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Original article

Vol. 149 No. 5152 (2019)

Duration of pharmacological thromboprophylaxis after outpatient endovenous laser ablation: a propensity score-matched analysis

  • Hak Hong Keo
  • Luca Spinedi
  • Daniel Staub
  • Nicolas Diehm
  • Daniel Holtz
  • Pavel Broz
  • Christian Regli
  • Heiko Uthoff
DOI
https://doi.org/10.4414/smw.2019.20166
Cite this as:
Swiss Med Wkly. 2019;149:w20166
Published
23.12.2019

Summary

AIM OF THE STUDY: The objective of this study was to identify the optimal duration of pharmacological thromboprophylaxis after outpatient endovenous laser ablation (EVLA).

METHODS: In this multicentre retrospective study in a university hospital, regional hospital and private practices, we collected the demographic, procedural and outcome data of all consecutive patients with varicose veins class C2 to C6 undergoing outpatient EVLA of truncal and accessory veins between February 2009 and December 2015. The cumulative primary efficacy endpoint consisted of endovenous heat-induced thrombosis (EHIT) class 2–4, deep vein thrombosis (DVT) and pulmonary embolism (PE) diagnosed with duplex ultrasound or computed tomography angiography after 1 and 4 weeks of follow-up. Cumulative secondary endpoints were complete ablation of the treated veins and major bleeding, skin burns and infection.

RESULTS: A total of 864 patients were treated with EVLA as an outpatient procedure. Of those, 35 patients were omitted because of therapeutic anticoagulation or dual antiplatelet therapy. Another 36 cases were excluded as the patients received pharmacological thromboprophylaxis for 5 days. A total of 793 were included in the final analysis. Of those, 225 patients (28.4%) received fondaparinux 2.5 mg s.c. for 3 days, 166 patients (20.9%) received rivaroxaban 10 mg p.o. for 3 days and 402 patients (50.7%) received rivaroxaban 10 mg for 10 days. The incidence of EHIT class 2–4 was 0.8% (n = 6) in total, 1.3% (n = 6) in group 1 (treated for 3 days) and 0.3% (n = 1) in group 2 (treated for 10 days) (odds ratio [OR] 0.19, confidence interval [CI] 0.02–1.66, p = 0.133). The cumulative primary composite endpoint at 4-week follow-up was 1.1% (n = 9) and was 2.1% (n = 8) in group 1 and 0.3% (n = 1) in group 2 (OR 0.0.12, CI 0.01–0.96, p = 0.046). Propensity score-matched analysis revealed no significant difference in the composite primary endpoint (CI −0.074 to 0.26). Complete occlusion rate was 99.2% in group 1 and 98.8% in group 2 (OR 0.61, CI 0.15–2.59, p = 0.506). No PE or major bleeding events occurred in either group. Propensity score-matched analysis showed no significant difference in the secondary endpoints.

CONCLUSION: Using propensity score-matched analysis we showed that pharmacological thromboprophylaxis after EVLA seems to be equally effective with 3 days or 10 days of treatment with a similar success rate and safety profile. Undoubtedly, a large randomised control trial, ideally including a group without pharmacological thromboprophylaxis, is needed to draw more definitive conclusions on the optimal duration of pharmacological post-EVLA thromboprophylaxis.

References

  1. Bonè C. Tratamiento endoluminal de las varices con laser de Diodo: estudio preliminary. Rev Patol Vasc. 1999;(5):35–46.
  2. Weiss RA, Munavalli G. Endovenous ablation of truncal veins. Semin Cutan Med Surg. 2005 Dec;24(4):193–9. https://doi.org/10.1016/j.sder.2005.10.006
  3. Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, et al.; Society for Vascular Surgery; American Venous Forum. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011 May;53(5 Suppl):2S–48S. https://doi.org/10.1016/j.jvs.2011.01.079
  4. National Institute for Health and Care Excellence. Available at http://guidance.nice.org.uk/CG168/NICEGuidance/pdf/English
  5. Oni OO, Mahabir JP, Iqbal SJ, Gregg PJ. Serum osteocalcin and total alkaline phosphatase levels as prognostic indicators in tibial shaft fractures. Injury. 1989 Jan;20(1):37–8. https://doi.org/10.1016/0020-1383(89)90042-9
  6. Kane K, Fisher T, Bennett M, Shutze W Jr, Hicks T, Grimsley B, et al. The incidence and outcome of endothermal heat-induced thrombosis after endovenous laser ablation. Ann Vasc Surg. 2014 Oct;28(7):1744–50. https://doi.org/10.1016/j.avsg.2014.05.005
  7. Boersma D, Kornmann VN, van Eekeren RR, Tromp E, Ünlü Ç, Reijnen MM, et al. Treatment Modalities for Small Saphenous Vein Insufficiency: Systematic Review and Meta-analysis. J Endovasc Ther. 2016 Feb;23(1):199–211. https://doi.org/10.1177/1526602815616375
  8. Malgor RD, Gasparis AP, Labropoulos N. Morbidity and mortality after thermal venous ablations. Int Angiol. 2016 Feb;35(1):57–61.
  9. Puggioni A, Kalra M, Carmo M, Mozes G, Gloviczki P. Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications. J Vasc Surg. 2005 Sep;42(3):488–93. https://doi.org/10.1016/j.jvs.2005.05.014
  10. Marsh P, Price BA, Holdstock J, Harrison C, Whiteley MS. Deep vein thrombosis (DVT) after venous thermoablation techniques: rates of endovenous heat-induced thrombosis (EHIT) and classical DVT after radiofrequency and endovenous laser ablation in a single centre. Eur J Vasc Endovasc Surg. 2010 Oct;40(4):521–7. https://doi.org/10.1016/j.ejvs.2010.05.011
  11. Kabnick L. Ombrellino M Agis Hea. Endovenous heat induced thrombus (EHIT) at the superficial-deep venous junction: a new post-treatment clinical entity, classification and potential treatment strategies. 18th Annual Meeting of the American Venous Forum, Miami, FL, USA. February 2006.
  12. The Daily Mail. Mother-of-two's death after varicose vein surgery 'could have been prevented', her husband claims. Accessed at at http://dailymial.co.uk/health/article-2980924/Mother-of-two's death after varicose vein surgery 'could have been prevented', her husband claims.html (accessed date 21.3.2019). Published 12:20 GMT, 5 March 2015.
  13. News RT. Inquest into the death of Karen McCabe adjourned until May. http://www.rte.ie/news/2016/0218/769058-inquest-varicose-veins-surgery-death. Date accessed 21.03.2019).
  14. Ash JL, Moore CJ. Laser treatment of varicose veins: order out of chaos. Semin Vasc Surg. 2010 Jun;23(2):101–6. https://doi.org/10.1053/j.semvascsurg.2010.01.005
  15. Spreafico G, Kabnick L, Berland TL, Cayne NS, Maldonado TS, Jacobowitz GS, et al. Laser saphenous ablations in more than 1,000 limbs with long-term duplex examination follow-up. Ann Vasc Surg. 2011 Jan;25(1):71–8. https://doi.org/10.1016/j.avsg.2010.09.005
  16. Gloviczki P, Gloviczki ML. Guidelines for the management of varicose veins. Phlebology. 2012 Mar;27(1_suppl Suppl 1):2–9. https://doi.org/10.1258/phleb.2012.012s28
  17. Knipp BS, Blackburn SA, Bloom JR, Fellows E, Laforge W, Pfeifer JR, et al.; Michigan Venous Study Group. Endovenous laser ablation: venous outcomes and thrombotic complications are independent of the presence of deep venous insufficiency. J Vasc Surg. 2008 Dec;48(6):1538–45. https://doi.org/10.1016/j.jvs.2008.07.052
  18. Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, et al.; Society for Vascular Surgery; American Venous Forum. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011 May;53(5 Suppl):2S–48S. https://doi.org/10.1016/j.jvs.2011.01.079
  19. http://www.nice.org.uk/guidance/cg168/chapter/1-Recommendations. Accessed Jan. 30. 2013.
  20. Kahn SR, Lim W, Dunn AS, Cushman M, Dentali F, Akl EA, et al. Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e195S-e226S.
  21. Christenson JT, Gueddi S, Gemayel G, Bounameaux H. Prospective randomized trial comparing endovenous laser ablation and surgery for treatment of primary great saphenous varicose veins with a 2-year follow-up. J Vasc Surg. 2010 Nov;52(5):1234–41. https://doi.org/10.1016/j.jvs.2010.06.104
  22. Schwarz T, von Hodenberg E, Furtwängler C, Rastan A, Zeller T, Neumann FJ. Endovenous laser ablation of varicose veins with the 1470-nm diode laser. J Vasc Surg. 2010 Jun;51(6):1474–8. https://doi.org/10.1016/j.jvs.2010.01.027
  23. Sweetland S, Green J, Liu B, Berrington de González A, Canonico M, Reeves G, et al.; Million Women Study collaborators. Duration and magnitude of the postoperative risk of venous thromboembolism in middle aged women: prospective cohort study. BMJ. 2009 Dec;339 dec03 1:b4583. https://doi.org/10.1136/bmj.b4583
  24. Porter JM, Moneta GL ; International Consensus Committee on Chronic Venous Disease. Reporting standards in venous disease: an update. J Vasc Surg. 1995 Apr;21(4):635–45. https://doi.org/10.1016/S0741-5214(95)70195-8
  25. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP ; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol. 2008 Apr;61(4):344–9. https://doi.org/10.1016/j.jclinepi.2007.11.008
  26. Labropoulos N, Tiongson J, Pryor L, Tassiopoulos AK, Kang SS, Ashraf Mansour M, et al. Definition of venous reflux in lower-extremity veins. J Vasc Surg. 2003 Oct;38(4):793–8. https://doi.org/10.1016/S0741-5214(03)00424-5
  27. http://www.uvs.ch/; accessed January 15th, 2017.
  28. Kaatz S, Ahmad D, Spyropoulos AC, Schulman S ; Subcommittee on Control of Anticoagulation. Definition of clinically relevant non-major bleeding in studies of anticoagulants in atrial fibrillation and venous thromboembolic disease in non-surgical patients: communication from the SSC of the ISTH. J Thromb Haemost. 2015 Nov;13(11):2119–26. https://doi.org/10.1111/jth.13140
  29. Hingorani AP, Ascher E, Markevich N, Schutzer RW, Kallakuri S, Hou A, et al. Deep venous thrombosis after radiofrequency ablation of greater saphenous vein: a word of caution. J Vasc Surg. 2004 Sep;40(3):500–4. https://doi.org/10.1016/j.jvs.2004.04.032
  30. Carradice D, Leung C, Chetter I. Laser; best practice techniques and evidence. Phlebology. 2015 Nov;30(2 Suppl):36–41. https://doi.org/10.1177/0268355515591440
  31. Akin M, Schäfer A, Akin I, Widder J, Brehm M. Use of New Oral Anticoagulants in the Treatment of Venous Thromboembolism and Thrombotic Prophylaxis. Cardiovasc Hematol Disord Drug Targets. 2015;15(2):92–6. https://doi.org/10.2174/1871529X1502151209110620
  32. Ageno W, Mantovani LG, Haas S, Kreutz R, Monje D, Schneider J, et al. Safety and effectiveness of oral rivaroxaban versus standard anticoagulation for the treatment of symptomatic deep-vein thrombosis (XALIA): an international, prospective, non-interventional study. Lancet Haematol. 2016 Jan;3(1):e12–21. https://doi.org/10.1016/S2352-3026(15)00257-4
  33. Chapter JJ. 41: Thrombotic Risk Assessment: A Hybrid Aproach. the Vein Book (ed. Bergan JJ). 2007 Elselvier Inc.
  34. Keo HH, Baumann F, Diehm N, Regli C, Staub D. Rivaroxaban versus fondaparinux for thromboprophylaxis after endovenous laser ablation. J Vasc Surg Venous Lymphat Disord. 2017 Nov;5(6):817–23. https://doi.org/10.1016/j.jvsv.2017.04.017
  35. Uthoff H, Holtz D, Broz P, Staub D, Spinedi L. Rivaroxaban for thrombosis prophylaxis in endovenous laser ablation with and without phlebectomy. J Vasc Surg Venous Lymphat Disord. 2017 Jul;5(4):515–23. https://doi.org/10.1016/j.jvsv.2016.12.002
  36. Goodyear SJ. A W K NI. Chapter 387: Anti-venous thrombosis protocol - a proposed scoring system. Charing Cross 1978-2017. Vascular and Endovasclar Consensus Update (ed. Greenhalgh RM). 2017 BIBA Publishing.
  37. Rhee SJ, Cantelmo NL, Conrad MF, Stoughton J. Factors influencing the incidence of endovenous heat-induced thrombosis (EHIT). Vasc Endovascular Surg. 2013 Apr;47(3):207–12. https://doi.org/10.1177/1538574413478494
  38. Manfrini S, Gasbarro V, Danielsson G, Norgren L, Chandler JG, Lennox AF, et al.; Endovenous Reflux Management Study Group. Endovenous management of saphenous vein reflux. J Vasc Surg. 2000 Aug;32(2):330–42. https://doi.org/10.1067/mva.2000.107573
  39. Merchant R Jr, Kistner RL, Kabnick LS. Is there an increased risk for DVT with the VNUS closure procedure? J Vasc Surg. 2003 Sep;38(3):628. https://doi.org/10.1016/S0741-5214(03)00322-7

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