Venous thromboembolism prophylaxis in thoracic surgery patients: an international survey

Post-operative hypercoagulable whole blood profiles in patients undergoing open thoracotomy vs video-assisted thoracoscopic surgery

BACKGROUND

Patients undergoing video-assisted thoracoscopic surgery (VATS) have a lower risk of thrombosis compared to those undergoing open thoracotomy (OT) which may be due to several post-operative factors such as early mobilisation, shorter hospital stays, lower transfusion rates and lower risk of infections. Whether the higher thrombotic risk after OT is also linked to a peri-operative hypercoagulable state is a matter of debate. We therefore conducted a case-control study to compare peri-operative coagulation profiles in patients with primary lung cancer undergoing VATS vs OT.

MATERIALS AND METHODS

All consecutive patients undergoing VATS or OT for primary lung cancer at the Department of Thoracic Surgery of Padua University Hospital, Italy, between February and June 2018 were enrolled. Each patient provided a venous blood sample at least 30 min prior to surgical incision (T0) and 4±1 days after surgery (T1). Peri-operative coagulation profiles were assessed via traditional, viscoelastic whole blood (ROTEM^® [Instrumentation Laboratory-Werfen]) and impedance aggregometry (Multiplate^® Analyser [Roche Diagnostics]) tests.

RESULTS

We enrolled 65 patients (males 43, females 22; mean age 65±13 years) of whom 35 (54%) underwent VATS and 30 (46%) underwent OT. Compared to healthy controls, the surgical group (VATS and OT patients) had a significantly shorter clot formation time and higher alpha angle and maximum clot firmness values, as well as increased mean platelet function. In the post-operative period, patients who underwent OT had a significantly shorter clot formation time, higher alpha angle and maximum clot firmness values and higher mean platelet function vs VATS patients.

DISCUSSION

Whole blood ROTEM^® profiles and Multiplate^® aggregometry identified a more hypercoagulable post-operative state in patients who underwent OT than in those who underwent VATS. Larger studies are warranted to confirm our results and ascertain whether the observed hypercoagulability might promote post-operative thrombosis.

Effect on thromboprophylaxis among hospitalized patients using a system-wide multifaceted quality improvement intervention: Rationale and design for a multicenter cluster randomized clinical trial in China

BACKGROUND

Venous thromboembolism (VTE) is a life-threatening disease that can affect each hospitalized patient. But the current in-hospital thromboprophylaxis remains suboptimal and there exists a large gap between clinical practice and guideline-recommended care in China.

METHODS

To facilitate implementation of guideline recommendations, we conduct a multicenter, adjudicator-blinded, cluster-randomized clinical trial, aiming to assess the effectiveness of a system-wide multifaceted quality improvement (QI) strategy on VTE prophylaxis improvement and thromboembolism reduction in clinical setting. Hospitals are randomized into intervention or control group. In intervention group, hospitals receive the concept of appropriate in-hospital thromboprophylaxis plus a multifaceted QI which encompasses four components: (1) an electronic alert combining computer-based clinical decision support system and electronic reminders, (2) appropriate prophylaxis based on dynamic VTE and bleeding risk assessments, (3) periodical audit and interactive feedback on performance, (4) strengthened training and patient education. In control, hospitals receive the concept of recommended prophylaxis alone without QI. Thromboprophylaxis will be at the discretion of hospitals and conducted as usual. With a final sample size of 5760 hospitalized patients in 32 hospitals on mainland China, this trial will examine the effect of QI on improvement in thromboprophylaxis and patient-centered outcomes. This is an open-label trial that patients and healthcare professionals will know group allocation after enrollment, but endpoint adjudicators and statisticians will be blinded. RCT# NCT04211181 CONCLUSIONS: The system-wide multifaceted QI intervention is expected to facilitate implementation of recommended VTE prophylaxis in hospital, thereafter reducing VTE incidence and relevant adverse events among hospitalized patients in China.

Thrombotic risk following video-assisted thoracoscopic surgery versus open thoracotomy: a systematic review and meta-analysis

OBJECTIVES

There is no consensus on the risk of thrombotic events following video-assisted thoracoscopic surgery (VATS) versus open thoracotomy (OT), despite multiple studies. In fact, the estimates for the overall thrombotic risk for VATS versus OT are inconclusive. In this systematic review and meta-analysis, we endeavoured to ascertain the best estimate of thrombotic risk in VATS versus OT.

METHODS

Relevant studies were searched through PubMed and Cochrane Library database. Outcomes of interests were myocardial infarction (MI), pulmonary embolism (PE) and deep vein thrombosis (DVT). Data were pooled using random-effects model. The results were presented as odds ratio (OR) with the corresponding 95% confidence interval (CI).

RESULTS

Nineteen studies were meta-analysed: 17 observational studies and 2 randomized controlled trials. Using propensity-matched data, in comparison with OT, VATS was associated with a statistically significant, postoperative reduction in MI (OR 0.60, 95% CI 0.39-0.91; P = 0.017), DVT/PE (OR 0.52, 95% CI 0.44-0.61; P < 0.001), PE (OR 0.59, 95% CI 0.43-0.82; P = 0.001) and DVT (OR 0.47, 95% CI 0.35-0.64; P < 0.001). Unadjusted data showed no statistical differences for all outcomes. The risk of DVT/PE (OR 0.55, 95% CI 0.42-0.72; P < 0.001), but not the other outcomes, remained significantly lower following the exclusion of the sole large study. There is no significant statistical heterogeneity between the included studies.

CONCLUSIONS

Overall, the postoperative thrombotic risk following VATS is significantly lower than OT. Further prospective randomized controlled trials with large sample sizes are warranted to corroborate our findings.