Review: compression plus pharmacological prophylaxis reduces VTE more than monotherapy in high-risk patients
S K Kakkos
Dr S K Kakkos, Henry Ford Hospital, Detroit, MI, USA;;
How does intermittent pneumatic leg compression (IPC) plus pharmacological prophylaxis compare with either monotherapy for preventing venous thromboembolism in high-risk patients?
Included studies compared ICP plus pharmacological prophylaxis with either therapy alone in patients at high risk of developing venous thromboembolism (including surgery and trauma patients). Studies evaluating intraoperative IPC were excluded. Outcomes were pulmonary embolism (PE) and deep venous thrombosis (DVT).
Medline, CINAHL, EMBASE/Excerpta Medica (all to present); Cochrane Peripheral Vascular Diseases Group Specialised Register (to Jul 2007); Cochrane Library (Issue 3, 2008); reference lists; and conference proceedings were searched for randomised controlled trials (RCTs) or controlled clinical trials. 6 RCTs (n = 6273) and 5 controlled clinical trials (n = 1158) met the selection criteria (mean age 66 y, based on 8 studies).
Meta-analysis of RCTs showed that combination therapy reduced PE and DVT compared with IPC alone (table) and reduced DVT compared with anticoagulant therapy alone (table). Combination therapy did not differ from IPC plus aspirin for PE or DVT.
Intermittent pneumatic leg compression plus pharmacological prophylaxis reduces venous thromboembolism more than monotherapy in high-risk patients.
Kakkos SK, Caprini JA, Geroulakos G, et al. Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism in high-risk patients. Cochrane Database Syst Rev 2008;(4):CD005258.
Clinical impact ratings: Cardiac surgery 6/7; Gastrointestinal/colorectal surgery 6/7; General surgery 6/7; Perioperative 6/7
VTE resulting from surgery or trauma has considerable effects on patient morbidity and mortality. In the perioperative period, 40–80% of patients having total hip replacements are at risk of developing DVT or PE if no prophylaxis is used.1 Although reduced by single-factor approaches, risk appears to be further reduced by combined approaches such as polypharmacy and mechanical interventions, including IPC. However, in the review by Kakkos et al, 5 of the 11 trials did not use randomised designs and 3 of the RCTs did not describe their randomisation processes. This ambiguity raises questions about the reliability of the results, although the findings were virtually the same for comparisons that included all trials and those that included only RCTs.
2 caveats to these findings must be considered. First, the review did not evaluate the duration or frequency of IPC. These will be important considerations for implementation. Second, the participant profile covered most high-risk areas, but some areas, such as neurological surgery, were not included. Therefore, the results may not be generalisable to all high-risk patients. That said, clinical benefit is clearly indicated, and a cost–benefit equation should be modelled to explore the implications of moving practice towards multimodal approaches.