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VTE and thromboprophylaxis in patients with IPD - the SPATA-DVT Study
Table 1. Inherited platelet disorders patient characteristics according to type of surgery.
Abdominal Gynecological Orthopedic Urological Cardiovascular Thoracic Neuro/spinal surgery surgery surgery surgery surgery surgery surgery
(N72) (N55) (N41) (N14) (N10) (N9) (N9)
Age in years, median (IQR)
Females, N (%)
Platelet count before surgery (x109/L),
median (IQR)
Malignancy, N (%)
WHO bleeding score, median (IQR)
Caprini score, median (IQR)
Caprini class risk, median (IQR)
Use of thromboprophylaxis, N (%)
Mechanical thromboprophylaxis, N (%)
LMWH thromboprophylaxis, N (%)
Preoperative antihemorrhagic prophylaxis, N (%)
Any excessive post-surgical bleeding, N (%)
47 (29-57)
38 (54.2) 120 (65-175) 1 (1.4) 2 (1-4) 2 (1-4) 1 (1-2) 7 (9) *5 (6.9) 3 (4.2) 34 (62.5)
22 (30)
36 (29-45)
55 (100) 56 (34-162.5) 2 (3.6) 2 (1-2) 3 (2-5) 2 (1-3) 12 (21.8) *7 (12.7) 7 (12.7) 27 (49.1)
42 (76.5)
42 (24-58)
22 (53.7) 139 (103-191.5) 1 (2.4)
2 (1-3)
4 (2-7)
2 (1-2) 13 (31.7) 4 (9.7)
9 (22) 25 (62)
5 (12.5)
58 (45-70)
3 (21.4) 75 (5-90) 1 (7.1) 2 (1-3) 3 (2-4) 2 (1-2) 7 (50) 6 (42.9) 1 (7.1) 9 (64.3)
2 (14.3)
54 (52-65)
6 (60) 60 (425-94) 2 (20) 3 (1-3) 7 (3-8) 4 (3-4) 0
0
0
7 (70) 6 (60)
37(28-58)
2 (22) NA
3 (33)
2 (1-3)
2(1-5)
2 (1-4)
7 (77)
6 (66)
1 (11)
5 (55)
3 (33)
40 (16-76)
3 (30) NA
1 (11)
3 (2-4)
2 (0-8)
2 (1-4)
3(30)
2(22)
1 (11)
7 (77)
4 (44)
IPD: inherited platelet disorders; IQR: interquartile range; LMWH: low molecular weight heparin; NA: not available; *: in some procedures both mechanical and LMWH throm- boprophylaxis was employed.
mechanical thromboprophylaxis in five and no prophylax- is in two. No VTE was recorded in this population (Online Supplementary Table S2).
Of the procedures at high VTE-risk according to the Caprini risk stratification (n=65),33 thromboprophylaxis was adopted in 22 (33.8%) (LWMH in 14, mechanical in six, and both in two) with no VTE events, while in 43 it was not adopted. Regarding procedures at intermediate VTE-risk (n=60), thromboprophylaxis was used in 15 (25%) (mechanical in 11 and pharmacologic in four), while of the procedures at low VTE-risk (n=53) thromboprophy- laxis was used in 10 (18.9%) (nine mechanical, one both mechanical and pharmacologic), and of the procedures at very low VTE-risk (n=32), thromboprophylaxis was used in only two patients (6.2%) (one mechanical, one pharma- cologic). According to the procedure-related VTE-risk stratification3,35 high-risk procedures, 114 intermediate- risk and 61 low-risk, were performed. Thromboprophylaxis was adopted in 42% (nine pharma- cologic and six mechanical) of the high-risk procedures, in 21% (six pharmacologic, 15 mechanical and three both) of the intermediate-risk and in 16.4% (four pharmacologic and six mechanical) of the low risk procedures. The choice of using LMWH, was significantly associated with the Caprini risk class (P<0.001 and P=0.002 respectively) (Online Supplementary Table S3) and with the procedure- related VTE-risk class (P=0.007 and P=0.009, respectively) (Figure 2A). The use of thromboprophylaxis with LMWH was similar between elective and urgent procedures: 10.2% versus 13% respectively (P=not significant [n.s.]).
Older age also independently predicted the use of phar- macologic thromboprophylaxis. In fact, LMWH-treated patients were significantly older (median age 67 vs. 42 years; P<0.01) and had a higher median Caprini score (8 vs. 4; P<0.01) than non-treated patients (Table 2). Additionally, history of cancer was more frequent in heparin users than in non-users (18% vs. 3.2%; P=0.018).
On the contrary, neither the WHO-BS nor sex distribu- tion (both in IPFD and IPND) were significantly associated with LMWH use.
Mechanical prophylaxis was applied with graduated
compression stockings in 30 procedures (14%) and with intermittent pneumatic compression in one (0.47%), while pharmacologic prophylaxis was undertaken with enoxaparin in 18 procedures (8%), tinzaparin in one (0.47%), dalteparin in one (0.47%), and in two cases (0.95%) type was not specified. Enoxaparin was adminis- tered at a median dose of 4,000 IU/day (IQR: 2,000-5,000 IU/day) for a median duration of 15 days (IQR: 7-18), starting on the day of surgery. The use of LMWH, as well as the use of any thromboprophylaxis, increased over time during the observation period covered by the study (LMWH: overall rate [OR] 2.5; 95% confidence interval [CI]: 1.31-4.96; any thromboprophylaxis: OR 1.4; 95% CI: 0.98-2.08) (Figure 3).
Thromboprophylaxis (pharmacologic and/or mechani- cal) was more common in patients with IPFD compared with those with IPND (34.5% vs. 11%; P<0.01) due to the greater use of mechanical thromboprophylaxis in the for- mer (24% vs. 3%; P<0.01), even if there was no difference in VTE-risk between the two groups. LMWH was admin- istered in 10% of procedures carried out in patients with IPND (10 procedures), and in 10.9% of those carried out in patients with IPFD (12 procedures).
None of the patients affected by biallelic Bernard Soulier syndrome (bBSS) (n=11) and Glanzmann thrombasthenia (GT) (n=5) received pharmacologic thromboprophylaxis. This finding probably reflects the perception that the VTE-risk of these patients is low, as suggested by previous reports14 and the fear of bleeding. In IPND, LMWH was neither administered in patients with ACTN1-related thrombocytopenia (n=5) nor in the only patient with X- linked thrombocytopenia (Online Supplementary Table S1). Median platelet count of the overall IPD population before surgery was 158x109/L (IQR: 120-287) in procedures fol- lowed by LMWH versus 120x109/L (IQR: 8-163) in those where LMWH was not administered (P=n.s.).
Thrombotic outcomes
Two thromboembolic events were recorded (0.95% of all interventions), both occurring in patients who did not receive thromboprophylaxis (3.5% of non-prophylaxed
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