**6. Conclusion**

166 Deep Vein Thrombosis

**Regimine (mg)**

Dab 12.5-, 25- , 50-, 100-, 150-, 200-, 300-BID; and 150-, 300-QD

Dab 50-, 150- , 225-BID; and 300-QD; Enox 40-QD

Dab 150-, 220- QD; Enox 40- QD

Dab 150-, 220- QD; Enox 40- QD

Dab 150-, 220- QD; Enox 30- BID

Riv 2.5-, 5-, 10-, 20-, 30- BID; Enox 30- BID

Riv 5-, 10-, 20-, 30-, 40- QD; Enox 40- QD

Riv 2.5-, 5-, 10-, 20-, 30- BID; Enox 40 QD

Riv 2.5-, 5-, 10-, 20-, 30- BID; 30-QD; Enox 40 QD

Enox 40-QD

Riv 10-QD; Enox 40-QD

Enox 40-QD

Enox 30-BID

Enox 40-QD

Riv 10-QD; Enox 40-QD or 30-BID

Apix 5-, 10-, 20-QD; 2.5-, 5-, 10-BID; Enox 30-BID or Warfarin (INR 1.8-3.0)

Enox 30-BID

Enox 40-QD

Enox 40-QD

Table 3. Major bleeding rates in VTE prophylaxis clinical trails in THA and TKA. (Reference: Huo, M. New oral anticoagulants in venous thromboembolism prophylaxis in orthopaedic

**Major Clinically Significant Bleeding**

8.2% Dab 150-BID; 8.3% Dab 300-QD; 4.6% Enox

6.0% Dab 150-QD; 6.2% Dab 220-QD; 5.1% Enox

8.1% Dab 150-QD; 7.4% Dab 220-QD; 6.6% Enox

3.1% Dab 150-QD; 3.3% Dab 220-QD; 3.8% Enox

2.9% Riv 5-BID; 4.8% Enox

2.8% Riv 10-QD;

8.1% Riv 5-BID; 1.5% Enox

3.8% Riv 5-BID; 1.9% Enox

3.2% Riv; 2.5%

3.4% Riv; 2.8%

3.3% Riv; 2.8%

3.0% Riv; 2.3%

3.3% Riv; 2.7%

3.19% Riv; 2.55% Enox

0% Apix 2.5-BID; 1.3% Enox; 0% Warfarin

2.9% Apix; 4.3% Enox

3.5% Apix; 4.8% Enox

4.8% Apix; 5.0% Enox

**Surgical Site Bleeding**

2.4% Dab 150-QD N/A 2.4% Dab 150-QD

N/A

N/A

N/A

N/A

0% Riv 5-BID; 1.9% Enox

5,1% Enox N/A 2.1% Riv 10-QD;

2.2% Riv 5-BID; 0.8% Enox

2.5% Riv 5-BID; 0% Enox

Enox N/A 2.9% Riv; 2.4%

Enox N/A 3.3% Riv; 2.7%

Enox N/A 2.7% Riv; 2.3%

Enox N/A 2.6% Riv; 2.0%

Enox N/A 3.0% Riv; 2.5%

Enox N/A

N/A N/A

1.8% Riv; 1.37%

0.5% Apix; 0.9% Enox

0.5% Apix; 0.7% Enox

0.7% Apix; 0.6% Enox

**Non-Major Clinically Relevant Bleeding**

4.1% Dab 150-QD; 4.9% Dab 300-QD; 2.6% Enox

4.7% Dab 150-QD; 4.2% Dab 220-QD; 3.5% Enox

6.8% Dab 150-QD; 5.9% Dab 220-QD; 5.3% Enox

2.5% Dab 150-QD; 2.7% Dab 220-QD; 2.4% Enox

2.9% Riv 5-BID; 2.9% Enox

3.2% Enox

5.9% Riv 5-BID; 0% Enox

1.3% Riv 5-BID; 1.9% Enox

Enox

Enox

Enox

Enox

Enox

2.2% Apix; 3.0% Enox

2.9% Apix; 3.8% Enox

4.1% Apix; 4.5% Enox

**(Days)**

**Patients Arthroplasty Duration** 

289 Hip 6-10

1949 Hip and Knee 6-10

3463 Hip 28-35

2076 Knee 6-10

2596 Knee 12-15

613 Knee 5-9

845 Hip 5-9

704 Hip 5-9

625 Hip 5-9

12383 Hip and Knee 10-39

1217 Knee 10-14

patients: Are they really better? *Thromb Haemost* 2011;106:45-57.

2457 Hip

<sup>4433</sup> Hip 31-39 Riv 10-QD;

<sup>2459</sup> Knee 10-14 Riv 10-QD;

<sup>3034</sup> Knee 10-14 Riv 10-QD;

9349 Hip and Knee 10-39 Riv 10-QD;

<sup>3184</sup> Knee 10-14 Apix 2.5-BID;

<sup>3009</sup> Knee 10-14 Apix 2.5-BID;

<sup>5332</sup> Hip N/A Apix 2.5-BID;

31-39 Riv; 10- 14 Enox

**Drug Study Number of** 

BISTRO I (Eriksson, 2004)

BISTRO II (Eriksson, 2005)

RE-NOVATE (Eriksson, 2007a)

RE-MODEL (Eriksson, 2008b)

RE-MOBILIZE (Ginsberg, 2009)

> ODIXa-KNEE (Turpie, 2005)

ODIXa-OD-HIP (Eriksson, 2006a)

ODIXa-HIP (Eriksson, 2006b)

Doseescalation study (Eriksson, 2007c)

RECORD1 (Eriksson, 2008)

**Rivaroxaban (Riv)**

**Apixaban (Apix)**

**Dabigatran etexilate (Dab)**

> RECORD2 (Kakkar, 2008)

> RECORD3 (Lassen, 2008)

> RECORD4 (Turpie, 2009)

RECORD1-3 (Eriksson, 2009)

RECORD1-4 (US FDA, 2009)

APROPOS (Lassen, 2007)

ADVANCE-1 (Lassen, 2009)

ADVANCE-2 (Lassen, 2010b)

ADVANCE-3 (Lassen, 2010a)

VTE remains a challenging problem that complicates many orthopaedic procedures. The incidence has been found to be particularly high following TKA and THA. Governmental and consumer governing bodies are beginning to recognize it as a "never-event" indicating that increased emphasis will be placed on prophylaxis in the years to come. Recommendations have been released by both the ACCP and the AAOS and there remains some disagreement as to the optimal management of VTE. Warfarin and LMWH remain the standard of care in many practices, but newer agents show increasing promise.

The authors have several recommendations regarding the duration and type of therapy. Patients should be anticoagulated for 25-30 days postoperatively following total hip arthroplasty and for 14 days following a total knee arthroplasty. Certain patients with high risk of VTE (obese, low mobility, prior VTE, family history of VTE, or protein C/S deficiency) should be treated for 25-30 days as well following hip or knee replacement. At our institution, we generally use enoxaparin for postoperative anticoagulation. For inpatients, either 30mg twice daily or 40mg daily may be used following total hip arthroplasty. The FDA has approved only the twice daily dosing after total knee arthroplasty. For outpatients, enoxaparin 40mg daily is our regimen of choice.

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**1. Introduction** 

attack.

mechanism.

their use.

**2. Incidence** 

appropriate prophylactic procedures.

after definitive radiotherapy

**11** 

*Egypt* 

**Deep Venous Thrombosis After** 

*Mansoura University, Urology and Nephrology Center* 

Deep venous thrombosis or DVT is a blood clot formation in one or more of the deep veins. The blood clot does not break down and therefore, it can become larger and occlude the blood flow within the affected vein. The most frequent sites are the leg veins (femoral and popliteal) and the deep pelvic veins. Rarely, the arm veins are affected (Paget-Schrötter disease). Pulmonary embolism (PE) is the most dangerous complication of DVT. PE occurs when the clot breaks into small pieces (emboli) and travel to the lung. The embolus may travel to other vital organs and cause life-threatening complications such as stroke or heart

The etiology of thrombosis is exactly unknown, however, the Virchow's triad of slow circulation (stasis), increased blood coagulability and vessel wall intimal injury is the alleged

DVT and PE developing after trauma and pelvic surgery are of a major concern to surgeons of all subspecialties. Therefore, proper assessment of the patient risk to develop DVT is of paramount importance. The risk of DVT can be decreased significantly by adopting some

Although adopting anti-DVT prophylactic measures is not debatable, the use of these measures has not yet been a universal issue, even in patients having no contraindications to

In this chapter, the term "radical pelvic surgeries" mean all types of major surgeries performed to treat malignancies developing in the pelvis, such as radical cystectomy, salvage cystectomy, radical prostatectomy, radical or pan-hysterectomy, radical surgery for colo-rectal cancer and excision of a local tumor recurrence after primary radical surgery or

DVT constitutes a major health problem, especially among the elderly. In comparison with previous era, the incidence of DVT remains the same among men and possibly increasing in elderly females (Silverstein et al., 1998). On the other hand, the incidence of PE is decreasing

 **Radical Pelvic Surgery** 

Bedeir Ali-El-Dein

