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    Late-Breakthrough Submission

    Venous Thromboembolism

    Late-Breakthrough Session II

    LB 02.3 - Targeted thromboprophylaxis in patients with lower limb trauma requiring immobilization : stepped wedge randomized trial

    Tuesday, June 27, 2023
    11:15 – 11:30 ET
    Room: 517
    Session Available As: Live-Streamed and On-Demand

      Presenting Author(s)

    • Delphine DOUILLET, PhD, MD (she/her/hers)

      Associate Professor
      Emergency Department, Angers University Hospital, Health Faculty, Angers, France. UNIV Angers, UMR MitoVasc CNRS 6015 – INSERM 1083, Equipe CARME, Angers, France. F-CRIN INNOVTE network, Saint-Etienne France.
      ANGERS, Pays de la Loire, France

      • Co-Author(s)

    • AP

      Andrea Penaloza

      MD, PhD
      Emergency Department, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium.
      Brussels, Brussels Hoofdstedelijk Gewest, Belgium

    • DV

      Damien Viglino

      MD, PhD, Emergency Medicine full professor
      Univ. Grenoble-Alpes, University Hospital of Grenoble Alpes, Emergency Department, Grenoble, France. HP2 Laboratory, Grenoble Alpes University, INSERM U1300, Grenoble, France.
      Grenoble, Rhone-Alpes, France

    • JB

      Jean-Jacques Banihachemi

      MD
      Department of Trauma and Musculo-Skeletal Emergency, University Hospital and Medical Centre of Grenoble-Alpes Hospital South, Grenoble, France.
      Grenoble, Rhone-Alpes, France

    • AA

      Anmar Abboodi

      MD
      Emergency Department, Cholet Hospital, Cholet, France.
      Cholet, Pays de la Loire, France

    • MH

      Mathilde Helderlé

      MD
      Emergency Department, Le Mans Hospital, Le Mans, France.
      Le Mans, Pays de la Loire, France

    • EM

      Emmanuel Montassier

      MD, PhD, ED full professor
      Emergency Department, Nantes University Hospital, Nantes, France. MiHAR Laboratory, EE1701, University of Nantes, Nantes, France.
      Nantes, Pays de la Loire, France

    • FB

      Fréderic Balen

      MD
      Department of Emergency Medicine, Toulouse University Hospital, Toulouse, France.
      Toulouse, Languedoc-Roussillon, France

    • CB

      Christian Brice

      MD
      Emergency Department, Centre Hospitalier de Saint-Brieuc, Saint-Brieuc, France.
      Saint-Brieuc, Bretagne, France

    • SL

      Saïd Laribi

      MD, PhD, ED full professor
      Emergency Department, Tours University Hospital, Tours, France.
      Tours, Centre, France

    • TD

      Thibault Duchenoy

      MD
      Emergency Department, AP-HP Cochin, Paris, France.
      Paris, Ile-de-France, France

    • PV

      Philippe Vives

      MD
      Emergency Department, Agen Hospital, Agen, France.
      Agen, Aquitaine, France

    • LS

      Louis Soulat

      MD, PhD
      Emergency Department, Rennes University Hospital, Rennes, France.
      Rennes, Bretagne, France

    • NM

      Nicolas Marjanovic

      MD, PhD
      Emergency Department, Poitiers University Hospital, Poitiers, France.
      Poitiers, Poitou-Charentes, France

    • TM

      Thomas Moumneh

      MD, PhD
      Emergency Department, Angers University Hospital, Health Faculty, Angers, France. 2 UNIV Angers, UMR MitoVasc CNRS 6015 – INSERM 1083, Equipe CARME, Angers, France
      Angers, Pays de la Loire, France

    • DS

      Dominique Savary

      MD, PhD
      Emergency Department, Angers University Hospital, Health Faculty, Angers, France.
      Angers, Pays de la Loire, France

    • JR

      Jérémie Riou

      MD, PhD
      Methodology and Biostatistics Department, Delegation to Clinical Research and Innovation, CHU Angers, Angers, France.
      Angers, Pays de la Loire, France

    • Pierre-Marie Roy, MD, PhD (he/him/his)

      MD, PhD
      Service des urgences, Centre Hospitalo-Universitaire d’Angers, Institut MITOVASC, EA 3860, Université d'Angers, Angers, FCRIN INNOVTE, France.
      Angers, Pays de la Loire, France

    Background: A small subgroup of patients treated for lower leg trauma requiring immobilization develop venous thromboembolism (VTE). The TRiP(cast) score is aimed to predict VTE risk in trauma patients.

    Aims: The aim was to assess the safety of a strategy to withhold preventive anticoagulation in patients with low VTE risk.

    Methods: CASTING was a stepped-wedge cluster-randomized trial. Fifteen Emergency Departments in France and Belgium were randomly assigned to staggered start dates for switching from the control phase (physician's usual practice) to the intervention phase (targeted anticoagulation according to TRiP(cast) score: no if < 7 and anticoagulation if ≥7). The primary outcome was 3-month cumulative symptomatic VTE rate during the intervention phase in patients with a TRiP(cast) score < 7. The targeted strategy was considered safe if this rate was < 2% (prespecified threshold). Secondary outcomes included overall rate of anticoagulated patients, cumulative 3-month VTE incidence, and bleeding rates.

    Results: Of the 2108 patients analyzed (out of 2120 included), 1159 (55.0%) were deemed at low risk during the interventional phase and received no anticoagulant. Their symptomatic VTE rate was 0.7% (95% confidence interval [CI] 0.3 to 1.4, n=8/1159). The overall anticoagulation rate was 50.4% (n=304/603) in the control phase and 24.5% (n=368/1505) in the interventional phase (absolute difference -26.0%; 95% CI -30.2 to -21.7, p< 0.001). The 3-month cumulative rate of symptomatic VTE was 1.0% (95%CI 0.2 to 1.8; n=6/603) in the control phase and 1.1% (95%CI 0.6 to 1.7; n=17/1505) in the intervention phase (absolute difference 0.1%; 95%CI -0.8 to 1.1).

    Conclusion(s): Targeting thromboprophylaxis on the TRiP(cast) score allowed to safely withhold anticoagulation in a large subgroup of patients at low risk of VTE. Overall anticoagulant prescription was significantly reduced as compared to current practice.