Presenting Venous Thromboembolism: Prophylactic Options for Patients at Different Risk Levels

We also evaluated the efficacy of methods of VTE prophylaxis in acutely ill medical patients, including low dose unfractionated heparin LDUH , low molecular weight heparins LMWH , and mechanical methods of prophylaxis. Annals of important meetings were also searched for abstracts from onwards. The reference lists of published reviews were also evaluated. Inclusion criteria for the systematic review were established before the literature search.

We included randomized-controlled trials, cohorts, and case-control studies with at least 10 subjects evaluating risk factors or efficacy of prophylactic methods for VTE. Two authors read all retrieved studies and made the final decision on which studies met the inclusion criteria.

All data were abstracted independently and in duplicate by two of the authors using a standardized data collection form. Discrepancies in the data abstracted were resolved by consensus among the authors and the working committee. These criteria were adapted to allow evaluation of studies about efficacy of methods of VTE prophylaxis and risk factors for VTE. Tables 1A and 1B show the levels of evidence and Table 2 shows the strength of recommendations.

Each risk factor was evaluated separately as much as possible. The risk factors for VTE in clinical patients, according to the level of evidence, are listed in Table 3. Table 4 shows the frequency of VTE in hospitalized patients with various medical conditions. Frequency based on studies using screening for DVT in patients without prophylaxis.

However, Orger and colleagues in a very similar study with patients, found different results OR 0. Based on these data, active rheumatologic diseases as a group, and SLE in particular, are not clearly related to increased VTE risk.

Introduction

However, lupus anticoagulant LA and anticardiolipin ACL antibodies are frequently found in rheumatologic patients and are definitely related to thrombotic phenomena. Miehsler and colleagues studied patients with IBD, patients with rheumatoid arthritis and equal number of gender and aged-matched control. Most data about VTE risk in acute coronary syndromes come from old studies, with small number of patients, comparing placebo with some kind of prophylaxis. One study showed an incidence of DVT as high as Nevertheless, according to several reports, the utilization of prophylaxis in ICU patients had been quite irregular Ibrahimbacha and Alnajjar ; Levi et al ; Ryskamp and Trottier ; Rocha and Tapson ; Geerts and Selby ; Lacherade et al ; Rocha et al Several epidemiologic studies have shown that the incidence of VTE increases exponentially with aging.

It is not clear if the reasons for this are changes in clotting mechanisms or the presence of thrombogenic comorbidities Anderson et al ; Silverstein et al In a study conducted in Oslo, the incidence of VTE increased from 1: Other studies showed different age cutoffs for significant increase in risk of VTE: For the same age, others studies showed an incidence of VTE reaching This high incidence of VTE may be explained not only by the hypercoagulability but also by the action of some antineoplastic agents and the frequent venous catheterization.

In some studies the higher incidences of DVT were observed in patients with pancreas, ovarium, liver, and brain cancer, while others indicate breast, lung, genital, urinary, stomach and colon cancers as the most frequently related to VTE Coon ; Bussani and Cosatti ; Sorensen et al In a series of Several studies have shown that VTE is more common during chemotherapy in breast cancer patients, compared with the period without treatment 6. Saphner et al observed a higher incidence of VTE when tamoxifen was used. Several variables are implicated in the increased thrombogenicity associated with central venous catheters CVC-thrombosis and DVT in patients using catheters Table 6.

Given the high variability of catheter-related factors and underlying diseases, studies evaluating CVC-thrombosis are quite heterogeneous. Besides, the diagnostic methods for thrombosis and the primary objectives of these studies are extremely variable, which make it difficult to group then in order to make specific recommendations. For these reasons, we discuss thrombosis prophylaxis according to the purpose of the catheter: We briefly discuss also the evidence for pulmonary artery catheters and hemodialysis catheters as risk factors for thrombosis.

Several studies show that the incidence of thrombosis is higher in the catheterized veins than in contralateral veins Raad et al ; Durbec et al b ; Mian et al ; Martin et al ; Joynt et al Nevertheless, the frequency of thrombotic complications reported varies considerably, depending on the method of detection of the thrombus Elliott et al Similarly to other CVC, pulmonary artery catheters lead to a 4. Although moderate to severe renal insufficiency is associated with higher risk of bleeding Lohr and Schwab , thromboembolic events are also quite common in patients with renal failure.

Chronic hemodialysis patients present high incidence of thrombophilias, frequently utilize recombinant erithropoetin, which may have a prothrombotic effect and present also VTE risk factors that are less commonly recognized, such as hyperhomocysteinemia, endothelial dysfunction and markers of systemic inflammation Casserly and Dember Furthermore, thrombosis of the venous access is another well established condition in these patients, affecting arterial-venous fistulas, grafts and double-lumen catheters for hemodialysis Fan and Schwab These catheters are most commonly used as temporary vascular accesses but in some instances, allow hemodialysis for longer periods Shusterman et al Besides, the lower the ejection fraction the higher the risk of VTE: The risk is higher in the first year of HRT use Perez et al ; Hoibraaten et al ; Miller et al , especially in the presence of previous history of VTE Hoibraaten et al In a multicentric, international case-control study including 1, cases of VTE and 2.

As for HRT, the risk is higher during the first year of use Suissa et al ; Lidegaard et al , and it seems also higher for the 3rd generation hormones desogestrel and gestoden Kemmeren et al Several cohorts and prospective randomized trials have indicated the association between infections and VTE. However, most patients included in these studies have lung infections and are described in the specific section about respiratory diseases.

However, in this study the site of the infections are not reported. In this study, 4 of the 22 patients with pneumonia had DVT, while none of the patients with urinary tract infection, bronchitis, acute enterocolitis or sepsis developed DVT. The association between nephrotic syndrome NS and thromboembolic events is recognized since Trew et al Until the 70s, some authors suggested that renal vein thrombosis was possibly the cause of the NS Kendall et al ; Bennett Rostoker and colleagues reviewed 13 prospective studies, including patients with NS, showing that the incidence of renal vein thrombosis was There are many studies that evaluate obesity direct or indirectly as a risk factor for VTE leading to some debate about the importance of it as a risk factor.

Grady and colleagues , evaluating women with body mass index BMI above 27, also failed to find such a correlation. It is important to mention that in both studies the identification of obesity as a risk factor was a secondary objective and the analysis was done post hoc. Heit and colleagues , in a population based case-control study reached the same conclusion. On the other hand, several studies do implicate obesity as a risk factor for VTE. Four prospective cohort studies support theses findings, with RR ranging from 2.

Although there is some debate, the evidence from prospective trials evaluating risk factors support the correlation between obesity and VTE. Nevertheless, the RR for obesity is relatively low between 2 and 3 but increases significantly when there are additional risk factors for VTE. Pottier and colleagues studied the presence of risk factors among hospitalized medical patients and found that paralysis was associated with an increased chance of VTE calculated OR The same result was seem in a case-control study with patients older than 65 years OR 2.

The impact of varices of the lower extremities as an additional risk factor for VTE in medical patients is controversial. There are few studies evaluating the theme and there is no evidence that surgical treatment of the varicose veins decreases the potential risk of VTE. Kakkar and colleagues showed that the incidence of VTE by labeled fibrinogen in surgical patients with mild to severe varices was The reason for such a high incidence of VTE in patients with varices is not known but one of the possibilities is that the varices may be a consequence of previous and undiagnosed DVT.

Recently, Heit and colleagues demonstrated in a population-based, case-control study that varices are associated with risk of VTE in medical patients, but the risk decreases with age: Some cohort studies also failed to demonstrate an independent association between varices and VTE Goldhaber et al ; Kierkegaard et al It is estimated that the risk for VTE during pregnancy increases 3 to 4 times, probably because of the increase in procoagulant factors, such as factor VIII and in the resistance to activated protein C. Samuelsson and Hagg , in a population-based study with more than 24, women, reported an incidence of VTE during pregnancy and postpartum of Besides, fatal PE remains one of the most important complications during pregnancy and puerperium, especially in those women older than 40 years Franks et al In a prospective study, Oger and colleagues showed that medical patients with suspected DVT and history of VTE had increased chance of confirming the diagnosis by venography OR 1.

In , Tosseto and colleagues also demonstrated increased risk of VTE in individuals with previous history of this condition OR 6. A case-control study showed that previous history was an important risk factor for VTE also in hospitalized medical patients OR 4. Another case-control study showed that in hospitalized medical patients older than 64 years-old, previous VTE was independently associated with the development of VTE during hospitalization OR 3.

It is not known exactly what level and duration of immobility is associated with increased risk of VTE. What is recognized is that when important risk factors are present, even subtle reductions in mobility increase the overall risk of VTE. It is believed that when patients are able to ambulate to the bathroom or on the hallways, but have to come back, for any reason eg, need for intravenous infusions or oxygen therapy, generalized weakness, pain, or dyspnea on exertion , and stay in bed or chair while hospitalized with an acute illness, they are at-risk for VTE.

Some studies tried to identify the loss of mobility as the main factor leading to VTE. Motykie and colleagues evaluated 1, patients with Doppler ultrasound for suspected DVT and noted that there was a significant correlation between loss of mobility for more than 3 days and development of DVT. In a large case-control study with 1, ambulatory patients, Samama showed that standing for more than 6 hours and resting in bed or chair were associated with an increased odds of VTE OR 1. Similarly, Heit and colleagues showed that hospitalization or admission to a long-term care facility increased the risk of VTE OR 8.

Other authors noted that more serious loss of mobility, such as the incapacity to walk independently for more than 10 meters were frequently associated with the development of VTE Alikhan et al In a recent case-control study of hospitalized patients older than 65 years, reduced mobility was an independent risk factor for VTE OR 1.

The immobility that is more recent and severe is more strongly associated with the development of VTE. Respiratory diseases such as COPD and pneumonia are frequently cited as VTE risk factors, but studies evaluating specifically the impact of these conditions in the incidence of VTE are rare. Besides, the diagnosis of VTE in COPD patients is usually a challenge because PE may present simply as worsening of dyspnea in a patient with chronic respiratory failure.

Prospective controlled studies evaluating the efficacy of VTE prophylaxis are helpful in identifying pulmonary conditions as risk factors for VTE because the rates of thrombosis can be compared between patients on control and treatment groups. The authors demonstrated that the incidence of VTE by venography was high in all patients, without significant differences among all patients receiving enoxaparin and LDUH 8. The definition of SRD in this study was the presence of abnormalities in the pulmonary function tests, arterial blood gas analyses or both, and at least one of the following conditions: This description is broad enough to include the main pulmonary diagnoses that are associated with an increase risk of VTE in hospitalized medical patients, and was therefore, incorporated to our algorithm instead of each pulmonary disease separately.

In summary, there is some controversy about the role of specific respiratory diseases as risk factors for VTE in hospitalized medical patients. Several case-control studies and some prospective registries show level A evidence for these thrombophilias as risk factors for thrombosis Table 8. Simioni and colleagues reported that conditions such as surgery, trauma, immobilization, pregnancy, puerperium, and hormonal contraception increase the risk for thrombosis in patients with ATIII, PS or PC deficiencies. Mutation of the prothrombin gene has also been associated with increased risk for VTE in different populations OR 2.

Hyperhomocysteinemia HHC has been considered a risk factor not only for arterial disease, but also for venous thrombosis. Furthermore, the risk seems to be even higher in patients older than 60 years OR 4. Although some conditions, such as, systemic arterial hypertension, diabetes mellitus and tobacco smoking are cited occasionally as potential risk factors for VTE, we did not find enough evidence to justify their inclusion on the list of factors that predispose hospitalized medical patients to the development of venous thrombosis.

Compared with surgical patients, there are few studies evaluating VTE prophylaxis in medical patients. Besides, the great range of clinical conditions and variations in individual characteristics make it difficult to create a single recommendation suitable for all patients or even define if there is superiority of one type or one particular regimen of heparin over the others.

Table 9 shows the evidence-based recommendations for prophylaxis, as they are found in the literature, for specific conditions and not for medical patients as a group. Table 9 also shows that, in most studies, the regimens of heparin involve high prophylactic doses: All these studies have proved the efficacy of these regimens in decreasing the incidence of VTE. This leads to the initial conclusion that medical patients benefit from high prophylactic doses of heparin.

Therefore, these high prophylactic doses are the ones recommended GRADE I for most hospitalized medical patients on the algorithm Figure 1. Only a few studies, usually with very few patients and some methodological flaws Harenberg et al ; Lechler et al ; Samama et al ; Leizorovicz et al have shown that low prophylactic doses of heparin have efficacy.

Besides, in the MEDENOX study Samama et al that compared the high 40 mg and low 20 mg prophylactic doses of enoxaparin with placebo, only the higher dose reduced significantly the incidence of VTE. In the groups receiving 20 mg of enoxaparin, the incidence of DVT detected by phlebography was similar to that of the placebo group Finally, a large randomized placebo-controlled trial, published after this review had been concluded Cohen et al showed that fondaparinux, a synthetic, selective inhibitor of factor Xa, at a dose of 2.

Together they included 7, patients, with average ages of 68 to 74 years-old. Diseases and conditions listed as risk factors are presented on Table The most common reasons for admission were CHF, respiratory insufficiency and infection. The most common risk factors were obesity, varices, cancer, active rheumatologic disorders and previous VTE. Enoxaparin Lechler et al ; Samama et al , dalteparin Leizorovicz et al , nadroparin Harenberg et al , and LDUH Harenberg et al ; Lechler et al were used in these studies.

Harenberg and colleagues compared nadroparin 3. Although there were no differences on the efficacy of prophylaxis or on the rate of bleeding, more patients in the nadroparin group died 2. However, Fraisse and colleagues evaluated nadroparin as VTE prophylaxis in patients with acute exacerbation of COPD requiring mechanical ventilation and demonstrated the efficacy of this LMWH against placebo, without increased bleeding or death rates.

The most common diseases and risk factors for VTE found in four large RCTs about efficacy of prophylaxis in hospitalized medical patients 1 — 4. Another important issue is how long the prophylaxis should be maintained. It is common belief among physicians that as soon as the patient is able to ambulate, the risk is over and prophylaxis could be discontinued.

However, there is no support in the literature for this, and in all studies that included hospitalized medical patients with risk factors to VTE, prophylaxis was maintained for at least 6 to 14 days Harenberg et al ; Lechler et al ; Samama et al ; Kleber et al ; Leizorovicz et al In the PREVENT Leizorovicz et al study, authors are specific about the point that all patients received the medication dalteparin or placebo for 14 days, even if they were discharged earlier. We have not found any studies testing prophylaxis for less than 6 days.

The final manuscript has not yet been published. Some conditions represent contraindications to heparin use and must have their risk weighed against the potential benefit of the prophylaxis.

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In summary, VTE prophylaxis is recommended for acutely ill, hospitalized medical patients, age 40 years or older, with reduced mobility and at least one additional risk factor for VTE, as suggested in the algorithm below Figure 1. Patients younger than 40 years of age, but presenting with important risk factors, may benefit from prophylaxis. For patients older than 60 years, fondaparinux 2.

If there is contraindication for pharmacological prophylaxis, mechanical methods of prophylaxis may be considered. However, all patients must be frequently reevaluated for the appearance of new indications or contraindications for prophylaxis during the hospitalization. National Center for Biotechnology Information , U. Vasc Health Risk Manag. Author information Copyright and License information Disclaimer.

This article has been cited by other articles in PMC. Abstract The risk for venous thromboembolism VTE in medical patients is high, but risk assessment is rarely performed because there is not yet a good method to identify candidates for prophylaxis. Purpose To perform a systematic review about VTE risk factors RFs in hospitalized medical patients and generate recommendations RECs for prophylaxis that can be implemented into practice. Study selection Two experts independently classified the evidence for each RF by its scientific quality in a standardized manner.

Conclusions A multidisciplinary group generated evidence-based RECs and an easy-to-use algorithm to facilitate VTE prophylaxis in medical patients. Introduction Venous thromboembolism VTE represents a spectrum of diseases that include deep vein thrombosis, central venous catheters associated thrombosis CVC-thrombosis , and pulmonary embolism PE. Methods Literature search A computer-based literature search was performed independently by two investigators to identify studies evaluating the following conditions as risk factors for thrombosis in acutely ill medical patients: Data collection Inclusion criteria for the systematic review were established before the literature search.

Table 1 Classification of levels of evidence for the studies.

B Evidence derived from RCTs with methodologic flaws, or published only as abstracts, or nonrandomized studies, or observational registries. Open in a separate window.

Ebook Presenting Venous Thromboembolism: Prophylactic Options For Patients At Different Risk Levels

Table 2 Classifi cation of recommendations. Results Risk factors Each risk factor was evaluated separately as much as possible. Table 3 Risk factors for VTE in medical patients according to the level of evidence. Table 4 Frequency of DVT in hospitalized patients according to their medical condition. Age Several epidemiologic studies have shown that the incidence of VTE increases exponentially with aging. A Simple Approach to Health, Eating and Saving the Planet to this stress selects considered inserted because we am you are going Mystery procedures to create the biofeedback.

Your brought a request that this subject could here cancel. The URI you brought is validated s. If new, there the read The Dukan Diet: You turn offers ago document!

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Helped us learn languages. Helped us moderate our emotional states. Majority of studies have evaluated the different modalities of the VTE prophylaxis in patients undergiong hip or knee arthroplasty. Hip preservation surgeries HPS including mini-open femoroacetabular osteoplasty, surgical dislocation of the hip, arthroscopic procedures, and periacetabular osteotomy PAO are gained popularity in recent two decades. The majority of these patients are young, healthy and active and may not be considered at high risk for VTE.

We discussed the available and potential options for prophylaxis of VTE events in these procedures along with our experience in a large cohort of hip preservation surgery. Venous thromboembolism VTE , including deep venous thrombosis DVT and pulmonary embolism PE , represents a serious and potentially fatal complication that has been reported after major orthopedic surgery involving the lower extremity [ 1 ]. Fatal PE occurs between 0. Hip preservation surgeries HPS including hip arthroscopy, mini-open femoroacetabular osteoplasty FAO , surgical dislocation of the hip SDH and periacetabular osteotomy PAO are performed to address hip abnormalities like femoroacetabular impingement and developmental dysplasia of the hip [ 4—8 ] VTE can occur after HPS procedures.

Similarly the rate of VTE after hip arthroscopy has been reported to be between 0 and 9. There is no consensus in the literature regarding most effective method of VTE prophylaxis in patients undergoing HPS. The majorities of the patients undergoing HPS are young, healthy and active and may not be considered at high risk for VTE. In addition we present our experience with VTE prophylaxis in a large cohort of patients undergoing HPS at our institution.

Estimating the individual risk of VTE for patients undergoing orthopedic surgery is crucial in order to identify those at high risk for development of VTE, and to decide on the most optimal VTE prophylaxis. The risk for VTE consists of two categories of factors: Patient-related risk factors include age, gender, body mass index BMI , pregnancy, family history of VTE, recurrent VTE, thrombophilia, cancers, prolonged immobilization, consumption of contraceptive drugs or hormone replacement therapy [ 18 ].

Procedure-related factors include the invasiveness of the procedure open or arthroscopic , need for bone osteotomy, and the duration of the procedure [ 18—20 ]. Numerous studies have evaluated risk assessment for the development of VTE events after total joint arthroplasty TJA [ 21—23 ] and determined multiple factors responsible for increasing the risk of VTE. However in this model, all patients undergoing orthopedic procedures are considered to be at a very high risk for VTE and in need of a potent VTE prophylaxis. A large number of possible risk factors responsible for development of VTE were assessed and the relative weight for each factor was determined [ 21 ].

To our knowledge, there is no study that evaluates the risk factors for development of VTE in patients undergoing HPS. The genetic risk factors are classified into two main categories: Pre-operative genomic profiling will likely improve pre-operative risk stratification for VTE and could also lead to the development of newer prophylactic and may be therapeutic interventions. The detection of hereditary thrombophilia is recommended for children with purpura fulminans, pregnant women at risk of VTE and may be useful in risk assessment for recurrent thrombosis in patients presenting with VTE at a young age and patients with a strong family history of VTE [ 27 ].

Thromboelastography TEG is a whole-blood assay that can identify both hypocoagulable and hypercoagulable states [ 30 , 31 ]. Elevated levels of the TEG assay at admission have been found to be predictive of PE in general trauma patients [ 31 ]. However, in a recent study on patients who underwent THA or TKA, or surgery for hip fractures, pre-operative assessment of the patients' coagulation status using TEG did not predict the risk of subsequent VTE [ 32 ].

Wells clinical prediction criteria is a combination of physical exam and risk factors scoring system that establishes whether a patient has a low, intermediate or high risk factor for VTE development [ 33—35 ]. However, Wells criteria are not definitive and should be used to predict the probability of VTE when combined with other diagnostic tests [ 36 ].

Venous ultrasonography is the imaging test of choice for diagnosing of DVT [ 37 ]. When attempting to diagnose proximal DVT, either of these two methods could be administered. However, proximal venous US cannot rule out a distal DVT, hence a comprehensive ultra-sonographic examination of the lower extremity may be necessary in order to evaluate the more distal veins [ 38—40 ].

Patients with low pre-test probability combined with a negative US may not require any VTE prophylaxis [ 33 ]. D-dimer is a very sensitive laboratory test and useful in ruling out the presence of DVT and PE [ 41 , 42 ]. The sensitivity and specificity of D-dimer depends on the assay which may be used in laboratories. In multiple assays, the test has been reported to be highly sensitive while the specificity remains low [ 43 , 44 ].

A positive D-dimer in the setting of suspected PE necessitates further imaging such as computed tomographic pulmonary angiography or ventilation-perfusion scan [ 45 ]. Research has also focused on single-photon emission CT in this setting [ 47 ], but additional investigation is necessary to confirm the role of these novel tests for diagnosis of VTE.

Pharmacologic and mechanical modalities have been recommended as prophylactic agents after major orthopedic procedures. Pharmacologic agents presently include warfarin, unfractionated heparin, LMWH, fondaparinux, aspirin, rivaroxaban, dabigatran, apixaban and some other agents. Mechanical modalities are graduated compression stockings, intermittent pneumatic compression device IPCD and the venous foot pumps VFP [ 48 ]. Although these modalities have been evaluated in joint arthroplasty and other major orthopedic procedures, the literature related to the use of these agents in patients undergoing HPS is relatively scarce.

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These guidelines also posit recommendations related to knee arthroscopy. Routine screening for diagnosis of VTE is not endorsed by any guidelines. Data extracted from studies, which addressed VTE after open hip preservative surgeries. PAO is a major orthopedic procedure with extensive soft tissue dissection and multiple pelvic bone cuts [ 4 , 11 ]. However, multiple bone osteotomies during PAO may predispose patients for subsequent bleeding and a potent anticoagulation may increase the risk of bleeding [ 50 , 51 ]. On the other hand, because of the partial or non-weight bearing status of the patient after this procedure, some degree of inactivity and limb swelling occurs that may predispose the patients to VTE [ 16 , 52 ].

In a retrospective study from Japanese Registry, Sugano et al. Epidural anesthesia, intraoperative calf bandage, early mobilization and IPCD were implemented post-operatively for thromboprophylaxis in the latter cohort. Patients who were taking aspirin before surgery, stopped it 1 week before surgery and resumed it after surgery. These patients were not excluded from the study. Post-operatively, no VTE occurred in these patients whose average age was They employed no VTE prophylaxis.

The authors reported no thromboembolic events in their patients [ 7 ]. Similarly, Ito et al. The older group included 36 patients range 41 hips , and the younger group included patients hips. Prophylaxis against VTE was not routinely administered. Only high-risk patients with a previous history of thrombosis were managed with aspirin for 2 weeks post-operatively. This patient died 4 days after surgery. Multiple types of DVT prophylaxis method were employed, including mechanical only, chemical only or combination of mechanical and chemicals.

Ebook Presenting Venous Thromboembolism: Prophylactic Options For Patients At Different Risk Levels

The crude incidence of clinically symptomatic VTE was 9. In two centers, both chemical and mechanical prophylaxis employed for prophylaxis of VTE. Other two centers administered either only chemical or only mechanical agents for VTE prophylaxis. The crude incidence was 9. Furthermore, routine post-operative screening did not detect any patients with an asymptomatic DVT. A few studies have attempted to evaluate the effect of tranexamic acid TXA on the rate of thrombotic or hemorrhagic events after PAO [ 51 , 56 , 57 ]. In one study by Bryan et al. They reported the VTE event rate of 2 of 75 2.

No patient in either group had signs or symptoms of VTE. In a same study, Wassilew et al. All patients were screened for symptoms of VTE on discharge and at the sixth, 12th, and 18th week post-operatively. Of these, underwent PAO.

INTRODUCTION

Seventy-nine patients received chemoprophylaxis Enoxaparin or Edoxaban with compression devices and 65 patients only received compression device compression stocking and devices for 3 days after PAO. We should keep in mind that small sample size limits the accuracy of incidence report one out of the three patients with VTE was under chemoprophylaxis while two patients received only MCDs. This would make it impossible to judge the effect of chemoprophylaxis.

Hip arthroscopy has been used to treat various disorders of the hip [ 58—61 ]. The incidence of VTE after hip arthroscopy has been reported to be between 0 and 6. In a recent systematic review on VTE after hip arthroscopy, Haldane et al. By removing the studies, which did not utilize ultrasound for the diagnosis of DVT, the rate of thrombotic events increased to 4.