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300 Current recommendations for the prevention of deep venous thrombosis
https://t.me/med1917
(e.g., aspirin or non-steroidal anti-inammatory drugs,
platelet inhibitors, or other anticoagulants).
●
Insertion of the spinal needle should be delayed for
10–12 hours aer the initial LMWH injection.
●
Regional anesthesia should be avoided in patients with
a hemorrhagic aspirate (e.g., “bloody tap”) during the
initial spinal needle placement.
●
A single-dose spinal anesthetic is preferred over continuous epidural anesthesia.
●
For patients receiving continuous anesthesia, the epidural catheter should be le indwelling overnight and
be removed the following day.
●
LMWH should be delayed for at least 2 hours aer spinal needle placement or catheter removal.
e timing of neuraxial anesthesia relative to the use
of direct oral factor inhibitor therapy is also an important variable, with limited information to guide clinicians.
Each of the respective package inserts contains a black box
warning regarding spinal and epidural hematomas with the
use of these agents and neuraxial interventions. e timing of drug discontinuation prior to neuraxial anesthesia
is not known. For rivaroxaban, catheter removal should be
delayed for at least 18 hours aer discontinuing this drug
and should not be restarted for at least 6 hours following
retrieval. For apixaban, catheter removal should be delayed
for at least 24 hours aer drug discontinuation and should
not be restarted for at least 5 hours following retrieval. If a
traumatic puncture is experienced, the timing of any drug
re-initiation should be delayed for at least 24–48 hours. For
dabigatran and edoxaban, the FDA-approved package insert
oers no specic timing suggestions, whereas optimal timing between the drug administration and neuraxial procedures is not known. Regardless of the agent, patients should
be carefully monitored for signs or symptoms of neurological impairment, with prompt assessment and intervention
should any occur.
For patients in whom spinal hematoma is suspected,
diagnostic imaging and denitive surgical therapy must
be performed as rapidly as possible in order to avoid permanent paresis. In summary, all patients receiving neuraxial anesthesia and anticoagulant prophylaxis should be
monitored carefully and frequently for early signs of cord
compression.
23.4.8 Acute stroke with lower
extremityparalysis
Low-dose heparin and LMWH are eective as prophylaxis
aer acute stroke with paresis or paralysis. IPC combined
with low-dose heparin is a more eective prophylaxis than
low-dose heparin alone.
of 2876 patients suering stroke, the CLOTS 3 investigators
compared IPC to no therapy. Aer 6 months of follow-up,
IPC therapy was associated with an absolute reduction of
proximal DVT from 8.5% to 3.6% favoring treatment.
Current guidelines recommend subcutaneous heparin
120
In a randomized controlled trial
121
prophylaxis for immobilized patients to prevent DVT (class
1; level of evidence A).
122
For patients who cannot receive anticoagulant prophylaxis, the use of aspirin is a reasonable alternative (class IIa;
level of evidence A). In the patient with stroke associated
with cerebral hemorrhage in whom anticoagulation cannot
be safely delivered, IPC may be an appropriate alternative.
Using a stroke registry study methodology, hematoma volumes were assessed by serial computed tomography imaging in 73 patients with intracranial hemorrhage and/or
intraventricular hemorrhage who received LMWH or UFH
prophylaxis.
123
Hematoma growth was identied in only two
patients. e authors concluded that pharmacological DVT
prophylaxis can be safely given to patients with intracranial
hemorrhage (ICH) and/or intraventricular hemorrhage in
the subacute period without risk of hematoma growth.
23.4.9 Acutely ill hospitalized patients
VTE is a recognized complication of hospitalization and is
a leading cause of morbidity and mortality in the acutely ill
patient.
gested in the absence of appropriate VTE prophylaxis.
shown to reduce the composite endpoint of symptomatic and asymptomatic venous thromboembolic events. A
group of 1102 hospitalized patients were randomized to
receive daily enoxaparin (20 mg or 40 mg) or placebo for
up to 14 days.
VTE rates were signicantly lower in the enoxaparin 40 mg
group (5.5%) compared to placebo (14.9%). is benet was
maintained at up to 3 months of follow-up. ere was no
dierence in major bleeding. e lower enoxaparin dose
was ineective. Similar ecacy and safety outcomes were
noted in randomized trials of dalteparin (5000 IU daily)
and fondaparinux (2.5 mg daily) compared to placebo in
acutely ill hospitalized patients.
boprophylaxis in medically ill patients has not been denitively shown. In the LIFENOX study, 8307 patients were
randomly assigned to receive enoxaparin or placebo plus
graduated elastic stockings in order to reduce the primary
ecacy outcome of all-cause mortality at 30 days.
was no dierence in death rates for those patients receiving
LMWH (4.9%) versus those who did not (4.8%). ere was
also no dierence in major bleeding (0.4% vs. 0.3%) between
groups.
safety, ecacy, and cost-eectiveness of thromboprophylaxis in hospitalized patients, and yet appropriate VTE
prophylaxis delivery is underutilized in both medically
and surgically hospitalized patients. In the multinational
cross-sectional ENDORSE study, which surveyed 68,183
patients (55% medical and 45% surgical), only half of highrisk patients (58.5% surgical and 39.5% medical patients)
received guideline-endorsed VTE prophylaxis.
interventions to improve rates of VTE prophylaxis use
124
Estimated rates of as high as 20% have been sug-
In medically ill patients, thromboprophylaxis has been
124
Combined symptomatic and asymptomatic
125,126
However, an improved survival advantage with throm-
Numerous randomized trials have demonstrated the
127
ere
128
Useful
23.5 Conclusions 301
https://t.me/med1917
include system-wide educational activities with real-time
23.5 CONCLUSIONS
alerts to providers. Multifaceted strategies were more eective than single interventions.
129
In summary, according to the recent guidelines, lowdose UFH, LMWH, or fondaparinux are safe and eective prophylaxis strategies for hospitalized patients with
other general medical conditions (grade 1B).9 For bleeding
patients, IPC would be expected to provide similar prophylaxis ecacy (grade 2C).
Guidelines 3.7.0 of the American Venous Forum on current recommendations for the prevention of deep venous thrombosis
No. Guideline
3.7.1 When the risk of bleeding from pharmacological agents is
high, we suggest using non-pharmacological methods of
venous thromboembolism prophylaxis, including elastic
compressive stockings, intermittent pneumatic compression
devices, leg elevation, and early ambulation. Each of these
reduces venous thrombotic events by approximately 20%.
3.7.2 For patients at very high risk of venous thromboembolism,
we suggest non-pharmacological methods of venous
thromboembolism prophylaxis in combination with
pharmacological agents.
3.7.3 For patients with acute venous thromboembolism within
1month who undergo urgent/emergency surgery, or if
other circumstances prohibit anticoagulation, we
recommend placement of an inferior vena cava filter.
3.7.4 We suggest against inferior vena cava filter therapy as
primary prophylaxis for unselected trauma patients.
3.7.5 We suggest that the indications for temporary, retrievable,
or optional inferior vena cava filters are the same as those
for permanent inferior vena cava filters.
3.7.6 Aspirin may provide modest risk reduction following major
joint surgery when added to other prophylaxis therapies.
3.7.7 For very-low-risk patients (Caprini score 0), the risk of
venous thromboembolism is sufficiently low that early
ambulation alone is recommended.
3.7.8 For low-risk patients (Caprini score 1–2), intermittent
pneumatic compression pumping is suggested.
3.7.9 For moderate-risk patients (Caprini score 3–4), we suggest
low-dose unfractionated heparin, prophylactic-dose
low-molecular-weight heparin, or intermittent pneumatic
compression pumping.
3.7.10 For high-risk general surgery patients (Caprini score ≥5),
either low-dose heparin or prophylactic-dose lowmolecular-weight heparin is recommended.
3.7.11 For patients undergoing cancer-related surgery, we
recommend pharmacological prophylaxis extended for
4weeks post-operatively.
3.7.12 For surgery patients at high risk of major bleeding, mechanical
prophylaxis with intermittent pneumatic compression
pumping is suggested over pharmacological prophylaxis.
In summary, VTE is the most common preventable cause
of death and suering. Providing appropriate VTE prophylaxis is the highest-ranked safety practice for patients who
are at risk. Recognition of the patient who is at risk, and
delivery of appropriate prophylaxis, is imperative in order
to reduce the incidence of VTE (including fatal PE) in hospitalized patients.
Grade of evidence
(A:high quality;
Grade of
recommendation
(1:strong; 2: weak)
2 C
2 C
1 B
2 C
2 C
1 B
1 B
2 C
2 B
1 B
1 B
2 C
B:moderate quality;
C:low or very low
quality)
Continued
302 Current recommendations for the prevention of deep venous thrombosis
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Guidelines 3.7.0 of the American Venous Forum on current recommendations for the prevention of deep venous thrombosis
Grade of evidence
(A:high quality;
B:moderate quality;
C:low or very low
quality)
No. Guideline
3.7.13 Following total joint replacement or hip fracture surgery, we
Grade of
recommendation
(1:strong; 2: weak)
1 A
recommend appropriate venous thromboembolism
prophylaxis for 10 days
3.7.14 For patients undergoing total hip arthroplasty, we
1 B
recommend either low-molecular-weight heparin,
fondaparinux (2.5 mg/day), or vitamin K antagonism with
warfarin (goal international normalized ratio: 2.0–3.0) for
prophylactic regimens. Based on the RECORD and
ADVANCE trials, both rivaroxaban and apixaban are
similarly acceptable options for this indication. Neither
dabigatran nor edoxaban are Food and Drug
Administration approved for venous thromboembolism
prophylaxis following hip replacement surgery.
3.7.15 For patients undergoing total knee replacement surgery,
1 B
either low-molecular-weight heparin, fondaparinux
(2.5 mg/day), or vitamin K antagonism with warfarin (goal
international normalized ratio: 2.0–3.0) are recommended
as prophylactic regimens for this indication. The RECORD
and ADVANCE trials justify the use of either rivaroxaban
or apixaban as reasonable alternative agents. Neither
dabigatran nor edoxaban are Food and Drug.
Administration approved for venous thromboembolism
prophylaxis following knee replacement surgery
3.7.16 For patients undergoing hip fracture surgery, fondaparinux,
1 B
low-molecular-weight heparin, or vitamin K antagonism
with warfarin are recommended as prophylactic regimens
for this indication.
3.7.17 For patients undergoing hip fracture surgery, intermittent
1 C
pneumatic compression pumping is recommended as an
acceptable alternative for patients at high risk of major
bleeding.
3.7.18 Low-dose unfractionated heparin, low-molecular-weight
1 B
heparin, or fondaparinux are recommended as safe and
effective prophylaxis strategies for hospitalized patients
with other general medical conditions.
3.7.19 For bleeding patients, we suggest intermittent pneumatic
2 C
compression for thrombosis prophylaxis.
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Axillo-subclavian venous thrombosis in the
https://t.me/med1917
setting of thoracic outlet syndrome
AURELIA T. CALERO AND KARL A. ILLIG
24
24.1 Introduction 309
24.2 Thrombolysis 309
24.3 Management after thrombolysis: Treatment
ofextrinsic compression 311
24.4 Management after thrombolysis: Treatment
ofthe subclavian vein abnormality 311
24.1 INTRODUCTION
Axillosubclavian vein thrombosis (Paget–Schroetter syndrome) is the most common manifestation of venous thoracic outlet syndrome (VTOS). e subclavian vein passes
through the anterior part of the thoracic outlet, where the
rst rib and clavicle are bound to the sternum and to each
other by the costoclavicular ligament and subclavius tendon
(Figures 24.1 and 24.2). e vein in this area can become
chronically injured if certain environmental conditions are
met, most commonly exercise with the arms over the head,
and the vein can then thrombose; this condition is thus also
termed “eort thrombosis.”
In the past, axillosubclavian vein thrombosis was
considered just another form of deep vein thrombosis
and was treated with anticoagulation and arm elevation
alone. However, this proved to result in unacceptably
poor outcomes. Chronic disability and persistent symptoms of upper extremity venous obstruction are present in
between 25% and 77% of aected patients so treated, and
pulmonary embolism can occur in 6%–15% of patients
with acute thrombosis.
Machleder at the University of California, Los Angeles
(UCLA) and several others began to aggressively treat
these patients with catheter-directed thrombolysis in the
1970s, and today, this has become the standard of care
for acute (within 14 days or so) thrombosis.
Machleder’s original algorithm incorporated a 6–12-week
1
1–5
Because of these poor results,
6,7
Although
24.5 Results 313
24.6 Conclusions 314
References 315
interval between thrombolysis and rib removal, the prevailing opinion today is that rst rib removal and intervention for any underlying venous abnormality at the
costoclavicular junction (CCJ) should be done within
days aer thrombolysis, to reduce the risk of recurrent
thrombosis.
8,9
24.2 THROMBOLYSIS
24.2.1 Indication
Most believe that any spontaneous acute axillosubclavian
thrombus represents VTOS and should be aggressively
treated. Modern techniques instill a thrombolytic agent
directly within the thrombus, and bleeding complications
are rare. e results of catheter-directed thrombolytic
therapy for any thrombosis are highly dependent on the
chronicity of the thrombus. Contemporary series report
rates of near-complete thrombus clearance when acute
thrombosis of the axillosubclavian segment is treated,
with low rates of hemorrhagic complications.
trast, once the thrombus has been present for 14 days or
so, it is much more dicult to remove the obstruction by
any means. us, a short interval from symptom onset to
initiation of thrombolysis (days to a week or so) is critical
for therapy.
Some patients present late aer symptom onset (or are
treated with anticoagulation before referral to an expert
1,10
By con-
309
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