Prevention of Pulmonary Embolism in General Surgery Patients

Abstract

HomeCirculationVol. 115, No. 9Prevention of Pulmonary Embolism in General Surgery Patients Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBPrevention of Pulmonary Embolism in General Surgery Patients Urszula Zurawska, BS, Sudha Parasuraman, MD and Samuel Z. Goldhaber, MD Urszula ZurawskaUrszula Zurawska From the University of Western Ontario, London, Ontario, Canada (U.Z.), and Cardiovascular Division, Brigham and Women’s Hospital (S.P., S.Z.G.) and Hematology/Oncology Division, Children’s Hospital (S.P.), Harvard Medical School, Boston, Mass. Search for more papers by this author , Sudha ParasuramanSudha Parasuraman From the University of Western Ontario, London, Ontario, Canada (U.Z.), and Cardiovascular Division, Brigham and Women’s Hospital (S.P., S.Z.G.) and Hematology/Oncology Division, Children’s Hospital (S.P.), Harvard Medical School, Boston, Mass. Search for more papers by this author and Samuel Z. GoldhaberSamuel Z. Goldhaber From the University of Western Ontario, London, Ontario, Canada (U.Z.), and Cardiovascular Division, Brigham and Women’s Hospital (S.P., S.Z.G.) and Hematology/Oncology Division, Children’s Hospital (S.P.), Harvard Medical School, Boston, Mass. Search for more papers by this author Originally published6 Mar 2007https://doi.org/10.1161/CIRCULATIONAHA.106.674663Circulation. 2007;115:e302–e307Case Presentation: A 29-year-old woman presented to the emergency department with complaints of pleuritic chest pain, fever, and left ankle swelling and tenderness. Cardiac examination was normal except for tachycardia. A chest computed tomography scan with contrast demonstrated extensive bilateral pulmonary emboli. Thirteen days previously, an intoxicated driver with multiple prior convictions for driving under the influence of alcohol crashed head-on into her car at a high speed. She was 8 months’ pregnant and suffered the loss of the child. She spent 7 days in the hospital and underwent cesarean section, exploratory laparotomy, and splenectomy. No preoperative pharmacological prophylaxis against venous thromboembolism (VTE) was administered.EpidemiologyVTE, which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is an important and common complication of general surgery.A new era in the postoperative management of surgical patients began in 1975 when the effectiveness of low-dose heparin in preventing postoperative DVT and PE was established by the pivotal International Multicenter Trial.1 The dose was 5000 U subcutaneously every 8 hours, with the first injection administered 2 hours before the skin incision. Compared with control, the incidence of DVT in patients receiving heparin decreased from 24.6% to 7.7%. Similarly, the incidence of autopsy-proven PE was reduced 8-fold. The results of this trial introduced and validated the concept of using low-dose heparin to prevent postoperative VTE. This trial revolutionized surgical practice. By 1994, 90% of North American general surgeons reported the routine use of thromboprophylaxis.2Natural HistoryMost postoperative DVT originates in the deep calf veins, primarily within the valve cusps. Most thrombi remain confined to the calf. Propagation into the proximal veins increases the risk of PE. Symptoms and signs of postoperative VTE such as mild hypoxia or low-grade fever are frequently nonspecific. Moreover, clinical manifestations of postoperative VTE may not occur until several weeks after general surgery.3 Consequently, most cases are not suspected clinically.Risk FactorsSurgery-Related FactorsSurgery-related risk factors for VTE include infection, immobilization, and dehydration, in addition to the duration and type of surgery.4 Patients undergoing outpatient surgery are at relatively low risk.4 The incidence of VTE associated with day surgery for inguinal hernia repair is a modest 0.04%.5 Similarly, minor abdominal surgery involving the abdominal wall or appendix carries a relatively low VTE risk of 0.1% to 0.6%.6 In contrast, major general surgery such as liver, pancreatic, gastric, or bowel surgery carries a higher risk, with 0.8% to 1.7% of patients developing PE.7Obese patients who undergo bariatric surgery have traditionally been categorized as at high risk for VTE, with PE being one of the most common causes of postoperative death.8 However, prospective studies indicate a modest rate of symptomatic PE, ranging from 0.8% to 1.2%.8,9VTE risk after laparoscopic surgery has been controversial. A meta-analysis of 153 832 patients who undergo laparoscopic cholecystectomy revealed a rate of 0.03% for postoperative DVT and 0.02% for fatal PE compared with a risk of 5% and 0.4%, respectively, for the conventional open surgical procedure.10,11 Studies of other laparoscopic procedures, including Nissen fundoplication, colon resection, and splenectomy, have found a low frequency of VTE.12–14The type and duration of anesthesia also play a role in the development of postoperative DVT. General anesthesia has been associated with higher risk of DVT than spinal or epidural anesthesia.15 A study of orthopedic surgery patients found that duration of anesthesia >3.5 hours was a strong risk factor for postoperative VTE regardless of the route of anesthesia.16Patient-Related FactorsPatient-related risk factors include cancer, advancing age, previous VTE, obesity, varicose veins, and estrogen use.4 Patients with malignancy who undergo surgery have at least twice the risk of postoperative DVT and >3 times the risk of fatal PE as noncancer patients who undergo similar procedures.4 Advancing age (>40 years of age) also is associated with a steady increase in VTE risk by ≈20% per decade after general surgical procedures such as cholecystectomy and appendectomy.17Formal risk assessment models that combine patient-related and surgery-related factors into a composite risk estimate have been proposed to optimize stratification of surgical patients into levels of VTE risk (Table 1). However, these models are complex, time-consuming, and unwieldy. They do not provide comprehensive guidance for all patient groups, and they have not been validated in clinical practice.18 We therefore advise a more straightforward approach: a default order to implement routine pharmacological prophylaxis against VTE in all patients who undergo major general surgery. Exceptions to the default can be made on the basis of bleeding risk and other special circumstances. TABLE 1. Performance Measures for VTE Prevention in General Surgery PatientsPerformance MeasureAdditional SpecificationsSurgical Care Improvement Project21 • Proportion of hospitalized surgery patients with recommended VTE prophylaxis ordered during admissionMajor exclusions: • Procedures entirely by laparoscope • Proportion of surgery patients who received appropriate VTE prophylaxis • Surgeries ≤30 min • Proportion of surgery patients with intraoperative or postoperative PE diagnosed during index hospitalization or within 30 d of surgery • Patients in hospital ≤24 h • Contraindications to both mechanical and prophylaxis • Proportion of surgery patients with intraoperative or postoperative DVT diagnosed during index hospitalization or within 30 days of surgeryLeapfrog Group20 Practice No. 17 • Document the VTE risk assessment and prevention plan in the patient’s record • Evaluate each patient on admission and regularly thereafter for the risk of developing VTE • Explicit organizational policies and procedures should be in place for the prevention of VTE • Use clinically appropriate methods to prevent VTE Practice No. 18 • Explicit organizational policies and procedures should be in place regarding antithrombotic services • Use dedicated antithrombotic (anticoagulation) services that facilitate coordinated care managementNational Quality Forum19 • Proportion of surgery patients with documented VTE risk assessment within 24 h of admissionMajor exclusions: • Procedures entirely by laparoscope • Proportion of hospitalized surgery patients with recommended VTE prophylaxis ordered during admission • Surgeries ≤30 min • Patients in hospital ≤24 h • Proportion of surgery patients who received appropriate VTE prophylaxis • Contraindications to both mechanical and pharmacological prophylaxisProphylaxisGuidelines from the Seventh American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy recommend that every hospital develop a formal strategy such as a written thromboprophylaxis policy to prevent thromboembolic complications.4 Several agencies, including the National Quality Forum,19 the Leapfrog Group,20 and the Surgical Care Improvement Project,21 also have developed performance measures regarding VTE prophylaxis in surgical patients (Table 1).Specific guidelines for prophylaxis have been issued by the American College of Chest Physicians, the Surgical Care Improvement Project, the International Union of Angiology,22 and the National Comprehensive Cancer Network23 (Table 2). There is universal consensus for the use of fixed, low-dose unfractionated heparin (LDUH) or low-molecular-weight heparin (LMWH) for VTE prophylaxis in general surgery. TABLE 2. Current Guidelines for VTE Prophylaxis in General Surgery PatientsAt-Risk PopulationRecommendationsINR indicates international normalized ratio; IPC, intermittent pneumatic compression; GCS, graduated compression stockings; q8 h, every 8 hours; and q12 h, every 12 hours.American College of Chest Physicians4 Highest risk• Low-dose LMWH Surgery in patients with multiple risk factors (age >40 y, cancer, prior VTE)• Fondaparinux 2.5 mg/d• Oral anticoagulants (target INR 2-3) Hip or knee arthroplasty, hip fracture surgery• IPC or GCS+LDUH or low-dose LMWH Major trauma, spinal cord injury High risk• LDUH q8 hours Surgery in patients >60 y or 40–60 y of age with additional risk factors (prior VTE, cancer, molecular hypercoagulability)• Low-dose LMWH• IPC Moderate risk• LDUH q12 hours Minor surgery in patients with additional risk factors• Low-dose LMWH Surgery in patients 40–60 y of age with no additional risk factors• GCS• IPC Low risk• No specific prophylaxis Minor surgery in patients <40 y of age with no additional risk factors• Early and “aggressive” mobilizationSurgical Care Improvement Project21 General surgery with moderate to high risk for VTE• LDUH• Low-dose LMWH• LDUH or low-dose LMWH+IPC or GCS General surgery with high risk for bleeding• GCS• IPCInternational Union of Angiology22 High risk• LDUH 5000 U 2 h before operation, continued q8 h until patient is ambulatory with or without GCS or IPC Major surgery, age >60 y Major surgery, age 40–60 y, and cancer or history of DVT/PE• Low-dose LMWH initiated and dosed according to manufacturers’ recommendations with or without GCS or IPC Thrombophilia• Fondaparinux Moderate risk• LDUH 5000 U 2 h before operation, continued q12 h or q8 h until patient is ambulatory Minor surgery, age >60 y Major surgery, age 40–60 y with no additional risk factors• Low-dose LMWH initiated and dosed according to manufacturer’s recommendations for moderate-risk patients Minor surgery, age 40–60 y with history of DVT/PE or on estrogen therapy• IPC+GCS until patient is ambulatory, especially in patients at risk for or with active bleeding Low risk• Insufficient data to make firm recommendations, but consider GCS, early ambulation, adequate hydration, Major surgery, age <40 y with no additional risk factors Minor surgery, age 40–60 y with no additional risk factors• LDUH 5000 U Patients undergoing laparoscopic surgery, with additional risk factors• Low-dose LMWH• IPC+GCSNational Comprehensive Cancer Network23 Adult inpatients with diagnosis or clinical suspicion of cancer, without relative contraindication to anticoagulation• Low-dose LMWH• Fondaparinux 2.5 mg/d• LDUH 5000 U q8 h• With or without IPC Adult inpatients with diagnosis or clinical suspicion of cancer, with relative contraindication to anticoagulation present• Mechanical prophylaxis: IPC or GCSThe purpose of thromboprophylaxis is to avert the formation of thrombin by preventing the initiation of intravascular coagulation. Trace amounts of heparin and LMWH can accelerate the antithrombin-mediated neutralization of activated factors IX, XI, XII, and X several-fold, thereby limiting thrombin generation.24,25 Hence, venous thrombosis can be prevented by halting the development of a hypercoagulable state that would otherwise occur during and after surgery.26 This forms the basis for the use of low-dose heparin in thromboprophylaxis. Heparin is a potent catalyst of the antithrombin-mediated inhibition of factor Xa in low doses, yet it also inhibits thrombin by forming an inactive heparin-thrombin-antithrombin complex when used in higher doses. Heparin also stimulates the release of the tissue factor pathway inhibitor from the vascular endothelium, which in turn inhibits the tissue factor–mediated coagulation pathway27 (the Figure and Table 3). Download figureDownload PowerPointMechanism of action of heparin. Heparin is released from the heparin-thrombin-antithrombin complex and is recycled (A). TF indicates tissue factor; TFPI, tissue factor pathway inhibitor; →, catalytic action; and ⊣, inhibitory action.TABLE 3. Sites and Magnitude of the Antithrombotic Action of Unfractionated Heparin, Low-Dose Heparin, LMWH, and FondaparinuxAgent/DosingThrombin InhibitionFactor Xa InhibitionFactor XIIa, XIa, and IXa InhibitionTFPI ReleaseTFPI indicates tissue factor pathway inhibitor; +, weak; ++, moderate; +++, strong; and UFH, unfractionated heparin.LDUH+++++++UFH+++++++++++LMWH+++++++Fondaparinux-+++--A large meta-analysis demonstrated that a regimen of 5000 U of subcutaneous unfractionated heparin started 2 hours before surgery and continued every 8 or 12 hours reduced the rates of DVT (from 22.4% to 9.0%), symptomatic PE (from 2.0% to 1.3%), fatal PE (from 0.8% to 0.3%), and all-cause mortality (from 4.2% to 3.2%) compared with control.28 Another meta-analysis showed that LDUH is not associated with increased rates of major bleeding.29LMWH offers an efficacy and safety profile that is at least equivalent to that of LDUH. A meta-analysis of 51 studies involving >48 000 patients undergoing general surgery found no statistically significant differences in rates of asymptomatic DVT, clinical PE, death, major hemorrhage, and wound hematoma between LMWH and LDUH.30 Advantages of LMWH are its greater ease of administration, lower risk of heparin-induced thrombocytopenia, and more predictable anticoagulant effect.4The newest thromboprophylactic agent evaluated in general surgical patients is fondaparinux, a synthetic selective factor Xa inhibitor. There have been no reported cases of heparin-induced thrombocytopenia with fondaparinux use. When fondaparinux was compared with LMWH in a study of nearly 3000 patients undergoing high-risk abdominal surgery, similar rates of VTE (4.6% and 6.1%, respectively) and major bleeding (3.4% and 2.4%, respectively) were observed.31 Thromboprophylaxis with fondaparinux has been studied most extensively in patients undergoing major orthopedic surgery, including hip and knee arthroplasty, and in patients suffering hip fracture. Fondaparinux administered 6 hours after surgery has consistently shown improved efficacy compared with enoxaparin, which is usually administered 12 hours after surgery. A meta-analysis of 4 studies involving >7000 patients concluded that, compared with enoxaparin, fondaparinux significantly reduced the incidence of VTE from 13.7% to 6.8%.32 However, major bleeding was more common in fondaparinux-treated than enoxaparin-treated patients (2.7% and 1.7%, respectively).The optimal duration of thromboprophylaxis in general surgical patients remains to be clarified. Patients with malignancy appear to benefit from extended prophylaxis, as illustrated by the significant reduction in VTE incidence from 12.0% to 4.8% in patients undergoing surgery for abdominal or pelvic cancer who received enoxaparin for 4 weeks compared with those given it for 1 week of prophylaxis.33Mechanical compression methods, which include graduated compression stockings, intermittent pneumatic compression, and foot pumps, reduce the risk of proximal vein thrombosis by about one-half and the risk of PE by two-fifths. They also reduce the risk of DVT by about two-thirds when used as monotherapy and by about one-half when added to a pharmacological method.34A meta-analysis of 2270 postoperative patients, including >427 general surgery patients, found that intermittent pneumatic compression reduced DVT risk by 60% compared with no prophylaxis.35 In laparoscopic surgery, the use of intermittent pneumatic compression has been shown to reverse the compressive effect of pneumoperitoneum on the femoral veins.36 Intraoperative intermittent pneumatic compression is thus strongly recommended by the European Association for Endoscopic Surgery for all prolonged laparoscopic procedures.37A systematic review and 2 meta-analyses have shown that graduated compression stockings also reduce the relative risk of DVT after general surgery by ≈66%.38–40 The use of graduated compression stockings, combined with pharmacological prophylaxis, has an additive effect, especially in patients at high risk for VTE.34,40,41Case PresentationThis case highlights surgery, trauma, immobilization, and pregnancy as risk factors for VTE. Multiple factors placed this patient in a high-risk category, indicating a strong need for thromboprophylaxis. LDUH or LMWH should have been started 2 hours before surgery and continued postoperatively. This case also demonstrates the nonspecific presentation of VTE in surgical patients and the difficulty of detecting DVT and pulmonary embolism postoperatively.We wish to acknowledge the guidance of Jawed Fareed, PhD, Ajay K. Kakkar, MD, and Arthur A. Sasahara, MD, while preparing this manuscript.DisclosuresDr Parasuraman receives clinical research support from Sanofi Aventis. Dr Goldhaber receives clinical research support from Sanofi Aventis, Bristol Myers Squibb, GlaxoSmithKline, and Eisai.FootnotesCorrespondence to Samuel Z. Goldhaber, MD, Cardiovascular Division, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115. E-mail [email protected] References 1 Kakkar VV, Corrigan TP, Fossard DP. Prevention of fatal postoperative pulmonary embolism by low doses of heparin. Lancet. 1975; 2: 45–51.MedlineGoogle Scholar2 Caprini JA, Arcelus JI, Hoffman K, Mattern T, Laubach M, Size GP, Traverso CI, Coats R. Prevention of venous thromboembolism in North America: results of a survey among general surgeons. J Vasc Surg. 1994; 20: 751–758.CrossrefMedlineGoogle Scholar3 Kearon C. Natural history of venous thromboembolism. Circulation. 2003; 107 (suppl): I-22–1-30.LinkGoogle Scholar4 Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004; 126: 338S–400S.CrossrefMedlineGoogle Scholar5 Riber C, Alstrup N, Nymann T, Bogstad JW, Wille-Jorgensen P, Tonnesen H. Postoperative thromboembolism after day-case herniorrhapy. Br J Surg. 1996; 83: 420–421.CrossrefMedlineGoogle Scholar6 Samama CM, Albaladejo P, Benhamou D, Bertin-Maghit M, Bruder N, Doublet JD, Laversin S, Leclerc S, Marret E, Mismetti P, Samain E, Steib A, for the Committee for Good Practice Standards of the French Society for Anaesthesiology and Intensive Care (SFAR). Venous thromboembolism prevention in surgery and obstetrics: clinical practice guidelines. Eur J Anaesthesiol. 2006; 23: 95–116.MedlineGoogle Scholar7 Huber O, Bounameaux H, Borst F, Rohner A. Postoperative pulmonary embolism after hospital discharge. Arch Surg. 1992; 127: 310–313.CrossrefMedlineGoogle Scholar8 Westling A, Bergqvist D, Bostrom A, Karacaqil S, Gustavsson S. Incidence of deep venous thrombosis in patients undergoing obesity surgery. World J Surg. 2002; 26: 470–473.CrossrefMedlineGoogle Scholar9 Prystowsky JB, Morasch MD, Eskandari MK, Hungness ES, Nagle AP. Prospective analysis of the incidence of deep venous thrombosis in bariatric surgery patients. Surgery. 2005; 138: 759–763.CrossrefMedlineGoogle Scholar10 Lindberg F, Bergqvist D, Rasmussen I. Incidence of thromboembolic complications after laparoscopic cholecystectomy: review of the literature. Surg Laparosc Endosc. 1997; 7: 324–331.CrossrefMedlineGoogle Scholar11 Bergqvist D, Matzsch T, Jendteg S, Lindgren B, Persson U. The cost-effectiveness of prevention of post-operative thromboembolism. Acta Chir Scand Suppl. 1990; 556: 36–41.MedlineGoogle Scholar12 Lind T. Changing surgical principles for gastro-oesophageal reflux disease: is laparoscopic fundoplication justified in the light of surgical complications? Eur J Surg. 200; 166 (suppl): 31–33.CrossrefGoogle Scholar13 Mall JW, Schwenk W, Rodiger O, Zippel K, Pollmann C, Muller JM. Blinded prospective study of the incidence of deep venous thrombosis following conventional or laparoscopic colorectal resection. Br J Surg. 2001; 88: 99–100.CrossrefMedlineGoogle Scholar14 Brodsky JA, Brody FJ, Walsh RM, Malm JA, Ponsky JL. Laparoscopic splenectomy. Surg Endosc. 2002; 16: 851–854.CrossrefMedlineGoogle Scholar15 Hendolin H, Mattila MA, Poikolainen E. The effect of lumbar epidural analgesia on the development of deep vein thrombosis of the legs after open prostatectomy. Acta Chir Scand. 1981; 147: 425–429.MedlineGoogle Scholar16 Jaffer AK, Barsoum WK, Krebs V, Hurbanek JG, Morra N, Brotman DJ. Duration of anesthesia and venous thromboembolism after hip and knee arthroplasty. Mayo Clin Proc. 2005; 80: 732–738.CrossrefMedlineGoogle Scholar17 White RH, Zhou H, Gage BF. Effect of age on the incidence of venous thromboembolism after major surgery. J Thromb Haemost. 2004; 2: 1327–1333.CrossrefMedlineGoogle Scholar18 Samama MM. Applying risk assessment models in general surgery: effective risk stratification. Blood Coagul Fibrinolysis. 1999; 10: S79–S84.MedlineGoogle Scholar19 National Quality Forum (NQF) consensus standards for prevention and care of venous thromboembolism. Available at: www.qualityforum.org/news/prDVTendorsed05–18–06.pdf. Accessed October 3, 2006.Google Scholar20 Leapfrog Group. The 2006 Leapfrog Group hospital quality and safety survey. Available at: www.leapfrog.medstat.com/pdf/Final.pdf. Accessed October 3, 2006.Google Scholar21 Surgical Care Improvement Project (SCIP). Venous thromboembolism: tools: DVT order set: Crozer DVT guidelines. Available at: www.medqic.org/dcs/ContentServer?cid=1147808149675&pagename=Medqic%2FMQTools%2FtoolTemplate&c=MQTools. Accessed October 3, 2006.Google Scholar22 Prevention and treatment of venous thromboembolism: International Consensus Statement (guidelines according to scientific evidence). Int Angiol. 2006; 25: 101–161.MedlineGoogle Scholar23 National Comprehensive Cancer Network (NCCN) clinical practice guidelines for supportive care: venous thromboembolic disease. Available at: www.nccn.org/professionals/physician_gls/PDF/vte.pdf. Accessed October 3, 2006.Google Scholar24 Yin ET, Wessler S, Stoll PJ. Identity of plasma-activated factor X inhibitor with antithrombin 3 and heparin cofactor. J Biol Chem. 1971; 246: 3712–3719.CrossrefMedlineGoogle Scholar25 Yin ET, Wessler S. Heparin-accelerated inhibition of activated factor X its natural plasma inhibitor. Biochim Biophys Acta. 1970; 201: 387–390.CrossrefMedlineGoogle Scholar26 Wessler S, Yin ET. Theory and practice of minidose heparin in surgical patients: a status report. Circulation. 1973; 47: 671–676.CrossrefMedlineGoogle Scholar27 Hansen JB, Sandset PM. Differential effects of low molecular weight heparin and unfractionated heparin on circulating levels of antithrombin and tissue factor pathway inhibitor (TFPI): a possible mechanism for difference in therapeutic efficacy. Thromb Res. 1998; 91: 177–181.CrossrefMedlineGoogle Scholar28 Collins R, Scrimgeour A, Yusuf S, Peto R. Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin: overview of results of randomized trials in general, orthopedic, and urologic surgery. N Engl J Med. 1988; 318: 1162–1173.CrossrefMedlineGoogle Scholar29 Clagett GP, Reisch JS. Prevention of venous thromboembolism in general surgical patients: results of meta-analysis. Ann Surg. 1988; 208: 227–240.CrossrefMedlineGoogle Scholar30 Mismetti P, Laporte S, Darmon JY, Buchmuller A, Decousus H. Meta-analysis of low molecular weight heparin in the prevention of venous thromboembolism in general surgery. Br J Surg. 2001; 88: 913–930.CrossrefMedlineGoogle Scholar31 Agnelli G, Bergqvist D, Cohen AT, Gallus AS, Gent M. Randomized clinical trial of postoperative fondaparinux versus perioperative dalteparin for prevention of venous thromboembolism in high-risk abdominal surgery. Br J Surg. 2005; 92: 1212–1220.CrossrefMedlineGoogle Scholar32 Turpie AG, Bauer KA, Eriksson BI, Lassen MR. Fondaparinux vs enoxaparin for the prevention of venous thromboembolism in major orthopedic surgery: a meta-analysis of 4 randomized double-blind studies. Arch Intern Med. 2002; 162: 1833–1840.CrossrefMedlineGoogle Scholar33 Bergqvist D, Agnelli G, Cohen AT, Eldor A, Nilsson PE, Le Moigne-Amrani A, Dietrich-Neto F, for the ENOXACAN II Investigators. Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer. N Engl J Med. 2002; 346: 975–980.CrossrefMedlineGoogle Scholar34 Roderick P, Ferris G, Wilson K, Halls H, Jackson D, Collins R, Baigent C. Towards evidence-based guidelines for the prevention of venous thromboembolism: systematic reviews of mechanical methods, oral anticoagulation, dextran and regional anaesthesia as thromboprophylaxis. Health Technol Assess. 2005; 9: 1–78.Google Scholar35 Urbankova J, Quiroz R, Kucher N, Goldhaber SZ. Intermittent pneumatic compression and deep vein thrombosis prevention. Thromb Haemost. 2005; 94: 1181–1185.CrossrefMedlineGoogle Scholar36 Schwenk W, Bohm B, Fugener A, Muller JM. Intermittent pneumatic sequential compression (ISC) of the lower extremities prevents venous stasis during laparoscopic cholecystectomy: a prospective randomized study. Surg Endosc. 1998; 12: 7–11.CrossrefMedlineGoogle Scholar37 Neudecker J, Sauerland S, Neugebauer E, Bergamaschi R, Bonjer HJ, Cuschieri A, Fuchs KH, Jacobi C, Jansen FW, Koivusalo AM, Lacy A, McMahon MJ, Millat B, Schwenk W. The European Association for Endoscopic Surgery clinical practice guideline on the pneumoperitoneum for laparoscopic surgery. Surg Endosc. 2002; 16: 1121–1143.CrossrefMedlineGoogle Scholar38 Wells PS, Lensing AW, Hirsh J. Graduated compression stockings in the prevention of postoperative venous thromboembolism: a meta-analysis. Arch Intern Med. 1994; 154: 67–72.CrossrefMedlineGoogle Scholar39 Agu O, Hamilton G, Baker D. Graduated compression stockings in the prevention of venous thromboembolism. Br J Surg. 1999; 86: 992–1004.CrossrefMedlineGoogle Scholar40 Amaragiri SV, Lees TA. Elastic compression stockings for prevention of deep vein thrombosis. Cochrane Database Syst Rev. 2000: CD001484.MedlineGoogle Scholar41 Wille-Jorgensen P, Rasmussen MS, Andersen BR, Borly L. Heparins and mechanical methods for thromboprophylaxis in colorectal surgery. Cochrane Database Syst Rev. 2003: CD001217.MedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Xiao W, Zhou W, Chen X, Zhu J, Xue Q and Shi J (2021) Analgesic effect of intercostal nerve block given preventively or at the end of operation in video-assisted thoracic surgery: a randomized clinical trial, Brazilian Journal of Anesthesiology (English Edition), 10.1016/j.bjane.2021.07.010, Online publication date: 1-Jul-2021. Handa A, Khanna R, Tendolkar M and Singh S (2021) Post-nephrectomy pulmonary thromboembolism, Medical Journal Armed Forces India, 10.1016/j.mjafi.2021.02.001, Online publication date: 1-Apr-2021. Makó K (2021) Current Recommendations for the Management of Cancer-Associated Venous Thromboembolism, Journal Of Cardiovascular Emergencies, 10.2478/jce-2021-0009, 7:2, (27-38), Online publication date: 1-Jun-2021., Online publication date: 1-Jun-2021. Muñoz Martín A, Gallardo Díaz E, García Escobar I, Macías Montero R, Martínez-Marín V, Pachón Olmos V, Pérez Segura P, Quintanar Verdúguez T and Salgado Fernández M (2020) SEOM clinical guideline of venous thromboembolism (VTE) and cancer (2019), Clinical and Translational Oncology, 10.1007/s12094-019-02263-z, 22:2, (171-186), Online publication date: 1-Feb-2020. García Escobar I, Antonio Rebollo M, García Adrián S, Rodríguez-Garzotto A and Muñoz Martín A (2016) Safety and efficacy of primary thromboprophylaxis in cancer patients, Clinical and Translational Oncology, 10.1007/s12094-016-1500-6, 19:1, (1-11), Online publication date: 1-Jan-2017. Choi Y, Jo Y, Jung W and Lee M (2016) Ultrasound-guided superficial cervical plexus block for carotid endarterectomy in a patient with Lemierre syndrome -A case report-, Anesthesia and Pain Medicine, 10.17085/apm.2016.11.4.345, 11:4, (345-348), Online publication date: 31-Oct-2016. English W, Williams D and Soto F (2016) Thromboembolic Disease in the Bariatric Patient: Prevention, Diagnosis, and Management Bariatric Surgery Complications and Emergencies, 10.1007/978-3-319-27114-9_4, (51-71), . Mulligan M, Berfield K and Abbaszadeh R (2015) Management of Postoperative Respiratory Failure, Thoracic Surgery Clinics, 10.1016/j.thorsurg.2015.07.007, 25:4, (429-433), Online publication date: 1-Nov-2015. Mlodinow A, Khavanin N, Ver Halen J, Rambachan A, Gutowski K and Kim J (2014) Increased anaesthesia duration increases venous thromboembolism risk in plastic surgery: A 6-year analysis of over 19,000 cases using the NSQIP dataset, Journal of Plastic Surgery and Hand Surgery, 10.3109/2000656X.2014.981267, 49:4, (191-197), Online publication date: 4-Jul-2015. Zhang Y, Miao Y, Cheng K, Yue J, Tan X and Liu J (2012) Protein C polymorphism and susceptibility to PTE in China, Blood Coagulation & Fibrinolysis, 10.1097/MBC.0b013e328355a7f2, 23:8, (693-699), Online publication date: 1-Dec-2012. Nason K, Luketich J, Witteman B and Levy R (2011) The Laparoscopic Approach to Paraesophageal Hernia Repair, Journal of Gastrointestinal Surgery, 10.1007/s11605-011-1690-8, 16:2, (417-426), Online publication date: 1-Feb-2012. Kakkar A and Rushton-Smith S (2011) Venous Thromboembolism Pharmacologic Prophylaxis After Major Surgery—Are We Doing Well or Not Well Enough?, Annals of Surgery, 10.1097/SLA.0b013e318208f427, 253:2, (221-222), Online publication date: 1-Feb-2011. Fischer S, Bader A and Sweitzer B (2010) Preoperative Evaluation Miller's Anesthesia, 10.1016/B978-0-443-06959-8.00034-0, (1001-1066), . Okadome M, Saito T, Miyahara D, Yamanaka T, Kuroiwa T and Kurihara Y (2010) Postoperative Pulmonary Embolism Including Asymptomatic Cases in Gynecologic Oncology, International Journal of Gynecological Cancer, 10.1111/IGC.0b013e3181bdbeb5, 20:4, (655-663), Online publication date: 1-May-2010. Patel A, Anraku M, Darling G, Shepherd F, Pierre A, Waddell T, Keshavjee S and de Perrot M (2009) Venous thromboembolism in patients receiving multimodality therapy for thoracic malignancies, The Journal of Thoracic and Cardiovascular Surgery, 10.1016/j.jtcvs.2009.02.028, 138:4, (843-848), Online publication date: 1-Oct-2009. Park B, Messina L, Dargon P, Huang W, Ciocca R and Anderson F (2009) Recent Trends in Clinical Outcomes and Resource Utilization for Pulmonary Embolism in the United States, Chest, 10.1378/chest.08-2258, 136:4, (983-990), Online publication date: 1-Oct-2009. Jung M and Lee H (2009) The treatment of the pulmonary embolism with tissue plasminogen activator - A case report -, Korean Journal of Anesthesiology, 10.4097/kjae.2009.57.6.758, 57:6, (758), . Egawa N, Hiromatsu S, Shintani Y, Kanaya K, Fukunaga S and Aoyagi S (2009) Prevention of Venous Thromboembolism in Thoracic and Cardiovascular Surgery, Asian Cardiovascular and Thoracic Annals, 10.1177/0218492309348639, 17:5, (505-509), Online publication date: 1-Oct-2009. Teachey D (2008) Saddle Pulmonary Embolism as a Complication of Vasectomy, Urology, 10.1016/j.urology.2007.10.031, 71:2, (351.e5-351.e6), Online publication date: 1-Feb-2008. Baroletti S, Munz K, Sonis J, Fanikos J, Fiumara K, Paterno M and Goldhaber S (2007) Electronic alerts for hospitalized high-VTE risk patients not receiving prophylaxis: a cohort study, Journal of Thrombosis and Thrombolysis, 10.1007/s11239-007-0081-1, 25:2, (146-150), Online publication date: 1-Apr-2008. Goldhaber S (2007) Venous thromboembolism risk among hospitalized patients: Magnitude of the risk is staggering, American Journal of Hematology, 10.1002/ajh.20997, 82:9, (775-776), Online publication date: 1-Sep-2007. March 6, 2007Vol 115, Issue 9 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.106.674663PMID: 17339555 Originally publishedMarch 6, 2007 Keywordsembolismanticoagulantsheparinprophylaxisrisk factorsthrombosissurgeryPDF download Advertisement SubjectsAnticoagulantsEpidemiology