Aspirin Versus Anticoagulation for the Prevention of Venous Thromboembolism in Orthopedic Patients After Lower Extremity Reconstructive Surgery - A Systematic Review.

Chest. 2012 Oct 1;142(4_MeetingAbstracts):832A

Authors: Lee A, Larson R, Morrison D, Chiang W, Drescher F

Abstract
SESSION TYPE: DVT/PE/Pulmonary Hypertension Posters IIPRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PMPURPOSE: To assess bleeding complications, venous thromboembolism (VTE) event rates, and mortality when comparing aspirin to anticoagulation in orthopedic patients after lower extremity reconstructive surgery.METHODS: We searched MEDLINE (1966-September 2011), CINAHL (1974-October 2011) and the Cochrane Controlled Clinical Trials Register Database (1966-October 2011), in addition to manual review of meeting abstracts and reference lists. Randomized controlled studies comparing aspirin to heparin, low-molecular weight heparin or Vitamin-K antagonists for prevention of VTE in orthopedic patients after hip arthroplasty, knee arthroplasty or hip fracture repair were included. Studies in oncologic patients were excluded whereas pneumatic compression devices in both study arms were allowed as a co-intervention.RESULTS: We identified 253 studies by initial search. Data were available from 8 randomized controlled trials (n=1408 participants). Compared with anticoagulants, aspirin was associated with significantly lower overall bleeding rates (RR 0.52, 95% CI 0.31 to 0.86). Overall deep vein thrombosis rates were not different between aspirin and anticoagulation (RR 1.15, 95% CI 0.49 to 2.05). Subgroup analyses were performed to determine the rate of proximal DVT for patients undergoing hip fracture surgery (RR 1.60, 95% CI 0.80-3.20) versus hip/knee arthroplasty (RR 1.00, 95% CI 0.49-2.05). Event rates of pulmonary embolism slightly favored anticoagulation (RR 1.73, 95% CI 0.69 to 4.34), but this was not statistically significant. Data was inadequate to assess for differences in mortality.CONCLUSIONS: The included studies suggest that aspirin may be associated with lower bleeding rates than anticoagulants following lower extremity reconstructive surgery. Aspirin should be used with caution in patients undergoing orthopedic surgery after hip fracture, however, further research should be conducted to determine if aspirin is safe and efficacious in preventing VTE for patients undergoing hip or knee arthroplasty.CLINICAL IMPLICATIONS: Administration of anticoagulants is standard of care for preventing VTE following lower extremity reconstructive orthopedic surgery; however, increased bleeding at the surgical site is a concern. While use of aspirin is supported by national guidelines, uncertainty remains as to whether the improved safety is offset by decreased efficacy.DISCLOSURE: The following authors have nothing to disclose: Alexandra Lee, Robin Larson, Daniel Morrison, Wesley Chiang, Frank DrescherNo Product/Research Disclosure InformationVeterans Affairs Medical Center, White River Junction, VT.

PMID: 23698101 [PubMed - as supplied by publisher]

A Prospective Study of the Incidence and Complications of Obstructive Sleep Apnea (OSA) in Patients Undergoing Total Joint Arthroplasty (TJA).

Chest. 2012 Oct 1;142(4_MeetingAbstracts):1048A

Authors: Subraya Bhat S, Pai S, Srinivasan LP, Mehta R

Abstract
SESSION TYPE: Sleep IPRESENTED ON: Sunday, October 21, 2012 at 10:30 AM - 11:45 AMPURPOSE: There is scant data on the prevalence of OSA in India, and even less on the prevalence in specific sub-populations. Total joint (knee and hip) arthroplasty is on the rise, and these patients often have other risk factors for OSA such as obesity. This prospective study defines the prevalence and impact of OSA on the peri-operative care of these patients.METHODS: 450 patients undergoing TJA over 3.5 years were screened for OSA using the Berlin (BQ) and Epworth questionnaires (ESS). Other parameters like neck circumference, Mallampatti score, and BMI were recorded.RESULTS: There were 128 (28.4%) males and 322 (71.5%) females in the study. 193/450 (42.8%) patients, 54/128 (42.1%) males and 139/322 (43.1%) females were found to be high risk for OSA, according to the BQ. 108/193 (55.9%) patients at high risk for OSA had a BMI more than 30 Kg/m2. Using the ESS, 32/450 (7.1%) patients were at high risk for OSA, indicating a difference between the BQ and ESS for screening of OSA. Assessing peri-operative complications, 15/193 (7.7%) had atelectasis requiring supplemental O2 and delaying mobilization. There were no other significant problemsCONCLUSIONS: (1) The prevalence of OSA as assessed by the BQ is significantly high (42.8%) in a TJA population in India, beyond what can be explained by the BMI. This is much higher than the prior mentioned prevalence in a general referral population (20%). (2) The incidence of OSA was similar in males and females. (3) There were mild peri - operative complications, predominantly atelectasis. (4) The significant discrepancy between the BQ and ESS in stratifying these patients could be due to the limited applicability of some of the ESS questions to the Indian populationCLINICAL IMPLICATIONS: This is the first Indian study, and one of the few worldwide studies to define the incidence and complications of OSA in the TJA population. Clinicians should be aware of the high incidence of OSA and implications in these patientsDISCLOSURE: The following authors have nothing to disclose: Srinidhi Subraya Bhat, Sanjay Pai, Lakshmi Priya Srinivasan, Ravindra MehtaNo Product/Research Disclosure InformationFortis Hospitals, Bangalore, India.

PMID: 23699538 [PubMed - as supplied by publisher]

Persistent Left Superior Vena Cava Leading to Stroke.

Chest. 2012 Oct 1;142(4_MeetingAbstracts):1007A

Authors: Malhotra A, Boppana VS, Martinez-Balzano C, Orellana A

Abstract
SESSION TYPE: Miscellaneous Student/Resident Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PMINTRODUCTION: Ischemic stroke has a high morbidity and mortality. Cardio-embolic phenomena secondary to congenital anomalies is a common cause of ischemic stroke in the younger population. We present a case of persistent left superior vena cava (PLSVC) leading to stroke.CASE PRESENTATION: A 54-year-old gentleman with congenital bilateral cleft lip, cleft palate and deafness was transferred to our hospital. Patient was mechanically ventilated, after an elective right hip arthroplasty for respiratory depression from opioids, and reportedly had some involuntary movements. MRI brain revealed subacute right posterior cerebral artery and anterior cerebral artery infarcts. Doppler showed acute deep venous thrombosis (DVT) of left lower extremity. Interestingly, a Chest X-ray done for the confirmation of peripherally inserted central catheter (PICC) placement showed its tip projecting over the left heart border. PLSVC was suspected but arterial catheterization of the PICC could not be excluded, so a blood gas was done which showed oxygen level of 35 mmHg, confirming venous placement. CT angiogram also revealed a PLSVC with a catheter in it along with right upper lobe pulmonary embolism. Trans-esophageal echocardiogram (TEE) with bubble study showed agitated saline injected in the left arm entering the right atrium from the area of the dilated coronary sinus, confirming PLSVC. No left atrial thrombus was seen. The patient was treated with low molecular weight heparin and warfarin and was discharged home on warfarin after extensive physical rehabilitation.DISCUSSION: PLSVC is the most common anomaly involving central venous return in the thorax with a prevalence of 0.3% in the general population. Approximately 50-70% of these patients are at risk of paradoxical embolism because of accompanying lesions like atrial septal defect, unroofed coronary sinus, or direct communication of the vein to the left atrium. Contrast TEE with left antecubital vein contrast injection is the best diagnostic modality for PLSVC. Our patient is thought to have had a paradoxical embolism reaching the systemic circulation secondary to the PSLVC, causing stroke.CONCLUSIONS: PLSVC needs to be considered as a cause of stroke in the younger population. Coordination between cardiologist, neurologist and radiologist is the key to diagnosis and management of PLSVC.1) Hutyra M, Skala T, Sanak D, et al: Persistent left superior vena cava connected through the left upper pulmonary vein to the left atrium: An unusual pathway for paradoxical embolization and a rare cause of recurrent transient ischaemic attack. Eur J Echocardiogr 11:E35, 20102) Tak T, Crouch E, Drake GB: Persistent left superior vena cava: Incidence, significance and clinical correlates. Int J Cardiol 82:91-93, 2002DISCLOSURE: The following authors have nothing to disclose: Akshiv Malhotra, V Subbarao Boppana, Carlos Martinez-Balzano, Anna OrellanaNo Product/Research Disclosure InformationSUNY Upstate Medical University, Syracuse, NY.

PMID: 23699692 [PubMed - as supplied by publisher]