Kakkos, Cochrane Database Syst Rev 2016 - Combined Intermittent Pneumatic Leg Compression and Pharmacological Prophylaxis for Prevention of Venous Thromboembolism - Article Summary

Combined Intermittent Pneumatic Leg Compression and Pharmacological Prophylaxis for Prevention of Venous Thromboembolism

Kakkos, Ntouvas, et al.·Cochrane Database Syst Rev·2016·169 citations·Meta-analysis

Background

It is generally assumed by practitioners and guideline authors that combined modalities (methods of treatment) are more effective than single modalities in preventing venous thromboembolism (VTE), defined as deep vein thrombosis (DVT) or pulmonary embolism (PE), or both. This is an update of the review first published in 2008.

Purpose

The aim of this review was to assess the efficacy of combined intermittent pneumatic leg compression (IPC) and pharmacological prophylaxis versus single modalities in preventing venous thromboembolism.

Methods

Search Methods:

For this update the Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (May 2016).
In addition the CIS searched the Cochrane Register of Studies (CENTRAL (2016, Issue 4)).
Clinical trials databases were searched for details of ongoing or unpublished studies.

Selection Criteria: Randomized controlled trials (RCTs) or controlled clinical trials (CCTs) of combined IPC and pharmacological interventions used to prevent VTE.

Data Collection and Analysis:

We independently selected trials and extracted data.
Disagreements were resolved by discussion.
We performed fixed-effect model meta-analyses with odds ratios (ORs) and 95% confidence intervals (CIs).
We used a random-effects model when there was heterogeneity.

Results

We included a total of 22 trials (9137 participants) of which 15 were randomized trials (7762 participants).
The overall risk of bias was mostly unclear or high due to selection and performance bias.
We used GRADE to assess the quality of the evidence and this was downgraded from high to moderate or very low due to the risk of bias, imprecision or indirectness.
The rate of PE in the studies comparing IPC alone with combined IPC and pharmacological prophylaxis was low, underpowering the analyses.
The incidence of symptomatic PE was 0.79% with IPC, but ranged between 0.1 to 1% with combined IPC and pharmacological prophylaxis (OR 0.49, 95% CI 0.18 to 1.34; 12 studies, 3017 participants, moderate quality evidence).
The incidence of DVT was 4.10% in the IPC group and 2.19% in the combined group showing a reduced incidence of DVT in favour of the combined group (OR 0.52, 95% CI 0.33 to 0.82; 11 studies, 2934 participants, moderate quality evidence).
The addition of an anticoagulant to IPC, however, increased the risk of any bleeding compared to IPC alone; 0.66% (7/1053) in the IPC group and 4.0% (44/1102) in the combined group (OR 5.04, 95% CI 2.36 to 10.77; 7 studies, 2155 participants, moderate quality evidence).
Major bleeding followed a similar pattern; 0.1% (1/1053) in the IPC group to 1.5% (17/1102) in the combined group (OR 6.81, 95% CI 1.99 to 23.28; 7 studies, 2155 participants, moderate quality evidence).
Compared with pharmacological prophylaxis alone, the use of combined IPC and pharmacological prophylaxis modalities reduced the incidence of symptomatic PE from 2.92% to 1.20% (OR 0.39, 95% CI 0.23 to 0.64; 10 studies, 3544 participants, moderate quality evidence).
The incidence of DVT was 6.2% in the pharmacological prophylaxis group and 2.9% in the combined group showing no difference between the combined and pharmacological prophylaxis groups (OR 0.42, 95% CI 0.18 to 1.03; 11 studies, 2866 participants, moderate quality evidence).
Increased bleeding side effects were not observed for IPC when it was added to anticoagulation (bleeding: OR 0.80, 95% CI 0.30 to 2.14, very low quality evidence; major bleeding: OR 1.21, 95% CI 0.35 to 4.18, very low quality evidence, 3 studies, 244 participants).

Conclusions

Moderate quality evidence suggests that combining IPC and pharmacological prophylaxis, compared with IPC or pharmacological prophylaxis alone, decreases the incidence of DVT when compared to compression, and incidence of PE when compared to anticoagulation. Moderate quality evidence suggests that there is no difference between combined and single modalities in the incidence of PE when compared with compression alone and DVT when compared with anticoagulation alone. The quality of evidence for PE or DVT was downgraded to moderate due to imprecision or risk of bias in study methodology, highlighting the need for further research. Moderate quality evidence suggests the addition of pharmacological prophylaxis to IPC increased the risk of bleeding compared to IPC alone, a side effect not observed for IPC when added to pharmacological prophylaxis (very low quality evidence), as expected for a physical method of thromboprophylaxis.

Supplemental

Combined Intermittent Pneumatic Leg Compression and Pharmacological Prophylaxis for Prevention of Venous Thromboembolism

Kakkos, Ntouvas, et al.Cochrane Database Syst Rev2016169 citationsMeta-analysis