Azlina A. Abbas, Steven M. Raikin.
Response/Recommendation: There is currently no evidence in the literature to determine if a diabetic patient undergoing ulcer debridement requires venous thromboembolism (VTE) prophylaxis. There is, however, an increased risk for morbidity and mortality in diabetic foot ulcers (DFU) patients who develop VTE. Therefore, it is justified to propose that patients with DFU are given thromboprophylaxis, particularly if they have reduced mobility and other medical comorbidities. This may not be true for all cases of surgical debridement alone of DFU without additional interventions when prolonged limited weight-bearing is not required.
Strength of Recommendation: Limited.
Rationale: There is increasing evidence that diabetes mellitus (DM) is associated with derangements in coagulation and fibrinolysis leading to a tendency to form thrombi1,2. The risk for developing VTE is also elevated in part due to associated co-morbid conditions and frequent hospitalization for acute medical conditions and surgery3–5. DM patients who develop VTE are more likely to suffer a complicated clinical course, including long-term major bleeding complications, recurrent VTE5,6, major adverse limb events, and a higher risk of all-cause mortality6.
Aside from neuropathy, the tendency for thrombosis places DM patients at risk of developing DFU. Patients with DFU have increased mortality rates compared to non-ulcerated diabetic patients7. Compounded with VTE, DFU patients may also have delayed ulcer healing rates4,8 and longer periods of immobility.
Despite many reports of elevated risk of VTE in DM patients, no specific recommendations can be found for managing diabetic patients at risk for VTE. For this review, a search in PubMed revealed 244 papers but none specifically discuss VTE prophylaxis for DFU patients undergoing surgery, nor for DM patients in general.
In a review of 2,488 patients with validated VTE in the Worcester Venous Thromboembolism Study, Piazza et al., reported a low rate of thromboprophylaxis among the 476 patients with VTE and DM5. Wang et al., highlighted the impact of a history of VTE on major adverse limb events (MALEs) and concluded that prevention of thrombotic events needed to be emphasized in patients requiring diabetic foot care6. Aside from increased all-cause mortality rates, they showed that a history of VTE was associated with a 1.6-fold increased risk of MALEs and a 1.4-fold higher risk of major amputation.
References:
1. Petrauskiene V, Falk M, Waernbaum I, Norberg M, Eriksson JW. The risk of venous thromboembolism is markedly elevated in patients with diabetes. Diabetologia. 2005;48(5):1017-1021. doi:10.1007/s00125-005-1715-5
2. Chung W-S, Lin C-L, Kao C-H. Diabetes increases the risk of deep-vein thrombosis and pulmonary embolism. A population-based cohort study. Thromb Haemost. 2015;114(4):812-818. doi:10.1160/TH14-10-0868
3. Gariani K, Mavrakanas T, Combescure C, Perrier A, Marti C. Is diabetes mellitus a risk factor for venous thromboembolism? A systematic review and meta-analysis of case-control and cohort studies. Eur J Intern Med. 2016;28:52-58. doi:10.1016/j.ejim.2015.10.001
4. Gatot D, Lindarto D, Mardia AI. Incidence of deep vein thrombosis in patients with diabetic foot ulcers. Bali Med J. 2019;8(2):642. doi:10.15562/bmj.v8i2.1048
5. Piazza G, Goldhaber SZ, Kroll A, Goldberg RJ, Emery C, Spencer FA. Venous thromboembolism in patients with diabetes mellitus. Am J Med. 2012;125(7):709-716. doi:10.1016/j.amjmed.2011.12.004
6. Wang P-C, Chen T-H, Chung C-M, et al. The effect of deep vein thrombosis on major adverse limb events in diabetic patients: a nationwide retrospective cohort study. Sci Rep. 2021;11(1):8082. doi:10.1038/s41598-021-87461-y
7. Chammas NK, Hill RLR, Edmonds ME. Increased Mortality in Diabetic Foot Ulcer Patients: The Significance of Ulcer Type. J Diabetes Res. 2016;2016:2879809. doi:10.1155/2016/2879809
8. Jenkins DA, Mohamed S, Taylor JK, Peek N, van der Veer SN. Potential prognostic factors for delayed healing of common, non-traumatic skin ulcers: A scoping review. Int Wound J. 2019;16(3):800-812. doi:10.1111/iwj.13100