, NY 10065 (A.K.S., D.C.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (S.V.); and Dotter Interventional Institute, Oregon Health and Science Center, Portland, Ore (J.A.K.)
| |
Collapse
|
16
|
Tie HT, Luo MZ, Luo MJ, Li K, Li Q, Wu QC. Compression Therapy in the Prevention of Postthrombotic Syndrome: A Systematic Review and Meta-Analysis. Medicine (Baltimore) 2015; 94:e1318. [PMID: 26252318 PMCID: PMC4616586 DOI: 10.1097/md.0000000000001318] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Although compression therapy has been widely used after deep vein thrombosis (DVT), its efficacy in prevention of postthrombotic syndrome (PTS) remains disputable. We aimed to update the meta-analysis to comprehensively evaluate the effect of compression therapy on the prevention of PTS in adult patients after DVT.PubMed, Embase, and Cochrane library databases were systematically searched. Randomized controlled trials (RCTs) evaluating the preventive effect of compression therapy on PTS in adult patients after DVT were included. The primary outcome was the incidence of PTS. All meta-analyses were performed using random-effects models regardless of the heterogeneity. Subgroup and sensitivity analysis were also performed to examine the robustness of the pooled effects according to our predesigned plan. Potential publication bias was assessed.Eight RCTs with 1598 patients were included. Overall, compression therapy could significantly reduce the incidence of PTS (estimate 0.68, 95% confidence interval [CI] 0.52-0.90; P = 0.007). However, it was only associated with a reduction in the incidence of mild/moderate PTS (relative risk [RR] 0.66, 95% CI 0.46-0.93; P = 0.019) but not in the incidence of severe PTS (RR 0.64, 95% CI 0.27-1.50; P = 0.31). Additionally, compression therapy failed to reduce the incidence of recurrent venous thromboembolism (RR 0.91, 95% CI 0.65-1.27; P = 0.58), the incidence of ulceration (RR 0.74, 95% CI 0.36-1.53; P = 0.42), or mortality (RR 0.99, 95% CI 0.72-1.37; P = 0.96). No publication bias was observed.Current evidence still supports compression therapy to be a clinical practice for prophylaxis of PTS in adult patients after DVT. However, our findings should be cautiously interpreted because of heterogeneity and hence more large-scale and well-designed RCTs are still warranted.
Collapse
Affiliation(s)
- Hong-Tao Tie
- From the Department of Cardiothoracic Surgery (H-TT, QL, Q-CW), The First Affiliated Hospital of Chongqing Medical University; Division of Immunology (M-ZL, M-JL), The Children's Hospital of Chongqing Medical University; and Department of Orthopedics Surgery (KL), The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | | | | | | | | | | |
Collapse
|
17
|
Vedantham S, Sista AK, Klein SJ, Nayak L, Razavi MK, Kalva SP, Saad WE, Dariushnia SR, Caplin DM, Chao CP, Ganguli S, Walker TG, Nikolic B. Quality Improvement Guidelines for the Treatment of Lower-Extremity Deep Vein Thrombosis with Use of Endovascular Thrombus Removal. J Vasc Interv Radiol 2014; 25:1317-25. [DOI: 10.1016/j.jvir.2014.04.019] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 04/22/2014] [Accepted: 04/22/2014] [Indexed: 02/07/2023] Open
|
18
|
Houweling AH, Shapiro S, Cohen JM, Kahn SR. Blinding strategies in the conduct and reporting of a randomized placebo-controlled device trial. Clin Trials 2014; 11:547-52. [PMID: 24902921 DOI: 10.1177/1740774514535999] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Blinding is a fundamental design strengthening feature in randomized clinical trials. Blinding is particularly important in trials whose outcome measures include subjective assessment of signs and symptoms, such as trials investigating the post-thrombotic syndrome, a frequent chronic complication of deep vein thrombosis. PURPOSE To determine whether strategies used to blind site investigators, research coordinators and patients were successful in a specific device trial, a multicenter trial of active versus placebo elastic compression stockings worn for 2 years to prevent post-thrombotic syndrome in patients with a first deep vein thrombosis (the SOX Trial). METHODS Patients were randomized to the active or placebo stocking intervention, which were indistinguishable in appearance at baseline. Replacement stockings were shipped directly to patients' homes and were not worn to any of the study visits during the study. Guesstimates of treatment group assignment were completed by site investigators, research coordinators and patients at the end of study follow-up. Statistical assessments of blinding were performed using the James and Bang blinding indices. RESULTS Overall rates of correct responses were 10.4% for site investigators, 17.8% for research coordinators and 29.4% for patients. James blinding index values suggest that blinding was achieved for site investigators, research coordinators and patients. The treatment specific Bang blinding index values suggest that blinding was achieved for site investigators and research coordinators, but detected possible unblinding and opposite guess for patients in the active and placebo elastic compression stocking groups, respectively. LIMITATIONS Post-study assessment of blinding, as was done for the SOX Trial, cannot distinguish between degree of blinding and hunches about an intervention's efficacy. However, as rates of post-thrombotic syndrome along with adverse events in the SOX Trial were similar between treatment groups, it is unlikely that hunches would have interfered with our end-of-trial assessment for blinding. CONCLUSION Blinding strategies used in our trial were successful overall and appeared to be most effective for site investigators and research coordinators. For patients, there may have been some degree of unblinding in the active stocking group. However, as the trial results were negative with active elastic compression stocking showing no benefit over placebo elastic compression stocking, this potential unblinding has minimal impact on the overall conclusions of the trial.
Collapse
Affiliation(s)
- Adrielle H Houweling
- Centre for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Stan Shapiro
- Centre for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, QC, Canada Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Jacqueline M Cohen
- Centre for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, QC, Canada Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Susan R Kahn
- Centre for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, QC, Canada
| |
Collapse
|
19
|
Sista AK. Postprocedural Management of Patients Undergoing Endovascular Therapy for Acute and Chronic Lower-Extremity Deep Venous Disease. Tech Vasc Interv Radiol 2014; 17:127-31. [DOI: 10.1053/j.tvir.2014.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
20
|
Kahn SR, Shapiro S, Wells PS, Rodger MA, Kovacs MJ, Anderson DR, Tagalakis V, Houweling AH, Ducruet T, Holcroft C, Johri M, Solymoss S, Miron MJ, Yeo E, Smith R, Schulman S, Kassis J, Kearon C, Chagnon I, Wong T, Demers C, Hanmiah R, Kaatz S, Selby R, Rathbun S, Desmarais S, Opatrny L, Ortel TL, Ginsberg JS. Compression stockings to prevent post-thrombotic syndrome: a randomised placebo-controlled trial. Lancet 2014; 383:880-8. [PMID: 24315521 DOI: 10.1016/s0140-6736(13)61902-9] [Citation(s) in RCA: 302] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Post-thrombotic syndrome (PTS) is a common and burdensome complication of deep venous thrombosis (DVT). Previous trials suggesting benefit of elastic compression stockings (ECS) to prevent PTS were small, single-centre studies without placebo control. We aimed to assess the efficacy of ECS, compared with placebo stockings, for the prevention of PTS. METHODS We did a multicentre randomised placebo-controlled trial of active versus placebo ECS used for 2 years to prevent PTS after a first proximal DVT in centres in Canada and the USA. Patients were randomly assigned to study groups with a web-based randomisation system. Patients presenting with a first symptomatic, proximal DVT were potentially eligible to participate. They were excluded if the use of compression stockings was contraindicated, they had an expected lifespan of less than 6 months, geographical inaccessibility precluded return for follow-up visits, they were unable to apply stockings, or they received thrombolytic therapy for the initial treatment of acute DVT. The primary outcome was PTS diagnosed at 6 months or later using Ginsberg's criteria (leg pain and swelling of ≥1 month duration). We used a modified intention to treat Cox regression analysis, supplemented by a prespecified per-protocol analysis of patients who reported frequent use of their allocated treatment. This study is registered with ClinicalTrials.gov, number NCT00143598, and Current Controlled Trials, number ISRCTN71334751. FINDINGS From 2004 to 2010, 410 patients were randomly assigned to receive active ECS and 396 placebo ECS. The cumulative incidence of PTS was 14·2% in active ECS versus 12·7% in placebo ECS (hazard ratio adjusted for centre 1·13, 95% CI 0·73-1·76; p=0·58). Results were similar in a prespecified per-protocol analysis of patients who reported frequent use of stockings. INTERPRETATION ECS did not prevent PTS after a first proximal DVT, hence our findings do not support routine wearing of ECS after DVT. FUNDING Canadian Institutes of Health Research.
Collapse
Affiliation(s)
- Susan R Kahn
- Centre for Clinical Epidemiology, Jewish General Hospital, Montreal, QC, Canada.
| | - Stan Shapiro
- Centre for Clinical Epidemiology, Jewish General Hospital, Montreal, QC, Canada; Department of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
| | - Philip S Wells
- Department of Medicine, University of Ottawa/Ottawa Hospital, Ottawa, ON, Canada; Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Marc A Rodger
- Ottawa Hospital Research Institute, Ottawa, ON, Canada; Thrombosis Program, Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Michael J Kovacs
- Division of Hematology, London Health Sciences Centre, London, ON, Canada
| | - David R Anderson
- Department of Medicine, Dalhousie University, Halifax, NS, Canada; Capital Health, Halifax, NS, Canada
| | - Vicky Tagalakis
- Centre for Clinical Epidemiology, Jewish General Hospital, Montreal, QC, Canada
| | | | - Thierry Ducruet
- Centre for Clinical Epidemiology, Jewish General Hospital, Montreal, QC, Canada
| | - Christina Holcroft
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA; Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA
| | - Mira Johri
- International Health Unit, University of Montreal Hospital Research Centre, Montreal, QC, Canada; Department of Health Administration, Faculty of Medicine, University of Montreal, Montreal, QC, Canada
| | - Susan Solymoss
- Division of Hematology, Montreal General Hospital, Montreal, QC, Canada; St Mary's Hospital, Montreal, QC, Canada
| | - Marie-José Miron
- Department of Medicine, Hôpital Notre-Dame, Montreal, QC, Canada
| | - Erik Yeo
- Division of Hematology, University Health Network, Toronto, ON, Canada
| | - Reginald Smith
- Divisions of Cardiology and Thrombosis, Victoria Heart Institute Foundation, Victoria, BC, Canada
| | - Sam Schulman
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada; Karolinska Institute, Stockholm, Sweden
| | - Jeannine Kassis
- Division of Hematology, Hôpital Maisonneuve-Rosemont, QC, Canada
| | - Clive Kearon
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Isabelle Chagnon
- Department of Medicine, Hôpital du Sacré-Coeur, University of Montreal, Montreal, QC, Canada
| | - Turnly Wong
- Department of Medicine, St Boniface General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Rajendar Hanmiah
- Division of General Internal Medicine, St Joseph's Hospital, Hamilton, ON, Canada
| | - Scott Kaatz
- Academic Hospital Medicine, Hurley Medical Center, Flint, MI, USA
| | - Rita Selby
- Department of Medicine and Department of Clinical Pathology, Sunnybrook Health Sciences Centre and University Health Network, University of Toronto, Toronto, ON, Canada
| | - Suman Rathbun
- Department of Medicine, Oklahoma University Health Sciences Center, Oklahoma City, OK, USA
| | - Sylvie Desmarais
- Department of Medicine, Hôpital Pierre-Boucher, Longueuil, QC, Canada
| | - Lucie Opatrny
- Professional Services, St Mary's Hospital Center, Montreal, QC, Canada
| | - Thomas L Ortel
- Division of Hematology, Duke University Medical Center, Durham, NC, USA
| | | |
Collapse
|
21
|
Guanella R, Kahn SR. Post-thrombotic syndrome: current prevention and management strategies. Expert Rev Cardiovasc Ther 2014; 10:1555-66. [DOI: 10.1586/erc.12.147] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
|
22
|
Baldwin MJ, Moore HM, Rudarakanchana N, Gohel M, Davies AH. Post-thrombotic syndrome: a clinical review. J Thromb Haemost 2013; 11:795-805. [PMID: 23433231 DOI: 10.1111/jth.12180] [Citation(s) in RCA: 106] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 02/14/2013] [Indexed: 02/03/2023]
Abstract
Up to half of patients with proximal deep vein thrombosis (DVT) will develop post-thrombotic syndrome (PTS) despite optimal anticoagulant therapy. PTS significantly impacts upon quality of life and has major health-economic implications. This narrative review describes the pathophysiology, risk factors, and diagnosis, prevention and treatment of PTS, to improve our understanding of the disease and guide treatment. Relevant articles were identified through systematic searches of the PubMed, EMBASE and Cochrane databases between 1966 and November 2011. Studies were included for detailed assessment if they met the following criteria: published in English, human study participants, study population aged > 18 years, and lower limb post-thrombotic syndrome. All non-systematic reviews and single patient case reports were excluded. Recurrent thrombosis, thrombus location and obesity are major risk factors, whereas the importance of gender and age remain uncertain. The diagnosis of PTS is based on clinical findings in patients with a known history of DVT. Several clinical scales have been described, with the Villalta Score gaining increasing popularity. Adequate anticoagulation and use of elastic compression stockings (ECS) following DVT can reduce the incidence of PTS. Catheter-directed thrombolysis and mechanical thrombectomy of acute DVT may preserve valvular function. Studies to date of these techniques are encouraging, and have reported improved hemodynamics and a reduced incidence of PTS. The management of established PTS is challenging. Compression therapy, aimed at reducing the underling venous hypertension, remains the mainstay of treatment. This is despite a paucity of high-quality evidence to support its use. Pharmacologic and surgical treatments have also been described, with a number of studies citing symptomatic improvement.
Collapse
Affiliation(s)
- M J Baldwin
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College School of Medicine, Charing Cross Hospital, London, UK
| | | | | | | | | |
Collapse
|
23
|
Sarici IS, Yanar F, Agcaoglu O, Ucar A, Poyanli A, Cakir S, Aksoy SM, Kurtoglu M. Our early experience with iliofemoral vein stenting in patients with post-thrombotic syndrome. Phlebology 2013; 29:298-303. [DOI: 10.1177/0268355513477641] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2013] [Indexed: 11/17/2022]
Abstract
Introduction: Venous balloon dilation and stent therapy have been proposed as effective treatments for chronic iliofemoral thrombosis. In this study, we report our experience and describe the one-year outcome and efficacy of balloon angioplasty and stenting for the treatment of post-thrombotic syndrome (PTS) in iliofemoral vein segments. Methods: From June 2011 to June 2012, 52 consecutive patients with chronic PTS (59 limbs; 75% women; median age 58 years; range: 23–76 years) referred to our unit for interventional assessment were included in the study. Treatment effects were assessed using Villalta scale, Venous Clinical Severity Score (VCSS) and Chronic Venous Insufficiency Questionnaire (CIVIQ)-20 for PTS, CEAP (clinical, aetiological, anatomical and pathological elements) grading and measurement of leg circumference, before and after intervention. Results: Stenting was successfully accomplished in all patients. Coagulation abnormality was identified in 21 subjects (40.3%). CEAP grades were as follows: C3 in 19 patients, C4 in 24 patients, C5 in one patient and C6 in eight patients. According to Villalta scores, three patients were mild, seven patients were moderate and 42 patients were severe PTS. VCSS, Villalta scale and CIVTQ-20 showed a significant decrease in the severity of PTS signs and symptoms ( P < 0.001). The calf and middle thigh circumferences decreased significantly on both sides ( P < 0.001). Conclusion: Treatment of iliac venous obstruction with balloon angioplasty and stenting appears to be a minimally invasive and safe therapeutic approach in patients with PTS offering quick symptomatic relief, good patency and minimal morbidity.
Collapse
Affiliation(s)
| | - F Yanar
- Department of General Surgery
| | | | - A Ucar
- Department of Radiology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - A Poyanli
- Department of Radiology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - S Cakir
- Department of Radiology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | | | | |
Collapse
|
24
|
Liew A, Douketis J. Initial and long-term treatment of deep venous thrombosis: recent clinical trials and their impact on patient management. Expert Opin Pharmacother 2013; 14:385-96. [DOI: 10.1517/14656566.2013.770838] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Aaron Liew
- McMaster University, Department of Medicine, St. Joseph's Healthcare, F-544, 50 Charlton Ave East, Hamilton, ON, L8N 4A6, Canada ;
| | - James Douketis
- McMaster University, Department of Medicine, St. Joseph's Healthcare, F-544, 50 Charlton Ave East, Hamilton, ON, L8N 4A6, Canada ;
| |
Collapse
|
25
|
Galanaud JP, Kahn SR. The Post-Thrombotic Syndrome: A 2012 Therapeutic Update. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 15:153-63. [DOI: 10.1007/s11936-012-0224-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
26
|
Abstract
OBJECTIVE To assess each of the scoring systems used to diagnose and classify post-thrombotic syndrome, a common chronic complication of deep vein thrombosis. The design of the study was a systematic review of the literature pertaining to post-thrombotic syndrome. METHODS A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines by a search of PubMed (1948 to September 2011) using the search terms "post-thrombotic syndrome," "postthrombotic syndrome," "post-phlebitic syndrome," and "postphlebitic syndrome." A manual reference list search was also carried out to identify further studies that would be appropriate for inclusion. The various scoring systems in use were identified and assessed against a list of criteria to determine their validity for use. For outcome measures, each scoring system was assessed for specific criteria, including interobserver reliability, association with ambulatory venous pressures, ability to assess severity of post-thrombotic syndrome, ability to assess change in condition over time, and association with patient-reported symptom severity. RESULTS The Villalta, Ginsberg, Brandjes, Widmer, CEAP, and Venous Clinical Severity Score systems all were assessed for the stated outcome measures. From their use in the literature, only the Villalta score was able to fulfill all the criteria described. The main criticism of the Villalta score in the literature appears to be its use of subjective measures. To that end, we propose that use of a venous disease-specific quality-of-life questionnaire in combination with the Villalta score may help standardize the subjective criteria. CONCLUSIONS The Villalta score, combined with a venous disease-specific quality-of-life questionnaire, should be considered the "gold standard" for the diagnosis and classification of post-thrombotic syndrome.
Collapse
Affiliation(s)
- Arany Soosainathan
- Academic Section of Vascular Surgery, Department of Surgery & Cancer, Imperial College School of Medicine, Charing Cross Hospital, London, United Kingdom
| | | | | | | |
Collapse
|
27
|
Advances in the diagnosis and management of postthrombotic syndrome. Best Pract Res Clin Haematol 2012; 25:391-402. [DOI: 10.1016/j.beha.2012.06.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
28
|
Bouman AC, Smits JJM, Ten Cate H, Ten Cate-Hoek AJ. Markers of coagulation, fibrinolysis and inflammation in relation to post-thrombotic syndrome. J Thromb Haemost 2012; 10:1532-8. [PMID: 22642402 DOI: 10.1111/j.1538-7836.2012.04798.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Post-thrombotic syndrome (PTS) occurs in 20-50% of patients after a deep venous thrombosis (DVT). It is difficult to accurately predict which patients will develop PTS. Biomarkers could be a valuable tool for PTS risk assessment. OBJECTIVES To investigate whether increased levels of factor (F)VIII, C-reactive protein (CRP) or D-dimer, over time, are associated with the development of PTS in patients after an acute DVT. METHODS PTS status was assessed using the Villalta scale. Blood sampling was performed at three points during follow-up. RESULTS A cohort of 228 consecutive patients was included after an acute DVT. At T1 (12 months after index DVT), both levels of D-dimer (median 725 ng mL(-1) [interquartile range, IQR 400-1400[ vs. 378 ng mL(-1) [251-652] P=0.004) and CRP (median 3.9 mg L(-1) [IQR 1.6-8.5] vs. 2.4 mg L(-1) [1.0-4.3] P=0.018) were increased in patients with PTS, compared with patients without PTS. Factor (F)VIII was not associated with PTS. In the multivariate logistic regression analysis, varicosities (odds ratio [OR] 13.4 95% confidence interval [CI] 3.0-59.1 P=0.001), a previous ipsilateral DVT (OR 6.3 95% CI 1.5-26.9 P=0.012) and CRP>5 mg L(-1) on T1 (OR 8.0 95% CI 2.4-26.4 P=0.001) were significantly associated with PTS. CONCLUSIONS Besides previous ipsilateral DVT and varicosities, CRP>5 mg L(-1) at T1 was strongly and independently associated with PTS. Persistent inflammation rather than hypercoagulability might be the most important etiological factor in PTS, and may be a target for future therapy. The development of a risk score for PTS, including both clinical risk factors and biomarker levels, such as CRP, might be desirable.
Collapse
Affiliation(s)
- A C Bouman
- Laboratory for Thrombosis and Hemostasis, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands.
| | | | | | | |
Collapse
|
29
|
Vedantham S. Interventional approaches to deep vein thrombosis. Am J Hematol 2012; 87 Suppl 1:S113-8. [PMID: 22389183 DOI: 10.1002/ajh.23145] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Revised: 01/29/2012] [Accepted: 01/30/2012] [Indexed: 11/12/2022]
Abstract
The last decade has seen increased use of aggressive, catheter-based methods of treating deep vein thrombosis (DVT). In this article, we outline the risks, benefits, and uncertainties surrounding endovascular DVT therapies, describe clinical situations in which endovascular treatment options should reasonably be considered, and update the reader on new outcome data that pertains to catheter-based DVT interventions. Endovascular thrombolytic therapy is reasonable to perform for selected patients with DVT causing acute limb-threatening circulatory compromise, acute inferior vena cava occlusion, or acute iliofemoral DVT for the purposes of limb salvage and relief of presenting DVT symptoms, and appears likely to prevent post-thrombotic syndrome (PTS) in patients with proximal DVT. A multicenter randomized trial, the ATTRACT Study, is currently underway in the United States to determine whether pharmacomechanical catheter-directed thrombolysis (PCDT) is sufficiently safe and effective to be recommended for routine use in proximal DVT patients. Selected patients with established moderate-to-severe PTS in association with an occluded iliac vein or a refluxing saphenous vein may also be amenable to endovascular intervention to reduce venous hypertension, alleviate symptoms, and improve limb function and quality of life. Pending the results of further studies, an individualized approach to patient selection for interventional DVT therapies is recommended.
Collapse
Affiliation(s)
- Suresh Vedantham
- Interventional Radiology Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri 63110, USA.
| |
Collapse
|
30
|
Klein SJ, Vedantham S. Acute deep vein thrombosis cases in the real world. Semin Intervent Radiol 2012; 29:23-8. [PMID: 23449022 PMCID: PMC3348761 DOI: 10.1055/s-0032-1302448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Practicing interventional radiologists (IRs) are routinely faced with challenging decisions that pertain to the management of patients with acute deep vein thrombosis (DVT). In this article, we describe five questions that are commonly posed by interventionalists and discuss both the indirect published evidence as well as our own experience in dealing with these issues. Our aim is to address procedural and, perhaps more importantly, nonprocedural-related knowledge domains with which the IR physician is less familiar and are often not directly addressed by published data or evidence-based clinical practice guidelines. This discussion is meant to facilitate a stronger understanding of the published literature as it pertains to the justifiable indications for endovascular thrombolytic therapy, the optimal use of anticoagulant therapy, and the reasonable use of adjuncts such as inferior vena cava filters and elastic compression stockings. Our goal is to provide a framework for practicing IRs to help them make the best clinical decisions for their individual patients and, ultimately, achieve optimal DVT treatment outcomes.
Collapse
Affiliation(s)
- Seth J. Klein
- The Interventional Radiology Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Suresh Vedantham
- The Interventional Radiology Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| |
Collapse
|
31
|
De Wolf MAF, Wittens CHA, Kahn SR. Incidence and Risk Factors of the Post-thrombotic Syndrome. Phlebology 2012; 27 Suppl 1:85-94. [DOI: 10.1258/phleb.2011.012s06] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Annually 1–2 in every 1000 adults will develop a deep venous thrombosis of the lower extremity. A third to half of these patients will develop the post-thrombotic syndrome (PTS). However, predicting which patients will develop the PTS remains elusive. Ipsilateral thrombosis recurrence seems to be the most important risk factor. Moreover, residual venous occlusion and valvular reflux seem to predict PTS incidence to some degree. Laboratory parameters, including D-dimers and inflammatory markers, have shown promise in predicting development of the PTS in patients and are currently under investigation. Creating a model based on all combined risk factors and patient characteristics might aid in risk stratification in individual patients.
Collapse
Affiliation(s)
- M A F De Wolf
- Department of Surgery, Maastricht University Medical Centre
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | - C H A Wittens
- Department of Surgery, Maastricht University Medical Centre
- Department of Vascular Surgery, Aachen University Hospital, Aachen, Germany
| | - S R Kahn
- Division of Internal Medicine, McGill University and Center for Clinical Epidemiology, Jewish General Hospital, Montreal, Canada
| |
Collapse
|
32
|
Evaluating the Role of Compression Stockings in Preventing Post thrombotic Syndrome: A Review of the Literature. THROMBOSIS 2012; 2012:694851. [PMID: 22315680 PMCID: PMC3270478 DOI: 10.1155/2012/694851] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Accepted: 11/29/2011] [Indexed: 11/17/2022]
Abstract
Background. Postthrombotic syndrome (PTS) is a burdensome and costly complication of deep vein thrombosis (DVT). Up to 50% of patients with DVT will develop the disease within two years following the diagnosis of acute DVT. Various risk factors for developing PTS have been identified and different modalities have been used to prevent its development. Compression stockings have been studied for the prevention of PTS in patients diagnosed with proximal DVT. Methods. MEDLINE and EMBASE databases were searched to identify relevant original articles. Results. Several trials including two metaanalyses have examined the role of compression stockings for the prevention of PTS. Although most trials showed significant reduction in the development of PTS with the use of compression stockings, limitations in study design prevent the generalizability of the data. Two studies supported an individualized tailored duration especially in patients at low risk for developing the syndrome. A randomized double-blind placebo-controlled trial involving 800 patients is currently ongoing and may confirm the results of older studies. Conclusions. Clinical trials support the use of compression stockings in patients diagnosed with proximal DVT for the prevention of PTS.
Collapse
|
33
|
Abstract
Abstract
The post-thrombotic syndrome (PTS) develops in 25%-50% of patients with proximal lower extremity deep vein thrombosis (DVT) despite the use of standard anticoagulant therapy and elastic compression stockings. PTS is a major cause of quality of life impairment in DVT patients and often leads to limiting venous claudication, work disability, and venous ulcers. Endovascular thrombolytic procedures that eliminate venous thrombus, restore venous flow, and show strong potential to prevent PTS are now under study in multicenter randomized clinical trials. In addition, endovascular procedures can be used to treat valvular reflux and venous obstruction and thereby provide symptom improvement to patients with chronic established PTS.
Collapse
|
34
|
Pernès JM. [The role of thrombolysis in the clinical management of deep vein thrombosis]. JOURNAL DES MALADIES VASCULAIRES 2011; 36 Suppl 1:S20-S27. [PMID: 22177765 DOI: 10.1016/s0398-0499(11)70004-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Acute Deep Venous Thrombosis (DVT) therapies have been judged primarily on their ability to prevent symptomatic pulmonary embolism, early thrombus progression, and recurrent VTE. The cornerstones of current management of DVT, supported by the 2008 American College of Chest Physicians (ACCP) guidelines, are the routine use of anticoagulant therapy, graduated elastic compression stockings, and early ambulation. For selected appropriate patients with extensive acute proximal DVT, while the French recommendations (Afssaps 2009) still consider thrombolysis not indicated, ACCP guidelines now suggest in-situ thrombolysis in addition to anticoagulation to reduce the risk of subsequent postthrombotic syndrome (PTS) and recurrent DVT (Grade 2 B recommendation). Contemporary invasive endovascular treatments, called pharmacomechanical treatment, mitigate the drawbacks (major bleeding) historically associated with systemic thrombolytic approaches, by means of intra-thrombus delivery of drugs, followed by mechanical dispersion to accelerate lysis and then aspiration of remaining drug and clot debris. The proof of concept for the "open vein" hypothesis - that a strategy of early thrombus removal can reduce the incidence of PTS long term - comes incrementally and randomized trials (ATTRACT trial with a 2016 target completion date) are currently under way and might lead to a shift of the paradigms of the management of acute DVT focused on active thrombus removal.
Collapse
Affiliation(s)
- J-M Pernès
- Pôle Cardiovasculaire Interventionnel, Hôpital Privé d'Antony, 25 rue de la providence, 92160 Antony, France.
| |
Collapse
|
35
|
Post-thrombotic Syndrome Patient Education Based on the Health Belief Model. J Wound Ostomy Continence Nurs 2011; 38:648-54. [DOI: 10.1097/won.0b013e31822efc86] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
36
|
|
37
|
Lowe GDO. Management of deep vein thrombosis to reduce the incidence of post-thrombotic syndrome. Phlebology 2011; 25 Suppl 1:9-13. [PMID: 20870814 DOI: 10.1258/phleb.2010.010s02] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The post-thrombotic syndrome (PTS) is the major chronic sequel of deep vein thrombosis (DVT) of the leg, and is a major socioeconomic challenge. In addition to systematic prophylaxis of DVT in hospitalized patients, effective management of DVT is important to reduce the incidence of PTS. Thrombolysis and thrombectomy are not indicated routinely. Optimal anticoagulation, usually with heparins initially and then with oral warfarin, is important to prevent recurrent DVT, which is a major risk factor for PTS. Following a routine three-month period of anticoagulation, patients with proximal idiopathic DVT should be individually assessed for the benefits and risks of continued oral anticoagulation, including patient preferences. Risk factors for recurrent DVT include active cancer, pregnancy, continued use of oral oestrogens, male sex, obesity, recurrent thrombosis, established PTS, permanent inferior vena caval filters, residual DVT, high fibrin d-dimer and other thrombophilias. Early walking, continued high levels of physical activity and wearing compression stockings for up to two years may also reduce the risk of PTS.
Collapse
Affiliation(s)
- G D O Lowe
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK.
| |
Collapse
|
38
|
Abstract
AbstractThe post-thrombotic syndrome (PTS) is an important chronic complication of deep vein thrombosis (DVT). The present review focuses on risk determinants of PTS after DVT and available means to prevent and treat PTS. More than one-third of patients with DVT will develop PTS, and 5% to 10% of patients develop severe PTS, which can manifest as venous ulcers. PTS has an adverse impact on quality of life as well as significant socioeconomic consequences. The main risk factors for PTS are persistent leg symptoms 1 month after acute DVT, anatomically extensive DVT, recurrent ipsilateral DVT, obesity, and older age. Subtherapeutic dosing of initial oral anticoagulation therapy for DVT treatment may also be linked to subsequent PTS. By preventing the initial DVT and DVT recurrence, primary and secondary prophylaxis of DVT will prevent cases of PTS. Daily use of elastic compression stockings for 2 years after proximal DVT appears to reduce the risk of PTS; however, uncertainty remains regarding optimal duration of use, optimal compression strength, and usefulness after distal DVT. The cornerstone of managing PTS is compression therapy, primarily using elastic compression stockings. Venoactive medications such as aescin and rutosides may provide short-term relief of PTS symptoms. Further studies to elucidate the pathophysiology of PTS, to identify clinical and biological risk factors, and to test new preventive and therapeutic approaches to PTS are needed.
Collapse
|
39
|
An update on etiology, prevention, and therapy of postthrombotic syndrome. J Vasc Surg 2010; 53:500-9. [PMID: 21129900 DOI: 10.1016/j.jvs.2010.08.050] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 08/19/2010] [Accepted: 08/19/2010] [Indexed: 11/20/2022]
Abstract
Postthrombotic syndrome is a common sequelae resulting from deep venous thrombosis. The primary interventions are prevention and treatment, both of which many vascular specialists may not always recognize. We review the definition, epidemiology, the basic pathophysiology, and preventative management for postthrombotic syndrome. The current primary medical and interventional treatment modalities to decrease the occurrence of postthrombotic syndrome are also highlighted. Many of these treatments are currently available and simply need to be adhered to, whereas others are a shift in the paradigm, focusing on active thrombus removal.
Collapse
|
40
|
Prevention and treatment of the postthrombotic syndrome. J Vasc Surg 2010; 52:21S-28S. [DOI: 10.1016/j.jvs.2010.05.070] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2010] [Revised: 05/10/2010] [Accepted: 05/12/2010] [Indexed: 11/24/2022]
|
41
|
|
42
|
|
43
|
Venous compression for prevention of postthrombotic syndrome: a meta-analysis. Am J Med 2010; 123:735-40. [PMID: 20670728 DOI: 10.1016/j.amjmed.2010.01.027] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Revised: 11/24/2009] [Accepted: 01/20/2010] [Indexed: 11/23/2022]
Abstract
PURPOSE To determine the effectiveness of venous compression stockings or compression bandages on the reduction of postthrombotic syndrome in patients with deep venous thrombosis. METHODS We attempted to identify all published trials in all languages identified by PubMed through June 2009. Meta-analysis was performed. RESULTS Based on 5 randomized trials of patients with deep venous thrombosis comparing treatment with venous compression to controls, mild-to-moderate postthrombotic syndrome occurred in 64 of 296 (22%) treated with venous compression, compared with 106 of 284 (37%) in controls (relative risk=0.52). Severe postthrombotic syndrome occurred in 14 of 296 (5%) treated, compared with 33 of 284 (12%) controls (relative risk=0.38). Any postthrombotic syndrome occurred in 89 of 338 (26%) treated, compared with 150 of 324 (46%) controls (relative risk=0.54). CONCLUSION Venous compression reduced the incidence of postthrombotic syndrome, particularly severe postthrombotic syndrome. Venous compression in patients with deep venous thrombosis would seem to be indicated for this purpose. There was, however, wide variation in the type of stockings used, time interval from diagnosis to application of stockings, and duration of treatment. Further investigation, therefore, is needed.
Collapse
|
44
|
Pesavento R, Villalta S, Prandoni P. The postthrombotic syndrome. Intern Emerg Med 2010; 5:185-92. [PMID: 20012232 DOI: 10.1007/s11739-009-0336-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2009] [Accepted: 11/11/2009] [Indexed: 10/20/2022]
Abstract
Following deep vein thrombosis (DVT), one of every two patients will develop postthrombotic syndrome (PTS), which causes remarkable consequences on the socioeconomic level. Residual thrombosis is an important predictor of PTS, and severe early symptoms, old age, obesity, improper anticoagulation, recurrent thrombosis and varicose veins are major risk factors. Diagnosis of PTS is mainly based on the clinical findings for patients with a history of DVT, while in those without it, instrumental diagnosis might help in detecting a previous DVT. Prompt administration of adequate compression elastic stockings (ECS) in patients with symptomatic DVT reduces the frequency of PTS by half. Usually, the management of an established PTS is demanding, and often discouraging. However, when carefully supervised and instructed to wear proper ECS, more than 50% of patients either remain quiescent or improve during long-term follow-up.
Collapse
Affiliation(s)
- Raffaele Pesavento
- Thromboembolic Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Via Giustiniani 2, Padua, Italy.
| | | | | |
Collapse
|
45
|
Labropoulos N, Spentzouris G, Gasparis AP, Meissner M. Impact and clinical significance of recurrent venous thromboembolism. Br J Surg 2010; 97:989-99. [DOI: 10.1002/bjs.7156] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background
The purpose of this review was to analyse current knowledge and controversies associated with the diagnosis, treatment and prevention of recurrent venous thromboembolism (VTE).
Methods
MEDLINE and manual searches were performed to select prospective papers on the diagnosis, treatment and prevention of recurrent VTE for their relevance and quality.
Results
The cumulative incidence of recurrent VTE increases from 11 per cent at 1 year to 40 per cent at 10 years. The incidence of recurrence is higher in unprovoked thrombosis compared with provoked VTE. Patients with unprovoked deep vein thrombosis also have a greater number of multiple recurrences. Ultrasonography or D-dimer monitoring may have an impact on the duration of anticoagulation but further refinements are needed. The incidence of skin damage is higher in ipsilateral recurrence compared with contralateral or no recurrence. Legs with ipsilateral recurrence more often have both reflux and obstruction.
Conclusion
The role and weight of the predictive factors for recurrent VTE and its sequelae, and the type and optimal duration of anticoagulation have not been studied adequately. Fatality associated with pulmonary embolism and rates of recurrent VTE remain unacceptably high.
Collapse
Affiliation(s)
- N Labropoulos
- Stony Brook University Medical Center, Stony Brook, New York, USA
| | - G Spentzouris
- Stony Brook University Medical Center, Stony Brook, New York, USA
| | - A P Gasparis
- Stony Brook University Medical Center, Stony Brook, New York, USA
| | - M Meissner
- University of Washington Medical Center, Seattle, Washington, USA
| |
Collapse
|
46
|
Abstract
Postthrombotic syndrome (PTS) is a chronic complication of deep venous thrombosis (DVT) that reduces quality of life and has important socioeconomic consequences. More than one-third of patients with DVT will develop PTS, and 5% to 10% of patients will develop severe PTS, which may manifest as venous ulceration. The principal risk factors for PTS are persistent leg symptoms 1 month after the acute episode of DVT, extensive DVT, recurrent ipsilateral DVT, obesity, and older age. Daily use of elastic compression stockings (ECSs) for 2 years after proximal DVT appears to reduce the risk of PTS; however, there is uncertainty about optimal duration of use and compression strength of ECSs and the magnitude of their effect. The cornerstone of managing PTS is compression therapy, primarily using ECSs. Venoactive medications such as aescin and rutoside may provide short-term relief of PTS symptoms. The likelihood of developing PTS after DVT should be discussed with patients, and symptoms and signs of PTS should be monitored during clinical follow-up. Further studies to elucidate the pathophysiology of PTS, to identify clinical and biologic risk factors, and to test new preventive and therapeutic approaches to PTS are needed to ultimately improve the long-term prognosis of patients with DVT.
Collapse
|
47
|
Vazquez SR, Freeman A, VanWoerkom RC, Rondina MT. Contemporary issues in the prevention and management of postthrombotic syndrome. Ann Pharmacother 2009; 43:1824-35. [PMID: 19737994 DOI: 10.1345/aph.1m185] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To provide an evidence-based review and clinical summary of postthrombotic syndrome (PTS). DATA SOURCES A literature review was performed via MEDLINE (1950-July 1, 2009) and International Pharmaceutical Abstracts (1970-June 2009) searches using the terms post-thrombotic syndrome, post-phlebitic syndrome, deep vein thrombosis, and compression stockings. DATA SYNTHESIS PTS is best characterized as a chronic syndrome of clinical signs and symptoms including pain, swelling, parasthesias, and ulceration in the affected limb following deep vein thrombosis (DVT). It occurs in up to half of patients with symptomatic DVT, usually within the first 2 years. Although the pathophysiology of PTS is not well understood, a thrombus may cause venous hypertension and valvular incompetence resulting in edema, tissue hypoxia, and in severe cases, ulceration. Risk factors for PTS include recurrent ipsilateral DVT, obesity, and poor quality of anticoagulant therapy. PTS diagnosis is based on the presence of typical signs and symptoms and may be made using one of several clinical scoring systems. Prevention of PTS should focus on DVT prevention and the use of elastic compression stockings following DVT, while fibrinolysis remains under investigation as an effective method for PTS prevention. The treatment of PTS may include either pharmacologic or mechanical modalities, although none of these regimens has been rigorously tested. Pharmacists have the opportunity to provide more comprehensive antithrombotic management by educating patients and providers on PTS, recommending appropriate preventive therapy, assisting patients in obtaining and adhering to this therapy, and assisting providers with the management of PTS. CONCLUSIONS Providers should be proactive in preventing PTS, with pharmacists taking an active role in optimal DVT prevention, identifying patients at risk for PTS, and counseling and directing preventive therapies.
Collapse
Affiliation(s)
- Sara R Vazquez
- University of Utah Thrombosis Service, Department of Pharmacy Services, University of Utah, Salt Lake City, UT, USA.
| | | | | | | |
Collapse
|
48
|
Prandoni P, Kahn SR. Post-thrombotic syndrome: prevalence, prognostication and need for progress. Br J Haematol 2009; 145:286-95. [DOI: 10.1111/j.1365-2141.2009.07601.x] [Citation(s) in RCA: 187] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
49
|
Kahn SR. Measurement properties of the Villalta scale to define and classify the severity of the post-thrombotic syndrome. J Thromb Haemost 2009; 7:884-8. [PMID: 19320818 DOI: 10.1111/j.1538-7836.2009.03339.x] [Citation(s) in RCA: 169] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
SUMMARY The post-thrombotic syndrome (PTS) is a frequent and important complication of deep venous thrombosis (DVT). The diagnosis of PTS is based primarily on the presence of typical symptoms and clinical signs. In the 1990s, a clinical scale known as the Villalta scale was proposed as a measure that could be used to diagnose and classify the severity of PTS. The objective of the present paper was to review the published evidence on the measurement properties of the Villalta scale. Results of the review demonstrate that the Villalta scale is a reliable and valid measure of PTS in patients with previous, objectively confirmed DVT. The scale is acceptable to research subjects and research personnel, and shows responsiveness to clinical change in PTS. Aspects of the Villalta scale that merit further evaluation include test-retest reliability, more detailed assessment of ulcer severity and assessment of responsiveness across the full range of PTS severity. Research aimed at improving the measurement of PTS will also help to improve the overall validity of findings generated by clinical studies of PTS.
Collapse
Affiliation(s)
- S R Kahn
- Division of Internal Medicine and Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, McGill University, Montréal, Canada.
| |
Collapse
|
50
|
Lozano Sánchez FS, Areitio-Aurtena Bolumburu A. [Quality of life and venous thromboembolic disease]. Med Clin (Barc) 2009; 131 Suppl 2:37-41. [PMID: 19087849 DOI: 10.1016/s0025-7753(08)76447-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Health-related quality of life (HRQoL) refers to patients' perceptions of their diseases or the application of specific treatments in various areas of their lives, especially the effects on physical, emotional and social well-being. The present article reviews current knowledge about HRQoL in venous thromboembolic disease (VTED). First, the importance and utility of the concept of HRQoL is discussed and then the instruments used to measure this concept are described. The central argument of this review has three main aims: To present the HRQoL measurement instruments designed specifically for VTED; to evaluate the impact of VTED on HRQoL in these patients; and to determine the changes produced by distinct therapeutic strategies on the already altered HRQoL in these patients. Both in the acute phase (venous thrombosis) and in the chronic phase (postthrombotic syndrome), VTED alters several dimensions of HRQoL. At all stages, treatment of VTED should aim to improve HRQoL. Do achieve this, clinical trials should incorporate HRQoL measurement in the evaluation of results.
Collapse
Affiliation(s)
- Francisco S Lozano Sánchez
- Servicio de Angiología y Cirugía Vascular, Hospital Clínico Universitario, Universidad de Salamanca, Salamanca, España.
| | | |
Collapse
|