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Thrombosis and haemostasis 122(4), 552-559 (2022). doi:10.1055/a-1549-6556, Published by Thieme, Stuttgart

ZUSAMMENFASSUNGBei bis zu 20 % aller Krebspatienten treten venöse Thromboembolien im Krankheitsverlauf auf. Patienten mit aktiver Krebserkrankung, die eine venöse Thrombose erleiden, weisen ein besonders hohes Rezidivthromboserisiko auf und benötigen daher bereits nach dem ersten venösen Thromboseereignis eine langfristige Antikoagulation. Neben dem erhöhten Erst- und Rezidivthromboserisiko besteht jedoch auch gleichzeitig ein erhöhtes Blutungsrisiko unter Antikoagulation. Aktuelle Leitlinien empfehlen niedermolekulare Heparine (NMH) für 3–6 Monate nach Auftreten einer venösen Thrombose bei Patienten mit aktiver Krebserkrankung, da diese bei vergleichbarem Blutungsrisiko zu niedrigeren Rezidivthromboseraten im Vergleich zu Vitamin-K-Antagonisten führen. In 2 aktuell publizierten Studien wurde erstmals untersucht, inwiefern direkte orale Antikoagulantien (DOAK) anstelle der NMH eine Therapieoption bei Malignompatienten mit venösen Thrombosen darstellen könnten. Während Thromboserezidive unter DOAK-Therapie seltener auftraten als unter Therapie mit niedermolekularen Heparinen, kam es unter DOAK-Therapie häufiger zu schweren Blutungen, insbesondere gastrointestinalen Blutungen. DOAK stellen daher inzwischen eine neue Alternative zum bisherigen Goldstandard NMH in der Antikoagulation dar, sollten jedoch bei gastrointestinalen Tumoren mit Zurückhaltung und nur nach eingehender Aufklärung des Patienten eingesetzt werden.

Summary: Background: Deep venous thrombosis (DVT) and in particular, iliofemoral thrombosis (IFT) can lead to recurrent thrombosis and postthrombotic syndrome (PTS). Data on the prevalence, predictors and outcome of IFT are scarce. Patients and methods: We retrospectively searched our database of outpatients who had presented with DVT and IFT including the iliac veins from 2014 until 2017. In addition, we performed a prospective registry in a subgroup of patients with IFT. These patients received duplex ultrasound, magnetic resonance venography and measurement of symptom-free walking distance using a standardized treadmill ergometry. The severity of PTS was analyzed using the Villalta-Scale (VS) and quality of life was assessed using the VEINES-QOL/Sym Questionnaire. Results: 847 patients were retrospectively identified with DVT and 19.7% (167/847) of these presented with IFT. 50.9% (85/167) of the IFT-patients agreed to participate in the prospective registry. The majority of these patients (76.5%: 65/85) presented with left-sided IFT. In 53.8% (35/65) May-Thurner syndrome was suspected. 27.1% (23/85) underwent invasive therapy. Moderate or severe PTS (VS ≥ 10) occurred in 10.6% (9/85). The severity of PTS is correlated with a reduced quality of life (ρ (CI 95%) = −0.63 (−0.76; −0.46); p th patient developed moderate or severe PTS (VS ≥ 10). A high body mass index was predictive for the development of PTS and venous claudication.

Background Few data have been published to date on outcomes after the common clinical experience of severe hemorrhage in orally anticoagulated patients. Methods A prospective, multicenter observational study was carried out to investigate outcomes and management in a series of consecutive patients who sustained a severe hemorrhage under treatment with vitamin K antagonists (VKA) or direct oral anticoagulant drugs (DOAC). The primary endpoint was in-hospital death up to and including day 30 after hospital admission. The secondary endpoints were the duration of bleeding, in-hospital death due to hemorrhage (as defined by the study physician examining the patient's records), the use of antagonists, the extent of supportive measures used to stop the hemorrhage, and an assessment of causality. Consecutive patients were recruited until a predefined number of patients was reached in both groups. Results Among 193 patients with severe hemorrhage, 97 had been taking a VKA, and 96 had been taking a DOAC. 13.0 % (95% confidence interval [8.6; 18.5]; 25/193) of the overall group patients died in the first 30 days after hospital admission, including 17.5% ([10.6; 26.6]; 17/97) in the VKA group and 8.3% ([3.7; 15.8]; 8/96) in the DOAC group (p = 0.085). The median duration of bleeding was 19.8 hours in the VKA group and 27.8 hours in the DOAC group (p = 0.632). The in-hospital mortality due to hemorrhage was higher in the VKA group than in the DOAC group (15.5% [15/97] versus 4.2% [4/97]; p = 0.014). Only the use of prothrombin complex concentrates (PCCs) lowered the median duration of hemorrhage in the two patient groups. In 35% (68/193) of the patients, the hemorrhage was caused by an external influence, most commonly a fall. Conclusion The in-hospital mortality was higher among patients treated with VKA than among patients treated with DOAC, although the difference failed to reach statistical significance.