Safety of Rivaroxaban for Postoperative Venous Thromboembolism Prophylaxis Following Abdominal Body Contouring Surgery: 600 Patients

Use of Thromboprophylaxis after Autologous Breast Reconstruction: A Cost-Effective Break-Even Analysis

BACKGROUND

Postoperative venous thromboembolism (VTE) is a major source of morbidity and mortality. The use of thromboprophylaxis among surgeons is not well studied in autologous breast reconstruction. The purpose of this study was to determine the rate of VTE in patients with breast cancer undergoing autologous breast reconstruction and to compare the cost-effectiveness of postoperative chemoprophylactic agents.

METHODS

The TriNetX National Health Research Network database was used to identify patients with breast cancer who underwent autologous breast reconstruction surgery between 2002 and 2022. The incidence of VTE within the first 30 days of surgery was calculated. A break-even analysis was performed to determine the break-even rate of VTE at which a chemoprophylactic agent would be cost-effective.

RESULTS

A cohort of 8221 patients was identified in this study. The rate of VTE was significantly higher in those without anticoagulation (4.0%) compared with those who received anticoagulation (2.6%) ( P = 0.0008). The break-even analysis for heparin and enoxaparin cost-effectiveness yielded absolute risk reductions of 0.73% and 1.63% for high-risk patients requiring 30 days of therapy and 0.20% and 0.43% for moderate-risk patients requiring 7 days of therapy, respectively.

CONCLUSIONS

The use of thromboprophylaxis significantly lowered the risk of VTE within 30 days after autologous breast reconstruction. Heparin appeared to be more cost-effective at preventing VTE compared with enoxaparin for both high- and moderate-risk patients. The presented model holds potential for other institution-specific variables that can be easily applied by plastic surgeons to determine the cost-effectiveness of any therapy.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

An In-Depth Analysis of 1370 Consecutive Abdominoplasties: Fascial Plication Increases Risk of Venous Thromboembolism, and Scoring for Plication Improves the Caprini Risk Assessment Model

BACKGROUND

Venous thromboembolism (VTE) is the most dangerous complication of abdominoplasty. One relatively undefined risk factor is plication, which in theory increases VTE risk.

OBJECTIVES

To assess the thromboembolic risk of plication.

METHODS

A retrospective review of 1370 consecutive abdominoplasties by one surgeon was undertaken. Two groups were considered, plicated (n= 1089) and non-plicated (n = 281), and VTE rates were compared between these groups.

RESULTS

There were 25/1089 cases of VTE (2.3%) in plicated patients and 1/281 case of VTE (0.36%) in non-plicated patients, which was statistically significant (Fisher's exact test, p=0.028) despite the non-plicated group being a higher risk population. Case-Control matching yielded 225 pairs which differed statistically only by the presence or absence of plication; there were 12/225(5.3%) VTE events in the plicated group and 0/225 in the non-plicated group (McNemar's test, p=0.0015). Logistic regression demonstrated increased VTE risk with increasing age (OR 1.08, p<0.001), BMI (OR 1.34, p=0.002), Caprini score (OR 2.17, p<0.001), and especially plication (OR 16.76, p=0.008). Adding two points for plication to Caprini scores offered better risk stratification at a level of 7, with an improved combination of sensitivity/specificity (0.31/0.98 vs 0.69/0.96) and a 27% improvement over the 2005 Caprini RAM in the area under a Receiver Operating Characteristic (ROC) curve (0.826 vs 0.651, Z-value -3.596, p = 0.003).

CONCLUSIONS

Plication was shown to be a powerful risk factor for the development of VTE in abdominoplasty. Abdominal wall plication should be considered in risk assessment, and scoring for plication may improve the performance of the Caprini RAM.

Unfractionated Heparins, Low-Molecular-Weight Heparins, and Indirect Factor Xa Inhibitors in Plastic and Reconstructive Surgery: An Evidence-Based Review

SUMMARY

Venous thromboembolism can present with devastating complications and sequalae, particularly in the surgical patient. Current data support prophylactic anticoagulant use in high-risk hospitalized patients, defined as those with a Caprini Risk Assessment Model score of 7 or greater. The most frequently used chemoprophylaxis agents include unfractionated heparin, low-molecular-weight heparin, and indirect factor Xa inhibitors. The authors review the mechanisms of action, metabolism, reversal agents, indications, contraindications, advantages, and disadvantages of these medications in plastic and reconstructive surgery.

The Majority of Venous Thromboembolism Events Should Occur in Lower Risk Aesthetic Surgery Patients: A Simulation Study

Evidence-based venous thromboembolism (VTE) prevention among aesthetic patients is lacking. This study seeks to (1) quantify 2005 Caprini scores in primary breast augmentation patients, (2) determine the proportion of patients with potentially modifiable VTE risk factors, and (3) project, using Monte Carlo simulation, the expected distribution of Caprini scores among aesthetic surgery patients who develop VTE.

Methods

The observational study (part 1) screened consecutive primary breast augmentation patients for VTE risk using the 2005 Caprini score. Aggregate scores were compiled, and the proportion of patients with potentially modifiable risk factors were identified. Part 2 used Monte Carlo simulation to generate risk score distributions for VTE events predicted to occur among randomly sampled patient cohorts with baseline Caprini risk profiles derived from the part 1 data.

Results

One hundred patients had mean age of 35.7 years and mean body mass index of 23.8 kg/m2. Median 2005 Caprini score was 3 (range, 2-8), with the majority (96%) having scores of ≤6. Twenty-eight percent of patients had at least one potentially modifiable risk factor or risk factor potentially benefiting from further investigation. Monte Carlo simulations demonstrated that for a population with 96% Caprini ≤6 (and 4% Caprini ≥7), 80% of VTE events would be expected to occur in patients with Caprini scores ≤6.

Conclusions

The majority of breast augmentation patients in this study (96%) have 2005 Caprini scores ≤6. Twenty-eight percent of patients have potentially modifiable risk factors. The majority of patients with VTE after aesthetic surgery are expected to have lower Caprini risk scores.