ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Prevention of venous thromboembolism in adult travelers

Prevention of venous thromboembolism in adult travelers
Literature review current through: Jan 2024.
This topic last updated: Jun 01, 2023.

INTRODUCTION — Long-distance travel confers a small increased risk of venous thromboembolism (VTE). This topic review discusses the risk and prevention of VTE in travelers.

Approaches to the prevention of VTE in hospitalized medical and surgical patients and patients with cancer and stroke, as well as patients who are pregnant, are presented separately. (See "Prevention of venous thromboembolic disease in acutely ill hospitalized medical adults" and "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients" and "Risk and prevention of venous thromboembolism in adults with cancer" and "Venous thromboembolism in pregnancy: Prevention" and "Prevention and treatment of venous thromboembolism in patients with acute stroke", section on 'Approach to VTE prevention'.)

EPIDEMIOLOGY — Long-distance travel, either by air or land, confers a small increased risk of VTE [1-14]. The rates are higher in those who travel for prolonged periods (eg, >4 hours) and is greatest in the first two weeks after travel.

The incidence of developing clinically important or symptomatic DVT after air travel is <0.05 percent [9,15]. Although some studies reported higher rates of DVT with >4 hours (2.8 percent) or >12 hours (3.6 percent) air travel, most of these DVTs were small, involving the distal (calf) veins and, likely, clinically unimportant [4,11,12,16-20].

The estimated risk of VTE conferred by prolonged travel by air or land (eg, car, train, bus) is variable (increased approximately two- to threefold). The highest risk is reported in those who spend longer periods of time traveling. In one meta-analysis of 14 studies, the pooled risk for VTE in travelers, compared with nontravelers, was 2.8 (95% CI 2.2-3.7) [9].

Although the duration of risk is not well studied, the incidence of VTE appears to be highest in the first two weeks after travel returning to normal by eight weeks [10,21].

RISK FACTORS — The majority of individuals with travel-associated VTE have one or more known risk factors for thrombosis, although isolated cases of idiopathic VTE have also been reported [4,6,7,12,22-31]. Common risk factors associated with travel-related VTE include those associated with VTE in general:

Recent major surgery (including hip or knee arthroplasty within six weeks)

Prior VTE (including travel-associated VTE)

Active malignancy

Pregnancy

Advanced age

Use of estrogen-containing oral contraceptives or other estrogen preparations

Obesity

Hereditary thrombophilia

Less commonly cited risk factors include:

Immobility and window seating [32]

The presence of two or more risk factors for VTE (eg, oral contraceptive use plus factor V Leiden mutation) [33,34]

Female sex [35]

PATHOGENESIS — The reasons for thrombosis associated with air travel are unclear. Possible contributing factors during extended travel may include venous stasis due to immobility, and elevated levels of, or activation of, coagulation factors (FII, FVIII, FIX, thrombin-antithrombin III complex, and fibrinogen) [22,27,33,36-40].

Although there is no definitive evidence that dehydration or alcohol consumption contribute to an increased risk of VTE, dehydration can theoretically promote a coagulopathic state and alcohol consumption can promote immobility.

The impact of screening for risk factors or coagulation factors prior to travel on the incidence of VTE has not been studied and is not routinely recommended.

SELECTING A METHOD OF PREVENTION — Our approach is, in general, consistent with that issued by several societies including the American College of Chest Physicians, the British Journal of hematology, and the American Society of Hematology [15,21,41,42]. (See 'Society guideline links' below.)

Patient selection — Thromboprophylaxis is not necessary for most travelers. Based upon extrapolated data from the general population and small studies in travelers that have methodologic limitations, we suggest the following:

Individuals at risk for travel-associated VTE (eg, travel more than four to six hours in individuals with risk factors for VTE) may benefit from simple general measures plus graduated compression stockings [14,21,41] (see 'General measures' below and 'Graduated compression stockings' below). What is considered extended travel is not clearly defined. However, we and others typically define it as travel for periods greater than four hours (particularly flights) [14,21,41]. Travelers considered at risk of VTE include those with individual risk factors commonly identified in the general population (eg, prior VTE, recent major surgery, and active malignancy). These and other risk factors for travel-associated VTE are discussed above. (See 'Risk factors' above.)

Data are insufficient for the administration of routine pharmacologic prophylaxis (eg, low molecular weight [LMW] heparin, aspirin) in this population. However, pharmacologic prophylaxis can be administered on an individual basis for those assessed by their physician to be at particularly high risk and in whom the benefits are thought to outweigh the risk of adverse events. (See 'Pharmacologic prophylaxis' below.)

In travelers without risk factors for VTE, general measures of thromboprophylaxis are of unproven value but are not typically harmful.

In travelers who are already receiving therapeutic anticoagulation regardless of the indication, no additional measures to prevent VTE are generally needed.

General measures — General measures have not been formally studied in the prevention of travel-associated VTE. However, the following precautions for VTE prevention are frequently suggested by experts and guideline committees for extended travel [14,21,41]:

Frequent ambulation, every one to two hours

Frequent flexion and extension of the ankles (calf muscle stretching) and knees (thigh muscle stretching)

Graduated compression stockings — We and others agree that below-knee graduated compression stockings (GCS) (15 to 30 mmHg of pressure at the ankle) may be beneficial in patients considered to be at high risk for travel-associated VTE [14,21,41].

GCS that provide 15 to 30 mmHg of pressure at the ankle may decrease the incidence of DVT associated with prolonged flights. A meta-analysis of 12 randomized trials reported that the use of properly fitted, below-knee GCS on flights lasting at least four hours reduced the rates of asymptomatic VTE (risk ratio 0.10, 95% CI 0.04-0.25) and leg edema [43].

There is no proven value to above knee GCS in travelers.

Pharmacologic prophylaxis — There is a paucity of data examining the safety and efficacy of pharmacologic prophylaxis for the prevention of travel-associated VTE. Data from small or retrospective studies provide insufficient evidence to support routine pharmacologic prophylaxis for extended travel in the at-risk population of travelers. However, pharmacologic prophylaxis can be administered on an individual basis to travelers at particularly high risk (eg, prior VTE plus multiple risk factors) when it is considered by their physician that the benefits of VTE prevention outweigh the risks of bleeding or other adverse event [41].

One small study randomized 249 travelers to LMW heparin (1 mg/kg, administered once, two to four hours prior to travel), oral aspirin (started 12 hours prior to travel, administered daily for three days), or no prophylaxis, for flights lasting seven to eight hours [44]. LMW heparin reduced the rate of asymptomatic DVT (0 versus 4.8 percent) while aspirin had no significant effect (3.6 versus 4.8 percent). No traveler had a symptomatic VTE event. This study should be interpreted with caution because it was not adequately powered to estimate the efficacy or safety of pharmacologic prophylaxis in an at risk population. In addition, the dropout rate was high and individuals were not followed after they left the airport.

One observational study of 608 travelers who were within six weeks of hip arthroplasty, treated with LMW heparin or warfarin prior to travel, had a 1 percent incidence of symptomatic DVT [45]. There were no cases of pulmonary embolus in any patient and bleeding events occurred in 1.5 percent of cases.

In the general population, pharmacologic agents including aspirin, LMW heparin, warfarin, factor Xa inhibitors, and direct thrombin inhibitors, when administered for prolonged periods (months to years) have proven value in the prevention of recurrent VTE following an unprovoked first event. However, the same efficacy cannot be assumed when these agents are administered for short periods before travel. The administration of pharmacologic agents for the prevention of recurrent VTE in the general population is discussed separately. (See "Selecting adult patients with lower extremity deep venous thrombosis and pulmonary embolism for indefinite anticoagulation".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Superficial vein thrombosis, deep vein thrombosis, and pulmonary embolism" and "Society guideline links: Anticoagulation".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Beyond the Basics topics (see "Patient education: Deep vein thrombosis (DVT) (Beyond the Basics)" and "Patient education: Warfarin (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Epidemiology – Long-distance travel, either by air or land, confers a small (two- to threefold) increased risk of symptomatic venous thromboembolism (VTE) compared with nontravelers. The reported incidence is <0.05 percent with the highest rates in those who spend longer periods of time traveling (eg, more than four to six hours). The peak rate occurs within the first two weeks after travel. (See 'Epidemiology' above.)

Risk factors – Most individuals with travel-associated VTE have one or more known risk factors for thrombosis, although isolated cases of idiopathic VTE have also been reported.

Common risk factors are those associated with VTE in the general population and include recent major surgery (especially hip or knee arthroplasty within six weeks), prior VTE (including travel-associated VTE), active malignancy, pregnancy, advanced age, use of estrogen-containing oral contraceptives or other estrogen preparations, obesity, and hereditary thrombophilia. (See 'Risk factors' above.)

Pathogenesis – The reasons for thrombosis with air travel are unclear. Possible contributing factors during extended travel may include venous stasis due to immobility, and elevated levels of, or activation of, coagulation factors. Although there is no definitive evidence that dehydration or alcohol consumption contribute to an increased risk of travel-associated VTE, they may indirectly contribute to coagulopathy and immobility. (See 'Pathogenesis' above.)

Prevention – Thromboprophylaxis is not necessary for most travelers. (See 'Selecting a method of prevention' above.)

For long-distance travelers with individual risk factors for VTE, we suggest thromboprophylaxis with general measures (frequent ambulation and calf exercises and graduated compression stockings) rather than no prophylaxis or pharmacologic prophylaxis to reduce the risk of travel-associated VTE (Grade 2C).

While pharmacologic thromboprophylaxis is not routinely indicated, it is an option for patients at particularly high risk for VTE who consider a potential decrease in travel-associated VTE to outweigh the small increased risk of bleeding.

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Menaka Pai, MD, FRCPC, who contributed to earlier versions of this topic review.

  1. Pérez-Rodríguez E, Jiménez D, Díaz G, et al. Incidence of air travel-related pulmonary embolism at the Madrid-Barajas airport. Arch Intern Med 2003; 163:2766.
  2. Ferrari E, Chevallier T, Chapelier A, Baudouy M. Travel as a risk factor for venous thromboembolic disease: a case-control study. Chest 1999; 115:440.
  3. Kelman CW, Kortt MA, Becker NG, et al. Deep vein thrombosis and air travel: record linkage study. BMJ 2003; 327:1072.
  4. Scurr JH, Machin SJ, Bailey-King S, et al. Frequency and prevention of symptomless deep-vein thrombosis in long-haul flights: a randomised trial. Lancet 2001; 357:1485.
  5. Giangrande PL. Air travel and thrombosis. Br J Haematol 2002; 117:509.
  6. Schwarz T, Siegert G, Oettler W, et al. Venous thrombosis after long-haul flights. Arch Intern Med 2003; 163:2759.
  7. Martinelli I, Taioli E, Battaglioli T, et al. Risk of venous thromboembolism after air travel: interaction with thrombophilia and oral contraceptives. Arch Intern Med 2003; 163:2771.
  8. Lapostolle F, Surget V, Borron SW, et al. Severe pulmonary embolism associated with air travel. N Engl J Med 2001; 345:779.
  9. Chandra D, Parisini E, Mozaffarian D. Meta-analysis: travel and risk for venous thromboembolism. Ann Intern Med 2009; 151:180.
  10. MacCallum PK, Ashby D, Hennessy EM, et al. Cumulative flying time and risk of venous thromboembolism. Br J Haematol 2011; 155:613.
  11. WHO Reserach Into Global Hazards of Travel (WRIGHT) Project. Final report of phase 1. Available at: www.who.int/cardiovascular_diseases/wright_project/phase1_report/WRIGHT%20REPORT.pdf (Accessed on May 14, 2010).
  12. Kuipers S, Venemans A, Middeldorp S, et al. The risk of venous thrombosis after air travel: contribution of clinical risk factors. Br J Haematol 2014; 165:412.
  13. Kuipers S, Venemans-Jellema A, Cannegieter SC, et al. The incidence of venous thromboembolism in commercial airline pilots: a cohort study of 2630 pilots. J Thromb Haemost 2014; 12:1260.
  14. Naouri D, Lapostolle F, Rondet C, et al. Prevention of Medical Events During Air Travel: A Narrative Review. Am J Med 2016; 129:1000.e1.
  15. Schünemann HJ, Cushman M, Burnett AE, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: prophylaxis for hospitalized and nonhospitalized medical patients. Blood Adv 2018; 2:3198.
  16. Kuipers S, Cannegieter SC, Middeldorp S, et al. The absolute risk of venous thrombosis after air travel: a cohort study of 8,755 employees of international organisations. PLoS Med 2007; 4:e290.
  17. Kuipers S, Schreijer AJ, Cannegieter SC, et al. Travel and venous thrombosis: a systematic review. J Intern Med 2007; 262:615.
  18. Watson HG. Travel and thrombosis. Blood Rev 2005; 19:235.
  19. Adi Y, Bayliss S, Rouse A, Taylor RS. The association between air travel and deep vein thrombosis: systematic review & meta-analysis. BMC Cardiovasc Disord 2004; 4:7.
  20. Philbrick JT, Shumate R, Siadaty MS, Becker DM. Air travel and venous thromboembolism: a systematic review. J Gen Intern Med 2007; 22:107.
  21. Watson HG, Baglin TP. Guidelines on travel-related venous thrombosis. Br J Haematol 2011; 152:31.
  22. Possick SE, Barry M. Evaluation and management of the cardiovascular patient embarking on air travel. Ann Intern Med 2004; 141:148.
  23. Paganin F, Bourdé A, Yvin JL, et al. Venous thromboembolism in passengers following a 12-h flight: a case-control study. Aviat Space Environ Med 2003; 74:1277.
  24. Gajic O, Warner DO, Decker PA, et al. Long-haul air travel before major surgery: a prescription for thromboembolism? Mayo Clin Proc 2005; 80:728.
  25. Arya R, Barnes JA, Hossain U, et al. Long-haul flights and deep vein thrombosis: a significant risk only when additional factors are also present. Br J Haematol 2002; 116:653.
  26. Hughes RJ, Hopkins RJ, Hill S, et al. Frequency of venous thromboembolism in low to moderate risk long distance air travellers: the New Zealand Air Traveller's Thrombosis (NZATT) study. Lancet 2003; 362:2039.
  27. Arfvidsson B, Eklof B, Kistner RL, et al. Risk factors for venous thromboembolism following prolonged air travel. Coach class thrombosis. Hematol Oncol Clin North Am 2000; 14:391.
  28. Kesteven P, Robinson B. Incidence of symptomatic thrombosis in a stable population of 650,000: travel and other risk factors. Aviat Space Environ Med 2002; 73:593.
  29. Cannegieter SC, Doggen CJ, van Houwelingen HC, Rosendaal FR. Travel-related venous thrombosis: results from a large population-based case control study (MEGA study). PLoS Med 2006; 3:e307.
  30. McQuillan AD, Eikelboom JW, Baker RI. Venous thromboembolism in travellers: can we identify those at risk? Blood Coagul Fibrinolysis 2003; 14:671.
  31. Rege KP, Bevan DH, Chitolie A, Shannon MS. Risk factors and thrombosis after airline flight. Thromb Haemost 1999; 81:995.
  32. Schreijer AJ, Cannegieter SC, Doggen CJ, Rosendaal FR. The effect of flight-related behaviour on the risk of venous thrombosis after air travel. Br J Haematol 2009; 144:425.
  33. Schreijer AJ, Cannegieter SC, Meijers JC, et al. Activation of coagulation system during air travel: a crossover study. Lancet 2006; 367:832.
  34. Kuipers S, Cannegieter SC, Doggen CJ, Rosendaal FR. Effect of elevated levels of coagulation factors on the risk of venous thrombosis in long-distance travelers. Blood 2009; 113:2064.
  35. Lapostolle F, Le Toumelin P, Chassery C, et al. Gender as a risk factor for pulmonary embolism after air travel. Thromb Haemost 2009; 102:1165.
  36. Delis KT, Knaggs AL, Sonecha TN, et al. Lower limb venous haemodynamic impairment on dependency: quantification and implications for the "economy class" position. Thromb Haemost 2004; 91:941.
  37. Bärtsch P, Straub PW, Haeberli A. Hypobaric hypoxia. Lancet 2001; 357:955.
  38. Schreijer AJ, Hoylaerts MF, Meijers JC, et al. Explanations for coagulation activation after air travel. J Thromb Haemost 2010; 8:971.
  39. Boccalon H, Boneu B, Emmerich J, et al. Long-haul flights do not activate hemostasis in young healthy men. J Thromb Haemost 2005; 3:1539.
  40. Toff WD, Jones CI, Ford I, et al. Effect of hypobaric hypoxia, simulating conditions during long-haul air travel, on coagulation, fibrinolysis, platelet function, and endothelial activation. JAMA 2006; 295:2251.
  41. Kahn SR, Lim W, Dunn AS, et al. Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e195S.
  42. Neumann I, Izcovich A, Aguilar R, et al. American Society of Hematology, ABHH, ACHO, Grupo CAHT, Grupo CLAHT, SAH, SBHH, SHU, SOCHIHEM, SOMETH, Sociedad Panameña de Hematología, Sociedad Peruana de Hematología, and SVH 2022 guidelines for prevention of venous thromboembolism in surgical and medical patients and long-distance travelers in Latin America. Blood Adv 2022; 6:3636.
  43. Clarke MJ, Broderick C, Hopewell S, et al. Compression stockings for preventing deep vein thrombosis in airline passengers. Cochrane Database Syst Rev 2021; 4:CD004002.
  44. Cesarone MR, Belcaro G, Nicolaides AN, et al. Venous thrombosis from air travel: the LONFLIT3 study--prevention with aspirin vs low-molecular-weight heparin (LMWH) in high-risk subjects: a randomized trial. Angiology 2002; 53:1.
  45. Ball ST, Pinsorsnak P, Amstutz HC, Schmalzried TP. Extended travel after hip arthroplasty surgery. Is it safe? J Arthroplasty 2007; 22:29.
Topic 101332 Version 24.0

References

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟