BACKGROUND: Venous thromboembolism (VTE) is the third most common cardiovascular condition, after myocardial infarction and stroke. Prophylactic measures in accordance with current guidelines can significantly reduce the risk of VTE and the associated morbidity and mortality. Until now, the German interdisciplinary, evidence- and consensus-based (S3) clinical practice guideline on VTE prophylaxis was based on a complete review of all pertinent literature available in MEDLINE up to January 2008. More recent publications and drug approvals have made a thorough revision necessary.
METHODS: A systematic search was carried out in the MEDLINE and Embase databases for publications that appeared from 1 January 2008 to 7 August 2013. Updates of 5 national and international reference guidelines and 2 new Health Technology Assessment (HTA) reports were considered as well. A structured consensus-finding process was carried out with delegates from 27 scientific medical societies and from the Union of Medical Specialist Associations.
RESULTS: 46 randomized controlled trials (RCTs) were included for critical appraisal. New findings led to re-evaluation of the value of compression stockings in combination with pharmacological prophylaxis (open recommendation), and suggest equal value of non-vitamin K antagonist oral anticoagulants (NOACs) and low molecular weight heparins (LMWH) or fondaparinux in elective hip and knee replacement (strong recommendation). For patients undergoing hip fracture surgery, we recommend LMWH or fondaparinux.
CONCLUSION: Further research is needed to assess the value of NOACs for pharmacological prophylaxis in orthopedic/trauma patients undergoing surgical procedures other than the ones mentioned above, and into the benefit and harm of new devices available for mechanical prophylaxis. The stringent implementation of basic measures such as early mobilization, movement exercises, and patient instruction is a key point to prevent venous thrombo - embolism.
CONTEXTE: Le meilleur test disponible pour le diagnostic de thrombose veineuse profonde supérieure (UEDVT) est phlébographie de contraste. Le but de cette revue systématique était d'évaluer si la précision diagnostique des tests pour d'autres UEDVT suspicion clinique est suffisamment élevé pour justifier leur utilisation en pratique clinique et d'évaluer si un test ne peut remplacer la phlébographie.
MÉTHODES: bases de données MEDLINE et EMBASE ont été fouillés de la création à Juin 2009. Deux réviseurs indépendants ont évalué l'admissibilité des études, des données extraites, et la qualité des études évaluées.
RÉSULTATS: Nous avons identifié 17 articles, de rapports sur 793 patients. Dans l'ensemble, la qualité méthodologique était pauvre, la taille des échantillons étaient de petite taille, et les grandes entre les études des différences ont été observées dans le spectre et la conception. Les estimations sommaires de la sensibilité (95% intervalle de confiance) a été de 97% (90-100%) pour la compression échographie, 84% (72-97%) pour l'échographie-doppler, 91% (85-97%) pour l'échographie-doppler avec compression, et 85% (72 à 99%) pour phleboreography. Les estimations sommaires correspondants de la spécificité étaient, respectivement, 96% (87-100%), 94% (86-100%), 93% (80-100%), et 87% (71-100%). Les résultats cliniques, un score clinique, D-dimères, imagerie par résonance magnétique, rhéographie et pléthysmographie ont été évaluées dans une étude de chaque, impliquant un nombre médian de 46 patients (21 à 214 plage). Sensibilité et la spécificité variait de 0% à 100% et de 14% à 100%.
CONCLUSIONS: limitations méthodologiques, de grandes différences entre les études et petite taille des échantillons limiter la preuve de tests pour UEDVT cliniquement suspects. Échographie de compression peut être une alternative acceptable à la phlébographie. L'ajout de (couleur) Doppler ne semble pas améliorer la précision. Des études bien conçues sont nécessaires pour confirmer ces résultats.
OBJECTIVE: The objective of this article is to provide up-to-date information about aetiology, pathogenesis, diagnostic modalities and treatment of upper limb deep vein thrombosis (ULDVT).
METHODS: Generic terms including ULDVT, axillary-subclavian DVT, and complications of central venous catheters were searched on electronic database. We analysed original studies, review articles and evaluation studies published over the last 25 years.
RESULTS: Forty-seven studies on ULDVT encompassing 2,557 patients were evaluated. The incidence of ULDVT was quoted 1-4% of the total DVT. Primary ULDVT (20% of the total) was due to activity-related venous trauma. Secondary ULDVT (80% of the total) was due to central venous catheters and malignancy. Duplex ultrasound (sensitivity 78-100% and specificity 82-100%), contrast venography (gold standard) and magnetic resonance venography were the diagnostic tools used. Pulmonary embolism (2-35%) and post-thrombotic syndrome (7-46%) were the main sequelae. Anticoagulation was the universal intervention, giving 79% symptom relief (13.2% rethrombosis rate). Thrombolysis and/or percutaneous thrombectomy were used in 38% of cases for the management of ULDVT, giving 83% symptom relief (90% recanalization rate and 9% rethrombosis rate). Surgical decompression, venous angioplasty and superior vena cava filters were the main adjunctive interventions.
CONCLUSION: ULDVT, although rare, is associated with considerable morbidity and mortality (29-40%) due to potential risks of pulmonary embolism, post-thrombotic syndrome and loss of vascular access. Simple anticoagulation is suitable for the majority of patients. Thrombolysis/thrombectomy is often successful but less frequently used. Surgical decompression, venous angioplasty and superior vena cava filters have some role in recurrent cases. An optimal management protocol can be established using a multimodality approach.
Venous thromboembolism (VTE) is the third most common cardiovascular condition, after myocardial infarction and stroke. Prophylactic measures in accordance with current guidelines can significantly reduce the risk of VTE and the associated morbidity and mortality. Until now, the German interdisciplinary, evidence- and consensus-based (S3) clinical practice guideline on VTE prophylaxis was based on a complete review of all pertinent literature available in MEDLINE up to January 2008. More recent publications and drug approvals have made a thorough revision necessary.
METHODS:
A systematic search was carried out in the MEDLINE and Embase databases for publications that appeared from 1 January 2008 to 7 August 2013. Updates of 5 national and international reference guidelines and 2 new Health Technology Assessment (HTA) reports were considered as well. A structured consensus-finding process was carried out with delegates from 27 scientific medical societies and from the Union of Medical Specialist Associations.
RESULTS:
46 randomized controlled trials (RCTs) were included for critical appraisal. New findings led to re-evaluation of the value of compression stockings in combination with pharmacological prophylaxis (open recommendation), and suggest equal value of non-vitamin K antagonist oral anticoagulants (NOACs) and low molecular weight heparins (LMWH) or fondaparinux in elective hip and knee replacement (strong recommendation). For patients undergoing hip fracture surgery, we recommend LMWH or fondaparinux.
CONCLUSION:
Further research is needed to assess the value of NOACs for pharmacological prophylaxis in orthopedic/trauma patients undergoing surgical procedures other than the ones mentioned above, and into the benefit and harm of new devices available for mechanical prophylaxis. The stringent implementation of basic measures such as early mobilization, movement exercises, and patient instruction is a key point to prevent venous thrombo - embolism.
