Venous Thromboembolism Prophylaxis Research Articles

Surgeon-led improvement in compliance with use of sequential compression devices in a neurosurgery patient population

IntroductionSequential compression devices (SCDs) are the mainstay of mechanical prophylaxis for venous thromboembolism in perioperative neurosurgical patients and are especially crucial when chemical prophylaxis is contraindicated.ObjectivesThis study aimed to characterise...

Evaluation of a Risk Screening Checklist for Venous Thromboembolism Prophylaxis in a Women and Newborn Hospital.

The venous thromboembolism (VTE) risk screening forms were developed to allow for recording identified risk factors for VTE including thrombophilia, history of VTE, postpartum hemorrhage, and cesarean delivery, and documentation of specific actions taken to mitigate these risks and reduce complications due to VTE. Compliance with hospital guidelines in assessing VTE risk and appropriate prescribing of thromboprophylaxis was evaluated prior to the introduction of VTE risk screening forms (March 2022). Efficacy of the new VTE risk screening forms was also assessed (April 2023). Patient discharge summaries and patient medical records including medication charts were used to review the documentation of VTE risk assessments and details of thromboprophylaxis prescribing. Of 74 postnatal patients, 37.8% had VTE risk assessment documented prior to the introduction of VTE risk screening forms. Of 37 patients identified to be at moderate to high risk of VTE requiring pharmacological prophylaxis, 70.3% (n = 26) were appropriately prescribed pharmacological prophylaxis. After the risk screening forms were introduced, a total of 67 antenatal, postnatal, and gynecologic patients were studied. Of these, 32.8% (n = 22) of patients had all required fields completed appropriately. When using the forms, 26.9% (n = 7) of postnatal and 88% (n = 22) of gynecological patients were rated as medium or high risk, and all received medical review within 24 hours. Pharmacological prophylaxis was indicated in 88% (n = 22) of gynecological, 43.8% (n = 7) of antenatal, and 38.5% (n = 10) of postnatal patients, and all were appropriately prescribed. The guideline review and introduction of VTE risk screening forms was valuable to provide guidance in the risk assessment for VTE and to identify patients requiring prophylaxis.

Tofacitinib Exposure Does Not Increase Postoperative Complications Among Patients With Ulcerative Colitis Undergoing Total Colectomy: A Retrospective Case-Control Study.

Ulcerative colitis, total colectomy and tofacitinib have all been associated with increased risk of venous thromboembolism. To determine if preoperative tofacitinib exposure increases venous thromboembolism or other postoperative complications among patients with ulcerative colitis undergoing subtotal colectomy, total colectomy or total proctocolectomy. Retrospective, case-control study at a single institution. A tertiary referral center. Adult patients with ulcerative colitis undergoing subtotal colectomy, total colectomy or total proctocolectomy after 2018 who were taking tofacitinib within 30 days of surgery (n = 56) were compared to age and sex-matched patients with ulcerative colitis undergoing the same surgeries but who were not exposed to tofacitinib (n = 56). The primary outcome was differences in the incidence of venous thromboembolism within 90 days of surgery based on tofacitinib exposure. Secondary outcomes were 90-day postoperative complications. Groups were well matched for age (non-tofacitinib: mean 35.2 years [SD 12.0], tofacitinib: 35.9 [SD 12.1], p = 0.36) and sex (41% female in each group, p = 1.00). Medical characteristics were similar between groups except for biologic medication exposure 30 days before surgery (non-tofacitinib: 66%, tofacitinib: 36%, p = 0.004). Surgical characteristics did not differ between groups. Most patients were discharged on extended venous thromboembolism prophylaxis (non-tofacitinib: 80% and tofacitinib: 77%). Adjusted for biologic exposure, there were no statistically significant differences in venous thromboembolism (non-tofacitinib exposed: 14%, tofacitinib-exposed: 4%, p = 0.09) or other postoperative outcomes. Retrospective, single institutional study. Among patients with ulcerative colitis undergoing total colectomy or proctocolectomy, exposure to tofacitinib was not associated with an increased risk of venous thromboembolism or other postoperative complications. See Video Abstract.

Venous Thromboembolism Prophylaxis in High-Risk Pediatric Trauma Patients

The indications, safety, and efficacy of chemical venous thromboembolism prophylaxis (cVTE) in pediatric trauma patients remain unclear. A set of high-risk criteria to guide cVTE use was recently recommended; however, these criteria have not been evaluated prospectively. To examine high-risk criteria and cVTE use in a prospective multi-institutional study of pediatric trauma patients. This cohort study was completed between October 2019 and October 2022 in 8 free-standing pediatric hospitals designated as American College of Surgeons level I pediatric trauma centers. Participants were pediatric trauma patients younger than 18 years who met defined high-risk criteria on admission. It was hypothesized that cVTE would be safe and reduce the incidence of VTE. Receipt and timing of chemical VTE prophylaxis. The primary outcome was overall VTE rate stratified by receipt and timing of cVTE. The secondary outcome was safety of cVTE as measured by bleeding or other complications from anticoagulation. Among 460 high-risk pediatric trauma patients, the median (IQR) age was 14.5 years (10.4-16.2 years); 313 patients (68%) were male and 147 female (32%). The median (IQR) Injury Severity Score (ISS) was 23 (16-30), and median (IQR) number of high-risk factors was 3 (2-4). A total of 251 (54.5%) patients received cVTE; 62 (13.5%) received cVTE within 24 hours of admission. Patients who received cVTE after 24 hours had more high-risk factors and higher ISS. The most common reason for delayed cVTE was central nervous system bleed (120 patients; 30.2%). There were 28 VTE events among 25 patients (5.4%). VTE occurred in 1 of 62 patients (1.6%) receiving cVTE within 24 hours, 13 of 189 patients (6.9%) receiving cVTE after 24 hours, and 11 of 209 (5.3%) who had no cVTE (P = .31). Increasing time between admission and cVTE initiation was significantly associated with VTE (odds ratio, 1.01; 95% CI, 1.00-1.01; P = .01). No bleeding complications were observed while patients received cVTE. In this prospective study, use of cVTE based on a set of high-risk criteria was safe and did not lead to bleeding complications. Delay to initiation of cVTE was significantly associated with development of VTE. Quality improvement in pediatric VTE prevention may center on timing of prophylaxis and barriers to implementation.

Priorities and strategy for the implementation of enhanced recovery after surgery (ERAS) in thoracic surgery.

Enhanced recovery after surgery (ERAS) is a perioperative care protocol, which was introduced several years ago and has gained increasing importance in thoracic surgery. The aim of this study was to provide guidance through clinical implementation and to identify factors for better compliance. This prospective cohort study collected data between July 2021 and June 2022 at the Department of Thoracic Surgery (University Hospital Regensburg, Germany). A modified enhanced recovery after thoracic surgery (ERATS) protocol with recommendations covering the pre-, intra- and postoperative phases was established and followed. The primary objective was to evaluate the implementation of the ERATS protocol. Secondary, specific and clinically relevant recommendations were analyzed regarding their compliance. The study included 139 patients undergoing elective lung resections. Many ERATS recommendations were already part of standard perioperative care, including perioperative antibiotics, venous thromboembolism prophylaxis and intraoperative warming. Other measures such as anemia management, carbohydrate loading or chest drain management were updated or newly established and standardized according to our ERATS protocol. The recommendations emphasizing early postoperative mobilization were found to be crucial. We identified three groups with significantly different compliance rates: (I) patient-dependent measures which require active participation (49.3%); (II) treatment measures requiring interdisciplinary consensus (85.8%); and (III) surgical measures (88%). The implementation and continuous evaluation of our perioperative ERATS protocol led to a new categorization of targeted measures into three groups with actors of different competencies. The new grouping enables gradual implementation and a step-by-step targeted approach in order to achieve a higher compliance of ERATS in the future as well as long-term sustainability.

Statins during Anticoagulation for Emergency Life-Threatening Venous Thromboembolism: A Review.

Venous thromboembolism (VTE) is the leading cause of morbidity and death worldwide, after cancer and cardiovascular diseases. VTE is defined to include pulmonary embolism (PE) and/or deep vein thrombosis (DVT). Approximately 25% of PE patients experience sudden death as an initial symptom of VTE, and between 10% and 30% of patients die within the first month after diagnosis. Currently, the only drugs approved for the treatment of both acute and chronic VTE are vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs). However, their effectiveness is limited due to their associated risk of bleeding. Ideally, therapy should be able to treat VTE and limit the risk of VTE recurrence without increasing the risk of bleeding. Several studies have shown that the use of statins during anticoagulation for VTE reduces the risk of death and VTE recurrence. However, to date, there are conflicting data on the impact of statins during anticoagulation for VTE. A biological protective function of statins during anticoagulation has also been reported. Statins affect D-dimer levels; tissue factor (TF) gene expression; and VIII, VII, and Von Willebrand clotting factors-the major clotting factors they are able to affect. However, the usefulness of statins for the treatment and prevention of VTE is currently under debate, and they should not be substituted for guideline-recommended VTE prophylaxis or anticoagulation treatment. In this review of the literature, we illustrate the advances on this topic, including data on the role of statins in primary VTE prevention and secondary VTE prevention, related biological mechanisms, the risk of bleeding during their use, and their ability to reduce the risk of death.

Does preperitoneal packing increase venous thromboembolim risk among trauma patients? A prospective multicenter analysis across 17 level I trauma centers.

Pelvic fractures are associated with a high risk of venous thromboembolism (VTE). Among treatment options, including pelvic angioembolization (PA), preperitoneal pelvic packing (PPP), and pelvic open reduction internal fixation (ORIF), PPP has been postulated as a VTE risk factor. We aimed to characterize the risk of VTE among pelvic fracture patients receiving PPP, PA or ORIF. We used observational data from a 17-site Consortium of Leaders in the Study of Traumatic Thromboembolism (CLOTT) study group, a US level I trauma center collaborative working to identify factors associated with posttraumatic VTE, deep venous thrombosis, pulmonary embolism, or pulmonary thrombosis. The CLOTT criteria included age 18 to 40 years with at least one independent VTE risk factor. We compared outcomes of PPP, PA, and pelvic ORIF to reference of no pelvic intervention. Our primary outcome was VTE. A competing risk analysis was performed. Among 1,387 pelvic fracture patients, VTE incidence was 5.6%. The ORIF patients were most likely to develop VTE (24.7%), while VTE incidence for PPP was 9.0% and 2.6% for PA. After multivariate, risk-competing analysis, none of the three treatment interventions for pelvic fractures were significantly associated with VTE. Initiation of VTE prophylaxis in the first 24 hours of admission independently halved VTE incidence (hazard ratio, 0.55; confidence interval, 0.33-0.91). Pelvic fracture interventions do not appear to be independent risk factors for VTE in our study. Initiation of VTE pharmacoprophylaxis within the first 24 hours of admission remains critical to significantly decreasing VTE formation in this high-risk population. Therapeutic Study; Level III.

Summary of the Best Evidence for Mechanical Prophylaxis of Venous Thromboembolism In Adult Hospitalized Patients

Summary of the Best Evidence for Mechanical Prophylaxis of Venous Thromboembolism In Adult Hospitalized Patients

Which individual components of a colorectal surgery enhanced recovery program are associated with improved surgical outcomes?

BackgroundEnhanced recovery programs improve surgical outcomes. However, the association of adherence to individual components and outcomes in a comprehensive enhanced recovery program remains unclear. MethodsWe performed a retrospective study of all elective colorectal surgery patients at our institution from 2019 to 2022 (n = 1,175). Data were acquired from our institution’s enhanced recovery program dashboard and American College of Surgeons National Surgical Quality Improvement Program database. Traditional analyses and machine-learning classification trees were used to identify enhanced recovery program components associated with length of stay, readmissions, and complication rates. ResultsThe average length of stay was 5.0 days, readmission rate was 12.3%, and complication rate was 32.6%. On linear regression analysis, adherence to preoperative education, regional analgesia, pre- and postoperative multimodal analgesia, no nasogastric tube, early mobilization, early regular diet, early discontinuation of maintenance intravenous fluids, postoperative venous thromboembolism prophylaxis, and early Foley catheter removal were associated with an decrease in length of stay by 0.7–7.1 days (P < .05). Patients who adhered to no prolonged fasting had a 4.1% decrease in readmission rate (P = .04). Patients who adhered to no nasogastric tube, early mobilization, early regular diet, postoperative multimodal analgesia, and discontinuation of maintenance intravenous fluids had decreases in complication rates ranging from 7.0 to 28.2% (P < .001). Machine learning demonstrated that no nasogastric tube and discontinuation of maintenance intravenous fluids were significant predictors of shorter length of stay and no nasogastric tube and early mobilization were significant predictors of reduced complication rates. ConclusionsAlthough multiple components were associated outcomes, no nasogastric tube, early mobilization, early regular diet, postoperative multimodal analgesia, and early discontinuation of maintenance intravenous fluids were associated with more than 1 outcome. Focusing on these components may make enhanced recovery program implementation more feasible for resource-limited hospitals.

Development and internal validation of the Cleveland Clinic Bleeding Model to predict major bleeding risk at admission in medical inpatients

BackgroundGuidelines recommend pharmacologic VTE prophylaxis for acutely ill medical patients at acceptable bleeding risk, but only the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) model has been validated for bleeding risk assessment. ObjectivesWe developed and internally validated a risk assessment model (RAM) to predict major in-hospital bleeding using risk factors at admission and compared our model with IMPROVE. MethodsWe selected patients admitted to medical services at 10 hospitals in the Cleveland Clinic Health System from 2017 to 2020. We identified major bleeding according to the International Society on Thrombosis and Haemostasis criteria, using a combination of diagnostic codes and laboratory values, and confirmed events with chart review. We fit a least absolute shrinkage selection operator logistic regression model in the training set and compared the discrimination and calibration of our model with the IMPROVE model in the validation set. ResultsAmong 46 314 admissions, 268 (0.58%) had a major bleed. The final RAM included 16 risk factors, of which prior bleeding (odds ratio [OR] = 4.83), peptic ulcer (OR = 3.82), history of sepsis (OR = 3.26), and steroid use (OR = 2.59) were the strongest. The Cleveland Clinic Bleeding Model had better discrimination than IMPROVE (area under the receiver operating characteristics curve = 0.85 vs 0.70; P < .001) and, at equivalent sensitivity (52%), categorized fewer patients as high risk (7.2% vs 11.8%; P < .001). Calibration was adequate (Brier score = 0.0057). ConclusionUsing a large population of medical inpatients with verified major bleeding events, we developed and internally validated a RAM for major bleeding whose performance surpassed the IMPROVE model.

Venous Thromboembolism Prophylaxis Should Be Recommended for Antepartum Admissions and Cesarean Delivery if Age and Body Mass Index are Greater Than 35.

Venous thromboembolism (VTE) is a major cause of maternal morbidity and mortality. Current expanded treatment recommendations result in the inclusion of a large percentage of the obstetric population, which has limited their adoption. The purpose of this study was to identify a population at high risk for VTE, with minimal impact on the number of patients that would qualify for expanded treatment. We performed a retrospective analysis of a large obstetric population. International Classification of Diseases, 10th Revsion (ICD-10) codes for VTE were used to identify patients presenting for obstetric or postpartum (PP) care from January 2016 to March 2018. The review focused on high-risk factors (history of VTE or high-risk thrombophilia), antepartum hospital admissions that were >72 hours in the previous 30 days, use of sequential compression devices, body mass index (BMI; kg/m2), age, and mode of delivery. Pharmacologic treatment efficacy was set at 90, 75, or 50%. During the 27-month review period, there were 120,235 deliveries and 93 had a VTE event in the index pregnancy or within 4 weeks PP (7.7/10,000 births). A history of VTE or high-risk thrombophilia was seen in 25.8% of cases. Antepartum admission was noted in 40.9%, and the combination of cesarean delivery (CD) with age and BMI ≥35 (Age + BMI + CD) was noted in 17.3% of PP cases. Targeting these latter two groups for VTE prophylaxis with a 75% efficacy suggests that 34% of the VTE events would likely have been prevented while increasing the total population treated by approximately 2%. Expanding pharmacologic prophylactical coverage to include an antepartum admission of >72 hours and those with Age + BMI + CD would result in about a one-third reduction in total VTE events with about 2% requiring treatment. These data support some of the suggested recommendations for expanded pharmacological deep venous thrombosis prophylaxis. · CD, and BMI and age >35 are high-risk factors for VTE.. · Antepartum admission >72 hours is a high-risk factor for VTE.. · Targeting antepartum admissions, CD, and BMI and age >35 would reduce VTE events by about 33%..

Aspirin is an Effective Prophylaxis for Venous Thromboembolism After Revision Hip and Knee Arthroplasty

BackgroundVenous thromboembolism (VTE) following revision total joint arthroplasty (TJA) poses significant risks despite prophylactic measures. The optimal VTE prophylaxis agent for revision TJA remains unclear. This study aimed to compare aspirin against various anticoagulant agents regarding efficacy and safety in preventing symptomatic VTE events after revision TJA. MethodsA retrospective analysis included 4,575 patients undergoing revision TJA between 2008 and 2020. Of these, 2,091 received aspirin, while 2,484 received other anticoagulants. Demographic, procedural, and outcome data were collected. Logistic regression models were used to identify predictors of symptomatic VTE. ResultsThe aspirin group showed a significantly lower incidence of symptomatic VTE compared to the other anticoagulant group (0.53 versus 2.54%, P < .001). Logistic regression confirmed a higher risk of VTE with other anticoagulants (odds ratio: 0.2 to 0.26, P < .001), while blood transfusion (odds ratio: 2.72, P = .001) were identified as risk factors. ConclusionsThis study demonstrated that aspirin is a viable and potentially safer option than other anticoagulants, exhibiting comparable efficacy in preventing VTE events in revision TJA. Balancing effectiveness and safety is crucial, considering patient-specific risk factors and bleeding tendencies. This large cohort study demonstrated that aspirin was associated with a more effective and safer VTE prophylaxis agent, compared to other anticoagulants, in patients undergoing revision TJA.

European guidelines on peri-operative venous thromboembolism prophylaxis: first update.: Chapter 3: Day surgery and fast-track surgery.

European guidelines on peri-operative venous thromboembolism prophylaxis: first update.: Chapter 3: Day surgery and fast-track surgery.

European guidelines on peri-operative venous thromboembolism prophylaxis: first update.: Chapter 9: Surgery during pregnancy and the immediate postpartum period.

European guidelines on peri-operative venous thromboembolism prophylaxis: first update.: Chapter 9: Surgery during pregnancy and the immediate postpartum period.

Patient Weight and Chemoprophylaxis in Abdominoplasty: Does It Result in More Bleeding Events?

Bariatric surgery has gained popularity in recent decades as an effective treatment for obesity. Abdominoplasty is one of the most often performed aesthetic procedures all over the world. In post-bariatric patients undergoing abdominoplasty, the diameter size and number of the abdominal wall perforators increase proportionally with increased body weight. Postoperative complications that may occur are haematoma, and venous thromboembolism (VTE). In plastic surgery procedures VTE prophylaxis grades vary due to the lack of consensus and clear guidelines. The aim of this study was to explore the frequency of postoperative bleeding and VTE in patients undergoing abdominoplasty and to explore the risk factors associated with major bleeding. A retrospective single-centre study of adult patients who were operated on by abdominoplasty between 2011 and 2020. Chemoprophylaxis including low molecular weight heparin (LMHW) was recommended when the operating time exceeded 2h. A total of 102 patients were included. There were no patients with VTE. Eight patients were re-operated for major haematoma. The weight loss (peak weight to weight before the abdominoplasty) was 14.4kg larger in the re-operation group (p = 0.03). Eighty-eight percent in the re-operation group and 67% in the other group were treated with LMWH (p = 0.43). Multivariable logistic regression showed that with each decrease from the peak in BMIkg/m2 the risk of re-operation for major haematoma was increased by 22% (p = 0.02). Abdominoplasty in patients after massive weight loss has a higher risk of postoperative bleeding. Having a clear protocol for chemoprophylaxis should be considered. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Venous Thromboembolism Risk Assessment and Prophylaxis in Obstetrics Patients in a Tertiary Health Center in Jeddah, Saudi Arabia.

Aim The study aimed to estimate the proportion of patients who were evaluated for thrombosis risk and received appropriate thromboprophylaxis, if indicated, in King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia. Method This was a retrospective cross-sectional study conducted among inpatients from May 1 to August 31, 2020, in KAUH. Results Out of 298 pregnant women, the mean age was 32.09± 5.29 years. A total of 136 (45.6%) were obese and 97 (32.6%) were overweight. There was a significant relationship between Caprini score categories and the following variables: age, body mass index (BMI), medical disease, history of deep vein thrombosis (DVT), mode of delivery, prophylaxis, and its duration (p < 0.05). Conclusion Awareness about thromboprophylaxis in reducing the risk of developing venous thrombosis has increased compared to before, with more than half of the cases receiving it regardless of the risk level. The highest risk of venous thromboembolism (VTE) was found in older women, obese women, and those with a previous history of DVT. Low-molecular-weight heparin (LMWH) was the main prophylaxis in the hospital with an average duration of three days.

Impact of Clinical Decision Support with Mandatory versus Voluntary Venous Thromboembolism Risk Assessment in Hospitalized Patients.

Background Venous thromboembolism (VTE) causes significant preventable morbidity and mortality in hospitalized patients. Assessing VTE risk is essential to initiating appropriate prophylaxis and reducing VTE outcomes. Studies show that computerized clinical decision support (CDS) can improve VTE risk assessment (RA), prophylaxis, and outcomes but few examined the effectiveness of specific design features. From 2008 to 2016, University of Michigan Health implemented CDS for VTE prevention in four stages, which alternated between voluntary and mandatory RA using the 2005 Caprini model and generated inpatient orders for risk-appropriate prophylaxis based on CHEST guidelines. This cross-sectional study evaluated the impact of mandatory versus voluntary RA on VTE prophylaxis and outcomes for adult medical and surgical patients admitted to the health system. Methods Interrupted time series analysis was conducted to evaluate the trend in smart order set-recommended VTE prophylaxis by CDS stage. Logistic regression with CDS stage as the primary independent variable was used in pairwise comparisons of VTE during hospitalization and within 90 days post-discharge for mandatory versus voluntary RA. Adjusted odd ratios (ORs) were calculated for total, in-hospital, and post-discharge VTE. Results In this study of 223,405 inpatients over 8 years, smart order set-recommended prophylaxis increased from 65 to 79%; it increased significantly when voluntary RA in Stage 1 became mandatory in Stage 2 (10.59%, p < 0.001) and decreased significantly when it returned to voluntary in Stage 3 (-11.24%, p < 0.001). The rate increased slightly when mandatory RA was reestablished in Stage 4 (0.23%, p = 0.935). Adjusted ORs for VTE were lower for mandatory RA versus adjacent stages with voluntary RA. The adjusted OR for Stage 2 versus Stage 1 was 14% lower ( p < 0.05) and versus Stage 3 was 11% lower ( p < 0.05). The adjusted OR for Stage 4 versus Stage 3 was 4% lower ( p = 0.60). These results were driven by changes in in-hospital VTE. By contrast, the incidence of post-discharge VTE increased in each successive stage. Conclusion Mandatory RA was more effective in improving smart order set-recommended prophylaxis and VTE outcomes, particularly in-hospital VTE. Post-discharge VTE increased despite high adherence to risk-appropriate prophylaxis, indicating that guidelines for extended, post-discharge prophylaxis are needed to further reduce VTE for hospitalized patients.

Assessment of rivaroxaban as venous thromboembolism prophylaxis after gastric bypass surgery

Assessment of rivaroxaban as venous thromboembolism prophylaxis after gastric bypass surgery

Oral rivaroxaban for postoperative prophylaxis of venous thromboembolism after sleeve gastrectomy in patients with morbid obesity, is it safe: A prospective randomized clinical trial

Oral rivaroxaban for postoperative prophylaxis of venous thromboembolism after sleeve gastrectomy in patients with morbid obesity, is it safe: A prospective randomized clinical trial

Pharmacotherapy for Venous Thromboprophylaxis following Total Hip or Knee Arthroplasty: A Systematic Review and Network Meta-analysis.

The optimal pharmacological prophylaxis for venous thromboembolism (VTE) after hip or knee arthroplasty is uncertain. We conducted a systematic review and network meta-analysis to compare the efficacy and safety of various medications. We searched multiple databases for randomized clinical trials (RCTs) comparing medications (including factor Xa inhibitors, factor IIa inhibitor, warfarin, unfractionated heparin [UFH], low-molecular-weight heparin [LMWH], aspirin, pentasaccharide) for VTE prophylaxis post-arthroplasty. Outcomes included any postoperative VTE identified with screening, major bleeding, and death. We used LMWH as the main comparator for analysis and performed trial sequential analysis (TSA) for each pairwise comparison. Certainty of evidence was assessed using GRADE (Grading of Recommendations, Assessments, Developments and Evaluations). We analyzed 70 RCTs (55,841 participants). Factor Xa inhibitors decreased postoperative VTE significantly compared with LMWH (odds ratio [OR]: 0.55, 95% confidence interval [CI]: 0.44-0.68, high certainty). Pentasaccharides probably reduce VTE (OR: 0.61, 95% CI: 0.36-1.02, moderate certainty), while the factor IIa inhibitor dabigatran may reduce VTE (OR: 0.75, 95% CI: 0.40-1.42, low certainty). UFH probably increases VTE compared with LMWH (OR: 1.31, 95% CI: 0.91-1.89, moderate certainty), and other agents like warfarin, aspirin, placebo, and usual care without thromboprophylaxis increase VTE (high certainty). Factor Xa inhibitors may not significantly affect major bleeding compared with LMWH (OR: 1.06, 95% CI: 0.81-1.39, low certainty). No medications had a notable effect on mortality compared with LMWH (very low certainty). TSA suggests sufficient evidence for the benefit of factor Xa inhibitors over LMWH for VTE prevention. Compared with LMWH and aspirin, factor Xa inhibitors are associated with reduced VTE after hip or knee arthroplasty, without an increase in bleeding and likely no impact on mortality.