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PubMed1996

[Venous thromboembolic disease and pregnancy].

Venous thrombo-embolic disease is the most common cause of maternal death during pregnancy. Haemodynamic, anatomical and biological changes support the notion that normal pregnancy in a prethrombotic state. But thrombotic events remain unusual episodes. A pre-thrombotic disease has to be investigated in such cases. Accurate diagnosis of deep vein thrombosis or pulmonary embolism is imperative, using non-invasive approaches. Heparin is the anticoagulant of choice to treat objective thrombosis. Thrombo-embolism prophylaxis using compression stockings and heparin has to be discussed in hypercoagulable disorders.

Female↗

PubMed1996

[Treatment of venous thromboembolic disease].

Except for the indications of thrombolytic treatment in severe pulmonary embolism, anticoagulant drugs are the treatment of venous thromboembolism. Low molecular weight heparins once or twice a day are at present the treatment of choice for deep venous thrombosis, however they do not have the legal indication for pulmonary embolism yet. Oral anticoagulants are started as soon as possible and are continued for at least 12 weeks with an INR maintained between 2 and 3. The use of low molecular weight heparins as long term treatment is at present in evaluation but seems promising. Early mobilization associated with compression stockings is an important part of the treatment.

Ambulatory Care↗

PubMed1996

[Prevention of venous thromboembolic disease].

The prevention of post-operative venous thromboembolic accidents is well documented. This is in contrast to prophylaxis in medical patients. In surgical patients, prophylaxis should take into consideration the risk associated with the operation and the patient's risk factors. Low molecular weight heparins (LMWH) are frequently used since they more convenient and at least as efficiacious or somewhat superior to subcutaneous administration of unfractionated heparin (UH). Gradued compression stockings are recommended for low or moderate risk of thrombosis. Their use in combination with LMWH is limited to high risk patients. Oral anticoagulants are mainly used when long term prophylaxis starting with LMWH administration is required. Several meta-analysis and consensus conferences in France, Europe or North-America have provided recommendations, the comparison of which shows a great homogeneity. It is generally accepted that the recommendations made for surgical patients may be extrapolated to medical patients. The medical situations associated with an increased risk of thrombosis which are well documented are cancer, myocardial infarction, cardiac insufficiency, ischemic cerebro-vascular accidents with paralysis of lower limb(s), acute respiratory insufficiency in patients admitted to intensive care unit, prolonged immobilisation in elderly invalid patients and paralysis of the limbs due to spinal trauma. Prophylactic treatment in medical patients is still empirical. The use of LMWH in these patients is related to results obtained when unfractionated heparin is used and in rare controlled clinical trials where LMWH were compared to UH.

Abdomen↗

PubMed1996

[Familial venous dysplasia and lymphedema].

We report on a familial case of venous dysplasia of the deep veins characterized by clinical chronic venous insufficiency with subsequent lymphedema (phlebolymphedema). Successful therapy consists of physical therapy in the acute phase and was followed for over eight years with compression stockings.

Adolescent↗

PubMed1995

Subcutaneous low-molecular weight heparin or oral anticoagulants for the prevention of deep-vein thrombosis in elective hip and knee replacement? Fraxiparine Oral Anticoagulant Study Group.

OBJECTIVE: To compare efficacy, safety, and feasibility of adjusted-dose oral anticoagulants (OAC) versus fixed-dose subcutaneous low molecular weight heparin (LMWH) for the prevention of deep venous thrombosis (DVT) in patients who have undergone elective hip or knee replacement. DESIGN: Multicentre, single blind randomised trial. OAC (acenocoumarol, target International Normalised Ratio, 2.0-3.0) and LMWH (nadroparine, 60 aXa IU/kg once daily) were started preoperatively and continued for 10 days. All outcome measures were adjudicated by an independent committee unaware of treatment allocation. SUBJECTS: 672 consecutive patients scheduled for elective hip or knee replacement surgery. All patients wore bilateral graduated compression stockings. MAIN OUTCOME MEASURES: The endpoint for the assessment of efficacy was venography confirmed DVT or confirmed symptomatic pulmonary embolism. The endpoint for the assessment of safety was clinically important bleeding during study treatment or within 48 h of the end of treatment. RESULTS: Among the 517 patients with interpretable venograms, 391 had a hip replacement and 126 had a knee implant. DVT was demonstrated in 50 (20%) of 257 patients allocated to OAC and 43 (17%) of 260 patients allocated to nadroparine (p = 0.45), for an absolute difference in DVT incidence of 2.9% in favour of nadroparine (95% CI, -3.7-9.5). Clinically important bleeding occurred in eight (2.3%) of the 342 oral anticoagulant treated patients and in five (1.5%) of the 330 nadroparine treated patients (p = 0.62), for an absolute difference in favour of nadroparine of 0.8% (95% Cl, -1.3-2.9). CONCLUSION: Patients who undergo major orthopaedic operations have a high risk of venous thromboembolism. Once daily fixed-dose subcutaneous nadroparine is at least as efficacious and safe as daily adjusted OAC for prophylaxis against DVT after hip or knee implantation but is more simple to administer.

Administration, Oral↗

PubMed1997

A short course of low-molecular-weight heparin to prevent deep venous thrombosis after elective total hip replacement.

OBJECTIVE: To determine the efficacy of a short course of low-molecular-weight heparin (enoxaparin) in the prevention of deep venous thrombosis and pulmonary embolism after elective total hip replacement. DESIGN: A prospective cohort study. Follow-up was a minimum of 3 months. SETTING: An acute-care hospital with a large-volume practice of elective total joint replacement. PATIENTS: A prospective group of 150 patients who required primary total hip arthroplasty and a historic control group of 150 patients. All patients were treated with compression stockings, indomethacin and early mobilization. The treatment group received low-molecular-weight heparin, 30 mg every 12 hours for 5 days postoperatively; the control group received no specific anticoagulant therapy. INTERVENTIONS: Total hip replacement. Doppler venography on postoperative day 5 and 2 to 5 days later if required. MAIN OUTCOME MEASURES: Presence or absence of deep venous thrombosis. Wound hemorrhage, transfusion rate, number of units of blood transfused and changes in the hemoglobin level. RESULTS: The incidence of proximal deep venous thrombosis (popliteal vein to common iliac vein) was 0% in the treatment group versus 4% in the control group. There was no difference in bleeding or number of transfusions required. There was, however, a significant (p = 0.005) drop in hemoglobin level in the treatment group. CONCLUSIONS: A short course of low-molecular-weight heparin provides effective protection against proximal deep venous thrombosis without significantly increasing the risk to the patient. The treatment is compatible with early patient discharge and the pharmacologic prevention of heterotopic ossification after total joint replacement.

Anticoagulants↗

PubMed1997

On the relationship between changes in the deep veins evaluated by duplex sonography and the postthrombotic syndrome 12 years after deep vein thrombosis.

In a prospective study we performed color duplex ultrasonography to evaluate patency and valvular function of previous thrombosed veins 12 years after the acute thrombosis. Normal clinical findings were found in 64% of the patients, mild postthrombotic skin changes in 28%, and marked trophic changes in 5%; only 1 venous ulcer occurred. In 39 patients, 114 initially thrombosed vein segments were evaluated. Thirty-seven of 72 proximal segments were completely recanalized (23 with valvular incompetence) and 21 segments exhibited partial recanalization (19 with valvular incompetence). Superficial femoral vein segments were completely occluded in 19%, however, excellent collateralization was provided via the deep femoral vein. Thromboses of the posterior tibial vein demonstrated a high rate of recanalization with development of valvular incompetence in 52%. Whereas obstruction and valvular incompetence as single factors led to a postthrombotic leg in 8.5% and 33%, respectively, the most frequent cause for the development of the postthrombotic syndrome was the combination of reflux plus obstruction in the deep veins (50%). Compression therapy with elastic compression stockings is recommended for at least 5 years after the acute thrombosis.

Adult↗

PubMed1997

The cost and benefit of prophylaxis against deep vein thrombosis in elective hip replacement. DVT/PE Prophylaxis Consensus Forum.

UNLABELLED: A consensus forum was convened to evaluate the economic considerations associated with prophylaxis against thrombo-embolic disease in patients undergoing hip replacement therapy in South Africa. This forum consists of orthopaedic surgeons, vascular surgeons and a statistician. METHODS: The forum was instructed to evaluate the economic costs of the commonly used forms of prophylaxis of thrombo-embolism in patients undergoing hip replacement surgery in South Africa, looking at short-term events only. The methods used for the prophylaxis of thrombo-embolism in South Africa were determined by a postal survey. A decision tree was constructed to determine the events that will occur after a clinical decision to use no prophylaxis. The probabilities of these events were then determined. Protocols for and costs of prophylaxis and treatment were established. With the decision tree and these costs, the cost of the various modalities of prophylaxis was then determined. RESULTS: The probability, determined by the forum, of developing a deep-vein thrombosis (DVT) when no prophylaxis is used was 0.5, with a mortality rate of 2.1%. The cost of this decision was R875. No prophylaxis given, but a venogram performed on day 7, reduced the mortality rate to 0.7%; however, this cost R3 017. The cost of low-molecular-weight heparin was R1 223 (probability 0.26, mortality rate 1.1%), while unfractionated heparin with a graduated compression stocking (GCS) cost R1 351 (probability 0.24, mortality rate 1%). Aspirin with a GCS cost R777 (probability 0.35, mortality rate 1.5%).

Anticoagulants↗

PubMed1996

Intermittent edema of the upper and lower extremities and the abdominal wall caused by membranous stenosis of the superior vena cava and membranous obstruction of the inferior vena cava.

We report on a 38-year-old patient with intermittent edema of the lower legs, arms and abdominal wall. The cause for his tendency to develop edema was a membranous obstruction of the inferior vena cava and a membranous stenosis of the superior vena cava. The etiology of these anomalies of the vena cava suggests a congenital malformation. In consideration of the cases of inferior and/or superior vena cava-anomalies published to date the patient received an anticoagulant therapy (coumarin) and treatment with graduated compression stockings. He now complains from time to time of a sensation tension in the lower legs after prolonged standing or sitting. Edema of the upper and lower extremities and the abdominal wall have disappeared.

Abdominal Muscles↗

PubMed1997

[Prevention of the extension of distal deep venous thrombosis. A randomized controlled trial with a 6-month follow-up].

BACKGROUND: Deep venous thrombosis (DVT) of distal veins of the legs is important for its frequency and its potential proximal extension. The incidence of embolization in distal DVT is limited and treatment still undefined. METHODS: After diagnosing with duplex scanning a distal DVT patients were included in a 24-week follow-up. All subjects used elastic compression (stockings TED = thromboembolic deterrent) for 24 weeks after DVT. In the 4 groups the following prophylaxis for 8 weeks were used: A: oral anticoagulant (INR 2.5). B: subcutaneous calcium heparin 0.2 ml bid (8.00 and 20.00). C: subcutaneous calcium heparin (0.5 ml at 20.00). D was the control group (only elastic TED stockings). heparin 0.2 ml bid (5000 IU) and 0.5 ml once daily (12.500 IU) were used for individuals with weight range between 65 and 90 kg. No patient was admitted into hospitals. Initially 106 patients were included. There were 17 (9.6%) drop outs and after 8 weeks 177 patients completed the study. No pulmonary embolisation or side effects were observed. In one patient (control group) an important extension of the thrombus to the femoral and iliac veins was observed. RESULTS: The percentage of thrombus reduction was higher in the treatment groups than in controls (p < 0.05). No significant differences were found among the 3 treatment groups. At 8 weeks 88.6% of patients treated with oral anticoagulant showed improvement (stability/reduction in size of the thrombus; the percentage was 88.4% in subjects treated with subcutaneous heparin bid and 93.2% in those treated with a single dosage). In the control group thrombus increase was observed in 78.3% of patients (this difference was significant in comparison with the treatment groups; p < 0.05). At the 24-week control in 97.6% of patients in group A thrombosis was reduced/stable. This percentage was 97.7% in the ca-heparin double-dose group (B) and 100% in the single dose group (C), significantly lower than in group D (75%; p < 0.05). CONCLUSIONS: Results indicate that untreated subjects with distal DVT are at risk of thrombus extension. In this study treatments were clinically equivalent. However one single dose of subcutaneous heparin is as effective as the double dose, is better tolerated, does not require haematological monitoring and has a lower cost.

Administration, Oral↗

PubMed1998

[Risk factors and prevention of thromboembolic risk in laparoscopy].

The aim of this prospective study was to assess the clinical thrombo-embolic risk in laparoscopic digestive surgery. The study prospectively included 2384 patients, who underwent surgery between April 1991 and June 1997. All patients received peri-operative Low Molecular Weight Heparin (LMWH) thromboprophylaxis. This regimen was administered until the patients resumed normal ambulatory activity. Eight cases of phlebitis were observed (3.36/1000), but no pulmonary embolism was noted. In six out of eight cases, the diagnosis of deep vein thrombosis was established after cessation of LMWH delivery, after the patients were discharged home, and before day postoperative 10. Pneumoperitoneum predisposes to deep vein thrombosis formation. Long operations, and reverse Trendelenburg are aggravating factors. In laparoscopy, heparin thromboprophylaxis has to be identical to that of open conventional surgery; i.e. appropriate for the potential risks and must be delivered for a duration of 7 to 10 days. We recommend the use of graduated compression stockings, to reduce intra-abdominal pressure and the duration of reverse Trendelenburg, and to perform intermittent exsufflation.

Adolescent↗

PubMed1996

Inelastic versus elastic leg compression in chronic venous insufficiency: a comparison of limb size and venous hemodynamics.

PURPOSE: Compression of the lower extremity is the mainstay of therapy in patients who have chronic venous insufficiency. We evaluated the ability of two forms of compression-elastic stockings and an inelastic compression garment-with air plethysmography to determine how well they corrected abnormal deep venous hemodynamics in patients who had class III chronic venous insufficiency and how well this correction was sustained over time. METHODS: Patients had measurements taken with no compression, with a 30 to 40 mm Hg below-knee stocking, and with the inelastic compression garment 2 hours and 6 hours after donning the garments. Therapies were compared with baseline and with themselves over time. RESULTS: Inelastic compression maintained limb size and reduced venous volume better than no compression or stockings over time (ankle circumference at 2 hr vs 6 hr: baseline, 24.7 +/- 7 cm vs 26.1 +/- 1.1 cm; stocking, 23.9 +/- 1.1 cm vs 26.2 +/- 1.2 cm; inelastic compression, 25.4 +/- 1.1 cm vs 25.4 +/- 0.9 cm; venous volume at 2 hr vs 6 hr: baseline, 97.5 +/- 14.1 ml vs 105.2 +/- 17.9 ml; stocking, 112.4 +/- 29.7 ml vs 77.5 +/- 13.2 ml; inelastic compression, 72.2 +/- 14.1 ml vs 56.1 +/- 10.2 ml). At 6 hours, the ejection fraction was increased and the venous filling index was significantly less with inelastic compression compared with the stocking and baseline (ejection fraction at 6 hr: baseline, 61.6% +/- 6.9%; stocking, 75.9% +/- 17.7%; inelastic compression, 78.8% +/- 12.2%). CONCLUSIONS: Inelastic compression has a significant effect on deep venous hemodynamics by decreasing venous reflux and improving calf muscle pump function when compared with compression stockings, which may exert their primary effect on the superficial venous system.

Adult↗

PubMed1996

Morphology of rod stock and compression-moulded sheets of ultra-high-molecular-weight polyethylene used in orthopaedic implants.

Compression-moulded sheets and extruded rods of ultra-high-molecular-weight polyethylene (UHMWPE) are currently used in the production of joint replacement prostheses. Crystallographic texture present in rods and sheets of UHMWPE was measured using a combination of small-angle X-ray scattering and wide-angle X-ray diffraction. Crystallographic texture can induce anisotropy in macroscopic properties of polymers, such as modulus and yield stress. Both rods and sheets of UHMWPE revealed a low but discernible degree of preferred orientation of polyethylene chains within crystallites. There was a spatial variation in crystallographic orientation in extruded rods. The direction of chain alignment within crystallites located near the outer surface of rods was orthogonal to the radial direction, whereas the chain direction was orthogonal to the axial or extrusion direction in crystallites located near the centreline of extruded rods. Crystallographic texture was spatially uniform in compression-moulded sheets with the chain direction within crystallites aligned orthogonal to the moulding direction. In both cases the induced crystallographic texture can be explained in terms of crystallization from an oriented melt.

Anisotropy↗

PubMed2001