Rate Of Deep Venous Thrombosis Research Articles

High Altitude is an Independent Risk Factor for Postoperative Venous Thromboembolism Following Primary Total Knee Arthroplasty: A Large Database Study.

High altitude may induce physiological changes that can predispose patients to venous thromboembolism (VTE), a relatively uncommon, but potentially fatal complication following total knee arthroplasty (TKA). The purpose of this study was to determine if high altitude is an independent risk factor for postoperative VTE following TKA. A large claims database was queried for patients who underwent TKA at high-altitude (≥ 1,219-meters) and low-altitude (≤ 30-meters) using Current Procedural Terminology codes, International Classification of Disease codes, and zip codes. High- and low-altitude cohorts were matched 1:3 by 5-year age range, sex, Charlson comorbidity index (CCI), diabetes mellitus, obesity (body mass index ≥ 30), hypertension, and tobacco use. There were 57,135 patients included in the high-altitude group and 171,322 in the low-altitude group. Outcome measures included 30- and 90-day incidence of VTE, deep venous thrombosis (DVT), and pulmonary embolism (PE). Chi-square was used to determine differences in demographics. Binomial logistic regression was used to determine postoperative rates of VTE, DVT, and PE. The incidence of VTE was significantly greater in the high-altitude versus the low-altitude group at 30-days (OR [odds ratio] 1.15 [95% CI (confidence interval) 1.02 to 1.30], P = 0.022) and 90-days (OR 1.20 [95% CI 1.08 to 1.34], P = 0.0007). The incidence of DVT was significantly higher for the high-altitude cohort at both 30- (OR 1.30 [95% CI 1.10 to 1.54], P = 0.002) and 90-days (OR 1.36 [95% CI 1.18 to 1.57], P < 0.0001). The incidence of PE within 30- and 90-days was not significantly different between groups. High altitude (> 1,219-meters) is an independent risk factor for VTE following TKA. Patients who undergo TKA at surgical centers greater than 1,219-meters in elevation are more likely to develop VTE and DVT within 30- and 90-days postoperatively. Surgeons may account for high altitude as a risk factor and determine the most suitable postoperative prophylaxis method for their patients.

IVC filter use in patients with a history of venous thromboembolism undergoing bariatric surgery: a MBSAQIP study.

Research on the use of prophylactic inferior vena cave filter (IVCF) placement prior to metabolic and bariatric surgery (MBS) in high risk patients has yielded conflicting results. We evaluated thrombotic events and mortality in patients with a history of venous thromboembolism (VTE) who underwent IVCF placement in anticipation of MBS. We queried the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for all patients undergoing primary sleeve gastrectomy or Roux-en-Y gastric bypass from 2015 to 2019 with a history of VTE. We tabulated yearly IVCF use and compared 30-day rates of deep venous thrombosis (DVT), pulmonary embolism (PE), readmission, mortality, and serious adverse events in patients with and without prophylactic IVCF placement. Multivariate logistic regression was used to assess the relationship between preoperative placement of an IVCF and postoperative outcomes. Of 754,397 patients undergoing MBS, 16,683 (2.2%) had a prior VTE. Placement of IVCF in anticipation of MBS decreased from 285/2245 (10.4%) in 2015 to 85/3750 (2.2%) in 2019 (p < 0.01). The incidence of PE did not differ significantly between patients with prophylactic IVCF vs. those without (0.1% vs 0.5%, p = 0.13). Postoperative DVT was more common in patients who underwent IVCF placement (1.7% vs. 0.8%, p < 0.01). No significant differences were observed in mortality. Preoperative placement of an IVCF was an independent risk factor for development of a postoperative DVT (OR 2.45; 95% CI 1.39-4.32). These data do not support a history of VTE as an indication for prophylactic IVCF placement in anticipation of MBS.

Intraoperative Tranexamic Acid in Radical Cystectomy: Impact on Bleeding, Thromboembolism, and Survival Outcomes.

Perioperative blood transfusion has been reported in > 50% of patients undergoing radical cystectomy (RC). Unfortunately, perioperative blood transfusion (PBT) in patients undergoing RC has been associated with poor oncological outcomes. Tranexamic acid (TXA) use has been proposed to decrease the need for PBT. Here, we seek to investigate the impact of intraoperative TXA on the risk of perioperative bleeding and venous thromboembolism (VTE) in patients undergoing RC. We also investigate its long-term impact on overall survival (OS) and cancer-specific survival (CSS) outcomes. We queried the prospectively maintained Mayo Clinic Radical Cystectomy registry and identified all RC performed for bladder cancer between 1990 and 2021. Primary outcomes assessed include the risk of perioperative bleeding, the need for blood transfusion, and the risk of VTE. Secondary outcomes include the impact of using TXA on OS and CSS. Of 2862 patients with complete available data, 468 received TXA (TXA recipient) and were matched 1:1 for age, neoadjuvant chemotherapy, pathologic staging, and preoperative hemoglobin with a group who did not receive TXA (TXA nonrecipient). TXA recipients experienced less estimated blood loss intraoperatively (median of 600 vs 650) cc and were less likely to need PBT (31% vs 50%, P value < .001) compared with TXA nonrecipients. There was no difference between groups in deep venous thrombosis and pulmonary embolism rates within 90 days of RC. In the adjusted survival model, use of TXA was not independently associated with significant impact on OS or CSS. However, perioperative blood transfusion was associated with poor OS and CSS (P value < .001). TXA use was associated with a significant reduction in estimated blood loss and PBT without increased risk of VTE. In univariable analyses, we observed an association between TXA use and improved OS as well as CSS. However, in multivariable analyses, TXA itself was not independently associated with improved OS or CSS; instead, PBT was. Further studies are warranted to explore strategies for minimizing PBTs and their impact on survival outcomes.

Direct Oral Anticoagulants vs. Heparin for Cancer-Related Stroke: Augmented Meta-Analysis.

Ischemic stroke is common among patients with systemic malignancy, associated with increased risk of neurological deterioration and mortality compared to the general population. Optimal approach to secondary stroke prevention in cancer patients is unclear. In this meta-analysis, we evaluated available data on the use of direct oral anticoagulants (DOACs) and heparin products for stroke prevention in this population. Using the Nested Knowledge AutoLit software, we performed PubMed search in September 2023 for articles reporting the use of antithrombotics for cancer-associated stroke. We conducted systematic review and meta-analysis. We also used a novel computational augmentation method to amplify the sample size to predict the effect before and after sample size augmentation and predict the results of further trials. Among 253 potential studies screened, 7 were eligible for inclusion. 439 patients were treated with DOACs and 3968 with heparin products. Among patients treated with heparin, intracerebral hemorrhage (8.8 % vs 1.6, p=.02), overall hemorrhagic complications (17.9% vs 3.5%, p<.001), and mortality [28.1% vs 23.5%, p<.001] were respectively significantly higher than those reported among patients who received DOAC for cancer-associated ischemic stroke. No significant difference was observed in the rates of recurrent deep venous thrombosis, clinically significant hemorrhage, and clinical outcomes between the treatment groups. Similar results were shown with augmented meta-analysis. This meta-analysis shows DOACs may have efficacy and safety profile similar to heparin products for recurrent stroke prevention in patients with cancer. Given the small number of studies and limited data, findings should be interpreted with caution.

The impact of stent protrusion into the inferior vena cava or jailing of the contralateral iliac vein on the incidence of contralateral deep vein thrombosis following venous stenting.

Iliac vein stenting is the standard of care for patients with pelvic venous disorders secondary to symptomatic iliac vein outflow obstruction. Venous stents are often extended proximally into the inferior vena cava (IVC) which may result in partial or complete coverage of the contralateral iliac vein. The purpose of this investigation is to determine if extension of iliac vein stents into the IVC results in increased risk of contralateral deep venous thrombosis (DVT). We retrospectively reviewed prospectively collected data from 409 patients who underwent iliac vein stenting at the Center for Vascular Medicine (CVM) from 2019 to 2020. Stent type, covered territories, initial and follow-up consults, ultrasound and operative reports were reviewed to assess for incidence of post-implantation DVT. Patients were stratified into three groups: Iliac vein stents which protruded into the IVC, stents that completely covered the orifice of the contralateral iliac vein and those with no stent protrusion into the IVC. Out of 409 patients, the average age was 53.96 ± 13.40 years with 94 males and 315 females. All stents placed were Venovo stents and all iliac vein lesions were non-thrombotic stenoses. The average follow-up period was 14.35 ± 10.09 months. The most common territories stented were the IVC-LCIV-LEIV (n = , 74%) and the IVC-RCIV-REIV (n = , 26%). Stent protrusion and distance into the IVC in millimeters (mm) was the following: Partial protrusion (n = 314, 77%, 27.6 ± 19.1), jailing of the contralateral iliac vein (n = 78, 19%, 45.9 ± 18.6), no protrusion (n = 16, 4%). The overall DVT rate post-implantation was 0.49% (n = 2). No DVTs ipsilateral to the index stent were identified and both DVTs were contralateral DVTs. A hypercoaguable disorder was reported in 6 patients (1.5%). There were no significant differences in prevalence of contralateral DVT between the three groups. (p = .35). The rate of contralateral DVTs post iliac vein stenting with Nitonol based stents is extremely low. Partial or complete coverage of the contralateral iliac vein via stenting does not result in an increased incidence of contralateral DVT in the short-term. Longer follow up is needed to determine if contralateral DVTs occur after long-term implantation.

Antithrombotic prophylaxis following total knee arthroplasty: a level I Bayesian network meta-analysis.

Venous thromboembolism (VTE) is a major concern following total knee arthroplasty (TKA). The optimal pharmacological prophylaxis remains, however, controversial. The present investigation compared several non-vitamin K antagonist oral anticoagulants commonly employed as VTE prophylaxis following TKA. A Bayesian network meta-analysis was conducted to compare apixaban, aspirin, dabigatran, edoxaban, enoxaparin, fondaparinux, and rivaroxaban. The outcomes of interest were to compare the rate of deep venous thrombosis (DVT), pulmonary embolism (PE), and major and minor haemorrhages. This study was conducted according to the PRISMA Extension Statement for Reporting of Systematic Reviews Incorporating Network Meta-Analyses of Health Care Interventions. In March 2024, PubMed, Web of Science, and Google Scholar were accessed with no time constraints. All randomised controlled trials (RCTs) comparing two or more drugs for the prevention of VTE following TKA were considered for inclusion. Data from 29,678 patients were collected. Of them, 67% (19,884 of 29,678 patients) were women. The mean age of the patients was 66.8 ± 2.8years, and the mean BMI was 29.2 ± 1.5kg/m2. There was comparability in age, sex, and BMI at baseline. Apixaban 5mg, dabigatran 220mg, and rivaroxaban 10mg were the most effective in reducing the rate of DVT. Apixaban 5mg, enoxaparin 60mg, and rivaroxaban 40mg were the most effective in reducing the rate of PE. Apixaban 5mg, rivaroxaban 10mg, and apixaban 10mg were associated with the lowest rate of major haemorrhages. Apixaban 5mg and 20mg, and dabigatran 220mg were associated with the lowest rate of minor haemorrhages. Administration of apixaban 5mg demonstrated the best balance between VTE prevention and haemorrhage control following TKA. Level I, network meta-analysis of RCTs.

Thrombotic Long-Term Consequences of SARS-CoV-2 Infection in Patients with Compensated Cirrhosis: A Propensity Score-Matched Analysis of a U.S. Database.

Cirrhosis causes an imbalance in the coagulation pathway and leads to a tendency for both bleeding and clotting. SARS-CoV-2 has been reported to be associated with a hypercoagulable state. This study examines SARS-CoV-2's impact on hemostasis in compensated patients with cirrhosis. We analyzed the US Collaborative Network, which comprises 63 HCOs in the U.S.A. Compensated cirrhosis patients were split into two groups: SARS-CoV-2-positive and -negative. Patients' baseline characteristics were used in a 1:1 propensity score-matched module to create comparable cohorts. We compared the risk of portal vein thrombosis (PVT), deep venous thrombosis (DVT), and pulmonary embolism (PE) at 6 months, and 1 and 3 years. Of 330,521 patients, 27% tested positive and 73% remained negative. After PSM, both cohorts included 74,738 patients. Patients with SARS-CoV-2 had a higher rate of PVT compared to those without at 6 months (0.63% vs 0.5%, p < 0.05), 1 year (0.8% vs 0.6%, p < 0.05), and 3 years (1% vs. 0.7%, p < 0.05), a higher rate of DVT at 6 months (0.8% vs. 0.4%, p < 0.05), 1 year (1% vs. 0.5%, p < 0.05), and 3 years (1.4% vs. 0.8%, p < 0.05), and a higher rate of PE at 6 months (0.6% vs. 0.3%, p < 0.05), 1 year (0.7% vs. 0.4%, p < 0.05), and 3 years (1% vs. 0.6%, p < 0.05). The presence of SARS-CoV-2 infection in patients with compensated cirrhosis was associated with a higher rate of PVT, DVT, and PE at 6 months, and 1 and 3 years.

Patients aged 55 or older undergoing around the knee osteotomy have a higher rate of deep vein thrombosis but not overall early post-operative complications.

Osteotomies around the knee have been established as an effective method for treating varus or valgus malalignment associated with other knee pathologies in young and middle-aged patients. There is limited literature regarding the risks and complications based on patient age. The purpose of this study is to determine whether age influences as a risk factor for developing intraoperative and early post-operative complications in patients undergoing osteotomies around the knee. A consecutive series of patients over 18 years old who underwent distal femoral osteotomy (DFO) or high tibial osteotomy (HTO) with a minimum follow-up period of 90 days were included. Demographic characteristics, surgical technique, intraoperative and post-operative complications up to 90 days were identified. A statistical comparison based on age younger than 55 years or 55 years and older was conducted to determine if patient age acted as a risk factor in the development of complications. A total of 159 osteotomies were included, of which 129 were HTOs. The average age was 46.16 years, and 118 patients were younger than 55 years. Seven hinge fractures were identified as the only intraoperative complication, while the overall early post-operative complication rate was 11.32%. The most frequent was deep venous thrombosis (DVT) in 5.66% of cases, followed by deep infection with a total rate of 2.52%. When performing the subgroup analysis by age, we observed a significantly higher rate of DVT in the group aged 55 years and older (p 0.036) (odds ratio 3.96 95% confidence interval 1.009-15.533; p 0.048); however, no significant differences were observed in the overall complication rate according to the age group of the patients. This study reveals that in patients undergoing osteotomies around the knee, the most common post-operative complication was DVT. The rate of DVT was significantly higher in patients aged 55 years and older, although no differences were observed in the overall complication rate according to the patients' age range. Level III (retrospective cohort study).

Two big bones, one big decision: When to fix bilateral femur fractures

PurposeFor polytrauma patients with bilateral femoral shaft fractures (BFSF), there is currently no consensus on the optimal timing of surgery. This study assesses the impact of early (≤ 24 h) versus delayed (>24 h) definitive fixation on clinical outcomes, especially focusing on concomitant versus staged repair. We hypothesized that early definitive fixation leads to lower mortality and morbidity rates. MethodsThe 2017–2020 Trauma Quality Improvement Program was used to identify patients aged ≥16 years with BFSF who underwent definitive fixation. Early definitive fixation (EDF) was defined as fixation of both femoral shaft fractures within 24 h, delayed definitive fixation (DDF) as fixation of both fractures after 24 h, and early staged fixation (ESF) as fixation of one femur within 24 h and the other femur after 24 h. Propensity score matching and multilevel mixed effects regression models were used to compare groups. Results1,118 patients were included, of which 62.8% underwent EDF. Following propensity score matching, 279 balanced pairs were formed. EDF was associated with decreased overall morbidity (12.9% vs 22.6%, p = 0.003), lower rate of deep venous thrombosis (2.2% vs 6.5%, p = 0.012), a shorter ICU LOS (5 vs 7 days, p < 0.001) and a shorter hospital LOS (10 vs 15 days, p < 0.001). When compared to DDF, early staged fixation (ESF) was associated with lower rates of ventilator acquired pneumonia (0.0% vs 4.9%, p = 0.007), but a longer ICU LOS (8 vs 6 days, p = 0.004). Using regression analysis, every 24-hour delay to definitive fixation increased the odds of developing complications by 1.05, postoperative LOS by 10 h and total hospital LOS by 27 h. ConclusionEarly definitive fixation (≤ 24 h) is preferred over delayed definitive fixation (>24 h) for patients with bilateral femur shaft fractures when accounting for age, sex, injury characteristics, additional fractures and interventions, and hospital level. Although mortality does not differ, overall morbidity and deep venous thrombosis rates, and length of hospital and intensive care unit stay are significantly lower. When early definitive fixation is not possible, early staged repair seems preferable over delayed definitive fixation.

Risk of deep venous thrombosis associated with peripherally inserted central catheter: A retrospective cohort study of 11.588 catheters in Brazil.

Deep Venous Thrombosis (DVT) due to Peripherally Inserted Central Catheter (PICC) is one of the most threatening complications after device insertion. To assess the rate of PICC-associated DVT and analyze the risk factors associated with this event in cancer and critically ill patients. We conducted a descriptive, retrospective cohort study with 11,588 PICCs from December 2014 to December 2019. Patients ≥ 18 years receiving a PICC were included. Pre-and post-puncture variables were collected and a logistic regression was used to identify the independent factors associated with the risk of DVT. The DVT prevalence was 1.8% (n = 213). The median length of PICC use was 15.3 days. The median age was 75 years (18; 107) and 52% were men, 53.5% were critically ill and 29.1% oncological patients. The most common indications for PICC's were intravenous antibiotics (79.1%). Notably, 91.5% of PICC showed a catheter-to-vein ratio of no more than 33%. The tip location method with intracavitary electrocardiogram was used in 43%. Most catheters (67.9%) were electively removed at the end of intravenous therapy. After adjusting for cancer profile ou chemotherapy, regression anaysis revealed that age (OR 1.011; 95% CI 1.002-1.020), previous DVT (OR 1.96; 95% CI 1.12-3.44) and obstruction of the device (OR 1.60; 95% CI 1.05-2.42) were independent factors associated with PICC-associated DVT, whereas the use of an anticoagulant regimen was a protective variable (OR 0.73; 95% CI 0.54-0.99). PICC is a safe and suitable intravenous device for medium and long-term therapy, with low rates of DVT even in a cohort of critically ill and cancer patients.

Morbidity and Mortality Following Total Hip and Knee Arthroplasty With Spinal Versus General Anesthesia: A Retrospective Analysis

BackgroundThe optimal anesthetic mode in total joint arthroplasty (TJA) has yet to be clearly identified. Patients undergoing TJA may recieve spinal anesthesia (SA) or general anesthesia (GA). While arthroplasty literature indicates differences in postoperative morbidity, hip fracture literature does not show clear superiority of SA or GA. The purpose of this study was to further investigate this relationship and determine if there is a significant difference in morbidity and mortality between GA and SA in patients undergoing primary total joint arthroplasty. MethodsPatients undergoing primary THA or TKA from February 2007 to February 2021 were retrospectively reviewed, creating four cohorts: THA/GA (n = 1,266), THA/SA (n = 1,084), TKA/GA (n = 882), and THA/SA (n = 2,067). Readmission within 90 days, mortality within 365 days, and thromboembolic events within 30 days postoperatively were compared using logistic regression, controlling for age, body mass index, and Charlson Comorbidity Index. ResultsThe odds of experiencing a deep venous thrombosis within 30 days postoperatively were elevated in the analysis of both the THA/GA (odds ratio (OR) = 3.1; 95% confidence interval (CI): 1.5 to 7.0; P = .004) and the TKA/GA (OR = 1.9; 95% CI: 1.2 to 3.0; P = .005) groups. Similarly, the risk of pulmonary embolism as higher in the THA/GA cohort (OR = 3.9; 95% CI: 1.2 to 17.3; P = .04). There were also higher odds of mortality within 365 days postoperatively in THA/GA patients (OR = 4.3; 95% CI: 1.7 to 13.0; P = .004). No other differences existed among TKA patients. ConclusionsBased upon these data, both SA and GA are reasonable options for primary TKA with similar risk profiles. However, GA may be associated with higher rates of deep venous thrombosis in TJA and pulmonary embolism in THA. General anesthesia (GA) was also loosely associated with increased mortality within 1 year of THA, but this result should be considered with caution. Level of evidence3.

Neoplastic pathologic hip fractures are associated with a higher risk of post-operative bleeding and thromboembolic events

IntroductionSurgical treatment of hip fractures leads to significant post-operative complications. Although pathologic fractures (PF) are associated with worse outcomes, most studies do not differentiate between etiology (neoplastic and non-neoplastic PF). We seek to compare 30-day complication rates between 1) native hip fractures and neoplastic PF, and 2) neoplastic and non-neoplastic PF. Materials and methodsA total of 127,819 patients with hip fractures and 5104 with PF diagnosed from 2005 to 2021 were retrieved from the NSQIP database. We included 1843 patients with neoplastic PF and 3261 with non-neoplastic PF. Demographics, pre-operative labs and co-morbidities, and post-operative outcomes were analyzed. Propensity-score matching was conducted to control for confounders. ResultsPatients with a neoplastic PF had a significantly higher rate of deep venous thrombosis (DVT) (4 % vs 1.2 %, p = 0.001) and pulmonary embolism (PE) (2.4 % vs 0.7 %, p < 0.001), than native hip fractures. Rates of post-operative bleeding were significantly higher in the neoplastic PF group (29.3 % vs 23.9 %, p < 0.001) than non-neoplastic PF. No differences in soft tissue complications were found. When comparing neoplastic and non-neoplastic PF, the former had a higher rate of PE (2.5 % vs 1.0 %, p = 0.015) and post-operative bleeding (27.6 % vs 22.0 %, p = 0.009). Unplanned readmission rates and 30-day mortality rate were also higher in the neoplastic PF group. ConclusionNeoplastic PF of the hip are associated with higher risk of thromboembolic event rates and post-operative bleeding than both native hip fractures and non-neoplastic PF. No differences in rates of soft tissue complications were found between groups.

Autologous cell salvage in off-pump coronary artery bypass surgery reduces post-operative complications: a retrospective weighted-matching analysis.

Blood transfusion plays a crucial role in coronary artery bypass grafting (CABG). The choice between autologouscell saver (CS) and allogenic blood transfusion (ABT) has been a continuous debate in the medical community, especially within cardiac surgery. This study aimed to assess the outcomes of off-pump CABG (OPCAB) surgery in patients receiving blood solely via cell salvage compared to those receiving ABT or a combination of ABT and CS perioperatively. A total of 414 patients who underwent isolated OPCAB surgery at our cardiovascular clinic were analyzed. Among them, 250 patients (60.4%) received blood via CS alone, while 164 patients (39.6%) received either ABT or a mix of ABT and CS. Stabilized inverse probability treatment weighted (IPTW) matching technique ensured balance in baseline covariates. We found no significant differences in 30-day mortality rates between the CS and ABT groups. The CS group displayed significantly lower rates of overall complications, encompassing stroke, acute kidney injury, atrial fibrillation, and pulmonary complications. Rates of sepsis, readmission, gastrointestinal complications, heparin-induced thrombosis, and deep venous thrombosis were comparable between the two groups. However, in contrast to the ABT group,the CS group exhibited significantly shorter median lengths of hospital stay (LOHS), ICU stay, andventilation time, along with higher rates of discharge to homerather than acute care facilities. Our data suggest that autologous blood transfusion via CS results in fewer perioperative complications and faster recovery following OPCAB procedures as compared to ABT.

Delayed Closure of Guillotine Lower Extremity Amputation in Obese Patients is Associated with Increased Mortality

OBJECTIVEStaged surgery with open guillotine amputation (OGA) prior to a definitive major lower extremity amputation (LEA) has been shown to be effective for sepsis control and improving wound healing. Studies have evaluated postoperative complications including infection, return to the operating room for re-amputation, and amputation failure following OGA. However, the role of timing to close OGA for predictive outcomes remains poorly understood. We aim to assess outcomes of major LEA related to the time of OGA closure. METHODSData from patients who underwent major LEA from 2015 to 2021 was collected retrospectively. The study included all patients undergoing below-, through-, or above-knee amputations. Next, patients who had OGA prior to a definitive amputation were selected. Patients who died before amputation closure were excluded. Post-amputation outcomes such as surgical site infection (SSI), postoperative sepsis, postoperative ambulation, hospital length of stay (LOS), and 30-day, 1-year, and 5-year mortality were reviewed. The study cohort was stratified by demographics and comorbidities. Receiver operating characteristic (ROC) curve analysis was performed to determine the time of closure (TOC) cut-off value. Univariate and multivariate analysis was performed to assess outcomes. Statistical significance was set at p < 0.05. RESULTOf 688 patients who underwent major LEA, 322 underwent staged amputation with OGA before the formalization procedure and were included. The TOC ranged from 1-47 days with a median of 4 days (interquartile range (IQR) from 3 to 7). The optimal TOC point of 8 days (ranging from 2 - 42 days) in obese patients (199/322) for predicting mortality showed the largest area under the curve (AUC) (0.709) with 64.71% sensitivity and 78.3% specificity. Patients who are obese and grouped in TOC less than 8 days had no 30-day mortality, significantly lower 1-year mortality, better survival, and a lower rate of deep venous thrombosis (DVT) complication. There was no significant difference in LOS, postoperative SSI, sepsis, and ambulation between the two subgroups of obese patients. Multivariable analysis showed that gender, CKD, and postoperative ambulation independently predict overall mortality in obese patients. CONCLUSIONTOC cutoff in obese patients showed statistically significant results in predicting mortality. Our findings indicated better survival in obese patients with a lower TOC (less than 8 days). This emphasizes the importance of earlier closure of OGA in obese patients.

(095) Comparative Analysis of Absolute Risk in Testosterone versus Clomiphene Therapy: A Bayesian Analysis of Adverse Effects

Abstract Introduction Clomiphene is a selective estrogen receptor modulator used to induce ovulation by increasing luteinizing (LH) and follicle-stimulating hormone (FSH) levels. Since the 1970’s, it has been used in males with hypogonadism as an alternative to testosterone therapy as it does not suppress the hypothalamic-pituitary-gonadal axis. Objective While there have been systematic reviews looking at the effectiveness of clomiphene, we sought to better characterize the average testosterone levels, as well as the rate of deep venous thrombosis (DVT), myocardial infarction (MI), stroke, and polycythemia in clomiphene vs. testosterone users. Methods We performed a retrospective chart review for 537 men with a hypogonadism diagnosis that were seen by two urology providers at our center. Of these 537 patients, 84 presented with prior use or were prescribed clomiphene. We measured the incidence of DVT, MI, stroke, polycythemia and average testosterone levels with clomiphene. Statistical analysis was conducted using both a beta binomial and linear model. Results Patients receiving testosterone (n=217) versus clomiphene (n=84) demonstrated a 99% chance of higher mean levels of testosterone (Difference=216.55, 95% CrI = 20.67-408.16). Among those taking testosterone or clomiphene at the final visit (N=237; testosterone n=185; clomiphene=52) adverse events included, polycythemia (n=28), one DVT, VTE’s (n=4), MI’s (n=4), and strokes (n=4). The absolute risk (AR) of experiencing at least one of these events (i.e. polycythemia, DVT, VTE, MI or stroke) was 13.8% (95% CrI = 10.1-17.9%) and 3.1% (95% CrI = 0.44-9.4%) for testosterone and clomiphene respectively (Absolute Risk Difference (ARD) = 10.5% (95% CrI = 3.4-15.7%); Posterior Probability (ARD&amp;gt;0) &amp;gt; 0.99. The AR of polycythemia was 12.6% (95% CrI = 8.9-16.7%) and 1.5% (95% CrI = 0.1-7.4%) for testosterone and clomiphene respectively (ARD = 10.7% (95% CrI = 4.3-15.6%); Posterior Probability (ARD &amp;gt; 0) &amp;gt; 0.99. The AR of stroke was 0.94% (95% CrI = 0.14-2.98%) and 1.56% (95% CrI = 0.1-7.4%) for testosterone and clomiphene respectively (ARD = -0.6% (95% CrI = -6.5-2.1%); Posterior Probability (ARD &amp;lt; 0) = 0.64. The AR of MI was 1.4% (95% CrI=0.33-3.8%) and 1.5% (95% CrI=0.1-7.4%) for testosterone and clomiphene respectively (ARD = 1.3% (95% CrI = -0.36-3.73%); Posterior Probability (ARD &amp;gt; 0) = 0.96. The AR of DVT was 0.37% (95% CrI = 0.01-1.99%) and &amp;lt;0.00001% (95% CrI = &amp;lt;0.00001-1.6%) for testosterone and clomid respectively (ARD = 0.30% (95% CrI = -1.24-1.92%); Posterior Probability (ARD &amp;gt; 0) = 0.88. Conclusions The absolute risk of experiencing at least one of the events was found to be significantly higher in patients receiving testosterone compared to those receiving clomiphene. The results should be interpreted with caution, given the broad credible intervals due to its small size. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Consultant for AbbVie, Marius, Tolmar, Endo, Petros, Boston Scientific, Coloplast Investor: Sprout.

Increase in venous thromboembolism in SARS-CoV-2 infected lung tissue: proteome analysis of lung parenchyma, isolated endothelium, and thrombi.

COVID-19 pneumonia is characterized by an increased rate of deep venous thrombosis and pulmonary embolism. To better understand the pathophysiology behind thrombosis in COVID-19, we performed proteomics analysis on SARS-CoV-2 infected lung tissue. Liquid chromatography mass spectrometry was performed on SARS-CoV-2 infected postmortem lung tissue samples. Five protein profiling analyses were performed: whole slide lung parenchyma analysis, followed by analysis of isolated thrombi and endothelium, both stratified by disease (COVID-19 versus influenza) and thrombus morphology (embolism versus in situ). Influenza autopsy cases with pulmonary thrombi were used as controls. Compared to influenza controls, both analyses of COVID-19 whole-tissue and isolated endothelium showed upregulation of proteins and pathways related to liver metabolism including urea cycle activation, with arginase being among the top upregulated proteins in COVID-19 lung tissue. Analysis of isolated COVID-19 thrombi showed significant downregulation of pathways related to platelet activation compared to influenza thrombi. Analysis of isolated thrombi based on histomorphology shows that in situ thrombi have significant upregulation of coronavirus pathogenesis proteins. The decrease in platelet activation pathways in severe COVID-19 thrombi suggests a relative increase in venous thromboembolism, as thrombi from venous origin tend to contain fewer platelets than arterial thrombi. Based on histomorphology, in situ thrombi show upregulation of various proteins related to SARS-CoV-2 pathogenesis compared to thromboemboli, which may indicate increased in situ pulmonary thrombosis in COVID-19. Therefore, this study supports the increase of venous thromboembolism without undercutting the involvement of in situ thrombosis in severe COVID-19.

The incidence and risk factors of proximal lower extremity deep vein thrombosis without pharmacologic prophylaxis in critically ill surgical Taiwanese patients: A prospective study.

Venous thromboembolism (VTE) in critically ill patients has been well-studied in Western countries. Many studies have developed risk assessments and established pharmacological protocols to prevent deep venous thrombosis (DVT). However, the DVT rate and need for pharmacologic VTE prophylaxis in critically ill Taiwanese patients are limited. This study aimed to prospectively determine the DVT incidence, risk factors, and outcomes in critically ill Taiwanese patients who do not receive pharmacologic VTE prophylaxis. We conducted a prospective study in a surgical intensive care unit (SICU) of a tertiary academic medical center in Taiwan. Adult patients admitted to SICU from March 2021 to June 2022 received proximal lower extremities DVT surveillance with venous duplex ultrasound. No patient received pharmacologic VTE prophylaxis. The outcomes were the incidence and risk factors of DVT. Among 501 enrolled SICU patients, 21 patients (4.2%) were diagnosed with proximal lower extremities DVT. In a multivariate regression analysis, hypoalbuminemia (odd ratio (OR) = 6.061, 95% confidence interval (CI): 1.067-34.421), femoral central venous catheter (OR = 4.515, 95% CI: 1.547-13.174), ICU stays more than 10 days (OR = 4.017, 95% CI: 1.270-12.707), and swollen leg (OR = 3.427, 95% CI: 1.075-10.930) were independent risk factors for DVT. In addition, patients with proximal lower extremities DVT have more extended ventilator days (p = 0.045) and ICU stays (p = 0.044). Our findings indicate critically ill Taiwanese patients have a higher incidence of DVT than results from prior retrospective studies in the Asian population. Physicians who care for this population should consider the specific risk factors for DVT and prescribe pharmacologic prophylaxis in high-risk groups.

Neoadjuvant Chemotherapy is Associated with Increased Risk of Postoperative DVT After Distal Pancreatectomy for Pancreatic Adenocarcinoma: a NSQIP Analysis.

Venous thromboembolism (VTE) remains a persistent source of postoperative morbidity despite prevention and mitigation efforts. Cancer, surgery, and chemotherapy are known risk factors for VTE. Existing literature suggests that neoadjuvant therapy (NAT) may contribute to increased VTE risk in the postoperative period, but few authors specifically examine this relationship in distal pancreatic adenocarcinoma (PDAC). In this study, we analyze the association of NAT and postoperative VTE in patients who underwent distal pancreatectomy (DP) for PDAC. Using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database, we analyzed the Procedure Targeted files for pancreatectomy from 2014 to 2020. Adults with PDAC who underwent DP were grouped by receipt of NAT. The primary outcome was the rate of deep venous thrombosis (DVT) and the secondary outcome was the rate of pulmonary embolism (PE). We performed univariate and multivariate logistic regression analysis to determine risk factors associated with postoperative DVT. There were 4327 patients with PDAC who underwent DP. Of these, 1414 (32.7%) had NAT. Receipt of NAT was significantly associated with postoperative DVT requiring therapy (3.5% vs. 2.3%, p = 0.02), but was not associated with PE (p = 0.42). On MVA, NAT was associated with a 73% greater chance of developing postoperative DVT [odds ratio (OR) 1.73, 95% CI 1.18-2.55]. Patients who receive NAT prior to DP for PDAC are 73% more likely to develop postoperative DVT compared with upfront resection. As NAT becomes more commonplace, these high-risk patients should be prioritized for guideline-recommended extended duration prophylaxis.

Prolonged operative time predicts postoperative deep venous thrombosis in head and neck cancer patients who undergo free flap reconstruction.

This study sought to quantify the deep venous thrombosis (DVT) incidence in head and neck cancer (HNC) patients undergoing free tissue transfer and to identify independent predictors of postoperative DVT. This is a cross-sectional study of the National Surgical Quality Improvement Program database from 2010 through 2020. The sample included all HNC surgical patients treated with free flap reconstruction. The study outcome was the presence of a DVT requiring treatment within 30 days of surgery. Univariate analyses were performed using chi-squared and independent t-tests. A multiple logistic regression model was created using all significant univariate predictors. A total of 3954 patients were identified, of whom 53 (1.3%) experienced a postoperative DVT. The only medical comorbidity associated with DVT was COPD (RR = 2.7 [1.3, 5.4]; p < .01). Operative time longer than 9 hours (RR = 1.9 [1.0, 3.2]; p = .04) and length of stay longer than 10 days (RR = 1.9 [1.1, 3.2]; p = .02) were associated with greater DVT rates. In the multivariate analysis, only COPD (p < .01) and operative time (p = .02) were independently associated with DVT risk. The presence of a DVT was found to increase the relative risk of readmission (RR = 2.1 [1.2, 3.6]; p < .01) and non-home disposition (RR = 2.4 [1.7, 3.5]; p < .01). The incidence of DVT in HNC free flap patients was comparable to what has been reported in the general population of HNC surgery patients. Operative time >9 h and COPD history were independent risk factors for DVT in this subset of patients. Symptomatic DVTs necessitating treatment were accompanied by poorer post-hospitalization outcomes. Level 3.

Epidural analgesia and post-operative ileus after incisional hernia repair with transversus abdominis release: Results of a 5-year quality improvement initiative

IntroductionThe optimal pain management strategy after open ventral hernia repair (VHR) with transversus abdominus release (TAR) is unknown. Opioids are known to have an inhibitory effect on the GI tract and cause postoperative ileus. Epidural analgesia is associated with lower postoperative ileus rates but may contribute to other postoperative complications. A propensity-matched retrospective review published by our group in 2018 found that epidural analgesia was associated with an increased length of stay and any postoperative complication after VHR. Epidural analgesia was therefore abandoned by our group following this publication. We aimed to determine if discontinuation of epidural analgesia affected ileus rates after open VHR. MethodsPatients who underwent open VHR with TAR from August 2014 to January 2022 ​at Cleveland Clinic Foundation with at least 30-day follow-up were retrospectively identified using the Abdominal Core Health Quality Collaborative registry. Patients with and without epidural analgesia were compared. The primary outcome was post-operative ileus. Additional outcomes included length of stay, deep venous thrombosis (DVT), pneumonia, wound complications and pain requiring intervention. ResultsA total of 2570 patients were included: 420 had an epidural, 2150 did not. Preoperative patient and hernia characteristics were similar between both groups. Mean hernia width was 15.5 ​cm in the epidural group and 16.1 ​cm in the no epidural group. In the epidural group, ileus was seen in 9 of 420 (2.15%) of patients which was significantly less than in the no epidural group, 400 of 2150 (18.6%), p=>0.001. On multivariate analysis, epidurals were predictive of lower risk of ileus (OR 0.04, 95%CI 0.01–0.17, p ​= ​0.001) and pain requiring intervention (OR 0.02, 95%CI 0.00–0.71, p ​= ​0.02). Epidural analgesia was not associated with increased DVT rates, pneumonia, length of stay, SSI, or SSOPI. DiscussionDiscontinuation of epidural analgesia was associated with a 9-fold increase in ileus rates after VHR with TAR. Epidurals may play an important role in limiting postoperative opioid use and therefore reducing risk of ileus. Other postoperative complications including pneumonia and venous thrombosis were not impacted by epidurals. Further prospective studies are needed to further define a ventral hernia patient population who will benefit from epidural analgesia.