Volume 8, Number 2;  July 5, 2007

Patient:

Session Handout:

Readings:

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Unique Identifier [PMID]: 17261856

Authors: Segal JB. Streiff MB. Hoffman LV. Thornton K. Bass EB.

Institution: Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA. jsegal@jhmi.edu

Title: Management of venous thromboembolism: a systematic review for a practice guideline.[summary for patients in Ann Intern Med. 2007 Feb 6;146(3):I43; PMID: 17261855]. [Review] [122 refs]

Source: Annals of Internal Medicine. 146(3):211-22, 2007 Feb 6.

Abstract: BACKGROUND: New treatments are available for treatment of venous thromboembolism. PURPOSE: To review the evidence on the efficacy of interventions for treatment of deep venous thrombosis (DVT) and pulmonary embolism. DATA SOURCES: MEDLINE, MICROMEDEX, the Cochrane Controlled Trials Register, and Cochrane Database of Systematic Reviews from the 1950s through June 2006. STUDY SELECTION: Randomized, controlled trials; systematic reviews of trials; and observational studies; all restricted to English-language articles. DATA EXTRACTION: Paired reviewers assessed study quality and abstracted data. The authors pooled results about optimal duration of anticoagulation. DATA SYNTHESIS: This review includes 101 articles. Low-molecular-weight heparin (LMWH) is modestly superior to unfractionated heparin at preventing recurrent DVT and is at least as effective as unfractionated heparin for treatment of pulmonary embolism. Outpatient treatment of venous thromboembolism is likely to be effective and safe in carefully chosen patients, with appropriate services available. Inpatient or outpatient use of LMWH is cost-saving or cost-effective compared with unfractionated heparin. In observational studies, catheter-directed thrombolysis safely restored vein patency in select patients. Moderately strong evidence supports early use of compression stockings to reduce postthrombotic syndrome. Limited evidence suggests that vena cava filters are only modestly efficacious for prevention of pulmonary embolism. Conventional-intensity oral anticoagulation beyond 12 months may be optimal for patients with unprovoked venous thromboembolism, although patients with transient risk factors benefit little from more than 3 months of therapy. High-quality trials support use of LMWH in place of oral anticoagulation, particularly in patients with cancer. Little evidence is available to guide treatment of venous thromboembolism during pregnancy. LIMITATIONS: The authors could not address all management questions, and excluded non-English-language literature. CONCLUSIONS: The strength of evidence varies across the study questions but generally is strong. [References: 122]

Publication Type: Journal Article. Research Support, U.S. Gov't, P.H.S.. Review.

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Unique Identifier [PMID]: 16009794

Authors: PREPIC Study Group.

Title: Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d'Embolie Pulmonaire par Interruption Cave) randomized study.[see comment].

Source: Circulation. 112(3):416-22, 2005 Jul 19.

Abstract: BACKGROUND: In a randomized trial in patients with proximal deep-vein thrombosis, permanent vena cava filters reduced the incidence of pulmonary embolism but increased that of deep-vein thrombosis at 2 years. An 8-year follow-up was performed to assess their very long-term effect. METHODS AND RESULTS: Four hundred patients with proximal deep-vein thrombosis with or without pulmonary embolism were randomized either to receive or not receive a filter in addition to standard anticoagulant treatment for at least 3 months. Data on vital status, venous thromboembolism, and postthrombotic syndrome were obtained once a year for up to 8 years. All documented events were reviewed blindly by an independent committee. Outcome data were available in 396 patients (99%). Symptomatic pulmonary embolism occurred in 9 patients in the filter group (cumulative rate 6.2%) and 24 patients (15.1%) in the no-filter group (P=0.008). Deep-vein thrombosis occurred in 57 patients (35.7%) in the filter group and 41 (27.5%) in the no-filter group (P=0.042). Postthrombotic syndrome was observed in 109 (70.3%) and 107 (69.7%) patients in the filter and no-filter groups, respectively. At 8 years, 201 (50.3%) patients had died (103 and 98 patients in the filter and no-filter groups, respectively). CONCLUSIONS: At 8 years, vena cava filters reduced the risk of pulmonary embolism but increased that of deep-vein thrombosis and had no effect on survival. Although their use may be beneficial in patients at high risk of pulmonary embolism, systematic use in the general population with venous thromboembolism is not recommended.

Publication Type: Journal Article. Randomized Controlled Trial. Research Support, Non-U.S. Gov't.

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Unique Identifier [PMID]: 17046435

Authors: Weichman K. Ansell JE.

Institution: Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA.

Title: Inferior vena cava filters in venous thromboembolism. [Review] [52 refs]

Source: Progress in Cardiovascular Diseases. 49(2):98-105, 2006 Sep-Oct.

Abstract: Vena cava filters have been used for the prevention of pulmonary embolism in patients with venous thromboembolism since the 1930s. Historically, vena cava filters were used in patients with either a contraindication to or a complication of systemic anticoagulation or in those with recurrent pulmonary embolism despite adequate anticoagulation. However, indications for placement have broadened even in the absence of support from randomized controlled trials as the deployment procedure became less complex. With more recently available optional retrievable filters, physicians have another valuable tool to use for the treatment of venous thromboembolism in patients who are not candidates for systemic anticoagulation or, perhaps, more importantly, have only a temporary indication for filtration. As with permanent filters, there is a clinical need for robust clinical studies to establish appropriate indications and define long-term outcomes because there are only case series to guide the current usage of such filters. [References: 52]

Publication Type: Journal Article. Review.

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Unique Identifier [PMID]: 16168892

Authors: Rutherford RB.

Institution: Emeritus Professor of Surgery, Department of Surgery, University of Colorado Medical School, Denver, CO, USA. rbruth@aol.com

Title: Prophylactic indications for vena cava filters: critical appraisal. [Review] [23 refs]

Source: Seminars in Vascular Surgery. 18(3):158-65, 2005 Sep.

Abstract: Vena caval filters (VCFs) were developed and initially used for therapeutic indications, primarily to prevent recurrence of pulmonary embolism (PE) or its occurrence in selected cases of deep venous thrombosis (DVT), where risk of PE was very high and anticoagulant therapy (AC Rx) was deemed ineffective, contraindicated by concurrent disease, or had to be discontinued because of complications. Prophylactic indications-where there was no DVT or PE but the risk of them was considered very high and AC Rx was contraindicated or considered ineffective-were invoked relatively infrequently at first, but when percutaneous placement became routine in the late 1980s, this indication increased steadily. The categories of patients considered at high-enough risk of venous thromboembolism (VTE), albeit temporary, to justify VCF have also expanded steadily, most with little objective basis for choosing VCFs over other methods of prophylaxis. In many of these prophylactic categories, eg, patients undergoing surgery associated with a high risk of VTE, the risk is for a limited period only, until the patient is ambulatory or AC Rx can be instituted. In addition, there are potential disadvantages to leaving a permanent filter in, especially in younger patients with an extended longevity outlook and no ongoing risk of VTE. This was brought out in the PREPIC trial. This realization has, in turn, spurred interest in developing temporary or retrievable filters for short-term prophylactic use. No design has yet proven entirely satisfactory for this purpose, but the practice of placing such filters for prophylactic indications has steadily grown, using available devices. This article critically reviews these trends, suggests directions for future developments, and recommends necessary studies on which to base the practice of prophylactic VCF use. [References: 23]

Publication Type: Journal Article. Review.

Resident Report / Department of Medicine & Grady Branch Library

Emory University School of Medicine

2007 Edition

Participating Faculty:  Carlos Del Rio MD  / Joyce Doyle MD / Lorenzo Difrancesco MD / Rachel Del Favero MD / Lewis Satterwhite  MD

Contact: Karl Woodworth