[Peculiarities of the treatment of venous thromboembolism with direct oral anticoagulants in challenging patients: senile age, renal failure, fragility]. / Osobennosti terapii venoznykh tromboembolicheskikh oslozhnenii pryamymi oral'nymi antikoagulyantami u oslablennykh patsientov: starcheskii vozrast, pochechnaya nedostatochnost', khrupkost'.

The paper is a narrative review of the literature on the use of direct oral anticoagulants (DOACs) for the VTE treatment in challenging patients: senile age (≥75 years), impaired renal function (estimated glomerular filtration rate ≤50 ml/min), fragility (one of the previous characteristics and/or bodyweight ≤50 kg). The paper discusses the studies of EINSTEIN DVT and PE (rivaroxaban), AMPLIFY (apixaban), HOKUSAI-VTE (edoxaban), RE-COVER I and II (dabigatran) in the focus of the secondary analysis in the pre-specified patient's subgroups, as well as their pooled analyzes and meta-analyzes. Based on the results of this review, it was concluded that in a subgroup of senile age patients, dabigatran increases the risk of major bleeding by 4.8 times and has no advantages over vitamin K antagonists (VKA); rivaroxaban and apixaban retain superiority over VKA on the safety outcomes and reduce the risk of major bleeding by 73% and 77%. In the subgroup of patients with impaired renal function, the use of apixaban and dabigatran is associated with an increase in the risk of major bleeding by 6.5 and 7.3 times, and these DOACs do not have advantages over VKA; rivaroxaban retains its superiority over VKA and reduces the risk of major bleeding by 78%. For fragile patients, a secondary analysis is available only for rivaroxaban, which remains superior to VKA on safety endpoints and reduces the risk of major bleeding by 73%. In the absence of direct comparisons between the available DOACs, the presented data can be used as a rational approach for the choice of appropriate treatment for VTE in challenging patients.

[Clinical efficacy of electric stimulation of crural muscles in comprehensive treatment of post-thrombotic disease]. / Klinicheskaia éffektivnost' élektricheskoi stimuliatsii myshts goleni v kompleksnom lechenii posttromboticheskoi bolezni.

The purpose of the study was to evaluate clinical efficacy of electromyostimulation (EMS) of the crural muscles as part of comprehensive therapy for post-thrombotic disease in patients with residual venous obstruction in the femoropopliteal segment. We carried out a prospective comparative clinical study enrolling patients having endured a fist episode of clinically unprovoked venous thrombosis of the femoropopliteal segment and completed the standard 6-month course of anticoagulant therapy and presenting with ultrasonographic signs of complete recanalization of the proximal venous segments (stenosis of 20% and more from the vessel's initial diameter), as well as scoring 5 points and more by the Villalta scale. The study included a total of 60 patients (38 men and 22 women, mean age 58.5±11.4 years) subdivided into two groups consisting of 30 patients each. Patients of both the Study and Control Groups underwent comprehensive therapy including wearing a compression knee sock (23-32 mmHg), a course phlebotrophic drugs, and dosed walking (not less than 5,000 steps a day). The Study Group patients were additionally subjected to daily electrical stimulation of the crural muscles with the "Veinoplus VI" unit (three 30-minute sessions a day). The duration of the follow up amounted to 12 months. The criteria for assessing therapeutic efficacy were as follows: severity of the disease by the VCSS and Villalta scales, quality of life as assessed by the CIVIQ-20 questionnaire, and lack of relapses of the venous thrombus. Clinical and instrumental assessment of the patients' condition was carried out monthly, with the disease's severity and quality of life assesses each 6 months. Relapses of venous thrombosis were registered in 7 (23.3%) patients from the Control Group and were not observed in patients undergoing EMS (p=0.011). In 5 cases, thrombosis was asymptomatic and in 4 cases it was presented by reocclusion of the involved venous segments. Patients of the Study Group were found to have a decrease in the disease's severity, reflected in points: VCSS (9.9±1.6 - 7.8 ± 1.6 - 6.1±1.5 (p <0.0001)); Villalta scale (18.9±3.9 - 12.8±4.0 - 8.3±2.7 (p<0.0001)); CIVIQ-20 score (67.8±8.4 - 51.3±8.4 - 40.0±10.5 (p<0.001)). The Control Group patients showed a similar tendency for the disease's severity: 8.1±2.8 - 7.3±2.1 - 7.2±2.1 points by the VCSS (p=0.014); 12.7±6.7 - 10.9±5.6 - 10.2±5.4 points by the Villalta scale (p=0.002), but not for quality of life: 48.2±19.3 - 46.7±17.3 - 47.4±16.2 points by the CIVIQ-20 (p>0.05). On the background of using EMS, the alterations in the studied parameters were characterized by higher velocity and intensity (p<0.05). The use of electromyostimulation as part of comprehensive treatment for post-thrombotic disease makes it possible to efficiently eliminate both subjective and objective signs of venous insufficiency, improve patients' quality of life and decrease the risk for the development of relapsing venous thrombosis.

[Treatment of acute deep vein thrombosis with new oral anticoagulant rivaroxaban: the first experience].

The aim of the study was to make a preliminary assessment of the efficacy and safety of acute deep vein thrombosis (DVT) prolonged treatment with new oral anticoagulant rivaroxaban. Materials and methods. It was a prospective observational study included patents with instrumentally verified DVT admitted to the Department of Vascular Surgery of the Clinical Hospital n.1 President's Administration of Russian Federation. All patients were administrated to the initial treatment with low-molecular weight heparins during first 24-48 hours followed by overlapped therapy with vitamin-K-antagonists. Patients who rejected a standard therapy were offered an alternative oral anticoagulant rivaroxaban: 15 mg bid during first 3 weeks followed by 20 mg qd. The duration of therapy varied from 3 to 12 month and more depend on localization and clinical provocation of the thrombosis. The dynamic control was performed on 3rd, 6th, 9th and 12th month. The endpoints of the study were recurrent DVT verified with duplex ultrasound or pulmonary embolism (PE) and hemorrhagic complications. In the study were enrolled 30 patients aged 27-87 years (mean age - 59.0±16.8), 13 men and 17 women who had from 0 to 6 individual risk factors (average - 2.4±1.6). In 33.3% cases DVT was clinically provoked and in 66.7% - unprovoked. Results. There were no recurrent DVT or PE observed. Cumulative rate of bleeding was 13.3% (95% CI: 1.2-25.5%): 6.65% (95% CI: 1.8-21.3%) - minor bleeding , that did not need drug withdrawal or extra visit to the doctor, and 6.65% (95% CI: 1.8-21.3%) - clinically significant bleeding, that needed an unscheduled visit to the doctor, the temporary interruption of the therapy or medical intervention. Major bleeding were not identified. Bleeding were presented as hematuria, petechial skin hemorrhages and epistaxis. Conclusion. The study demonstrates feasibility and safety of the new oral anticoagulant rivaroxaban application in the prolonged treatment of acute DVT.