Search Results (62)

Pulmonary embolism (PE) is an under-recognised yet serious complication in patients with acute ischaemic stroke (AIS), contributing significantly to morbidity and mortality. The interplay of traditional risk factors—such as immobility, endothelial dysfunction, and hypercoagulability—with AIS-specific conditions, including atrial fibrillation, malignancy, and reperfusion therapies, complicates both diagnosis and management. Despite available prophylactic strategies, including low-molecular-weight heparin and intermittent pneumatic compression, their use remains limited by bleeding concerns and a lack of tailored guidelines. This review synthesises the current evidence on the incidence, risk factors, pathophysiology, diagnostic approaches, and preventive strategies for PE in AIS, identifying critical gaps in risk stratification and clinical decision-making. We propose a novel mechanistic framework—the Brain–Lung Thromboinflammatory Axis Hypothesis—which posits that stroke-induced systemic inflammation, neutrophil extracellular trap (NET) formation, and pulmonary endothelial activation may drive in situ pulmonary thrombosis independent of deep vein thrombosis. This conceptual model highlights new diagnostic and therapeutic targets and underscores the need for stroke-specific VTE risk calculators, biomarker-guided prophylaxis, and prospective trials to optimise prevention and outcomes in this vulnerable population. Full article

Venous thromboembolism (VTE) is a relatively common condition that is the leading cause of preventable deaths in developed nations. VTE encompasses deep vein thrombosis (DVT) and pulmonary embolism (PE) and affects both hospitalized and non-hospitalized patients. When left untreated, VTE is associated with substantial morbidity and mortality; accurate risk assessment and appropriate prophylaxis programs are therefore vital, as overlooked risk factors of these processes can potentially result in misdiagnosis and inappropriate treatment of the condition, with associated complications. In this study, we aimed to assess the impact of active monitoring on VTE management practices among healthcare providers to improve patient outcomes at Imam Abdulrahman Al Faisal Hospital (IAFH) in Riyadh, Saudi Arabia, from April 2018 to July 2023. In this study, a longitudinal retrospective study design was utilized and data from 33,237 admitted patients were analyzed using a Statistical Process Control (SPC) chart to evaluate the relationship between VTE risk assessment, active monitoring, and patient outcomes. In total, 11 cases of hospital-acquired VTE were identified, with patients aged 18–40 years representing most cases (7 out of 11 cases) and a male predominance of 54.5%. The overall VTE incidence rate during the study period was 0.31%, or one case per 11,000 admissions, including four cases of PE and seven cases of DVT. The results of this study indicate that active monitoring through continuous education and regular patient rounds significantly improves adherence to VTE risk assessment and prophylaxis at IAFH. The researchers attributed the increased identification and timely reporting of VTE cases to vigilance by healthcare providers and not to a decline in the quality of care. A comprehensive multidisciplinary strategy for VTE management and continuous quality improvement can aid in reducing VTE-related morbidity and improve patient outcomes. Lastly, we recommend addressing the risk factors associated with the occurrence of hospital-acquired VTE and performing post-discharge follow-ups of patients. Full article

Background and Objectives: Total hip replacement and total knee arthroplasty carry a high risk of postoperative venous thromboembolism (VTE); therefore, anticoagulation prophylaxis is recommended in these patients. Unfortunately, there are no guidelines about VTE prophylaxis in patients with hemophilia who underwent these high-risk surgeries. To determine whether these patients have a high risk of VTE, we conducted a retrospective study on patients with hemophilia who underwent elective arthroplasty at our hospital in 2016. Materials and Methods: There were 11 patients with hemophilia A and B who underwent high-risk surgeries. Recombinant factor VIII or IX and also active recombinant Factor VII were used for perioperative hemostasis, and LMWH was administered for thromboembolic prophylaxis. Postoperatively, we collected information on the duration of factor VIII/IX infusion, VTE-prophylaxis, and complications. Results: Postoperative bleeding was minimal in most cases, with an average blood loss of 500 mL. No major thrombotic events were reported, and the need for transfusion was low, with only one patient requiring additional blood products. The VTE prophylaxis included prophylactic enoxaparin and hemostatic treatment. At the 1-year follow-up, we did not find any evidence of clinical VTE in our patients. Conclusions: Better risk stratification is needed to identify patients who would benefit from pharmacological prophylaxis. Total arthroplasty in hemophilic patients is feasible and safe when managed by a multidisciplinary team and supported by tailored antithrombotic prophylaxis protocols. The use of recombinant coagulation factors and LMWH ensures effective bleeding control and thromboembolic prevention, enhancing patient outcomes. These findings underscore the importance of individualized care in this high-risk population. Full article

Background/Objectives: Venous thromboembolism (VTE) is a major risk for cancer patients undergoing surgery due to hypercoagulability and surgical stress. Traditional low-molecular-weight heparins (LMWHs) are used as the standard of care for VTE prophylaxis, but subcutaneous administration often leads to suboptimal patient adherence. Direct oral anticoagulants (DOACs) are being explored as more convenient and effective alternatives. This study employed a network meta-analysis approach to comparatively assess the safety and efficacy of DOACS and LMWH in preventing VTE among cancer patients undergoing oncologic surgery. Methods: A systematic review and network meta-analysis were conducted. The search strategy included randomized controlled trials (RCTs) retrieved from databases such as CLINICALTRIAL.GOV, MEDLINE, and EMBASE. The search encompassed studies published up to October 2023 and compared the efficacy and safety of DOACs with LMWHs in patients undergoing cancer surgery. The primary outcome was the incidence of VTE, and the secondary outcomes included the incidences of major bleeding events (MB) and clinically relevant non-major bleeding (CRNMB). Results: A network meta-analysis of four randomized controlled trials (RCTs) involving 1600 cancer surgery patients was conducted. No statistically significant differences in VTE rates were observed between DOACs and LMWHs. While rivaroxaban 10 mg once daily for 30 days significantly reduced VTE risk compared to placebo (RR: 0.27, 95% CI: 0.08–0.95), no significant differences were found in major or clinically relevant non-major bleeding risks between DOACs and LMWH or placebo. Conclusions: This network meta-analysis provides evidence supporting the use of DOACs, specifically apixaban and rivaroxaban, as safe and efficacious alternatives to LMWHs for VTE prophylaxis in cancer patients undergoing surgery. The oral administration and reduced monitoring requirements associated with DOACs address the limitations inherent to LMWHs, potentially improving patient adherence. These findings emphasize the need for additional head-to-head trials and long-term studies further to solidify their role in this high-risk patient population. Full article

Background/Objectives: The incidences of venous thromboembolism (VTE) in patients undergoing neurological surgeries vary. The objectives were to assess the incidence and risk factors of VTE, bleeding and all-cause mortality in patients undergoing neurological surgery. Methods: This retrospective cohort study was conducted at a single center, a university-based hospital in Thailand. Inclusion criteria comprised patients aged 15 years or older who were admitted for elective or emergency neurosurgery. Patients with preoperative VTE diagnosed within three months or a history of anticoagulant use were excluded. Outcomes measured included the 90-day incidences of VTE, any bleeding, major bleeding, and mortality. Results: Between January 2021 and December 2022, a total of 626 patients were included. The mean age was 50.21 ± 17.37 years, and 55.27% were males. Thromboprophylaxis was administered to 86 patients (13.74%, 95% CI 11.14–16.69). Fourteen patients were confirmed to have symptomatic VTE, resulting in an incidence of 2.24%, with a 95% confidence interval (CI) of 1.23–3.72. Patients aged ≥75 years (HR 4.53; 95% CI 1.25–16.38; p = 0.021), those with cancer (HR 8.51; 95% CI 2.95–24.60, p <0.001), and those experiencing postoperative paraparesis/paralysis (HR 3.26; 95% CI 1.12–9.45; p = 0.030) were associated with an increased risk of postoperative VTE. Fifty-three patients (8.47%, 95% CI 6.41–10.93) experienced any bleeding, with 23 patients (3.67%, 95% CI 2.34–5.46) having major bleeding. The incidence of postoperative mortality was 6.55%, with a 95% CI of 4.74–8.78. Conclusions: This study revealed that elderly patients, those with cancer or those experiencing postoperative paraparesis/paralysis were at higher risk of VTE. These patients were likely to benefit from VTE prophylaxis. Full article

Background/Objectives: The optimal venous thromboembolism (VTE) chemoprophylaxis approach after hip or knee total joint arthroplasty (TJA) remains controversial. This study aimed to characterize antithrombotic-related complications associated with various chemoprophylaxis regimens after TJA and to assess our current institutional risk-stratified prescribing tool. Methods: This retrospective case–control study and regression analysis included elective unilateral TJA patients at a single institution between 1 July 2015 and 31 December 2021. The primary outcome was a composite of antithrombotic-related complications within 30 days of surgery, including thrombotic and hemorrhagic/wound-related adverse events. The duration of anticoagulant chemoprophylaxis prescribed prior to aspirin monotherapy (0–28 days) was compared between patients who did vs. did not experience a complication, with stratification by institutionally defined VTE risk categories (Routine, Moderate, or High Risk). The complication rate was then assessed as a function of anticoagulant duration within each risk subgroup. Results: The study included 5420 patients, with 279 (5.2%) experiencing ≥1 complication. Routine VTE risk patients experienced few complications, with no significant difference between aspirin monotherapy and various initial anticoagulant durations (p = 0.6118). Moderate and High VTE Risk patients saw significantly lower complication rates with initial anticoagulant prophylaxis of increasing durations (p = 0.0090 and p = 0.0050), with a significant overall effect of VTE Risk strata observed (p = 0.0006). Conclusions: When both bleeding and thrombotic events are considered, anticoagulant-to-aspirin regimens were associated with lower complication rates than aspirin monotherapy in higher risk patients, while routine patients saw no significant benefit over aspirin. Our risk-stratified prescribing approach should be prospectively evaluated. Full article

Background/Objectives: Deep venous thrombosis (DVT), the formation of a blood clot within a large vein, is one of the most common problems among hospitalized patients. The annual prevalence of DVT is 48 per 1,000,000. Nurses’ knowledge significantly affects compliance with VTE risk assessment and prevention. This study aimed to assess the knowledge and practices regarding deep venous thrombosis prevention among nurses in Ministry of Health hospitals and King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia. Methods: This study was conducted in Jeddah using a quantitative, descriptive, cross-sectional design. A sample of 240 registered nurses were conveniently recruited to complete a self-administered online questionnaire. The data were coded and analyzed through SPSS version 24. Results: The participants had adequate knowledge on the prevention of DVT (75.64 ± 18.88), and the highest level was observed for knowledge about the prevention and prophylaxis of DVT (81.98 ± 45.73%). The practice level of nurses in preventing DVT was 71.92%, with a mean score of 18.7. Conclusions: There is a significant effect of nurses’ level of academic qualifications, working ward, and DVT prevention training on their knowledge and practice of DVT prevention. Full article

Subcutaneous enoxaparin has been shown to reduce the risk of venous thromboembolism (VTE) among hospitalized patients. However, alternative enoxaparin dosing strategies may be necessary in morbid obesity. The objective of this study was to assess the rate of target anti-Xa attainment with three enoxaparin dosing regimens for venous thromboembolism (VTE) prophylaxis in morbidly obese patients. In this retrospective study, anti-Xa target attainment was assessed among adult patients with a body mass index (BMI) ≥ 40 kg/m² receiving enoxaparin 40 mg twice daily (BID), 60 mg BID, or 0.5 mg/kg BID. Univariate and multivariate analyses were conducted. Target anti-Xa levels were defined as a steady-state, peak level of 0.2–0.5 IU/mL. This study included 120 patients with 55 patients receiving 40 mg BID, 44 patients receiving 60 mg BID, and 21 patients receiving 0.5 mg/kg BID. Target anti-Xa levels were achieved in 29.1% of patients in the 40 mg BID arm, 54.5% in the 60 mg BID arm, and 90.5% in the 0.5 mg/kg BID arm. Anti-Xa target attainment was significantly increased in both the 60 mg BID arm (p = 0.01) and the 0.5 mg/kg arm (p < 0.0001), compared to the 40 mg BID arm. In morbidly obese patients, weight-based dosing was associated with a greater attainment of target anti-Xa levels. Further studies are needed to determine the impact of these dosing regimens on clinical outcomes. Full article

Venous thromboembolism (VTE) is the leading cause of morbidity and death worldwide, after cancer and cardiovascular diseases. VTE is defined to include pulmonary embolism (PE) and/or deep vein thrombosis (DVT). Approximately 25% of PE patients experience sudden death as an initial symptom of VTE, and between 10% and 30% of patients die within the first month after diagnosis. Currently, the only drugs approved for the treatment of both acute and chronic VTE are vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs). However, their effectiveness is limited due to their associated risk of bleeding. Ideally, therapy should be able to treat VTE and limit the risk of VTE recurrence without increasing the risk of bleeding. Several studies have shown that the use of statins during anticoagulation for VTE reduces the risk of death and VTE recurrence. However, to date, there are conflicting data on the impact of statins during anticoagulation for VTE. A biological protective function of statins during anticoagulation has also been reported. Statins affect D-dimer levels; tissue factor (TF) gene expression; and VIII, VII, and Von Willebrand clotting factors—the major clotting factors they are able to affect. However, the usefulness of statins for the treatment and prevention of VTE is currently under debate, and they should not be substituted for guideline-recommended VTE prophylaxis or anticoagulation treatment. In this review of the literature, we illustrate the advances on this topic, including data on the role of statins in primary VTE prevention and secondary VTE prevention, related biological mechanisms, the risk of bleeding during their use, and their ability to reduce the risk of death. Full article

Background: Manual calf massage and passive ankle motion (CaM) can reduce the incidence of venous thromboembolism (VTE) after total hip arthroplasty (THA). However, these methods cannot be used in all patients; thus, elastic bandage (EB) compression is an alternative method. The efficacy of EB compression in preventing VTE has not yet been investigated; thus, this study aimed to compare the effects of EB compression and manual calf massage. Methods: Of the 363 patients who underwent unilateral primary THA at our hospital between 1 August 2018 and 31 October 2023, CaM without anticoagulation therapy was administered to 206 patients (CaM group) and 157 patients underwent EB without anticoagulation therapy (EB group). Duplex ultrasonography was performed 7 days postoperatively to check for deep vein thrombosis (DVT) in both legs. Results: The surgical time (122.2 min vs. 155.5 min), the incidence of DVT (4.5% vs. 4.8%) and pulmonary thromboembolism (PTE) (0% vs. 0.7%), intraoperative bleeding (305.4 mL vs. 301 mL), and estimated actual blood loss (846.6 mL vs. 811.6 mL) were not significantly different between the CaM and EB group. However, there was one case of symptomatic PTE in the EB group. Conclusions: The incidences of DVT, PTE, and intraoperative bleeding were not significantly different between the groups. Moreover, EB can be administered to patients with DVT and is considered to be a DVT prophylaxis method that can be used in a larger number of patients. Therefore, we recommend that EB be performed in all the patients undergoing THA. Full article

Introduction: Hospital-acquired venous thromboembolisms (HA-VTEs) carry a significant health burden on patients and a financial burden on hospitals due to reimbursement penalties. VTE prophylaxis at our institute was performed through utilizing an order set based on healthcare professionals’ perceived level of risk. However, the use of standardized risk assessment models is recommended by multiple professional societies. Furthermore, integrating decision support tools (DST) based on the standardized risk assessment models has been shown to increase the administration of appropriate deep vein thrombosis (DVT) prophylaxis. Nonetheless, such scoring systems are not inherently flawless and their integration into EMR as a mandatory step can come at the risk of healthcare professional fatigue and burnout. We conducted a study to evaluate the incidence of HA-VTE and length of stay pre- and post implementation of a DST. Methods: We conducted a retrospective, pre–post-implementation observational study at a tertiary medical center after implementing a mandatory DST. The DST used Padua scores for medical patients and Caprini scores for surgical patients. Patients were identified through ICD-10 codes and outcomes were collected from electronic charts. Healthcare professionals were surveyed through an anonymous survey and stored securely. Statistical analysis was conducted by using R (version 3.4.3). Results: A total of 343 patients developed HA-VTE during the study period. Of these, 170 patients developed HA-VTE in the 9 months following the implementation of the DST, while 173 patients were identified in the 9 months preceding the implementation. There was no statistically significant difference in mean HA-VTE/1000 discharge/month pre- and post implementation (4.4 (SD 1.6) compared to 4.6 (SD 1.2), confidence interval [CI] −1.6 to 1.2, p = 0.8). The DST was used in 73% of all HA-VTE cases over the first 6 months of implementation. The hospital length of stay (LOS) was 14.2 (SD 1.9) days prior to implementation and 14.1 (SD 1.6) days afterwards. No statistically significant change in readmission rates was noted (8.8% (SD 2.6) prior to implementation and 15.53% (SD 9.6) afterwards, CI −14.27 to 0.74, p = 0.07). Of the 56 healthcare professionals who answered the survey, 84% (n = 47) reported to be dissatisfied or extremely dissatisfied with the DST, while 91% (n = 51) reported that it slowed them down. Conclusions: There were no apparent changes in the prevalence of HA-VTE, length of stay, or readmission rates when VTE prophylaxis was mandated through DST compared to a prior model which used order sets based on perceived risk. Further studies are needed to further evaluate the current risk assessment models and improve healthcare professionals’ satisfaction with DST. Full article

Cancer-associated thrombosis is the second leading cause of death in cancer patients, and its incidence has been increasing in recent years. This survey was aimed at gathering information regarding the management of thromboembolic prophylaxis within the MITO (Multicenter Italian Trials in Ovarian Cancer)-MaNGO (Mario Negri Gynecologic Oncology) groups. We designed a self-administered, multiple-choice online questionnaire available only for MITO-MaNGO members for one month, starting in May 2022 and ending in June 2022. We processed one response form per center, and 50 responses were analyzed, with most of the respondents (78%) over 40 years old. We found that 82% of them consider thromboembolic prophylaxis in gynecologic oncology to be relevant. In 82% of the centers, a standardized protocol on venous thromboembolism (VTE) prophylaxis is used, which is applied to both patients undergoing surgery and those undergoing chemotherapy. In the remaining 18% of centers, prophylaxis is used exclusively for patients undergoing chemotherapy treatment. Prophylaxis of patients undergoing surgery and chemotherapy treatment is managed in most cases by the surgeon (72%) and oncologist (76%), respectively. Only 26% of respondents use a thromboembolic risk assessment scale, and of these, those used are the Caprini Score (6%), Khorana Score (6%), and Wells Score (2%). The respondents have good knowledge of low-molecular-weight heparin (90%) and average knowledge of dicumarolics (40%), direct oral anticoagulants (DOACs) (68%), and antiplatelet agents (40%). The results of our survey indicate that there is a good awareness of thromboembolic prophylaxis in gynecologic oncology. Nevertheless, it is used less in outpatients than in patients undergoing surgery. Moreover, the thromboembolic risk assessment scores are barely used. Full article

Venous thromboembolism (VTE) (deep vein thrombosis and its complication, pulmonary embolism) is a major cause of morbidity and mortality in hospitalized patients and about 7% of these cases are due to immobility secondary to a neurological impairment. Acquired brain injury (ABI) has also been recognized as one of the main risk factors for VTE. Numerous epidemiological studies have been conducted to assess the risk factors for VTE in institutionalized polytrauma patients, although there is a lack of information about neurorehabilitation wards. Since VTE is often undiagnosed, this prospective study aimed to determine the prevalence and clinical characteristics of lower-limb deep venous thrombosis (DVT) in ABI patients at neurorehabilitation admission. Methods: ABI patients were screened for DVT on admission to the intensive rehabilitation unit (IRU) with compression ultrasonography and basal D-dimer assay and were daily clinically monitored until discharge. A total of 127 consecutive ABI patients (mean age: 60.1 ± 17.6 years; 63% male; time from event: 30.9 ± 22.1 days; rehabilitation time in IRU: 84.6 ± 58.4 days) were enrolled. Results: On admission to the IRU, the DVT prevalence was about 8.6%. The mean D-dimer level in patients with DVT was significantly higher than in patients without DVT (6 ± 0.9 vs. 1.97 ± 1.61, p-value = 0.0001). ABI patients with DVT did not show any significant clinical characteristics with respect to ABI without DVT, although a prevalence of hemorrhagic strokes and patients originating from the Intensive Care Unit and Neurosurgery ward was revealed. During the rehabilitation period, patients with DVT showed a significant difference in pharmacological DVT prophylaxis (high prevalence of nadroparin with 27.3% vs. 1.7%, p-value = 0.04) and a prevalence of transfers in critical awards (36% versus 9.5% of patients without DVT, p-value = 0.05). The mortality rate was similar in the two groups. Conclusions: Our research offers a more comprehensive view of the clinical development of DVT patients and confirms the prevalence rate of DVT in ABI patients as determined upon IRU admission. According to our findings, screening these individuals regularly at the time of rehabilitation admission may help identify asymptomatic DVT quickly and initiate the proper treatment to avoid potentially fatal consequences. However, to avoid time-consuming general ultrasonography observation, a more precise selection of patients entering the rehabilitation ward is required. Full article

Cancer is a known risk factor for venous thromboembolism (VTE). The wider adoption of immunotherapy and anti-angiogenic drugs in recent years have increased this risk further. Central venous catheters (CVCs) are widely used access devices utilized to deliver infusion therapy, mostly in ambulatory settings. The endothelial injury associated with the use of these catheters adds to the risk of VTE to already high-risk patients. The introduction of direct oral anticoagulants (DOACs), with its proven efficacy and safety in multiple clinical indications, have renewed the attention to VTE prophylaxis in cancer patients with CVC. Several clinical trials and meta-analyses had shown that both apixaban and rivaroxaban are effective in lowering the risk of VTE, without increasing the risk of bleeding. Several risk assessment models (RAM) have utilized patient-related, tumor-related, and treatment-related factors, in addition to widely available biomarkers, like Hemoglobin (Hb) level, white blood cell (WBC) and platelets counts to stratify patients into two or three VTE risk levels. In this manuscript, we review the published clinical trials and meta-analyses that attempted to study the efficacy and safety of anticoagulants, mostly the DOACs, in cancer patients with CVCs. We will also propose a practical risk-directed approach to enhance VTE prophylaxis rate. Full article

Background: Internationally established guidelines mention pharmacological prophylaxis for all hospitalized COVID-19 patients. However, there are concerns regarding the efficacy and safety of anticoagulants. This study investigated the associations between thrombosis/bleeding risk scores and clinical outcomes. Methods: We conducted a retrospective review of adult patients admitted to two hospitals between 2021 and 2022. We analyzed clinical data, laboratory results, low molecular weight heparin (LMWH) use, thrombosis, bleeding, and 30-day survival. Results: Of the 160 patients, 69.4% were female, and the median age was 59 years. The rates of thrombotic complications and mortality were 12.5% and 36.3%, respectively. LMWH prophylaxis was administered to 73 of the patients (45.6%). The patients with high Padua prediction scores (PPS) and high IMPROVE_VTE scores had a significantly higher risk of venous thromboembolism (VTE) compared to those with low scores (30.8% vs. 9.0%, p = 0.006 and 25.6% vs. 7.7%, p = 0.006). Similarly, elevated IMPROVE_VTE and IMPROVE_BRS scores were associated with increased mortality (hazard ratios of 7.49 and 6.27, respectively; p < 0.001). Interestingly, LMWH use was not associated with a decreased incidence of VTE when stratified by risk groups. Conclusions: this study suggests that COVID-19 patients with high thrombosis and bleeding risk scores have a higher mortality rate. Full article