Transcript Apresentação do PowerPoint

1
Content
2
Introduction

Definition

Causes

Risk Factors

Symptoms

Importance

Treatments
Aims
Methods

Collecting Articles

Research Question

Query

Inclusion / Exclusion criteria

Data to extract from the
articles

Variables for data extraction
Results

Study type

Follow-up

Participants

Treatments applied
Conclusions
Introduction
Aims
Methods
Results
Definition
3
• Superficial venous thrombosis consists in
the formation of a blood clot in a
superficial vein. Most commonly, it
affects the lower limbs.
• Under normal physiological conditions,
there is a continuous formation of clots in
the veins, but they disintegrate rapidly,
not causing any harm.
Superficial Venous Thrombosis of the Lower Limbs
Conclusions
Introduction
Aims
Methods
Results
Conclusions
Risk Factors
4
 Varicose veins;
 Cigarette smoking;
 Hormone therapy;
 Obesity;
 Family history;
 Diabetes…
 History of malignancy;
Uncu H., 2009
Superficial Venous Thrombosis of the Lower Limbs
Introduction
Aims
Methods
Results
Causes
5
Superficial Venous Thrombosis of the Lower Limbs
Conclusions
Introduction
Aims
Methods
Results
Conclusions
Symptoms
6
•
Pain
•
Redness of the skin with increase of temperature
•
Induration
•
Edema (swelling)
•
Fever
Superficial Venous Thrombosis of the Lower Limbs
Introduction
Aims
Methods
Results
Conclusions
Importance
7
The thrombus can reach the deep
venous system through:
SVT
• Saphenofemoral junction
• Perforator veins
• Saphenopopliteal junction
DVT (deep
venous
thrombosis)
• The thrombus can detach
and clot the pulmonary
artery
Pulmonary
Embolism
Introduction
Aims
Results
Methods
Conclusions
Importance - statistics
8
Superficial venous
complications,
thrombosis
rarely
causes
serious
BUT
In some cases, SVT can evolve (Litzendorf and Satiani, 2011):
• 6-40% - Deep Venous Thrombosis (DVT);
• 2-13% - Pulmonary embolism.
Superficial Venous Thrombosis of the Lower Limbs
Introduction
Aims
Methods
Results
Conclusions
Treatment temporal evolution
9
Elastic
compression
bandages and
anti-inflammatory
creams
Surgery (patients
with serious pain)
Medical therapy –
Drugs*
(Decousus H, Epinat M, Guillot K, 2003)
* There is still no consensus about
using surgery as a possible treatment.
Therefore, in some cases, it is still used.
Superficial Venous Thrombosis of the Lower Limbs
Introduction
Aims
Methods
Results
Conclusions
Treatments
Possible Treatments
10
Symptomatic control
Surgery (cut of the saphenofemoral junction)
Drugs:
- Warfarin;
- Low Molecular Weight Heparin;
- Nonsteroidal Anti-inflammatory Agent;
- Xabans (Direct Xa factor inhibitor);
- Fondaparinux (indirect Xa factor inhibitor)
If SVT has a history longer than one week, medical therapy is considered to be more effective than
surgical therapy (Bergqvist D, Brunkwell J, Jensen N, Persson NH 1990)
Superficial Venous Thrombosis of the Lower Limbs
Introduction
Aims
Methods
Results
Conclusions
Costs
11
Medical costs
• Compressions
alone had the
lowest costs
• Treatments
including LMWH
had the highest
costs
Medical costs
• Lost of working
days
and/or
inactivity
was
higher
in
the
subjects
treated
only with stockings
Social costs
(Belcaro G. et al, 1999)
Superficial Venous Thrombosis of the Lower Limbs
Introduction
Aims
Methods
Results
Conclusions
Aims
12
 Discovering the possible treatments
 Evaluate their results and complications
Superficial Venous Thrombosis of the Lower Limbs
Introduction
Aims
Methods
Results
Collecting Articles
13
Databases used:

Pubmed

Scopus

ISI Web of Knowledge
Superficial Venous Thrombosis of the Lower Limbs
Conclusions
Introduction
Aims
Methods
Results
Conclusions
Research Question:
14
Which are the results and complications of
Superficial Venous Thrombosis’ treatments?
Superficial
Superficial
Venous
Venous
Thrombosis
Thrombosis
of of
thethe
Lower
Lower
Limbs
Limbs
Introduction
Aims
Results
Methods
Aim to achieve with the queries
15
SVT of the Lower
Limbs
Our aim
Treatment
Results/
complications
Superficial Venous Thrombosis of the Lower Limbs
Conclusions
Introduction
Aims
Methods
Results
Conclusions
Query - Pubmed
16
Venous Thrombosis – Entry Terms
Thrombosis, Venous; Thromboses, Venous; Venous Thromboses; Phlebothrombosis;
Phlebothromboses; Deep Vein Thrombosis; Deep Vein Thromboses; Thromboses,
Deep Vein; Vein Thromboses, Deep
Venous Thrombosis, Deep; Deep-Vein Thrombosis; Deep-Vein Thromboses;
Thromboses, Deep-Vein; Thrombosis, Deep-Vein; Vein Thrombosis, Deep;
Thrombosis, Deep Vein; Deep-Venous Thrombosis
Deep-Venous Thromboses; Thromboses, Deep-Venous; Thrombosis, Deep-Venous;
Deep Venous Thrombosis; Deep Venous Thromboses; Thromboses, Deep Venous;
Thrombosis, Deep Venous; Venous Thromboses, Deep
Introduction
Aims
Methods
Results
Query - Pubmed
17
Lower Extremity – Entry Terms
Extremities, Lower; Lower Extremities; Lower Limb
Limb, Lower; Limbs, Lower; Lower Limbs
Membrum inferius; Extremity, Lower
Therapeutics – Entry Terms
Therapeutic
Treatment
Treatments
Superficial Venous Thrombosis of the Lower Limbs
Conclusions
Introduction
Aims
Methods
Results
Conclusions
Query - Pubmed
18
Pubmed Query - Main Topics
Condition definition: (superficial venous thrombosis OR SVT) AND (lower extremity
OR leg OR lower limb)
Intervention: (Treatments OR therapeutics OR therapy)
Analysis of: (results OR complications)
Query applied on Pubmed
(superficial venous thrombosis OR SVT)
AND (lower extremity OR leg OR lower limb)
AND (Treatments OR therapeutics OR therapy)
AND (results OR complications)
Superficial Venous Thrombosis of the Lower Limbs
Introduction
Aims
Methods
Results
Conclusions
Query - Scopus
19
Scopus Query - Main Topics
Condition definition: (svt OR superficial venous thrombosis) AND (lower limbs OR
lower extremity OR legs)
Intervention: (Treatments or therapy or therapeutics)
Analysis of: (results OR complications)
Query applied on Scopus
TITLE-ABS-KEY (svt OR superficial venous thrombosis)
AND (lower limbs OR lower extremity OR legs))
AND (Treatments or therapy or therapeutics)
AND (results OR complications)
AND DOCTYPE(ar)
Superficial Venous Thrombosis of the Lower Limbs
Introduction
Aims
Methods
Results
Query - ISI Web of Knowledge
20
Definition of the topic
TOPICS
(superficial venous thrombosis OR svt)
(treatment OR therapy OR therapeutics )
(lower limb)
NOT (varicose)
NOT (artery)
NOT (ulcers)
Definition of the target group and thematic scope
REFINED BY
Languages=(ENGLISH)
Document Type=(ARTICLE)
Conclusions
Introduction
Aims
Methods
Results
Query - ISI Web of Knowledge
21
Query obtained and applied on ISI Web of Knowledge
Topic=(superficial venous thrombosis OR svt)
AND Topic=(treatment OR therapy OR therapeutics)
AND Topic=(lower limb)
NOT Topic=(varicose)
NOT Topic=(artery)
NOT Topic=(ulcers)
Refined by: Languages=(ENGLISH) AND Document Type=(ARTICLE)
Timespan=1980-2011
Superficial Venous Thrombosis of the Lower Limbs
Conclusions
Introduction
Aims
Methods
Results
Conclusions
Outcome
22

Articles obtained:
Deadline for the research of the articles: March 22, 2012
Superficial Venous Thrombosis of the Lower Limbs
Introduction
Flowchart
23
Aims
Methods
Results
Conclusions
Introduction
Aims
Methods
First selection phase
24
Results
Conclusions
Introduction
Aims
Methods
Results
Conclusions
Inclusion and exclusion criteria
25
Inclusion Criteria


Studies
that
fully
describe the treatment
applied in SVT;
Studies describing the
evolution
of
SVT
according
to
the
treatment applied.
Exclusion Criteria




Articles without original
data
(ex:
systematic
review);
Articles not written in
English, Portuguese or
Spanish;
Articles whose full-text
was not available.
Articles describing only
one clinical case.
Introduction
Aims
Methods
Results
Conclusions
First selection phase
26
- Language
- Study Type
- Not relevant
By reading the abstracts a first
selection of the articles was
made.
Introduction
Flowchart
27
Aims
Methods
Results
Conclusions
Introduction
Aims
Methods
Second selection phase
28
Results
Conclusions
Introduction
Aims
Methods
Results
Conclusions
Second selection phase
29
- Not available
- Not relevant1
- Repeated
1 – Articles in doubt, during
the first selection phase, due
to their ambiguous abstracts.
Introduction
Aims
Methods
Results
Conclusions
Order of exclusion - summary
30
Language
13% of the
articles
excluded
Type of
Study
5% of the
articles
excluded
Relevance
73% of the
articles
excluded
For a total of 361 articles obtained
Superficial Venous Thrombosis of the Lower Limbs
Availability
6% of the
articles
excluded
Introduction
Aims
Methods
Results
Conclusions
List of the articles
31

1 – High vs. low doses of low-molecular-weight heparin for the treatment of superficial vein thrombosis of
the legs: a double-blind, randomized trial

2 – Superficial Thrombophlebitis ofthe Legs: A Randomized, Controlled, Follow-up Study

3 – Simultaneous occurrence of superficial and deep thrombophlebitis in the lower extremity

4 – High versus low doses of unfractionated heparin for the treatment of superficial thrombophlebitis of
the leg. A prospective, controlled, randomized study

5 – A comparison of low-molecular-weight heparin and combined therapy of low-molecular-weight
heparin with an anti-inflammatory agent in the treatment of superficial vein thrombosis
Introduction
Aims
Methods
Results
Conclusions
List of the articles
32

6 – The use of liposomal heparin spray-gel in the treatment of superficial thrombophlebitis: a multicenter
clinical investigation analysis;

7 – A Pilot Randomized Double-blind Comparison of a Low-Molecular-Weight Heparin, a Nonsteroidal
Anti-inflammatory Agent, and Placebo in the Treatment of Superficial Vein Thrombosis;

8 – Prospective five-year study of ultrasound-guided foam sclerotherapy in the treatment of great
saphenous vein reflux;

9 – Fondaparinux for the Treatment of Superficial-Vein Thrombosis in the Legs;

10 – A retrospective analysis of patients treated for superficial vein thrombosis;

11 – Fondaparinux for Isolated Superficial Vein Thrombosis of the Legs : A Cost-Effectiveness Analysis;
Introduction
Aims
Results
Methods
Conclusions
33
Distribution of the articles through time
4
2008
Number of Articles
3
2
1990
1999
2002
2003
2005
2009
2010
2011
1
0
1988
1993
1998
2003
2008
2013
Introduction
Aims
Methods
Results
Conclusions
General table of the articles’ data
34
Article nº
Follow-up (in
days)
Nº of participants
Treatments
1
90
164
LMWH*
2
6
562
Surgery, LMWH*, elastic compression
3
1825
42
Heparin; Warfarin; surgery
4
183
60
LMWH*
5
10
50
LMWH*
6
14
88
Lipossomal gel-spray heparin
7
97
427
Heparin; placebo; tenoxicam
8
1825
146
Ultra-sound guided foam sclerotherapy
9
77
3002
Fondaparinux; Placebo
10
1825
73
LMWH*; vitamin k antagonists; nasodroparin
11
45
10000
Fondaprinux; Placebo
* LMWH: Low Molecular Weight Heparin
Introduction
Aims
Methods
Results
Conclusions
Variables for data extraction
35
Superficial Venous Thrombosis of the Lower Limbs
Introduction
Aims
Results
Methods
Conclusions
Variables
36
Relative to the article extraction:




Database
Article number
Year
Study Type
Relative to article’s content:








Nº of participants
Nº of groups
Follow-up
Drop out
Age
Gender
Treatments
Efficacy
Superficial Venous Thrombosis of the Lower Limbs
Introduction
Aims
Methods
Results
Data extraction to SPSS
37
Superficial Venous Thrombosis of the Lower Limbs
Conclusions
Introduction
Aims
Methods
Results
Conclusions
Study Type
38
1
Double-blind,
randomized trial
(including clinical trials)
Restrospective study
2
Cohort
8
Superficial Venous Thrombosis of the Lower Limbs
Introduction
Aims
Results
Methods
Conclusions
Follow-up (in days)
39
2000
1800
1600
Follow-up (days)
1400
1200
1000
800
600
400
200
Article nº0
Series1
1
90
2
6
3
1825
4
183
5
10
6
14
7
97
8
1825
Superficial Venous Thrombosis of the Lower Limbs
9
77
10
1825
11
45
Introduction
Aims
Results
Methods
Conclusions
Participants
40
60
164
42
50
88
562
427
Article nº
146
1
2
3
3002
4
5
6
7
73
10000
8
9
10
11
Total of participants: 14 488
Superficial Venous Thrombosis of the Lower Limbs
Introduction
Aims
Results
Methods
Conclusions
Different treatments applied
41
Eleven articles analyzed: a total of 14 488 patients received treatment, 1502 with placebo
and 11500 with Fondaparinux. The remaining treatments used are in the chart below.
Treatments applied
350
300
309
301
298
250
200
150
100
50
0
146
112
102
78
71
40
20
6
3
Introduction
Aims
Results
Methods
Conclusions
Heparin Data
42
Use of different kinds of heparin
15
25
LMWH
Low dose LMWH
113
111
High dose LMWH
Nasodoparin
Superficial Venous Thrombosis of the Lower Limbs
Introduction
Aims
Results
Methods
Conclusions
Antithrombotic therapy vs placebo (1/2)
43
Incidence of DVT by day 12
Placebo
4/111 - (3.6%)
40-mg enoxaparin*
1/109 - (0.9%)
1.5 mg/kg enoxaparin*
1/102 - (1.0%)
Data obtained from
article 7
Incidence of DVT and SVT by day
12
Placebo
34/111 - (30.6%)
40-mg enoxaparin*
9/109 - (8.3%)
1.5 mg/kg enoxaparin*
7/102 - (6.9%)
* enoxaparin: a kind of heparin (in this case, different doses were used)
Superficial Venous Thrombosis of the Lower Limbs
Introduction
Aims
Methods
Results
Conclusions
Antithrombotic therapy vs placebo (2/2)
44
Incidence of pulmonary embolism
or DVT
Placebo
20/1500 - (1.3%)
Fondaparinux
3/1502 - (0.2%)
Incidence of delayed surgery by
day 77
Placebo
52/1500 - (3.5%)
Fondaparinux
8/1502 - (0.5%)
Data obtained from
article 9
Superficial Venous Thrombosis of the Lower Limbs
Introduction
Aims
Methods
Results
Conclusions
Elastic compression vs anti-coagulants and surgery (1/2)
45
Elastic compression only
Thrombus extension at 3 months
32/78 - (41.0%)
DVT at 3 months
6/78 - (7.7%)
Thrombus extension at 6 months
13/78 - (16.7%)
Total for complications
51/78 - (65.4%)
Data obtained from
article 2
Elastic compression +
LMWH + Delayed surgery
Thrombus extension at 3 months
4/76 - (5.3%)
DVT at 3 months
0/76 - (0.0%)
Thrombus extension at 6 months
1/76 - (1.3%)
Total for complications
5/76 - (6.6%)
Superficial Venous Thrombosis of the Lower Limbs
Introduction
Aims
Methods
Results
Conclusions
Elastic compression vs anti-coagulants and surgery (2/2)
46
Elastic compression + oral
anti-coagulant
Thrombus extension at 3 months
5/71 - (7.0%)
DVT at 3 months
0/71 - (0.0%)
Thrombus extension at 6 months
5/71 - (7.0%)
Total for complications
10/71 - (14.0%)
Data obtained from
article 2
Superficial Venous Thrombosis of the Lower Limbs
Introduction
Aims
Methods
Results
Conclusions
High vs low doses of LMWH
47
Incidence of thromboembolic
complications
During treatment
period
After drug
discontinuation
High doses
Low doses
0/30 - (0%)
4/30 - (13.3%)
1/30 - (3.3%)
2/30 - (6.7%)
Data obtained from
article 4
Incidence of thrombus extension
During treatment
period
After drug
discontinuation
High doses
Low doses
3/30 - (10.0%)
7/30 - (23.3%)
0/30 - (0%)
0/30 - (0%)
Superficial Venous Thrombosis of the Lower Limbs
Introduction
Aims
Methods
Results
Conclusions
Prophylactic vs therapeutic doses of LMWH
48
Prophylatic doses
Nº of patients with
complications
During treatment period
5/81 - (6.2%)
After drug discontinuation
2/81 - (2.5%)
Data obtained from
article 1
Therapeutic doses
Nº of patients with
complications
During treatment period
2/83 - (2.4%)
After drug discontinuation
4/83 - (4.8%)
Superficial Venous Thrombosis of the Lower Limbs
Introduction
Aims
Methods
Results
Conclusions
Lipossomal gel-spray heparin vs heparin injections
49
Data obtained from
article 6
N – Lipohep: 43

N – injections: 45
Lipohep spray-gel is an heparin gel that has recently appeared on the market. Its effect
has been compared with subcutaneous injections of heparin (as showed above) .
Introduction
Aims
Methods
Results
Conclusions
Conclusions (1/3)
50

Antithrombotic therapy is more effective than placebo and may avoid
surgery;

Elastic compression by itself seems not to be a good option of
treatment. Although the group involving delayed surgery as treatment
had better outcomes, anti-coagulants seem to be a good alternative to
it;

High doses of LMWH have better results than low doses.
Introduction
Aims
Methods
Results
Conclusions
Conclusions (2/3)
51

There are no statistically significant differences between prophylactic
and therapeutic doses of LMWH, after drug discontinuation.

There are no statistically significant differences between the spray-gel
and the injections, so as it represents an easier way of treatment
Lipohep spray gel seems to be an alternative to be considered.
Introduction
Aims
Methods
Results
Conclusions
Conclusions (3/3)
52

It also important to mention ultrasound-guided foam sclerotherapy
(UGFS), a recent treatment in which study (article 8) no serious
adverse outcomes were observed and it had 100% patient acceptance
of success. However, as it is a recent finding, more studies need to be
done in order to evaluate its effect in treating SVT.
Unfortunately, we did not found any articles comparing fondaparinux
and heparin, therefore we were not able to conclude which one was
the best. Even so, there seems to exist a preference regarding heparin.
Introduction
Aims
Methods
Results
Conclusions
Study Limitations
53

Heterogeneity of the articles included: each article presented
unique points of view and different methodology;

Unavailability of articles in the UP database (23 articles): we
can't assure the inexistence of important information among those whose
full-text wasn’t available;

Articles describing very specific populations: clinical cases or
articles describing SVT within very specific populations (cancer patients,
etc.) were excluded.
Superficial Venous Thrombosis of the Lower Limbs