Charles Marc Samama1, Anne Godier. 1. Department of Anaesthesiology and Intensive Care Medicine, Hotel-Dieu University Hospital, Assistance Publique - Hôpitaux de Paris, Université Paris Descartes, Paris, France. marc.samama@htd.aphp.fr
Abstract
PURPOSE OF REVIEW: To critically evaluate the benefit/risk ratio of some strategies for venous thromboembolism prophylaxis (VTE) RECENT FINDINGS: A growing body of evidence shows that graduated elastic stockings are not effective in medical patients. Special surgical settings as bariatric surgery deserve attention with a high VTE risk and no evidence-based data with regard to prophylaxis. Extended prophylaxis is being evaluated in these patients, whereas its efficacy has been demonstrated in abdominal and pelvic surgery for cancer. New oral anticoagulants are about to change the clinical landscape but yet some issues are not solved: no antidote, no monitoring, no standardization for the perioperative bridging in patients with therapeutic doses. In addition, they have not been tested in fragile patients in whom an increased bleeding risk could be feared. Finally, a large bunch of guidelines are now available to help the physician in the decision-making process. SUMMARY: Studies evaluating the benefit/risk ratio of graduated elastic stockings should now take place in surgery. Increasing and splitting the anticoagulant dose (mainly low molecular weight heparins) by two injections a day could be recommended in bariatric surgery and morbidly obese patients. New anticoagulant agents should also be tested in special populations, following the European Medicines Agency guidance. The methodology of clinical trials in VTE prophylaxis has to be moved forward, pending the choice of debatable surrogate end-points as asymptomatic venous thrombosis and disputed issues on the assessment of major bleeding.
PURPOSE OF REVIEW: To critically evaluate the benefit/risk ratio of some strategies for venous thromboembolism prophylaxis (VTE) RECENT FINDINGS: A growing body of evidence shows that graduated elastic stockings are not effective in medical patients. Special surgical settings as bariatric surgery deserve attention with a high VTE risk and no evidence-based data with regard to prophylaxis. Extended prophylaxis is being evaluated in these patients, whereas its efficacy has been demonstrated in abdominal and pelvic surgery for cancer. New oral anticoagulants are about to change the clinical landscape but yet some issues are not solved: no antidote, no monitoring, no standardization for the perioperative bridging in patients with therapeutic doses. In addition, they have not been tested in fragilepatients in whom an increased bleeding risk could be feared. Finally, a large bunch of guidelines are now available to help the physician in the decision-making process. SUMMARY: Studies evaluating the benefit/risk ratio of graduated elastic stockings should now take place in surgery. Increasing and splitting the anticoagulant dose (mainly low molecular weight heparins) by two injections a day could be recommended in bariatric surgery and morbidly obesepatients. New anticoagulant agents should also be tested in special populations, following the European Medicines Agency guidance. The methodology of clinical trials in VTE prophylaxis has to be moved forward, pending the choice of debatable surrogate end-points as asymptomatic venous thrombosis and disputed issues on the assessment of major bleeding.