Rapid-inflation intermittent pneumatic compression for prevention of deep venous thrombosis. Prevention of deep-vein thrombosis after total hip and knee replacement. Low-molecular-weight heparin in combination with intermittent pneumatic compression. Prophylactic mini-dose heparin in patients undergoing radical retropubic prostatectomy. A prospective trial. Is heparin contraindicated in pelvic lymphadenectomy and radical prostatectomy? The effectiveness of intermittent plantar venous compression in prevention of deep venous thrombosis after total hip arthroplasty. The efficacy of pneumatic compression stockings in the prevention of pulmonary embolism after cardiac surgery. VenaFlow plus Lovenox vs VenaFlow plus aspirin for thromboembolic disease prophylaxis in total knee arthroplasty. Thromboembolic disease prophylaxis in patients with hip fracture: a multimodal approach. Intermittent pneumatic compression to prevent proximal deep venous thrombosis during and after total hip replacement. A prospective, randomized study of compression alone, compression and aspirin, and compression and low-dose warfarin. Prevention of postoperative deep venous thrombosis and pulmonary emboli with combined modalities.
Current treatment regimens that are designed to prevent deep venous thrombosis in patients undergoing orthopaedic procedures rely predominantly on drug prophylaxis alone. The purpose of this randomized clinical study was to evaluate the effectiveness of a mechanical adjunct to chemoprophylaxis that involves intermittent compression of the legs.
                During a twenty-two month period, 1803 patients undergoing a variety of orthopaedic procedures were prospectively randomized to receive either chemoprophylaxis alone or a combination of chemoprophylaxis and mechanical prophylaxis. Nine hundred and two patients were managed with low-molecular-weight heparin alone, and 901 were managed with low-molecular-weight heparin and intermittent pneumatic compression of the calves for varying time periods. Twenty-four percent of the patients underwent total hip or knee joint replacement. Screening for deep venous thrombosis was performed on the day of discharge with duplex-color-coded ultrasound.
                In the chemoprophylaxis-only group, fifteen patients (1.7%) were diagnosed with a deep venous thrombosis; three thromboses were symptomatic. In the chemoprophylaxis plus intermittent pneumatic compression group, four patients (0.4%) were diagnosed with deep venous thrombosis; one thrombosis was symptomatic. The difference between the groups with regard to the prevalence of deep venous thrombosis was significant (p = 0.007). In the chemoprophylaxis plus intermittent pneumatic compression group, no deep venous thromboses were found in patients who received more than six hours of intermittent pneumatic compression daily.
                Venous thrombosis prophylaxis with low-molecular-weight heparin augmented with a device that delivers rapid-inflation intermittent pneumatic compression to the calves was found to be significantly more effective for preventing deep venous thrombosis when compared with a treatment regimen that involved low-molecular-weight heparin alone. After total hip (THR) or knee replacement (TKR), there is still an appreciable risk of developing deep-vein thrombosis despite prophylaxis with low-molecular-weight heparin (LMWH). In a prospective, randomised study we examined the efficacy of LMWH in combination with intermittent pneumatic compression in patients undergoing primary unilateral THR or TKR. We administered 40 mg of enoxaparin daily to 131 patients combined with either the use of intermittent pneumatic compression or the wearing of graduated compression stockings. Compression ultrasonography showed no evidence of thrombosis after LMWH and intermittent pneumatic compression. In the group with LMWH and compression stockings the prevalence of thrombosis was 28.6% (40% after TKR, 14% after THR). This difference was significant (p < 0.0001). In the early post-operative phase after THR and TKR, combined prophylaxis with LMWH and intermittent pneumatic compression is more effective than LMWH used with graduated compression stockings. We initiated a prospective, partially randomized trial of the effects of perioperative prophylactic mini-dose heparin on the incidence of clinically evident pulmonary emboli, intraoperative blood loss, blood transfusions, duration of postoperative pelvic drainage, and lymphocele formation in 68 consecutive patients undergoing radical retropubic prostatectomy. We treated 32 patients with mini-dose heparin and 36 without it. We detected pulmonary emboli in 4 (11%) patients not treated with mini-dose heparin and in none treated with heparin (p = 0.052). Anesthesiologists estimated a mean intraoperative blood loss of 2,152 cc in the heparinized patients compared with 1,886 cc in controls (p = 0.2). At a time when our policy was to replace all blood loss, we transfused a mean of 3.9 units to heparinized patients and 3.2 units to controls (p = 0.1). Persistent lymphatic drainage requiring more than six days of closed suction drainage occurred in 12 of 32 (38%) heparinized patients as compared with 4 of 36 (11%) controls (p = 0.01). We discontinued the study after 68 patients because of the morbidity associated with mini-dose heparin. Because of the associated morbidity we do not recommend the routine use of mini-dose heparin in patients undergoing radical prostatectomy. We initiated a prospective study to verify or refute the complications of lymphocele formation and excessive blood loss associated with heparin prophylaxis in pelvic lymphadenectomy and radical prostatectomy.
                A prospective study was completed on 579 men undergoing pelvic lymphadenectomy usually in association with radical prostatectomy. Patients were assigned to group 1 (given preoperative and postoperative subcutaneous heparin) and group 2 (no heparin). All patients were evaluated 2 to 3 weeks after surgery with ultrasound for pelvic lymphocele.
                There was no statistically significant difference in the number or size of pelvic lymphoceles or blood loss in group 1 versus group 2.
                The use of heparin prophylaxis to prevent thromboembolic complications in conjunction with pelvic lymphadenectomy and radical prostatectomy is not associated with increased blood loss or increased rate of lymphocele formation. The purpose of this study was to investigate the effectiveness of intermittent pneumatic compression of the plantar venous plexus with the newly developed arteriovenous impulse system. Seventy-four patients about to undergo primary unilateral total hip arthroplasty for osteoarthrosis, all receiving a standard thrombosis prophylaxis regime of thigh-length anti-embolic stockings, 5,000 IU heparin delivered subcutaneously twice daily, and 400 mg hydroxychloroquine sulfate delivered twice daily, were entered in a prospective trial. The patients were allocated at random to also receive the arteriovenous impulse system on the foot of the operated side. On approximately postoperative day 12 bilateral ascending venography was performed. There were 44 patients in the nonpumped group and 30 patients in the pumped group. The incidence of deep venous thrombosis was 6.6% in the pumped group and 27.27% in the nonpumped group. The incidence of thrombosis was significantly lower in the pumped group (P < .025). The authors conclude that chemical prophylaxis plus the use of the mechanical, pneumatic, and arteriovenous impulse system reduces the incidence of thromboembolic complications further than chemical prophylaxis alone. Pneumatic compression stocking (PCS) devices have been introduced to decrease the incidence of postoperative deep venous thrombosis (DVT). However, their role in the prophylaxis against pulmonary embolism (PE) remains unclear. This study was undertaken to compare the prophylactic effectiveness of subcutaneous heparin (SCH) alone vs the combined use of PCS and SCH in the prevention of PE following cardiac surgery.
                We studied 2,551 consecutive patients who underwent cardiac surgery over a 10-year period. They were randomly allocated to two groups. Group A included 1,196 patients who were treated with 5,000 U of SCH every 12 h and group B included 1,355 patients treated with a combined prophylactic regimen of PCS and SCH.
                The diagnosis of PE was established in 69 patients by either high-probability ventilation perfusion scan, pulmonary angiogram, or autopsy. The incidence of PE in group A patients was 4% (48/1,196) and in group B was 1.5% (21/1,355). The concomitant use of bilateral PCS and SCH reduced the frequency of postoperative PE in 62% in comparison to the prophylaxis with SCH alone (p < 0.001).
                These data suggest that the combined prophylactic method of bilateral PCS and SCH is superior to SCH alone in the prevention of PE after cardiac surgery. Two hundred seventy-five patients undergoing unilateral total knee arthroplasty were prospectively randomized to receive spinal epidural anesthesia (SEA), a VenaFlow calf compression device, and enoxaparin (group A) or SEA, VenaFlow, and aspirin (group B). Aspirin was started on the day of surgery, whereas enoxaparin was started 48 hours after surgery. Anticoagulants were continued for 4 weeks after surgery. All patients had an in-hospital ultrasound screening test on postoperative days 3 to 5 and a second follow-up ultrasound 4 to 6 weeks after surgery. The overall deep venous thrombosis rates in groups A and B were 14.1% and 17.8% (P = not significant), respectively. When used in combination with pneumatic compression devices and SEA, enoxaparin was not superior to aspirin in preventing deep venous thrombosis after total knee arthroplasty. To assess if pneumatic compression in conjunction with chemoprophylaxis is an effective way to reduce the incidence of deep vein thrombosis in orthopedic trauma patients sustaining fragility hip fractures.
                Two hundred patients admitted to the authors' institution between May 1998 and June 2002 for fractures of the hip were prospectively studied. All patients were treated operatively and received the VenaFlow calf compression device on both lower extremities immediately following surgery. Chemical prophylaxis of either aspirin (n = 67) or warfarin (n = 133) was administered in addition to mechanical compression. A noninvasive serial color flow duplex scan was performed 1 to 11 days postoperatively (mean 4.5 days) to determine the presence or absence of deep vein thrombosis. All patients were followed clinically 3 months postoperatively for a clinical evaluation of symptomatic deep vein thrombosis or pulmonary embolism.
                Overall, the incidence of deep vein thrombosis was 3.5% (7 of 200) and included only 1 proximal thrombosis (1 out of 200, or 0.5%) and no pulmonary embolism. Five of the 7 patients positive for deep vein thrombosis were in the mechanical compression and warfarin prophylaxis group and 2 were in the aspirin arm of the study. For patients with deep vein thrombosis, the average number of risk factors was 3.71, whereas patients without clots averaged 1.75 clinical risk factors (P < or = 0.05). Three patients in the warfarin group developed bleeding complications (1 with a gastrointestinal bleed and 2 with minor bleeding not at the operative site). No evidence of a symptomatic deep vein thrombosis or pulmonary embolism was reported within a 3-month period following hospitalization.
                Our findings suggest mechanical compression with the VenaFlow calf compression device in conjunction with chemoprophylaxis is an effective means of reducing thromboembolic disease in this high-risk population. A prospective, randomized study of the effectiveness of intraoperative and postoperative use of intermittent pneumatic compression, alone or in combination with oral administration of either aspirin or low-dose warfarin, was done of a consecutive series of patients who had a total hip replacement and were more than thirty-nine years old. All patients began walking by the third postoperative day. One hundred and ninety-six patients who had 217 total hip arthroplasties were included. Twenty-eight per cent of the procedures were revisions of a previous total hip replacement or of an endoprosthesis, and the remainder were primary arthroplasties. Patients were randomized as to the type of prophylaxis that they received: intermittent pneumatic compression alone, seventy-six hips; intermittent pneumatic compression and aspirin, seventy-two hips; or intermittent pneumatic compression and low-dose warfarin, sixty-nine hips. Before discharge from the hospital, and at an average of seven days after the operation, all patients were evaluated for the presence of proximal deep-vein thrombosis with either venography on the side of the operation or with bilateral venous ultrasonography. The relative frequency with which thrombosis occurred in a proximal vein was not significantly different in the three groups; the over-all relative frequency was 10 per cent. Intermittent compression during and after the operation effectively reduces the rate of proximal-vein thrombosis after total hip replacement. With the number of patients in our study, the effectiveness of this technique could not be shown to be augmented by oral administration of either aspirin or low-dose warfarin. Worldwide statistics reveal that 25 to 40 per cent of patients who are over the age of 40 years and operated on for 1 or more hours will develop a deep venous thrombosis (DVT). The studies reviewed in this paper were performed to evaluate several modalities and compare their effectiveness in preventing DVT in postoperative patients. In the first study, five modalities plus a control group were evaluated in 562 patients from five surgical specialties. The incidence of DVT in the control group was 35 per cent. Though most of the pharmacologic agents were effective in reducing the incidence of DVT, the antistasis devices (gradient elastic stockings and intermittent pneumatic compression) were most effective. The purpose of the second study was to evaluate the effectiveness of combining a pharmacologic drug with an antistasis modality. Deep venous thrombosis was virtually eliminated in this group of 328 patients. There was only a 1.5 per cent incidence of DVT in the treated population as compared to a 26.8 per cent incidence in the control group. Thus, it seems that combining one antistasis and one pharmacologic agent greatly reduces the incidence of lower extremity thrombi. I-125 fibrinogen scanning was the most sensitive test in detecting DVT and had an accuracy of 97 per cent.
Compared with compression alone, combined prophylactic modalities decrease significantly the incidence of venous thromboembolism. Compared with pharmacological prophylaxis alone, combined modalities reduce significantly the incidence of DVT but the effect on PE is unknown. The results of the current review support, especially in high-risk patients, the use of combined modalities. More studies on their role in PE prevention, compared with pharmacological prophylaxis alone, are urgently needed.