Abstract
Background
Lower limb amputation surgery is associated with a high risk of venous thromboembolism. There is evidence that pharmacological thromboprophylaxis is not widely prescribed to patients undergoing this type of procedure.
Objectives
To investigate the profile of the thromboprophylaxis practices of angiologists and vascular surgeons in Brazil during the perioperative period of lower limb amputation surgery and conduct a descriptive analysis of the findings.
Methods
This is a cross-sectional, descriptive study, with simple probabilistic sampling, carried out with angiologists and vascular surgeons working in Brazil. Data were collected through electronic questionnaires, from February to June 2023.
Results
There were 237 respondents, 58.6% of whom conduct thrombotic risk stratification. Of these, 86.3% use the Caprini score. Only 27% of participants stratify patients’ bleeding risk. Low molecular weight heparin is the medication of choice for 85.7% of study participants, 78.9% of whom use a dosage of 40 IU per day. Around 46.8% use direct oral anticoagulants in addition to low molecular weight heparin and rivaroxaban is the drug they most often prescribe (94.6%). A little more than half (51.15%) routinely recommend pharmacological thromboprophylaxis until hospital discharge.
Conclusions
The study revealed the heterogeneous nature of conduct related to prescription of pharmacological thromboprophylaxis, highlighting the need for more studies to support prophylaxis decision-making in this patient population.
Keywords:
deep vein thrombosis; amputation; prophylaxis; patient safety; pulmonary embolism; health services research
Resumo
Contexto
As cirurgias de amputação de membros inferiores são associadas a alto risco de tromboembolismo venoso. Existem evidências de que a farmacoprofilaxia não é amplamente prescrita para pacientes submetidos a esse tipo de procedimento.
Objetivos
Conhecer o perfil e realizar a análise descritiva das práticas de tromboprofilaxia no perioperatório das cirurgias de amputação de membros inferiores feitas por angiologistas e cirurgiões vasculares no Brasil.
Métodos
Tratou-se de um estudo transversal, descritivo e de amostragem probabilística simples, realizado entre angiologistas e cirurgiões vasculares atuantes no Brasil. Os dados foram coletados por meio de questionários eletrônicos no período de fevereiro a junho de 2023.
Resultados
Entre os 237 respondentes, 58,6% realizavam a estratificação do risco trombótico, e 86,3% deles utilizavam o escore de Caprini. Apenas 27% dos participantes realizavam a estratificação do risco hemorrágico do paciente. A heparina de baixo peso molecular é a medicação de preferência de 85,7% dos participantes, sendo a dose de 40 UI por dia a escolha de 78,9% deles. Cerca de 46,8% utilizavam, além da heparina, anticoagulantes orais diretos, e, entre eles, a rivaroxabana é a droga mais prescrita (94,6%). Um pouco mais da metade (51,15%) tem como rotina a indicação da farmacoprofilaxia até o momento da alta hospitalar.
Conclusões
O estudo expôs a heterogeneidade nas condutas relacionadas à prescrição de tromboprofilaxia farmacológica, evidenciando a necessidade de mais estudos para dar respaldo à tomada de decisão relacionada à profilaxia nessa população de pacientes.
Palavras-chave:
trombose venosa profunda; amputação; profilaxia; segurança do paciente; embolia pulmonar; pesquisa sobre serviços de saúde
INTRODUCTION
Lower limb (LL) amputations are frequently performed by vascular surgeons because of complications caused by infections, peripheral arterial disease, trauma, or less frequently, cancer.11 Cook KD. Perioperative management of pedal amputations. Clin Podiatr Med Surg. 2005;22(3):329-41. http://doi.org/10.1016/j.cpm.2005.03.006. PMid:15978405.
http://doi.org/10.1016/j.cpm.2005.03.006...
In Brazil, it is estimated that the incidence of LL amputations is 18.93 per 100,000 inhabitants. From 2010 to 2020, 247,047 admissions related to LL amputation were registered22 Silva AAS, Castro AA, Bomfim LG, Pitta GBB. Amputações de membros inferiores por diabetes mellitus nos estados e nas regiões do Brasil. Res Soc Dev. 2021;10(4):e11910413837. http://doi.org/10.33448/rsd-v10i4.13837.
http://doi.org/10.33448/rsd-v10i4.13837...
and, despite improvements in health care, these procedures are still associated with considerable perioperative mortality.33 Stern JR, Wong CK, Yerovinkina M, et al. A meta-analysis of long-term mortality and associated risk factors following lower extremity amputation. Ann Vasc Surg. 2017;42:322-7. http://doi.org/10.1016/j.avsg.2016.12.015. PMid:28389295.
http://doi.org/10.1016/j.avsg.2016.12.01...
The percentage mortality in the LL amputation population after 30 days varied from 7 to 22%, with higher mortality rates among older patients and those who underwent transfemoral amputation.44 van Netten JJ, Fortington LV, Hinchliffe RJ, Hijmans JM. Early post-operative mortality after major lower limb amputation: a systematic review of population and regional based studies. Eur J Vasc Endovasc Surg. 2016;51(2):248-57. http://doi.org/10.1016/j.ejvs.2015.10.001. PMid:26588994.
http://doi.org/10.1016/j.ejvs.2015.10.00...
A proportion of this mortality can be attributed to thromboembolic complications and so adequate perioperative management of thrombotic risk is essential to reduce morbidity and mortality among amputees.
Individuals who undergo major LL amputations are at high risk of venous thromboembolism (VTE), with incidence ranging from 9.4 to 13.2%.55 Libertiny G, Hands L. Deep venous thrombosis in peripheral vascular disease. Br J Surg. 1999;86(7):907-10. http://doi.org/10.1046/j.1365-2168.1999.01129.x. PMid:10417563.
http://doi.org/10.1046/j.1365-2168.1999....
6 Yeager RA, Moneta GL, Edwards JM, Taylor LM Jr, McConnell DB, Porter JM. Deep vein thrombosis associated with lower extremity amputation. J Vasc Surg. 1995;22(5):612-5. http://doi.org/10.1016/S0741-5214(95)70048-X. PMid:7494364.
http://doi.org/10.1016/S0741-5214(95)700...
-77 Herlihy DR, Thomas M, Tran QH, Puttaswamy V. Primary prophylaxis for venous thromboembolism in people undergoing major amputation of the lower extremity. Cochrane Database Syst Rev. 2020;7(7):CD010525. PMid:32692430. Immobility and surgically induced endothelial venous trauma may be related to the increased thrombotic risk in this population. The risk is not limited to the amputation stump, but can also involve the contralateral limb.88 Alsheef MA, Schulman S, Donadini M, Zaidi ARZ. Venous Thromboembolism in lower extremity amputees: a systematic review of the literature. Blood. 2019;134(Supl Suppl 1):4980. http://doi.org/10.1182/blood-2019-130751.
http://doi.org/10.1182/blood-2019-130751...
Moreover, comorbidities and risk factors for amputation such as advanced age, smoking, and atherosclerotic disease superimpose conditions that generate a hypercoagulable state and, consequently, increased risk of VTE.66 Yeager RA, Moneta GL, Edwards JM, Taylor LM Jr, McConnell DB, Porter JM. Deep vein thrombosis associated with lower extremity amputation. J Vasc Surg. 1995;22(5):612-5. http://doi.org/10.1016/S0741-5214(95)70048-X. PMid:7494364.
http://doi.org/10.1016/S0741-5214(95)700...
,77 Herlihy DR, Thomas M, Tran QH, Puttaswamy V. Primary prophylaxis for venous thromboembolism in people undergoing major amputation of the lower extremity. Cochrane Database Syst Rev. 2020;7(7):CD010525. PMid:32692430.
Despite the proven efficacy and safety of thromboprophylaxis and its ample publicity over recent years, there are published Brazilian data showing that its use has still not reached the appropriate levels in our country.99 Pereira CA, Brito SSD, Martins AS, Almeida CM. Profilaxia da trombose venosa profunda: aplicação prática e conhecimento teórico em um hospital geral. J Vasc Bras. 2008;7(1):18-27. http://doi.org/10.1590/S1677-54492008000100005.
http://doi.org/10.1590/S1677-54492008000...
,1010 Engelhorn ALV, Garcia ACF, Cassou MF, Birckholz L, Engelhorn CA. Profilaxia da trombose venosa profunda – estudo epidemiológico em um hospital escola. J Vasc Bras. 2002;1(2):97-102. http://doi.org/10.1590/S1677-54492012000200005.
http://doi.org/10.1590/S1677-54492012000...
One of the main barriers to its implementation in hospitals is professionals’ difficulties with systematic thrombotic risk stratification, whether in clinical or surgical patients.1111 Rocha ATC, Pinheiro TB, Souza PRSPD, Marques MA. Protocolos de profilaxia de tromboembolismo venoso (TEV) em hospitais brasileiros - PROTEV Brasil. J Vasc Bras. 2020;19:e20190119. http://doi.org/10.1590/1677-5449.190119. PMid:34178064.
http://doi.org/10.1590/1677-5449.190119...
Against this background, the objective of this study was to investigate the profile of the thromboprophylaxis practices of angiologists and vascular surgeons in Brazil during the perioperative period of lower limb amputation surgery and conduct a descriptive analysis of the findings.
METHODS
This was a cross-sectional descriptive study with simple probabilistic sampling conducted with angiologists and vascular surgeons practicing in Brazil.
From February to June, 2023, electronic questionnaires were sent to all specialists registered with the Brazilian Society of Angiology and Vascular Surgery (SBACV). Additionally, a link to the study was sent to telephone contacts, physicians’ groups on messaging apps (WhatsApp®), and posted on the authors’ social networks (Instagram®), in order to reach a large sample and include professionals who were not SBACV members. There were no exclusion criteria.
Data were collected using an online form developed with the Google Forms® platform. The survey developed by the authors comprised 10 questions about practices related to LL amputation and thromboprophylaxis, based on references from published literature on the subject. The survey included questions about prescription of pharmacological thromboprophylaxis, thrombotic risk stratification, bleeding risk stratification, and preferred drug class, dosage, and duration used, for patients in the perioperative period of LL amputation surgery.
There are currently approximately 4,000 specialists on the SBACV national registry. Based on this number, it was estimated that a sample of 351 completed questionnaires would be needed to enable statistical inference, calculated for a 5% margin of error and 95% confidence level.
After collection, data were tabulated in a Microsoft Excel® spreadsheet for simple descriptive analysis with absolute and relative frequencies. The project was approved by the Ethics Committee under Ethics Appraisal Submission Certificate number 65867422.0.0000.0057 and decision number 5.820.754.
RESULTS
A total of 237 of the questionnaires sent out were answered in full, with no incompletely or incorrectly answered questionnaires. Inclusions and losses were not calculated. All answered questionnaires were compiled and none were incomplete or had problems. A majority (139 [58.6%]) of the participants conduct thrombotic risk stratification for patients admitted for LL amputation. The Caprini risk assessment model is the most widely used, by 120 (86.3%) participants. The Safety Zone (5 [3.6%]) and Rogers (1 [0.7%]) VTE scores are used by fewer specialists (Figure 1). Although they are not validated for thrombotic risk stratification in surgical patients, the IMPROVE and Padua risk models are used by three (2.2%) and two (1.4%) participants, respectively. Eight respondents (5.8%) use a different score from those listed above.
Just 64 (27%) participants conduct hemorrhagic risk stratification of their patients. The majority (38 [59.4%]) choose the IMPROVE Bleeding Risk Score. Some specialists used the American College of Chest Physicians (10 [15.6%]), HAS-Bleed (6 [9.4%]), and VTE-Bleed (1 [1.6%]) scores, in addition to others not listed (9 [14.1%]).
Around half of the participants (118 [49.8%]) most often perform amputations at the level of the toes. Others most often performed partial foot amputations (57 [24.1%]), transtibial amputations (14 [5.9%]), and transfemoral amputations (48 [20.3%]) (Figure 2). According to 145 (61.2%) specialists, the level of LL amputation has an impact on prescription of thromboprophylaxis.
Figure 3 illustrates the drug classes most often prescribed for thromboprophylaxis during the perioperative period of surgery for LL amputation, showing that low molecular weight heparin (LMWH) is preferred by 203 (85.7%) of the study participants.
Drug classes most often prescribed for thromboprophylaxis during the perioperative period of lower limb amputation surgery.
The group that prescribes LMWH most often employs a 40 UI dose, subcutaneously, once a day, which was the preferred option of 187 (78.9%) participants. Twenty participants (8.4%) stated that they use varying dosages, while seven (3%) use a 60 UI dose, subcutaneously, once a day, and four (1.7%) use 20 UI, subcutaneously, once a day. Nineteen (8%) participants stated that they do not use LMWH.
A little less than half (111 [46.8%]) of the respondents use direct oral anticoagulants (DOACs), in addition to LMWH, as part of the pharmacological thromboprophylaxis strategy for LL amputation surgery. Rivaroxaban is the drug of choice of the majority of those who employ drugs in this class (105 [94.6%]), followed by apixaban (5 [4.5%]) and edoxaban (1 [0.9%]). None of the participants endorsed dabigatran.
With regard to the duration of pharmacological thromboprophylaxis, Figure 4 illustrates the routine prescribed by a little more than half of the specialists up to the point of hospital discharge.
Duration of pharmacological thromboprophylaxis prescription during the perioperative period of lower limb amputation surgery.
DISCUSSION
The wider group of patients who undergo LL amputation encompasses several subpopulations with differing levels of thrombotic risk, which varies depending on individual factors – advanced age, obesity, preoperative infection, long-term peripheral arterial disease, and identifiable hypercoagulability status – and also on factors relating to the procedure, primarily duration of surgery and level of amputation.1212 Ewada AA, Eldieb KAE, Ibrahim AAE. Incidence of Deep Venous Thrombosis (DVT) Postoperatively Following Major Lower Limb Amputation in Patients on Prophylactic Anticoagulation. Med J Cairo Univ. 2023;91(1):43-9.,1313 Matielo MF, Presti C, Casella IB, Netto BM, Puech-Leão P. Incidence of ipsilateral postoperative deep venous thrombosis in the amputated lower extremity of patients with peripheral obstructive arterial disease. J Vasc Surg. 2008;48(6):1514-9. http://doi.org/10.1016/j.jvs.2008.07.055. PMid:18829221.
http://doi.org/10.1016/j.jvs.2008.07.055...
It is essential that VTE risk stratification is performed using a model validated specifically for the subpopulation concerned, employed systematically at each of the major stages of care: hospital admission, transfer between department, and hospital discharge. It should be emphasized that the discharge assessment, in particular, is of great importance in those patients who still have VTE risk factors, such as prolonged immobility.1414 Chindamo MC, Marques MA. Avaliação do risco de sangramento na profilaxia do tromboembolismo venoso. J Vasc Bras. 2021;20:e20200109. http://doi.org/10.1590/1677-5449.200109. PMid:34093680.
http://doi.org/10.1590/1677-5449.200109...
To date, there is no specific model for assessment of thrombotic risk for these patients. The Caprini score was originally validated for general abdominal and pelvic, vascular, bariatric, and reconstructive plastic surgery and is currently the best tool for this purpose, even though it does not address the specifics of this subpopulation.1515 Chindamo MC, Paiva EF, do Carmo Jr PR, Rocha ATC, Marques MA. Desafios da profilaxia estendida do tromboembolismo venoso em pacientes clínicos e cirúrgicos. J Vasc Bras. 2022;21:e20210195. http://doi.org/10.1590/1677-5449.202101951. PMid:35836745.
http://doi.org/10.1590/1677-5449.2021019...
The data collected in this study showed that a little more than half of the interviewees stratify their patients’ thrombotic risk and that the great majority use the Caprini score for this purpose, illustrating that its use has been incorporated from other types of vascular surgery. While few, it should be noted that some specialists use scores that have not been validated for surgical patients, such as the IMPROVE and Pádua scores.
In contrast, it was found that only just over 1/4 of the interviewees habitually assess their patients’ hemorrhagic risk, which may indicate that there is a gap in their knowledge of information supporting this practice. In vascular surgery, pharmacological thromboprophylaxis is associated with different levels of bleeding risk, which vary depending on the procedure. However, in general, it is known that this risk is around 2% or more for minor episodes of bleeding and less than 1% for major bleeding.1414 Chindamo MC, Marques MA. Avaliação do risco de sangramento na profilaxia do tromboembolismo venoso. J Vasc Bras. 2021;20:e20200109. http://doi.org/10.1590/1677-5449.200109. PMid:34093680.
http://doi.org/10.1590/1677-5449.200109...
,1515 Chindamo MC, Paiva EF, do Carmo Jr PR, Rocha ATC, Marques MA. Desafios da profilaxia estendida do tromboembolismo venoso em pacientes clínicos e cirúrgicos. J Vasc Bras. 2022;21:e20210195. http://doi.org/10.1590/1677-5449.202101951. PMid:35836745.
http://doi.org/10.1590/1677-5449.2021019...
In the absence of a specific model for assessment of bleeding risk, since this is a subject that has been studied little in the non-orthopedic surgical population, the recommendation is to check for presence of comorbidities associated with hemorrhagic events such as advanced age, thrombocytopenia, anemia, and renal or hepatic dysfunction, among others.1414 Chindamo MC, Marques MA. Avaliação do risco de sangramento na profilaxia do tromboembolismo venoso. J Vasc Bras. 2021;20:e20200109. http://doi.org/10.1590/1677-5449.200109. PMid:34093680.
http://doi.org/10.1590/1677-5449.200109...
The pharmacological thromboprophylaxis drug class of choice among the participants in this study was LMWH, and the regimen most often reported was enoxaparin at a dosage of 40 UI, subcutaneously, once a day. This conduct is in line with the prophylaxis recommendations for the majority of the surgical population.1616 Pollak AW, McBane RD 2nd. McBane RD2nd. Succint review of the new VTE prevention and management guidelines. Mayo Clin Proc. 2014;89(3):394-408. http://doi.org/10.1016/j.mayocp.2013.11.015. PMid:24582197.
http://doi.org/10.1016/j.mayocp.2013.11....
Among those who choose to use DOACs, the drug of choice was rivaroxaban. This coincides with the findings of a study of thromboprophylaxis for LL varicose vein surgery in Brazil.1717 Ribeiro AJA, Mendes-Pinto D, Erzinger FL, et al. Tromboprofilaxia na cirurgia de varizes dos membros inferiores no Brasil. J Vasc Bras. 2022;21:e20210172. http://doi.org/10.1590/1677-5449.202101721. PMid:35677747.
http://doi.org/10.1590/1677-5449.2021017...
The choice of rivaroxaban rather than other DOACs may be influenced by several factors, including cost, safety profile, and posological convenience. It is also possible that the specialists prefer rivaroxaban because they are more familiar with it, since it has been studied most and has been on the market the longest. It is important to point out that edoxaban was also mentioned, even though its use for primary prophylaxis was not supported by pivotal studies.
The duration of use of pharmacological thromboprophylaxis was highly variable, but there was a discrete predominance of only prescribing during the hospital stay. It was not possible to establish an association between individual thrombotic risk and the duration for which pharmacological thromboprophylaxis was prescribed. It is known that the duration of anticoagulation prophylactic should be based on the Caprini score, so that only patients classified as moderate risk (Caprini score 3 or 4) should be given prophylaxis exclusively while in hospital.1818 Cassidy MR, Rosenkranz P, McAneny D. Reducing postoperative venous thromboembolism complications with a standardized risk-stratified prophylaxis protocol and mobilization program. J Am Coll Surg. 2014;218(6):1095-104. http://doi.org/10.1016/j.jamcollsurg.2013.12.061. PMid:24768293.
http://doi.org/10.1016/j.jamcollsurg.201...
,1919 Hanh BM, Cuong LQ, Son NT, et al. Determination of risk factors for venous thromboembolism by an adapted Caprini scoring system in surgical patients. J Pers Med. 2019;9(3):36. http://doi.org/10.3390/jpm9030036. PMid:31319527.
http://doi.org/10.3390/jpm9030036...
Although the risk of VTE after hospital discharge is well recognized among high-risk patients, studies demonstrate that extended prophylaxis is still underutilized.1212 Ewada AA, Eldieb KAE, Ibrahim AAE. Incidence of Deep Venous Thrombosis (DVT) Postoperatively Following Major Lower Limb Amputation in Patients on Prophylactic Anticoagulation. Med J Cairo Univ. 2023;91(1):43-9.,1515 Chindamo MC, Paiva EF, do Carmo Jr PR, Rocha ATC, Marques MA. Desafios da profilaxia estendida do tromboembolismo venoso em pacientes clínicos e cirúrgicos. J Vasc Bras. 2022;21:e20210195. http://doi.org/10.1590/1677-5449.202101951. PMid:35836745.
http://doi.org/10.1590/1677-5449.2021019...
This survey was subject to certain limitations. The number of recipients who received the electronic questionnaire cannot be determined exactly since it was sent out via the official SBACV communication channels and also publicized via the researchers’ social networks, resulting in some professionals receiving it multiple times. Moreover, no detailed information was collected on the profile of the services where the specialists practice, but it is probable that the ways in which they prescribe pharmacological thromboprophylaxis varies from region to region in Brazil.
Notwithstanding these limitations, this initial survey of the conduct of angiologists and vascular surgeons practicing in Brazil suggests a need for development and implementation of clinical protocols and therapeutic guidelines for prevention in a population that can be at high risk for VTE occurrence.
CONCLUSIONS
This study revealed the heterogeneous nature of conduct related to prescription of pharmacological thromboprophylaxis for patients undergoing LL amputation procedures, especially with regard to the tools used for thrombotic risk stratification and the duration of maintenance of prophylactic anticoagulation. Moreover, bleeding risk was not assessed by the majority of interviewees. These findings reflect the need for more studies to correctly stratify these patients, with the objective of supporting decision making related to prophylaxis in this population.
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How to cite: Cerqueira MMBF, Marques MA, Ribeiro AJA, Mendes-Pinto D, Sanches SMV. Thromboprophylaxis in lower limb amputation surgery. J Vasc Bras. 2024;23:e20230144. https://doi.org/10.1590/1677-5449.202301442
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Financial support: None.
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The study was carried out at Universidade do Estado da Bahia (UNEB), Salvador, BA, Brazil.
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Ethics committee approval: CAAE number 65867422.0.0000.0057 and decision number 5.820.754.
REFERÊNCIAS
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1Cook KD. Perioperative management of pedal amputations. Clin Podiatr Med Surg. 2005;22(3):329-41. http://doi.org/10.1016/j.cpm.2005.03.006 PMid:15978405.
» http://doi.org/10.1016/j.cpm.2005.03.006 -
2Silva AAS, Castro AA, Bomfim LG, Pitta GBB. Amputações de membros inferiores por diabetes mellitus nos estados e nas regiões do Brasil. Res Soc Dev. 2021;10(4):e11910413837. http://doi.org/10.33448/rsd-v10i4.13837
» http://doi.org/10.33448/rsd-v10i4.13837 -
3Stern JR, Wong CK, Yerovinkina M, et al. A meta-analysis of long-term mortality and associated risk factors following lower extremity amputation. Ann Vasc Surg. 2017;42:322-7. http://doi.org/10.1016/j.avsg.2016.12.015 PMid:28389295.
» http://doi.org/10.1016/j.avsg.2016.12.015 -
4van Netten JJ, Fortington LV, Hinchliffe RJ, Hijmans JM. Early post-operative mortality after major lower limb amputation: a systematic review of population and regional based studies. Eur J Vasc Endovasc Surg. 2016;51(2):248-57. http://doi.org/10.1016/j.ejvs.2015.10.001 PMid:26588994.
» http://doi.org/10.1016/j.ejvs.2015.10.001 -
5Libertiny G, Hands L. Deep venous thrombosis in peripheral vascular disease. Br J Surg. 1999;86(7):907-10. http://doi.org/10.1046/j.1365-2168.1999.01129.x PMid:10417563.
» http://doi.org/10.1046/j.1365-2168.1999.01129.x -
6Yeager RA, Moneta GL, Edwards JM, Taylor LM Jr, McConnell DB, Porter JM. Deep vein thrombosis associated with lower extremity amputation. J Vasc Surg. 1995;22(5):612-5. http://doi.org/10.1016/S0741-5214(95)70048-X PMid:7494364.
» http://doi.org/10.1016/S0741-5214(95)70048-X -
7Herlihy DR, Thomas M, Tran QH, Puttaswamy V. Primary prophylaxis for venous thromboembolism in people undergoing major amputation of the lower extremity. Cochrane Database Syst Rev. 2020;7(7):CD010525. PMid:32692430.
-
8Alsheef MA, Schulman S, Donadini M, Zaidi ARZ. Venous Thromboembolism in lower extremity amputees: a systematic review of the literature. Blood. 2019;134(Supl Suppl 1):4980. http://doi.org/10.1182/blood-2019-130751
» http://doi.org/10.1182/blood-2019-130751 -
9Pereira CA, Brito SSD, Martins AS, Almeida CM. Profilaxia da trombose venosa profunda: aplicação prática e conhecimento teórico em um hospital geral. J Vasc Bras. 2008;7(1):18-27. http://doi.org/10.1590/S1677-54492008000100005
» http://doi.org/10.1590/S1677-54492008000100005 -
10Engelhorn ALV, Garcia ACF, Cassou MF, Birckholz L, Engelhorn CA. Profilaxia da trombose venosa profunda – estudo epidemiológico em um hospital escola. J Vasc Bras. 2002;1(2):97-102. http://doi.org/10.1590/S1677-54492012000200005
» http://doi.org/10.1590/S1677-54492012000200005 -
11Rocha ATC, Pinheiro TB, Souza PRSPD, Marques MA. Protocolos de profilaxia de tromboembolismo venoso (TEV) em hospitais brasileiros - PROTEV Brasil. J Vasc Bras. 2020;19:e20190119. http://doi.org/10.1590/1677-5449.190119 PMid:34178064.
» http://doi.org/10.1590/1677-5449.190119 -
12Ewada AA, Eldieb KAE, Ibrahim AAE. Incidence of Deep Venous Thrombosis (DVT) Postoperatively Following Major Lower Limb Amputation in Patients on Prophylactic Anticoagulation. Med J Cairo Univ. 2023;91(1):43-9.
-
13Matielo MF, Presti C, Casella IB, Netto BM, Puech-Leão P. Incidence of ipsilateral postoperative deep venous thrombosis in the amputated lower extremity of patients with peripheral obstructive arterial disease. J Vasc Surg. 2008;48(6):1514-9. http://doi.org/10.1016/j.jvs.2008.07.055 PMid:18829221.
» http://doi.org/10.1016/j.jvs.2008.07.055 -
14Chindamo MC, Marques MA. Avaliação do risco de sangramento na profilaxia do tromboembolismo venoso. J Vasc Bras. 2021;20:e20200109. http://doi.org/10.1590/1677-5449.200109 PMid:34093680.
» http://doi.org/10.1590/1677-5449.200109 -
15Chindamo MC, Paiva EF, do Carmo Jr PR, Rocha ATC, Marques MA. Desafios da profilaxia estendida do tromboembolismo venoso em pacientes clínicos e cirúrgicos. J Vasc Bras. 2022;21:e20210195. http://doi.org/10.1590/1677-5449.202101951 PMid:35836745.
» http://doi.org/10.1590/1677-5449.202101951 -
16Pollak AW, McBane RD 2nd. McBane RD2nd. Succint review of the new VTE prevention and management guidelines. Mayo Clin Proc. 2014;89(3):394-408. http://doi.org/10.1016/j.mayocp.2013.11.015 PMid:24582197.
» http://doi.org/10.1016/j.mayocp.2013.11.015 -
17Ribeiro AJA, Mendes-Pinto D, Erzinger FL, et al. Tromboprofilaxia na cirurgia de varizes dos membros inferiores no Brasil. J Vasc Bras. 2022;21:e20210172. http://doi.org/10.1590/1677-5449.202101721 PMid:35677747.
» http://doi.org/10.1590/1677-5449.202101721 -
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Publication Dates
-
Publication in this collection
09 Aug 2024 -
Date of issue
2024
History
-
Received
16 Oct 2023 -
Accepted
05 Mar 2024