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Ikesaka R, Kaur B, Crowther M, Rajasekhar A. Efficacy and safety of pre-operative insertion of inferior vena cava filter in patients undergoing bariatric surgery: a systematic review. J Thromb Thrombolysis 2022; 54:502-523. [PMID: 35960423 DOI: 10.1007/s11239-022-02689-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2022] [Indexed: 10/15/2022]
Abstract
Prophylactic placement of inferior vena cava (IVC) filters prior to performing bariatric surgery is an intervention of unclear safety and efficacy with disagreement between current practice guidelines. To better characterize the risk and benefit of IVC filter insertion prior to bariatric surgery based on the current evidence. A systematic review of the literature of patients with prophylactic IVC filter insertion prior to bariatric surgery was performed and 32 studies were identified for inclusion into the review, of which none were randomized controlled trials. Meta-analysis was performed including the high-quality included studies. Seven high quality studies reported thrombotic events in patients undergoing bariatric surgery who had an IVCF and a control group which allowed for meta-analysis. The pooled odds ratio of venous thrombotic events in the IVC filter population versus the group without IVC filters was 1.57 (95%CI 0.89, 2.76). Among high quality studies 5 reported major bleeding with a rate of 0.76% and 6 reported on IVC filter complications with a rate of 0.67%. Overall no significant reduction in the rate of venous thrombosis was found with prophylactic IVC filter insertion. Use of IVC filters for prophylaxis remains a concern given the lack of clear efficacy in this setting and a small but present complication risk.
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Affiliation(s)
| | - Bhagwanpreet Kaur
- Health Research Methodology, McMaster University, Hamilton, ON, Canada
| | | | - Anita Rajasekhar
- Division of Hematology/Oncology, Department of Medicine, University of Florida, Gainesville, FL, USA
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Anderson DR, Morgano GP, Bennett C, Dentali F, Francis CW, Garcia DA, Kahn SR, Rahman M, Rajasekhar A, Rogers FB, Smythe MA, Tikkinen KAO, Yates AJ, Baldeh T, Balduzzi S, Brożek JL, Ikobaltzeta IE, Johal H, Neumann I, Wiercioch W, Yepes-Nuñez JJ, Schünemann HJ, Dahm P. American Society of Hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients. Blood Adv 2019; 3:3898-3944. [PMID: 31794602 PMCID: PMC6963238 DOI: 10.1182/bloodadvances.2019000975] [Citation(s) in RCA: 270] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/22/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common source of perioperative morbidity and mortality. OBJECTIVE These evidence-based guidelines from the American Society of Hematology (ASH) intend to support decision making about preventing VTE in patients undergoing surgery. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline-development process, including performing systematic reviews. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 30 recommendations, including for major surgery in general (n = 8), orthopedic surgery (n = 7), major general surgery (n = 3), major neurosurgical procedures (n = 2), urological surgery (n = 4), cardiac surgery and major vascular surgery (n = 2), major trauma (n = 2), and major gynecological surgery (n = 2). CONCLUSIONS For patients undergoing major surgery in general, the panel made conditional recommendations for mechanical prophylaxis over no prophylaxis, for pneumatic compression prophylaxis over graduated compression stockings, and against inferior vena cava filters. In patients undergoing total hip or total knee arthroplasty, conditional recommendations included using either aspirin or anticoagulants, as well as for a direct oral anticoagulant over low-molecular-weight heparin (LMWH). For major general surgery, the panel suggested pharmacological prophylaxis over no prophylaxis, using LMWH or unfractionated heparin. For major neurosurgery, transurethral resection of the prostate, or radical prostatectomy, the panel suggested against pharmacological prophylaxis. For major trauma surgery or major gynecological surgery, the panel suggested pharmacological prophylaxis over no prophylaxis.
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Affiliation(s)
- David R Anderson
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Gian Paolo Morgano
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Charles W Francis
- Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
| | - David A Garcia
- Division of Hematology, Department of Medicine, University of Washington Medical Center, University of Washington School of Medicine, Seattle, WA
| | - Susan R Kahn
- Department of Medicine, McGill University and Lady Davis Institute, Montreal, QC, Canada
| | | | - Anita Rajasekhar
- Division of Hematology and Oncology, Department of Medicine, University of Florida, Gainesville, FL
| | - Frederick B Rogers
- Trauma and Acute Care Surgery, Penn Medicine Lancaster General Health, Lancaster, PA
| | - Maureen A Smythe
- Department of Pharmaceutical Services, Beaumont Hospital, Royal Oak, MI
- Department of Pharmacy Practice, Wayne State University, Detroit, MI
| | - Kari A O Tikkinen
- Department of Urology and
- Department of Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Adolph J Yates
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Tejan Baldeh
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Sara Balduzzi
- Department of Diagnostic, Clinical, and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Jan L Brożek
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine and
| | | | - Herman Johal
- Center for Evidence-Based Orthopaedics, Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Ignacio Neumann
- Department of Internal Medicine, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Holger J Schünemann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine and
| | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, MN; and
- Department of Urology, University of Minnesota, Minneapolis, MN
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Sheu AY, Hoang NS, Kesselman AJ, Liang T, Rosenberg JK, Kuo WT. Prophylactic IVC filter placement in bariatric surgery patients: results from a prospective filter registry. CVIR Endovasc 2019; 1:13. [PMID: 30652145 PMCID: PMC6319537 DOI: 10.1186/s42155-018-0021-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 06/27/2018] [Indexed: 12/16/2022] Open
Abstract
Background Bariatric surgery patients are at increased risk for VTE, but potential risks versus benefits of IVC filters in this group remain unclear. Indwelling filters may increase risk of VTE, and removal of filters in obese patients can be challenging. This study evaluated the incidence of VTE in select bariatric patients receiving prophylactic IVC filters, their risk of filter-related complications, and outcomes from attempted filter retrieval. Results Postsurgical DVT occurred in 3 patients within 3 months postoperatively (3%)(95%CI:1-9%), and 1 patient(1%)(95%CI:0-5%) developed acute low-risk PE at 31 days postoperatively, prior to filter removal. All VTE patients were successfully managed with therapeutic anticoagulation alone except one who required thrombolysis. Median filter dwell time was 54 days (range:22-1548), and there were no major filter-related complications (0%)(95%CI:0-3%). Retrieval was attempted in 104 cases (97%)(95%CI:92-99%) and successful in 104 cases (100%)(95%CI:97-100%). Thirty-three patients (32%)(95%CI:23-42%) required advanced techniques for filter removal, and there were no major procedural complications (0%)(95%CI:0-3%). Median follow-up occurred at 344 days (range:3-1570) days after filter retrieval. Conclusions No cases of life-threatening post-op PE occurred in this cohort of high-risk bariatric surgery patients receiving prophylactic IVC filters in combination with mechanical and chemoprophylaxis. The risk of filter-related complications was low and retrieval success was high with adjunctive use of advanced techniques. Clinical trial registration NCT01158482.
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Affiliation(s)
- Alexander Y Sheu
- Division of Vascular and Interventional Radiology, Stanford University Medical Center, 300 Pasteur Drive, H-3651, Stanford, CA 94305-5642 USA
| | - Nam Sao Hoang
- Division of Vascular and Interventional Radiology, Stanford University Medical Center, 300 Pasteur Drive, H-3651, Stanford, CA 94305-5642 USA
| | - Andrew J Kesselman
- Division of Vascular and Interventional Radiology, Stanford University Medical Center, 300 Pasteur Drive, H-3651, Stanford, CA 94305-5642 USA
| | - Tie Liang
- Division of Vascular and Interventional Radiology, Stanford University Medical Center, 300 Pasteur Drive, H-3651, Stanford, CA 94305-5642 USA
| | - Jarrett K Rosenberg
- Division of Vascular and Interventional Radiology, Stanford University Medical Center, 300 Pasteur Drive, H-3651, Stanford, CA 94305-5642 USA
| | - William T Kuo
- Division of Vascular and Interventional Radiology, Stanford University Medical Center, 300 Pasteur Drive, H-3651, Stanford, CA 94305-5642 USA
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Overby DW. Inferior vena cava filters in patients undergoing bariatric surgery: Good intentions, dubious outcomes. Surg Obes Relat Dis 2018; 15:115-116. [PMID: 30579717 DOI: 10.1016/j.soard.2018.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 11/12/2018] [Indexed: 11/18/2022]
Affiliation(s)
- David Wayne Overby
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Dalla Vestra M, Grolla E, Bonanni L, Pesavento R. Are too many inferior vena cava filters used? Controversial evidences in different clinical settings: a narrative review. Intern Emerg Med 2018; 13:145-154. [PMID: 27873159 DOI: 10.1007/s11739-016-1575-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 11/12/2016] [Indexed: 10/20/2022]
Abstract
The use of inferior vena cava filters to prevent pulmonary embolism is increasing mainly because of indications that appear to be unclearly codified and recommended. The evidence supporting this approach is often heterogeneous, and mainly based on observational studies and consensus opinions, while the insertion of an IVC filter exposes patients to the risk of complications and increases health care costs. Thus, several proposed indications for an IVC filter placement remain controversial. We attempt to review the proof on the efficacy and safety of IVC filters in several "special" clinical settings, and assess the robustness of the available evidence for any specific indication to place an IVC filter.
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Affiliation(s)
- Michele Dalla Vestra
- Department of Internal Medicine, Angiology Unit, Ospedale dell'Angelo, Via Paccagnella 11, 30174, Mestre (VE), Italy.
| | | | - Luca Bonanni
- Department of Internal Medicine, Ospedale dell'Angelo, Mestre (VE), Italy
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Meyer G, Parent F, Mismetti P, Girard P. Medical literature, vena cava filters and evidence of efficacy. Thromb Haemost 2017; 111:761-9. [DOI: 10.1160/th13-07-0601] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 11/03/2013] [Indexed: 11/05/2022]
Abstract
SummaryUp to 15% of all patients with venous thromboembolism (VTE) receive an inferior vena cava filter, and prophylactic placements are increasing. To determine whether current use of filters is based on robust evidence, a global review of the recent (2001–2012) literature on filters was undertaken. The MEDLINE database was searched for articles related to filters appearing during the period 2001–2012, updating a prior search of literature from 1975–2001. All retrieved articles were analysed, classified into predetermined categories and compared to the prior analysis; randomised and large (>100 patients with a filter) comparative non-randomised clinical studies were read in full. The 651 articles, vs 568 in the period 1975–2000, consisted mainly of retrospective series (37.8%), case reports (31.7%), reviews (14.7%, vs 6.7%, p<0.001), animal and/or in vitro studies (7.5%, vs 12.9%, p=0.002), and prospective series or trials (4.9%, vs 7.4%, p=0.07). Of 4 new randomised trials (RCT), none were designed to test the efficacy of the device; to date, only one RCT has attempted to ascertain efficacy, occurring during the period 1975–2000. Eleven large non-randomised studies compared clinical outcomes of patients with and without filters, in VTE patients (n=5) or prophylactic indications (n=6); two studies found statistically significant relationships between filter use and lower mortality rates, though none could demonstrate a causal relationship. Hence, the plethoric literature on filters parallels growing experience with these devices, but still fails to provide reliable evidence that filter use improves relevant clinical outcomes. No indication for filter placement is based on appropriate scientific evidence.
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Bartlett MA, Mauck KF, Daniels PR. Prevention of venous thromboembolism in patients undergoing bariatric surgery. Vasc Health Risk Manag 2015; 11:461-77. [PMID: 26316771 PMCID: PMC4544624 DOI: 10.2147/vhrm.s73799] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Bariatric surgical procedures are now a common method of obesity treatment with established effectiveness. Venous thromboembolism (VTE) events, which include deep vein thrombosis and pulmonary embolism, are an important source of postoperative morbidity and mortality among bariatric surgery patients. Due to an understanding of the frequency and seriousness of these complications, bariatric surgery patients typically receive some method of VTE prophylaxis with lower extremity compression, pharmacologic prophylaxis, or both. However, the optimal approach in these patients is unclear, with multiple open questions. In particular, strategies of adjusted-dose heparins, postdischarge anticoagulant prophylaxis, and the role of vena cava filters have been evaluated, but only to a limited extent. In contrast to other types of operations, the literature regarding VTE prophylaxis in bariatric surgery is notable for a dearth of prospective, randomized clinical trials, and current professional guidelines reflect the uncertainties in this literature. Herein, we summarize the available evidence after systematic review of the literature regarding approaches to VTE prevention in bariatric surgery. Identification of risk factors for VTE in the bariatric surgery population, analysis of the effectiveness of methods used for prophylaxis, and an overview of published guidelines are presented.
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Affiliation(s)
- Matthew A Bartlett
- Division of General Internal Medicine, Mayo Clinic Thrombophilia Center, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Karen F Mauck
- Division of General Internal Medicine, Mayo Clinic Thrombophilia Center, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Paul R Daniels
- Division of General Internal Medicine, Mayo Clinic Thrombophilia Center, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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Rowland SP, Dharmarajah B, Moore HM, Lane TRA, Cousins J, Ahmed AR, Davies AH. Inferior Vena Cava Filters for Prevention of Venous Thromboembolism in Obese Patients Undergoing Bariatric Surgery. Ann Surg 2015; 261:35-45. [DOI: 10.1097/sla.0000000000000621] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Bos A, Van Ha T, van Beek D, Ginsburg M, Zangan S, Navuluri R, Lorenz J, Funaki B. Strut penetration: local complications, breakthrough pulmonary embolism, and retrieval failure in patients with Celect vena cava filters. J Vasc Interv Radiol 2014; 26:101-6. [PMID: 25446424 DOI: 10.1016/j.jvir.2014.09.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Revised: 09/10/2014] [Accepted: 09/16/2014] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To investigate strut penetration in patients with Celect filters, specifically local complications and association with breakthrough pulmonary embolism (PE) or retrieval failure. MATERIALS AND METHODS A retrospective single-center study was conducted to evaluate patients who received Celect filters between January 2007 and May 2013. A total of 595 filters were placed during the study period. Primary indications included thromboembolic disease (93%) and primary surgical prophylaxis (7%). Complications and retrieval data were assessed by computed tomography (CT) and electronic medical records. RESULTS A total of 193 patients underwent follow-up abdominal CT at a mean follow-up interval of 176.2 days (range, 0-1,739 d). The rate of strut penetration more than 3 mm outside the caval wall was 28.5% (n = 55). One patient had CT evidence of clinically major strut penetration (1.8%) with strut compression of the right ureter causing hydronephrosis. Indwelling filter time longer than 100 days was associated with strut penetration (P < .001). Age, sex, and history of thromboembolic disease were not associated with strut penetration (P = .51, P = .81, and P = .89). Sixty-three patients presented for follow-up CT pulmonary angiography at a mean of 128.1 days (range, 1-895 d). The rate of breakthrough PE was 12.7%. The overall retrieval success rate was 96.7% (n = 150). Strut penetration was not associated with breakthrough PE or retrieval failure (P = .49 and P = .22). CONCLUSIONS Although strut penetration is a common complication with Celect filters, there is no association with breakthrough PE or retrieval failure. CT evidence of local complications associated with strut penetration is rare.
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Affiliation(s)
- Aaron Bos
- Department of Radiology, University of Chicago Medical Center, 5841 S. Maryland Ave., MC 2026, Chicago, IL 60637.
| | - Thuong Van Ha
- Department of Radiology, University of Chicago Medical Center, 5841 S. Maryland Ave., MC 2026, Chicago, IL 60637
| | - Darren van Beek
- Department of Radiology, University of Chicago Medical Center, 5841 S. Maryland Ave., MC 2026, Chicago, IL 60637
| | - Michael Ginsburg
- Department of Radiology, University of Chicago Medical Center, 5841 S. Maryland Ave., MC 2026, Chicago, IL 60637
| | - Steven Zangan
- Department of Radiology, University of Chicago Medical Center, 5841 S. Maryland Ave., MC 2026, Chicago, IL 60637
| | - Rakesh Navuluri
- Department of Radiology, University of Chicago Medical Center, 5841 S. Maryland Ave., MC 2026, Chicago, IL 60637
| | - Jonathan Lorenz
- Department of Radiology, University of Chicago Medical Center, 5841 S. Maryland Ave., MC 2026, Chicago, IL 60637
| | - Brian Funaki
- Department of Radiology, University of Chicago Medical Center, 5841 S. Maryland Ave., MC 2026, Chicago, IL 60637
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The efficacy of prophylactic IVC filters in gastric bypass surgery. Surg Endosc 2014; 29:882-9. [DOI: 10.1007/s00464-014-3746-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 07/11/2014] [Indexed: 10/24/2022]
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13
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Kaw R, Pasupuleti V, Wayne Overby D, Deshpande A, Coleman CI, Ioannidis JP, Hernandez AV. Inferior vena cava filters and postoperative outcomes in patients undergoing bariatric surgery: a meta-analysis. Surg Obes Relat Dis 2014; 10:725-33. [DOI: 10.1016/j.soard.2014.04.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 03/21/2014] [Accepted: 04/09/2014] [Indexed: 12/20/2022]
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Nelson JA, Fischer JP, Cleveland EC, Wink JD, Serletti JM, Kovach SJ. Abdominal wall reconstruction in the obese: an assessment of complications from the National Surgical Quality Improvement Program datasets. Am J Surg 2014; 207:467-75. [PMID: 24507860 DOI: 10.1016/j.amjsurg.2013.08.047] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 07/26/2013] [Accepted: 08/01/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study utilizes the American College of Surgeons National Surgical Quality Improvement Program database to better understand the impact of obesity on perioperative surgical morbidity in abdominal wall reconstruction (AWR). METHODS We reviewed the 2005 to 2010 American College of Surgeons National Surgical Quality Improvement Program databases, identifying cases of AWR and examining early complications in the context of obesity (body mass index > 30, World Health Organization classes 1 to 3). RESULTS Of 1,695 patients undergoing AWR, 1,078 (63.2%) patients were obese (mean body mass index = 37.6 kg/m(2)). Major surgical complications (15.3% vs 10.1%, P = .003), wound complications (12.5% vs 8.1%, P = .006), medical complications (16.2% vs 11.2%, P = .005) and return to the operating room (9.1% vs 5.4%, P = .006) were significantly increased, while renal complications (1.9% vs .8%, P = .09) neared significance. On logistic regression, obesity only directly led to a significantly increased odds of having a renal complication (odds ratio = 4.4, P = .04). Complications were still noted to increase with World Health Organization classification, including a concerning incidence of venous thromboembolism. CONCLUSIONS Although the incidence of complications increased with obesity, obesity itself does not appear to increase the odds of perioperative morbidity. Specific care should be given to VTE prophylaxis and to preventing renal complications.
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Affiliation(s)
- Jonas A Nelson
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - John P Fischer
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Emily C Cleveland
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Jason D Wink
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Joseph M Serletti
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Stephen J Kovach
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
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Abstract
Inferior vena cava filter (IVCF) use continues to increase in the United States (US) despite questionable clinical benefit and increasing concerns over long-term complications. For this review we comprehensively examine the randomized, prospective data on IVC filter efficacy, compare relative rates of IVCF placement in the US and Europe, compare commonly considered guidelines for IVCF indications, and the current data on IVCF complications. Searches of MEDLINE and Cochrane databases were conducted for randomized prospective IVCF studies. Only three randomized prospective studies for IVCFs were identified. Commonly cited IVCF guidelines were reviewed with attention to their evolution over time. No evidence has shown a survival benefit with IVCF use. Despite this, continued rising utilization, especially for primary prophylactic indications, is concerning, given increasing evidence of long-term filter-related complications. This is particularly noted in the US where IVCF placements for 2012 are projected to be 25 times that of an equivalent population in Europe (224,700 versus 9,070). Pending much-needed randomized controlled trials that also evaluate long-term safety, we support the more stringent American College of Chest Physicians (ACCP) guidelines for IVCF placement indications and advocate a close, structured follow-up of retrievable IVCFs to improve filter retrieval rates.
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Affiliation(s)
- Stephen L Wang
- Division of Vascular and Interventional Radiology, Kaiser Permanente Santa Clara , Santa Clara, CA , USA
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Pulmonary embolism and fatal stroke in a patient with severe factor XI deficiency after bariatric surgery. Blood Coagul Fibrinolysis 2013. [PMID: 23187784 DOI: 10.1097/mbc.0b013e32835bdbec] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report the case of a 40-year-old woman with a severe factor XI (FXI) deficiency who died from a stroke due to bilateral internal carotid arteries occlusion after a laparoscopic gastric bypass (bariatric surgery). This stroke was probably secondary to a pulmonary embolism with a paradoxical embolism through a previously unknown foramen ovale. This woman who had one severe episode of bleeding before the bypass received for the intervention a single infusion of 27 U/kg of FXI concentrate. A careful evaluation of the bleeding and thrombotic risk was performed before surgery, and despite all preventive measures, this tragic event occurred. The aim of this report is to alert medical teams to carefully balance the benefit-risk of such an intervention in a patient with a severe FXI deficiency.
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Morales JP, Li X, Irony TZ, Ibrahim NG, Moynahan M, Cavanaugh KJ. Decision analysis of retrievable inferior vena cava filters in patients without pulmonary embolism. J Vasc Surg Venous Lymphat Disord 2013; 1:376-84. [PMID: 26992759 DOI: 10.1016/j.jvsv.2013.04.005] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Revised: 04/09/2013] [Accepted: 04/22/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND Retrievable filters are increasingly implanted for prophylaxis in patients without pulmonary embolism (PE) but who may be at transient risk. These devices are often not removed after the risk of PE has diminished. This study employs decision analysis to weigh the risks and benefits of retrievable filter use as a function of the filter's time in situ. METHODS Medical literature on patients with inferior vena cava (IVC) filters and a transient risk of PE were reviewed. Weights reflecting relative severity were assigned to each adverse event. The risk score was defined as weight × occurrence rate and combines the frequency and severity for each type of adverse event. The value function in the decision model combines the following risks: (1) risk in situ; (2) risk of removal, and (3) relative risk without filters. A decreasing net risk score represents a net expected benefit, and an increasing net risk score indicates the expected harm outweighs the expected benefit. RESULTS The net risk score reaches its minimum between day 29 and 54 postimplantation. This is consistent with an increasing net risk associated with continued use of retrievable IVC filters in patients with transient, reversible risk of PE. The results were insensitive to reasonable variations in the assessed weights and adverse event occurrence rates. CONCLUSIONS For patients with retrievable IVC filters in whom the transient risk of PE has passed, quantitative decision analysis suggests the benefit/risk profile begins to favor filter removal between 29 and 54 days after implantation.
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Affiliation(s)
- Jose Pablo Morales
- Office of Device Evaluation, Division of Cardiovascular Devices, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, Md.
| | - Xuefeng Li
- Office of Surveillance and Biometrics, Division of Biostatistics, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, Md
| | - Telba Z Irony
- Office of Surveillance and Biometrics, Division of Biostatistics, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, Md.
| | - Nicole G Ibrahim
- Office of Device Evaluation, Division of Cardiovascular Devices, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, Md
| | - Megan Moynahan
- Office of the Center Director, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, Md
| | - Kenneth J Cavanaugh
- Office of Device Evaluation, Division of Cardiovascular Devices, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, Md
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Birkmeyer NJ, Finks JF, English WJ, Carlin AM, Hawasli AA, Genaw JA, Wood MH, Share DA, Birkmeyer JD. Risks and benefits of prophylactic inferior vena cava filters in patients undergoing bariatric surgery. J Hosp Med 2013; 8:173-7. [PMID: 23401464 DOI: 10.1002/jhm.2013] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 12/18/2012] [Accepted: 12/23/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND The United States Food and Drug Administration recently issued a warning about adverse events in patients receiving inferior vena cava (IVC) filters. OBJECTIVE To assess relationships between IVC filter insertion and complications while controlling for differences in baseline patient characteristics and medical venous thromboembolism prophylaxis. DESIGN Propensity-matched cohort study. SETTING The prospective, statewide, clinical registry of the Michigan Bariatric Surgery Collaborative. PATIENTS Bariatric surgery patients (n=35,477) from 32 hospitals during the years 2006 through 2012. INTERVENTION Prophylactic IVC filter insertion. MEASUREMENTS Outcomes included the occurrence of complications (pulmonary embolism, deep vein thrombosis, and overall combined rates of complications by severity) within 30 days of bariatric surgery. RESULTS There were no significant differences in baseline characteristics among the 1,077 patients with IVC filters and in 1,077 matched control patients. Patients receiving IVC filters had higher rates of pulmonary embolism (0.84% vs 0.46%; odds ratio [OR], 2.0; 95% confidence interval [CI], 0.6-6.5; P=0.232), deep vein thrombosis (1.2% vs 0.37%; OR, 3.3; 95% CI, 1.1-10.1; P=0.039), venous thromboembolism (1.9% vs 0.74%; OR, 2.7; 95% CI, 1.1-6.3, P=0.027), serious complications (5.8% vs 3.8%; OR, 1.6; 95% CI, 1.0-2.4; P=0.031), permanently disabling complications (1.2% vs 0.37%; OR, 4.3; 95% CI, 1.2-15.6; P=0.028), and death (0.7% vs 0.09%; OR, 7.0; 95% CI, 0.9-57.3; P=0.068). Of the 7 deaths among patients with IVC filters, 4 were attributable to pulmonary embolism and 2 to IVC thrombosis/occlusion. CONCLUSIONS We have identified no benefits and significant risks to the use of prophylactic IVC filters among bariatric surgery patients and believe that their use should be discouraged.
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Affiliation(s)
- Nancy J Birkmeyer
- Center for Healthcare Outcomes and Policy and Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA.
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Wehrenberg-Klee E, Stavropoulos SW. Inferior vena cava filters for primary prophylaxis: when are they indicated? Semin Intervent Radiol 2013; 29:29-35. [PMID: 23450194 DOI: 10.1055/s-0032-1302449] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Over the past several years there has been a rapid increase in the number of inferior vena cava (IVC) filters placed for primary thromboprophylaxis. Increased use has occurred in settings where other methods of thromboprophylaxis are viewed to be inadequate, technically challenging, or that place patients at an unacceptably high bleeding risk. These clinical services include trauma, bariatric surgery, neurosurgery, cancer, intensive care unit populations, and patients with a relative contraindication to anticoagulation. We review the studies to date addressing filter placement for these indications. Although preliminary data are promising, the patient populations most likely to benefit from prophylactic IVC filter placement have not been well defined, and randomized studies demonstrating efficacy have not been conducted. Moving forward, it will be critical to accomplish these two tasks if IVC filters are to continue to have a role in primary thromboprophylaxis.
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Affiliation(s)
- Eric Wehrenberg-Klee
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Stein PD, Matta F. Pulmonary Embolism and Deep Venous Thrombosis Following Bariatric Surgery. Obes Surg 2013; 23:663-8. [DOI: 10.1007/s11695-012-0854-2] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Shamian B, Chamberlain RS. The Role for Prophylaxis Inferior Vena Cava Filters in Patients Undergoing Bariatric Surgery: Replacing Anecdote with Evidence. Am Surg 2012. [DOI: 10.1177/000313481207801227] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The number of patients choosing surgical alternatives for weight reduction continues to increase. Despite common thromboembolic preventive methods, which include perioperative subcutaneous heparin injections, early mobilization, and sequential compression devices, postoperative deep vein thrombosis/pulmonary embolism remains a devastating complication after bariatric surgery. The role prophylactic inferior vena cava (IVC) filters may play in bariatric surgery remains controversial, and this article aims to address the risks and benefits of prophylactic IVC filters in high-risk bariatric patients and suggest an evidence-based algorithm for their use.
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Affiliation(s)
- Ben Shamian
- Department of Surgery, Saint Barnabas Medical Center, Livingston, New Jersey
| | - Ronald S. Chamberlain
- Department of Surgery, Saint Barnabas Medical Center, Livingston, New Jersey
- Department of Surgery, University of Medicine and Dentistry of New Jersey, Newark, New Jersey
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Abstract
Enhanced recovery after surgery (ERAS) programs have been shown to minimise morbidity in other types of surgery, but comparatively less data exist investigating ERAS in bariatric surgery. This article reviews the existing literature to identify interventions which may be included in an ERAS program for bariatric surgery. A narrative literature review was conducted. Search terms included 'bariatric surgery', 'weight loss surgery', 'gastric bypass', 'ERAS', 'enhanced recovery', 'enhanced recovery after surgery', 'fast-track surgery', 'perioperative care', 'postoperative care', 'intraoperative care' and 'preoperative care'. Interventions recovered by the database search, as well as interventions garnered from clinical experience in ERAS, were used as individual search terms. A large volume of evidence exists detailing the role of multiple interventions in perioperative care. However, efficacy and safety for a proportion of these interventions for ERAS in bariatric surgery remain unclear. This review concludes that there is potential to implement ERAS programs in bariatric surgery.
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Overby DW, Kohn GP, Colton KJ, Stavas JM, Dixon RG, Passannante A, Farrell TM. Central Venous Line Placement prior to Gastric Bypass Improves Operating Room Efficiency. ISRN SURGERY 2012; 2012:816871. [PMID: 22830049 PMCID: PMC3399345 DOI: 10.5402/2012/816871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 04/19/2012] [Indexed: 11/23/2022]
Abstract
Background. Bariatric surgery has increased across America. Venous access is difficult in these patients. Anesthesiologists often utilize valuable operating room (OR) time acquiring reliable intravenous lines. Our objective was to determine if outpatient central venous line (CVL) placement improves OR efficiency and professional reimbursement for CVL insertion. Methods. In our bariatric practice, selected surgery patients have outpatient CVLs placed during prophylactic vena cava filter placement. In a cohort of 268 gastric bypass patients operated between 1/01 and 11/06, we compared time-to-incision between 106 with pre-established CVLs and 162 without. In addition, we determined professional compensation rates for CVLs placed outpatient versus CVLs inserted in the OR. Results. Patients with preoperative (outpatient) CVLs required 35.6 ± 12.5 minutes to skin incision compared with 42.5 ± 13.9 minutes for controls (P < 0.0001), and 34.9% had skin incision in <30 minutes compared with 16.4% of controls. Radiologists collected 28.2% of outpatient billings for CPT code 36556, compared with anesthesiologists who collected <1% when placing CVLs in the OR. Conclusions. Outpatient CVLs prior to gastric bypass improve efficiency in the OR with earlier skin incision. Professional reimbursement is better for outpatient CVLs than intraoperative inpatient CVLs.
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Affiliation(s)
- D Wayne Overby
- Department of Surgery, The University of North Carolina at Chapel Hill, Campus Box 7081, Chapel Hill, NC 27599, USA
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Li W, Gorecki P, Semaan E, Briggs W, Tortolani AJ, D'Ayala M. Concurrent prophylactic placement of inferior vena cava filter in gastric bypass and adjustable banding operations in the Bariatric Outcomes Longitudinal Database. J Vasc Surg 2012; 55:1690-5. [DOI: 10.1016/j.jvs.2011.12.056] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Revised: 12/09/2011] [Accepted: 12/22/2011] [Indexed: 01/10/2023]
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Rajasekhar A, Crowther MA. ASH evidence-based guidelines: what is the role of inferior vena cava filters in the perioperative prevention of venous thromboembolism in bariatric surgery patients? Hematology Am Soc Hematol Educ Program. 2009;2009:302–304. Hematology 2011. [DOI: 10.1182/asheducation.v2011.1.561.3730330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Buchwald H, Ikramuddin S, Dorman RB, Schone JL, Dixon JB. Management of the metabolic/bariatric surgery patient. Am J Med 2011; 124:1099-105. [PMID: 22014789 DOI: 10.1016/j.amjmed.2011.05.035] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Revised: 05/11/2011] [Accepted: 05/11/2011] [Indexed: 01/06/2023]
Abstract
There is currently a global pandemic of obesity and obesity-engendered comorbidities; in particular, certain major chronic metabolic diseases (eg, type 2 diabetes) which markedly reduce life expectancy and quality of life. This review is predicated on the fact that management of the obese patient is a primary concern of all physicians and health care providers, and that metabolic/bariatric surgery is a highly successful therapeutic option for this disease.
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Affiliation(s)
- Henry Buchwald
- Department of Surgery, University of Minnesota, Minneapolis, 55455, USA.
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Rajasekhar A, Crowther MA. ASH evidence-based guidelines: what is the role of inferior vena cava filters in the perioperative prevention of venous thromboembolism in bariatric surgery patients? Hematology Am Soc Hematol Educ Program. 2009;2009:302-304. Hematology 2011. [DOI: 10.1182/asheducation-2011.1.561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
Managing patients who are morbidly obese in the intensive care unit is associated with a variety of problems uncommonly experienced with the those who are not morbidly obese. Clinicians experience a myriad of unique problems and circumstances, from the need for special beds and lifts to unusual and unknown volumes of distribution resulting in unclear drug dosing. This review examines several issues including sedation, invasive monitoring, venous thromboembolism prophylaxis, surgical infections, nutritional support, and other complications that may be of particular importance to the critically ill patient who is morbidly obese. In many cases, care is altered based on the complicating issues surrounding morbid obesity. In other cases, the presence of obesity suggests no alterations in our routine critical care delivery. A comprehensive review of the literature is undertaken, data are critically considered, and overall opinion is rendered based on the available peer-reviewed literature. In many cases, data are not available that address the specific patient population in question, so related papers (like gastric bypass data) are considered. Many issues do not have definitive answers based on randomized controlled trials, and much is left to treating clinician opinion and local practice patterns. Where good data exist, however, one should consider carefully and individually deviation from the evidence-based approach.
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Rajasekhar A, Crowther M. Inferior vena caval filter insertion prior to bariatric surgery: a systematic review of the literature. J Thromb Haemost 2010; 8:1266-70. [PMID: 20345723 DOI: 10.1111/j.1538-7836.2010.03858.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Placement of inferior vena cava filters (IVCFs) is considered in many patients undergoing bariatric surgery. Their placement is driven by a high rate of pulmonary embolism (PE), uncertainty as to the effectiveness of pharmacologic prophylaxis, and a lack of alternate methods to prevent pulmonary embolism. We performed a systematic review of the literature to evaluate the evidence supporting placement of IVCFs in patients undergoing bariatric surgery. Eleven studies were identified; none were randomized trials. Descriptive analysis suggests that IVCFs reduced PE; however, the strength of this observation is tempered by the lack of use of effective forms of prophylaxis and the failure to account for complications of IVCF placement. We conclude, pending the results of controlled studies, that the use of IVCFs cannot be recommended for routine patients undergoing bariatric surgery.
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Affiliation(s)
- A Rajasekhar
- Department of Medicine, University of Florida, Gainesville, FL, USA
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Overby DW, Kohn GP, Cahan MA, Galanko JA, Colton K, Moll S, Farrell TM. Prevalence of thrombophilias in patients presenting for bariatric surgery. Obes Surg 2009; 19:1278-85. [PMID: 19579050 DOI: 10.1007/s11695-009-9906-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2009] [Accepted: 06/15/2009] [Indexed: 12/19/2022]
Abstract
BACKGROUND The rise in bariatric surgery has driven an increased number of complications from venous thromboembolism (VTE). Evidence supports obesity as an independent risk factor for VTE, but the specific derangements underlying the hypercoagulability of obesity are not well defined. To better characterize VTE risk for the purpose of tailoring prophylactic strategies, we developed a protocol for thrombophilia screening in patients presenting for bariatric surgery at our institution. METHODS Between April 2004 and April 2006, 180 bariatric surgery candidates underwent serologic screening for inherited thrombophilias (Factor V-Leiden mutation, low Protein C activity, low Protein S activity, Free Protein S deficiency) and acquired thrombophilias (D-Dimer elevation, Fibrinogen elevation, elevation of coagulation factors VIII, IX, and XI, elevation of Lupus anticoagulants and homocysteine level, and Antithrombin III deficiency). Prevalence rate of each thrombophilia in the subject group was compared to the actual prevalence rate of the general population. RESULTS Most plasma markers of both inherited and acquired thrombophilias were identified in higher than expected proportions, including D-Dimer elevation in 31%, Fibrinogen elevation in 40%, Factor VIII elevation in 50%, Factor IX elevation in 64%, Factor XI elevation in 50%, and Lupus anticoagulant in 13%. CONCLUSIONS Obesity is a well-described demographic risk factor for VTE. In bariatric surgery candidates routinely screened for serologic markers, both inherited and acquired thrombophilias occurred more frequently than in the general population, and may therefore prove to be useful for individualized VTE risk assessment and prophylaxis.
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Affiliation(s)
- D Wayne Overby
- Department of Surgery, University of North Carolina at Chapel Hill, Campus Box 7081, Chapel Hill, NC 27599-7081, USA.
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Rajasekhar A, Crowther MA. ASH evidence-based guidelines: what is the role of inferior vena cava filters in the perioperative prevention of venous thromboembolism in bariatric surgery patients? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2009; 2009:302-304. [PMID: 20008214 DOI: 10.1182/asheducation-2009.1.302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
A 38-year-old morbidly obese male (BMI > 50 kg/m(2)) presents for an elective gastric bypass surgery. He has no personal or family history of venous thromboembolism or hypercoaguability. You are asked by his primary team whether he should receive a retrievable inferior vena cava filter preoperatively for venous thromboembolism prophylaxis.
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Affiliation(s)
- Anita Rajasekhar
- Division of Hematology/Oncology, Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
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