Superficial phlebitis and Fondaparinux

Cochrane Database Syst Rev. 2013 Apr 30;4:CD004982. doi: 10.1002/14651858.CD004982.pub5.

Treatment for superficial thrombophlebitis of the leg.

Di Nisio M¹, Wichers IM, Middeldorp S.

The optimal treatment of superficial thrombophlebitis (ST) of the legs remains poorly defined. While improving or relieving the local painful symptoms, treatment should aim at preventing venous thromboembolism (VTE), which might complicate the natural history of ST. This is the second update of a review first published in 2007. To assess the efficacy and safety of topical, medical, and surgical treatments in patients presenting with ST of the legs. For this update, the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched November 2012) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue 11). We handsearched the reference lists of relevant papers and conference proceedings. Randomised controlled trials (RCTs) evaluating topical, medical, and surgical treatments for ST of the legs that included participants with a clinical diagnosis of ST of the legs or an objective diagnosis of a thrombus in a superficial vein.

Two authors assessed the trials for inclusion in the review, extracted the data, and assessed the quality of the studies. Data were independently extracted from the included studies and any disagreements resolved by consensus.

MAIN RESULTS:

We identified four additional trials (986 patients), so this update considered 30 studies involving 6507 participants with ST of the legs.Treatment ranged from fondaparinux, low molecular weight heparin (LMWH), unfractionated heparin (UFH), non-steroidal anti-inflammatory agents (NSAIDs), topical treatment, oral treatment, intramuscular treatment, and intravenous treatment to surgery. Only a minority of trials compared treatment with placebo rather than an alternative treatment, none evaluated the same treatment comparisons on the same study outcomes (which precluded meta-analysis), and many of the studies were small and of poor quality. In one large, placebo-controlled RCT of about 3000 patients, subcutaneous fondaparinux was associated with a significant reduction in symptomatic VTE (RR 0.15; 95% CI 0.04 to 0.50), ST extension (RR 0.08; 95% CI 0.03 to 0.22), and ST recurrence (RR 0.21; 95% CI 0.08 to 0.54) with comparable rates of major bleeding (RR 0.99; 95% CI 0.06 to 15.86) relative to placebo. In a further placebo-controlled trial, both prophylactic and therapeutic doses of LMWH (RR 0.40; 95% CI 0.22 to 0.72 and RR 0.42; 95% CI 0.23 to 0.75, respectively) and NSAIDs (RR 0.41; 95% CI 0.23 to 0.75) reduced the extension and recurrence of ST in comparison to placebo, with no significant effects on symptomatic VTE nor major bleeding. Overall, topical treatments improved local symptoms compared with placebo but no data were provided on the effects on VTE and ST extension. Surgical treatment combined with elastic stockings was associated with a lower VTE rate and ST progression compared with elastic stockings alone. However, the majority of studies that compared different oral treatment, topical treatment, or surgery did not report VTE, ST progression, adverse events, or treatment side effects.

AUTHORS' CONCLUSIONS:

Prophylactic dose fondaparinux given for six weeks appears to be a valid therapeutic option for ST of the legs. The evidence on oral treatments, topical treatment, or surgery is too limited and does not inform clinical practice about the effects of these treatments in terms of VTE and ST progression. Further research is needed to assess the role of the new oral direct thrombin and activated factor-X inhibitors, LMWH, and NSAIDs; the optimal doses and duration of treatment; and whether a combination therapy may be more effective than single treatment. Adequately designed and conducted studies are required to clarify the role of topical and surgical treatments.

Update of Treatment for superficial thrombophlebitis of the leg

We all should be careful and judicious in selecting the procedures protecting the safety of patients

http://mobile.nytimes.com/2015/01/30/business/medicare-payments-surge-for-stents-to-unblock-blood-vessels-in-limbs.html

Medicare Payments Surge for Stents to Unblock Blood Vessels in Limbs

JANUARY 29, 2015Earlier this month, the Justice Department said it joined two whistle-blower lawsuits accusing one of these doctors of performing unnecessary procedures, including placing a stent in the leg of a patient who later died of complications. A Shift in Procedures

By JULIE CRESWELL and REED ABELSON

At a time of increasing scrutiny of procedures to open blocked heart arteries, cardiologists are turning to — and reaping huge payments from -- controversial techniques that relieve blockages in the arms and legs.

Unlike heart procedures, which must be done in a hospital or outpatient facility, where oversight is typically more intense, the opening of the peripheral arteries and veins of the arms and legs can be done in a doctor’s office.

Medical experts are questioning the necessity of some of these treatments, and many believe the condition is more safely treated with drugs and exercise. Nonetheless, some of the nation’s most highly reimbursed cardiologists are making millions of dollars from Medicare for performing these procedures, as payments for relieving blockages in the heart have fallen.

Among Medicare patients, operations to improve blood flow in the heart (including balloon angioplasties and stents, but excluding coronary bypass surgery) have fallen by 30 percent since 2005. But in the peripheral vessels, mainly in the leg, similar operations have increased by 66 percent.