A call for standardization of anticoagulant therapy in venous malformation.

We thank Shah et al for their meaningful comments, and we are glad to see this issue result in great interest, not just from investigators of vascular anomalies. However, after careful study, we believed they misunderstood some important information, and we are still confident in our results. Venous malformation (VM), a type of congenital vascular malformation with a long and relatively stable course, has a high risk of localized intravascular coagulation (LIC), which is characterized by elevated D-dimer and/or fibrin degradation product levels and a low fibrinogen level. A large surface area, muscle involvement, and palpable phleboliths are strong predictable criteria for LIC.1Dompmartin A. Acher A. Thibon P. et al.Association of localized intravascular coagulopathy with venous malformations.Arch Dermatol. 2008; 144: 873-877Crossref PubMed Scopus (234) Google Scholar A VM with LIC is generally tolerable for most patients and might not cause impaired renal function. This observational study was performed in accordance with the STROBE (strengthening the reporting of observational studies in epidemiology) statement and reported the eligibility criteria and methods of participant selection in the Methods section.2Cuschieri S. The STROBE guidelines.Saudi J Anaesth. 2019; 13: S31-S34Crossref PubMed Scopus (766) Google Scholar As we described in the contraindications for patient inclusion, no patient with a history of impaired renal function was enrolled. No consensus has been reached regarding the use anticoagulant therapy for patients with VMs, especially regarding dabigatran etexilate.3van der Vleuten C.J.M. Zwerink L. Klappe E.M. de Jong E. Te Loo D. Is there a place for prophylaxis with DOACs in Klippel-Trenaunay syndrome and other low-flow vascular malformations with intravascular coagulopathy and thromboembolic events?.Thromb Res. 2022; 213: 30-33Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,4Budge E.J. Khalil Allam M.A. Mechie I. Scully M. Agu O. Lim C.S. Venous malformations: coagulopathy control and treatment methods.Phlebology. 2021; 36: 361-374Crossref PubMed Scopus (6) Google Scholar When to start and when to stop are two key questions. Our study addressed two conditions: (1) pain potentially caused by LIC; and (2) the improvement of coagulation status to allow for further treatment. Both short- and long-term use of dabigatran etexilate can relieve pain and improve coagulation status, in some cases, in as short as 2 days. Shah et al misunderstood the data presented in our Table II, which illustrated that the change (differences) in four indexes (index names provided in column 1) before and after treatment (columns 2 and 3, respectively) between the two duration groups showed no statistical significance (P values in column 4). The differences in the visual analog scale scores and fibrinogen levels from before to after treatment were statistically significant between the two duration groups. The difference in the D-dimer levels was also statistically significant in the short-term group. To check the confounders for the two duration groups, we used the Fisher exact test for gender and unpaired t tests for age, visual analog scale scores, and fibrinogen, D-dimer, and fibrin degradation product levels and did not find any statistical significance (P > .1 for all). We conducted our study, enrolling all outpatients, in the vascular anomaly center of the Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, which performs ∼30,000 outpatient services annually. For statistical analysis, we use GraphPad Prism 8 to conduct paired t tests for paired continuous variables between before and after treatment, and unpaired t tests for continuous variables between the two duration groups. According to our center's experience, LIC can cause hemorrhagic complications, local ulceration, and, eventually, can progress to disseminated intravascular coagulation in severe cases (Fig). A coagulation disorder can be a contraindication for emergency anesthesia and surgery. A quick correction of coagulation status, in particular, elevating the fibrinogen level, is necessary and urgent. Thus, the use of dabigatran etexilate can be an option. Our study accounted for a modest spur to induce more high-quality retrospective or prospective studies to standardize the use of anticoagulant therapy for patients with VMs. We hope that a consensus can be reached with guidelines provided for pain management and LIC treatment for those with VMs. Dabigatran for venous malformations: A call for a stringent approachJournal of Vascular Surgery: Venous and Lymphatic DisordersVol. 11Issue 5PreviewGiven the health burden of venous malformations, the study by Liu et al1 is a commendable effort to evaluate the efficacy and safety of dabigatran. The study concluded that dabigatran is a viable treatment option for managing pain and localized intravascular coagulation. However, we believe the authors have drawn significant correlations based on a tenuous foundation. Full-Text PDF