Canadian Journal of Anesthesia

, Volume 53, Supplement 2, pp S80–S88

Traitement de la maladie thromboembolique veineuse

  • Philippe de Moerloose
  • Charles Marc Samama
  • Serge Motte
III-Managing the risk of thrombosis

Management of venous thromboembolism

Abstract

Purpose

To describe the drugs used to treat venous thromboembolism (VTE) and to review particular aspects of the management (elastic stockings, thrombolysis, thrombectomy, vena cava filter).

Source

Our review of the literature is focused on consensus documents and recent large randomized trials.

Principal findings

Subcutaneous low molecular weight heparins (LMWH) have been shown to be both safe and effective for the initial treatment of VTE and have largely replaced unfractionated heparin, unless there is a contraindication to LMWH such as severe renal insufficiency. Low molecular weight heparins or unfractionated heparin are usually administered for five to seven days. Treatment is gradually switched from heparin to oral vitamin K antagonists (VKA) which are usually started the same day as heparin. The duration of oral anticoagulation must be tailored to the individual patient according to the presence of reversible or continuing risk factors. In patients with active cancer, long-term treatment of VTE with LMWH has been shown to be more effective than oral anticoagulation and is recommended for the first three to six months of long-term anticoagulant therapy as an alternative approach to VKA. Elastic stockings are recommended because they have been shown to prevent postthrombotic syndrome. Thrombolysis is, usually, not justified for the treatment of deep venous thrombosis, but is used in cases of massive pulmonary embolism with arterial hypotension and/or shock. Vena cava filter placement is mainly indicated in patients with a proximal deep venous thrombosis and an absolute contraindication to anticoagulation.

Conclusions

The initial management of patients with acute VTE has largely been simplified due to the use of LMWH. Early conversion to VKA is recommended for the great majority of patients. New agents, such as anti-Xa or oral thrombin inhibitors, are promising alternatives to heparins or VKA.

Objectif

Présenter les médicaments utilisés pour traiter la maladie thromboembolique veineuse (MTEV) et revoir des aspects particuliers de la thérapie comme les bas élastiques, la thrombolyse, la thrombectomie et le filtre cave.

Source

Revue de documents de consensus et de grandes études récentes.

Constatations principales

Les héparines de bas poids moléculaire (HBPM) sont sûres et efficaces comme traitement initial de la MTEV et remplacent largement ľhéparine non fractionnée, à moins ďune contre-indication à ľHBPM comme ľinsuffisance rénale sévère. Les HBPM ou ľhéparine non fractionnée sont habituellement administrées pendant cinq à sept jours. Puis, on passe graduellement de ľhéparine à la prise orale ďantagonistes de la vitamine K (AVK), débutés en général le même jour que ľhéparine. La durée de ľanticoagulation orale doit être adaptée au patient en fonction de facteurs de risque réversible ou continu. Dans les cas de cancer actif, le traitement de la MTEV avec ľHBPM s’est montré plus efficace que ľanticoagulation orale et il est recommandé pour les trois à six premiers mois de traitement. Les bas élastiques sont recommandés pour prévenir le syndrome post-thrombotique. La thrombolyse n’est pas habituellement justifiée pour traiter la thrombose veineuse profonde, mais est utilisée en cas ďembolie pulmonaire massive avec hypotension et/ou choc artériels. La mise en place ďun filtre cave est principalement indiquée chez les patients souffrant de thrombose veineuse profonde proximale chez qui ľanticoagulation est une contre-indication absolue.

Conclusion

Le traitement initial des patients atteints de MTEV a été grandement simplifié avec ľusage de ľHBPM. Le passage précoce aux AVK est recommandé pour la grande majorité des patients. De nouveaux médicaments comme les anti-Xa ou les inhibiteurs de la thrombine oraux, sont des équivalents prometteurs des héparines ou des AVK.

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Copyright information

© Canadian Anesthesiologists 2006

Authors and Affiliations

  • Philippe de Moerloose
    • 1
  • Charles Marc Samama
    • 2
  • Serge Motte
    • 3
  1. 1.Service ďAngiologie et ďHémostaseHôpitaux Universitaires de GenèveGenèveSwitzerland
  2. 2.Department of Anesthésie-RéanimationAssistance Publique-Hôpitaux de Paris; the Centre Hospitalier Universitaire AvicenneParisFrance
  3. 3.Service de Pathologie VasculaireCliniques Universitaires de Bruxelles, Hôpital Erasme, Université Libre de BruxellesBelgique

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