Background: We have recently shown that continuing or holding anticoagulation during conditioning-induced thrombocytopenia was not associated with 30-day venous thromboembolism (VTE) recurrence in high-risk patients; however, reliable strategies to prevent longer-term VTE recurrence were not evaluated.
Aims: (1) Assess impact of resuming anticoagulation on VTE recurrence at 100 days post-allogeneic HCT,
(2) assess impact of pre-transplant ultrasound in patients with lower extremity deep venous thrombosis (LE-DVT)/catheter-related DVT (CR-DVT) on decision to resume anticoagulation and on 100-day VTE recurrence.
Methods: We selected patients undergoing first allogeneic HCT 2006-2015 with VTE history as detected by ICD9 codes and verified by chart review. Anticoagulation resumption after platelet engraftment (platelets >50 x109/L without transfusion support after conditioning) was captured. Use of routine venous doppler ultrasound (without residual venous occlusion (RVO) assessment) pre-transplant was also obtained. Multivariable logistic regression was used to assess the impact of anticoagulation resumption and HIGH-2-LOW risk modela on 100-day VTE recurrence.
Results: In this retrospective cohort study, 250 among 2,091 allogeneic HCT recipients had history of VTE, and 199 patients had LE-DVT/CR-DVT. Every 1-point increase of HIGH-2-LOW score was significantly associated with VTE and pulmonary embolism (PE)/LE-DVT recurrence at 100 days (odds ratio [OR] 1.57 and 1.83, respectively), while resuming anticoagulation upon platelet engraftment was associated with lower risks of VTE and PE/LE-DVT recurrence (OR 0.48 and 0.10, respectively) (Table 1). In some patients, pre-transplant ultrasound was used to decide whether to continue anticoagulation through thrombocytopenia and resume, or not, upon platelet recovery. Notably, patients who had complete DVT resolution on ultrasound developed higher VTE recurrence post-transplant (Table 2).
|Outcome at 100d||Variable||Odds Ratio (95% CI)||p-value||C-statistic|
|All VTE recurrence||HIGH-2-LOWa every 1-point increase||1.57 (1.10 – 2.23)||0.01||0.67|
|Anticoagulation upon platelet recovery||0.48 (0.20 – 1.14)||0.10|
|PE/LE-DVT recurrence||HIGH-2-LOWa every 1-point increase||1.83 (1.13 – 2.96)||0.01||0.78|
|Anticoagulation upon platelet recovery||0.10 (0.13 – 0.79)||0.03|
|aHIGH-2-LOW risk model incorporates 7 clinical predictors (with assigned integer score) associated with increased risk of VTE in the post-allogeneic HCT setting: history of CR-DVT (+1), inpatient at day 30 (+1), graft-versus-host disease grade 3-4 at day 30 (+1), history of PE or LE-DVT (+2), lymphoid diagnosis (+1), obesity with body mass index ≥35 kg/m2 (+1), and white blood cell ≥11×109/L at day 30 (+1).
Reference: Martens KL, da Costa WL, Amos CI, et al. HIGH-2-LOW risk model to predict venous thromboembolism in allogeneic transplant patients after platelet engraftment. Blood Adv 2021;5(1):167-175.
Abbreviations: HCT, hematopoietic cell transplantation; VTE, venous thromboembolism; CI, confidence interval; PE, pulmonary embolism; LE-DVT, lower-extremity deep venous thrombosis; CR-DVT, catheter-related deep venous thrombosis
|Ultrasound Finding Pre-transplant||AC at onset of thrombocytopenia||AC at resolution of thrombocytopenia||VTE recurrence by 100d||PE/LE-DVT recurrence by 100d|
|No evidence of DVT||7% (3/41)||15% (6/41)||20% (8/41)||12% (5/41)|
|Persistent DVT||50% (27/54)||63% (34/54)||7% (4/54)||0% (0/54)|
|Not checked||27% (28/104)||35% (36/104)||11% (11/104)||5% (5/104)|
|Abbreviations: LE-DVT, lower-extremity deep venous thrombosis; CR-DVT, catheter-related deep venous thrombosis; VTE, venous thromboembolism; PE, pulmonary embolism; AC, anticoagulation|
Conclusions: Among patients with history of VTE, reinitiating anticoagulation upon platelet engraftment is crucial to preventing VTE recurrence after allogeneic HCT. Routine use of venous doppler ultrasound without RVO assessment may contribute to false reassurance about prematurely stopping anticoagulation and result in higher VTE recurrence post-transplant.
To cite this abstract in AMA style:Martens K, Amos C, Rojas Hernandez C, Kebriaei P, Basom R, Davis C, Kesten M, Carrier M, Garcia D, Lee S, Li A. Association of Anticoagulation Resumption and Repeat Imaging on Venous Thromboembolism Recurrence after Allogeneic Hematopoietic Cell Transplantation (HCT) [abstract]. Res Pract Thromb Haemost. 2021; 5 (Suppl 2). https://abstracts.isth.org/abstract/association-of-anticoagulation-resumption-and-repeat-imaging-on-venous-thromboembolism-recurrence-after-allogeneic-hematopoietic-cell-transplantation-hct/. Accessed December 8, 2021.
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