Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (72 page)

BOOK: Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice
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Duration of anticoagulation

There remains uncertainty about the optimal duration of anticoagulation following a VTE. Systematic reviews have considered the duration of anticoagulation after an episode of VTE and have reported that, while the risk of recurrent VTE is low should anticoagulant therapy be continued, the risk of bleeding is increased.
93
Short-term anticoagulation (less than 3 months) is associated with a higher risk of recurrence compared with longer-term treatment.
94
Following cessation of oral anticoagulation after a first episode of VTE, the risk of recurrence is 7–12.9% after 1 year and 21.5–22.8% after 5 years.
9,
95

 

At least 3 months of anticoagulant therapy is required after a proximal DVT or PE; 3 months is likely sufficient after a first event if it was associated with a transient risk factor, such as surgery. Calf vein thromboses, if diagnosed, should be treated with anticoagulation for 6–12 weeks.
85

A prospective study followed 570 patients with a first episode of VTE for 2 years after the cessation of oral anticoagulant therapy.
95
The risk of recurrence at 2 years in those who had presented with VTE within 6 weeks of surgery or in pregnancy or postpartum was zero, in contrast to those who had had idiopathic events (19.4%) and those who had had a non-surgical risk factor for VTE (8.8%). Patients with a clear precipitating factor for VTE are at low risk of recurrence once stopping anticoagulation if the underlying risk factor has resolved.

Longer-term anticoagulation after a first idiopathic VTE may be appropriate in patients considered at high risk of recurrent VTE, who are at low risk of bleeding, following an individual assessment of risk factors. As active cancer and anticancer treatment both increase the risk of VTE, consideration should be given to continuing anticoagulation.

 

Key points

• 
The risk of developing VTE increases steadily with age, with 1 in 100 individuals over the age of 80 developing a VTE each year.
• 
Thromboembolism in hospital inpatients is common, developing in over 20% of general surgical patients in the absence of thromboprophylaxis. PE is a well-recognised complication of surgery, and a significant cause of perioperative morbidity and death. There are frequently no signs of DVT prior to the onset of PE.
• 
Patients can be identified to be at risk of VTE both by surgical (i.e. procedural) and patient (i.e. thrombophilia or medical comorbidity) risk factors. Undertaking a risk assessment and using appropriate thromboprophylaxis will reduce the risk of VTE.
• 
Thromboprophylaxis with a combination of mechanical and pharmacological agents is effective in preventing VTE in high-risk surgical patients. Further studies to evaluate the efficacy of newer methods (both pharmacological and mechanical) are needed.
• 
If a diagnosis of VTE is considered, appropriate investigations should be performed. Clinical pretest probability and D-dimer testing are useful in the assessment of outpatients, but have not been validated within the hospital inpatient population. Such patients should have appropriate imaging investigations undertaken. If there is a delay in investigation, therapeutic anticoagulation should be commenced unless the bleeding risks outweigh the potential benefits of anticoagulation.
• 
Anticoagulation is the mainstay of treatment for DVT and PE. If anticoagulation is contraindicated, IVC filter insertion should be considered.
References

1.
House of Commons Health Committee.
The prevention of venous thromboembolism in hospitalised patients
. London: The Stationery Office; 2005.

2.
White, R.H. The epidemiology of venous thromboembolism.
Circulation
. 2003;107(23, Suppl.):I4–I8.

3.
Naess, I.A., Christiansen, S.C., Romundstad, P., et al. Incidence and mortality of venous thrombosis: a population-based study.
J Thromb Haemost
. 2007;5:692–699.

4.
Cohen, A.T., Agnelli, G., Anderson, F.A., et al, Venous thromboembolism in Europe.
Thromb Haemost
2007;98:756–764.
17938798

5.
Buller, H.R., Sohne, M., Middeldorp, S. Treatment of venous thromboembolism.
J Thromb Haemost
. 2005;3:1554–1560.

6.
Spencer, F.A., Lessard, D., Emery, C., et al, Venous thromboembolism in the outpatient setting.
Arch Intern Med
. 2007;167(14):1471–1475.
17646600

7.
Kearon, C. Natural history of venous thromboembolism.
Circulation
. 2003;107(23):I22–I30.

8.
Geerts, W.H., Bergqvist, D., Pineo, G.F., et al. Prevention of venous thromboembolism: the Eighth ACCP Clinical Practice Guidelines.
Chest
. 2008;133(6, Suppl.):318S–453S.

9.
Pineda, L.A., Hatahwar, V.S., Grant, B.J. Clinical suspicion of fatal pulmonary embolism.
Chest
. 2001;120(3):791–795.

10.
Thomas, D.P. Pathogenesis of venous thrombosis. In: Bloom A.L., Forbes C.D., Tuddenham E.G.D., eds.
Haemostasis and thrombosis
. 3rd ed. Edinburgh: Churchill Livingstone; 1994:1327–1333.

11.
Hamilton, G., Platt, S.A. Deep vein thrombosis. In: Beard J.D., Gaines P.A., eds.
Vascular and endovascular surgery
. London: WB Saunders; 1998:351–396.

12.
Gillet, J.L., Perrin, M.R., Allaert, F.A., Short-term and mid-term outcome of isolated symptomatic muscular calf vein thrombosis.
J Vasc Surg
. 2007;46(3):513–519.
17681715

13.
Warlow, C., Ogston, D., Douglas, A.S. Deep venous thrombosis of the legs after strokes. Part I: Incidence and predisposing factors.
Br Med J
. 1976;1:1178–1181.

14.
Comerota, A.J., Stewart, G.J., Alburger, P.D., et al. Operative venodilation: a previously unsuspected factor in the cause of postoperative deep vein thrombosis.
Surgery
. 1989;106:301–309.

15.
Flynn, P.D., Byrne, C.D., Baglin, T.P., et al, Thrombin generation by apoptotic vascular smooth muscle cells.
Blood
1997;89:4378–4384.
9192761

16.
Rosendaal, F.R., Risk factors for venous thrombotic disease.
Thromb Haemost
. 1999;82(2):610–619.
10605758

17.
Lane, D.A., Mannucci, P.M., Bauer, K.A., et al, Inherited thrombophilia: part 1.
Thromb Haemost
1996;76:651–662.
8950768

18.
Lijfering, W.M., Coppens, M., Veeger, N.J., et al, Hyperhomocysteinemia is not a risk factor for venous and arterial thrombosis, and is associated with elevated factor VIII levels.
Thromb Res
. 2008;123(2):244–250.
18279917

19.
Baglin, T., Gray, E., Greaves, M., et al, Clinical guidelines for testing for heritable thrombophilia.
Br J Haematol
2010;149:209–220.
20128794

20.
Cristina, L., Benilde, C., Michela, C., et al, High plasma levels of factor VIII and risk of recurrence of venous thromboembolism.
Br J Haematol
. 2004;124(4):504–510.
14984502

21.
Bolton-Maggs, P.H., Perry, D.J., Chalmers, E.A., et al, The rare coagulation disorders – review with guidelines for management from the United Kingdom Haemophilia Centre Doctors' Organisation.
Haemophilia
2004;10:593–628.
15357789

22.
Zwicker, J., Bauer, K.A. Thrombophilia. In: Kitchens C.S., Alving B.A., Kessler C.M., eds.
Consultative hemostasis and thrombosis
. Elsevier Science; 2002:181–196.

23.
Rand, J.H., The antiphospholipid syndrome.
Hematology Am Soc Hematol Educ Program
2007:136–142.
18024621

24.
Linkins, L.A., Dans, A.L., Moores, L.K., et al, Treatment and prevention of HIT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.
Chest
2012;141:e495S–e530S.
22315270

25.
Keeling, D., Davidson, S., Watson, H., The management of heparin-induced thrombocytopenia.
Br J Haematol
2006;133:259–269.
16643427

26.
Heit, J.A., Silverstein, M.D., Mohr, D.N., et al, The epidemiology of venous thromboembolism in the community.
Thromb Haemost
. 2001;86(1):452–463.
11487036

27.
Bezemer, I.D., van der Meer, F.J., Eikenboom, J.C., et al, The value of family history as a risk indicator for venous thrombosis.
Arch Intern Med
. 2009;169(6):610–615.
19307525

28.
Prandoni, P., Samama, M.M., Risk stratification and venous thromboprophylaxis in hospitalized medical and cancer patients.
Br J Haematol
2008;141:587–597.
18422787

29.
NICE (National Institute for Health and Clinical Excellence). Clinical Guideline 144. Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing. Available at
http://publications.nice.org.uk/venous-thromboembolic-diseases-the-management-of-venous-thromboembolic-diseases-and-the-role-of-cg144
, 2012. [[accessed 06.12.12]].

30.
SIGN (Scottish Intercollegiate Guidelines Network). Guideline 122. Prevention and management of venous thromboembolism. A national clinical guideline. Available at
http://www.sign.ac.uk/pdf/sign122.pdf
, 2010. [[accessed 06.12.12]].

31.
Wu, O., Robertson, L., Langhorne, P., et al. Oral contraceptives, hormone replacement therapy, thrombophilias and risk of venous thromboembolism: a systematic review. The Thrombosis: Risk and Economic Assessment of Thrombophilia Screening (TREATS) Study.
Thromb Haemost
. 2005;94(1):17–25.

32.
Rosendaal, F.R., Van Hylckama Vlieg, A., Tanis, B.C., et al. Estrogens, progestogens and thrombosis.
J Thromb Haemost
. 2003;1:1371–1380.

33.
Jick, S., Kaye, J.A., Li, L., et al. Further results on the risk of non-fatal venous thrombembolism in users of the contraceptive transdermal patch compared to users of oral contraceptives containing norgestimate and 35 μg of ethinyl estradiol.
Contraception
. 2007;76(1):4–7.

34.
Daly, E., Vessey, M.P., Hawkins, M.M., et al, Risk of venous thromboembolism in users of hormone replacement therapy.
Lancet
1996;348:977–980.
8855852

35.
Jick, H., Derby, L.E., Myers, M.W., et al, Risk of hospital admission for idiopathic venous thromboembolism among users of postmenopausal oestrogens.
Lancet
1996;348:981–983.
8855853

36.
Grodstein, F., Stampfer, M.J., Goldhaber, S.Z., et al, Prospective study of exogenous hormones and risk of pulmonary embolism in women.
Lancet
1996;348:983–987.
8855854

37.
Wu, O. Postmenopausal hormone replacement therapy and venous thromboembolism.
Gend Med
. 2005;2(Suppl. A):S18–S27.

38.
Confidential Enquiry into Maternal and Child Health, et al, Saving Mothers' Lives: Reviewing Maternal Deaths to Make Motherhood Safer, 2006–2008. The Eigth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH; 2011. BJOG vol 118; suppl 1, March 2011.
http://www.oaa-anaes.ac.uk/assets/_managed/editor/File/Reports/2006-2008%20CEMD.pdf

39.
Watson, H.G., Baglin, T.P., Guidelines on travel-related venous thrombosis.
Br J Haematol
. 2011;152(1):31–34.
21083651

40.
Kuipers, S., Cannegieter, S.C., Middeldorp, S., et al, The absolute risk of venous thrombosis after air travel: a cohort study of 8755 employees of international organizations.
PLoS Med
. 2007;4(9):e290.
17896862

41.
Cannegieter, S.C., Doggen, C.J., van Houwelingen, H.C., et al, Travel-related venous thrombosis: results from a large population-based case control study (MEGA study).
PLoS Med
. 2006;3(8):e307.
16933962

42.
Decousus, H., Quere, I., Presle, E., et al, Superficial vein thrombosis and venous thromboembolism: a large, prospective epidemiological study.
Ann Intern Med
2010;152:218–224.
20157136

43.
Sweetland, S., Green, J., Liu, B., et al. Duration and magnitude of the postoperative risk of venous thromboembolism in middle aged women: prospective cohort study.
Br Med J
. 2009;339:b4583.

44.
White, R.H., Zhou, H., Romano, P.S., Incidence of symptomatic venous thromboembolism after different elective or urgent surgical procedures.
Thromb Haemost
2003;90:446–455.
12958614

45.
Thromboembolic Risk Factors (THRIFT) Consensus Group. Risk of, and prophylaxis for, venous thromboembolism in hospital patients.
Br Med J
. 1992;305:567–574.

46.
Sachdeva, A., Dalton, M., Amaragiri, S.V., et al. Elastic compression stockings for prevention of deep vein thrombosis.
Cochrane Database Syst Rev
. (7):2010. [CD001484].

47.
Wells, P.S., Lensing, A.W., Hirsh, J. Graduated compression stockings in the prevention of postoperative venous thromboembolism. A meta-analysis.
Arch Intern Med
. 1994;154:67–72.
Graduated compression stockings significantly reduce venous thromboembolic disease in moderate-risk patients (insufficient evidence in high-risk orthopaedic surgery).

48.
Amaragiri, S.V., Lees, T.A. Elastic compression stocking for prevention of deep vein thrombosis.
Cochrane Database Syst Rev
. (3):2000. [CD001484].
A review of randomised controlled trials that confirms the efficacy of stockings in prevention of venous thromboembolic disease in hospitalised patients.

49.
Comerota, A.J., Chouhan, V., Harada, R.N., et al, The fibrinolytic effects of intermittent pneumatic compression: mechanism of enhanced fibrinolysis.
Ann Surg
1997;226:306–313.
9339937

50.
Chouhan, V.D., Comerota, A.J., Sun, L., et al, Inhibition of tissue factor pathway during intermittent pneumatic compression: a possible mechanism for antithrombotic effect.
Arterioscler Thromb Vasc Biol
1999;19:2812–2817.
10559031

51.
Browse, N.L., Burnand, K.G., Irvine, A.T., et al. Deep vein thrombosis: prevention. In: Browse N.L., Burnand K.G., Irvine A.T., eds.
Diseases of the veins
. 2nd ed. London: Arnold; 1999:359–383.

52.
Watson, H.G., Chee, Y.L., Aspirin and other antiplatelet drugs in the prevention of venous thromboembolism.
Blood Rev
2008;22:107–116.
18226435

53.
Imperiale, T.F., Speroff, T., A meta-analysis of methods to prevent venous thromboembolism following total hip replacement.
JAMA
1994;271:1780–1785.
7515115

54.
Antiplatelet Trialists' Collaboration. Collaborative overview of randomized trials of antiplatelet therapy – III: Reduction in venous thrombosis and pulmonary embolism by antiplatelet prophylaxis among surgical and medical patients.
Br Med J
. 1994;308:235–246.

55.
Pulmonary Embolism Prevention (PEP) Trial, Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin.
Lancet
2000;355:1295–1302.
10776741

56.
Collins, R., Scrimgeour, A., Yusuf, S., et al, Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin. Overview of results of randomized trials in general, orthopaedic and urological surgery.
N Engl J Med
1988;318:1162–1173.
3283548

57.
Leizorovicz, A., Haugh, M.C., Chapuis, F.R., et al. Low molecular weight heparin in prevention of perioperative thrombosis.
Br Med J
. 1992;305:913–920.

58.
Nurmohamed, M.T., Rosendaal, F.R., Buller, H.R., et al, Low-molecular-weight heparin versus standard heparin in general and orthopaedic surgery: a meta-analysis.
Lancet
1992;340:152–156.
1352573

59.
Bergqvist, D., Burmark, U.S., Flordal, P.A., et al, Low molecular weight heparin started before surgery as prophylaxis against deep vein thrombosis: 2500 versus 5000 Xai units in 2070 patients.
Br J Surg
1995;82:496–501.
7613894

60.
Agnelli, G., Bergqvist, D., Cohen, A.T., et al, Randomized clinical trial of postoperative fondaparinux versus perioperative dalteparin for prevention of venous thromboembolism in high-risk abdominal surgery.
Br J Surg
. 2005;92(10):1212–1220.
16175516

61.
Bergqvist, D., Lowe, G.D., Berstad, A., et al, Prevention of venous thromboembolism after surgery: a review of enoxaparin.
Br J Surg
1992;79:495–498.
1319256

62.
Bergqvist, D., Agnelli, G., Cohen, A.T., et al, Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer.
N Engl J Med
. 2002;346(13):975–980.
11919306

63.
Arumilli, B.R., Lenin Babu, V. Paul AS. Painful swollen leg: think beyond deep vein thrombosis or Baker's cyst.
World J Surg Oncol
. 2008;6:6.

64.
Wells, P.S. Integrated strategies for the diagnosis of venous thromboembolism.
J Thromb Haemost
. 2007;5(Suppl. 1):41–50.

65.
Wells, P.S., Anderson, D.R., Bormanis, J., et al, Value of assessment of pretest probability of deep vein thrombosis in clinical management.
Lancet
1997;350:1795–1798.
9428249

66.
Keeling, D.M., Mackie, I.J., Moody, A., et al. The Haemostasis and Thrombosis Task Force of the British Committee for Standards in Haematology. The diagnosis of deep vein thrombosis in symptomatic outpatients and the potential for clinical assessment and D-dimer assays to reduce the need for diagnostic imaging.
Br J Haematol
. 2004;124(1):15–25.

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