Closing the treatment gap in knee osteoarthritis — the GEKO trial begins

Superficial venous intervention has transformed the treatment of varicose veins, offering patients minimally invasive solutions with excellent short-term outcomes. Yet, despite technical advances, an important question remains unresolved: Should pharmacological thromboprophylaxis be routinely prescribed to prevent postoperative deep vein thrombosis (DVT)?

The THRIVE trial (THRomboprophylaxis In superficial endovenous interVEntion) is the first randomised controlled study designed to address this uncertainty.1 By generating robust clinical evidence, THRIVE has the potential to influence international practice and shape future guideline recommendations.

Varicose veins are common, affecting up to 45% of the UK population and are associated with reduced physical and mental health-related quality of life.2,3 Symptomatic varicose veins are now routinely treated with endovenous thermal ablation, non-thermal ablation or mechanochemical techniques.4 While effective, these procedures carry a recognised risk of venous thromboembolism (VTE).

In the UK, around 5,000 major lower limb amputations (MLLA) occur every year, meaning that every 2 hours, someone in the UK has a leg removed and their life is changed forever. This number is increasing due to the ageing population and rising prevalence of diabetes. The care of these patients costs the NHS approximately £200 million a year, not including costs associated with formal and informal care, homecare visits and residential or nursing home placement. Following MLLA many patients do not return to independent living, with approximately one third being discharged to a care facility. MLLA also leads to substantial health implications, including anxiety, depression, altered body image and social discomfort, and the loss of general fitness and independence, which all contribute further to patient burden and healthcare costs.

MLLA includes below knee amputations (BKA), above knee amputations (AKA) and through knee amputations (TKA). Irrespective of the level of amputation, a MLLA has a significant impact on quality of life, though this can be mitigated. A recent review found that the ability to walk successfully with a prosthetic limb following MLLA, something more difficult with an AKA, had the greatest positive impact on quality of life. Accordingly, a BKA to preserve the knee joint, and thus maximise potential to utilise a prosthesis, is performed in preference to higher levels of amputation wherever possible. Patients not suitable for a BKA are usually offered an AKA, and less commonly a TKA as an alternative. Compared to an AKA, a TKA may result in superior outcomes via improved rehabilitation, easier control of an artificial leg and/or balance in a wheelchair. However, a TKA can also result in wound healing complications. Patients report positive and negative experiences with both AKA and TKA.

When a BKA is not suitable, both AKA and TKA surgeries are used in clinical practice. TKA is rarely used in the UK (less than 2% of MLLA) though may confer benefits as above, however, high-quality research to provide evidence to clearly define which amputation method results in the best outcomes for patients is lacking.

The IMPROVE-AD study is funded by the National Heart, Lung, and Blood Institute in the US. The study aims to understand how best to treat type B aortic dissection. It will include up to 1,100 patients from 60 hospitals across the United States and Canada. The trial is powered to demonstrate whether upfront thoracic endovascular repair (TEVAR) is superior to the standard of care of Medical Therapy and intervention when needed during follow up over 4 years. The entire study duration is 7 years with a planned completion in 2030.