Postoperative Thromboprophylaxis Research Articles

Acetylsalicylic acid alone or in combination with either enoxaparin or unfractionated heparin for postoperative thromboprophylaxis in coronary artery bypass surgery patients. A randomised clinical trial assessing surrogate outcomes

IntroductionCoronary artery bypass graft surgery has considerable effects on patient haemostasis. Heparins as thromboprophylaxis may be beneficial but may also increase the risk of bleeding complications. ObjectivesTo assess the effects of heparins on haemostasis in post-coronary artery bypass graft patients. MethodsAcross one year, we randomised 60 participants scheduled for an elective coronary artery bypass graft-procedure with or without aortic valve replacement. The trial was a prospective, open-label (though blinded for the laboratory), randomised, single-centre trial with three intervention groups (n = 20 in each): group 1 received acetylsalicylic acid, group 2 received subcutaneous low molecular weight heparin and acetylsalicylic acid, and group 3 received intravenous unfractionated heparin and acetylsalicylic acid. Primary outcomes were platelet activation (Multiplate® ASPI-test) and time to clot initiation (TEG® R-time). We secondly assessed several additional Multiplate® and TEG® parameters. ResultsGroup 3 (intravenous unfractionated heparin) compared with group 1 (acetylsalicylic acid alone) showed evidence of 1) increased clot initiation time (R-time + 0.9 min; 95 % CI: +0.4 to +1.4 min; P = 0.009), and 2) decreased 30-min lysis (−1.3 %; 95 % CI: −2.1 to −0.5 %; P = 0.02). The remaining analyses of primary and secondary outcomes showed no evidence of a difference between the three groups. DiscussionIntravenous unfractionated heparins may increase the clot initiation time post-operatively after coronary artery bypass graft surgery and reduce lysis. Otherwise, there seems to be no effect of low molecular weight or unfractionated heparin on haemostatic parameters after coronary artery bypass surgery patients.

Thromboprophylaxis in oesophageal cancer patients—a study protocol for a randomised, controlled trial (TOP-RCT)

BackgroundThe purpose of the study is to examine if prolonged thromboprophylaxis decreases the risk of thrombosis after intended curative surgery for oesophageal cancer.Study results are expected to inform a guideline for thromboprophylaxis after oesophageal cancer surgery. The perspective is to reduce morbidity and mortality in this critically ill patient group.Thrombosis is the second-most common cause of cancer death after the cancer itself. The risk of thrombosis depends on the cancer type, and upper gastrointestinal cancers are considered high risk. This risk is further increased when patients undergo surgery. However, only few studies have investigated the peri- and postoperative coagulation profile in oesophageal cancer patients. Due to this lack of knowledge, prophylaxis is currently restricted to 5000 IU (international units) low-molecular weight heparin daily from surgery until discharge from hospital (approximately 10 days), whereas patients with gastric cancer receive 30 days of treatment.The present study examines whether a 30-day treatment is superior and safe, compared with the current standard treatment.MethodsThe study is a randomised controlled trial. Inclusion is ongoing, and we aim to include 100 patients. Blood samples are drawn before and after surgery, and the coagulation is extensively examined. The primary endpoint is the difference in plasma levels of prothrombin fragment 1 + 2 (F1 + 2) 30 days after surgery between the intervention and the standard group. Furthermore, patients are examined with ultrasound to screen for asymptomatic venous thrombotic events (VTE).Secondary endpoints are incidence of bleeding, symptomatic and asymptomatic VTE and mortality 30 days 1 one year after surgery.DiscussionThe study will provide valuable information on the perioperative coagulation profile and VTE risk of oesophageal cancer patients. The study seeks to aid in optimising the postoperative thromboprophylaxis, and the perspective is to reduce morbidity and mortality in this at-risk patient population.Trials registrationThe trial was prospectively registered at the EU Clinical Trials Register with ID 2021–001335-24 on 30 June 2021 and at ClinicalTrials.gov with study identifier NCT05067153.

Rivaroxaban for Postoperative Pharmacologic Thromboprophylaxis After Bariatric Surgery.

Rivaroxaban for Postoperative Pharmacologic Thromboprophylaxis After Bariatric Surgery.

Avoiding the needle: A quality improvement program introducing apixaban for extended thromboprophylaxis after major gynecologic cancer surgery

ObjectivePatients undergoing gynecologic cancer surgery at our centre are recommended up to 28 days of enoxaparin for extended post-operative thromboprophylaxis (EP). Baseline survey revealed 92% patient adherence, but highlighted negative effects on patient experience due to the injectable route of administration. We aimed to improve patient experience by reducing pain and bruising by 50%, increasing adherence by 5%, and reducing out-of-pocket cost after introducing apixaban as an oral alternative for EP. MethodsIn this interrupted time series quality improvement study, gynecologic cancer patients were offered a choice between apixaban (2.5 mg orally twice daily) or enoxaparin (40 mg subcutaneously once daily) at time of discharge. A multidisciplinary team informed project design, implementation, and evaluation. Process interventions included standardized orders, patient and care team education programs. Telephone survey at 1 and 6 weeks and chart audit informed outcome, process, and balancing measures. ResultsFrom August to October 2022, 127 consecutive patients were included. Apixaban was chosen by 84%. Survey response rate was 74%. Patients who chose apixaban reported significantly reduced pain, bruising, increased confidence with administration, and less negative impact of the medication (p < 0.0001 for all). Adherence was unchanged (92%). The proportion of patients paying less than $125 (apixaban cost threshold) increased from 45% to 91%. There was no difference in bleeding and no VTE events. ConclusionsIntroduction of apixaban for EP was associated with significant improvement in patient-reported quality measures and reduced financial toxicity with no effect on adherence or balancing measures. Apixaban is the preferred anticoagulant for EP at our centre.

Risk Factors for Anemia Exacerbation Requiring Red Blood Cell Transfusion During Edoxaban Thromboprophylaxis After Orthopedic Surgery.

Background An increased risk of anemia during edoxaban thromboprophylaxis in orthopedic surgery has been reported. However, the risk factors for the exacerbation of anemia requiring transfusion with irradiated red blood cell concentrates during postoperative edoxaban thromboprophylaxis remain unknown. Therefore, this study investigated the factors that increase the possibility of transfusion during edoxaban thromboprophylaxis after orthopedic surgery by reanalyzing clinical data from a previous collection. Methods A total of 221 patients who underwent total hip or knee arthroplasty at a single center between July 2011 and June 2012 were included in this study. Among these, 167 patients who received 30 mg of postoperative edoxaban thromboprophylaxis were retrospectively analyzed to identify critical factors for transfusion during edoxaban thromboprophylaxis after orthopedic surgery. Results Lower preoperative hemoglobin levels and higher intraoperative blood loss per body weight were significantly associated with an increase in the frequency of transfusion during postoperative edoxaban thromboprophylaxis. These factors were also potentially related to increased coagulation parameters during edoxaban thromboprophylaxis. Conclusion Our study shows that lower preoperative hemoglobin levels and higher intraoperative blood loss are associated with increased coagulation parameters with edoxaban thromboprophylaxis after orthopedic surgery and may lead to worsening of anemia, thereby requiring blood transfusion.

Splenomegaly and Response to Splenectomy in Immune Thrombocytopenia.

Background: Immune thrombocytopenia (ITP) is an acquired autoimmune disorder affecting patients of all ages and backgrounds. While current standards favor medical therapy in the frontline setting, splenectomy remains an integral part of treatment in refractory cases. Ideal parameters for patient selection for surgery remain elusive. Methods: Data for 40 adult patients undergoing splenectomy for ITP at a large urban center between 1 January 2010 and 1 July 2021 were collected and analyzed. Results: Most patients underwent uneventful laparoscopic splenectomy (95%). Complete or partial response at the time of last follow-up occurred in most patients (92.5%), with 60.0% requiring no additional medical therapy following surgery. Thrombosis was the predominant adverse event and the leading cause of death for two patients. Age and presence of splenomegaly appear to be associated with response to splenectomy. Conclusions: Splenectomy remains an effective therapy for selected patients with ITP. Predictors of positive response to splenectomy, such as younger age and the presence of splenomegaly, may help inform clinicians during patient selection for therapy. With strict attention paid to postoperative thromboprophylaxis, the diminishing use of splenectomy may not be warranted.

Characteristics of Patients Not Receiving Chemical Thromboprophylaxis Following Foot and Ankle Surgery: Data From the Multicenter, Prospective UK Foot and Ankle Thrombo-Embolism Audit (UK-FATE).

Although the rate of venous thromboembolism (VTE) after foot and ankle surgery is low, multiple factors influence risk for individual patients. Furthermore, there are no clear guidelines on which patients may benefit from chemical thromboprophylaxis. Our aim was to assess patients not treated with chemical thromboprophylaxis after foot and ankle surgery, and to report on their specific patient and surgical risk factors for VTE. This was a multicenter, prospective, national audit of patients undergoing foot and ankle surgery (including Achilles tendon ruptures) from 68 participating UK centers. The study was conducted between June 1, 2022, and November 30, 2022, with a further 3-month follow-up. Following data cleansing, 3309 patients were included who did not receive postoperative thromboprophylaxis. Most patients were elective cases (2589 patients, 78.24%) with ASA grade I or II (2679 patients, 80.96%), fully weightbearing postoperatively (2752 patients, 83.17%), and either without ankle splintage, or splinted in a plantigrade boot (2797 patients, 84.53%). The VTE rate was 0.30% overall (11 cases), with no VTE-related mortality. No single demographic, surgical, or postoperative factor was associated with reduced risk of VTE. However, patients who had elective or trauma surgery not involving the ankle, who were ASA grade I or II and who were weightbearing immediately postoperatively (without splinting or in a plantigrade boot) had a VTE rate of 0.05% (1 of 1819 patients), compared with 0.67% (10 of 1490 patients, P = .002). Patients not receiving chemical thromboprophylaxis had a low incidence of symptomatic VTE, although they do represent a curated group considered lower risk. Within this group we describe characteristics associated with a substantially lower risk of VTE. All patients should be assessed on an individual basis, and further work is required to substantiate our findings.

Variations in Perioperative Thromboprophylaxis Practices: Do the Guidelines Need a Closer Look?

BackgroundIn 2022, the American Association for Thoracic Surgery (AATS) and the European Society of Thoracic Surgeons (ESTS) published joint guidelines regarding the timing, duration, and choice of agent for perioperative venous thromboembolism prophylaxis for thoracic cancer patients. Now, 1 year after their release, we looked to assess practices and general adherence to these recommendations. MethodsWe conducted a survey among board-certified/board-eligible thoracic surgeons in the United States, between July and October 2023. ResultsA total of 103 board-certified thoracic surgeons responded to the survey. Over half of the surgeons reported using preoperative chemical thromboprophylaxis routinely for lobectomy/sublobar resections (56.3%), pneumonectomy/extended lung resections (64.1%), and esophagectomy (67%). Over two thirds of thoracic surgeons limited the duration of postoperative chemical thromboprophylaxis to the patient’s length of hospital stay and never administered chemoprophylaxis post-discharge. Among surgeons who always continued chemical thromboprophylaxis post-discharge, low-molecular-weight heparin (LMWH) was the most commonly used agent (>70%), followed by direct oral anticoagulants (13.8%-16.7%). Only 33.3% of surgeons prescribing post-discharge chemical thromboprophylaxis after lobectomy/sublobar resections continued prophylaxis up to 4 weeks postoperatively. ConclusionsContrary to the 2022 joint AATS/ESTS guidelines, the majority of surveyed thoracic surgeons in the United States do not routinely prescribe postoperative thromboprophylaxis after lung and esophageal cancer resections. The dogma of routine extended thromboprophylaxis must be reevaluated as modern minimally invasive thoracic surgery allows for very earlier ambulation and enhanced recovery. There is a need for randomized controlled trials exploring the utility of extended thromboprophylaxis and newer agents such as direct oral anticoagulants.

Safety and efficacy of apixaban vs. enoxaparin in thromboprophylaxis after spinal stenosis and degenerative spine surgery

IntroductionDegenerative spine surgeries often require postoperative immobilization or reduced mobility, predisposing patients to the formation of thrombosis and higher risk of thromboembolic complications. Despite the significance of this issue, there remains a lack of consensus on the optimal anticoagulant agent for postoperative thromboprophylaxis in spinal stenosis and degenerative spine surgeries. Low molecular weight heparins and direct Xa inhibitors represent two anticoagulant groups with high chemoprophylactic potential. MethodsThis study included a prospective cohort of patients undergoing posterior decompressive surgery with or without instrumentation for degenerative spine disease and/or spinal stenosis. Patients receiving postoperative prophylactic Enoxaparin and Apixaban were selected to evaluate the rate of complications, as assessed by Clavien-Dindo classification, thromboembolic events, and 30-day mortality, readmission, and reoperation rate between the two anticoagulants. Results130 patients were included in the analysis. 65 patients received Apixaban and Enoxaparin in each group. Mean age of the participants was 57.6±11.0. 83.1% underwent laminectomy and posterior spinal fusion, while 22 patients underwent decompressive surgery only. The incidence of venous thromboembolism (P-value=0.403), deep vein thrombosis (p-value=0.999), hematoma formation (p-value=0.403), surgical site infection (p-value=0.901), readmission (p-value=0.545), reoperation (p=0.510), mortality (p=0.648), and complications rate (p-value=0.232) were not statistically different between Enoxaparin and Apixaban. DiscussionBoth Apixaban and Enoxaparin may be viable options for postoperative thromboprophylaxis in spine surgeries with comparable efficacy and safety profile. Future research endeavors should investigate the efficacy of these agents in comparison to placebo in a randomized setting.

Efficacy and safety of direct oral anticoagulants versus low-molecular-weight heparin for thromboprophylaxis after cancer surgery: a systematic review and meta-analysis.

Direct oral anticoagulants (DOACs) used as an alternative to low-molecular-weight heparin (LMWH) for thromboprophylaxis after cancer surgery for venous thromboembolic events (VTE) remains unclear. This study aimed to investigate the efficacy and safety of DOACs versus LMWH in these patients. A search of EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science was carried out and included all randomized controlled trials (RCTs) and observational studies that directly compared DOACs with LMWH for thromboprophylaxis in patients after cancer surgery through July 25, 2023. The primary efficacy and safety outcomes were VTE, major bleeding, and clinically relevant non-major bleeding (CRNMB) within 30days of surgery. The risk of bias was assessed using the Cochrane Risk of Bias 2 (RoB2) tool for RCTs and ROBINS-I tool for non-randomized studies. This study was registered in PROSPERO (CRD42023445386). We retrieved 5149articles, selected 27 for eligibility, and included 10 studies (three RCTs and seven observational studies) encompassing 3054 patients who underwent postoperative thromboprophylaxis with DOACs (41%) or LMWH (59%). Compared to LMWH thromboprophylaxis, DOACs had a comparable risk of VTE (RR:0.69[95% CI:0.46-1.02], I2 = 0%), major bleeding (RR:1.55 [95% CI:0.82-2.93], I2 = 2%), and CRNMB (RR, 0.89 [95% CI, 0.4-1.98], I2 = 31%) during the 30-day postoperative period. Subgroup analysis of VTE and major bleeding suggested no differences according to study type, extended thromboprophylaxis, tumor types, or different types of DOAC. DOACs are potentially effective alternatives to LMWH for thromboprophylaxis in patients undergoing cancer surgery, without increasing the risk of major bleeding events.

Testing of a risk-stratified patient decision aid to facilitate shared decision-making for extended postoperative thromboprophylaxis after major abdominal surgery for cancer.

Use of extended pharmacologic thromboprophylaxis after major abdominopelvic cancer surgery should depend on best-available scientific evidence and patients' informed preferences. We developed a risk-stratified patient decision aid to facilitate shared decision-making and sought to evaluate its effect on decision-making quality regarding use of extended thromboprophylaxis. We enrolled patients undergoing major abdominopelvic cancer surgery at an academic tertiary care centre in this pre-post study. We evaluated change in decisional conflict, readiness to decide, decision-making confidence, and change in patient knowledge. Participants were provided the appropriate risk-stratified decision aid (according to their Caprini score) in either the preoperative or postoperative setting. A sample size calculation determined that we required 17 patients to demonstrate whether the decision aid meaningfully reduced decisional conflict. We used the Wilcoxon matched-pairs signed ranks test for interval scaled measures. We included 17 participants. The decision aid significantly reduced decisional conflict (median decisional conflict score 2.37 [range 1.00-3.81] v. 1.3 [range 1.00-3.25], p < 0.01). With the decision aid, participants had high confidence (median 86.4 [range 15.91-100]) and felt highly prepared to make a decision (median 90 [range 55-100]). Median knowledge scores increased from 50% (range 0%-100%) to 75% (range 25%-100%). Our risk-stratified, evidence-based decision aid on extended thromboprophylaxis after major abdominopelvic surgery significantly improved decision-making quality. Further research is needed to evaluate the usability and feasibility of this decision aid in the perioperative setting.

Rates of venous thromboembolism and use of thromboprophylaxis after major orthopedic surgery in patients with congenital hemophilia A or B: a systematic review

BackgroundVenous thromboembolism (VTE) is a well-recognized complication after total joint replacement (TJR). Persons with hemophilia A or B are considered at low postoperative VTE risk due to their coagulation factor deficiencies, and administering pharmacologic thromboprophylaxis is often considered contraindicated. However, using factor replacement therapy could increase the postoperative VTE risk. ObjectivesTo analyze best available evidences of VTE rates in persons with hemophilia A or B undergoing lower limb TJR and the use of postoperative pharmacologic thromboprophylaxis. MethodsWe systematically screened 4 online biomedical databases to identify studies reporting VTE rates in patients with hemophilia after TJR. Case reports and case series with less than 10 patients were excluded. ResultsTwenty-six observational studies were included in this systematic review, reporting 1181 TJRs in patients with hemophilia A or B. Eight studies had VTE rates as the primary outcome. Five studies reported screen-detected VTE, while 21 reported symptomatic VTE events. Overall, 17 VTE events were reported (1.4%; 95% CI, 0.9%-2.3%), including 10 (6.6%) after 151 surgeries with postoperative VTE screening and 7 (0.7%) after 1080 surgeries without postoperative screening. Thromboprophylaxis protocols were specified in 21 studies; postoperative thromboprophylaxis was used in 15 (1.3%) surgeries. This information was not available for 29.0% of the analyzed population. ConclusionDespite the low thromboprophylaxis use in patients with hemophilia, rates of symptomatic VTE after TJR appeared to be low. We also highlighted the need to better report the thrombotic outcome in persons with hemophilia to face the ongoing changes in the hemophilia landscape.

Efficacy and Safety of Extended Duration Postoperative Thromboprophylaxis with Low-Molecular-Weight-Heparin Among Subgroups of Patients Undergoing Surgical Resection of Colorectal Cancer: A Post-Hoc Analysis of the Periop-01 Trial

Background: Clinical practice guidelines suggest the use of extended duration of postoperative thromboprophylaxis to prevent venous thromboembolic (VTE) complications after any cancer-related major abdominal or pelvic surgeries. However, recent trials including patients undergoing surgical resection of colorectal cancer have reported relatively low rates of symptomatic VTE. Hence, the risk and benefits of extended postoperative thromboprophylaxis need to be carefully assessed in this patient population. We sought to determine the impact of extended duration thromboprophylaxis with low-molecular-weight-heparin on VTE and bleeding events among different subgroups of patients undergoing surgical resection of localized colorectal cancer. Methods: This is a pre-planned post-hoc analysis of the PERIOP-01 randomized controlled trial which compared extended (up to 6 weeks) to standard duration (in hospital only) of perioperative thromboprophylaxis with tinzaparin (4500 IU SC daily) in patients undergoing surgical resection of localized colorectal cancer. Subgroup analyses were performed based on different baseline characteristics. The primary efficacy and safety outcomes were objectively documented major VTE and combination of major bleeding (MB) and clinically relevant non-major bleeding (CRNMB) events, respectively. Hazard ratios (HR) with 95% confidence intervals (CI) were calculated using the Cox proportional hazards model to compare the treatment effect accounting for clustering at study center level. Results: A total of 614 patients were randomized in the PERIOP-01 trial (307 in the extended and 307 in the standard duration thromboprophylaxis groups). Overall, the mean age of the participants was 61 years, 41% of them were women, and most patients were white (90%). Type of primary cancer was well-balanced with 311 patients having rectal cancer (51%), whereas 303 (49%) had primary colon cancer. During the study period, major VTE events occurred in 2% and 1% of the extended- and standard-duration prophylaxis groups, respectively (P=0.8). Combination of MB and CRNMB events occurred in 3% of each group. No specific characteristics were found to be associated with a decreased risk of major VTE among patients on extended duration thromboprophylaxis (Figure 1). Patients with colon cancer resection receiving extended thromboprophylaxis were at an increased risk of bleeding complication compared to patients with rectal cancer (HR 2.57, 95%CI 1.25-5.3) (Figure 1). Other characteristics that may be associated with an increased risk of bleeding among patient on extended thromboprophylaxis included age &amp;gt;= 75 (HR 2.37, 95%CI 0.47-11.98) and male sex (HR 2.13, 95%CI 0.2-23.17), although these characteristics were not statistically significant. Conclusions: In the PERIOP-01 trial, extended thromboprophylaxis didn't reduce the risk of major VTE in any subgroups of patients. On the other hand, extended duration of thromboprophylaxis may be associated with an increased bleeding risk among male, elderly patients, and those with colon cancer.

Thrombosis Rates and Use of Thromboprophylaxis after Discharge from Gynecologic Cancer-Related Surgery

Background: Cancer and major abdominopelvic surgeries pose significant thrombosis risks, making cancer-related surgery highly susceptible to venous thromboembolism (VTE) despite prophylaxis. Without post-operative thromboprophylaxis (TPX), VTE risk can reach 29% in the weeks following major surgeries. National Comprehensive Cancer Network (NCCN) guidelines recommend anticoagulation for up to 4 weeks after such surgeries, primarily using low molecular weight heparin (LMWH) for 28 days postoperatively. This study aimed to determine VTE rates linked to various gynecologic cancer-related surgeries and explore TPX utilization in a large cancer-center cohort. Additionally, we sought to further understand the necessity for post-discharge TPX in this setting. Methods: Patients (pts) diagnosed with gynecologic cancer between January 1st, 2012, through September 15th, 2022, at our institution were identified through our tumor registry. Using an in-house automated text search tool from our electronic medical record (Epic®), combined with natural language processing review, venous thromboembolism (VTE) events were identified, with secondary adjudication by the study leader (GAS). VTE was defined as either lower extremity deep vein thrombosis (DVT), or pulmonary embolism (PE) diagnosed from the day of surgery until 90 days after the first day of surgery. Logistic regression was performed on binary outcomes for the presence of VTE and TPX use at discharge. Kaplan-Meier curves and Cox regression were used for overall survival analysis. Results: 801 pts who underwent gynecologic cancer-related surgeries were identified. Patient demographics and surgery types are described in Table 1. VTE occurred in 1.9% (n=15) of the overall population but was unequally distributed. The number of VTE in those undergoing minimally invasive surgery (MIS), vulvovaginal surgery, and biopsies collectively was low (0.57%, n=3), even when considering that only 11.1% of those pts received TPX at discharge. VTE was more commonly diagnosed in patients who underwent open surgery (4.3%, n=12), with 5 pts (1.8%) diagnosed before discharge and 7 pts (2.5%) after discharge. In multivariable logistic regression analysis, during the full study period, open procedures were associated with a higher risk of thrombosis, (relative risk 7.5, p &amp;lt; 0.001) and higher use of post-discharge TBX (RR 4.55, p &amp;lt; 0.001). Notably, only 50% (139 of 279) of pts who underwent open surgery received TPX at the time of discharge. Within the open surgery cohort, the rate of post-discharge VTE correlated with the use of post-discharge TPX. Of pts on TPX, 0.7% (n=1) were diagnosed with VTE compared to 4.3% (n=6) of pts who did not receive TPX (RR=0.17, p= 0.12). There was no difference in overall survival in pts who received TPX and those who did not after open surgery up to 36 months after the surgery. Conclusions: Our findings suggest a tiered risk of post-operative VTE after gynecologic cancer surgery, with a clinically relevant risk observed only in women undergoing open surgery. Our gynecologic oncology practice already reflects this, as post-operative TPX is not routinely prescribed for lower-risk procedures. In patients who underwent open surgery, TPX at discharge showed a trend towards a protective effect, although this result did not reach statistical significance, probably due to sample size, it supports the need for a targeted prospective study. If this trend towards benefit holds in a prospective study, the number needed to treat to avoid one clinically detected post-operative VTE would be 28 pts. The relatively high fraction of post-op VTE events during the inpatient hospital stay also supports efforts for early TPX, as has been done with a prophylactic dose of pre-operative unfractionated heparin or LMWH in other high-risk cancer surgery settings (Selby et al, J Am Coll Surg. 2016). The limitations of this study include being conducted at a single institution, retrospective and non-randomized.

UK Foot and Ankle Thrombo-Embolism Audit (UK-FATE): A Multicentre Prospective Study of Venous Thromboembolism in Foot and Ankle Surgery

Category: Other Introduction/Purpose: There is wide variation in the threshold and provision of thromboprophylaxis in the treatment of foot and ankle conditions. One of the difficulties in affecting change in practice in this area is the low incidence of postoperative, symptomatic VTE. Therefore, a large number of patients need to be included in any series for meaningful conclusions to be drawn. Primary objective To observe the UK-wide variation in post-operative thromboprophylaxis, and to analyse the 90-day incidence of symptomatic venous thrombo-embolism related to: -Elective foot and ankle surgery -Trauma foot and ankle surgery -Treatment of Achilles tendon ruptures (operative and non-operative) Methods: This was a multi-centre prospective audit spanning a collection duration of 9 months. Primary outcomes included symptomatic VTE up to 90 days following foot &amp; ankle surgery and Achilles tendon rupture and VTE related mortality up to 90 days following treatment. Secondary outcomes included methods of thromboprophylaxis used, and possible confounding variables and influencing factors for VTE. Results: A total of 10,983 patients were included from 56 sites in the UK. This was split into 51.72% trauma (n=5571), 3.78% diabetic surgery (n=415) and 45.18% elective surgery (n=4962). There was 95 VTE events across the whole cohort (0.86%). Diabetic foot disease surgery had the highest rate of VTE (Below knee amputation 5.3% and acute foot debridement 2.6%). The trauma diagnosis with the highest rate of VTE was Achilles tendon rupture (3.7%). All elective foot procedures had a VTE rate &lt; 1% except elective tendon procedure (1.1%). Factors with statistically significant association with VTE included trauma surgery where prophylaxis stopped greater than 1day pre surgery (p=.027), non-compliance with prophylaxis (p=.001), post-surgical infection (p=.005), and the comorbidities asthma (p=.014), cancer (p=.014), dementia (p=.001), diabetes (p=.005), stroke (p &lt; 0.001) and recent long-distance travel (p=.048). Conclusion: This is a large-scale multicentre study which recorded multiple possible confounding variables. There were 12 different chemical prophylaxis used across the study, with the highest rate of VTE in patients administered Apixaban (4.9%). The most common chemical prophylaxis used in the study was Enoxaparin (27.19%) followed by Dalteparin (20.38%). There was no evidence of a decrease in VTE if mechanical prophylaxis was used. The study identified specific diagnosis with increased risk of VTE and comorbidities.

Significant Variability in Postoperative Thromboprophylaxis in Cushing's Disease Patients: A Survey of the North American Skull Base Society and the AANS/CNS Joint Tumor Section.

Introduction Cushing's disease (CD) is associated with hypercoagulability which is associated with an increased risk of venous thromboembolic events (VTEs) perioperatively. This risk persists even after successful transsphenoidal surgery (TSS). However, there are no current guidelines for pharmacologic thromboprophylaxis in this patient population. Objective Characterize existing thromboprophylaxis management practices in patients undergoing TSS for CD. Methods An anonymous RedCap survey comprised of questions about perioperative thromboprophylaxis in CD patients was distributed via the American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) Joint Tumor Section and the North American Skull Base Society (NASBS) email lists. Results The survey was distributed to 554 members of the AANS/CNS Joint Tumor Section and 1,094 members of NASBS asking that members who surgically treat CD respond. Sixty responses (3.0% response rate) were received. Fifty-two (86.7%) respondents are involved in the postoperative management of CD patients. Thirty-six (69.2%) treat all patients with postoperative VTE chemoprophylaxis, 8 (15.4%) treat some patients, while 8 (15.4%) do not use chemoprophylaxis. Preferred chemoprophylaxis varies as 26 (59.1%) administer low molecular weight heparin, 14 (31.8%) give unfractionated heparin, 1 (2.3%) give direct oral anticoagulants, and 3 (6.8%) give aspirin. Most (28, 53.8%) of the respondents perceive the VTE risk in this patient population to be 0 to 5%, 16 (30.8%) perceive the risk to be 6 to 10%, and 8 (15.4%) perceive it to be 11 to 20%. Conclusion There is great variability in VTE detection and postoperative prevention practice patterns in CD patients. This study highlights the need for prospective studies to clarify optimal pharmacologic chemoprophylaxis strategies and duration in this patient population.

Comparative Study for Portomesentric Venous Thrombosis after Laparoscopic Sleeve Gastrectomy in Morbidly Obese Patients with BMI 35-45 with and without Anticoagulation, Retrospective Study

Abstract Background Portomesentric vein thrombosis is a rare but documented complication of laparoscopic surgery. This rare complication is currently being encountered more frequently with the increase in the rates of laparoscopic bariatric surgery procedures being performed worldwide. Obesity is a worldwide health problem and Bariatric surgery has demonstrated to be an effective and sustainable method for regulation of morbid obesity, especially when it is resistant to both pharmaceuticals and combinations of diet and lifestyle regimens. Aim of the Work This study will evaluate the efficacy of use of anticoagulation after LSG in morbidly obese patients with BMI 35-45, to guard against PVT, through retrospective comparative study. Patients and Methods A retrospective analysis was performed on all sleeve gastrectomies performed in Ain Shams University Hospitals &amp; some other hospitals between January 2020 &amp; January 2021 to identify cases complicated by Portomesentric venous thrombosis. A total of 60 patients underwent LSG between January 2020 &amp; January 2021 were divided into two groups in a retrospective comparative Pilot study with an average BMI 39.53 kg/m2. Patients from the two groups 10 patients underwent laparoscopic cholecystectomy along with LSG. Results There are chemical prophylactic measures can be used pre and post laparoscopic sleeve surgery however, as suggested by some papers post-operative thromboprophylaxis to all patients for 1 week duration and from 3 to 6 months for thrombophilia and high-risk patients, yet specific recommendation regarding VTE prophylaxis after sleeve gastrectomy is in need for prospective trial to guard from developing PVT. Conclusion As a phenomenon with an ambiguous and unpredictable symptom, PMVT should be kept in mind in any patient with unexplained abdominal pain after sleeve gastrectomy; in addition, portal venous phase contrast enhanced studies should always be considered when a diagnostic computerized tomography scan is performed. Strong evidence data about PMVT anticoagulant prophylaxis plan is still lacking, however; extended prophylaxis to 2 weeks in a high-risk patient may lower the PMVT incidence.

Venous thrombosis following endovenous laser ablation with and without thromboprophylaxis

ObjectiveVenous thromboembolism (VTE) occurs infrequently after endovenous laser ablation (EVLA). The purpose of this study was to assess the incidence of VTE after EVLA with and without pharmacologic prophylaxis. MethodsFrom October 2019 to March 2020, a series of consecutive patients from the prospectively maintained VEINOVA (vein occlusion with various techniques) registry was retrospectively analyzed. All the patients underwent EVLA with and without postoperative thromboprophylaxis. A 1470-nm laser wavelength with a radial fiber was used for EVLA. Concomitant phlebectomy or sclerotherapy of insufficient tributaries was allowed. Perivenous tumescence was applied with 1% Rapidocaine (lidocaine hydrochloride monohydrate; Sintetica SA). Ablation of varicose veins was performed by continuously drawing back the laser fiber at a power of 10 W, aiming for a linear endovenous energy delivery of 60 to 90 J/cm. Compression stockings were applied postoperatively, and the patients were advised to wear them for 1 week. Duplex ultrasound was performed at the 1- and 4-week follow-up visits to determine the occlusion rate and the occurrence of EHIT and VTE. ResultsOverall, 249 patients were identified from the registry. Of the 249 patients, 26 were omitted because of treatment of recurrent varicose veins. Finally, 223 consecutive patients with 223 legs and 227 saphenous veins (159 great saphenous veins, 49 small saphenous veins, and 19 anterior accessory saphenous veins) were included in the final analysis. Their mean age was 58.1 ± 13.8 years, and 167 patients (73.1%) were women. The clinical CEAP (clinical, etiology, anatomy, pathophysiology) classification was C2 for 11 legs (4.9%), C3 for 123 legs (55.2%), C4a or C4b for 86 legs (38.6%), and C5 to C6 for 3 legs (1.4%). Thromboprophylaxis was given to 132 patients (59.2%) for 3 days (rivaroxaban 10 mg once daily to 130 patients [98.5%] and low-molecular-weight heparin to 2 patients [1.5%]). No thromboprophylaxis was administered to 91 patients (40.8%) after EVLA. The average treatment length was 34.2 ± 19.3 cm and the average diameter was 5.0 ± 1.3 mm. At 1 week of follow-up, no thrombotic event had occurred in either group. At 4 weeks of follow-up, one case of EHIT class 2 (1.1%) and one case of pulmonary embolism (1.1%) had occurred in the group without thromboprophylaxis. In the thromboprophylaxis group, one deep vein thrombosis (0.8%) event had occurred (adjusted P = .135). At 1 and 4 weeks of follow-up, the treated varicose veins remained occluded in both groups. ConclusionsEndovenous ablation of truncal varicose veins appears to be safe with a low thrombotic event rate with or without pharmacologic thromboprophylaxis. However, more data are needed before a final recommendation regarding the best thromboprophylaxis treatment option can be given.

Direct oral anticoagulants (DOACs) use for prolonged venous thromboembolism prophylaxis following surgery for gynaecological malignancies in Australia and New Zealand - A clinician survey.

Current international guidelines recommend 28 days of enoxaparin as venous thromboembolism (VTE) prophylaxis after surgery for gynaecologic cancer. Direct oral anticoagulants (DOACs) have been investigated as an alternative to enoxaparin for post-operative VTE prophylaxis. High-quality evidence to demonstrate safety and efficacy is lacking. We aim to investigate the current practice regarding VTE prophylaxis among gynaecological oncologists in Australia and New Zealand following laparotomy for gynaecological malignancy, in particular the use of DOACs for VTE prophylaxis. Sixty-seven practising gynaecologic oncologists (GO) were identified through Royal Australia and New Zealand College of Obstetricians and Gynaecologists database and emailed online surveys that asked about VTE prophylaxis practice and views of DOACs in this setting. Data were then collected through Survey Monkey and evaluated. The majority (77.1%) routinely prescribed 28 days of enoxaparin following laparotomy for gynaecological malignancies. In clinical circumstance such as laparoscopy for gynaecological malignancies and surgery for vulva malignancies, there was variation in thromboprophylaxis practices. No GO reported routine use of DOACs in any clinical circumstance. There were 56% of GOs who used a DOAC in their practice at some point. Barriers to routine use of DOACs in current practice included insufficient evidence (68%), issue with cost (40.4%) and concerns about safety (29.7%). Enoxaparin prescribed for 28 days remains the current clinical practice in preventing VTE following laparotomy for gynaecological malignancy. The main barrier to routine DOAC use as post-operative thromboprophylaxis is a lack of evidence which reflects the need for a larger prospective study.

Risk of venous thromboembolism or hemorrhage among individuals with chronic kidney disease on prophylactic anticoagulant after hip or knee arthroplasty.

Chronic kidney disease (CKD) confers a high risk of thrombosis and bleeding. However, little evidence exists regarding the optimal choice of postoperative thromboprophylaxis in these patients. We conducted a population-based, retrospective cohort study among adults ≥66 years old with CKD undergoing hip or knee arthroplasty who had filled an outpatient prophylactic anticoagulant prescription between 2010 and 2020 in Ontario, Canada. The primary outcomes of venous thrombosis (VTE) and hemorrhage were identified by validated algorithms using relevant diagnoses and billing codes. Overlap-weighted cause-specific Cox proportional hazard models were used to examine the association of direct oral anticoagulants (DOAC) on the 90-day risk of VTE and hemorrhage compared with low-molecular-weight heparin (LMWH). A total of 27 645 patients were prescribed DOAC (N = 22 943) or LMWH (N = 4702) after arthroplasty. Rivaroxaban was the predominant DOAC (94.5%), while LMWH mainly included enoxaparin (67%) and dalteparin (31.5%). DOAC users had higher eGFRs, fewer co-morbidities, and surgery in more recent years compared to LMWH users. After weighing, DOAC (compared with LMWH) was associated with a lower risk of VTE (DOAC: 1.5% vs. LMWH: 2.1%, weighted hazard ratio [HR] 0.75, 95% confidence interval [CI] 0.59-0.94) and a higher risk of hemorrhage (DOAC: 1.3% vs. LMWH: 1.0%, weighted HR 1.44, 95% CI 1.04-1.99). Additional analyses including a more stringent VTE defining algorithm, different eGFR cut-offs, and limiting to rivaroxaban and enoxaparin showed consistent findings. Among elderly adults with CKD, DOAC was associated with a lower VTE risk and a higher hemorrhage risk compared to LMWH following hip or knee arthroplasty.