Method of venous thromboembolism prophylaxis is not a predictor of pulmonary embolus following elective bariatric surgery: a retrospective cohort study of 135,409 patients

BackgroundPatients with obesity are at increased risk of pulmonary embolus (PE), a risk that increases perioperatively and is challenging to manage.ObjectiveAn analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was performed to determine predictors of PE in patients undergoing elective bariatric surgery.SettingNorth American accredited bariatric surgery institutions included in the MBSAQIP database from 2020–2021.MethodsWe extracted data from the MBSAQIP database (2020–2021) on patients who underwent elective Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Data were extracted on patient co-morbidities, race, prior history of deep vein thrombosis (DVT), and type of DVT prophylaxis. A multivariate logistic regression model was developed to determine predictors of PE and impact of PE on 30-day serious complications and mortality.ResultsIn the MBSAQIP database, a total of 135,409 patients underwent SG or RYGB from 2020 to 2021. PE was reported in 194 patients (.14%). Prior history of DVT (odds ratio [OR] = 3.28; 95% confidence interval [CI]: 1.85–5.83; P < .0001), Black race (OR = 3.03; 95% CI: 2.22–4.13; P < .0001), gastroesophageal reflux disease (OR = 1.51; 95% CI: 1.11–2.04; P = .008), higher body mass index (OR = 1.11; 95% CI: 1.01–1.20; P = .023), male sex (OR = 1.76; 95% CI: 1.26–2.45; P = .001), and older age (OR = 1.27; 95% CI: 1.10–1.46; P = .001) were associated with increased odds of PE. Chronic obstructive pulmonary disease, sleep apnea, and hypertension were not significant predictors of PE (P > .05). Neither combined mechanical and pharmacologic DVT prophylaxis nor pharmacologic prophylaxis alone was a significant predictor of PE (P > .05).ConclusionPrior history of DVT is the strongest predictor of PE after bariatric surgery. African American race, male sex, and gastroesophageal reflux disease are additional risk factors. Method of venous thromboembolism prophylaxis was not identified as significant predictor of PE. Further, studies on the evaluation and optimization of venous thromboembolism prophylaxis are required.     

Micropunch grafting for healing of refractory chronic venous leg ulcers

BackgroundChronic venous ulcers are a serious problem for both patients and physicians. The CEAP classification (clinical manifestations (C), etiologic factors (E), anatomic distribution of disease (A), and underlying pathophysiologic findings (P)) for chronic venous disorders (CVD) was developed in 1994. Published papers on CVD use all or part of the CEAP. Micropunch grafts, which are a variation of skin grafts, have been used with great success in plastic surgery for both esthetic and reconstructive purposes. This study aimed to assess the outcomes of micropunch grafting in the treatment of chronic refractory venous ulcers.MethodsPatients with chronic venous ulcers who did not respond to conservative treatment for more than 6 months were included in the study. All patients underwent ulcer coverage by micropunch skin grafts using a micrometer. The patients were discharged on the same day as the surgery. Micropunch skin grafts were manually counted per square centimeter intraoperatively and during follow-up using Dermlite Dermatoschope? II Pro HR. Patient satisfaction was assessed by using a questionnaire.ResultsTwenty patients underwent the surgery. Most of the patients were middle-aged males. The ulcers were predominantly small- and medium-sized. The mean operation time was 167.00 ?± ?86.01 ?min. After 6 months, the survival rate of the planted micrografts was 84%. Three ulcers had graft loss and two patients had an infection at the ulcer site, which was managed conservatively. The patients were followed-up for 14 months.ConclusionMicropunch grafting is a useful and convenient method for the treatment of difficult venous ulcers and can be performed on an outpatient basis.     

腹部外科病人术后症状性静脉血栓栓塞症多中心临床流行病学研究

目的探讨腹部外科病人术后症状性静脉血栓栓塞症(VTE)的流行病学特点。方法回顾性分析上海交通大学医学院附属第九人民医院、滁州市第一人民医院、郑州大学第二附属医院、上海市奉贤区奉城医院4家医院自2015-01-01—2019-06-30期间就诊于普通外科,入院后行腹部外科手术的病人共计24336例相关临床资料,并观察术后14 d内发生VTE事件的情况。结果VTE事件发生率为0.89%(216/24336),其中,深静脉血栓形成(DVT)发生率0.75%(183/24336),肺动脉栓塞(PE)发生率0.35%(86/24336)。男性VTE事件发生率为0.85%(123/14443),女性为0.94%(93/9893),男女VTE事件发生率差异无统计学意义(χ^2=2.15,P>0.05)。DVT病人常见的症状是下肢肿胀177例(96.72%),疼痛104例(56.83%),浅静脉曲张36例(19.67%)。PE病人常见的症状是呼吸困难和气促77例(89.53%),胸痛55例(63.95%)。DVT易累及左下肢;混合型最多见,左、右下肢分别为61.11%(88/144)和52.11(37/71)。PE病人最常见低危组病人45例(52.32%)。常见的VTE危险因素包括:年龄≥40岁208例(96.30%),手术时间>45 min 139例(64.35%),恶性肿瘤病史99例(45.83%)。主要的腹部外科手术类型是消化道恶性肿瘤手术105例(48.61%),胆囊切除术73例(33.80%)。腹腔镜手术(1.61%,179/11123)较开放手术(0.28%,37/13213)VTE事件发生率低(χ^2=45.56,P<0.05)。VTE相关病人的病死率为0.10%(25/24336)。结论腹部外科病人术后VTE发生率已经明显降低,医生应当根据其流行病学特点,早期发现,早期诊断和早期预防干预,避免严重不良事件的发生。     

恶性肿瘤与血栓性疾病

血栓栓塞性疾病是恶性肿瘤疾病过程中常见的并发症,其存在与肿瘤本身的进展、治疗及预后密切相关。本文对恶性肿瘤伴血栓栓塞性疾病的发生机制、危险因素、预防、治疗,抗凝/抗栓治疗的现状及对肿瘤预后的影响进行回顾。     

Acute experimental venous thrombosis impairs venous relaxation but not contraction

ObjectiveVenous thrombosis (VT) damages the vein wall, both physically by prolonged distension and from inflammation. These factors contribute to post-thrombotic syndrome (PTS). Interleukin (IL)-6 might play a role in experimental PTS and vein wall responses. Previous assessments of post-thrombotic vein wall injury used static measures such as histologic examination and immunologic assays. The purpose of the present study was to use myography to quantify the changes in contraction and relaxation of murine vessels exposed to an acute VT.MethodsWild-type (WT) C57BL/6 mice were used to determine the baseline vein wall passive tension on a DMT 610m myograph (DMT-USA, Inc., Ann Arbor, Mich), including dosing concentrations of phenylephrine (Phe) and acetylcholine (Ach). WT and IL-6^−/− mice underwent VT using inferior vena cava (IVC) ligation (complete stasis) and stenosis (partial stasis), with no-surgery mice used as controls. The mice were harvested at 2 days (2D) and analyzed using a myograph. The vessels were stimulated with Phe and Ach to stimulate a contraction and relaxation response. The endothelial responses to VT were quantified by CD31 immunohistochemistry, Greiss assay, polymerase chain reaction, and Evans blue assay.ResultsOptimal passive tension was determined to be 2 mN, with an optimal concentration of Phe and Ach of 7E-3M and 1E-5M, respectively. No significant differences were found in the contractions when exposed to Phe between the WT control, WT 2D ligation, and WT 2D stenosis IVC segments and the IL-6^−/− mice with and without thrombus (P > .05 for all). When treated with Ach, significantly more relaxation was found in the nonthrombosed control IVC segments than in those IVC segments that had had a 2D thrombus from either ligation- or stenosis-derived thrombotic mechanisms in both WT and IL-6^−/− mice. CD31 staining showed ∼20% less luminal endothelium after stasis thrombosis (P ≤ .01) but no loss in the controls (P > .05). Evans blue staining showed a trend toward increased leakiness in post-thrombotic vein walls. No significant difference in the endothelial gene markers or nitric oxide production was found.ConclusionsCompared with the controls, acute thrombosis in the total or partial stasis models did not impair IVC contractile responses, suggesting no effect on the medial vascular smooth muscle response. The relaxation response was significantly reduced in the post-thrombotic groups, likely from direct endothelial injury. These findings suggest, at acute points, that VT impairs the endothelial function of a vein wall while retaining the vascular smooth muscle cell function and might be a mechanism that promotes PTS.     

A Prospective Cohort Comparative Study of Rivaroxaban,Dabigatran, and Apixaban Oral Thromboprophylaxis in 2431 Hip and Knee Arthroplasty Patients: Primary Efficacy Outcomes and Safety Profile

BackgroundDirect oral anticoagulants (DOACs) have promised superior efficacy to low molecular weight heparins in the prevention of venous thromboembolism (VTE) in total hip and knee arthroplasty. However, there are concerns about raised associated bleeding and wound problems with these agents. This study aims to evaluate and compare the efficacy and safety of the 3 DOAC drugs: rivaroxaban, dabigatran and apixaban.MethodsThe primary outcome measures were rate of symptomatic VTE and major bleeding. Secondary outcome measures were wound healing problems and requirement for return to theater. A total of 2431 patients received one of the DOAC drugs as thromboprophylaxis following total hip arthroplasty (35 days) or total knee arthroplasty (14 days) between 2011 and 2015. Binary variables were compared between the 3 groups by using the chi-squared test or Fisher’s exact test. Relative risks of selected primary and secondary end points were also calculated for the prespecified pairwise comparison.ResultsThe overall symptomatic VTE rate was 2%. Rivaroxaban had a statistically significant superior efficacy for overall VTE prevention (0.8% vs 2.6%) compared with dabigatran (P < .01) and apixaban (P < .01), and deep vein thrombosis prevention (0.3% vs 2.2%) over dabigatran (P < .01). The overall rate of major bleeding was 1.2% with no significant difference observed between the 3 studied drugs.ConclusionAll 3 drugs had symptomatic VTE rates comparable with low molecular weight heparin from the published literature. Rivaroxaban appears to have superior efficacy in VTE prevention over apixaban and dabigatran. No statistical difference was observed for major bleeding with any of the 3 agents.     

Impact of a risk-stratified thromboprophylaxis protocol on the incidence of postoperative venous thromboembolism and bleeding

Efforts to reduce postoperative venous thromboembolism are challenging due to heterogeneity in thromboprophylaxis practice. As a result, a ‘one-size-fits-all’ approach that accounts for surgery-specific risk, but fails to account for patient-level variation, is often adopted by healthcare networks. Updated clinical practice guidelines have advocated an individualised risk-stratified approach that balances the risk:benefit ratio associated with thromboprophylaxis; however, there are limited data confirming effectiveness of these recommendations on the incidence of postoperative venous thromboembolism and bleeding. We developed the surgical-thrombo-embolism-prevention protocol, a novel risk-stratified algorithm that classified patients into low-, intermediate-, and high-risk profiles according to surgical procedure and patient baseline medical risk. Expert-endorsed risk-specific thromboprophylaxis strategies were then applied. A staged quality improvement program was developed to implement the protocol. We postulated that compliance with the protocol would reduce postoperative venous thromboembolism rates without increasing the incidence of postoperative bleeding. Between June 2013 and March 2018, we evaluated the efficacy, safety and sustainability of this risk-stratified approach in 24,953 surgical admissions at a dedicated cancer centre. By final implementation, program compliance was 91%. Postoperative venous thromboembolism rates reduced from 3.1 per 1000 surgical admissions to 0.6 per 1000 surgical admissions (relative risk reduction 79%; p < 0.005). Postoperative bleeding rates also declined from 10.0 per 1000 surgical admissions to 6.3 per 1000 surgical admissions (relative risk reduction 37%; p = 0.02). Sustained improvement was evident more than 3 years after implementation. Implementation of the surgical-thrombo-embolism-prevention protocol significantly reduced the incidence of postoperative venous thromboembolism supporting its validation at other institutions.     

PICC management led by technicians: Establishment of a cooperation program with radiologists and evaluation of complications

PurposeThe purpose of this study was to evaluate a cooperation program in order to compare incidence of complications after peripherally inserted central catheter (PICC) placement between radiologists and technicians.Materials and methodsPICC placement technique was standardized with ultrasound-guided puncture and fluoroscopic guidance. Numbers of PICC delegated to technicians, and PICC placement difficulties, were prospectively recorded for the whole study population whereas complications such as PICC infection, deep venous thrombosis and catheter occlusion were prospectively recorded until PICC removal for a subgroup of patients included during one month.ResultsA total of 722 patients had PICC placement. There were 382 men and 340 women with a mean age of 66.8 ± 15.8 (SD) years (range: 18–94 years); of these, 442/722 patients (61.22%) were included in the cooperation program with 433/722 patients (59.97%) who effectively had PICC placement by technicians and 289/722 (40.03%) by radiologists. Technicians needed radiologists’ help for 23/442 patients (5.20%) including 6 failed PICC placement subsequently performed by radiologists. Twenty complications (20/77; 26%) were recorded in the subgroup of 77 patients studied for complications. No differences in complications rate were found between the 33 patients who underwent PICC placement by radiologists (6/33; 18%) and the 44 patients who underwent PICC placement by technicians (14/44; 32%) (P = 0.296). Complications included 8 PICC-related infections (8/77; 10.4%), 3 deep venous thromboses (3/77; 3.9%) and 9 catheter occlusions (9/77; 11.7%).ConclusionPICC placement led by technicians is feasible and safe without statistical difference in terms of complications compared to PICC placement made by radiologists.     

门诊静脉血栓栓塞症患者抗凝手册的建立及有效性分析

目的评估门诊静脉血栓栓塞症(venous thromboembolism,VTE)患者抗凝手册的建立及其临床可行性、安全性和有效性。方法前瞻性分析上海交通大学医学院附属第九人民医院2018年10月至2019年3月采用门诊VTE抗凝手册的门诊VTE患者随访资料,主要研究终点为规范性抗凝的依从性,次要研究终点包括出血并发症发生率和症状性血栓复发率和失访率。结果门诊VTE患者规范性抗凝依从性为89.4%,其中口服利伐沙班和皮下注射低分子量肝素患者的依从性分别为92.9%和100%,口服华法林患者的依从性为77.8%。出血并发症发生率为5.3%,均为轻微出血。症状性血栓复发率为2.1%,均发生于口服华法林患者。患者总失访率为4.3%。结论建立门诊VTE患者抗凝手册可以有效提高患者治疗依从性,降低失访率,且具有较低的并发症发生率和血栓复发率。