GENERAL MEDICINE

Prevention of Venous Thromboembolism (VTE)

Created 22/02/2022, last revision 28/04/2023

ESO guidelines for prophylaxis for venous thromboembolism in immobile patients with acute ischaemic stroke

deep vein thrombosis (DVT) is a condition where blood clots form in the veins. It most commonly occurs in the deep veins of the calf or thigh but can appear in other parts of the body (such as the deep pelvic veins, veins in the abdomen, or arms)
immobility increases the risk of DVT
without prevention, DVT is detected in the first two weeks in up to 50% of immobile patients [Brandstater, 1992]
- thrombi form in the paretic leg and/or the pelvic veins
- 2/3 of thrombi occur below the knee and are often asymptomatic, but there is a risk of proximal thrombus extension
- most symptomatic DVTs are proximally located (thigh, pelvis)
- the maximum incidence is between days 3-7
the most feared complication is pulmonary embolism (PE)
- incidence ~1% in 2 weeks [IST trial, 1997]
- PE is responsible for up to 25% of deaths in stroke patients [Kelly, 2001]
in bedridden patients, the calves should be checked regularly (swelling, palpation pain); nonetheless, many thromboses remain asymptomatic
recommended VTE prophylaxis:
- mechanical prophylaxis is essential: IPC (intermittent pneumatic compression)
- medication: LMWH or UFH (according to AHA/ASA 2019, the benefit is not sufficiently established – IIb/A)

Mechanical prophylaxis

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Anticoagulants

in general, the benefit of prophylactic administration of subcutaneous heparin (UFH or LMWH) in patients with acute stroke is not well established (AHA/ASA 2019 IIb/A)
- there were no significant effects on death or disability for LMWH compared with UFH
- LMWH was associated with a statistically significant reduction in mostly asymptomatic DVTs
in routine practice, medical prophylaxis is used; according to data from the PREVAIL study, enoxaparin 40mg 1xd may be preferred to heparin 2x 5000 IU given its better clinical benefits to risk ratio and convenience of once-daily administration [Sherman, 2007]

→ FRAXIPARINE , CLEXANE

According to the AHA/ASA guidelines 2019, IPC is the preferred prophylactic method, the most effective is a combination of LMWH + IPC (Wan, 2015)

How to proceed in different types of stroke

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Consider implantation of Inferior Vena Cava (IVC) filter in SAH or ICH patients with acute PE or DVT (AHA/ASA 2010 class IIb, LoE C)