Isabelle Gouin

Safety profile of tinzaparin administered once daily at a standard curative dose in two hundred very elderly patients.

AbstractObjectives: Too few very elderly patients with an age-related renal impairment are included in clinical trials. We conducted a study in order to evaluate the safety profile of tinzaparin, a low molecular weight heparin (LMWH), given at a curative dose (175 IU/kg once daily) in very elderly patients treated for up to 30 days. Setting: An 800-bed geriatric hospital. Design: A 1-year prescribing study. Patients: Consecutive in-patients older than age 70, whose creatinine clearance was above 20 ml/min, and requiring full anticoagulation with LMWH were included. Measurements: Safety parameters (major bleeding/heparin-induced thrombocytopenia/death) were recorded. Plasma anti-Xa activity levels were regularly measured throughout the treatment period. Results: Two-hundred in-patients, mean age 85.2 ± 6.9 years (70 to 102), mean creatinine clearance 51.2 ± 22.9 ml/min, were given tinzaparin. Six patients died during the treatment period: only one could be related to the anticoagulation treatment. Three major bleeding episodes (1.5%) were reported. Antithrombotic drug interactions likely contributed to the bleeding event in two of them. Heparin-induced thrombocytopenia was confirmed in two patients (1%). No correlation was found between anti-Xa activity and creatinine clearance or age. Conclusions: Tinzaparin can be used safely at a curative dose in very elderly patients as long as (i) the accurate bodyweight-adjusted dose is given; (ii) platelet counts and anti-Xa levels are regularly monitored and; (iii) the interaction with other antithrombotic drugs is correctly managed.

Placement of the VenaTech LP Caval Filter in the Elderly: Feasibility and Clinical Benefits of Insertion Via the Arm

PurposeTo evaluate routine use of access sites in the arm for percutaneous caval filter placement (PCFP) in elderly patients. Neck arthritis, patient anxiety, access site thrombosis or fecal/urinary incontinence complicating jugular or femoral access may require alternative access sites in this population.MethodsAccess via the right arm was chosen for PCFP (VenaTech LP). The indication for PCFP was deep vein thrombosis, a history of pulmonary embolism, and a contraindication to anticoagulant therapy. Ultrasound-guided puncture was performed after diameter measurement of the arm veins (ØAV). The filter was inserted with standard imaging procedures. Procedural difficulty was graded and compared with ØAV and the angle from the arm vein to the superior vena cava (αAV/SVC).ResultsOver 2 years, 16 patients (14 women, 2 men) with an average age of 90 years (range 79–97 years) were included in the study. The average ØAV value of the basilic or brachial veins was 4.2 mm (range 3.0–5.1 mm). The minimal ØAV for successful access was determined after the first 15 patients. No hematoma occurred at the puncture sites. The average αAV/SVC value was 62° (range 29°–90°). Arm access was possible in 12 of 16 patients (75%) with ØAV ≥ 3.5 mm and αAV/SVC ≥ 29°. Every procedure via the arm was graded “easy” by the operator, regardless of angulation values. Femoral access was used in one case due to the impossibility of traversing the heart (patient no. 2), and jugular access was used in 3 of 16 (19%) patients due to puncture failure (patient no. 4), small ØAV (3 mm) (patient no. 6), and stenosis of the distal right subclavian vein (patient no.16), respectively.ConclusionPCFP via the arm can be routinely accomplished in patients older than 75 years, provided ØAV ≥ 3.5 mm, and αAV/SVC ≥ 29°.