1 CURRENT GUIDELINES : VTE PROPHYLAXIS ACCP GUIDELINES AFTER THA - - PDF document

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Compression Stockings, HOT or NOT?

The use of Graduated Compression Stockings after THA : Tradition or Evidence-Based Medicine ?

Dr Sophie MERCIER (PG – UCL) Dr Xavier MOREL (PG – ULB)

PLAN

1) Introduction 2) Current guidelines in VTE prophylaxis after THA 3) What about GCS? Literature review 4) Conclusion

CHEMICAL VTE PROPHYLAXIS

• Low Molecular Weight Heparin (LMWH)
• Unfractionated Heparin (UFH)
• Fondaparinux
• Vitamin K Antagonists (VKA)
• Direct-Acting Oral Anticoagulants (DOAC)
• Factor Xa inhibitor
• Thrombin inhibitor
• Aspirin

MECHANICAL VTE PROPHYLAXIS

• Intermittent Pneumatic Compression

Device (IPCD)

• Mobilization
• Venous Foot Pump (VFP)
• Graduated Compression Stockings (GCS)

FOCUS ON GCS

• Optimal pressure gradient :
• 18 mmHg at the ankle
• 14 mmHg at the calf
• 8 mmHg at the knee

▷ 98% of stockings failed to produce this gradient

• Existence of a “reversed gradient” : higher incidence
• f DVT!
• Must be sized and fitted properly
• No statistical difference between below-knee or

above-knee stockings

Best AJ, Williams S, Crozier A, Bhatt R, Gregg PJ, et al. Graded compression stockings in elective orthopaedic surgery. An assessment of the in vivo performance of commercially available stockings in patients having hip and knee arthroplasty. J Bone Joint Surg Br 2000; 82: 116-118.

FOCUS ON GCS : CONS

• Contraindicated when peripheral arterial

insufficiency, severe cardiac insufficiency and ulceration of the lower limb

• Risk of impairment in tissue oxygenation
• Risk of skin complication
• Lack of compliance (uncomfortable,

difficult to use)

• Costly

Shalhoub J, et al. Graduated Compression Stockings as an Adjunct to Low Dose Low Molecular Weight Heparin in Venous Thromboembolism Prevention in Surgery: A Multicentre Randomised Controlled Trial, European Journal of Vascular and Endovascular Surgery (2017)

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CURRENT GUIDELINES : VTE PROPHYLAXIS AFTER THA

• American College of Chest Physicians (ACCP) 2012
• National Institute for Health and Care Excellence (NICE) 2018
• Scottish Intercollegiate Guidelines Network (SIGN) 2010 – 2015
• American Academy of Orthopaedic Surgeons (AAOS) 2011

ACCP GUIDELINES

• Use of one of the following for a minimum of 10 to 14 days rather than

no anti- thrombotic prophylaxis: low-molecular-weight heparin (LMWH), fondaparinux, apixaban, dabigatran, rivaroxaban, low-dose unfractionated heparin (LDUH), adjusted-dose VKA, aspirin (all Grade 1B), or an intermittent pneumatic compression device (IPCD) (Grade 1C)

• In patients undergoing major orthopedic surgery, we suggest using dual

prophylaxis with an antithrombotic agent and an IPCD during the hospital stay (Grade 2C)

• In patients undergoing major orthopedic surgery and increased risk of

bleeding, we suggest using an IPCD or no prophylaxis rather than pharmacologic treatment

Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombolic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e278S-325S.

NICE GUIDELINES

• LMWH (for 10 days) followed by aspirin (75 or 150 mg) for a further

28 days.

• LMWH (for 28 days) combined with anti-embolism stockings (until

discharge).

• Rivaroxaban
• NICE. Venous thromboembolism: reducing the risk: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital.

London: National Institute for Health and Clinical Excellence; 2010.

SIGN GUIDELINES

• Patients

undergoing THA

• r

TKA surgery should receive pharmacological prophylaxis (with LMWH, fondaparinux, rivaroxaban or dabigatran) combined with mechanical prophylaxis unless contraindicated (GRADE A)

• Patients

with increased risk

• f

bleeding should be given mechanical prophylaxis alone (GRADE C)

Scottish Intercollegiate Guidelines Network (SIGN). Prevention and management of venous thromboembolism. SIGN publication no. 122. Edinburgh: SIGN; 2010.

AAOS GUIDELINES

• Patients with no other VTE or bleeding risk than the surgery : Chemical

and/or compressive devices (Moderate)

• Patients with previous VTE history : Chemical and compressive devices

(Consensus)

• Patients with a known bleeding disorder (e.g., hemophilia) and/or

active liver disease : Compressive devices alone (Consensus)

Unit ACPG ed. AAOS clinical guideline on preventing venous thrombo- embolic disease in patients undergoing elective hip and knee arthroplasty. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2011.

CHALLENGING THE GUIDELINES…

• ACCP does not mention the use of GCS
• NICE recommends the use of GCS + LMWH, though none of the

reviewed studies included the comparison between LMWH alone vs LMWH + GCS

• SIGN recommends the use of IPCD or VFP
• AAOS does not specify the type of mechanical device recommended

Lack of evidence/support regarding the use of GCS

Whittaker L, Baglin T, Vuylsteke A. Challenging the evidence for graduated compression stockings. BMJ 2013;346:f3653

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WHAT ABOUT GCS? LITERATURE REVIEW

1) GCS for prevention of DVT after hip and knee replacement (1996) 2) The use of GCS in association with fondaparinux in surgery of the hip (2007) 3) Value of GCS in Prevention of VTE after THA and TKA (2013) 4) Traditions and myths in hip and knee arthroplasty (2014) 5) Combination prophylaxis versus pharmacologic prophylaxis alone for preventing DVT in hip surgery (2016) 6) Thromboembolism prophylaxis in orthopaedics : an update (2018) 7) DVT in orthopaedic surgery (2018) 8) Prevention of VTE in adult orthopaedic surgical patients (2018)

• Features :
• Prospective, randomised controlled-trial (RCT)
• n = 177 (THA = 64)
• 2 groups : GCS vs no prophylaxis
• Conclusions :
• GCS are ineffective as a DVT prophylaxis in THA patients
• Use of GCS is based on weak scientific and clinical evidence
• Higher proportion of patients developed DVT when wearing the

stockings (p = 0.03 with below-knee stockings)

Hui AC, Heras-Palou C, Dunn I, et al. Graded compression stockings for prevention of deep-vein thrombosis after hip and knee replacement. J Bone Joint Surg [Br] 1996;78-B:550-4

• Features :
• Multicentre, multinational, randomised, open–label comparative study
• Single-blind
• 2 groups : fondaparinux (n = 400) vs fondaparinux + GCS (n = 395)
• DVT prevalence :
• 5.5% in group I vs 4.8% in group II
• Conclusions :
• The addition of GCS does not appear to improve the effectiveness of VTE prophylaxis

with fondaparinux

• Negative sides : THA + HFS patients

Cohen AT. The use of graduated compression stockings in association with fondaparinux in surgery of the hip. A multicentre, multinational, randomised, open-label, parallel-group comparative study. J Bone Joint Surg Br 2007; 89: 887-92.

• Features :
• Retrospective study, over 18 months
• 2 groups : Enoxaparin + GCS (n = 480 THA) vs Enoxaparin (n = 368 THA)
• DVT prevalence :
• 0.47% (group I) vs 0.81% (groupe II)
• Conclusions :
• No obvious benefit of GCS in the prevention of VTE after THA in the

presence of Enoxaparin prophylaxis

Majeed H, Szypryt EP (2013) Value of Graduated Compression Stockings in Prevention of Venous Thromboembolism after Total Hip and Knee Arthroplasty. J Gen Pract 1: 116. doi: 10.4172/2329-9126.1000116

Traditions and myths in hip and knee arthroplasty : a narrative review

• Features :
• Narrative review
• Conclusion :
• There is no evidence to recommend the use of GCS after THA or TKA

Husted H, Gromov K, et al. Traditions and myths in hip and knee arthroplasty. A narrative review. Acta Orthopaedica 2014; 85 (6): 548-555

• Features :
• Meta-analysis of VTE prophylaxis in hip surgery
• 3 high-quality studies (though one of them as Dextran as VTE

prophylaxis)

• Results :
• Excluding

the Fredin’s 1989 study (Dextran), combinated pharmacologic + GCS did not reduce the risk of distal DVT.

• It is not necessary to combined the use of GCS if we use the current

recommended prophylaxis

Lin F-F, Lin C-H, Chen B, Zheng K. Combination prophylaxis versus pharmacologic prophylaxis alone for preventing deep vein thrombosis in hip surgery. Hip Int 2016; 26 (6): 561-566

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• Features :
• Literature Review
• Conclusion :
• ACCP guidelines for VTE prophylaxis are adequate enough and

should be endorsed for daily clinical practice

EFORT Open Rev 2018;3:136-148. DOI: 10.1302/2058-5241.3.170018

Deep Venous Thrombosis Prophylaxis in Orthopaedic Surgery

• Features :
• Literature Review, published on Medscape
• Recommendations :
• TVE prevention strategies include LMWH, fondaparinux,

coumarins.

• Dose-adjusted LDUH or LMWH may be used with or without

IPCD/GCS

Forsh, DA. Deep Venous Thrombosis Prophylaxis in Orthopedic Surgery. [consulté le 20 janvier 2019] En ligne : https://emedicine.medscape.com/article/1268573-overview#showall

Prevention of venous Thromboembolism in adult orthopaedic surgical patients

• Features :
• Literature Review, published on UpToDate
• Recommendations for low bleeding risk THA patients:
• Pharmacologic prophylaxis (LMWH, Rivaroxaban or Apixaban)

with or without IPCD rather than no prophylaxis

• Recommendations for high bleeding risk THA patients:
• Mechanical methods : IPC preferentially. Evidence to support

the use of GCS is derived from indirect data (other surgical and medical patients)

Pai M, Douketis JD. Prevention of venous thromboembolism in adult orthopedic surgical patients. [consulté le 20 janvier 2019] En ligne : https://www.uptodate.com/contents/prevention-of-venous-thromboembolism-in-adult-orthopedic-surgical-patients#H1189569341

CONCLUSIONS

• Guidelines : support the use of mechanical VTE prophylaxis but…
• ACCP recommends IPCD
• SIGN recommends the use of IPCD or VFP
• AAOS does not specify the type of mechanical device recommended
• NICE recommends the use of GCS + LMWH, though none of the reviewed

studies included the comparison between LMWH alone vs LMWH + GCS. Moreover, evidence to support the use of GCS is derived from indirect data in

• ther surgical and medical patients
• Studies :
• GCS alone are ineffective as a DVT prophylaxis in THA patients
• Use of GCS is based on weak scientific and clinical evidence
• The addition of GCS does not appear to improve the effectiveness of VTE

prophylaxis with neither fondaparinux nor Enoxaparin

CONCLUSIONS

• Meta-analysis : no necessity to add GCS to current recommended

chemical VTE prophylaxis

• Literature Reviews : support the use of chemical VTE prophylaxis

with or without mechanical prophylaxis (preferentially IPCD)

OUR OPINION

• None of the studies demonstrates a clinical benefit of the use of GCS in addition to

current chemical prophylaxis

• There is a lack of evidence regarding the benefits of GCS
• GCS may be harmful

BUT….

• There is a lack of studies comparing combination prophylaxis (GCS + chemical VTE

prophylaxis) to chemical VTE prophylaxis alone

• There is no study comparing DOAC + GCS vs DOAC alone, or VKA + GCS vs VKA alone.
• Absence of evidence is not evidence of absence

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THANK YOU BIBLIOGRAPHY

• EFORT Open Rev 2018;3:136-148. DOI: 10.1302/2058-5241.3.170018
• Caprini JA, et al. Update on Risk Factors For Venous Thromboembolism. The American Journal of Medicine

(2005)

• Best AJ, Williams S, Crozier A, Bhatt R, Gregg PJ, et al. Graded compression stockings in elective
• rthopaedic surgery. An assessment of the in vivo performance of commercially available stockings in patients

having hip and knee arthroplasty. J Bone Joint Surg Br 2000; 82: 116-118.

• Shalhoub J, et al. Graduated Compression Stockings as an Adjunct to Low Dose Low Molecular Weight

Heparin in Venous Thromboembolism Prevention in Surgery: A Multicentre Randomised Controlled Trial, European Journal of Vascular and Endovascular Surgery (2017)

• Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients:

Antithrombolic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e278S-325S.

• NICE. Venous thromboembolism: reducing the risk: reducing the risk of venous thromboembolism (deep vein

thrombosis and pulmonary embolism) in patients admitted to hospital. London: National Institute for Health and Clinical Excellence; 2010.

• Scottish Intercollegiate Guidelines Network (SIGN). Prevention and management of venous
• thromboembolism. SIGN publication no. 122. Edinburgh: SIGN; 2010.
• Unit ACPG ed. AAOS clinical guideline on preventing venous thrombo- embolic disease in patients undergoing

elective hip and knee arthroplasty. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2011.

BIBLIOGRAPHY

• Whittaker L, Baglin T, Vuylsteke A. Challenging the evidence for graduated compression stockings.

BMJ 2013;346:f3653.

• Hui AC, Heras-Palou C, Dunn I, et al. Graded compression stockings for prevention of deep-vein

thrombosis after hip and knee replacement. J Bone Joint Surg [Br] 1996;78-B:550-4

• Cohen AT. The use of graduated compression stockings in association with fondaparinux in surgery of

the hip. A multicentre, multinational, randomised, open-label, parallel-group comparative study. J Bone Joint Surg Br 2007; 89: 887-92.

• Majeed H, Szypryt EP (2013) Value of Graduated Compression Stockings in Prevention of Venous

Thromboembolism after Total Hip and Knee Arthroplasty. J Gen Pract 1: 116. doi: 10.4172/2329- 9126.1000116

• Husted H, Gromov K, et al. Traditions and myths in hip and knee arthroplasty. A narrative review. Acta

Orthopaedica 2014; 85 (6): 548-555

• Lin F-F, Lin C-H, Chen B, Zheng K. Combination prophylaxis versus pharmacologic prophylaxis alone

for preventing deep vein thrombosis in hip surgery. Hip Int 2016; 26 (6): 561-566

• Forsh DA. Deep Venous Thrombosis Prophylaxis in Orthopedic Surgery. [consulté le 20 janvier 2019]

En ligne : https://emedicine.medscape.com/article/1268573-overview#showall

BIBLIOGRAPHY

• Pai M, Douketis JD. Prevention of venous thromboembolism in adult
• rthopedic surgical patients. [consulté le 20 janvier 2019] En ligne :

https://www.uptodate.com/contents/prevention-of-venous- thromboembolism-in-adult-orthopedic-surgical-patients#H1189569341

• Kalodiki EP, Hoppensteadt DA, Nicolaides AN, Fareed J, Gill K, Regan F, et
• al. Deep venous thrombosis prophylaxis with low molecular weight heparin

and elastic compression in patients having total hip replacement. A randomised controlled trial. International Angiology 1996;15(2):162–8.

• Sachdeva A, Dalton M, Amaragiri SV, Lees T. Graduated compression

stockings for prevention of deep vein thrombosis. Cochrane Database Syst

• Rev. 2014;12:CD001484.