Skip to main content
SpringerLink
Log in

Air Travel and Venous Thromboembolism: A Systematic Review

  • Original Article
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Context

Despite multiple attempts to document and quantify the danger of venous thromboembolism (VTE) following prolonged travel, there is still uncertainty about the magnitude of risk and what can be done to lower it.

Objectives

To review the methodologic strength of the literature, estimate the risk of travel-related VTE, evaluate the efficacy of preventive treatments, and develop evidence-based recommendations for practice.

Data Sources

Studies identified from MEDLINE from 1966 through December 2005, supplemented by a review of the Cochrane Central Registry of Controlled Trials, the Database of Abstracts of Reviews of Effects, and relevant bibliographies.

Study Selection

We included all clinical studies that either reported primary data concerning travel as a risk factor for VTE or tested preventive measures for travel-related VTE.

Data Extraction and Analysis

Two reviewers reviewed each study independently to assess inclusion criteria, classify research design, and rate methodologic features. The effect of methodologic differences, VTE risk, and travel duration on VTE rate was evaluated using a logistic regression model.

Data Synthesis

Twenty-four published reports, totaling 25 studies, met inclusion criteria (6 case-control studies, 10 cohort studies, and 9 randomized controlled trials). Method of screening for VTE [screening ultrasound compared to usual clinical care, odds ratio (OR) 390], outcome measure [all VTE compared to pulmonary embolism (PE) only, OR 21], duration of travel (<6 hours compared to 6–8 hours, OR 0.011), and clinical risk (“higher” risk travelers compared to “lower,” OR 3.6) were significantly related to VTE rate. Clinical VTE after prolonged travel is rare [27 PE per million flights diagnosed through usual clinical care, 0.05% symptomatic deep venous thrombosis (DVT) diagnosed through screening ultrasounds], but asymptomatic thrombi of uncertain clinical significance are more common. Graduated compression stockings prevented travel-related VTE (P < 0.05 in 4 of 6 studies), aspirin did not, and low-molecular-weight heparin (LMWH) showed a trend toward efficacy in one study.

Conclusions

All travelers, regardless of VTE risk, should avoid dehydration and frequently exercise leg muscles. Travelers on a flight of less than 6 hours and those with no known risk factors for VTE, regardless of the duration of the flight, do not need DVT prophylaxis. Travelers with 1 or more risk factors for VTE should consider graduated compression stockings and/or LMWH for flights longer than 6 hours.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. International Trade Administration. U.S. International Air Travel Statistics Report: U.S. Department of Commerce; 2003.

  2. Homans J. Thrombosis of the deep leg veins due to prolonged sitting. N Engl J Med. 1954;250:148–9.

    Article  PubMed  CAS  Google Scholar 

  3. Cruickshank J, Gorlin R, Jennett B. Air travel and thrombotic episodes: the economy class syndrome. Lancet. 1988;2:497–8.

    Article  PubMed  CAS  Google Scholar 

  4. Symington I, Stack B. Pulmonary embolism after travel. Br J Dis Chest. 1977;71:138–40.

    Article  PubMed  CAS  Google Scholar 

  5. Database of Abstracts of Reviews of Effects. University of York. Available at: http://www.york.ac.uk/inst/crd/crddatabases.htm. Accessed May 26, 2006.

  6. Girard T, Philbrick J, Angle F, Becker D. Prophylactic vena cava filters for trauma patients: a systematic review of the literature. Thromb Res. 2003;112:261–7.

    Article  PubMed  CAS  Google Scholar 

  7. Philbrick J, Becker D. Calf deep venous thrombosis: a wolf in sheep’s clothing? Arch Intern Med. 1988;148:2131–8.

    Article  PubMed  CAS  Google Scholar 

  8. Siadaty M, Philbrick J, Heim S, Schectman J. Repeated-measures modeling improved comparison of diagnostic tests in meta-analysis of dependent studies. J Clin Epidemiol. 2004;57:698–710.

    Article  PubMed  Google Scholar 

  9. Siadaty M, Shu J. Proportional odds ratio model for comparison of diagnostic tests in meta-analysis. BMC Med Res Methodol. 2004;10(1):27.

    Article  Google Scholar 

  10. Clerel M, Caillard G. Syndrome thrombo-embolique de la station assise prolongee et vols de longue duree: l’experience du Service Medicale d’Urgence d’Aeroports De Paris. Bull Acad Natl Med. 1999;183(5):985–97.

    PubMed  CAS  Google Scholar 

  11. Ferrari E, Chevallier T, Chapelier A, Baudouy M. Travel as a risk factor for venous thromboembolic disease. Chest. 1999;115:440–4.

    Article  PubMed  CAS  Google Scholar 

  12. Samama M-M. An epidemiologic study of risk factors for deep venous thrombosis in medical outpatients: the Sirius Study. Arch Intern Med. 2000;160:3415–20.

    Article  PubMed  CAS  Google Scholar 

  13. Kraaijenhagen R, Haverkamp D, Koopman M, Prandoni P, Piovella F, Buller H. Travel and risk of venous thrombosis. Lancet. 2000;356:1492–3.

    Article  PubMed  CAS  Google Scholar 

  14. Hosoi Y, Geroulakos G, Belcaro G, Sutton S. Characteristics of deep vein thrombosis associated with prolonged travel. Eur J Vasc Endovasc Surg. 2002;24:235–8.

    Article  PubMed  CAS  Google Scholar 

  15. Arya R, Barnes J, Hossain U, Patel R, Cohen A. Long-haul flights and deep vein thrombosis: a significant risk only when additional factors are also present. Br J Haematol. 2002;116:653–4.

    Article  PubMed  Google Scholar 

  16. Martinelli I, Taioli E, Battaglioli T, et al. Risk of venous thromboembolism after air travel. Arch Intern Med. 2003;163:2771–4.

    Article  PubMed  Google Scholar 

  17. Lapostolle F, Surget V, Borron S, et al. Severe pulmonary embolism associated with air travel. N Engl J Med. 2001;345:783–99.

    Article  Google Scholar 

  18. Belcaro G, Geroulakos G, Nicolaides A, Myers K, Winford M. Venous thromboembolism from air travel: the LONFLIT Study. Angiology. 2001;52(6):369–74.

    PubMed  CAS  Google Scholar 

  19. Schwarz T, Langenberg K, Oettler W, et al. Deep vein and isolated calf muscle vein thrombosis following long-haul flights: pilot study. Blood Coagul Fibrinolysis. 2002;13:755–7.

    Article  PubMed  CAS  Google Scholar 

  20. Schwarz T, Siegert G, Oettler W, et al. Venous thrombosis after long-haul flights. Arch Intern Med. 2003;163:2759–64.

    Article  PubMed  Google Scholar 

  21. Perez-Rodriquez E, Jimenez D, Diaz G, et al. Incidence of air travel-related pulmonary embolism at the Madrid-Barajas airport. Arch Intern Med. 2003;163:2766–70.

    Article  Google Scholar 

  22. Hughes R, Hopkins R, Weatherall M, et al. Frequency of venous thromboembolism in low to moderate risk long distance air travelers: the New Zealand Air Traveler’s Thrombosis (NZATT) study. Lancet. 2003;362:2039–44.

    Article  PubMed  CAS  Google Scholar 

  23. Kelman C, Kortt M, Becker N, et al. Deep vein thrombosis and air travel: record linkage study. BMJ. 2003;327:1072–6.

    Article  PubMed  CAS  Google Scholar 

  24. Jacobson B, Munster M, Smith A, et al. The BEST study: a prospective study to compare business class versus economy class air travel as a cause of thrombosis. S Afr Med J. 2003;93:522–8.

    PubMed  Google Scholar 

  25. Gajic O, Warner D, Decker P, Rana R, Bourke D, Sprung J. Long-haul air travel before major surgery: a prescription for thromboembolism. Mayo Clin Proc. 2005;80:728–31.

    Article  PubMed  Google Scholar 

  26. Scurr J, Machin S, Bailey-King S, Mackie I, McDonald S, Coleridge Smith P. Frequency and prevention of symptomless deep-vein thrombosis in long-haul flights: a randomized trial. Lancet. 2001;357:1485–9.

    Article  PubMed  CAS  Google Scholar 

  27. Belcaro G, Cesarone M, Shah S, et al. Prevention of edema, flight microangiopathy, and venous thrombosis in long flights with elastic stockings: a randomized trial. Angiology. 2002;53:635–45.

    PubMed  Google Scholar 

  28. Cesarone MR, Belcaro G, Errichi B, et al. The LONFLIT4-Concorde deep venous thrombosis and edema study: prevention with travel stockings. Angiology. 2003;54(2):143–54.

    Google Scholar 

  29. Cesarone MR, Belcaro G, Nicolaides A, et al. The LONFLIT4-Concorde-Sigvaris Traveno stockings in long flights (EcoTRaS) study. Angiology. 2003;54(1):1–9.

    Google Scholar 

  30. Cesarone MR, Belcaro G, Nicolaides A, et al. Venous thrombosis from air travel: the LONFLIT3 study. Angiology. 2002;53:1–6.

    Google Scholar 

  31. Belcaro G, Cesarone MR, Nicolaides A, et al. Prevention of venous thrombosis with elastic stockings during long-haul flights: the LONFLIT 5 JAP study. Clin Appl Thromb Hemost. 2003;9(3):197–201.

    Article  PubMed  CAS  Google Scholar 

  32. Cesarone MR, Belcaro G, Nicolaides A, et al. Prevention of venous thrombosis in long-haul flights with Flite Tabs: the LONFLIT-FLITE randomized, controlled trial. Angiology. 2003;54(5):531–9.

    Article  PubMed  CAS  Google Scholar 

  33. Belcaro G, Cesarone M, Rohdewald P, et al. Prevention of venous thrombosis and thrombophlebitis in long-haul flights with Pycnogenol. Clin Appl Thromb Hemost. 2004;10:373–7.

    Article  PubMed  CAS  Google Scholar 

  34. Bland M. An Introduction to Medical Statistics (3rd edn). Oxford: Oxford University Press; 2000.

    Google Scholar 

  35. American Cancer Society. Pycnogenol, Pine Bark Extract. Available at: www.cancer.org. Accessed February 18, 2006.

  36. Anderson F, Wheeler H, Goldberg R, et al. A population-based perspective of the hospital incidence and case—fatality rates of deep vein thrombosis and pulmonary embolism: the Worchester DVT Study. Arch Intern Med. 1991;151:933–8.

    Article  PubMed  Google Scholar 

  37. Nordstrom M, Lindblad B, Bergqvist D, Kjellstrom T. A prospective study of the incidence of deep-vein thrombosis within a defined urban population. J Intern Med. 1992;232:155–60.

    Article  PubMed  CAS  Google Scholar 

  38. Hansson P, Welin L, Tibblin G, Eriksson H. Deep vein thrombosis and pulmonary embolism in the general population: the Study of Men Born in 1913. Arch Intern Med. 1997;157:1665–70.

    Article  PubMed  CAS  Google Scholar 

  39. Silverstein M, Heit J, Mohr D, Petterson T, O’Fallon W, Melton L. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based cohort study. Arch Intern Med. 1998;158:585–93.

    Article  PubMed  CAS  Google Scholar 

  40. Oger E. Incidence of venous thromboembolism: a community-based study in Western France. EPI-GETBP Study Group. Groupe d’Etude de la Thrombose de Bretagne Occidentale. Thromb Haemost. 2000(83):657–60.

  41. Huisman M, HR B, ten Cate J, et al. Serial impedance plethysmography for suspected deep venous thrombosis in outpatients: the Amsterdam General Practitioner Study. N Engl J Med. 1986;314:823–8.

    Article  PubMed  CAS  Google Scholar 

  42. Hull R, Hirsh J, Carter D, et al. Diagnostic efficacy of impedance phethysmography for clinically suspected deep-vein thrombosis: a randomized trial. Ann Intern Med. 1985;102:21–8.

    PubMed  CAS  Google Scholar 

  43. Geerts W, Pineo G, Heit J, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3 Suppl):338S–400S.

    Article  PubMed  CAS  Google Scholar 

  44. Anderson F, Spencer F. Risk factors for venous thromboembolism. Circulation. 2003;107:I-9-I-16.

    Article  Google Scholar 

  45. van der Meer F, Koster T, Vandenbroucke J, Briet E, Rosendaal F. The Leiden Thrombophilia Study (LETS). Thromb Haemost. 1997;78:631–5.

    PubMed  Google Scholar 

Download references

Potential Financial Conflicts of Interest

None disclosed.

Author information

Authors and Affiliations

  1. Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA

    John T. Philbrick MD, Rebecca Shumate MD & Daniel M. Becker MD, MPH

  2. Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA

    John T. Philbrick MD, Mir S. Siadaty MD, MS & Daniel M. Becker MD, MPH

  3. University of Virginia Health Sciences Center, Box 800744, Charlottesville, VA, 22908, USA

    John T. Philbrick MD

Authors
  1. John T. Philbrick MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Rebecca Shumate MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Mir S. Siadaty MD, MS
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Daniel M. Becker MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to John T. Philbrick MD.

Appendix

Appendix

Description of methodologic standards

Standard 1: Adequate description of the subject assembly process

(a) Methods for patient selection should be described in enough detail that the study could be replicated with a similar group of patients. (b) The number of eligible but not enrolled subjects, as well as any reasons for exclusion, should also be reported.

Standard 2: Adequate description of subjects

Summary demographic information (gender, age), as well as type and duration of travel, should be reported.

Standard 3: Equality of comparison groups

RCT should not only employ random allocation to treatment modality but also demonstrate that the treatment groups were similar in terms of demographics (age and sex) and duration of travel. In cohort studies with control groups, both demographic characteristics and VTE risk should be similar between groups; if not, statistical adjustment for differences should have been performed. In case-control studies, the cases and controls should be matched for age, sex, and at least 1 VTE risk factor; otherwise, statistical adjustment should take these variables into account. With the exception of travel history, cases and controls should be enrolled using the same selection criteria.

Standard 4: Adequate reporting of subject follow-up

The number of patients unavailable for outcome or exposure ascertainment should be reported, as well as the reasons why this information was not available.

Standard 5: Adequate description of treatment

Treatment should be described in enough detail so that other subjects could be treated in a similar fashion.

Standard 6: Unbiased surveillance for adverse outcomes and determination of exposure

For cohort and RCT studies, either objective VTE test results or systematic survey for travel-related VTE symptoms should be reported. For case-control studies, travel exposure should be ascertained in the same fashion for cases and controls, including use of measures that would limit recall bias.

Standard 7: Adequate VTE diagnostic evaluation

Any diagnoses of DVT or PE should be based on objective test results.

Standard 8: Analysis that takes type and duration of travel into account

VTE risk should be adjusted by travel type and duration.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Philbrick, J.T., Shumate, R., Siadaty, M.S. et al. Air Travel and Venous Thromboembolism: A Systematic Review. J GEN INTERN MED 22, 107–114 (2007). https://doi.org/10.1007/s11606-006-0016-0

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-006-0016-0

Key words

Search

Navigation