LOW-MOLECULAR-WEIGHT HEPARIN AND COMPRESSION STOCKINGS IN THE PREVENTION OF VENOUS THROMBOEMBOLISM IN NEUROSURGERY

Perioperative anticoagulant prophylaxis for postoperative venous throm boembolism (VTE) in neurosurgical patients has not gained wide accepta nce due to the fear of intracranial bleeding. Physical methods give a worthwhile reduction of postoperative VTE but there still remains a su bstantial residual incidence. In other clinical indications, low molec ular weight heparins have proven to be effective for prophylaxis of VT E when administered postoperatively, with the advantage of no bleeding enhancement during surgery. Therefore, we performed a multicentre, ra ndomized, double-blind trial in neurosurgical patients to investigate the efficacy and safety of adding a low molecular weight heparin (LMWH ), nadroparin, initiated postoperatively, to graduated compression sto ckings in the prevention of VTE. Deep-vein thrombosis was detected by mandatory venography. Bleeding was determined according to pre-defined objective criteria for major and minor episodes. An adequate bilatera l venogram was obtained in 166 of 241 LMWH patients (68.9%) and 179 of 244 control patients (73.4%). A total of 31 of 166 LMWH patients (18. 79b) and 47 of 179 control patients (26.3%) had VTE up to Day 10 posto peratively (p = 0.047). The relative risk reduction (RRR) was 28.9%. T he rates for proximal deep-vein thrombosis/pulmonary embolism were 6.9 % and 11.5% for the two groups, respectively (RRR: 40.2%; p = 0.065). Secondary analyses involved all VTE up to day 56 post-surgery which wa s detected in 33 patients of 241 in the LMWH group (13.7%) and 51 of 2 44 control patients (20.9%; RRR 34.5%; p = 0.018). The corresponding p ercentages for proximal deep-vein thrombosis/pulmonary embolism were 5 .8% and 10.2% for the two groups, respectively, giving a RRR of 43.3%; p = 0.036. Major bleeding complications, during the treatment period, occurred in six low molecular weight heparin treated patients (2.5%) and in two control patients (0.8%); p = 0.087. A higher mortality was observed in the low molecular weight heparin group over the 56-day fol low-up period (22 versus 10; p = 0.026). However, none of these deaths was judged by a blinded adjudication committee to be related to the s tudy drug. In conclusion, this study demonstrates that the low molecul ar weight heparin, nadroparin, added to graduated compression stocking s results in a clinically significant decrease in VTE without inducing any significant increase of major bleeding.