Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York.
Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania.
Neurosurgery. 2018 Feb 1;82(2):142-154. doi: 10.1093/neuros/nyx156.
Studies have evaluated various strategies to prevent venous thromboembolism (VTE) in neuro-oncology patients, without consensus.
To perform a systematic review with cost-effectiveness analysis (CEA) of various prophylaxis strategies in tumor patients undergoing craniotomy to determine the safest and most cost-effective prophylaxis regimen.
A literature search was conducted for VTE prophylaxis in brain tumor patients. Articles reporting the type of surgery, choice of VTE prophylaxis, and outcomes were included. Safety of prophylaxis strategies was determined by measuring rates of VTE and intracranial hemorrhage. Cost estimates were collected based on institutional data and existing literature. CEA was performed at 30 d after craniotomy, comparing the following strategies: mechanical prophylaxis (MP), low molecular weight heparin with MP (MP+LMWH), and unfractionated heparin with MP (MP+UFH) to prevent symptomatic VTE. All costs were reported in 2016 US dollars.
A total of 34 studies were reviewed (8 studies evaluated LMWH, 12 for MP, and 7 for UFH individually or in combination; 4 studies used LMWH and UFH preoperatively). Overall probability of VTE was 1.49% (95% confidence interval (CI) 0.42-3.72) for MP+UFH, 2.72% [95% CI 1.23-5.15] for MP+LMWH, and 2.59% (95% CI 1.31-4.58) for MP, which were not statistically significant. Compared to a control of MP alone, the number needed to treat for MP+UFH is 91 and 769 for MP+LMWH. The risk of intracranial hemorrhage was 0.26% (95% CI 0.01-1.34) for MP, 0.74% (95% CI 0.09-2.61) for MP+UFH, and 2.72% (95% CI 1.23-5.15) for MP+LMWH, which were also not statistically significant. Compared to MP, the number needed to harm for MP+UFH was 208 and for MP+LMWH was 41. Fifteen studies were included in the final CEA. The estimated cost of treatment was $127.47 for MP, $142.20 for MP+UFH, and $169.40 for MP+LMWH. The average cost per quality-adjusted life-year for different strategies was $284.14 for MP+UFH, $338.39 for MP, and $722.87 for MP+LMWH.
Although MP+LMWH is frequently considered the optimal prophylaxis for VTE risk reduction, our model suggests that MP+UFH is the safest and most cost-effective measure to balance VTE and hemorrhage risks in brain tumor patients at lower risk of hemorrhage. MP+LMWH may be more effective for patients at higher risk of VTE.
已有研究评估了多种预防神经肿瘤患者静脉血栓栓塞症（VTE）的策略，但尚未达成共识。
对接受开颅手术的肿瘤患者的各种预防策略进行系统评价和成本效益分析（CEA），以确定最安全和最具成本效益的预防方案。
对脑肿瘤患者 VTE 预防的相关文献进行检索。纳入报告手术类型、VTE 预防选择和结局的文章。通过测量 VTE 和颅内出血的发生率来评估预防策略的安全性。根据机构数据和现有文献收集成本估算值。在开颅术后 30d 进行 CEA，比较以下策略：机械预防（MP）、MP 联合低分子肝素（MP+LMWH）和 MP 联合普通肝素（MP+UFH）预防有症状 VTE。所有成本均以 2016 年美元报告。
共纳入 34 项研究（8 项研究评估 LMWH，12 项研究单独评估 MP，7 项研究评估 UFH 或联合评估；4 项研究在术前使用 LMWH 和 UFH）。MP+UFH 组总体 VTE 发生率为 1.49%（95%CI 0.42-3.72），MP+LMWH 组为 2.72%（95%CI 1.23-5.15），MP 组为 2.59%（95%CI 1.31-4.58），差异均无统计学意义。与单独使用 MP 相比，MP+UFH 需治疗人数为 91，MP+LMWH 为 769。颅内出血风险 MP 组为 0.26%（95%CI 0.01-1.34），MP+UFH 组为 0.74%（95%CI 0.09-2.61），MP+LMWH 组为 2.72%（95%CI 1.23-5.15），差异均无统计学意义。与 MP 相比，MP+UFH 需治疗人数为 208，MP+LMWH 为 41。最终纳入 15 项 CEA 研究。MP 治疗费用为 127.47 美元，MP+UFH 为 142.20 美元，MP+LMWH 为 169.40 美元。不同策略的每质量调整生命年的平均成本分别为 MP+UFH 组 284.14 美元、MP 组 338.39 美元和 MP+LMWH 组 722.87 美元。
尽管 MP+LMWH 常被认为是降低 VTE 风险的最佳预防策略，但我们的模型表明，对于颅内出血风险较低的脑肿瘤患者，MP+UFH 是最安全和最具成本效益的措施，可平衡 VTE 和出血风险。MP+LMWH 可能对 VTE 风险较高的患者更有效。
