Low Molecular Weight Heparin and Compression Stockings in the Prevention of Venous Thromboembolism in Neurosurgery

Abstract

SummaryPerioperative anticoagulant prophylaxis for postoperative venous thromboembolism (VTE) in neurosurgical patients has not gained wide acceptance due to the fear of intracranial bleeding. Physical methods give a worthwhile reduction of postoperative VTE but there still remains a substantial residual incidence. In other clinical indications, low molecular weight heparins have proven to be effective for prophylaxis of VTE when administered postoperatively, with the advantage of no bleeding enhancement during surgery.Therefore, we performed a multicentre, randomized, double-blind trial in neurosurgical patients to investigate the efficacy and safety of adding a low molecular weight heparin (LMWH), nadroparin, initiated postoperatively, to graduated compression stockings in the prevention of VTE. Deep-vein thrombosis was detected by mandatory venography. Bleeding was determined according to pre-defined objective criteria for major and minor episodes.An adequate bilateral venogram was obtained in 166 of 241 LMWH patients (68.9%) and 179 of 244 control patients (73.4%). A total of 31 of 166 LMWH patients (18.7%) and 47 of 179 control patients (26.3%) had VTE up to Day 10 postoperatively (p = 0.047). The relative risk reduction (RRR) was 28.9%. The rates for proximal deep-vein thrombosis/pulmonary embolism were 6.9% and 11.5% for the two groups, respectively (RRR: 40.2%; p = 0.065).Secondary analyses involved all VTE up to day 56 post-surgery which was detected in 33 patients of 241 in the LMWH group (13.7%) and 51 of 244 control patients (20.9%; RRR 34.5%; p = 0.018). The corresponding percentages for proximal deep-vein thrombosis/pulmonary embolism were 5.8% and 10.2% for the two groups, respectively, giving a RRR of 43.3%; p = 0.036. Major bleeding complications, during the treatment period, occurred in six low molecular weight heparin treated patients (2.5%) and in two control patients (0.8%); p = 0.087.A higher mortality was observed in the low molecular weight heparin group over the 56-day follow-up period (22 versus 10; p = 0.026). However, none of these deaths was judged by a blinded adjudication committee to be related to the study drug.In conclusion, this study demonstrates that the low molecular weight heparin, nadroparin, added to graduated compression stockings results in a clinically significant decrease in VTE without inducing any significant increase of major bleeding.

The incidence of deep vein thrombosis detected by routine surveillance ultrasound in neurosurgery patients receiving dual modality prophylaxis

“…Patients in that study received LMWH (nadroparin) and graduated compression stockings, and by venography were found to have a proximal lower extremity incidence of 7%; however, the incidence of total lower extremity DVT was considerably higher at 19% [14]. Similarly, Agnelli et al demonstrated an incidence of 5% proximal and 17% total lower extremity DVT, in patients treated with both LMWH (enoxaparin) and compression stockings as detected by venography at treatment day 8 (or sooner if the patient developed symptoms of DVT confirmed by compression ultrasound) [8].…”

Prevention of Venous Thromboembolism in Surgical Patients

“…1 Two double-blind, randomized, venography-based studies compared graduated compression stockings alone or a combination of graduated elastic stockings and LMWH started postoperatively in neurosurgical patients. 78,79 In the first trial, the rates of overall DVT and proximal DVT were 26% and 12% in patients given graduated compression stockings alone and 19% and 7%, respectively, in those given the stockings plus LMWH. 78 In the second study, the rates of overall and proximal DVT were 33% and 13% in the group wearing graduated compression stockings compared with 17% and 5%, respectively, in patients receiving the combined prophylaxis.…”

“…78,79 In the first trial, the rates of overall DVT and proximal DVT were 26% and 12% in patients given graduated compression stockings alone and 19% and 7%, respectively, in those given the stockings plus LMWH. 78 In the second study, the rates of overall and proximal DVT were 33% and 13% in the group wearing graduated compression stockings compared with 17% and 5%, respectively, in patients receiving the combined prophylaxis. 79 Therefore, prophylaxis with the combination of LMWH and graduated compression stockings is more efficacious than prophylaxis with the stockings alone.…”

Adjuvant enoxaparin therapy may decrease the incidence of postoperative thrombotic events though does not increase the incidence of postoperative intracranial hemorrhage in patients with meningiomas

“…DVT and VTEs significantly increase tumor patient morbidity and mortality and therefore are important aspects of tumor treatment to address. Prior studies have shown that prophylactic treatment with low molecular weight heparin leads to fewer vascular complications such DVT and VTEs [10][11][12][13][14][15]. However, the risk of postoperative hematoma has been shown to increase with early anticoagulation [16].…”