Abstract
Direct-acting oral anticoagulants in patients at extremes of body weight: a review of pharmacological considerations and clinical implications
Talerico R, Pola R, Klok FA, Huisman MV. TH Open. 2024 Jan 8;8(1):e31-e41.
The authors’ objective of this review is to summarize the evidence on the pharmacokinetic and pharmacodynamic profile of direct-acting oral anticoagulants (DOACs) for treating patients at extremes of body weight in venous thromboembolism (VTE) in the prevention of cardioembolic stroke in nonvalvular atrial fibrillation (NVAF). A literature search was conducted; the most relevant reviews and original articles on the topic were selected. Apixaban and rivaroxaban show a favorable pharmacokinetic and pharmacodynamic profile in obese VTE treatment and NVAF patients and, in the case of apixaban, also in underweight patients. These drugs demonstrated comparable efficacy and safety to standard therapy. There was a paucity of information for dabigatran and edoxaban; the latter drug was safer at a lower dose, mainly in underweight patients.
The authors conclude that they support the last International Society of Hemostasis and Thrombosis position paper and European Heart Rhythm Association 2021 practical guide, suggesting the use of apixaban and rivaroxaban in morbidly obese patients (>120 kg or body mass index ≥40 kg/m2) and the reduced dosage of edoxaban in low-weight patients. In addition, the authors suggest that further studies with larger inclusion sets are needed.
Factors associated with ablation related thrombus extension (ARTE) following microfoam versus radiofrequency saphenous vein closure
Chin AL, Talutis SD, Lawrence PF, Woo K, Rigberg DA, Rollo JC, Jimenez JC. J Vasc Surg Venous Lymphat Disord. 2024
The authors’ aim is to identify characteristics and outcomes associated with endovenous heat-induced thrombosis (EHIT) and endovenous foam-induced thrombosis (EFIT) following polidocanol endovenous microfoam (MFA) versus radiofrequency ablation (RFA). A retrospective review was conducted of patients who underwent MFA and RFA closure of incompetent above-knee great saphenous veins. Patients who were treated for isolated tributary vein treatment or did not have a post-procedure duplex ultrasound (DU) within 48–72 h were not included. Patients were classified into two groups: EHIT or EFIT or no EHIT or EFIT. Demographic data, CEAP class, venous clinical severity score (VCSS), operative details, post-procedure (48–72 h) duplex ultrasound (DU) findings, and adverse events were analyzed. Variables which were significant on univariate analysis were evaluated using multivariate logistic regression with the primary outcome being development of thrombus extension into the deep system (TEDS). From June 2018 to February 2023, 800 limbs were treated with either MFA (n = 224) or RFA (n = 576). A total of 96 GSVs treated with MFA met study criteria. A total of 150 successive GSVs treated with RFA were included as a comparison group. There was no statistically significant difference in baseline demographics between the two groups. Six patients (2.4%) demonstrated TEDS on postoperative DU at 48–72 h (MFA: n = 5 [5.2%], RFA: n = 1 [0.7%]; p = .02). Saphenous vein ablation with MFA (p = .045) and vein diameter >10 mm (p = .017) were associated with TEDS on both univariable and multivariable analyses. All patients who developed EHIT or EFIT were treated with oral anticoagulants (mean = 15.6 days). Body mass index, CEAP class, VCSS, microfoam volume, operative time, and prior DVT were not predictive of venous thrombus extension.
Ablation-related thrombus extension following above-knee GSV closure occurred more frequently following MFA. Our results suggest that a saphenous vein diameter greater than 10 mm may be associated with TEDS. These patients were treated with short-term anticoagulation with no related complications. Larger studies are needed to understand the natural history of EFIT in MFA. For the present, DU should be performed routinely post-procedure on MFA patients. EFIT patients should be anticoagulated until the thrombus is no longer present on duplex examination.
Effectiveness of sclerotherapy to cure lower limb chronic venous insufficiency grades 1-6: a systematic review and meta-analysis
Dewi DAR, Arimuko A, Norawati L, Dewi RK, Wiraguna AAGP, Allatib A, Arkania N, Nadhira F, Wiliantari NM. Cureus. 2023 Dec 1;15(12): e49770.
The authors’ aim of this study was to evaluate the effectiveness of sclerotherapy in treating chronic venous insufficiency grades 1–6 in the lower-limb through a systematic review and meta-analysis. The authors conducted this systemic review and meta-analysis using PRISMA (Preferred Items for Systematic Reviews and Meta-Analyses) guidelines and Cochrane Handbook for Systematic Reviews of Interventions using targeted literature from 2000 to 2023. The inclusion criteria are (1) randomized studies, including randomized controlled trials and clinical trials; (2) patients with lower-limb chronic venous insufficiency grades C1–C6 by the comprehensive classification system (CEAP); (3) with and without sclerotherapy interventions; (4) assessing outcomes such as patient satisfaction, clinical resolution, QoL, side effects, clinical improvement, pain, and skin hyperpigmentation, and (5) using the English language. Exclusion criteria were (1) the study being not a clinical trial; (2) combining sclerotherapy with other therapies in the same population; (3) the patient with another comorbid and not lower-limb venous insufficiency; and (4) using incompatible language. The results from 9.670 total samples demonstrated that sclerotherapy is the most effective therapy for reducing clinical severity in lower-limb venous insufficiency patients (pooled MD = −0.85, 95% CI (−1.41, −0.29), p < .00001, I2 = 99%). Sclerotherapy is the most effective therapy for increasing QoL, Epidemiology and Economic Study-Quality of Life (VEINES-QOL; pooled MD = 10.34, 95% CI (8.78, 11.90), p < .00001, I2 = 0%). Additionally, sclerotherapy is a more effective therapy for increasing QoL than placebo (pooled MD = −1.64, 95% CI (−2.60, −0.67), p = .002, I2 = 90%), deferred ablation (pooled MD = −0.22, 95% CI (−0.40, −0.03), p = .02), and ligation therapy (pooled MD = −1.29, 95% CI (−1.62, −0.97), p = .00001). It is also the most effective therapy for increasing the closure rate for 12-month duration outcome measures (pooled RR = 0.72, 95% CI (0.55, 0.94), p = .001, I2 = 91%). However, high heterogeneity was observed in the meta-analysis results, indicating the need for further research to address this variability.
This study contributes to the existing body of knowledge on the treatment options for chronic venous insufficiency and highlights the potential of sclerotherapy as an effective treatment modality. The authors conclude the following from this study: (1) Sclerotherapy is the most effective therapy for reducing clinical severity in lower-limb venous insufficiency patients. (2) Sclerotherapy is the most effective therapy for increasing QoL if we use VEINES-QOL and AVVS as tools for measuring QoL. (3) Sclerotherapy is the most effective therapy for increased QoL than placebo, deferred ablation, and ligation therapy. (4) Sclerotherapy is the most effective therapy for reducing clinical severity than placebo and deferred ablation therapy. (5) Sclerotherapy is the most effective therapy for increasing the closure than EVLA therapy. (6) Sclerotherapy is the most effective therapy for increasing the closure rate for 12-month outcome measures. (7) Sclerotherapy provides a viable alternative to conventional surgery and endovenous laser ablation.
Rates of venous thromboembolism and use of thromboprophylaxis after major orthopedic surgery in patients with congenital hemophilia A or B: a systematic review
Santagata D, Abenante A, Squizzato A, Dentali F, Donadini MP, Ageno W, Pabinger I, Tiede A, Ay C. J Thromb Haemost. 2024 Jan 10:S1538-7836.
The authors’ objective was to analyze best available evidence of venous thromboembolism (VTE) rates in persons with hemophilia A or B undergoing lower-limb total-joint replacement (TJR) and the use of postoperative pharmacological thromboprophylaxis. The authors systematically screened 4 online databases to identify studies reporting VTE rates in patients with hemophilia after TJR. Case reports and case series with less than ten patients were excluded. Twenty-six observational studies were included in this systematic review, reporting 1181 TJRs in patients with hemophilia A or B. Eight studies had VTE rates as the primary outcome. Five studies reported screen-detected VTE, while 21 papers reported symptomatic VTE events. Overall, 17 VTE events were reported (1.4%, 95% CI 0.9%–2.3%); 10 (6.6%) after 151 procedures with postoperative VTE screening and 7 (0.7%) events in 1080 procedures without postoperative screening. Thromboprophylaxis protocols were specified in 21 studies; postoperative thromboprophylaxis was used in 15 (1.3%) procedures. This information was not available for 29.0% of the analyzed population.
The authors concluded that despite the low thromboprophylaxis use in patients with hemophilia, rates of symptomatic VTE after TJR appeared to be low. In addition, they also emphasized the need to better report the thrombotic outcome in persons with hemophilia to face the ongoing changes in the hemophilia environment.
Hyperbaric oxygen as an adjunct in the treatment of venous ulcers: a systematic review
Keohane C, Westby D, Nolan FC, Twyford M, Tawfick W, Walsh SR. Vasc Endovascular Surgery 2023. Aug 57 (6) 607-616.
The authors did a systematic review to evaluate the available evidence in patients with venous leg ulcers (VLUs) when treated with hyperbaric oxygen therapy (HBOT) regarding complete healing and reduction of ulcer area compared to controls. The authors reviewed 6 trials. There was heterogeneity across the studies, with no standard control intervention, method of outcome reporting, or duration of follow-up. The review found that HBOT does not significantly affect ulcer healing; however, there is a reduction in ulcer size that was found to be statistically significant.
The authors concluded that HBOT cannot be justified for widespread use in venous ulcer patients.
Adjustable compression wraps: stretch, interface pressures and static stiffness indices
Benigni JP, Uhl JF, Filori P, Balet F, Penoel L. Int Angiol. 2023 Jun;42(3):247-253.
The authors performed a pilot study by testing 5 healthy subjects using Coolflex (Sigvaris), Juzo wrap 6000, Readywrap from Lohmann Rauscher, Juxtafit and Juxtalite from Medi, and Compreflex from Sigvaris. They studied stretch (maximum length), interface pressures (using a PicoPress transducer), and static stiffness index (SSI) for each wrap. The SSI was measured in the supine and in the standing position, starting at 20 mmHg, and then increasing by 5 mmHg increments. The authors proposed a classification of wraps according to their stretch: short or long. Coolflex was found to be inelastic and cannot exceed a pressure of 30 mmHg at rest with a maximum SSI of 30 mmHg. Juzo wrap 6000 and Readywrap were found to have 50% and 60% stretch, respectively, with similar stiffness profiles. Readywrap was found to have 17–30 mmHg stiffness with maximum SSI of 35 mmHG. Juxtafit, Juxtalite, and Compreflex can be applied with pressures about 60 mmHg.
The authors concluded that these results may help guide clinical expectations.
Frequency of lipoedema in patients consulting a vein clinic for mild to moderate superficial venous disorder with symptoms: A retrospective analysis
Rastel D, Urbinelli R. JMed Vasc 2023 Apr;48(2):55-61.
The authors conducted a retrospective review of phlebology consultations in a private practice center in 464 women aged 18–80 years with symptoms attributable to veins and at least one dilated reticular vein on examination. They wanted to determine the number of patients with lipoedema. They found that 7.7% had lipoedema, 3.7% had lymphedema, and 3% had stage 3 obesity. In those presenting with lipoedema, BMI was 31.3 + 5.5 and leg pain as the major symptom.
The authors concluded that lipoedema is a frequent condition in phlebology consultations.
Venous and arterial thrombosis in patients with VEXAS syndrome
Kusne Y, Ghorbanzadeh A, Florea AD, Shalhoub RN, Andrade PEA, Nghiem K, Ferrada MA, Hines A, Quinn KA, Panicker SR, Ombrello AK, Reichard KK, Darden I, Goodspeed W, Durrani J, Wilson L, Olteanu H, Lasho TL, Kastner DL, Warrington KJ, Mangaonkar AA, Go RS, Braylan RC, Beck DB, Patnaik MM, Young NS, Calvo KR, Casanegra A, Grayson PC, Koster MJ, Wu CO, Kanthi Y, Patel BA, Houghton DE, Groarke EM. 2024 Blood. 2023022329. doi: 10.1182/blood.2023022329. Online ahead of print.
VEXAS (Vacuoles, E1 enzyme, X-linked, Autoinflammatory, Somatic) syndrome is an autoinflammatory disorder with systemic manifestations caused by mutations in UBA1. It is a newly characterized disorder with venous and arterial thrombosis. The authors studied 119 VEXAS patients. Thrombosis occurred in 49% with venous thromboembolism (VTE) in 41%. Unprovoked VTE was found in two-thirds of patients, 41% were recurrent, and 20% occurred in anticoagulated patients. The cumulative incidence of VTE was 17% at 1 year and 40% by 5 years. The overall survival at 4.8 years was 88% with no difference in patients with or without thrombosis.
The authors recommend thromboprophylaxis in patients who are in high-risk settings.