Use of the Low-Molecular-Weight Heparin Reviparin to Prevent Deep-Vein Thrombosis after Leg Injury Requiring Immobilization

Department of Orthopedics, Hillerød Hospital, Hillerød, Denmark.
New England Journal of Medicine (Impact Factor: 55.87). 10/2002; 347(10):726-30. DOI: 10.1056/NEJMoa011327
Source: PubMed


Deep-vein thrombosis is a well-recognized complication after trauma to the legs and subsequent immobilization, but there are no generally accepted approaches to preventing this complication.
We performed a prospective, double-blind, placebo-controlled trial to evaluate the efficacy and safety of subcutaneous reviparin (1750 anti-Xa units given once daily) in 440 patients who required immobilization in a plaster cast or brace for at least five weeks after a leg fracture or rupture of the Achilles tendon. The study drug was given throughout the period of immobilization. Venography of the injured leg was performed within one week after removal of the plaster cast or brace, or earlier if there were symptoms suggesting deep-vein thrombosis.
Data on efficacy and end points were available for 371 patients. Deep-vein thrombosis was diagnosed in 17 of the 183 patients randomly assigned to receive reviparin (9 percent) and in 35 of the 188 patients randomly assigned to receive placebo (19 percent) (odds ratio, 0.45; 95 percent confidence interval, 0.24 to 0.82). Most of the thromboses were distal (14 in the reviparin group and 25 in the placebo group). There were two cases of pulmonary embolism, both in patients in the placebo group who also had proximal deep-vein thrombosis. There were no differences between the two groups with respect to bleeding or other adverse events.
Deep-vein thrombosis is common in persons with leg injury requiring prolonged immobilization. Reviparin given once daily appears to be effective and safe in reducing the risk of this complication.

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Available from: Lars Carl Borris, Dec 27, 2013
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    • "A number of factors are believed to contribute to the risk of developing DVT/PE with cast immobilization of the lower limb following injury. These include trauma, prolonged immobilization, and surgery [11]. However, several authors disagree that surgery for Achilles tendon rupture is a risk factor for DVT/PE [7] [9]. "
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    ABSTRACT: Deep venous thrombosis (DVT) is a significant source of morbidity in orthopaedic surgery. It can progress to a pulmonary embolism, a significant source of mortality. Up to date, patients with Achilles tendon rupture routinely do not receive DVT chemical prophylaxis. We are presenting a case of fatal pulmonary embolism after a surgically treated Achilles tendon rupture in a forty-two-year-old male healthy patient. In the current body of the literature, the reported incidence of DVT after Achilles tendon rupture is highly variable ranging from less than 1% to 34%, and there is a disagreement in the international guidelines regarding the need of chemical DVT prophylaxis with this type of injury. Further research needs to be conducted to investigate the risks and benefits of chemical DVT prophylaxis following Achilles tendon rupture. For low-risk patients, the use of milder forms of prophylaxis such as aspirin should also be explored.
    05/2013; 2013:401968. DOI:10.1155/2013/401968
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    • "A number of other risk factors for VTE are also suggested but not consistent across the trials: non-weight bearing cast immobilisation – leading to inactive calf pump (Kock et al, 1995; Lapidus et al, 2007a), cast greater risk than brace (Lapidus et al, 2007b), fracture versus soft tissue injury (Kujath et al, 1993;. Lassen et al, 2002). Kujath et al (1993) demonstrated the presence of 1AE24 risk factors when no demonstrable DVT, 1AE96 risk factors when DVT was identified and 2AE7 risk factors in the presence of VTE in association with TP. "
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    ABSTRACT: The risk for venous thromboembolism (VTE) associated with lower limb immobilisation is unclear, owing to of a lack of evidence from studies in this patient group. However, six small, randomised control trials (RCTs), totalling 1536 patients, compared low molecular weight heparin (LMWH) with controls and showed a significant reduction in asymptomatic deep vein thrombosis (DVT) from 17.1% to 9.8%, with very low bleeding rates. This is likely to be an underestimate of the real risk reduction as most trials excluded high-risk patients from randomisation. There have been no other controlled trials in cast-immobilised patients using alternative prophylactic measures. Together with the RCTs, other cohort studies have identified risk factors that increase the risk for VTE in lower limb immobilisation. In summary, patients in lower limb cast (or brace) immobilisation should be risk assessed and those deemed high risk for VTE should receive prophylactic LMWH for at least the duration of cast immobilisation.
    British Journal of Haematology 07/2009; 146(4):361-8. DOI:10.1111/j.1365-2141.2009.07737.x · 4.71 Impact Factor
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    • "Deep venous thrombosis (DVT) is a frequently reported complication (Geerts et al. 1994, Jorgensen et al. 2002, Lassen et al. 2002, Anderson & Spencer 2003) during lower leg immobilization after fracture, requiring an efficient countermeasure to prevent or decrease its incidence. Previously mentioned drawbacks of lowmolecular-weight-heparin (Kujath et al. 1993, Spannagel & Kujath 1993, Handoll et al. 2002, Lassen et al. 2002, Schonenberg et al. 2003) or mechanical interventions (Klecker & Theiss 1994, Bulitta et al. 1996, Kaplan et al. 2002) as a preventive strategy for DVT asks for other methods. "
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    ABSTRACT: During lower limb immobilization, patients are at risk to develop deep venous thrombosis. Recently, a water-pad was developed that should counteract venous stasis. The water-pad, located under the plaster, mobilizes water from the foot to the calf during weight bearing and, thereby, imitates muscle pump function. The purpose of this study was to assess the effect of the water-pad on venous pump function in healthy individuals. In 21 healthy subjects (10 men and 11 women) both legs were plastered. Venous pump function was assessed by plethysmography measuring lower leg venous ejection fraction and volume. Subjects were tilted from the supine position to upright standing to determine total venous volume. Hereafter, stepping was performed to measure venous ejection fraction and volume under different filling conditions of the water-pad (0, 50, 100, 150, 200, 250 and 300 mL). Different sizes of water-pads (small, medium and large) were applied to each plastered leg in order to test the effectiveness and to relate optimum size to anthropometrical data. The venous ejection fraction increased significantly from 30 +/- 17% to a maximum of 42 +/- 19% during stepping with increasing filling condition (RM anova; P = 0.009). Ejection volume also enhanced significantly during stepping with increasing filling condition from 1.3 +/- 0.7 to 1.9 +/- 0.9 mL (100 mL)(-1) (RM ANOVA; P = 0.006). The optimal filling condition of the water-pad depended on the water-pad size, while body height was the best predictive value for the water-pad size (Pearson's R = 0.72, P < 0.001). The filled water-pad markedly increased the venous ejection fraction and volume of the lower leg during stepping, hereby counteracting stasis of venous blood in the immobilized lower leg. Therefore, the water-pad seems to be a promising tool to prevent deep venous thrombosis during periods of lower leg immobilization.
    Acta Physiologica 03/2006; 186(2):111-8. DOI:10.1111/j.1748-1716.2005.01514.x · 4.38 Impact Factor
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