Mode of Minimally Invasive Surgery Associated with Venous Thromboembolism Incidence in Gynecologic Cancer Patients.

Postoperative venous thromboembolism in gynecologic oncology patients undergoing minimally invasive surgery: does modality matter?

Thromboembolic events in gynecologic cancer patients treated with chemotherapy (380)

IntroductionPostoperative venous thromboembolism (VTE) after minimally invasive surgery (MIS) for gynecologic malignancy is uncommon. Our objective was to characterize the rates of postoperative VTE and identify factors that may increase...

Heart failure (HF) represents a major and growing public health problem because of its prevalence, incidence, morbidity, mortality, and economic costs. The prevalence of HF is 2% to 3% of the general population.1 Five million Americans are affected, with >550 000 cases diagnosed each year.2 The mortality rate from severe HF remains >60% within 5 years of diagnosis, and 50% of hospitalized patients with HF require readmission within 6 months of discharge. In the US estimated costs amount to > $35 billion per year.3 Although several therapies (eg, β-blockers, angiotensin-converting enzyme [ACE] inhibitors, and cardiac resynchronization therapy) have been proven effective in improving HF outcomes, many unanswered questions about optimal treatment remain. One area of ongoing uncertainty is the appropriate role for antithrombotic therapy in patients with HF. Observational data suggest that patients with HF have an increased venous thromboembolism (VTE) risk (deep venous thromboembolism [DVT], pulmonary embolism [PE], peripheral arterial thromboembolism, and stroke).4 These epidemiological findings are supported by multiple mechanisms that can contribute to a hypercoagulable state in patients with HF. Despite this increased risk of VTE, the role of antithrombotic therapy remains unclear. In this article, we provide an overview of epidemiology, pathophysiology, clinical trial data, and therapeutic recommendations for prevention of thromboembolism in HF. We searched PubMed for articles published between 1958 and 2010 using the following search terms: epidemiology of heart failure , thromboembolism and heart failure , thrombogenesis and heart failure , anticoagulation in heart failure , antiplatelet agent and heart failure , aspirin and heart failure , bleeding risk and anticoagulation , and aspirin and angiotensin-converting enzyme inhibitors . We also studied abstracts from national and international cardiovascular meetings to identify unpublished studies using the key words anticoagulation and dilated cardiomyopathy . Data from published observational studies and secondary …

Using a large comprehensive population-based cohort from Canada, Doiron et al. 1 present an in-depth analysis of risk factors and timing of venous thromboembolism (VTE) after radical cystectomy (RC) for bladder cancer. This report reiterates what is already known, which is that VTE after RC occurs at a non-negligible rate (5.4%) and most VTEs occur after hospital discharge (55%). VTE is an established complication in patients undergoing major oncological surgery, with some guidelines recommending 4 weeks of VTE prophylaxis after major pelvic surgery. This significant incidence of VTE after discharge highlights the potential impact of extended VTE prophylaxis for up to 28 days. Level I evidence for such practice was published more than a decade ago 2. Yet, the uptake of these data remains low, at least in urological oncology. A recent survey-based study of pelvic cancer centres from the UK showed that only two-thirds of centres use post-discharge prophylaxis 3. Using highly granular data, Doiron et al. 1 provide a detailed timeline of VTE occurrence after RC. They found that among patients who were diagnosed with VTE after discharge, >60% of these events occurred at ≤4 weeks of discharge. Unfortunately, there were no data on whether VTE prophylaxis was used in the study population. The authors identified greater surgeon volume and increased length of hospital stay as risk factors for postoperative VTE, while accounting for important disease-related covariates. As mentioned by the authors, surgeon volume is most likely a surrogate for another unmeasured confounder. Higher volume surgeons, who often practice in large/academic institutions, may have increased case complexity with patients at higher risk for VTE. Additionally, such institutions may be more prone to perform diagnostic testing in high-risk patients and identify VTEs that would have otherwise gone unnoticed. A report from France found that the rate of VTE after RC was 24% in a cohort of patients who all underwent complete lower limb ultrasound, yet the vast majority (92%) were asymptomatic 4. In other words, if you are looking for a VTE, you are more likely to find one. However, the clinical relevance of these VTEs remains unclear. As shown from prior studies, length of stay was also found to be a risk factor for VTEs. Why does an increase in length of stay lead to a higher rate of VTE? One explanation is that patients who stay in the hospital longer are more likely to be immobilised for longer. This may explain why patients undergoing RC have higher rates of VTE than those undergoing other urological oncology procedures. However, immobilisation is a difficult variable to define or to measure. If longer immobilisation leads to increased VTE incidence, recently implemented enhanced recovery after surgery (ERAS) protocols that lead to earlier mobilisation would be expected to be associated with fewer VTEs. It is important to mention that other previously associated factors with VTE, including operative time and body mass index, which may be related to immobilisation time are not recorded in this study. The use of neoadjuvant chemotherapy (NACT) for muscle-invasive bladder cancer has been shown to improve overall survival and is being increasingly used in RC patients. This study examined NACT as a risk factor but did not find an association. Notably, they were limited by the few patients who had received NACT. The use of chemotherapy in patients with cancer is a well-recognised risk factor for VTE 5. It will be important in the future to continue to examine the incidence of VTE in NACT patients as this population grows. Taken together, patients undergoing major cancer surgery have a significant risk of postoperative VTE, with evidence showing that rates of VTE are increasing over time 6. Although guidelines for VTE prophylaxis are not uniform, this study's findings 1 that most VTEs occur after discharge is a reason for urological surgeons to strongly consider extended VTE prophylaxis in this high-risk population. Funded partially by Quebec Urological Association (to Nawar Hanna). None.

Venous thromboembolism in cancer clinical trials: recommendation for standardized reporting and analysis

Psoriasis is associated with a greater risk of incident venous thromboembolism: the Iowa Women's Health Study

Background: Venous thromboembolism (VTE) is a major healthcare problem that has resulted in a significant increase in mortality, morbidity, and healthcare cost. Our knowledge of the incidence and risk factors of VTE differs among various ethnic backgrounds and nationalities, therefore, there is a need to explore the incidence of VTE and to understand the role of risk factors that require a pooled analysis. The aim of this review is to assess the incidence and risk factors of venous thromboembolism (VTE) in hospitalized patients. Methods: We searched PubMed, Embase, Scopus and Web of Sciences databases from 2015 to 2022, to identify studies reporting the incidence and risk factor of VTE among hospitalized patients. Descriptive statistics were described to present the results. Results: We identified 17 studies comprising 17703 participants, and only 1132 (6.4%) of them developed VTE. 12 studies were retrospectives, while 5 studies were prospective. The majority of participants 9573 (54%) were female, while 8130 (4645.9%) were male. 13 (76%) studies reported a low incidence of VTE, while 2 (12%%) studies concluded high incidence and 2 (12%) studies reported moderate incidence of VTE. 12 (70%) studies revealed low risk factors associated with VTE, while 3 (18%) studies found high risk factors associated with VTE and 2 (12%) studies described moderate risk factors related to VTE. Conclusions: Despite universal thromboprophylaxis, medical and surgical ill patients continue to be at risk for VTE. Incidence of VTE among hospitalized patients was low and associated with several risk factors. All patients need to undertake dynamic and constant risk assessment for VTE with laboratory monitoring, associated medications, invasive procedures, and previous medical history considered, particularly for severe and critically ill patients. We strongly urge clinicians to be conscious of VTE risk factors and highlight on optimizing patients' comorbidities before admission to the hospital.

Category: Basic Sciences/Biologics Introduction/Purpose: The purpose of this study is to evaluate the incidence and risk factors of symptomatic postoperative venous thromboembolism (VTE) in a single surgeon’s (JA) practice at a tertiary care center after orthopaedic foot/ankle surgery. We hypothesize that the incidence of postoperative VTE is not significant, but certain patients may be at higher risk for VTE than others. Methods: This is a retrospective review of patients that received orthopaedic foot/ankle surgery between September 2006 and September 2015 by a single surgeon (JA). Inclusion criteria involved surgical patients that were without coagulopathy, previous VTE, and/or using anti-coagulation medications including aspirin. Patients with coagulopathy, prior VTE, and/or taking anti- coagulation medication were excluded from this study. Patients’ charts were reviewed for their age, weight, and medical co- morbidities. The diagnosis and procedure(s) that each patient received was recorded. Postoperatively, all patients were immobilized (i.e., surgical shoe, splint, or external fixator) and rendered partial or nonweightbearing for a minimum of 4 weeks after surgery. Every patient’s postsurgical course was examined for the occurrence of a symptomatic postoperative VTE. This event was defined as a superficial vein thrombosis (SVT), deep vein thrombosis (DVT), or pulmonary embolus (PE) within 90 days from surgery. Results: Of 2746 patients that received foot/ankle surgery, 22 (0.80%) developed a post-operative VTE. The mean age of these patients was 47.3 years. 12 patients were male and the remaining 10 were female. 16 patients were obese and the remaining 6 were non-obese. Surgeries performed were ankle fracture repair in 8 (0.29%), hindfoot arthrodesis in 3 (0.11%), Achilles tendon repair in 2 (0.07%), ankle ligament reconstruction in 2, hammer-toe correction in 2, calcaneal fracture repair in 1 (0.04%), metatarsal fracture repair in 1, ankle cartilage repair in 1, peroneal tendon repair in 1, and below-knee amputation in 1. Obesity was predictive of post-operative VTE to a significant (P=0.04) degree. Age, sex, medical co-morbidities, and type of surgery were not significantly prognostic for a post-surgical VTE. Conclusion: This study demonstrates that the incidence of VTE after orthopaedic foot and/or ankle surgery is low. However, this research shows that obese patients are at significantly higher risk for VTE after such surgeries. This is highly important when educating patients as to their chances of developing a VTE from foot/ankle surgery and preventing its occurrence in those at risk.

This study examines the incidence and risk of postoperative symptomatic venous thromboembolism (VTE) after orthopaedic foot/ankle surgery. Patients that received foot/ankle surgery between 2006 and 2016 were reviewed. Inclusion criteria were surgical patients that were without coagulopathy, previous VTE, and/or using anticoagulation medications including aspirin. Age, sex, body mass index, medical comorbidities, and surgical diagnosis and procedure(s) were noted. Records were reviewed to see who developed a symptomatic VTE within 90 days from surgery. This study involved 2774 patients that received foot/ankle surgery between 2006 and 2016. Of them, 22 (0.79%) developed a VTE within 90 days from surgery. The mean age of these patients was 49.5 years. Twelve patients were male and 10 were female. Sixteen patients were obese and 6 were nonobese. Postoperative VTEs were 14 infrapopliteal deep vein thrombosis (DVT), 1 suprapopliteal DVT, and 7 pulmonary emboli. The most common surgeries involved were ankle fracture repair in 8 (0.29%), Achilles tendon repair in 2 (0.07%), ankle ligament reconstruction in 2, and hammer-toe correction in 2 patients. Obesity was predictive of a postoperative VTE to a statistically significant degree (P = .04). Age, sex, medical comorbidities, diagnosis, and type of surgery were not significantly prognostic for a postsurgical VTE (P ≥ .05). The incidence of VTE after foot/ankle surgery is low. However, obese patients are at significantly higher risk for VTE after such procedures. These findings are important when educating patients as to their risks of developing a VTE after orthopaedic foot/ankle surgery. Level III: Retrospective cohort study.

We hypothesized that a high rate of prescription of VTE chemoprophylaxis would be associated with decreased VTE incidence and mortality. Recommendations for VTE prevention in surgical patients include chemoprophylaxis based upon preoperative risk stratification. This retrospective cohort study analyzed VTE incidence, morbidity, and mortality amongst postsurgical patients with and without VTE chemoprophylaxis between April 2013 and September 2017 from 63 hospitals within the Michigan Surgical Quality Collaborative. A VTE risk assessment survey was distributed to providers. Bivariate and multivariate comparisons were made, as well as using propensity score matched cohorts to determine if VTE chemoprophylaxis was associated with decreased VTE events. Hospitals were compared using risk-reliability adjusted VTE prophylaxis and postoperative VTE event rates. Within the registry, 80% of practitioners reported performing formal VTE risk assessment. Amongst 32,856 operations, there were 480 (1.46%) postoperative VTE, and an overall mortality of 609 (1.85%) patients. Using a propensity matched cohort, we found that rates of VTE were similar in those receiving unfractionated heparin or low molecular weight heparin compared to those not receiving chemoprophylaxis (1.22 vs 1.13%, P = 0.57). When stratified further by VTE risk scoring, even the highest risk patients did not have an associated lower VTE rate (3.68 vs 4.22% P = 0.092). Postoperative transfusion (8.28 vs 7.50%, P = 0.057) and mortality (2.00% vs 1.62%, P = 0.064) rates were similar amongst those receiving and those not receiving chemoprophylaxis. No correlation was found between postoperative VTE chemoprophylaxis application and hospital specific risk adjusted postoperative VTE rates. In modern day postsurgical care, VTE remains a significant occurrence, despite wide adoption of VTE risk assessment. Although postoperative VTE chemoprophylaxis was broadly applied, after adjusting for confounders, no reduction in VTE was observed in at-risk surgical patients.

Low incidence of venous thromboembolism after gynecologic oncology surgery: Who is at greatest risk?

Venous Thromboembolism Incidence In The Cooperative Study Of Sickle Cell Disease: The Untold Story

Addressing the burden of hospital‐related venous thromboembolism: the role of extended anticoagulant prophylaxis

INTRODUCTION: Venous thromboembolism (VTE) is a source of significant morbidity and mortality in surgical patients. Prediction models have been developed to determine VTE risk in plastic surgery patients including the Davison risk score1 and the 2005 Caprini risk score2. This retrospective study evaluates the incidence of symptomatic VTE in breast reconstruction and the efficacy of current models in predicting VTE in different methods of breast reconstruction. METHODS: Breast reconstruction patients by a single surgeon were retrospectively evaluated. One hundred consecutive TRAM reconstructions, one hundred consecutive implant reconstructions, and fifty consecutive latissimus reconstructions were identified. These surgical reconstructions all took place over a ten year period in which VTE chemoprophylaxis was not routinely performed. Each patient’s chart was reviewed for the parameters needed to calculate the 2005 Caprini risk score and the Davison risk score. Outpatient follow up, operative notes, and other procedures were also reviewed. Fisher’s exact test was used to calculate differences in VTE incidence and risk factor incidence. ANOVA test was used to compare mean risk scores between the reconstruction groups. RESULTS: The TRAM reconstruction group had a significantly higher VTE rate (6%) than the implant (0%) or the latissimus (0%) reconstruction groups (p<0.01). There was no significant difference (p>0.05) in the 2005 Caprini risk scores or the Davison risk scores between the TRAM, implant, and latissimus reconstruction groups (Figure 1). The Davison risk score and the 2005 Caprini score stratified the majority of patients as “high risk” with a calculated risk score ≥5 (Davison score 64.8%, 2005 Caprini score 86%). Interestingly, the VTE rate among “high risk” patients in each group was not statistically different from the overall VTE rate of each reconstruction group (p>0.05).Figure 1: Mean 2005 Caprini risk score and mean Davison risk score by breast reconstruction type. (p>0.05).CONCLUSION: TRAM reconstruction is associated with a higher VTE rate than both implant reconstruction and latissimus reconstruction. Implant and latissimus reconstruction patients appear at low risk for VTE even in the presence of many “high risk” features. Overall, neither the 2005 Caprini risk score nor the Davison risk score demonstrated effective VTE risk stratification in breast reconstruction patients. Current and future VTE prediction models should take into account the specific surgical procedure to more accurately determine VTE risk.