The outcome of ambulatory DVT management using a multidisciplinary approach

Outpatient Management of Deep Vein Thrombosis: a Model with a Breakdown of the Continuum of Care

Objectives

For emergency department (ED) patients with deep venous thrombosis (DVT) treated as outpatients, to determine treatment duration, complications and follow-up arrangements, in particular thrombophilia screening.

Methods

Explicit, retrospective medical record review of patients with an ED discharge diagnosis of DVT over a three-year period. Data collected included demographics, location of DVT, duration of treatment, complications, hospital admission, mortality, follow-up arrangements and referral for thrombophilia screening. Main outcomes were the duration of treatment, rate of complications and requirement for hospital admission, follow-up arrangements and referral for thrombophilia screening for patients treated as outpatients.

Results

Two hundred and fourteen patients with DVT were identified, of whom 74 [35%] were treated as outpatients. For this group, the median duration of treatment was eight days. There was one death from advanced neoplasia, two proven pulmonary emboli (PE) [2.7%, 95% CI 0.74–9.3%] and one suspected PE [1.4%, 95% CI 0.24–7.3%]. One patient had a recurrence of DVT within three months [1.4%, 95% CI 0.24–7.3%]. Few patients received specialist follow-up [25/74, 34%]. In 20 cases [27%], thrombophilia screening was neither performed nor recommended, despite no obvious cause for the DVT.

Conclusion

Outpatient treatment of selected DVT is safe, although there is a small incidence of non-fatal PE. Follow-up and screening arrangements were sub-optimal in the study sample and treatment duration was long. An ambulatory care model with direct physician control is recommended to improve follow-up arrangements, monitor service performance and ensure that the service evolves with new evidence and processes.

Modest response in translation to home management of deep venous thrombosis

BACKGROUND

years may elapse between the publication of results of rigorous randomized trials and changes in clinical practice. It is not often that a definitive time interval can be identified that shows the time taken for published clinical trials to affect clinical practice. In the present study, we track the timelines of evidence for home treatment of deep venous thrombosis and its eventual impact on hospitalizations and early discharge.

METHODS

the number of patients discharged from short-stay hospitals throughout the United States between 1979 and 2006 with a principal diagnosis of deep venous thrombosis and the proportion discharged in ≤ 2 days was determined from The National Hospital Discharge Survey. We also attempted to identify all published articles that reported home treatment of deep venous thrombosis in unselected populations.

RESULTS

eleven years after demonstration of the safety and efficacy of home treatment, there was only a 21% decrease in the population-based incidence of hospitalizations of patients with a principal diagnosis of deep venous thrombosis. The proportion of patients with a principal diagnosis of deep venous thrombosis who were discharged in ≤ 2 days began to increase prominently after the 1996 publication of trials showing the safety and efficacy of home treatment, and continued to increase through 2006. However, the proportion discharged early remained modest (21% to 25%).

CONCLUSIONS

whether the slow implementation of home treatment reflects a cautious approach accompanied by a gradual testing of shortened hospitalization for deep venous thrombosis or other factors is uncertain.

Stenting of Common Iliac Vein Obstructions Combined with Regional Thrombolysis and Thrombectomy in Acute Deep Vein Thrombosis

OBJECTIVES

To evaluate the efficacy of stent placement after infrainguinal loco-regional thrombolysis and iliac thrombectomy (surgical TT) of acute deep vein thrombosis (DVT) in patients with May-Thurner-Syndrome.

MATERIAL AND METHODS

We retrospectively analysed a group of 11 patients (9 women) (mean age 34 years, range 16-64 years) with surgical TT and additional intra-operative stenting due to compression of the common iliac vein. Patients underwent venography to demonstrate outflow patency after surgical TT, and to identify any obstruction at the level of the left-sided common iliac vein ("Beckenvenen-Sporn"). Obstruction at the level of arterial crossing was treated using Wallstents placed via an introducer sheath from the inguinal access site. Stents were fully deployed using balloons adjusted to the size of vein. Patients were treated with oral anticoagulants for 6 months, and followed using duplex ultrasonography.

RESULTS

Technical success defined as complete vein patency and normal valve function was documented in all 11 patients. One patient needed early stent extension due to residual stenosis. At 6 months follow-up one patient (9%) had an asymptomatic occlusion of the stented common iliac vein. In all 11/11 (100%) patients the femoral segment was found to be patent, and in 1/11 (9%) there was mild reflux with few clinical symptoms of post-thrombotic syndrome. The calculated cumulative primary patency rate for venous iliac stents was 82%, and assisted patency rate was 91%, which remained unchanged over a mean follow-up of 22 months.

CONCLUSION

Combining surgical TT and stenting of common iliac vein obstructions in DVT is safe, effective, and results in a acceptable venous patency.

Stopping warfarin therapy is unnecessary for hand surgery

Interruption of appropriate therapeutic warfarin therapy imposes a risk of morbidity and mortality on the patient. Strategies to reduce the risks of interruption impose relatively large costs in terms of prolonged hospital stay, medication and coagulation monitoring. We report a series of 47 consecutive surgical episodes on the hands of 39 patients without interruption of therapeutic warfarin anticoagulation and with an INR of between 1.3 and 2.9. There was no difficulty with intraoperative haemostasis. Two patients had minor bleeding-related complications with no long-term sequelae. The authors conclude that interruption to warfarin therapy is unnecessary if the INR is less than 3.0 and therefore inappropriate for therapeutically anticoagulated patients undergoing hand surgery.

Tinzaparin sodium: a review of its pharmacology and clinical use in the prophylaxis and treatment of thromboembolic disease

Tinzaparin sodium (tinzaparin; innohep) is a low molecular weight heparin (LMWH) formed by the enzymatic degradation of porcine unfractionated heparin (UFH). In clinical trials, once-daily subcutaneous (SC) tinzaparin was effective and generally well tolerated in the prophylaxis and treatment of thromboembolic disease. SC tinzaparin 75 anti-Xa IU/kg/day showed similar thromboprophylactic efficacy to adjusted-dosage oral warfarin in patients undergoing total hip arthroplasty; in patients undergoing knee replacement, the incidence of deep vein thrombosis (DVT) was significantly lower with tinzaparin. The drug had similar efficacy to equivalent-dosage SC enoxaparin sodium in orthopaedic surgery. In patients undergoing general surgery, SC tinzaparin 3500 anti-Xa IU/day was of equivalent thromboprophylactic efficacy to SC UFH 5000IU twice daily. Encouraging preliminary results have been obtained with tinzaparin in the prevention of DVT in patients with complete motor paralysis. In the initial treatment of acute proximal DVT and pulmonary embolism, SC tinzaparin 175 anti-Xa IU/kg/day was at least as effective as adjusted-dosage intravenous (IV) UFH. In the outpatient treatment of venous thromboembolism, tinzaparin has demonstrated similar efficacy to dalteparin sodium (dalteparin) and warfarin. Tinzaparin was effective in preventing clotting in haemodialysis circuits; the anticoagulant efficacy of tinzaparin in patients undergoing haemodialysis was similar to that of SC dalteparin and similar to or less than (although in this case the tinzaparin dose was too low for sufficient anticoagulant efficacy) that of IV UFH. Advantages of tinzaparin over UFH and warfarin include ease of administration and lack of need for laboratory monitoring. Tinzaparin is more cost effective than UFH in the treatment of established thromboembolic disease, and home-based treatment with tinzaparin may offer greater cost benefits than hospital-based therapy. Tinzaparin is well tolerated, including in elderly patients and those with renal impairment receiving long-term treatment. Incidences of major bleeding complications were low and reports of heparin-induced thrombocytopenia were infrequent in clinical studies. In conclusion, tinzaparin is a valuable LMWH in the prophylaxis and management of thromboembolic disease.